Special Topic - HIV/AIDS

HIV

human immunodeficiency virus

• attacks the immune system, immunocompromised, decreased amount of T helper cells

HIV untreated

leads to acquired immune deficiency syndrome (AIDS), no cure

paradigm shift

treat as fatal, stigmatized disease to now manage as chronic condition

• decreased conversion to AIDS with treatment, increased life expectancy

viral classification

lentivirus genus of retroviridae family

• retrovirus = RNA to DNA with reverse transcriptase

2 HIV strains

• HIV-1: most common and pathogenic (2023 - 1.3 million infections annually), Major group (M) >90% of cases

• HIV-2 in Africa

HIV statistics

• 85.6 mil infected, 40.4 mil died, 39 mil living (2022)

• 1.3 mil infections 2023, dropped 60% from peak in 1996

• new infections in Middle East, North Africa, Eastern Europe, Central Asia, Latin America

• 1.2 mil in US had HIV, 13% don’t know

• US = homosexual/bisexual men most at risk (37% AA, 33% hispanic)

• gay, bisexual and MSM = 67% of new infections, 22% heterosexual, 7% IV drug use

• adult HIV prevalence = 1.2% worldwide, 9% in sub-saharan africa

• women and girls = 45% new infections (2024)

world’s epicenter of HIV/AIDS

sub-saharan africa

routine HIV testing

all people 13-64, how often depends on risk factors

viral statistics

• highly variable and mutates easily, persistent and slow (NOT latent)

• normal CD4 = 600-1200 cells/mm

• AIDS CD4= <200 cells/mm

• turnover = 180 generations/day, 10-100 bil virions/day

  • 1-2 bil CD4 cells die and regenerate/day

  • RT is not accurate = mutations

    • every possible single mutation occurs

      • mutation rate and not taking meds properly = drug resistance

lymph nodes

reservoirs for HIV and site for replication

HIV history

• HIV infxn in humans originally seen in chimpanzees in central africa

  • jumped species, late 1800s = Simian immunodeficiency virus

  • speculation that crossed to humans when hunted for meat and contact with infected blood

• slow spread across Africa, earliest in 1959 in Belgian Congo (Kinshasa)

• initial US cases mid-late 1970s, 1980s US/Caribbean/Europe

• 1981 = 1st report, homosexual men

• 1983 = identified HIV

• 1984 = ID HIV-1 (primary cause)

• 1985 screen HIV-1

• 1986 ID HIV-2, 1992 screen HIV-2 (6 year gap b/c less prevalent and in Africa)

• 1990s Africa/Asia rise, Russia became a worldwide pandemic

• 1992 AIDS = #1 CAUSE OF DEATH FOR US MEN AGE 25-44

• 2014 = PrEP (pre-exposure prophylaxis) released for prevention

HIV prevalence and incidence

cases continue to rise although incidence is stable because people living longer, new cases with less deaths

Transmission

• sexual contact

• blood

• perinatal or mother-to-child

sexual contact

• anal sex, vaginal sex

  • oral sex (rare =.1%/contact)

• vaginal and cervical secretions, semen, menses, deep/open mouth kissing - minimal risk

• most risky = receptive anal sex

  • due to thin rectum epithelium lining, opening of urethra for insertive - increased risk of ripping, increased opening to blood

blood

transfusion, blood factors (1978-1985), IVDA (needles, syringes, drug injection equipment)

• healthcare stick = .4% risk

perinatal or mother-to-child

delivery, breastfeeding - recommend testing if pregnant

• C-section decreases passage by 50% (15-25% risk)

  • HIV + mom = HIV meds during pregnancy and childbirth, HIV meds to baby 4-6 weeks after birth = transmission <1%

not as risky transmission

don’t survive well outside body, not on toilet seats, mosquitos, NOT saliva/tears/sweat/casual contact

• rare = female to female

• interacting factors, infectiousness of HIV person, susceptibility of uninfected, efficiency of transmission mode, strain infectivity, influenced by STD’s

HIV transmitted by…

sexual contact, sharing needles to inject drugs, during pregnancy/birth/breastfeeding

HIV not transmitted by…

air, water, insects/pets, saliva, sweat, tears, closed-mouth kissing, sharing toilets/food/drinks

stage 1 of HIV

acute HIV infection = 1-2 weeks post exposure, flu-like symptoms (sick), large amount of HIV in blood and very contagious

stage 2 of HIV

chronic HIV infection = asymptomatic HIV or clinical latency, HIV still active and reproduces in body, may/may not have symptoms or get sick - can still transmit HIV (less contagious), prolonged timeframe = 10-12 years

stage 3 HIV

symptomatic stage, clinically apparent, early and late phase

early stage 3

night sweats, candida albicans, fever, herpes infection, swollen LN

late stage 3

severe weight loss, shingles, pancreatitis, gastric ulcers, chronic diarrhea

stage 4

AIDS, <200 helper T cells/mm, high viral load, easy transmission to others

• opportunistic infections (Kaposi’s sarcoma, pneumocystis pneumonia, CMV, severe dementia), T cell count <59, leads to death by cancer or infection

HIV testing

• CDC recommends 13-64 year olds tested at least 1x

• higher risk = tested more often

• pregnant = tested and HIV meds if +

• risky behavior = tested yearly, gay/bisexual = 3-6 months

• testing is quick, free, painless

• fear exposure within 72 hours = post-exposure prophylaxis (ER), take for 28 days

types of HIV tests

window period (exposure to detection), soonest in NAT

• antibody tests- check HIV Ab in blood, oral fluid (RAPID)

• antigen/antibody tests - detect HIV Ab and Ag in blood

• nucleic acid test (NAT) - actual HIV in blood, check viral load (10-33 days)

prevention

• abstinence/safe sex - both=HIV test prior to activity, condom with lube

• don’t share needle, drug paraphernalia

• don’t breastfeed, don’t natural delivery

• PrEP (pre-exposure prophylaxis) - oral medication daily if high risk behavior to prevent infection

  • reduces risk to acquire HIV from sex 99%

  • reduces HIV risk from injected brugs by 74%

  • max protection for anal receptive at 7 days daily use

    • receptive vaginal and IV drug use at 21 days daily use

treatment

no cure

• antiretroviral drugs (ART)

  • recommended for all people with HIV, regardless of CD4 cell count

  • start ASAP after diagnosis

  • reduces amount of HIV in body

  • treat with pill (start of treatment)

  • when undetectable viral load for 3 months → shots (long acting) 1/month

  • undetectable = untransmissible via sex and perinatal transmission, reduces IVDA and breastfeeding

    • still no breastfeeding/vaginal delivery

• drug cocktail - combination treatment ; postpones drug resistance

1980s culture

AIDS epidemic

• foster widespread fear

• social stigma → medical panic due to fear of casual contact = patient neglect

• discrimination LGBTQ+ “gay plague” → homophobia (god’s punishment)

• affected the masses = fund research

  • simultaneous massive, creative political mobilization

  • transformation public health, altered sexual behavior, lasting effect in arts and activism

19802-1990s culture

Aids activists/celebrities with HIV/AIDS

Elizabeth Taylor

cofounder amFAR, american foundation for Aids research

• 1st major celebrity = michael jackson

Princess Diana

crucial role to remove stigma with shaking hands with AIDS patient - 1987

rock hudson

1st famous celebrity to disclose disease

elton john

AIDS foundation 1992, >6bil $

The Kiss

1985 - Dynasty

• actor with AIDS at end or career

Freddy Mercury

attention to disease, ill on stage, 1991

magic johnson

heterosexual, HIV not AIDS, undetectable, announced then retired 1991, 1992 all star game = big deal b/c other people played with him

arthur ashe

professional tennis player, blood transfusion with heart surgery, 1983-ADIS 1992, died 1993 of AIDS -related pneumonia

1990s soaps:

general hospital - AIDS storyline = Stone Cates and Robin Scorpio in 1995, HIV/AIDS, huge story in TV, hetoerosexual couple, unprotected sex with prior partner, he died of AIDS, wife got AIDS

• attention for protected sex and mother to child transmission

healthcare practitioner patient

fear of needlestick, prophylactic PPE, blood transfusion risk