HIV/AIDS

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Dr. Sachin Shelke
Internal Medicine

verified

HIV (human immunodeficiency virus) is a viral infection transmitted through the sexual route.  Intravenous needle sharing, infected blood transfusions and transmission from mother to child during birth and breastfeeding can also cause HIV infection. The symptoms become manifest two to four weeks after HIV infection.  Symptoms can also be delayed for as long as ten months. HIV causes acquired immunodeficiency syndrome (AIDS) and can cause complications.  Treatment of HIV / AIDS comprises antiretroviral drugs and lifestyle management. The patient may suffer from opportunistic infections, which are usually fatal. Hence control of infection in an HIV positive patient is a crucial part.

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Types

HIV is classified into two different types:


  • HIV-1: HIV-1 is commonly found all around the world

  • HIV-2: HIV-2 is prevalent in Western Africa. It is uncommon elsewhere.

Stages

The stages and progression of HIV infection is as following:

Asymptomatic phase: HIV infection initial stages without any significant symptoms. However, changes in the immune system are noted. This phase can last up to 3 months. Primary infection to develop into HIV disease and immunosuppression takes many years.

Primary infection: The patient replicates the HIV in his bloodstream and lymph nodes in this phase of the disease.

Symptomatic stage: this is known as the late phase of HIV disease, also known as acquired immunodeficiency syndrome. The patient is at risk of developing opportunistic infections such as tuberculosis, candidiasis during this phase of infection.

Symptoms

Patients may remain asymptomatic initially after infection. Symptoms progress over two to three weeks after infection, the delay in symptoms for ten months has also been noted in many patients. Non-specific symptoms of HIV may occur during the Acute retroviral phase of the illness. Symptoms pointed out during this phase are as following-


  • Headache

  • Diarrhoea

  • Swollen lymph nodes

  • Fatigue

  • Skin rash

  • Night sweats

  • Sore throat

  • Joint pain

  • Muscle pain


The symptoms during chronic HIV infection symptoms of the following disease can be observed:

Chronic HIV infection without AIDS

  • Vaginal candidiasis

  • Herpes zoster

  • Thrush

  • Cervical dysplasia

  • Bacillary angiomatosis

  • Cervical carcinoma in situ


Chronic HIV infection with AIDS

  • Candidiasis

  • Recurrent Pneumonia

  • Chronic ulcers

  • Herpes simplex

  • HIV related encephalopathy etc.

Risk Factors

Following are the routes of acquiring HIV/AIDS infection:


  • Sexual transmission is a primary route of getting HIV infection

  • Blood transfusions from infected individuals

  • Needle sharing with an infected individual.

  • Transmission from an infected mother to child.

Prevention

The following measures can prevent the spread of HIV infection:


  • Sharing needle should be avoided. Discard it after using it once.

  • Use a clean condom; discard the used condom.

  • A pregnant female with HIV infection should be treated.

  • It is essential to inform the sexual partner if the individual is HIV positive.

Diagnosis

Screening test and confirmatory test are the mainstays for the diagnosis of HIV infection. A complete blood count is performed to assess thrombocytopenia, leukopenia or anaemia. CD4 cell count and viral load are also essential in the diagnosis of HIV infection. Differential diagnosis also plays a significant role in testing for HIV infection. For example, considering cardiovascular disorders, order cardiac biomarkers.

In the case of acquired immunodeficiency syndrome, pneumonia is a significant complication. Planning of chest X-Ray may be valuable to detect pulmonary infiltrates. Arterial blood gases provide essential information about an HIV infected person. Tuberculosis testing should be done. Sputum cultures are necessary for detecting bacterial infections. Other diagnostic tests such as CT scan may be crucial if disseminated TB is a possible diagnosis, especially in patients with acquired immunodeficiency syndrome. Individual with AIDS and decreased cd4 cell counts are at risk for pancreatitis and cholecystitis. Industries diagnostic tests such as bilirubin, transaminase and light base are functional.

Esophagogastroduodenoscopy is essential in patients with dysphagia. Diarrhoea is a common symptom in patients with AIDS. In these patients testing for bacteria, parasite, and ova should be performed. In severe refractory cases, colonoscopy is essential. Neurological complaints of HIV and AIDS should be detected using CT scan, CSF analysis, and lumbar puncture.

Treatment

Antiretroviral drugs: Antiretroviral drugs are the mainstay of treatment in HIV infected patients. Nucleoside/ nucleoid reverse transcriptase inhibitors in many combinations available. Along with this, CCR5 inhibitors and protease inhibitors are also used in the treatment of HIV infected patience.

Highly active antiretroviral therapy (HAART) is a vital part of HIV treatment.


  1. Single tablet regimens of tenofovir disoproxil 245mg, Rilpivirine 25mg and Emtricitabine 200mg are used in a frequency of once daily. Associated side effects can be insomnia, flatulence, diarrhoea, nausea, vomiting, rash, weakness, fatigue, etc.

  2. Elvitegravir 150mg/emtricitabine 200mg/cobicistat 150mg/tenofovir 245mg is given as once a day single tablet. Side effects such as fatigue, dizziness, flatulence, rash, sleepiness, and diarrhoea are associated with this drug.

  3. Dolutegravir 50mg/abacavir 600mg/lamivudine 300mg is used as a single tablet daily. Side effects such as itching, depression, muscle pain running nose, indigestion, nausea, vomiting, fatigue loss of appetite can occur.


Nucleoside/ nucleotides reverse transcriptase inhibitors (NRTIs)

  1. Abacavir in the dose of 300 MG tablet is given two times a day. Associated side effects can be abdominal pain, headache, tiredness, fever, nausea and vomiting.

  2. Emtricitabine in the doze off of 200 mg capsule should be given once daily. Associated side effects can be diarrhoea, nausea, high creatinine kinase levels, headache, and dark skin.

  3. Lamivudine tablet with a dose of 150 and 300 mg two times a day should be prescribed. Hair loss, nausea, vomiting, diarrhoea and joint pain are some Ill effects that can occur.

  4. Zidovudine which comes in 100 and 250 mg capsules, should be given two times a day. Muscle pain, headache, nausea and vomiting, loss of appetite, fever, and fatigue are possible effects of the drug.

  5. Tenofovir disoproxil 245 mg should be given once a day. Side effect such as rash, weakness, dizziness, headache for fatigue and stomach pain are associated with this drug.


Fixed-dose combinations of NRTI

  1. Abacavir 600mg/Lamivudine 300mg once a day should be taken.

  2. Abacavir 300mg/ Lamivudine 150mg/Zidovudine 300mg is another Fixed-dose combination used.

  3. Emtricitabine 200mg/tenofovir disoproxil 245mg is available.

  4. Lamivudine 150mg/Zidovudine 300mg once daily is another fixed-dose combination available to treat HIV.


Integrase inhibitors

Dolutegravir 50mg once or twice a day, Raltegravir 400mg tablet twice a day should be taken.

  • Non-nucleoside reverse transcriptase inhibitors (NNRTIs):


Ultrafine 100/200mg tablets and Rilpivirine 25mg tablets are taken.

  • CCR5 Inhibitors:


Maraviroc 150mg and 300mg tablets twice a day.

Protease Inhibitors

  1. Atazanavir 150,200 and 300mg capsules once a day.

  2. Darunavir 600 and 800 mg tablets once a day.

  3. Lopinavir 20mg /ritonavir 50mg tablet twice a day.

  4. Atazanavir 300mg/cobicistat 150mg taken once a day.

Lifestyle Management


  1. Inform your sexual partners about your HIV status.

  2. You must use clean needles for injecting drugs; dispose of them after use.

  3. Circumcision reduces the risk of HIV infection.

  4. Use of condoms containing a water-based lubricant that is more protective.

  5. Pregnant women can take the treatment.

Prognosis And Complications

Prognosis

The progress of a patient suffering HIV with CD4 count greater than 500 lives a normal life compared to a person with a low CD4 level. Patients with AIDS who have untreated opportunistic infections have a low life expectancy.

Complications

A major complication to HIV is its progression to AIDS. It can be recognised when there is a low CD4 count with signs of opportunistic infections.

AIDS usually occurs when the lymphocyte count is below a specific level, and one of the following infections is present:


  1. Tuberculosis

  2. Cytomegalovirus

  3. Candidiasis

  4. Lymphoma

References


  1. Stat Pearls. Acquired Immunodeficiency Syndrome. [Internet] [Updated on Sept 8, 2020] Available at https://www.ncbi.nlm.nih.gov/books/NBK537293/.

  2. Stat Pearls. HIV disease current practice. [Internet] [Updated on Dec 30, 2020] Available at https://www.ncbi.nlm.nih.gov/books/NBK534860/.

  3. Infectious disease reports. Pathogenesis of HIV Infection. [Internet] Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3892619/.



  1. HHS Public Access. Barriers and facilitators to engagement in lifestyle interventions among individuals with HIV.[Internet] Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4130780/.

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