Human immunodeficiency virus (HIV) has led to a worldwide pandemic that has exacted a dramatic toll on children, especially in resource-limited countries. It is estimated that there are approximately 2.1 million children younger than 14 years living with HIV, with the vast majority in sub-Saharan Africa. Worldwide, approximately 700,000 children were infected perinatally with HIV in 2005, and 570,000 children died due to HIV/AIDS (acquired immunodeficiency syndrome) in 2005 (see www.cdc.gov and www.unaids.org). As of 2003, there were more than 9000 children younger than 13 years living with AIDS in the United States. The vast majority of these children were infected by perinatal transmission. In resource-rich countries, the perinatal infection rate has dropped to less than 2%, and combination antiretroviral therapy (known as highly active antiretroviral therapy, or HAART) has diminished mortality and morbidity associated with HIV disease.1 The pediatric hospitalist must be familiar with the care of HIV-exposed newborns and HIV-infected children, because the initial diagnosis and management of complications often occur in the hospital setting.
McCune has worked for many years with Steven Deeks and the SCOPE Study. When I spoke with McCune in San Francisco, he said, “There is a yin and yang of the immune system. We are trying to recapitulate the orchestrated balance found in the fetus.” McCune is now working on interventions that would prevent inflammation against H.I.V. in the adult, hoping to partly mimic the balance found in utero. He’s also developing methods that would allow the immune system to better recognize, and destroy, the virus when it manifests itself. These studies are being carried out on nonhuman primates, and may lead to human trials within a year or two.
^ Jump up to: a b Jolly C, Kashefi K, Hollinshead M, Sattentau QJ (2004). “HIV-1 cell to cell transfer across an Env-induced, actin-dependent synapse”. Journal of Experimental Medicine. 199 (2): 283–293. doi:10.1084/jem.20030648. PMC 2211771 . PMID 14734528.
When a patient is infected with HIV, the virus slowly begins to destroy that patient’s immune system. How fast this occurs is different in each individual. Treatment with HAART can help slow and even halt the destruction of the immune system.
Malaria occurs in over 100 countries and territories. More than 40% of the people in the world are at risk. Large areas of Central and South America, Hispaniola (Haiti and the Dominican Republic), Africa, the Indian subcontinent, Southeast Asia, the Middle East, and Oceania are considered malaria-risk areas. The World Health Organization estimates that yearly 300-500 million cases of malaria occur and more than 1 million people die of malaria. About 1,200 cases of malaria are diagnosed in the United States each year. Most cases in the United States are in immigrants and travelers returning from malaria-risk areas, from sub-Saharan Africa and the Indian subcontinent.
HIV contains 3 species-defining retroviral genes: gag, pol, and env. The gag gene encodes group-specific antigen; the inner structural proteins. The pol gene encodes polymerase; it also contains integrase and protease (the viral enzymes) and is produced as a C-terminal extension of the Gag protein). The env gene encodes the viral envelope—the outer structural proteins responsible for cell-type specificity. Glycoprotein 120, the viral-envelope protein, binds to the host CD4+ molecule.
The success of ART is assessed by measuring plasma HIV RNA levels every 8 to 12 wk for the first 4 to 6 mo or until HIV levels are undetectable and every 3 to 6 mo thereafter. Increasing HIV levels are the earliest evidence of treatment failure and may precede a decreasing CD4 count by months. Maintaining patients on failing drug regimens selects for HIV mutants that are more drug-resistant. However, compared with wild-type HIV, these mutants appear less able to reduce the CD4 count, and failing drug regimens are often continued when no fully suppressive regimen can be found.
^ Jump up to: a b Boily MC, Baggaley RF, Wang L, Masse B, White RG, Hayes RJ, Alary M (February 2009). “Heterosexual risk of HIV-1 infection per sexual act: systematic review and meta-analysis of observational studies”. The Lancet Infectious Diseases. 9 (2): 118–29. doi:10.1016/S1473-3099(09)70021-0. PMID 19179227.
Jump up ^ Nora T, Charpentier C, Tenaillon O, Hoede C, Clavel F, Hance AJ (2007). “Contribution of recombination to the evolution of human immunodeficiency viruses expressing resistance to antiretroviral treatment”. Journal of Virology. 81 (14): 7620–8. doi:10.1128/JVI.00083-07. PMC 1933369 . PMID 17494080.
If you’re at a high risk of HIV, talk to your doctor about pre-exposure prophylaxis (PrEP). PrEP is a combination of two drugs available in pill form. If you take it consistently, you can lower your risk of contracting HIV.
Primary infection with HIV is probably asymptomatic in 50% of cases but often causes an influenza-like illness with an abundance of virus in the peripheral blood and a marked drop in the numbers of circulating CD4 T cells. This acute viremia is associated in virtually all patients with the activation of CD8 T cells, which kill HIV-infected cells, and subsequently with antibody production, or seroconversion. The cytotoxic T-cell response is thought to be important in controlling virus levels, which peak and then decline, as the CD4 T-cell counts rebound to around 800 cells μl-1 (the normal value is 1200 cells μl-1). At present, the best indicator of future disease is the level of virus that persists in the blood plasma once the symptoms of acute viremia have passed.
Clinics that do HIV tests keep your test results secret. Some clinics even perform HIV tests without ever taking your name (anonymous testing). You must go back to the clinic to get your results. A positive test means that you have HIV. A negative test means that no signs of HIV were found in your blood.
The HIV virion enters macrophages and CD4+ T cells by the adsorption of glycoproteins on its surface to receptors on the target cell followed by fusion of the viral envelope with the target cell membrane and the release of the HIV capsid into the cell.
After the first symptoms disappear, most people, even without treatment, have no symptoms or only occasionally have a few mild symptoms. This interval of few or no symptoms may last from 2 to 15 years. The symptoms that most commonly occur during this interval include the following:
Behçet’s syndrome chronic vasculitic disease of unknown cause; characterized by seronegative arthritis of knees and ankles, elbows and wrists, mouth ulcers, erythema nodosum, visual impairment and cerebrovascular accident
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