Jump up ^ Cohen, Myron S; Chen, Ying Q; McCauley, Marybeth; Gamble, Theresa; Hosseinipour, Mina C; Kumarasamy, Nagalingeswaran; Hakim, James G; Kumwenda, Johnstone; Grinsztejn, Beatriz; Pilotto, Jose H.S; Godbole, Sheela V; Mehendale, Sanjay; Chariyalertsak, Suwat; Santos, Breno R; Mayer, Kenneth H; Hoffman, Irving F; Eshleman, Susan H; Piwowar-Manning, Estelle; Wang, Lei; Makhema, Joseph; Mills, Lisa A; De Bruyn, Guy; Sanne, Ian; Eron, Joseph; Gallant, Joel; Havlir, Diane; Swindells, Susan; Ribaudo, Heather; Elharrar, Vanessa; et al. (2011). “Prevention of HIV-1 Infection with Early Antiretroviral Therapy”. New England Journal of Medicine. 365 (6): 493–505. doi:10.1056/NEJMoa1105243. PMC 3200068 . PMID 21767103.
Once in the body, HIV attaches to several types of white blood cells. The most important are certain helper T lymphocytes (T cells). Helper T lymphocytes activate and coordinate other cells of the immune system. On their surface, these lymphocytes have a receptor called CD4, which enables HIV to attach to them. Thus, these helper lymphocytes are designated as CD4+.
Suggested citation for this article: Dailey AF, Hoots BE, Hall HI, et al. Vital Signs: Human Immunodeficiency Virus Testing and Diagnosis Delays — United States. MMWR Morb Mortal Wkly Rep 2017;66:1300–1306. DOI: http://dx.doi.org/10.15585/mmwr.mm6647e1.
Many patients living with HIV infection are taking complex regimens involving multiple pills to control the HIV RNA level (viral load), but often, no conventional HIV RNA resistance tests were done when viral treatment failed. With the availability of new co-formulated HIV drugs, many patients could benefit from simplification of their ART regimen, guided by HIV DNA archive genotype testing (GenoSure Archive). The HIV DNA genotype archive provides HIV-1 antiretroviral drug resistance data when conventional HIV RNA resistance testing cannot be done because patients have a low plasma HIV RNA level (< 500 copies/mL). The HIV DNA archive genotype test analyzes integrated and unintegrated archived HIV-1 proviral DNA embedded in host cells. The test amplifies cell-associated HIV-1 DNA from infected cells in whole blood samples, then uses next-generation sequencing technology to analyze the HIV-1 polymerase region. The positive predictive value of the HIV DNA archive resistance test results may enable clinicians to identify HIV-resistance mutations that were previously unidentified and to select a potentially simpler regimen with co-formulated drugs (≥ 2 drugs in a single pill). At the household level, AIDS causes both loss of income and increased spending on healthcare. A study in Côte d'Ivoire showed that households having a person with HIV/AIDS spent twice as much on medical expenses as other households. This additional expenditure also leaves less income to spend on education and other personal or family investment. The main cellular target of HIV is a special class of white blood cells critical to the immune system known as helper T lymphocytes, or helper T cells. Helper T cells are also called CD4+ T cells, because they have on their surfaces a protein called CD4. Helper T cells play a central role in normal immune responses by producing factors that activate virtually all the other immune system cells. Those include B lymphocytes, which produce antibodies needed to fight infection; cytotoxic T lymphocytes, which kill cells infected with a virus; and macrophages and other effector cells, which attack invading pathogens. AIDS results from the loss of most of the helper T cells in the body. The election of Barack Obama brought renewed attention to the domestic epidemic and loosened the conservative grip on the federal government’s prevention and research agenda. At the first post-Bush national H.I.V.-prevention conference in 2009, Christopher Bates, then the director of H.I.V./AIDS policy for Health and Human Services and interim executive director of the Presidential Advisory Council on H.I.V./AIDS, kicked off the event in Atlanta by jumping onstage with duct tape on his mouth, ripping it off and shouting, “Finally, I can speak!” On World AIDS Day in 2011, Obama directly addressed the H.I.V. crisis among gay black men in a speech at George Washington University: “When new infections among young black gay men increase by nearly 50 percent in three years, we need to do more to show them that their lives matter.” Newborn babies of HIV-positive mothers may also receive medication. Studies have found that giving a mother antiretroviral medications during pregnancy, labor, and delivery can reduce the chance of transmission of HIV to the baby to less than 2 percent. Correct and consistent use of male and female condoms during vaginal or anal penetration can protect against the spread of sexually transmitted infections, including HIV. Evidence shows that male latex condoms have an 85% or greater protective effect against HIV and other sexually transmitted infections (STIs). Transition to these new ARV options has already started in more than 20 countries and is expected to improve the durability of the treatment and the quality of care of people living with HIV. Despite improvements, limited options remain for infants and young children. For this reason, WHO and partners are coordinating efforts to enable a faster and more effective development and introduction of age-appropriate pediatric formulations of antiretrovirals. In August, Janet and Robert Siliciano wrote about the Brigham men and the Mississippi baby in Science, saying that the cases confirmed that researchers were on the right path in attacking latent infection. The Berlin patient was an even more compelling example. Karl Salzwedel, the chief of Pathogenesis and Basic Research in the Division of aids at the National Institute of Allergy and Infectious Diseases, told me that until Timothy Brown “it wasn’t really clear how we would go about getting rid of the last bits of virus that remain in the reservoir.” Brown’s case provided “a proof of concept: it may be possible to eradicate latent H.I.V. from the body. It may be from a very risky and toxic method, but it’s proof of concept nonetheless.” Jump up ^ Wilson, David P; Law, Matthew G; Grulich, Andrew E; Cooper, David A; Kaldor, John M (2008). "Relation between HIV viral load and infectiousness: A model-based analysis". The Lancet. 372 (9635): 314–20. doi:10.1016/S0140-6736(08)61115-0. PMID 18657710. ^ Jump up to: a b Sodora DL, Allan JS, Apetrei C, Brenchley JM, Douek DC, Else JG, Estes JD, Hahn BH, Hirsch VM, Kaur A, Kirchhoff F, Muller-Trutwin M, Pandrea I, Schmitz JE, Silvestri G (2009). "Toward an AIDS vaccine: lessons from natural simian immunodeficiency virus infections of African nonhuman primate hosts". Nature Medicine. 15 (8): 861–865. doi:10.1038/nm.2013. PMC 2782707 . PMID 19661993. ^ Jump up to: a b Sharp, PM; Hahn, BH (September 2011). "Origins of HIV and the AIDS Pandemic". Cold Spring Harbor perspectives in medicine. 1 (1): a006841. doi:10.1101/cshperspect.a006841. PMC 3234451 . PMID 22229120. The basis of management is described in the separate article Human Immunideficiency Virus (HIV). There may be defining conditions such as Pneumocystis jirovecii pneumonia that will need treatment. Highly active antiretroviral therapy (HAART) has improved the prognosis enormously in terms of duration of survival but premature death is to be expected. There has been a great deal of attention given to the more recently identified problem of "lipodystrophy." Individuals suffering from this syndrome can be categorized as having lipohypertrophy (fat accumulation) syndromes, such as the "buffalo hump" on the back of the neck, breast enlargement, or increased abdominal girth. Others primarily suffer from lipoatrophy with fat loss under the skin with complaints of prominent veins on the arms and legs, sunken cheeks, and decreased gluteal (buttock) size. These syndromes appear to be related to multiple factors, including, but not limited to, drug therapy. The NRTIs appear to be most closely linked to lipoatrophy, in particular D4T and to a lesser extent ZDV. In fact, some studies have suggested slow accumulation of fat in those who modify the NRTI component of their regimen. Some NRTIs also have been linked to elevation in lipid (fat) levels in the blood. While switching therapy is always a consideration in those experiencing potential drug-related toxicity, this should only be done under the careful supervision of an experienced HIV provider. Viruses. AIDS patients are highly vulnerable to cytomegalovirus (CMV), herpes simplex virus (HSV), varicella zoster virus (VZV), and Epstein-Barr virus (EBV) infections. Another virus, JC virus, causes progressive destruction of brain tissue in the brain stem, cerebrum, and cerebellum (multifocal leukoencephalopathy or PML), which is regarded as an AIDS-defining illness by the CDC. CDC recommends routine testing for HIV infection for persons aged 13–64 years in health care settings and testing at least annually for persons at high risk for HIV infection (7). Yet, according to National HIV Behavioral Surveillance (NHBS), one third of gay, bisexual, and other men who have sex with men (MSM) have not been tested in the past year, with even lower percentages of recent testing reported among other population segments at high risk for HIV infection. Cellular: Cell-mediated immunity is a more important means of controlling the high levels of viremia (usually over 106 copies/mL) at first. But rapid mutation of viral antigens that are targeted by lymphocyte-mediated cytotoxicity subvert control of HIV in all but a small percentage of patients. At the present time, there is no cure for AIDS. It has proven to be a universally fatal illness. However, most patients survive many years following diagnosis. HAART has dramatically increased the time from diagnosis to death, and research continues in drug treatments and vaccine development. HIV infection can cause AIDS to develop. However, it is possible to contract HIV without developing AIDS. Without treatment, HIV can progress and, eventually, it will develop into AIDS in the vast majority of cases. (Acquired Immune Deficiency Syndrome) An immunological disorder in which the body’s immune response system becomes defective, leaving the sufferer open to opportunistic infections and some forms of cancer, such as Kaposi’s sarcoma. It is caused by infection with the HIV virus, transmitted mainly through sexual intercourse or infected blood products. Rockstroh JK, DeJesus E, JL, et al. Durable efficacy and safety of raltegravir versus efavirenz when combined with tenofovir/emtricitabine in treatment-naive HIV-1-infected patients: final 5-year results from STARTMRK. J Acquir Immune Defic Syndr. 2013 May 1. 63(1):77-85. [Medline]. In the absence of direct epidemiological evidence, molecular evolutionary studies of primate lentiviruses provide the most definitive information about the origins of human immunodeficiency virus (HIV)–1 and HIV–2. Related lentiviruses have been found infecting numerous species of primates in sub–Saharan Africa. The only species naturally infected with viruses closely related to HIV–2 is the sooty mangabey (Cercocebus atys) from western Africa, the region where HIV–2 is known to be endemic. Similarly, the only viruses very closely related to HIV–1 have been isolated from chimpanzees (Pan troglodytes), and in particular those from western equatorial Africa, again coinciding with the region that appears to be the hearth of the HIV–1 pandemic. HIV–1 and HIV–2 have each arisen several times: in the case of HIV–1, the three groups (M, N and O) are the result of independent cross–species transmission events. Consistent with the phylogenetic position of a ‘fossil’ virus from 1959, molecular clock analyses using realistic models of HIV–1 sequence evolution place the last common ancestor of the M group prior to 1940, and several lines of evidence indicate that the jump from chimpanzees to humans occurred before then. Both the inferred geographical origin of HIV–1 and the timing of the cross–species transmission are inconsistent with the suggestion that oral polio vaccines, putatively contaminated with viruses from chimpanzees in eastern equatorial Africa in the late 1950s, could be responsible for the origin of acquired immune deficiency syndrome. AIDS is the most severe form of HIV infection. HIV infection is considered to be AIDS when at least one serious complicating illness develops or the number (count) of CD4+ lymphocytes decreases substantially. Acronym for acquired immune deficiency (or immunodeficiency) syndrome; disorder of the immune system characterized by opportunistic diseases, including candidiasis, Pneumocystis jiroveci and others. Caused by the human immunodeficiency virus, which is transmitted in body fluids (notably breast milk, blood, and semen) through sexual contact, sharing of contaminated needles (by injecting drug abusers), accidental needle sticks, and contact with contaminated blood. Most patients who are infected with HIV will eventually develop AIDS, after a period of apparent quiescence of the disease known as clinical latency or the asymptomatic period (Fig. 11.20). This period is not silent, however, for there is persistent replication of the virus, and a gradual decline in the function and numbers of CD4 T cells until eventually patients have few CD4 T cells left. At this point, which can occur anywhere between 2 and 15 years or more after the primary infection, the period of clinical latency ends and opportunistic infections begin to appear. Personal risks to the individual whose confidence is breached, such as serious implications for the patient's relationship with family and friends, the threat of discrimination in employment and housing, intimate partner violence, and the impact on family members Counseling for pregnant women:Mother-to-child transmission has been virtually eliminated by HIV testing, treatment with ART, and, in developed countries, use of breast milk substitutes. If pregnant women test positive for HIV, risk of mother-to-child transmission should be explained. Pregnant women who do not accept immediate treatment for their HIV infection should be encouraged to accept therapy to protect the unborn baby, typically beginning at about 14 wk gestation. Combination therapy is typically used because it is more effective than monotherapy and less likely to result in drug resistance. Some drugs can be toxic to the fetus or woman and should be avoided. If women meet criteria for ART, they should begin a regimen tailored to their history and stage of pregnancy and continue it throughout pregnancy. Cesarean delivery can also reduce risk of transmission. Regardless of the antepartum regimen used or mode of delivery, all HIV-infected women should be given IV zidovudine during labor, and after birth, neonates should be given oral zidovudine, which is continued for 6 wk after delivery (see also Prevention of Perinatal Transmission). Some women choose to terminate their pregnancy because HIV can be transmitted in utero to the fetus or for other reasons. Jump up ^ Woods, S.; Moore, D.; Weber, E.; Grant, I. (2009). "Cognitive neuropsychology of HIV-associated neurocognitive disorders". Neuropsychology review. 19 (2): 152–168. doi:10.1007/s11065-009-9102-5. PMC 2690857 . PMID 19462243. [redirect url='http://penetratearticles.info/bump' sec='7']