AIDS and HIV

It was in 1980 that cases of a new disease were observed in Los Angeles, New York and San Francisco. Strikingly, it seemed to affect homosexual men exclusively. Of the 80 or so cases described, 26 died that same year.

It quickly became clear that the disease and its causes needed to be addressed to prevent further spread. It was also considered very serious, as the mortality rate was over 40%.

At some point, the disease was called AIDS, which is an abbreviation for "acquired immuno deficiency syndrome". Translated into German, it means something like the syndrome of acquired immune deficiency. Over time, it was possible to prove that AIDS was caused by the HI virus.

Prejudices that need to be refuted

Contrary to the prejudices, by far not only male homosexuals with frequently changing partners and drug addicts are affected by the disease. On the contrary, patients carrying the HI virus can be found in all social classes. In the German-speaking world, however, we are currently in the fortunate position that the number of new infections is relatively low. The situation is quite different in Africa or India, for example.

Figures on HIV and Aids

In recent years, HIV and Aids have become less important in our country. The number of new infections has stabilised and the number of people affected is relatively low, in contrast to other countries. Nevertheless, the disease should not be underestimated. Because even if the therapy works well today, it is a disease that ends in death in any case. In addition, the HIV infection also brings with it a massive restriction of the quality of life, even if AIDS has not yet broken out.

On a global scale, the figures surrounding AIDS and HIV are devastating. The United Nations AIDS Control Programme UNAIDS published some statistical figures at the end of 2010 that more than clearly depict the situation around AIDS: For example, there are about 33.3 million people infected with HIV worldwide. In 2009, 1.8 million people died of AIDS.

Africa is one of the hot spots

One of the regions of the world particularly affected by AIDS is southern Africa. South of the Sahara there are about 22.5 million people who have to live with an HIV infection. This means that about 5% of all adults are infected with the virus.

The numbers among children are also devastating. Especially infants and small children are often affected, because with the poor living situations it can hardly be prevented that the virus is transmitted from the mother to the child.

The number of people who die of AIDS in this region every year is particularly alarming. In 2009, this figure was 1.9 million people.

AIDS in Western and Central Europe

The figures for Western and Central Europe are much more positive than for South Africa. Nevertheless, it is frightening how many people are affected by the disease. About 0.2% of all adults are infected with HIV. Expressed in figures, this amounts to 820,000 people.

The number of newly infected people is relatively stable and was 31,000 people newly infected with HIV in 2009. In the same year, 8,500 people died of AIDS - even though medical care here can be described as very good.

The situation in Germany

In Germany alone there are about 70,000 people infected with HIV. The majority of these are men. Shockingly, 200 children under the age of 15 are also infected with HIV.

In 2009, there were a total of about 550 people who died of AIDS. The number of new infections is quite constant and affected in 2010 in about 3,000 people. Of those infected, 760 people newly contracted AIDS, the final stage of HIV infection that inevitably leads to death, in the same year. Among them were also five children.

Once you have AIDS, it can no longer be cured. Attempts can be made to manage and alleviate the symptoms as best as possible, but sooner or later these will lead to death. In addition, the quality of life is drastically reduced from the onset of AIDS.

The AIDS disease is preceded by an infection with the HI virus. This infection progresses in several stages, of which AIDS can be considered the final stage.

The HI virus

The abbreviation HIV stands for the human immunodeficiency virus. Once it has entered the body, it damages and destroys the so-called CD4 cells. These are white blood cells that are absolutely necessary to trigger a defence reaction. The CD4 cells organise and coordinate the defence against pathogens that have entered the body.

The more CD4 cells have been destroyed, the less the body is able to defend itself against bacteria, viruses or fungi. Although there are still enough phagocytes and other defence cells, they can no longer fulfil their tasks because the defence reaction is no longer coordinated.

This leads to even harmless pathogens causing persistent infections. These are then called opportunistic infections, because they do not occur in people with a healthy immune system. In addition, the occurrence of certain carcinomas is also favoured, in which viruses and bacteria play a role.

The reproduction of the HI virus

The HI virus is actually not interested in compromising the immune system of the infected person. It is only interested in surviving itself. For this, it absolutely needs the CD4 cells. Once it has infected these, it enters the cell and multiplies there. After multiplication, the new viruses are smuggled out of the cell and the cell is destroyed.

The new viruses then infect the cells in the neighbourhood and continue to multiply there. In this way, more than ten billion new viruses can be formed and released in the body every day. To fight this, the body creates about two billion new CD4 cells every day. However, since the viruses outnumber the cells, the number of CD4 cells continuously decreases, a massive immune deficiency develops and invading pathogens can no longer be fought.

The transmission of the HI virus

Only if you know the ways of transmission, you can protect yourself from the HI-virus. Therefore, it makes sense to find out which contacts are potentially dangerous and which can be allowed without hesitation.

Sexual contact

The HI virus can be transmitted through vaginal as well as anal or oral sexual intercourse. The virus is contained in both semen and vaginal secretions and can enter the organism of the sexual partner through small injuries that occur almost every time sexual intercourse takes place. Existing venereal diseases make it easier for the virus to be transmitted, which is why particular caution must then be exercised.

In industrialised countries, sexual contact is by far the most common route of transmission. Both homosexual and heterosexual contact play a role. In heterosexual intercourse, it is mainly women who become infected, while the risk of infection for men is relatively low.

Infected blood

A few years ago, there were several reports that HIV had been transmitted via blood products and organ donations. This has certainly been the case time and time again because testing methods for the HI virus were not yet mature. Today, simple tests that are carried out as standard can prevent contamination of blood and organs.

The route via the blood plays a major role, especially in the case of drug addicts. Often, syringes and needles are used by several addicts at once. And even the small amount of blood found in a needle is enough to trigger an infection.

Particular care must be taken by medical personnel who repeatedly come into contact with blood. Not only needlestick injuries, but also touching open wounds or blood splashes are potential transmission routes. However, strict precautionary measures have drastically reduced transmission in everyday medical practice.

Vertical infection from mother to child

The risk of passing the HI virus on to one's own child is particularly high during birth. During childbirth, there are often small injuries which cause blood to pass from the mother into the child's organism. After birth, breast milk plays a particularly important role, in which the HI virus can be detected.

The risk for the child is drastically reduced if the mother is treated with antiretroviral drugs throughout the pregnancy. These are different drugs that aim to prevent the virus from replicating. Giving birth by caesarean section also reduces the risk of infection. Breastfeeding should logically be avoided after birth.

No transmission through everyday contacts

Transmission of the HI virus is not possible through normal everyday contacts. Thus, you can shake hands with infected people and have other close physical contact without hesitation. Transmission is also not possible through the saliva of an infected person due to the low viral load.

Insects are also not suitable as a transmission route, even if they ingest blood from an infected person and then sting another person. The amounts of blood transferred are simply not sufficient to introduce enough viruses into the organism.

The symptoms of HIV infection are not directly due to the virus. It does not cause any symptoms at all. However, it increasingly destroys the immune system, which means that it is no longer possible to defend against pathogens. Therefore, infections occur more frequently and spread unchecked in the body.

CDC staging

The Center of Disease Control has classified HIV infection into three clinical categories (categories A through C) and three CD4 cell count ranges. Combining categories A, B, and C with the three CD4 cell count ranges creates nine sub-ranges.

The exact classification based on the CDC scheme helps to determine the right time for therapy. This is because aggressive therapy does not always have to be started immediately to keep the infection at bay. It is often more sensible if the natural course of the HIV infection is closely monitored and observed for the time being.

CDC Category A

Category A includes both acute symptomatic HIV infection, which occurs shortly after infection, and the asymptomatic stage of HIV infection.

Acute symptomatic HIV infection occurs in approximately half of newly infected persons. Over a period of one week to six weeks after infection, individuals develop flu-like symptoms, including fever, headache, sore throat, swollen lymph nodes, and a discrete rash on the trunk of the body.

Asymptomatic HIV infection used to be called the latency phase. It is a phase without symptoms that can last a few months or many years, depending on the severity of the infection and the health of the infected person. Even if nothing is noticed, the virus continues to multiply during this time and destroys more and more CD4 cells, the decrease of which can be detected via tests.

CDC Category B

In Category B, the first symptoms that indicate HIV infection slowly appear. The infections caused by the weakened immune system are called opportunistic infections.

These symptoms include, but are not limited to, the following illnesses and symptoms:

• permanent increase in body temperature
• chronic diarrhea
• recurrent or therapy-resistant fungal infections
• tendency to carcinomas
• white, wipeable coatings on the side of the tongue
• extensive or recurrent infestation with zoster
• herpes infections
• Diseases of the nervous system (peripheral neuropathies)

CDC Category C

In this stage, the disease AIDS breaks out as the final stage of the HIV infection. For this to occur, the so-called AIDS-defining symptoms must be present, indicating that the immune system has been severely damaged.

These include:

• Fungal infections in the esophagus, trachea, bronchi and lungs.
• HIV-associated inflammation of the brain
• chronic herpes infection
• Kaposi's sarcoma
• formation of lymphomas
• tuberculosis
• repeated pneumonia
• repeated and severe salmonella infections
• toxoplasmosis of the brain
• wasting syndrome: unwanted severe weight loss with persistent diarrhea and fatigue
• invasive cervical carcinomas
• generalized infections with the cytomegalovirus

Before therapy can be started, a reliable and detailed diagnosis must be available. Only when the progress of the infection has been determined can the correct therapy be selected.

Medical history

As with any other disease, the medical history is a major component of the diagnosis. If HIV infection is suspected, you will be asked questions mainly about the following topics:

• Travel history: has there been any travel to the US, Asia or Africa?
• Pre-existing conditions: Are there any current infections? Which infectious diseases have you already had? Are there any other underlying diseases?
• Sexual history: What contacts have there been with how many and which partners? Have there already been sexually transmitted diseases?
• Risk history: Have drugs been used or has there been contact with foreign blood?

Clinical examination

In the clinical examination, it is examined whether there are any indications of an HIV infection. In addition, the physical status including a basic neurological examination must be done to determine the state of health. This has an impact on therapy and prognosis.

Laboratory tests

HIV infection can be detected by various laboratory methods. The simplest and cheapest method is a so-called ELISA test (enzyme-linked immunosorbent assay). If the ELISA test is positive, another HIV antibody test is done to confirm the diagnosis. If this test is also positive, a third test, the so-called Western blot test, is carried out. Only if all three tests are positive, the diagnosis "HIV positive" is made. This should prevent a false positive result from being passed on.

Legal aspects of the HIV test

In contrast to the other laboratory tests, the HIV test is only permitted if you have given your own consent. The result of the test is then of course subject to medical confidentiality, which may only be broken if there is a justifiable emergency. In addition, once you have been diagnosed as HIV positive, no therapy can be forced upon you.

The result of the HIV test

If the HIV test is positive, this means that HI viruses are present in the blood. However, this does not mean that one suffers from AIDS. However, a transmission to another person is possible at any time, because the viruses spread in the whole organism. A prognosis about the course of the disease is not possible with a positive test result. For this purpose, the viral load and the CD4 cell count must first be determined.

If the HIV test is negative, an HIV infection may still be present. The viruses need at least three to twelve weeks to multiply to such an extent that they can be detected by the tests. A negative result therefore only means that you did not have HIV in your blood at least three months ago.

If the HIV test is positive

A positive test result is probably shocking to everyone, even if you have considered the possibility. It's easy to say, but hard to do, but you should try not to let the diagnosis beat you to death. Take your time, and ask the doctor any questions you can think of. It is often easier to do this if you make another appointment in a few days to clarify any unanswered questions and discuss how to proceed.

In addition to the care provided by the doctor, there are also a number of counselling centres and other institutions that can provide further help if you are diagnosed HIV-positive. Help is also available on the Internet in the form of information sites and exchange platforms.

Your own social network should also be used in a supportive way, if possible. Talking to your partner may be difficult, but it is definitely advisable. Especially since the partner should also be tested in order to exclude infection or to enable early therapy.

In recent years, rapid progress has been made in research into HIV infection, which has led to many new drugs currently being launched on the market. These are not only more effective, but above all have fewer side effects. However, there is still no drug that can cure AIDS. However, antiretroviral therapy can prolong life enormously and, above all, improve the quality of life.

Which drug should be used for therapy must be determined individually for each case. Not only does the mode of action play a role, but above all how the medication is to be taken and what side effects can occur.

Between effective action and severe side effects

All drugs used for antiretroviral therapy are highly potent drugs, but they not only have a strong effect but also produce strong side effects. When choosing the right drug, one must therefore always try to find the right balance between effect and side effect.

The progress of the disease also plays a major role. If the infection is progressing rapidly or if symptoms are already occurring, a more aggressive treatment is indicated because the side effects are still tolerable compared to the symptoms of the infection.

No matter which drug cocktail is chosen together with an expert, within a few weeks the first positive effects should already be visible in the laboratory tests. The viral load should drop significantly and, ideally, the CD4 cells should also recover soon.

Drug groups for the therapy of HIV infection

Currently, a total of three drug groups are available to treat HIV infection. The aim of the therapy is to reduce the viral load to such an extent that the virus can no longer be detected. This not only slows down the progression of the infection, but also makes it more difficult for the infection to be passed on.

An overview of the active substance groups used:

• Fusion inhibitors: the virus can no longer penetrate the cell and therefore no longer reproduce.
• Reverse transcriptase inhibitors: Viruses that are in the cell can no longer reproduce.
• Protease inhibitors: Viruses newly formed in the cell can no longer be released and infect neighboring cells.

With all three groups of active substances, it must be taken into account that it is never possible to protect all cells. Thus, it can never be completely prevented that the virus continues to multiply.

Indication for antiretroviral therapy

The challenge is to find the right time to start therapy. There are voices in favour of starting as early as possible, as well as experts who believe that the therapy should be started as late as possible. An important indication of the right time to start therapy is given by the CD4 cell count and the viral load.

In addition to antiretroviral therapy, any symptoms that occur as a result of the HIV infection must of course also be treated effectively. In addition, measures must be taken to prevent further infections.

Supportive measures for HIV infection

Even though drug therapy is the basis of AIDS therapy, you should take action yourself to prevent the progression of the infection.

This starts with finding a sympathetic AIDS specialist. Only then it is guaranteed that a long lasting good cooperation will be possible. The instructions you receive from the specialist should also be followed to the letter. The antiretroviral therapy is very stressful in everyday life, because many drugs with strong side effects have to be taken at exactly certain times. Neither the time of intake nor the dosage may be changed independently.

In order to prevent further infections, one should not only be vaccinated against possible pathogens, but also minimize contact with pathogens. This includes avoiding raw foods (fish, meat, eggs) and unpasteurized dairy products, but also being very careful when handling pets. Frequent hand washing can also drastically reduce the rate of infection.

A healthy lifestyle can strengthen the immune system and thus prevent infections. This includes an adequate and balanced diet, adequate physical activity and abstaining from drugs and nicotine. Furthermore, sufficient sleep and phases of relaxation are necessary in which the body can recover. Sport can not only strengthen the immune system, but above all it can also reduce depression, which often occurs in the context of HIV infection.

When it comes to intimate contact with your life partner, special caution is of course required. A condom should always be used to reduce the risk of infection. Once the condom has broken, prophylactic chemotherapy should be started immediately. This works best if it is started within two hours of the possible infection. It is therefore best to talk to your doctor about this in advance.

The great advances in antiretroviral therapy lead to a high quality of life and a very extended symptom-free latency phase. Of course, this is only true if the therapy is carried out regularly and carefully, despite the strong side effects of the drugs.

However, since the therapy is very expensive and time-consuming, only people in industrialized areas can benefit from this highly effective treatment. Poorer areas of the world still have to live with the fact that HIV is an infection that inevitably leads to a painful and protracted death.

Researchers are working diligently to develop a vaccine that prevents infection with HIV. However, no effective preparations have yet been developed. It is not yet foreseeable when a vaccination against HIV will be introduced into the market.

Through various infection campaigns, the number of new infections has been drastically reduced since the discovery of the disease. Recently, however, it has become increasingly apparent that the younger generation is not as aware of the danger of AIDS and does not protect itself adequately against infection.

Measures for self-protection

The best way to protect yourself is to practice safer sex. This means always using condoms for both vaginal and anal intercourse. During oral sex, you should make sure that no sperm or blood (e.g. menstrual blood) gets into your mouth or eyes.

Living together with an infected person and close physical contact cannot lead to infection. So you can safely share towels, hug and kiss each other.