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Wikipedia

HIV/AIDS

March 20, 2023

"AIDS" and "Aids" redirect here. For other uses, see AIDS (disambiguation).

Human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV),[9][10][11] a retrovirus.[12] Following initial infection an individual may not notice any symptoms, or may experience a brief period of influenza-like illness.[4] Typically, this is followed by a prolonged incubation period with no symptoms.[5] If the infection progresses, it interferes more with the immune system, increasing the risk of developing common infections such as tuberculosis, as well as other opportunistic infections, and tumors which are rare in people who have normal immune function.[4] These late symptoms of infection are referred to as acquired immunodeficiency syndrome (AIDS).[5] This stage is often also associated with unintended weight loss.[5]

HIV/AIDS
Other namesHIV disease, HIV infection[1][2]
The red ribbon is a symbol for solidarity with HIV-positive people and those living with AIDS.[3]
SpecialtyInfectious disease, immunology
SymptomsEarly: Flu-like illness[4]
Later: Large lymph nodes, fever, weight loss[4]
ComplicationsOpportunistic infections, tumors[4]
DurationLifelong[4]
CausesHuman immunodeficiency virus (HIV)[4]
Risk factorsUnprotected anal or vaginal sex, having another sexually transmitted infection, needle sharing, medical procedures involving unsterile cutting or piercing, and experiencing needlestick injury[4]
Diagnostic methodBlood tests[4]
PreventionSafe sex, needle exchange, male circumcision, pre-exposure prophylaxis, post-exposure prophylaxis[4]
TreatmentAntiretroviral therapy[4]
PrognosisNear normal life expectancy with treatment[5][6]
11 years life expectancy without treatment[7]
Frequency64.4 million – 113 million total cases[8]
1.5 million new cases (2021)[8]
38.4 million living with HIV (2021)[8]
Deaths40.1 million total deaths[8]
650,000 (2021)[8]

HIV is spread primarily by unprotected sex (including anal and vaginal sex), contaminated hypodermic needles or blood transfusions, and from mother to child during pregnancy, delivery, or breastfeeding.[13] Some bodily fluids, such as saliva, sweat and tears, do not transmit the virus.[14] Oral sex has little to no risk of transmitting the virus.[15] Methods of prevention include safe sex, needle exchange programs, treating those who are infected, as well as both pre- and post-exposure prophylaxis.[4] Disease in a baby can often be prevented by giving both the mother and child antiretroviral medication.[4]

Recognized worldwide in the early 1980s,[16] HIV/AIDS has had a large impact on society, both as an illness and as a source of discrimination.[17] The disease also has large economic impacts.[17] There are many misconceptions about HIV/AIDS, such as the belief that it can be transmitted by casual non-sexual contact.[18] The disease has become subject to many controversies involving religion, including the Catholic Church's position not to support condom use as prevention.[19] It has attracted international medical and political attention as well as large-scale funding since it was identified in the 1980s.[20]

HIV made the jump from other primates to humans in west-central Africa in the early-to-mid 20th century.[21] AIDS was first recognized by the U.S. Centers for Disease Control and Prevention (CDC) in 1981 and its cause—HIV infection—was identified in the early part of the decade.[16] Between the first time AIDS was readily identified through 2021, the disease is estimated to have caused at least 40 million deaths worldwide.[22] In 2021, there were 650,000 deaths and about 38 million people worldwide living with HIV.[8] An estimated 20.6 million of these people live in eastern and southern Africa.[23] HIV/AIDS is considered a pandemic—a disease outbreak which is present over a large area and is actively spreading.[24]

The United States' National Institutes of Health (NIH) and the Gates Foundation have pledged $200 million focused on developing a global cure for AIDS.[25] While there is no broadly available cure or vaccine, antiretroviral treatment can slow the course of the disease and may lead to a near-normal life expectancy.[5][6] Treatment is recommended as soon as the diagnosis is made.[26] Without treatment, the average survival time after infection is 11 years.[7]

Signs and symptoms

Main article: Signs and symptoms of HIV/AIDS

There are three main stages of HIV infection: acute infection, clinical latency, and AIDS.[1][27]

Acute infection

 
Main symptoms of acute HIV infection

The initial period following the contraction of HIV is called acute HIV, primary HIV or acute retroviral syndrome.[27][28] Many individuals develop an influenza-like illness or a mononucleosis-like illness 2–4 weeks after exposure while others have no significant symptoms.[29][30] Symptoms occur in 40–90% of cases and most commonly include fever, large tender lymph nodes, throat inflammation, a rash, headache, tiredness, and/or sores of the mouth and genitals.[28][30] The rash, which occurs in 20–50% of cases, presents itself on the trunk and is maculopapular, classically.[31] Some people also develop opportunistic infections at this stage.[28] Gastrointestinal symptoms, such as vomiting or diarrhea may occur.[30] Neurological symptoms of peripheral neuropathy or Guillain–Barré syndrome also occur.[30] The duration of the symptoms varies, but is usually one or two weeks.[30]

Owing to their nonspecific character, these symptoms are not often recognized as signs of HIV infection. Even cases that do get seen by a family doctor or a hospital are often misdiagnosed as one of the many common infectious diseases with overlapping symptoms. Thus, it is recommended that HIV be considered in people presenting with an unexplained fever who may have risk factors for the infection.[30]

Clinical latency

The initial symptoms are followed by a stage called clinical latency, asymptomatic HIV, or chronic HIV.[1] Without treatment, this second stage of the natural history of HIV infection can last from about three years[32] to over 20 years[33] (on average, about eight years).[34] While typically there are few or no symptoms at first, near the end of this stage many people experience fever, weight loss, gastrointestinal problems and muscle pains.[1] Between 50% and 70% of people also develop persistent generalized lymphadenopathy, characterized by unexplained, non-painful enlargement of more than one group of lymph nodes (other than in the groin) for over three to six months.[27]

Although most HIV-1 infected individuals have a detectable viral load and in the absence of treatment will eventually progress to AIDS, a small proportion (about 5%) retain high levels of CD4+ T cells (T helper cells) without antiretroviral therapy for more than five years.[30][35] These individuals are classified as "HIV controllers" or long-term nonprogressors (LTNP).[35] Another group consists of those who maintain a low or undetectable viral load without anti-retroviral treatment, known as "elite controllers" or "elite suppressors". They represent approximately 1 in 300 infected persons.[36]

Acquired immunodeficiency syndrome

 
Main symptoms of AIDS

Acquired immunodeficiency syndrome (AIDS) is defined as an HIV infection with either a CD4+ T cell count below 200 cells per µL or the occurrence of specific diseases associated with HIV infection.[30] In the absence of specific treatment, around half of people infected with HIV develop AIDS within ten years.[30] The most common initial conditions that alert to the presence of AIDS are pneumocystis pneumonia (40%), cachexia in the form of HIV wasting syndrome (20%), and esophageal candidiasis.[30] Other common signs include recurrent respiratory tract infections.[30]

Opportunistic infections may be caused by bacteria, viruses, fungi, and parasites that are normally controlled by the immune system.[37] Which infections occur depends partly on what organisms are common in the person's environment.[30] These infections may affect nearly every organ system.[38]

People with AIDS have an increased risk of developing various viral-induced cancers, including Kaposi's sarcoma, Burkitt's lymphoma, primary central nervous system lymphoma, and cervical cancer.[31] Kaposi's sarcoma is the most common cancer, occurring in 10% to 20% of people with HIV.[39] The second-most common cancer is lymphoma, which is the cause of death of nearly 16% of people with AIDS and is the initial sign of AIDS in 3% to 4%.[39] Both these cancers are associated with human herpesvirus 8 (HHV-8).[39] Cervical cancer occurs more frequently in those with AIDS because of its association with human papillomavirus (HPV).[39] Conjunctival cancer (of the layer that lines the inner part of eyelids and the white part of the eye) is also more common in those with HIV.[40]

Additionally, people with AIDS frequently have systemic symptoms such as prolonged fevers, sweats (particularly at night), swollen lymph nodes, chills, weakness, and unintended weight loss.[41] Diarrhea is another common symptom, present in about 90% of people with AIDS.[42] They can also be affected by diverse psychiatric and neurological symptoms independent of opportunistic infections and cancers.[43]

Transmission

Average per act risk of getting HIV
by exposure route to an infected source
Exposure route Chance of infection
Blood transfusion 90%[44]
Childbirth (to child) 25%[45][clarification needed]
Needle-sharing injection drug use 0.67%[46]
Percutaneous needle stick 0.30%[47]
Receptive anal intercourse* 0.04–3.0%[48]
Insertive anal intercourse* 0.03%[49]
Receptive penile-vaginal intercourse* 0.05–0.30%[48][50]
Insertive penile-vaginal intercourse* 0.01–0.38%[48][50]
Receptive oral intercourse*§ 0–0.04%[48]
Insertive oral intercourse*§ 0–0.005%[51]
* assuming no condom use
§ source refers to oral intercourse
performed on a man

HIV is spread by three main routes: sexual contact, significant exposure to infected body fluids or tissues, and from mother to child during pregnancy, delivery, or breastfeeding (known as vertical transmission).[13] There is no risk of acquiring HIV if exposed to feces, nasal secretions, saliva, sputum, sweat, tears, urine, or vomit unless these are contaminated with blood.[52] It is also possible to be co-infected by more than one strain of HIV—a condition known as HIV superinfection.[53]

Sexual

The most frequent mode of transmission of HIV is through sexual contact with an infected person.[13] However, an HIV-positive person who has an undetectable viral load as a result of long-term treatment has effectively no risk of transmitting HIV sexually.[54][55] The existence of functionally noncontagious HIV-positive people on antiretroviral therapy was controversially publicized in the 2008 Swiss Statement, and has since become accepted as medically sound.[56]

Globally, the most common mode of HIV transmission is via sexual contacts between people of the opposite sex;[13] however, the pattern of transmission varies among countries. As of 2017, most HIV transmission in the United States occurred among men who had sex with men (82% of new HIV diagnoses among males aged 13 and older and 70% of total new diagnoses).[57][58] In the US, gay and bisexual men aged 13 to 24 accounted for an estimated 92% of new HIV diagnoses among all men in their age group and 27% of new diagnoses among all gay and bisexual men.[59]

With regard to unprotected heterosexual contacts, estimates of the risk of HIV transmission per sexual act appear to be four to ten times higher in low-income countries than in high-income countries.[60] In low-income countries, the risk of female-to-male transmission is estimated as 0.38% per act, and of male-to-female transmission as 0.30% per act; the equivalent estimates for high-income countries are 0.04% per act for female-to-male transmission, and 0.08% per act for male-to-female transmission.[60] The risk of transmission from anal intercourse is especially high, estimated as 1.4–1.7% per act in both heterosexual and homosexual contacts.[60][61] While the risk of transmission from oral sex is relatively low, it is still present.[62] The risk from receiving oral sex has been described as "nearly nil";[63] however, a few cases have been reported.[64] The per-act risk is estimated at 0–0.04% for receptive oral intercourse.[65] In settings involving prostitution in low-income countries, risk of female-to-male transmission has been estimated as 2.4% per act, and of male-to-female transmission as 0.05% per act.[60]

Risk of transmission increases in the presence of many sexually transmitted infections[66] and genital ulcers.[60] Genital ulcers appear to increase the risk approximately fivefold.[60] Other sexually transmitted infections, such as gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis, are associated with somewhat smaller increases in risk of transmission.[65]

The viral load of an infected person is an important risk factor in both sexual and mother-to-child transmission.[67] During the first 2.5 months of an HIV infection a person's infectiousness is twelve times higher due to the high viral load associated with acute HIV.[65] If the person is in the late stages of infection, rates of transmission are approximately eightfold greater.[60]

Commercial sex workers (including those in pornography) have an increased likelihood of contracting HIV.[68][69] Rough sex can be a factor associated with an increased risk of transmission.[70] Sexual assault is also believed to carry an increased risk of HIV transmission as condoms are rarely worn, physical trauma to the vagina or rectum is likely, and there may be a greater risk of concurrent sexually transmitted infections.[71]

Body fluids

 
CDC poster from 1989 highlighting the threat of AIDS associated with drug use

The second-most frequent mode of HIV transmission is via blood and blood products.[13] Blood-borne transmission can be through needle-sharing during intravenous drug use, needle-stick injury, transfusion of contaminated blood or blood product, or medical injections with unsterilized equipment. The risk from sharing a needle during drug injection is between 0.63% and 2.4% per act, with an average of 0.8%.[72] The risk of acquiring HIV from a needle stick from an HIV-infected person is estimated as 0.3% (about 1 in 333) per act and the risk following mucous membrane exposure to infected blood as 0.09% (about 1 in 1000) per act.[52] This risk may, however, be up to 5% if the introduced blood was from a person with a high viral load and the cut was deep.[73] In the United States, intravenous drug users made up 12% of all new cases of HIV in 2009,[74] and in some areas more than 80% of people who inject drugs are HIV-positive.[13]

HIV is transmitted in about 90% of blood transfusions using infected blood.[44] In developed countries the risk of acquiring HIV from a blood transfusion is extremely low (less than one in half a million) where improved donor selection and HIV screening is performed;[13] for example, in the UK the risk is reported at one in five million[75] and in the United States it was one in 1.5 million in 2008.[76] In low-income countries, only half of transfusions may be appropriately screened (as of 2008),[77] and it is estimated that up to 15% of HIV infections in these areas come from transfusion of infected blood and blood products, representing between 5% and 10% of global infections.[13][78] It is possible to acquire HIV from organ and tissue transplantation, although this is rare because of screening.[79]

Unsafe medical injections play a role in HIV spread in sub-Saharan Africa. In 2007, between 12% and 17% of infections in this region were attributed to medical syringe use.[80] The World Health Organization estimates the risk of transmission as a result of a medical injection in Africa at 1.2%.[80] Risks are also associated with invasive procedures, assisted delivery, and dental care in this area of the world.[80]

People giving or receiving tattoos, piercings, and scarification are theoretically at risk of infection but no confirmed cases have been documented.[81] It is not possible for mosquitoes or other insects to transmit HIV.[82]

Mother-to-child

Main articles: HIV and pregnancy and HIV and breastfeeding

HIV can be transmitted from mother to child during pregnancy, during delivery, or through breast milk, resulting in the baby also contracting HIV.[83][13] As of 2008, vertical transmission accounted for about 90% of cases of HIV in children.[84] In the absence of treatment, the risk of transmission before or during birth is around 20%, and in those who also breastfeed 35%.[84] Treatment decreases this risk to less than 5%.[85]

Antiretrovirals when taken by either the mother or the baby decrease the risk of transmission in those who do breastfeed.[86] If blood contaminates food during pre-chewing it may pose a risk of transmission.[81] If a woman is untreated, two years of breastfeeding results in an HIV/AIDS risk in her baby of about 17%.[87] Due to the increased risk of death without breastfeeding in many areas in the developing world, the World Health Organization recommends either exclusive breastfeeding or the provision of safe formula.[87] All women known to be HIV-positive should be taking lifelong antiretroviral therapy.[87]

Virology

Main article: HIV
 
Diagram of a HIV virion structure
 
Scanning electron micrograph of HIV-1, colored green, budding from a cultured lymphocyte

HIV is the cause of the spectrum of disease known as HIV/AIDS. HIV is a retrovirus that primarily infects components of the human immune system such as CD4+ T cells, macrophages and dendritic cells. It directly and indirectly destroys CD4+ T cells.[88]

HIV is a member of the genus Lentivirus,[89] part of the family Retroviridae.[90] Lentiviruses share many morphological and biological characteristics. Many species of mammals are infected by lentiviruses, which are characteristically responsible for long-duration illnesses with a long incubation period.[91] Lentiviruses are transmitted as single-stranded, positive-sense, enveloped RNA viruses. Upon entry into the target cell, the viral RNA genome is converted (reverse transcribed) into double-stranded DNA by a virally encoded reverse transcriptase that is transported along with the viral genome in the virus particle. The resulting viral DNA is then imported into the cell nucleus and integrated into the cellular DNA by a virally encoded integrase and host co-factors.[92] Once integrated, the virus may become latent, allowing the virus and its host cell to avoid detection by the immune system.[93] Alternatively, the virus may be transcribed, producing new RNA genomes and viral proteins that are packaged and released from the cell as new virus particles that begin the replication cycle anew.[94]

HIV is now known to spread between CD4+ T cells by two parallel routes: cell-free spread and cell-to-cell spread, i.e. it employs hybrid spreading mechanisms.[95] In the cell-free spread, virus particles bud from an infected T cell, enter the blood/extracellular fluid and then infect another T cell following a chance encounter.[95] HIV can also disseminate by direct transmission from one cell to another by a process of cell-to-cell spread.[96][97] The hybrid spreading mechanisms of HIV contribute to the virus's ongoing replication against antiretroviral therapies.[95][98]

Two types of HIV have been characterized: HIV-1 and HIV-2. HIV-1 is the virus that was originally discovered (and initially referred to also as LAV or HTLV-III). It is more virulent, more infective,[99] and is the cause of the majority of HIV infections globally. The lower infectivity of HIV-2 as compared with HIV-1 implies that fewer people exposed to HIV-2 will be infected per exposure. Because of its relatively poor capacity for transmission, HIV-2 is largely confined to West Africa.[100]

Pathophysiology

Main article: Pathophysiology of HIV/AIDS
HIV/AIDS explained in a simple way
 
HIV replication cycle

After the virus enters the body, there is a period of rapid viral replication, leading to an abundance of virus in the peripheral blood. During primary infection, the level of HIV may reach several million virus particles per milliliter of blood.[101] This response is accompanied by a marked drop in the number of circulating CD4+ T cells. The acute viremia is almost invariably associated with activation of CD8+ T cells, which kill HIV-infected cells, and subsequently with antibody production, or seroconversion. The CD8+ T cell response is thought to be important in controlling virus levels, which peak and then decline, as the CD4+ T cell counts recover. A good CD8+ T cell response has been linked to slower disease progression and a better prognosis, though it does not eliminate the virus.[102]

Ultimately, HIV causes AIDS by depleting CD4+ T cells. This weakens the immune system and allows opportunistic infections. T cells are essential to the immune response and without them, the body cannot fight infections or kill cancerous cells. The mechanism of CD4+ T cell depletion differs in the acute and chronic phases.[103] During the acute phase, HIV-induced cell lysis and killing of infected cells by CD8+ T cells accounts for CD4+ T cell depletion, although apoptosis may also be a factor. During the chronic phase, the consequences of generalized immune activation coupled with the gradual loss of the ability of the immune system to generate new T cells appear to account for the slow decline in CD4+ T cell numbers.[104]

Although the symptoms of immune deficiency characteristic of AIDS do not appear for years after a person is infected, the bulk of CD4+ T cell loss occurs during the first weeks of infection, especially in the intestinal mucosa, which harbors the majority of the lymphocytes found in the body.[105] The reason for the preferential loss of mucosal CD4+ T cells is that the majority of mucosal CD4+ T cells express the CCR5 protein which HIV uses as a co-receptor to gain access to the cells, whereas only a small fraction of CD4+ T cells in the bloodstream do so.[106] A specific genetic change that alters the CCR5 protein when present in both chromosomes very effectively prevents HIV-1 infection.[107]

HIV seeks out and destroys CCR5 expressing CD4+ T cells during acute infection.[108] A vigorous immune response eventually controls the infection and initiates the clinically latent phase. CD4+ T cells in mucosal tissues remain particularly affected.[108] Continuous HIV replication causes a state of generalized immune activation persisting throughout the chronic phase.[109] Immune activation, which is reflected by the increased activation state of immune cells and release of pro-inflammatory cytokines, results from the activity of several HIV gene products and the immune response to ongoing HIV replication. It is also linked to the breakdown of the immune surveillance system of the gastrointestinal mucosal barrier caused by the depletion of mucosal CD4+ T cells during the acute phase of disease.[110]

Diagnosis

Main article: Diagnosis of HIV/AIDS
 
A generalized graph of the relationship between HIV copies (viral load) and CD4+ T cell counts over the average course of untreated HIV infection.
  CD4+ T Lymphocyte count (cells/mm³)
  HIV RNA copies per mL of plasma
Days after exposure needed for the test to be accurate[111]
Blood test Days
Antibody test (rapid test, ELISA 3rd gen) 23–90
Antibody and p24 antigen test (ELISA 4th gen) 18–45
PCR 10–33

HIV/AIDS is diagnosed via laboratory testing and then staged based on the presence of certain signs or symptoms.[28] HIV screening is recommended by the United States Preventive Services Task Force for all people 15 years to 65 years of age, including all pregnant women.[112] Additionally, testing is recommended for those at high risk, which includes anyone diagnosed with a sexually transmitted illness.[31][112] In many areas of the world, a third of HIV carriers only discover they are infected at an advanced stage of the disease when AIDS or severe immunodeficiency has become apparent.[31]

HIV testing

 
HIV rapid test being administered
 
Oraquick

Most people infected with HIV develop specific antibodies (i.e. seroconvert) within three to twelve weeks after the initial infection.[30] Diagnosis of primary HIV before seroconversion is done by measuring HIV-RNA or p24 antigen.[30] Positive results obtained by antibody or PCR testing are confirmed either by a different antibody or by PCR.[28]

Antibody tests in children younger than 18 months are typically inaccurate, due to the continued presence of maternal antibodies.[113] Thus HIV infection can only be diagnosed by PCR testing for HIV RNA or DNA, or via testing for the p24 antigen.[28] Much of the world lacks access to reliable PCR testing, and people in many places simply wait until either symptoms develop or the child is old enough for accurate antibody testing.[113] In sub-Saharan Africa between 2007 and 2009, between 30% and 70% of the population were aware of their HIV status.[114] In 2009, between 3.6% and 42% of men and women in sub-Saharan countries were tested;[114] this represented a significant increase compared to previous years.[114]

Classifications

Two main clinical staging systems are used to classify HIV and HIV-related disease for surveillance purposes: the WHO disease staging system for HIV infection and disease,[28] and the CDC classification system for HIV infection.[115] The CDC's classification system is more frequently adopted in developed countries. Since the WHO's staging system does not require laboratory tests, it is suited to the resource-restricted conditions encountered in developing countries, where it can also be used to help guide clinical management. Despite their differences, the two systems allow a comparison for statistical purposes.[27][28][115]

The World Health Organization first proposed a definition for AIDS in 1986.[28] Since then, the WHO classification has been updated and expanded several times, with the most recent version being published in 2007.[28] The WHO system uses the following categories:

  • Primary HIV infection: May be either asymptomatic or associated with acute retroviral syndrome[28]
  • Stage I: HIV infection is asymptomatic with a CD4+ T cell count (also known as CD4 count) greater than 500 per microlitre (µl or cubic mm) of blood.[28] May include generalized lymph node enlargement.[28]
  • Stage II: Mild symptoms, which may include minor mucocutaneous manifestations and recurrent upper respiratory tract infections. A CD4 count of less than 500/µl[28]
  • Stage III: Advanced symptoms, which may include unexplained chronic diarrhea for longer than a month, severe bacterial infections including tuberculosis of the lung, and a CD4 count of less than 350/µl[28]
  • Stage IV or AIDS: severe symptoms, which include toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi, or lungs, and Kaposi's sarcoma. A CD4 count of less than 200/µl[28]

The U.S. Centers for Disease Control and Prevention also created a classification system for HIV, and updated it in 2008 and 2014.[115][116] This system classifies HIV infections based on CD4 count and clinical symptoms, and describes the infection in five groups.[116] In those greater than six years of age it is:[116]

  • Stage 0: the time between a negative or indeterminate HIV test followed less than 180 days by a positive test.
  • Stage 1: CD4 count ≥ 500 cells/µl and no AIDS-defining conditions.
  • Stage 2: CD4 count 200 to 500 cells/µl and no AIDS-defining conditions.
  • Stage 3: CD4 count ≤ 200 cells/µl or AIDS-defining conditions.
  • Unknown: if insufficient information is available to make any of the above classifications.

For surveillance purposes, the AIDS diagnosis still stands even if, after treatment, the CD4+ T cell count rises to above 200 per µL of blood or other AIDS-defining illnesses are cured.[27]

Prevention

Main article: Prevention of HIV/AIDS
 
AIDS clinic, McLeod Ganj, Himachal Pradesh, India, 2010

Sexual contact

 
People wearing AIDS awareness signs. On the left: "Facing AIDS a condom and a pill at a time"; on the right: "I am Facing AIDS because people I ♥ are infected"

Consistent condom use reduces the risk of HIV transmission by approximately 80% over the long term.[117] When condoms are used consistently by a couple in which one person is infected, the rate of HIV infection is less than 1% per year.[118] There is some evidence to suggest that female condoms may provide an equivalent level of protection.[119] Application of a vaginal gel containing tenofovir (a reverse transcriptase inhibitor) immediately before sex seems to reduce infection rates by approximately 40% among African women.[120] By contrast, use of the spermicide nonoxynol-9 may increase the risk of transmission due to its tendency to cause vaginal and rectal irritation.[121]

Circumcision in sub-Saharan Africa "reduces the acquisition of HIV by heterosexual men by between 38% and 66% over 24 months".[122] Owing to these studies, both the World Health Organization and UNAIDS recommended male circumcision in 2007 as a method of preventing female-to-male HIV transmission in areas with high rates of HIV.[123] However, whether it protects against male-to-female transmission is disputed,[124][125] and whether it is of benefit in developed countries and among men who have sex with men is undetermined.[126][127][128]

Programs encouraging sexual abstinence do not appear to affect subsequent HIV risk.[129] Evidence of any benefit from peer education is equally poor.[130] Comprehensive sexual education provided at school may decrease high-risk behavior.[131][132] A substantial minority of young people continues to engage in high-risk practices despite knowing about HIV/AIDS, underestimating their own risk of becoming infected with HIV.[133] Voluntary counseling and testing people for HIV does not affect risky behavior in those who test negative but does increase condom use in those who test positive.[134] Enhanced family planning services appear to increase the likelihood of women with HIV using contraception, compared to basic services.[135] It is not known whether treating other sexually transmitted infections is effective in preventing HIV.[66]

Pre-exposure

Antiretroviral treatment among people with HIV whose CD4 count ≤ 550 cells/µL is a very effective way to prevent HIV infection of their partner (a strategy known as treatment as prevention, or TASP).[136] TASP is associated with a 10- to 20-fold reduction in transmission risk.[136][137] Pre-exposure prophylaxis (PrEP) with a daily dose of the medications tenofovir, with or without emtricitabine, is effective in people at high risk including men who have sex with men, couples where one is HIV-positive, and young heterosexuals in Africa.[120][138] It may also be effective in intravenous drug users, with a study finding a decrease in risk of 0.7 to 0.4 per 100 person years.[139] The USPSTF, in 2019, recommended PrEP in those who are at high risk.[140]

Universal precautions within the health care environment are believed to be effective in decreasing the risk of HIV.[141] Intravenous drug use is an important risk factor, and harm reduction strategies such as needle-exchange programs and opioid substitution therapy appear effective in decreasing this risk.[142][143]

Post-exposure

A course of antiretrovirals administered within 48 to 72 hours after exposure to HIV-positive blood or genital secretions is referred to as post-exposure prophylaxis (PEP).[144] The use of the single agent zidovudine reduces the risk of a HIV infection five-fold following a needle-stick injury.[144] As of 2013, the prevention regimen recommended in the United States consists of three medications—tenofovir, emtricitabine and raltegravir—as this may reduce the risk further.[145]

PEP treatment is recommended after a sexual assault when the perpetrator is known to be HIV-positive, but is controversial when their HIV status is unknown.[146] The duration of treatment is usually four weeks[147] and is frequently associated with adverse effects—where zidovudine is used, about 70% of cases result in adverse effects such as nausea (24%), fatigue (22%), emotional distress (13%) and headaches (9%).[52]

Mother-to-child

Main article: HIV and pregnancy

Programs to prevent the vertical transmission of HIV (from mothers to children) can reduce rates of transmission by 92–99%.[84][142] This primarily involves the use of a combination of antiviral medications during pregnancy and after birth in the infant, and potentially includes bottle feeding rather than breastfeeding.[84][148] If replacement feeding is acceptable, feasible, affordable, sustainable and safe, mothers should avoid breastfeeding their infants; however, exclusive breastfeeding is recommended during the first months of life if this is not the case.[149] If exclusive breastfeeding is carried out, the provision of extended antiretroviral prophylaxis to the infant decreases the risk of transmission.[150] In 2015, Cuba became the first country in the world to eradicate mother-to-child transmission of HIV.[151]

Vaccination

Main article: HIV vaccine

Currently there is no licensed vaccine for HIV or AIDS.[6] The most effective vaccine trial to date, RV 144, was published in 2009; it found a partial reduction in the risk of transmission of roughly 30%, stimulating some hope in the research community of developing a truly effective vaccine.[152]

Treatment

Main article: Management of HIV/AIDS

There is currently no cure, nor an effective HIV vaccine. Treatment consists of highly active antiretroviral therapy (HAART), which slows progression of the disease.[153] As of 2010, more than 6.6 million people were receiving HAART in low- and middle-income countries.[154] Treatment also includes preventive and active treatment of opportunistic infections. As of July 2022, four people have been successfully cleared of HIV.[155][156][157] Rapid initiation of antiretroviral therapy within one week of diagnosis appear to improve treatment outcomes in low and medium-income settings.[158]

Antiviral therapy

 
Stribild – a common once-daily ART regime consisting of elvitegravir, emtricitabine, tenofovir and the booster cobicistat

Current HAART options are combinations (or "cocktails") consisting of at least three medications belonging to at least two types, or "classes", of antiretroviral agents.[159] Initially, treatment is typically a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two nucleoside analog reverse transcriptase inhibitors (NRTIs).[160] Typical NRTIs include: zidovudine (AZT) or tenofovir (TDF) and lamivudine (3TC) or emtricitabine (FTC).[160] As of 2019, dolutegravir/lamivudine/tenofovir is listed by the World Health Organization as the first-line treatment for adults, with tenofovir/lamivudine/efavirenz as an alternative.[161] Combinations of agents that include protease inhibitors (PI) are used if the above regimen loses effectiveness.[159]

The World Health Organization and the United States recommend antiretrovirals in people of all ages (including pregnant women) as soon as the diagnosis is made, regardless of CD4 count.[26][162][163] Once treatment is begun, it is recommended that it is continued without breaks or "holidays".[31] Many people are diagnosed only after treatment ideally should have begun.[31] The desired outcome of treatment is a long-term plasma HIV-RNA count below 50 copies/mL.[31] Levels to determine if treatment is effective are initially recommended after four weeks and once levels fall below 50 copies/mL checks every three to six months are typically adequate.[31] Inadequate control is deemed to be greater than 400 copies/mL.[31] Based on these criteria treatment is effective in more than 95% of people during the first year.[31]

Benefits of treatment include a decreased risk of progression to AIDS and a decreased risk of death.[164] In the developing world, treatment also improves physical and mental health.[165] With treatment, there is a 70% reduced risk of acquiring tuberculosis.[159] Additional benefits include a decreased risk of transmission of the disease to sexual partners and a decrease in mother-to-child transmission.[159][166] The effectiveness of treatment depends to a large part on compliance.[31] Reasons for non-adherence to treatment include poor access to medical care,[167] inadequate social supports, mental illness and drug abuse.[168] The complexity of treatment regimens (due to pill numbers and dosing frequency) and adverse effects may reduce adherence.[169] Even though cost is an important issue with some medications,[170] 47% of those who needed them were taking them in low- and middle-income countries as of 2010,[154] and the rate of adherence is similar in low-income and high-income countries.[171]

Specific adverse events are related to the antiretroviral agent taken.[172] Some relatively common adverse events include: lipodystrophy syndrome, dyslipidemia, and diabetes mellitus, especially with protease inhibitors.[27] Other common symptoms include diarrhea,[172][173] and an increased risk of cardiovascular disease.[174] Newer recommended treatments are associated with fewer adverse effects.[31] Certain medications may be associated with birth defects and therefore may be unsuitable for women hoping to have children.[31]

Treatment recommendations for children are somewhat different from those for adults. The World Health Organization recommends treating all children less than five years of age; children above five are treated like adults.[175] The United States guidelines recommend treating all children less than 12 months of age and all those with HIV RNA counts greater than 100,000 copies/mL between one year and five years of age.[176]

The European Medicines Agency (EMA) has recommended the granting of marketing authorizations for two new antiretroviral (ARV) medicines, rilpivirine (Rekambys) and cabotegravir (Vocabria), to be used together for the treatment of people with human immunodeficiency virus type 1 (HIV-1) infection.[177] The two medicines are the first ARVs that come in a long-acting injectable formulation.[177] This means that instead of daily pills, people receive intramuscular injections monthly or every two months.[177]

The combination of Rekambys and Vocabria injection is intended for maintenance treatment of adults who have undetectable HIV levels in the blood (viral load less than 50 copies/ml) with their current ARV treatment, and when the virus has not developed resistance to a certain class of anti-HIV medicines called non-nucleoside reverse transcriptase inhibitors (NNRTIs) and integrase strand transfer inhibitors (INIs).[177]

Cabotegravir combined with rilpivirine (Cabenuva) is a complete regimen for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults to replace a current antiretroviral regimen in those who are virologically suppressed on a stable antiretroviral regimen with no history of treatment failure and with no known or suspected resistance to either cabotegravir or rilpivirine.[178][179]

Opportunistic infections

Main article: Opportunistic infection § Opportunistic Infection and HIV/AIDS

Measures to prevent opportunistic infections are effective in many people with HIV/AIDS. In addition to improving current disease, treatment with antiretrovirals reduces the risk of developing additional opportunistic infections.[172]

Adults and adolescents who are living with HIV (even on anti-retroviral therapy) with no evidence of active tuberculosis in settings with high tuberculosis burden should receive isoniazid preventive therapy (IPT); the tuberculin skin test can be used to help decide if IPT is needed.[180] Children with HIV may benefit from screening for tuberculosis.[181] Vaccination against hepatitis A and B is advised for all people at risk of HIV before they become infected; however, it may also be given after infection.[182]

Trimethoprim/sulfamethoxazole prophylaxis between four and six weeks of age, and ceasing breastfeeding of infants born to HIV-positive mothers, is recommended in resource-limited settings.[183] It is also recommended to prevent PCP when a person's CD4 count is below 200 cells/uL and in those who have or have previously had PCP.[184] People with substantial immunosuppression are also advised to receive prophylactic therapy for toxoplasmosis and MAC.[185] Appropriate preventive measures reduced the rate of these infections by 50% between 1992 and 1997.[186] Influenza vaccination and pneumococcal polysaccharide vaccine are often recommended in people with HIV/AIDS with some evidence of benefit.[187][188]

Diet

Main article: Nutrition and HIV/AIDS

The World Health Organization (WHO) has issued recommendations regarding nutrient requirements in HIV/AIDS.[189] A generally healthy diet is promoted. Dietary intake of micronutrients at RDA levels by HIV-infected adults is recommended by the WHO; higher intake of vitamin A, zinc, and iron can produce adverse effects in HIV-positive adults, and is not recommended unless there is documented deficiency.[189][190][191][192] Dietary supplementation for people who are infected with HIV and who have inadequate nutrition or dietary deficiencies may strengthen their immune systems or help them recover from infections; however, evidence indicating an overall benefit in morbidity or reduction in mortality is not consistent.[193]

People with HIV/AIDS are up to four times more likely to develop type 2 diabetes than those who are not tested positive with the virus.[194]

Evidence for supplementation with selenium is mixed with some tentative evidence of benefit.[195] For pregnant and lactating women with HIV, multivitamin supplement improves outcomes for both mothers and children.[196] If the pregnant or lactating mother has been advised to take anti-retroviral medication to prevent mother-to-child HIV transmission, multivitamin supplements should not replace these treatments.[196] There is some evidence that vitamin A supplementation in children with an HIV infection reduces mortality and improves growth.[197]

Alternative medicine

In the US, approximately 60% of people with HIV use various forms of complementary or alternative medicine,[198] whose effectiveness has not been established.[199] There is not enough evidence to support the use of herbal medicines.[200] There is insufficient evidence to recommend or support the use of medical cannabis to try to increase appetite or weight gain.[201]

Prognosis

 
Deaths due to HIV/AIDS per million people in 2012:
  0
  1–4
  5–12
  13–34
  35–61
  62–134
  135–215
  216–458
  459–1,402
  1,403–5,828

HIV/AIDS has become a chronic rather than an acutely fatal disease in many areas of the world.[202] Prognosis varies between people, and both the CD4 count and viral load are useful for predicted outcomes.[30] Without treatment, average survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV subtype.[7] After the diagnosis of AIDS, if treatment is not available, survival ranges between 6 and 19 months.[203][204] HAART and appropriate prevention of opportunistic infections reduces the death rate by 80%, and raises the life expectancy for a newly diagnosed young adult to 20–50 years.[202][205][206] This is between two thirds[205] and nearly that of the general population.[31][207] If treatment is started late in the infection, prognosis is not as good:[31] for example, if treatment is begun following the diagnosis of AIDS, life expectancy is ~10–40 years.[31][202] Half of infants born with HIV die before two years of age without treatment.[183][clarification needed]

 
Disability-adjusted life year for HIV and AIDS per 100,000 inhabitants as of 2004:

The primary causes of death from HIV/AIDS are opportunistic infections and cancer, both of which are frequently the result of the progressive failure of the immune system.[186][208] Risk of cancer appears to increase once the CD4 count is below 500/μL.[31] The rate of clinical disease progression varies widely between individuals and has been shown to be affected by a number of factors such as a person's susceptibility and immune function;[209] their access to health care, the presence of co-infections;[203][210] and the particular strain (or strains) of the virus involved.[211][212]

Tuberculosis co-infection is one of the leading causes of sickness and death in those with HIV/AIDS being present in a third of all HIV-infected people and causing 25% of HIV-related deaths.[213] HIV is also one of the most important risk factors for tuberculosis.[214] Hepatitis C is another very common co-infection where each disease increases the progression of the other.[215] The two most common cancers associated with HIV/AIDS are Kaposi's sarcoma and AIDS-related non-Hodgkin's lymphoma.[208] Other cancers that are more frequent include anal cancer, Burkitt's lymphoma, primary central nervous system lymphoma, and cervical cancer.[31][216]

Even with anti-retroviral treatment, over the long term HIV-infected people may experience neurocognitive disorders,[217] osteoporosis,[218] neuropathy,[219] cancers,[220][221] nephropathy,[222] and cardiovascular disease.[173] Some conditions, such as lipodystrophy, may be caused both by HIV and its treatment.[173]

Epidemiology

Main article: Epidemiology of HIV/AIDS
See or edit source data.
Percentage of people with HIV/AIDS[223]
 
Trends in new cases and deaths per year from HIV/AIDS[223]

Some authors consider HIV/AIDS a global pandemic.[224] As of 2016 approximately 36.7 million people worldwide have HIV, the number of new infections that year being about 1.8 million.[225] This is down from 3.1 million new infections in 2001.[226] Slightly over half the infected population are women and 2.1 million are children.[225] It resulted in about 1 million deaths in 2016, down from a peak of 1.9 million in 2005.[225]

Sub-Saharan Africa is the region most affected. In 2010, an estimated 68% (22.9 million) of all HIV cases and 66% of all deaths (1.2 million) occurred in this region.[227] This means that about 5% of the adult population is infected[228] and it is believed to be the cause of 10% of all deaths in children.[229] Here, in contrast to other regions, women comprise nearly 60% of cases.[227] South Africa has the largest population of people with HIV of any country in the world at 5.9 million.[227] Life expectancy has fallen in the worst-affected countries due to HIV/AIDS; for example, in 2006 it was estimated that it had dropped from 65 to 35 years in Botswana.[24] Mother-to-child transmission in Botswana and South Africa, as of 2013, has decreased to less than 5%, with improvement in many other African nations due to improved access to antiretroviral therapy.[230]

South & South East Asia is the second most affected; in 2010 this region contained an estimated 4 million cases or 12% of all people living with HIV resulting in approximately 250,000 deaths.[228] Approximately 2.4 million of these cases are in India.[227]

During 2008 in the United States approximately 1.2 million people were living with HIV, resulting in about 17,500 deaths. The US Centers for Disease Control and Prevention estimated that in that year, 20% of infected Americans were unaware of their infection.[231] As of 2016 about 675,000 people have died of HIV/AIDS in the US since the beginning of the HIV epidemic.[232] In the United Kingdom as of 2015, there were approximately 101,200 cases which resulted in 594 deaths.[233] In Canada as of 2008, there were about 65,000 cases causing 53 deaths.[234] Between the first recognition of AIDS (in 1981) and 2009, it has led to nearly 30 million deaths.[235] Rates of HIV are lowest in North Africa and the Middle East (0.1% or less), East Asia (0.1%), and Western and Central Europe (0.2%).[228] The worst-affected European countries, in 2009 and 2012 estimates, are Russia, Ukraine, Latvia, Moldova, Portugal and Belarus, in decreasing order of prevalence.[236]

History

Main article: History of HIV/AIDS
For a chronological guide, see Timeline of HIV/AIDS.
Further information: Category:HIV/AIDS by country

Discovery

 
The Morbidity and Mortality Weekly Report reported in 1981 on what was later to be called "AIDS".

The first news story on the disease appeared on May 18, 1981, in the gay newspaper New York Native.[237][238] AIDS was first clinically reported on June 5, 1981, with five cases in the United States.[39][239] The initial cases were a cluster of injecting drug users and gay men with no known cause of impaired immunity who showed symptoms of Pneumocystis carinii pneumonia (PCP), a rare opportunistic infection that was known to occur in people with very compromised immune systems.[240] Soon thereafter, a large number of homosexual men developed a generally rare skin cancer called Kaposi's sarcoma (KS).[241][242] Many more cases of PCP and KS emerged, alerting U.S. Centers for Disease Control and Prevention (CDC) and a CDC task force was formed to monitor the outbreak.[243]

In the early days, the CDC did not have an official name for the disease, often referring to it by way of diseases associated with it, such as lymphadenopathy, the disease after which the discoverers of HIV originally named the virus.[244][245] They also used Kaposi's sarcoma and opportunistic infections, the name by which a task force had been set up in 1981.[246] At one point the CDC referred to it as the "4H disease", as the syndrome seemed to affect heroin users, homosexuals, hemophiliacs, and Haitians.[247][248] The term GRID, which stood for gay-related immune deficiency, had also been coined.[249] However, after determining that AIDS was not isolated to the gay community,[246] it was realized that the term GRID was misleading, and the term AIDS was introduced at a meeting in July 1982.[250] By September 1982 the CDC started referring to the disease as AIDS.[251]

In 1983, two separate research groups led by Robert Gallo and Luc Montagnier declared that a novel retrovirus may have been infecting people with AIDS, and published their findings in the same issue of the journal Science.[252][245] Gallo claimed a virus which his group had isolated from a person with AIDS was strikingly similar in shape to other human T-lymphotropic viruses (HTLVs) that his group had been the first to isolate. Gallo's group called their newly isolated virus HTLV-III. At the same time, Montagnier's group isolated a virus from a person presenting with swelling of the lymph nodes of the neck and physical weakness, two characteristic symptoms of AIDS. Contradicting the report from Gallo's group, Montagnier and his colleagues showed that core proteins of this virus were immunologically different from those of HTLV-I. Montagnier's group named their isolated virus lymphadenopathy-associated virus (LAV).[243] As these two viruses turned out to be the same, in 1986, LAV and HTLV-III were renamed HIV.[253]

Origins

 
Left to right: the African green monkey source of SIV, the sooty mangabey source of HIV-2, and the chimpanzee source of HIV-1

The origin of HIV / AIDS and the circumstances that led to its emergence remain unsolved.[254]

Both HIV-1 and HIV-2 are believed to have originated in non-human primates in West-central Africa and were transferred to humans in the early 20th century.[21] HIV-1 appears to have originated in southern Cameroon through the evolution of SIV(cpz), a simian immunodeficiency virus (SIV) that infects wild chimpanzees (HIV-1 descends from the SIVcpz endemic in the chimpanzee subspecies Pan troglodytes troglodytes).[255][256] The closest relative of HIV-2 is SIV (smm), a virus of the sooty mangabey (Cercocebus atys atys), an Old World monkey living in coastal West Africa (from southern Senegal to western Ivory Coast).[100] New World monkeys such as the owl monkey are resistant to HIV-1 infection, possibly because of a genomic fusion of two viral resistance genes.[257] HIV-1 is thought to have jumped the species barrier on at least three separate occasions, giving rise to the three groups of the virus, M, N, and O.[258]

There is evidence that humans who participate in bushmeat activities, either as hunters or as bushmeat vendors, commonly acquire SIV.[259] However, SIV is a weak virus which is typically suppressed by the human immune system within weeks of infection. It is thought that several transmissions of the virus from individual to individual in quick succession are necessary to allow it enough time to mutate into HIV.[260] Furthermore, due to its relatively low person-to-person transmission rate, SIV can only spread throughout the population in the presence of one or more high-risk transmission channels, which are thought to have been absent in Africa before the 20th century.

Specific proposed high-risk transmission channels, allowing the virus to adapt to humans and spread throughout society, depend on the proposed timing of the animal-to-human crossing. Genetic studies of the virus suggest that the most recent common ancestor of the HIV-1 M group dates back to c. 1910.[261] Proponents of this dating link the HIV epidemic with the emergence of colonialism and growth of large colonial African cities, leading to social changes, including a higher degree of sexual promiscuity, the spread of prostitution, and the accompanying high frequency of genital ulcer diseases (such as syphilis) in nascent colonial cities.[262] While transmission rates of HIV during vaginal intercourse are low under regular circumstances, they are increased manyfold if one of the partners has a sexually transmitted infection causing genital ulcers. Early 1900s colonial cities were notable for their high prevalence of prostitution and genital ulcers, to the degree that, as of 1928, as many as 45% of female residents of eastern Kinshasa were thought to have been prostitutes, and, as of 1933, around 15% of all residents of the same city had syphilis.[262]

An alternative view holds that unsafe medical practices in Africa after World War II, such as unsterile reuse of single-use syringes during mass vaccination, antibiotic and anti-malaria treatment campaigns, were the initial vector that allowed the virus to adapt to humans and spread.[260][263][264]

The earliest well-documented case of HIV in a human dates back to 1959 in the Congo.[265] The virus may have been present in the U.S. as early as the mid-to-late 1950s, as a sixteen-year-old male named Robert Rayford presented with symptoms in 1966 and died in 1969. In the 1970s, there were cases of getting parasites and becoming sick with what was called "gay bowel disease", but what is now suspected to have been AIDS.[266]

The earliest retrospectively described case of AIDS is believed to have been in Norway beginning in 1966, that of Arvid Noe.[267] In July 1960, in the wake of Congo's independence, the United Nations recruited Francophone experts and technicians from all over the world to assist in filling administrative gaps left by Belgium, who did not leave behind an African elite to run the country. By 1962, Haitians made up the second-largest group of well-educated experts (out of the 48 national groups recruited), that totaled around 4500 in the country.[268][269] Dr. Jacques Pépin, a Canadian author of The Origins of AIDS, stipulates that Haiti was one of HIV's entry points to the U.S. and that a Haitian may have carried HIV back across the Atlantic in the 1960s.[269] Although there was known to have been at least one case of AIDS in the U.S. from 1966,[270] the vast majority of infections occurring outside sub-Saharan Africa (including the U.S.) can be traced back to a single unknown individual who became infected with HIV in Haiti and brought the infection to the U.S. at some time around 1969.[254] The epidemic rapidly spread among high-risk groups (initially, sexually promiscuous men who have sex with men). By 1978, the prevalence of HIV-1 among gay male residents of New York City and San Francisco was estimated at 5%, suggesting that several thousand individuals in the country had been infected.[254]

Society and culture

Stigma

Main article: Discrimination against people with HIV/AIDS
 
Ryan White became a poster child for HIV after being expelled from school because he was infected.[271]

AIDS stigma exists around the world in a variety of ways, including ostracism, rejection, discrimination and avoidance of HIV-infected people; compulsory HIV testing without prior consent or protection of confidentiality; violence against HIV-infected individuals or people who are perceived to be infected with HIV; and the quarantine of HIV-infected individuals.[17] Stigma-related violence or the fear of violence prevents many people from seeking HIV testing, returning for their results, or securing treatment, possibly turning what could be a manageable chronic illness into a death sentence and perpetuating the spread of HIV.[272]

AIDS stigma has been further divided into the following three categories:

  • Instrumental AIDS stigma—a reflection of the fear and apprehension that are likely to be associated with any deadly and transmissible illness.[273]
  • Symbolic AIDS stigma—the use of HIV/AIDS to express attitudes toward the social groups or lifestyles perceived to be associated with the disease.[273]
  • Courtesy AIDS stigma—stigmatization of people connected to the issue of HIV/AIDS or HIV-positive people.[274]

Often, AIDS stigma is expressed in conjunction with one or more other stigmas, particularly those associated with homosexuality, bisexuality, promiscuity, prostitution, and intravenous drug use.[275]

In many developed countries, there is an association between AIDS and homosexuality or bisexuality, and this association is correlated with higher levels of sexual prejudice, such as anti-homosexual or anti-bisexual attitudes.[276] There is also a perceived association between AIDS and all male-male sexual behavior, including sex between uninfected men.[273] However, the dominant mode of spread worldwide for HIV remains heterosexual transmission.[277] To get a better understanding of the anti-homosexual attitudes around AIDs the musical Rent explores this.[278]

In 2003, as part of an overall reform of marriage and population legislation, it became legal for those diagnosed with AIDS to marry in China.[279]

In 2013, the U.S. National Library of Medicine developed a traveling exhibition titled Surviving and Thriving: AIDS, Politics, and Culture;[280] this covered medical research, the U.S. government's response, and personal stories from people with AIDS, caregivers, and activists.[281]

Economic impact

Main articles: Economic impact of HIV/AIDS and Cost of HIV treatment
 
Changes in life expectancy in some African countries, 1960–2012

HIV/AIDS affects the economics of both individuals and countries.[229] The gross domestic product of the most affected countries has decreased due to the lack of human capital.[229][282] Without proper nutrition, health care and medicine, large numbers of people die from AIDS-related complications. Before death they will not only be unable to work, but will also require significant medical care. It is estimated that as of 2007 there were 12 million AIDS orphans.[229] Many are cared for by elderly grandparents.[283]

Returning to work after beginning treatment for HIV/AIDS is difficult, and affected people often work less than the average worker. Unemployment in people with HIV/AIDS also is associated with suicidal ideation, memory problems, and social isolation. Employment increases self-esteem, sense of dignity, confidence, and quality of life for people with HIV/AIDS. Anti-retroviral treatment may help people with HIV/AIDS work more, and may increase the chance that a person with HIV/AIDS will be employed (low-quality evidence).[284]

By affecting mainly young adults, AIDS reduces the taxable population, in turn reducing the resources available for public expenditures such as education and health services not related to AIDS, resulting in increasing pressure on the state's finances and slower growth of the economy. This causes a slower growth of the tax base, an effect that is reinforced if there are growing expenditures on treating the sick, training (to replace sick workers), sick pay, and caring for AIDS orphans. This is especially true if the sharp increase in adult mortality shifts the responsibility from the family to the government in caring for these orphans.[283]

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.[285]

Religion and AIDS

Main article: Religion and HIV/AIDS

The topic of religion and AIDS has become highly controversial, primarily because some religious authorities have publicly declared their opposition to the use of condoms.[286][287] The religious approach to prevent the spread of AIDS, according to a report by American health expert Matthew Hanley titled The Catholic Church and the Global AIDS Crisis, argues that cultural changes are needed, including a re-emphasis on fidelity within marriage and sexual abstinence outside of it.[287]

Some religious organizations have claimed that prayer can cure HIV/AIDS. In 2011, the BBC reported that some churches in London were claiming that prayer would cure AIDS, and the Hackney-based Centre for the Study of Sexual Health and HIV reported that several people stopped taking their medication, sometimes on the direct advice of their pastor, leading to many deaths.[288] The Synagogue Church Of All Nations advertised an "anointing water" to promote God's healing, although the group denies advising people to stop taking medication.[288]

Media portrayal

Main article: Media portrayal of HIV/AIDS

One of the first high-profile cases of AIDS was the American gay actor Rock Hudson. He had been diagnosed during 1984, announced that he had had the virus on July 25, 1985, and died a few months later on October 2, 1985.[289] Another notable British casualty of AIDS that year was Nicholas Eden, a gay politician and son of former prime minister Anthony Eden.[290] On November 24, 1991, the virus claimed the life of British rock star Freddie Mercury, lead singer of the band Queen, who died from an AIDS-related illness having only revealed the diagnosis on the previous day.[291]

One of the first high-profile heterosexual cases of the virus was American tennis player Arthur Ashe. He was diagnosed as HIV-positive on August 31, 1988, having contracted the virus from blood transfusions during heart surgery earlier in the 1980s. Further tests within 24 hours of the initial diagnosis revealed that Ashe had AIDS, but he did not tell the public about his diagnosis until April 1992.[292] He died as a result on February 6, 1993, aged 49.[293]

Therese Frare's photograph of gay activist David Kirby, as he lay dying from AIDS while surrounded by family, was taken in April 1990. Life magazine said the photo became the one image "most powerfully identified with the HIV/AIDS epidemic." The photo was displayed in Life, was the winner of the World Press Photo, and acquired worldwide notoriety after being used in a United Colors of Benetton advertising campaign in 1992.[294]

Many famous artists and AIDS activists such as Larry Kramer, Diamanda Galás and Rosa von Praunheim[295] campaign for AIDS education and the rights of those affected. These artists worked with various media formats.

Criminal transmission

Main article: Criminal transmission of HIV

Criminal transmission of HIV is the intentional or reckless infection of a person with the human immunodeficiency virus (HIV). Some countries or jurisdictions, including some areas of the United States, have laws that criminalize HIV transmission or exposure.[296] Others may charge the accused under laws enacted before the HIV pandemic.

In 1996, Ugandan-born Canadian Johnson Aziga was diagnosed with HIV; he subsequently had unprotected sex with eleven women without disclosing his diagnosis. By 2003, seven had contracted HIV; two died from complications related to AIDS.[297][298] Aziga was convicted of first-degree murder and sentenced to life imprisonment.[299]

Misconceptions

Main articles: Misconceptions about HIV/AIDS and Discredited HIV/AIDS origins theories

There are many misconceptions about HIV and AIDS. Three misconceptions are that AIDS can spread through casual contact, that sexual intercourse with a virgin will cure AIDS,[300][301][302] and that HIV can infect only gay men and drug users.[303][304] In 2014, some among the British public wrongly thought one could get HIV from kissing (16%), sharing a glass (5%), spitting (16%), a public toilet seat (4%), and coughing or sneezing (5%).[305] Other misconceptions are that any act of anal intercourse between two uninfected gay men can lead to HIV infection, and that open discussion of HIV and homosexuality in schools will lead to increased rates of AIDS.[306][307]

A small group of individuals continue to dispute the connection between HIV and AIDS,[308] the existence of HIV itself, or the validity of HIV testing and treatment methods.[309][310] These claims, known as AIDS denialism, have been examined and rejected by the scientific community.[311] However, they have had a significant political impact, particularly in South Africa, where the government's official embrace of AIDS denialism (1999–2005) was responsible for its ineffective response to that country's AIDS epidemic, and has been blamed for hundreds of thousands of avoidable deaths and HIV infections.[312][313][314]

Several discredited conspiracy theories have held that HIV was created by scientists, either inadvertently or deliberately. Operation INFEKTION was a worldwide Soviet active measures operation to spread the claim that the United States had created HIV/AIDS. Surveys show that a significant number of people believed—and continue to believe—in such claims.[315]

At the peak of the HIV/AIDS outbreak, there was also misinformation spread from some governmental institutions. For example, Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases during the AIDS outbreak, stated in the context of a conversation about childhood infections, “if the close contact of a child is a household contact, perhaps there will be a certain number of cases of individuals who are just living with and in close contact with someone with AIDS, or at risk of AIDS, who does not necessarily have to have intimate sexual contact or share a needle, but just the ordinary close contact that one sees in normal interpersonal relations.”[316] This and similar statements made by governmental agencies potentially fueled the unfounded fear that the public had that AIDS could be spread by ordinary close contact rather than through sexual or fluid transmission as is most commonly the case.

Research

Main article: HIV/AIDS research

HIV/AIDS research includes all medical research which attempts to prevent, treat, or cure HIV/AIDS, along with fundamental research about the nature of HIV as an infectious agent, and about AIDS as the disease caused by HIV.

Many governments and research institutions participate in HIV/AIDS research. This research includes behavioral health interventions such as sex education, and drug development, such as research into microbicides for sexually transmitted diseases, HIV vaccines, and antiretroviral drugs. Other medical research areas include the topics of pre-exposure prophylaxis, post-exposure prophylaxis, and circumcision and HIV. Public health officials, researchers, and programs can gain a more comprehensive picture of the barriers they face, and the efficacy of current approaches to HIV treatment and prevention, by tracking standard HIV indicators.[317] Use of common indicators is an increasing focus of development organizations and researchers.[318][319]

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March 20, 2023
aids, aids, aids, redirect, here, other, uses, aids, disambiguation, human, immunodeficiency, virus, infection, acquired, immunodeficiency, syndrome, spectrum, conditions, caused, infection, with, human, immunodeficiency, virus, retrovirus, following, initial,. AIDS and Aids redirect here For other uses see AIDS disambiguation Human immunodeficiency virus infection and acquired immunodeficiency syndrome HIV AIDS is a spectrum of conditions caused by infection with the human immunodeficiency virus HIV 9 10 11 a retrovirus 12 Following initial infection an individual may not notice any symptoms or may experience a brief period of influenza like illness 4 Typically this is followed by a prolonged incubation period with no symptoms 5 If the infection progresses it interferes more with the immune system increasing the risk of developing common infections such as tuberculosis as well as other opportunistic infections and tumors which are rare in people who have normal immune function 4 These late symptoms of infection are referred to as acquired immunodeficiency syndrome AIDS 5 This stage is often also associated with unintended weight loss 5 HIV AIDSOther namesHIV disease HIV infection 1 2 The red ribbon is a symbol for solidarity with HIV positive people and those living with AIDS 3 SpecialtyInfectious disease immunologySymptomsEarly Flu like illness 4 Later Large lymph nodes fever weight loss 4 ComplicationsOpportunistic infections tumors 4 DurationLifelong 4 CausesHuman immunodeficiency virus HIV 4 Risk factorsUnprotected anal or vaginal sex having another sexually transmitted infection needle sharing medical procedures involving unsterile cutting or piercing and experiencing needlestick injury 4 Diagnostic methodBlood tests 4 PreventionSafe sex needle exchange male circumcision pre exposure prophylaxis post exposure prophylaxis 4 TreatmentAntiretroviral therapy 4 PrognosisNear normal life expectancy with treatment 5 6 11 years life expectancy without treatment 7 Frequency64 4 million 113 million total cases 8 1 5 million new cases 2021 8 38 4 million living with HIV 2021 8 Deaths40 1 million total deaths 8 650 000 2021 8 HIV is spread primarily by unprotected sex including anal and vaginal sex contaminated hypodermic needles or blood transfusions and from mother to child during pregnancy delivery or breastfeeding 13 Some bodily fluids such as saliva sweat and tears do not transmit the virus 14 Oral sex has little to no risk of transmitting the virus 15 Methods of prevention include safe sex needle exchange programs treating those who are infected as well as both pre and post exposure prophylaxis 4 Disease in a baby can often be prevented by giving both the mother and child antiretroviral medication 4 Recognized worldwide in the early 1980s 16 HIV AIDS has had a large impact on society both as an illness and as a source of discrimination 17 The disease also has large economic impacts 17 There are many misconceptions about HIV AIDS such as the belief that it can be transmitted by casual non sexual contact 18 The disease has become subject to many controversies involving religion including the Catholic Church s position not to support condom use as prevention 19 It has attracted international medical and political attention as well as large scale funding since it was identified in the 1980s 20 HIV made the jump from other primates to humans in west central Africa in the early to mid 20th century 21 AIDS was first recognized by the U S Centers for Disease Control and Prevention CDC in 1981 and its cause HIV infection was identified in the early part of the decade 16 Between the first time AIDS was readily identified through 2021 the disease is estimated to have caused at least 40 million deaths worldwide 22 In 2021 there were 650 000 deaths and about 38 million people worldwide living with HIV 8 An estimated 20 6 million of these people live in eastern and southern Africa 23 HIV AIDS is considered a pandemic a disease outbreak which is present over a large area and is actively spreading 24 The United States National Institutes of Health NIH and the Gates Foundation have pledged 200 million focused on developing a global cure for AIDS 25 While there is no broadly available cure or vaccine antiretroviral treatment can slow the course of the disease and may lead to a near normal life expectancy 5 6 Treatment is recommended as soon as the diagnosis is made 26 Without treatment the average survival time after infection is 11 years 7 Contents 1 Signs and symptoms 1 1 Acute infection 1 2 Clinical latency 1 3 Acquired immunodeficiency syndrome 2 Transmission 2 1 Sexual 2 2 Body fluids 2 3 Mother to child 3 Virology 4 Pathophysiology 5 Diagnosis 5 1 HIV testing 5 2 Classifications 6 Prevention 6 1 Sexual contact 6 2 Pre exposure 6 3 Post exposure 6 4 Mother to child 6 5 Vaccination 7 Treatment 7 1 Antiviral therapy 7 2 Opportunistic infections 7 3 Diet 7 4 Alternative medicine 8 Prognosis 9 Epidemiology 10 History 10 1 Discovery 10 2 Origins 11 Society and culture 11 1 Stigma 11 2 Economic impact 11 3 Religion and AIDS 11 4 Media portrayal 11 5 Criminal transmission 11 6 Misconceptions 12 Research 13 References 13 1 Notes 14 External linksSigns and symptomsMain article Signs and symptoms of HIV AIDS There are three main stages of HIV infection acute infection clinical latency and AIDS 1 27 Acute infection Main symptoms of acute HIV infection The initial period following the contraction of HIV is called acute HIV primary HIV or acute retroviral syndrome 27 28 Many individuals develop an influenza like illness or a mononucleosis like illness 2 4 weeks after exposure while others have no significant symptoms 29 30 Symptoms occur in 40 90 of cases and most commonly include fever large tender lymph nodes throat inflammation a rash headache tiredness and or sores of the mouth and genitals 28 30 The rash which occurs in 20 50 of cases presents itself on the trunk and is maculopapular classically 31 Some people also develop opportunistic infections at this stage 28 Gastrointestinal symptoms such as vomiting or diarrhea may occur 30 Neurological symptoms of peripheral neuropathy or Guillain Barre syndrome also occur 30 The duration of the symptoms varies but is usually one or two weeks 30 Owing to their nonspecific character these symptoms are not often recognized as signs of HIV infection Even cases that do get seen by a family doctor or a hospital are often misdiagnosed as one of the many common infectious diseases with overlapping symptoms Thus it is recommended that HIV be considered in people presenting with an unexplained fever who may have risk factors for the infection 30 Clinical latency The initial symptoms are followed by a stage called clinical latency asymptomatic HIV or chronic HIV 1 Without treatment this second stage of the natural history of HIV infection can last from about three years 32 to over 20 years 33 on average about eight years 34 While typically there are few or no symptoms at first near the end of this stage many people experience fever weight loss gastrointestinal problems and muscle pains 1 Between 50 and 70 of people also develop persistent generalized lymphadenopathy characterized by unexplained non painful enlargement of more than one group of lymph nodes other than in the groin for over three to six months 27 Although most HIV 1 infected individuals have a detectable viral load and in the absence of treatment will eventually progress to AIDS a small proportion about 5 retain high levels of CD4 T cells T helper cells without antiretroviral therapy for more than five years 30 35 These individuals are classified as HIV controllers or long term nonprogressors LTNP 35 Another group consists of those who maintain a low or undetectable viral load without anti retroviral treatment known as elite controllers or elite suppressors They represent approximately 1 in 300 infected persons 36 Acquired immunodeficiency syndrome Main symptoms of AIDS Acquired immunodeficiency syndrome AIDS is defined as an HIV infection with either a CD4 T cell count below 200 cells per µL or the occurrence of specific diseases associated with HIV infection 30 In the absence of specific treatment around half of people infected with HIV develop AIDS within ten years 30 The most common initial conditions that alert to the presence of AIDS are pneumocystis pneumonia 40 cachexia in the form of HIV wasting syndrome 20 and esophageal candidiasis 30 Other common signs include recurrent respiratory tract infections 30 Opportunistic infections may be caused by bacteria viruses fungi and parasites that are normally controlled by the immune system 37 Which infections occur depends partly on what organisms are common in the person s environment 30 These infections may affect nearly every organ system 38 People with AIDS have an increased risk of developing various viral induced cancers including Kaposi s sarcoma Burkitt s lymphoma primary central nervous system lymphoma and cervical cancer 31 Kaposi s sarcoma is the most common cancer occurring in 10 to 20 of people with HIV 39 The second most common cancer is lymphoma which is the cause of death of nearly 16 of people with AIDS and is the initial sign of AIDS in 3 to 4 39 Both these cancers are associated with human herpesvirus 8 HHV 8 39 Cervical cancer occurs more frequently in those with AIDS because of its association with human papillomavirus HPV 39 Conjunctival cancer of the layer that lines the inner part of eyelids and the white part of the eye is also more common in those with HIV 40 Additionally people with AIDS frequently have systemic symptoms such as prolonged fevers sweats particularly at night swollen lymph nodes chills weakness and unintended weight loss 41 Diarrhea is another common symptom present in about 90 of people with AIDS 42 They can also be affected by diverse psychiatric and neurological symptoms independent of opportunistic infections and cancers 43 TransmissionAverage per act risk of getting HIVby exposure route to an infected source Exposure route Chance of infectionBlood transfusion 90 44 Childbirth to child 25 45 clarification needed Needle sharing injection drug use 0 67 46 Percutaneous needle stick 0 30 47 Receptive anal intercourse 0 04 3 0 48 Insertive anal intercourse 0 03 49 Receptive penile vaginal intercourse 0 05 0 30 48 50 Insertive penile vaginal intercourse 0 01 0 38 48 50 Receptive oral intercourse 0 0 04 48 Insertive oral intercourse 0 0 005 51 assuming no condom use source refers to oral intercourseperformed on a manHIV is spread by three main routes sexual contact significant exposure to infected body fluids or tissues and from mother to child during pregnancy delivery or breastfeeding known as vertical transmission 13 There is no risk of acquiring HIV if exposed to feces nasal secretions saliva sputum sweat tears urine or vomit unless these are contaminated with blood 52 It is also possible to be co infected by more than one strain of HIV a condition known as HIV superinfection 53 Sexual The most frequent mode of transmission of HIV is through sexual contact with an infected person 13 However an HIV positive person who has an undetectable viral load as a result of long term treatment has effectively no risk of transmitting HIV sexually 54 55 The existence of functionally noncontagious HIV positive people on antiretroviral therapy was controversially publicized in the 2008 Swiss Statement and has since become accepted as medically sound 56 Globally the most common mode of HIV transmission is via sexual contacts between people of the opposite sex 13 however the pattern of transmission varies among countries As of 2017 update most HIV transmission in the United States occurred among men who had sex with men 82 of new HIV diagnoses among males aged 13 and older and 70 of total new diagnoses 57 58 In the US gay and bisexual men aged 13 to 24 accounted for an estimated 92 of new HIV diagnoses among all men in their age group and 27 of new diagnoses among all gay and bisexual men 59 With regard to unprotected heterosexual contacts estimates of the risk of HIV transmission per sexual act appear to be four to ten times higher in low income countries than in high income countries 60 In low income countries the risk of female to male transmission is estimated as 0 38 per act and of male to female transmission as 0 30 per act the equivalent estimates for high income countries are 0 04 per act for female to male transmission and 0 08 per act for male to female transmission 60 The risk of transmission from anal intercourse is especially high estimated as 1 4 1 7 per act in both heterosexual and homosexual contacts 60 61 While the risk of transmission from oral sex is relatively low it is still present 62 The risk from receiving oral sex has been described as nearly nil 63 however a few cases have been reported 64 The per act risk is estimated at 0 0 04 for receptive oral intercourse 65 In settings involving prostitution in low income countries risk of female to male transmission has been estimated as 2 4 per act and of male to female transmission as 0 05 per act 60 Risk of transmission increases in the presence of many sexually transmitted infections 66 and genital ulcers 60 Genital ulcers appear to increase the risk approximately fivefold 60 Other sexually transmitted infections such as gonorrhea chlamydia trichomoniasis and bacterial vaginosis are associated with somewhat smaller increases in risk of transmission 65 The viral load of an infected person is an important risk factor in both sexual and mother to child transmission 67 During the first 2 5 months of an HIV infection a person s infectiousness is twelve times higher due to the high viral load associated with acute HIV 65 If the person is in the late stages of infection rates of transmission are approximately eightfold greater 60 Commercial sex workers including those in pornography have an increased likelihood of contracting HIV 68 69 Rough sex can be a factor associated with an increased risk of transmission 70 Sexual assault is also believed to carry an increased risk of HIV transmission as condoms are rarely worn physical trauma to the vagina or rectum is likely and there may be a greater risk of concurrent sexually transmitted infections 71 Body fluids CDC poster from 1989 highlighting the threat of AIDS associated with drug use The second most frequent mode of HIV transmission is via blood and blood products 13 Blood borne transmission can be through needle sharing during intravenous drug use needle stick injury transfusion of contaminated blood or blood product or medical injections with unsterilized equipment The risk from sharing a needle during drug injection is between 0 63 and 2 4 per act with an average of 0 8 72 The risk of acquiring HIV from a needle stick from an HIV infected person is estimated as 0 3 about 1 in 333 per act and the risk following mucous membrane exposure to infected blood as 0 09 about 1 in 1000 per act 52 This risk may however be up to 5 if the introduced blood was from a person with a high viral load and the cut was deep 73 In the United States intravenous drug users made up 12 of all new cases of HIV in 2009 74 and in some areas more than 80 of people who inject drugs are HIV positive 13 HIV is transmitted in about 90 of blood transfusions using infected blood 44 In developed countries the risk of acquiring HIV from a blood transfusion is extremely low less than one in half a million where improved donor selection and HIV screening is performed 13 for example in the UK the risk is reported at one in five million 75 and in the United States it was one in 1 5 million in 2008 76 In low income countries only half of transfusions may be appropriately screened as of 2008 77 and it is estimated that up to 15 of HIV infections in these areas come from transfusion of infected blood and blood products representing between 5 and 10 of global infections 13 78 It is possible to acquire HIV from organ and tissue transplantation although this is rare because of screening 79 Unsafe medical injections play a role in HIV spread in sub Saharan Africa In 2007 between 12 and 17 of infections in this region were attributed to medical syringe use 80 The World Health Organization estimates the risk of transmission as a result of a medical injection in Africa at 1 2 80 Risks are also associated with invasive procedures assisted delivery and dental care in this area of the world 80 People giving or receiving tattoos piercings and scarification are theoretically at risk of infection but no confirmed cases have been documented 81 It is not possible for mosquitoes or other insects to transmit HIV 82 Mother to child Main articles HIV and pregnancy and HIV and breastfeeding HIV can be transmitted from mother to child during pregnancy during delivery or through breast milk resulting in the baby also contracting HIV 83 13 As of 2008 vertical transmission accounted for about 90 of cases of HIV in children 84 In the absence of treatment the risk of transmission before or during birth is around 20 and in those who also breastfeed 35 84 Treatment decreases this risk to less than 5 85 Antiretrovirals when taken by either the mother or the baby decrease the risk of transmission in those who do breastfeed 86 If blood contaminates food during pre chewing it may pose a risk of transmission 81 If a woman is untreated two years of breastfeeding results in an HIV AIDS risk in her baby of about 17 87 Due to the increased risk of death without breastfeeding in many areas in the developing world the World Health Organization recommends either exclusive breastfeeding or the provision of safe formula 87 All women known to be HIV positive should be taking lifelong antiretroviral therapy 87 VirologyMain article HIV Diagram of a HIV virion structure Scanning electron micrograph of HIV 1 colored green budding from a cultured lymphocyte HIV is the cause of the spectrum of disease known as HIV AIDS HIV is a retrovirus that primarily infects components of the human immune system such as CD4 T cells macrophages and dendritic cells It directly and indirectly destroys CD4 T cells 88 HIV is a member of the genus Lentivirus 89 part of the family Retroviridae 90 Lentiviruses share many morphological and biological characteristics Many species of mammals are infected by lentiviruses which are characteristically responsible for long duration illnesses with a long incubation period 91 Lentiviruses are transmitted as single stranded positive sense enveloped RNA viruses Upon entry into the target cell the viral RNA genome is converted reverse transcribed into double stranded DNA by a virally encoded reverse transcriptase that is transported along with the viral genome in the virus particle The resulting viral DNA is then imported into the cell nucleus and integrated into the cellular DNA by a virally encoded integrase and host co factors 92 Once integrated the virus may become latent allowing the virus and its host cell to avoid detection by the immune system 93 Alternatively the virus may be transcribed producing new RNA genomes and viral proteins that are packaged and released from the cell as new virus particles that begin the replication cycle anew 94 HIV is now known to spread between CD4 T cells by two parallel routes cell free spread and cell to cell spread i e it employs hybrid spreading mechanisms 95 In the cell free spread virus particles bud from an infected T cell enter the blood extracellular fluid and then infect another T cell following a chance encounter 95 HIV can also disseminate by direct transmission from one cell to another by a process of cell to cell spread 96 97 The hybrid spreading mechanisms of HIV contribute to the virus s ongoing replication against antiretroviral therapies 95 98 Two types of HIV have been characterized HIV 1 and HIV 2 HIV 1 is the virus that was originally discovered and initially referred to also as LAV or HTLV III It is more virulent more infective 99 and is the cause of the majority of HIV infections globally The lower infectivity of HIV 2 as compared with HIV 1 implies that fewer people exposed to HIV 2 will be infected per exposure Because of its relatively poor capacity for transmission HIV 2 is largely confined to West Africa 100 PathophysiologyMain article Pathophysiology of HIV AIDS source source source source source source source source source source track track track HIV AIDS explained in a simple way HIV replication cycle After the virus enters the body there is a period of rapid viral replication leading to an abundance of virus in the peripheral blood During primary infection the level of HIV may reach several million virus particles per milliliter of blood 101 This response is accompanied by a marked drop in the number of circulating CD4 T cells The acute viremia is almost invariably associated with activation of CD8 T cells which kill HIV infected cells and subsequently with antibody production or seroconversion The CD8 T cell response is thought to be important in controlling virus levels which peak and then decline as the CD4 T cell counts recover A good CD8 T cell response has been linked to slower disease progression and a better prognosis though it does not eliminate the virus 102 Ultimately HIV causes AIDS by depleting CD4 T cells This weakens the immune system and allows opportunistic infections T cells are essential to the immune response and without them the body cannot fight infections or kill cancerous cells The mechanism of CD4 T cell depletion differs in the acute and chronic phases 103 During the acute phase HIV induced cell lysis and killing of infected cells by CD8 T cells accounts for CD4 T cell depletion although apoptosis may also be a factor During the chronic phase the consequences of generalized immune activation coupled with the gradual loss of the ability of the immune system to generate new T cells appear to account for the slow decline in CD4 T cell numbers 104 Although the symptoms of immune deficiency characteristic of AIDS do not appear for years after a person is infected the bulk of CD4 T cell loss occurs during the first weeks of infection especially in the intestinal mucosa which harbors the majority of the lymphocytes found in the body 105 The reason for the preferential loss of mucosal CD4 T cells is that the majority of mucosal CD4 T cells express the CCR5 protein which HIV uses as a co receptor to gain access to the cells whereas only a small fraction of CD4 T cells in the bloodstream do so 106 A specific genetic change that alters the CCR5 protein when present in both chromosomes very effectively prevents HIV 1 infection 107 HIV seeks out and destroys CCR5 expressing CD4 T cells during acute infection 108 A vigorous immune response eventually controls the infection and initiates the clinically latent phase CD4 T cells in mucosal tissues remain particularly affected 108 Continuous HIV replication causes a state of generalized immune activation persisting throughout the chronic phase 109 Immune activation which is reflected by the increased activation state of immune cells and release of pro inflammatory cytokines results from the activity of several HIV gene products and the immune response to ongoing HIV replication It is also linked to the breakdown of the immune surveillance system of the gastrointestinal mucosal barrier caused by the depletion of mucosal CD4 T cells during the acute phase of disease 110 DiagnosisMain article Diagnosis of HIV AIDS A generalized graph of the relationship between HIV copies viral load and CD4 T cell counts over the average course of untreated HIV infection CD4 T Lymphocyte count cells mm HIV RNA copies per mL of plasma Days after exposure needed for the test to be accurate 111 Blood test DaysAntibody test rapid test ELISA 3rd gen 23 90Antibody and p24 antigen test ELISA 4th gen 18 45PCR 10 33HIV AIDS is diagnosed via laboratory testing and then staged based on the presence of certain signs or symptoms 28 HIV screening is recommended by the United States Preventive Services Task Force for all people 15 years to 65 years of age including all pregnant women 112 Additionally testing is recommended for those at high risk which includes anyone diagnosed with a sexually transmitted illness 31 112 In many areas of the world a third of HIV carriers only discover they are infected at an advanced stage of the disease when AIDS or severe immunodeficiency has become apparent 31 HIV testing HIV rapid test being administered Oraquick Most people infected with HIV develop specific antibodies i e seroconvert within three to twelve weeks after the initial infection 30 Diagnosis of primary HIV before seroconversion is done by measuring HIV RNA or p24 antigen 30 Positive results obtained by antibody or PCR testing are confirmed either by a different antibody or by PCR 28 Antibody tests in children younger than 18 months are typically inaccurate due to the continued presence of maternal antibodies 113 Thus HIV infection can only be diagnosed by PCR testing for HIV RNA or DNA or via testing for the p24 antigen 28 Much of the world lacks access to reliable PCR testing and people in many places simply wait until either symptoms develop or the child is old enough for accurate antibody testing 113 In sub Saharan Africa between 2007 and 2009 between 30 and 70 of the population were aware of their HIV status 114 In 2009 between 3 6 and 42 of men and women in sub Saharan countries were tested 114 this represented a significant increase compared to previous years 114 Classifications Two main clinical staging systems are used to classify HIV and HIV related disease for surveillance purposes the WHO disease staging system for HIV infection and disease 28 and the CDC classification system for HIV infection 115 The CDC s classification system is more frequently adopted in developed countries Since the WHO s staging system does not require laboratory tests it is suited to the resource restricted conditions encountered in developing countries where it can also be used to help guide clinical management Despite their differences the two systems allow a comparison for statistical purposes 27 28 115 The World Health Organization first proposed a definition for AIDS in 1986 28 Since then the WHO classification has been updated and expanded several times with the most recent version being published in 2007 28 The WHO system uses the following categories Primary HIV infection May be either asymptomatic or associated with acute retroviral syndrome 28 Stage I HIV infection is asymptomatic with a CD4 T cell count also known as CD4 count greater than 500 per microlitre µl or cubic mm of blood 28 May include generalized lymph node enlargement 28 Stage II Mild symptoms which may include minor mucocutaneous manifestations and recurrent upper respiratory tract infections A CD4 count of less than 500 µl 28 Stage III Advanced symptoms which may include unexplained chronic diarrhea for longer than a month severe bacterial infections including tuberculosis of the lung and a CD4 count of less than 350 µl 28 Stage IV or AIDS severe symptoms which include toxoplasmosis of the brain candidiasis of the esophagus trachea bronchi or lungs and Kaposi s sarcoma A CD4 count of less than 200 µl 28 The U S Centers for Disease Control and Prevention also created a classification system for HIV and updated it in 2008 and 2014 115 116 This system classifies HIV infections based on CD4 count and clinical symptoms and describes the infection in five groups 116 In those greater than six years of age it is 116 Stage 0 the time between a negative or indeterminate HIV test followed less than 180 days by a positive test Stage 1 CD4 count 500 cells µl and no AIDS defining conditions Stage 2 CD4 count 200 to 500 cells µl and no AIDS defining conditions Stage 3 CD4 count 200 cells µl or AIDS defining conditions Unknown if insufficient information is available to make any of the above classifications For surveillance purposes the AIDS diagnosis still stands even if after treatment the CD4 T cell count rises to above 200 per µL of blood or other AIDS defining illnesses are cured 27 PreventionMain article Prevention of HIV AIDS AIDS clinic McLeod Ganj Himachal Pradesh India 2010 Sexual contact People wearing AIDS awareness signs On the left Facing AIDS a condom and a pill at a time on the right I am Facing AIDS because people I are infected Consistent condom use reduces the risk of HIV transmission by approximately 80 over the long term 117 When condoms are used consistently by a couple in which one person is infected the rate of HIV infection is less than 1 per year 118 There is some evidence to suggest that female condoms may provide an equivalent level of protection 119 Application of a vaginal gel containing tenofovir a reverse transcriptase inhibitor immediately before sex seems to reduce infection rates by approximately 40 among African women 120 By contrast use of the spermicide nonoxynol 9 may increase the risk of transmission due to its tendency to cause vaginal and rectal irritation 121 Circumcision in sub Saharan Africa reduces the acquisition of HIV by heterosexual men by between 38 and 66 over 24 months 122 Owing to these studies both the World Health Organization and UNAIDS recommended male circumcision in 2007 as a method of preventing female to male HIV transmission in areas with high rates of HIV 123 However whether it protects against male to female transmission is disputed 124 125 and whether it is of benefit in developed countries and among men who have sex with men is undetermined 126 127 128 Programs encouraging sexual abstinence do not appear to affect subsequent HIV risk 129 Evidence of any benefit from peer education is equally poor 130 Comprehensive sexual education provided at school may decrease high risk behavior 131 132 A substantial minority of young people continues to engage in high risk practices despite knowing about HIV AIDS underestimating their own risk of becoming infected with HIV 133 Voluntary counseling and testing people for HIV does not affect risky behavior in those who test negative but does increase condom use in those who test positive 134 Enhanced family planning services appear to increase the likelihood of women with HIV using contraception compared to basic services 135 It is not known whether treating other sexually transmitted infections is effective in preventing HIV 66 Pre exposure Antiretroviral treatment among people with HIV whose CD4 count 550 cells µL is a very effective way to prevent HIV infection of their partner a strategy known as treatment as prevention or TASP 136 TASP is associated with a 10 to 20 fold reduction in transmission risk 136 137 Pre exposure prophylaxis PrEP with a daily dose of the medications tenofovir with or without emtricitabine is effective in people at high risk including men who have sex with men couples where one is HIV positive and young heterosexuals in Africa 120 138 It may also be effective in intravenous drug users with a study finding a decrease in risk of 0 7 to 0 4 per 100 person years 139 The USPSTF in 2019 recommended PrEP in those who are at high risk 140 Universal precautions within the health care environment are believed to be effective in decreasing the risk of HIV 141 Intravenous drug use is an important risk factor and harm reduction strategies such as needle exchange programs and opioid substitution therapy appear effective in decreasing this risk 142 143 Post exposure A course of antiretrovirals administered within 48 to 72 hours after exposure to HIV positive blood or genital secretions is referred to as post exposure prophylaxis PEP 144 The use of the single agent zidovudine reduces the risk of a HIV infection five fold following a needle stick injury 144 As of 2013 update the prevention regimen recommended in the United States consists of three medications tenofovir emtricitabine and raltegravir as this may reduce the risk further 145 PEP treatment is recommended after a sexual assault when the perpetrator is known to be HIV positive but is controversial when their HIV status is unknown 146 The duration of treatment is usually four weeks 147 and is frequently associated with adverse effects where zidovudine is used about 70 of cases result in adverse effects such as nausea 24 fatigue 22 emotional distress 13 and headaches 9 52 Mother to child Main article HIV and pregnancy Programs to prevent the vertical transmission of HIV from mothers to children can reduce rates of transmission by 92 99 84 142 This primarily involves the use of a combination of antiviral medications during pregnancy and after birth in the infant and potentially includes bottle feeding rather than breastfeeding 84 148 If replacement feeding is acceptable feasible affordable sustainable and safe mothers should avoid breastfeeding their infants however exclusive breastfeeding is recommended during the first months of life if this is not the case 149 If exclusive breastfeeding is carried out the provision of extended antiretroviral prophylaxis to the infant decreases the risk of transmission 150 In 2015 Cuba became the first country in the world to eradicate mother to child transmission of HIV 151 Vaccination Main article HIV vaccine Currently there is no licensed vaccine for HIV or AIDS 6 The most effective vaccine trial to date RV 144 was published in 2009 it found a partial reduction in the risk of transmission of roughly 30 stimulating some hope in the research community of developing a truly effective vaccine 152 TreatmentMain article Management of HIV AIDS There is currently no cure nor an effective HIV vaccine Treatment consists of highly active antiretroviral therapy HAART which slows progression of the disease 153 As of 2010 update more than 6 6 million people were receiving HAART in low and middle income countries 154 Treatment also includes preventive and active treatment of opportunistic infections As of July 2022 update four people have been successfully cleared of HIV 155 156 157 Rapid initiation of antiretroviral therapy within one week of diagnosis appear to improve treatment outcomes in low and medium income settings 158 Antiviral therapy Stribild a common once daily ART regime consisting of elvitegravir emtricitabine tenofovir and the booster cobicistat Current HAART options are combinations or cocktails consisting of at least three medications belonging to at least two types or classes of antiretroviral agents 159 Initially treatment is typically a non nucleoside reverse transcriptase inhibitor NNRTI plus two nucleoside analog reverse transcriptase inhibitors NRTIs 160 Typical NRTIs include zidovudine AZT or tenofovir TDF and lamivudine 3TC or emtricitabine FTC 160 As of 2019 update dolutegravir lamivudine tenofovir is listed by the World Health Organization as the first line treatment for adults with tenofovir lamivudine efavirenz as an alternative 161 Combinations of agents that include protease inhibitors PI are used if the above regimen loses effectiveness 159 The World Health Organization and the United States recommend antiretrovirals in people of all ages including pregnant women as soon as the diagnosis is made regardless of CD4 count 26 162 163 Once treatment is begun it is recommended that it is continued without breaks or holidays 31 Many people are diagnosed only after treatment ideally should have begun 31 The desired outcome of treatment is a long term plasma HIV RNA count below 50 copies mL 31 Levels to determine if treatment is effective are initially recommended after four weeks and once levels fall below 50 copies mL checks every three to six months are typically adequate 31 Inadequate control is deemed to be greater than 400 copies mL 31 Based on these criteria treatment is effective in more than 95 of people during the first year 31 Benefits of treatment include a decreased risk of progression to AIDS and a decreased risk of death 164 In the developing world treatment also improves physical and mental health 165 With treatment there is a 70 reduced risk of acquiring tuberculosis 159 Additional benefits include a decreased risk of transmission of the disease to sexual partners and a decrease in mother to child transmission 159 166 The effectiveness of treatment depends to a large part on compliance 31 Reasons for non adherence to treatment include poor access to medical care 167 inadequate social supports mental illness and drug abuse 168 The complexity of treatment regimens due to pill numbers and dosing frequency and adverse effects may reduce adherence 169 Even though cost is an important issue with some medications 170 47 of those who needed them were taking them in low and middle income countries as of 2010 update 154 and the rate of adherence is similar in low income and high income countries 171 Specific adverse events are related to the antiretroviral agent taken 172 Some relatively common adverse events include lipodystrophy syndrome dyslipidemia and diabetes mellitus especially with protease inhibitors 27 Other common symptoms include diarrhea 172 173 and an increased risk of cardiovascular disease 174 Newer recommended treatments are associated with fewer adverse effects 31 Certain medications may be associated with birth defects and therefore may be unsuitable for women hoping to have children 31 Treatment recommendations for children are somewhat different from those for adults The World Health Organization recommends treating all children less than five years of age children above five are treated like adults 175 The United States guidelines recommend treating all children less than 12 months of age and all those with HIV RNA counts greater than 100 000 copies mL between one year and five years of age 176 The European Medicines Agency EMA has recommended the granting of marketing authorizations for two new antiretroviral ARV medicines rilpivirine Rekambys and cabotegravir Vocabria to be used together for the treatment of people with human immunodeficiency virus type 1 HIV 1 infection 177 The two medicines are the first ARVs that come in a long acting injectable formulation 177 This means that instead of daily pills people receive intramuscular injections monthly or every two months 177 The combination of Rekambys and Vocabria injection is intended for maintenance treatment of adults who have undetectable HIV levels in the blood viral load less than 50 copies ml with their current ARV treatment and when the virus has not developed resistance to a certain class of anti HIV medicines called non nucleoside reverse transcriptase inhibitors NNRTIs and integrase strand transfer inhibitors INIs 177 Cabotegravir combined with rilpivirine Cabenuva is a complete regimen for the treatment of human immunodeficiency virus type 1 HIV 1 infection in adults to replace a current antiretroviral regimen in those who are virologically suppressed on a stable antiretroviral regimen with no history of treatment failure and with no known or suspected resistance to either cabotegravir or rilpivirine 178 179 Opportunistic infections Main article Opportunistic infection Opportunistic Infection and HIV AIDS Measures to prevent opportunistic infections are effective in many people with HIV AIDS In addition to improving current disease treatment with antiretrovirals reduces the risk of developing additional opportunistic infections 172 Adults and adolescents who are living with HIV even on anti retroviral therapy with no evidence of active tuberculosis in settings with high tuberculosis burden should receive isoniazid preventive therapy IPT the tuberculin skin test can be used to help decide if IPT is needed 180 Children with HIV may benefit from screening for tuberculosis 181 Vaccination against hepatitis A and B is advised for all people at risk of HIV before they become infected however it may also be given after infection 182 Trimethoprim sulfamethoxazole prophylaxis between four and six weeks of age and ceasing breastfeeding of infants born to HIV positive mothers is recommended in resource limited settings 183 It is also recommended to prevent PCP when a person s CD4 count is below 200 cells uL and in those who have or have previously had PCP 184 People with substantial immunosuppression are also advised to receive prophylactic therapy for toxoplasmosis and MAC 185 Appropriate preventive measures reduced the rate of these infections by 50 between 1992 and 1997 186 Influenza vaccination and pneumococcal polysaccharide vaccine are often recommended in people with HIV AIDS with some evidence of benefit 187 188 Diet Main article Nutrition and HIV AIDS The World Health Organization WHO has issued recommendations regarding nutrient requirements in HIV AIDS 189 A generally healthy diet is promoted Dietary intake of micronutrients at RDA levels by HIV infected adults is recommended by the WHO higher intake of vitamin A zinc and iron can produce adverse effects in HIV positive adults and is not recommended unless there is documented deficiency 189 190 191 192 Dietary supplementation for people who are infected with HIV and who have inadequate nutrition or dietary deficiencies may strengthen their immune systems or help them recover from infections however evidence indicating an overall benefit in morbidity or reduction in mortality is not consistent 193 People with HIV AIDS are up to four times more likely to develop type 2 diabetes than those who are not tested positive with the virus 194 Evidence for supplementation with selenium is mixed with some tentative evidence of benefit 195 For pregnant and lactating women with HIV multivitamin supplement improves outcomes for both mothers and children 196 If the pregnant or lactating mother has been advised to take anti retroviral medication to prevent mother to child HIV transmission multivitamin supplements should not replace these treatments 196 There is some evidence that vitamin A supplementation in children with an HIV infection reduces mortality and improves growth 197 Alternative medicine In the US approximately 60 of people with HIV use various forms of complementary or alternative medicine 198 whose effectiveness has not been established 199 There is not enough evidence to support the use of herbal medicines 200 There is insufficient evidence to recommend or support the use of medical cannabis to try to increase appetite or weight gain 201 Prognosis Deaths due to HIV AIDS per million people in 2012 0 1 4 5 12 13 34 35 61 62 134 135 215 216 458 459 1 402 1 403 5 828 HIV AIDS has become a chronic rather than an acutely fatal disease in many areas of the world 202 Prognosis varies between people and both the CD4 count and viral load are useful for predicted outcomes 30 Without treatment average survival time after infection with HIV is estimated to be 9 to 11 years depending on the HIV subtype 7 After the diagnosis of AIDS if treatment is not available survival ranges between 6 and 19 months 203 204 HAART and appropriate prevention of opportunistic infections reduces the death rate by 80 and raises the life expectancy for a newly diagnosed young adult to 20 50 years 202 205 206 This is between two thirds 205 and nearly that of the general population 31 207 If treatment is started late in the infection prognosis is not as good 31 for example if treatment is begun following the diagnosis of AIDS life expectancy is 10 40 years 31 202 Half of infants born with HIV die before two years of age without treatment 183 clarification needed Disability adjusted life year for HIV and AIDS per 100 000 inhabitants as of 2004 no data 10 10 25 25 50 50 100 100 500 500 1000 1 000 2 500 2 500 5 000 5 000 7500 7 500 10 000 10 000 50 000 50 000 The primary causes of death from HIV AIDS are opportunistic infections and cancer both of which are frequently the result of the progressive failure of the immune system 186 208 Risk of cancer appears to increase once the CD4 count is below 500 mL 31 The rate of clinical disease progression varies widely between individuals and has been shown to be affected by a number of factors such as a person s susceptibility and immune function 209 their access to health care the presence of co infections 203 210 and the particular strain or strains of the virus involved 211 212 Tuberculosis co infection is one of the leading causes of sickness and death in those with HIV AIDS being present in a third of all HIV infected people and causing 25 of HIV related deaths 213 HIV is also one of the most important risk factors for tuberculosis 214 Hepatitis C is another very common co infection where each disease increases the progression of the other 215 The two most common cancers associated with HIV AIDS are Kaposi s sarcoma and AIDS related non Hodgkin s lymphoma 208 Other cancers that are more frequent include anal cancer Burkitt s lymphoma primary central nervous system lymphoma and cervical cancer 31 216 Even with anti retroviral treatment over the long term HIV infected people may experience neurocognitive disorders 217 osteoporosis 218 neuropathy 219 cancers 220 221 nephropathy 222 and cardiovascular disease 173 Some conditions such as lipodystrophy may be caused both by HIV and its treatment 173 EpidemiologyMain article Epidemiology of HIV AIDS See or edit source data Percentage of people with HIV AIDS 223 Trends in new cases and deaths per year from HIV AIDS 223 Some authors consider HIV AIDS a global pandemic 224 As of 2016 update approximately 36 7 million people worldwide have HIV the number of new infections that year being about 1 8 million 225 This is down from 3 1 million new infections in 2001 226 Slightly over half the infected population are women and 2 1 million are children 225 It resulted in about 1 million deaths in 2016 down from a peak of 1 9 million in 2005 225 Sub Saharan Africa is the region most affected In 2010 an estimated 68 22 9 million of all HIV cases and 66 of all deaths 1 2 million occurred in this region 227 This means that about 5 of the adult population is infected 228 and it is believed to be the cause of 10 of all deaths in children 229 Here in contrast to other regions women comprise nearly 60 of cases 227 South Africa has the largest population of people with HIV of any country in the world at 5 9 million 227 Life expectancy has fallen in the worst affected countries due to HIV AIDS for example in 2006 it was estimated that it had dropped from 65 to 35 years in Botswana 24 Mother to child transmission in Botswana and South Africa as of 2013 update has decreased to less than 5 with improvement in many other African nations due to improved access to antiretroviral therapy 230 South amp South East Asia is the second most affected in 2010 this region contained an estimated 4 million cases or 12 of all people living with HIV resulting in approximately 250 000 deaths 228 Approximately 2 4 million of these cases are in India 227 During 2008 in the United States approximately 1 2 million people were living with HIV resulting in about 17 500 deaths The US Centers for Disease Control and Prevention estimated that in that year 20 of infected Americans were unaware of their infection 231 As of 2016 update about 675 000 people have died of HIV AIDS in the US since the beginning of the HIV epidemic 232 In the United Kingdom as of 2015 update there were approximately 101 200 cases which resulted in 594 deaths 233 In Canada as of 2008 there were about 65 000 cases causing 53 deaths 234 Between the first recognition of AIDS in 1981 and 2009 it has led to nearly 30 million deaths 235 Rates of HIV are lowest in North Africa and the Middle East 0 1 or less East Asia 0 1 and Western and Central Europe 0 2 228 The worst affected European countries in 2009 and 2012 estimates are Russia Ukraine Latvia Moldova Portugal and Belarus in decreasing order of prevalence 236 HistoryMain article History of HIV AIDS For a chronological guide see Timeline of HIV AIDS Further information Category HIV AIDS by country Discovery The Morbidity and Mortality Weekly Report reported in 1981 on what was later to be called AIDS The first news story on the disease appeared on May 18 1981 in the gay newspaper New York Native 237 238 AIDS was first clinically reported on June 5 1981 with five cases in the United States 39 239 The initial cases were a cluster of injecting drug users and gay men with no known cause of impaired immunity who showed symptoms of Pneumocystis carinii pneumonia PCP a rare opportunistic infection that was known to occur in people with very compromised immune systems 240 Soon thereafter a large number of homosexual men developed a generally rare skin cancer called Kaposi s sarcoma KS 241 242 Many more cases of PCP and KS emerged alerting U S Centers for Disease Control and Prevention CDC and a CDC task force was formed to monitor the outbreak 243 In the early days the CDC did not have an official name for the disease often referring to it by way of diseases associated with it such as lymphadenopathy the disease after which the discoverers of HIV originally named the virus 244 245 They also used Kaposi s sarcoma and opportunistic infections the name by which a task force had been set up in 1981 246 At one point the CDC referred to it as the 4H disease as the syndrome seemed to affect heroin users homosexuals hemophiliacs and Haitians 247 248 The term GRID which stood for gay related immune deficiency had also been coined 249 However after determining that AIDS was not isolated to the gay community 246 it was realized that the term GRID was misleading and the term AIDS was introduced at a meeting in July 1982 250 By September 1982 the CDC started referring to the disease as AIDS 251 In 1983 two separate research groups led by Robert Gallo and Luc Montagnier declared that a novel retrovirus may have been infecting people with AIDS and published their findings in the same issue of the journal Science 252 245 Gallo claimed a virus which his group had isolated from a person with AIDS was strikingly similar in shape to other human T lymphotropic viruses HTLVs that his group had been the first to isolate Gallo s group called their newly isolated virus HTLV III At the same time Montagnier s group isolated a virus from a person presenting with swelling of the lymph nodes of the neck and physical weakness two characteristic symptoms of AIDS Contradicting the report from Gallo s group Montagnier and his colleagues showed that core proteins of this virus were immunologically different from those of HTLV I Montagnier s group named their isolated virus lymphadenopathy associated virus LAV 243 As these two viruses turned out to be the same in 1986 LAV and HTLV III were renamed HIV 253 Origins Left to right the African green monkey source of SIV the sooty mangabey source of HIV 2 and the chimpanzee source of HIV 1 The origin of HIV AIDS and the circumstances that led to its emergence remain unsolved 254 Both HIV 1 and HIV 2 are believed to have originated in non human primates in West central Africa and were transferred to humans in the early 20th century 21 HIV 1 appears to have originated in southern Cameroon through the evolution of SIV cpz a simian immunodeficiency virus SIV that infects wild chimpanzees HIV 1 descends from the SIVcpz endemic in the chimpanzee subspecies Pan troglodytes troglodytes 255 256 The closest relative of HIV 2 is SIV smm a virus of the sooty mangabey Cercocebus atys atys an Old World monkey living in coastal West Africa from southern Senegal to western Ivory Coast 100 New World monkeys such as the owl monkey are resistant to HIV 1 infection possibly because of a genomic fusion of two viral resistance genes 257 HIV 1 is thought to have jumped the species barrier on at least three separate occasions giving rise to the three groups of the virus M N and O 258 There is evidence that humans who participate in bushmeat activities either as hunters or as bushmeat vendors commonly acquire SIV 259 However SIV is a weak virus which is typically suppressed by the human immune system within weeks of infection It is thought that several transmissions of the virus from individual to individual in quick succession are necessary to allow it enough time to mutate into HIV 260 Furthermore due to its relatively low person to person transmission rate SIV can only spread throughout the population in the presence of one or more high risk transmission channels which are thought to have been absent in Africa before the 20th century Specific proposed high risk transmission channels allowing the virus to adapt to humans and spread throughout society depend on the proposed timing of the animal to human crossing Genetic studies of the virus suggest that the most recent common ancestor of the HIV 1 M group dates back to c 1910 261 Proponents of this dating link the HIV epidemic with the emergence of colonialism and growth of large colonial African cities leading to social changes including a higher degree of sexual promiscuity the spread of prostitution and the accompanying high frequency of genital ulcer diseases such as syphilis in nascent colonial cities 262 While transmission rates of HIV during vaginal intercourse are low under regular circumstances they are increased manyfold if one of the partners has a sexually transmitted infection causing genital ulcers Early 1900s colonial cities were notable for their high prevalence of prostitution and genital ulcers to the degree that as of 1928 as many as 45 of female residents of eastern Kinshasa were thought to have been prostitutes and as of 1933 around 15 of all residents of the same city had syphilis 262 An alternative view holds that unsafe medical practices in Africa after World War II such as unsterile reuse of single use syringes during mass vaccination antibiotic and anti malaria treatment campaigns were the initial vector that allowed the virus to adapt to humans and spread 260 263 264 The earliest well documented case of HIV in a human dates back to 1959 in the Congo 265 The virus may have been present in the U S as early as the mid to late 1950s as a sixteen year old male named Robert Rayford presented with symptoms in 1966 and died in 1969 In the 1970s there were cases of getting parasites and becoming sick with what was called gay bowel disease but what is now suspected to have been AIDS 266 The earliest retrospectively described case of AIDS is believed to have been in Norway beginning in 1966 that of Arvid Noe 267 In July 1960 in the wake of Congo s independence the United Nations recruited Francophone experts and technicians from all over the world to assist in filling administrative gaps left by Belgium who did not leave behind an African elite to run the country By 1962 Haitians made up the second largest group of well educated experts out of the 48 national groups recruited that totaled around 4500 in the country 268 269 Dr Jacques Pepin a Canadian author of The Origins of AIDS stipulates that Haiti was one of HIV s entry points to the U S and that a Haitian may have carried HIV back across the Atlantic in the 1960s 269 Although there was known to have been at least one case of AIDS in the U S from 1966 270 the vast majority of infections occurring outside sub Saharan Africa including the U S can be traced back to a single unknown individual who became infected with HIV in Haiti and brought the infection to the U S at some time around 1969 254 The epidemic rapidly spread among high risk groups initially sexually promiscuous men who have sex with men By 1978 the prevalence of HIV 1 among gay male residents of New York City and San Francisco was estimated at 5 suggesting that several thousand individuals in the country had been infected 254 Society and cultureStigma Main article Discrimination against people with HIV AIDS Ryan White became a poster child for HIV after being expelled from school because he was infected 271 AIDS stigma exists around the world in a variety of ways including ostracism rejection discrimination and avoidance of HIV infected people compulsory HIV testing without prior consent or protection of confidentiality violence against HIV infected individuals or people who are perceived to be infected with HIV and the quarantine of HIV infected individuals 17 Stigma related violence or the fear of violence prevents many people from seeking HIV testing returning for their results or securing treatment possibly turning what could be a manageable chronic illness into a death sentence and perpetuating the spread of HIV 272 AIDS stigma has been further divided into the following three categories Instrumental AIDS stigma a reflection of the fear and apprehension that are likely to be associated with any deadly and transmissible illness 273 Symbolic AIDS stigma the use of HIV AIDS to express attitudes toward the social groups or lifestyles perceived to be associated with the disease 273 Courtesy AIDS stigma stigmatization of people connected to the issue of HIV AIDS or HIV positive people 274 Often AIDS stigma is expressed in conjunction with one or more other stigmas particularly those associated with homosexuality bisexuality promiscuity prostitution and intravenous drug use 275 In many developed countries there is an association between AIDS and homosexuality or bisexuality and this association is correlated with higher levels of sexual prejudice such as anti homosexual or anti bisexual attitudes 276 There is also a perceived association between AIDS and all male male sexual behavior including sex between uninfected men 273 However the dominant mode of spread worldwide for HIV remains heterosexual transmission 277 To get a better understanding of the anti homosexual attitudes around AIDs the musical Rent explores this 278 In 2003 as part of an overall reform of marriage and population legislation it became legal for those diagnosed with AIDS to marry in China 279 In 2013 the U S National Library of Medicine developed a traveling exhibition titled Surviving and Thriving AIDS Politics and Culture 280 this covered medical research the U S government s response and personal stories from people with AIDS caregivers and activists 281 Economic impact Main articles Economic impact of HIV AIDS and Cost of HIV treatment Changes in life expectancy in some African countries 1960 2012 HIV AIDS affects the economics of both individuals and countries 229 The gross domestic product of the most affected countries has decreased due to the lack of human capital 229 282 Without proper nutrition health care and medicine large numbers of people die from AIDS related complications Before death they will not only be unable to work but will also require significant medical care It is estimated that as of 2007 there were 12 million AIDS orphans 229 Many are cared for by elderly grandparents 283 Returning to work after beginning treatment for HIV AIDS is difficult and affected people often work less than the average worker Unemployment in people with HIV AIDS also is associated with suicidal ideation memory problems and social isolation Employment increases self esteem sense of dignity confidence and quality of life for people with HIV AIDS Anti retroviral treatment may help people with HIV AIDS work more and may increase the chance that a person with HIV AIDS will be employed low quality evidence 284 By affecting mainly young adults AIDS reduces the taxable population in turn reducing the resources available for public expenditures such as education and health services not related to AIDS resulting in increasing pressure on the state s finances and slower growth of the economy This causes a slower growth of the tax base an effect that is reinforced if there are growing expenditures on treating the sick training to replace sick workers sick pay and caring for AIDS orphans This is especially true if the sharp increase in adult mortality shifts the responsibility from the family to the government in caring for these orphans 283 At the household level AIDS causes both loss of income and increased spending on healthcare A study in Cote 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 285 Religion and AIDS Main article Religion and HIV AIDS The topic of religion and AIDS has become highly controversial primarily because some religious authorities have publicly declared their opposition to the use of condoms 286 287 The religious approach to prevent the spread of AIDS according to a report by American health expert Matthew Hanley titled The Catholic Church and the Global AIDS Crisis argues that cultural changes are needed including a re emphasis on fidelity within marriage and sexual abstinence outside of it 287 Some religious organizations have claimed that prayer can cure HIV AIDS In 2011 the BBC reported that some churches in London were claiming that prayer would cure AIDS and the Hackney based Centre for the Study of Sexual Health and HIV reported that several people stopped taking their medication sometimes on the direct advice of their pastor leading to many deaths 288 The Synagogue Church Of All Nations advertised an anointing water to promote God s healing although the group denies advising people to stop taking medication 288 Media portrayal Main article Media portrayal of HIV AIDS One of the first high profile cases of AIDS was the American gay actor Rock Hudson He had been diagnosed during 1984 announced that he had had the virus on July 25 1985 and died a few months later on October 2 1985 289 Another notable British casualty of AIDS that year was Nicholas Eden a gay politician and son of former prime minister Anthony Eden 290 On November 24 1991 the virus claimed the life of British rock star Freddie Mercury lead singer of the band Queen who died from an AIDS related illness having only revealed the diagnosis on the previous day 291 One of the first high profile heterosexual cases of the virus was American tennis player Arthur Ashe He was diagnosed as HIV positive on August 31 1988 having contracted the virus from blood transfusions during heart surgery earlier in the 1980s Further tests within 24 hours of the initial diagnosis revealed that Ashe had AIDS but he did not tell the public about his diagnosis until April 1992 292 He died as a result on February 6 1993 aged 49 293 Therese Frare s photograph of gay activist David Kirby as he lay dying from AIDS while surrounded by family was taken in April 1990 Life magazine said the photo became the one image most powerfully identified with the HIV AIDS epidemic The photo was displayed in Life was the winner of the World Press Photo and acquired worldwide notoriety after being used in a United Colors of Benetton advertising campaign in 1992 294 Many famous artists and AIDS activists such as Larry Kramer Diamanda Galas and Rosa von Praunheim 295 campaign for AIDS education and the rights of those affected These artists worked with various media formats Criminal transmission Main article Criminal transmission of HIV Criminal transmission of HIV is the intentional or reckless infection of a person with the human immunodeficiency virus HIV Some countries or jurisdictions including some areas of the United States have laws that criminalize HIV transmission or exposure 296 Others may charge the accused under laws enacted before the HIV pandemic In 1996 Ugandan born Canadian Johnson Aziga was diagnosed with HIV he subsequently had unprotected sex with eleven women without disclosing his diagnosis By 2003 seven had contracted HIV two died from complications related to AIDS 297 298 Aziga was convicted of first degree murder and sentenced to life imprisonment 299 Misconceptions Main articles Misconceptions about HIV AIDS and Discredited HIV AIDS origins theories There are many misconceptions about HIV and AIDS Three misconceptions are that AIDS can spread through casual contact that sexual intercourse with a virgin will cure AIDS 300 301 302 and that HIV can infect only gay men and drug users 303 304 In 2014 some among the British public wrongly thought one could get HIV from kissing 16 sharing a glass 5 spitting 16 a public toilet seat 4 and coughing or sneezing 5 305 Other misconceptions are that any act of anal intercourse between two uninfected gay men can lead to HIV infection and that open discussion of HIV and homosexuality in schools will lead to increased rates of AIDS 306 307 A small group of individuals continue to dispute the connection between HIV and AIDS 308 the existence of HIV itself or the validity of HIV testing and treatment methods 309 310 These claims known as AIDS denialism have been examined and rejected by the scientific community 311 However they have had a significant political impact particularly in South Africa where the government s official embrace of AIDS denialism 1999 2005 was responsible for its ineffective response to that country s AIDS epidemic and has been blamed for hundreds of thousands of avoidable deaths and HIV infections 312 313 314 Several discredited conspiracy theories have held that HIV was created by scientists either inadvertently or deliberately Operation INFEKTION was a worldwide Soviet active measures operation to spread the claim that the United States had created HIV AIDS Surveys show that a significant number of people believed and continue to believe in such claims 315 At the peak of the HIV AIDS outbreak there was also misinformation spread from some governmental institutions For example Anthony Fauci head of the National Institute of Allergy and Infectious Diseases during the AIDS outbreak stated in the context of a conversation about childhood infections if the close contact of a child is a household contact perhaps there will be a certain number of cases of individuals who are just living with and in close contact 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