HIV Infection

For decades, the mention of HIV (Human Immunodeficiency Virus) often conjured fear and misunderstanding. However, in recent years, significant strides in medical research and public health initiatives have transformed the landscape of HIV infection. What was once seen as a rapidly progressing, fatal illness is now, for many, a manageable chronic health condition, much like diabetes or hypertension. This remarkable shift is largely due to highly effective antiretroviral therapies (ART) that allow people with HIV to live long, healthy, and fulfilling lives. Yet, despite these advancements, stigma and lack of accurate information persist. 

This detailed guide aims to shed light on HIV infection, providing a clear, compassionate, and up-to-date overview of what it is, how it's transmitted, the importance of early diagnosis, the power of modern treatments, and how individuals can live well with HIV.

HIV stands for Human Immunodeficiency Virus. It's a virus that attacks the body's immune system, specifically targeting CD4 cells (a type of T-cell), which are crucial for fighting off infections. Without these cells, the body becomes progressively weaker at defending itself against various pathogens, making individuals vulnerable to opportunistic infections and certain cancers.

If left untreated, HIV infection typically progresses through several stages, eventually leading to Acquired Immunodeficiency Syndrome (AIDS). AIDS is the most advanced stage of HIV infection, characterised by a severely compromised immune system and the presence of defining opportunistic illnesses.

It's vital to understand that simply having HIV does not mean a person has AIDS. With effective treatment, HIV can be suppressed to undetectable levels, meaning the virus is present in such small amounts that standard blood tests cannot find it. When a person's viral load is undetectable, they cannot sexually transmit HIV to others. This concept, known as "Undetectable = Untransmittable" (U=U), is a cornerstone of modern HIV prevention and awareness. HIV is a chronic, lifelong condition, but with proper management, individuals can maintain their health and prevent progression to AIDS.

HIV remains a significant global health challenge, though efforts to combat it have led to remarkable progress. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) data, in 2022, there were an estimated 39.0 million people globally living with HIV. Of these, 37.5 million were adults and 1.5 million were children (0–14 years). The same year saw 1.3 million new HIV infections and 630,000 AIDS-related deaths worldwide.

While there are two main types of Human Immunodeficiency Virus, HIV-1 is by far the most common and globally prevalent, accounting for the vast majority of HIV infections worldwide.

• HIV-1: This is the most widespread and virulent type of HIV. It is responsible for the global HIV pandemic and is found in virtually every country. Within HIV-1, there are several groups and subtypes, with Group M being the most common.
• HIV-2: This type is less common and primarily found in West Africa, though cases can be seen elsewhere due to international travel and migration. HIV-2 is generally less aggressive than HIV-1, progresses more slowly, and has a lower viral load, meaning it is less easily transmitted. However, it can still lead to AIDS if left untreated.

Because HIV-1 is so dominant globally, when people refer to "HIV," they are almost always referring to HIV-1. The diagnostic tests and treatments available today are highly effective against HIV-1, and often effective against HIV-2 as well, though specific treatment considerations might apply for HIV-2.

HIV is primarily transmitted through the exchange of specific bodily fluids from an infected person to an uninfected person. For transmission to occur, the virus needs to be present in a sufficient quantity in these fluids. The main routes of HIV transmission are:

• Unprotected Sexual Contact: This is the most common mode of transmission worldwide. HIV can be transmitted through unprotected anal, vaginal, or oral sex with someone who has HIV. Anal sex carries the highest risk due to the delicate lining of the rectum.
• Sharing Contaminated Needles or Syringes: This includes sharing injecting drug equipment, such as needles, syringes, or other drug preparation equipment (e.g., "works"). When contaminated blood from an HIV-positive person enters the bloodstream of another person, transmission can occur. This can also happen with sharing needles for tattooing or piercing if proper sterilisation is not followed.
• Mother-to-Child Transmission (MTCT): HIV can be transmitted from a mother living with HIV to her child during pregnancy, childbirth (delivery), or breastfeeding. However, with effective antiretroviral treatment during pregnancy and proper care during and after birth, the risk of MTCT can be reduced to less than 1%.
• Contaminated Blood Transfusions or Organ Transplants: While extremely rare in countries with robust screening programmes for blood products and organs, this was a significant route of transmission in the past. Modern screening has virtually eliminated this risk in high-income countries.
• Accidental Needle-Stick Injuries: Healthcare workers are at a very low risk of acquiring HIV from accidental needle-stick injuries involving HIV-infected blood, especially if post-exposure prophylaxis (PEP) is promptly administered.

It's crucial to understand what doesn't transmit HIV. HIV is not spread through casual contact like hugging, kissing (on the cheek), shaking hands, sharing food or drinks, using public toilets, coughing, sneezing, or through insects like mosquitoes.

The symptoms of HIV infection vary depending on the stage of the disease. It's important to remember that many people with HIV may not have any noticeable symptoms for years, which is why testing is so crucial.

Acute HIV Infection (Primary HIV Infection): This stage occurs within 2-4 weeks after initial infection. Many people experience flu-like symptoms as their body mounts an initial immune response. These symptoms can be mild and easily mistaken for a common cold or flu, often disappearing within a few weeks.

• Fever
• Rash (often on the torso)
• Muscle aches and joint pain
• Headache
• Sore throat
• Swollen lymph nodes (neck, armpits, groin)
• Fatigue
• Nausea, vomiting, or diarrhoea
• Mouth ulcers or sores

Clinical Latency (Asymptomatic HIV Infection or Chronic HIV Infection): After the acute stage, the virus continues to multiply, but at lower levels. People in this stage may not have any symptoms for many years (even up to a decade or longer). During this period, the virus is still active and damaging the immune system, even if the person feels well. Regular monitoring and adherence to antiretroviral therapy (ART) are vital to keep the virus suppressed and prevent progression.

AIDS (Acquired Immunodeficiency Syndrome): This is the final and most severe stage of HIV infection. It occurs when the immune system is severely damaged, making the body highly vulnerable to opportunistic infections (infections that a healthy immune system could normally fight off) and certain cancers. Symptoms at this stage are usually more severe and persistent:

• Rapid weight loss
• Recurring fever or profuse night sweats
• Extreme and unexplained tiredness
• Prolonged swelling of lymph nodes in the armpits, groin, or neck
• Diarrhoea that lasts for more than a week
• Sores of the mouth, anus, or genitals
• Pneumonia
• Red, brown, pink, or purple blotches on or under the skin or inside the mouth, nose, or eyelids (Kaposi's Sarcoma)
• Memory loss, depression, or other neurological disorders

Diagnosing HIV infection involves specific tests that look for either the virus itself or the antibodies the body produces in response to the virus. Early diagnosis is crucial for starting treatment promptly and preventing onward transmission.

• HIV Antibody Tests: These tests look for antibodies that your immune system makes against HIV. Antibodies take some time to develop after infection (usually 3-12 weeks), so there's a "window period" when a test might be negative even if infection has occurred.
  • Rapid HIV Tests: These can provide results in 20-30 minutes using a finger-prick blood sample or an oral fluid swab. They are screening tests, and a positive result needs to be confirmed with a laboratory test.
  • Laboratory-based Antibody Tests: More sensitive than rapid tests.
• Combination (Antigen/Antibody) Tests: These tests look for both HIV antibodies and p24 antigen, a part of the virus itself. The p24 antigen is detectable earlier than antibodies, typically within 2-6 weeks after infection, which shortens the window period. These are often the first-line screening tests.
• Nucleic Acid Tests (NATs) / Viral Load Tests: These tests directly detect the HIV virus's genetic material (RNA). They are very sensitive and can detect HIV infection even earlier than antigen/antibody tests (within 7-28 days of infection). NATs are expensive and usually not used for routine screening unless there's a high risk of recent exposure and early detection is critical (e.g., if a combination test is negative but recent exposure is suspected). They are also used to monitor treatment effectiveness.
• Confirmation Tests: If an initial screening test (rapid or combination) is positive, a confirmatory laboratory test (e.g., Western blot or an HIV-1/HIV-2 differentiation assay) is always performed to ensure accuracy before a diagnosis is made.

HIV testing is confidential and, in many places, can be done anonymously. Regular testing is recommended for individuals at higher risk of exposure.

The cornerstone of HIV treatment is Antiretroviral Therapy (ART). ART involves taking a combination of different medications every day. These medicines don't cure HIV, but they work by preventing the virus from multiplying, thereby reducing the amount of HIV in the body (the viral load) to very low, often "undetectable," levels.

How ART Works: ART medications target different stages of the HIV life cycle, preventing the virus from replicating, infecting new cells, or assembling new viral particles. A combination of at least three different antiretroviral drugs from at least two different classes is usually prescribed to minimise the risk of drug resistance.

Benefits of ART:

• Improved Health and Longevity: ART allows people with HIV to live long, healthy, and productive lives, often with a near-normal life expectancy. It prevents the immune system from being destroyed and significantly reduces the risk of developing opportunistic infections and AIDS-related conditions.
• Prevention of Transmission (U=U): When a person's viral load becomes undetectable (usually within 3-6 months of starting ART and maintaining adherence), they cannot sexually transmit HIV to others. This scientific breakthrough, "Undetectable = Untransmittable" (U=U), is a powerful message for both prevention and reducing stigma.
• Reduced Risk of Non-AIDS Conditions: ART also reduces the risk of certain non-AIDS related conditions that can occur with chronic inflammation from HIV, such as cardiovascular disease, kidney disease, and some cancers.

Adherence is Key: Taking ART exactly as prescribed is crucial for its effectiveness. Missing doses can lead to the virus multiplying and developing resistance to the drugs, making future treatment more challenging.

Lifelong Treatment: ART is a lifelong treatment. If someone stops taking their medication, the viral load will increase, and their immune system will begin to weaken again.

Pre-Exposure Prophylaxis (PrEP): For HIV-negative individuals at high risk of acquiring HIV, PrEP is a daily medication that can significantly reduce the risk of HIV infection. It's often used in combination with condoms and other prevention strategies.

Post-Exposure Prophylaxis (PEP): If an HIV-negative person has a potential exposure to HIV (e.g., unprotected sex with someone of unknown HIV status, needle-stick injury), PEP is a course of antiretroviral drugs taken for 28 days, started as soon as possible (within 72 hours) after exposure, to prevent HIV infection.

Some medications used to treat HIV can lead to anaemia, a condition wherein the body does not have sufficient healthy red blood cells to carry oxygen to various tissues of the body. In such cases, Recombinant Epoetin Alpha (Brands available: Zyrop, Renocel, Renocrit) is used to treat anaemia in the patient. 

• Unprotected Sexual Contact: Engaging in vaginal or anal sex without condoms.
• Multiple Sexual Partners: Increases exposure likelihood.
• Sharing Needles/Syringes: For injecting drugs or unsterile tattooing/piercing.
• Mother-to-Child Transmission: During pregnancy, childbirth, or breastfeeding without interventions.
• Existing STIs: Having another sexually transmitted infection (STI) like syphilis, herpes, or gonorrhoea, which can create open sores or inflammation, increasing HIV transmission risk.
• Uncircumcised Males: Uncircumcised men have a higher risk of acquiring HIV from heterosexual intercourse.
• Certain Medical Procedures Abroad: In countries with less stringent sterilisation practices for medical equipment or blood screening.

• Opportunistic Infections: Pneumocystis pneumonia (PCP), Kaposi's Sarcoma, toxoplasmosis, candidiasis, tuberculosis (TB), cytomegalovirus (CMV).
• Cancers: Increased risk of certain cancers, including Kaposi's Sarcoma, non-Hodgkin lymphoma, and cervical cancer.
• Neurological Complications: HIV-associated neurocognitive disorders (HAND), leading to memory loss, confusion, and behavioural changes.
• Kidney Disease: HIV-associated nephropathy (HIVAN).
• Cardiovascular Disease: Increased risk of heart disease and stroke due to chronic inflammation.
• Wasting Syndrome: Significant unintentional weight loss, often accompanied by chronic diarrhoea, weakness, and fever.
• Lipodystrophy: Changes in body fat distribution (fat loss in face/limbs, fat accumulation in abdomen/back of neck), often linked to older ART drugs.
• Mental Health Issues: Higher rates of depression, anxiety, and substance use disorders.

Living with HIV in the modern era is about proactive health management and embracing a full life.

• Adhere Strictly to Antiretroviral Therapy (ART): This is the most critical step. Take your medications exactly as prescribed, every day, without missing doses, to keep your viral load undetectable and protect your immune system.
• Maintain Regular Medical Appointments: Attend all scheduled appointments with your HIV specialist. Regular monitoring of your viral load and CD4 count helps ensure your treatment remains effective and your health is stable.
• Prioritise Your Mental Health: Living with a chronic condition can be challenging. Seek support from mental health professionals, support groups, or trusted friends and family to cope with any anxiety, depression, or stigma.
• Embrace a Healthy Lifestyle: Eat a balanced diet, engage in regular physical activity, get adequate sleep, and avoid smoking and excessive alcohol consumption. These choices support overall health and immune function.
• Educate Yourself and Others (if comfortable): Understanding your condition empowers you to make informed decisions. If you feel comfortable, sharing accurate information can help combat stigma and educate those around you.

"HIV is a death sentence." 

This is no longer true. With modern antiretroviral therapy (ART), people living with HIV can live long, healthy lives with a near-normal life expectancy, preventing progression to AIDS.

"You can get HIV from casual contact." 

HIV is not transmitted through casual contact like hugging, shaking hands, sharing food, using public toilets, or from mosquito bites. It is only transmitted through specific bodily fluids during certain activities (sexual contact, sharing needles, mother-to-child).

"If someone has HIV, you can tell by looking at them." 

Many people living with HIV, especially those on effective treatment, do not show any visible signs or symptoms of the infection. The only way to know one's HIV status is through testing.

It is advisable to see a doctor for HIV testing or discussion if:

• You believe you may have been exposed to HIV (e.g., through unprotected sex, sharing needles).
• You experience flu-like symptoms within 2-4 weeks after a potential exposure.
• You are pregnant or planning to become pregnant.
• You want to start Pre-Exposure Prophylaxis (PrEP) to prevent HIV.
• You have an STI, as having an STI increases the risk of acquiring or transmitting HIV.
• You want to know your HIV status for peace of mind or for your partner's health.

• What type of HIV test is best for me, given my recent potential exposure or risk factors?
• If I test positive, what are the next steps for starting treatment?
• What are the common side effects of antiretroviral therapy, and how can they be managed?
• How often will I need to have blood tests (viral load, CD4 count) to monitor my condition?
• What resources are available for psychological support or connecting with other people living with HIV?
• How can I ensure I don't transmit HIV to others, particularly my sexual partners?
• What lifestyle changes can I make to support my immune system and overall health while living with HIV?

• Learn the facts about HIV transmission and modern treatment. This helps you dispel myths and avoid perpetuating stigma.
• Listen without judgment. Living with HIV can come with emotional challenges, including fear, anxiety, and stigma. Let them know you are there for them.
• Gently remind and support them in taking their medications regularly and attending appointments, without being intrusive or judgmental.
• The decision of who to tell about their HIV status is deeply personal. Respect their privacy and confidentiality.

HIV infection, once a feared and stigmatised diagnosis, has been profoundly reshaped by advancements in medical science. With effective antiretroviral therapy, it is now a manageable chronic condition, allowing millions to lead healthy, full lives. The powerful message of Undetectable = Untransmittable (U=U) has revolutionised prevention efforts and is helping to dismantle the stigma that has historically surrounded the virus. 

While challenges remain, particularly in ensuring equitable access to testing and treatment globally, the future for people living with HIV is brighter than ever. Continued education, compassion, and a commitment to testing and treatment are key to ending the HIV epidemic and fostering a world where everyone can live free from stigma and with dignity.