1. Epidemiology

  • Current U.S. information is available at http://www.cdc.gov/hiv/dhap.htm.

  • Since 1995, there has been a large decline in death rates because of antiretroviral therapy.

  • The overall prevalence of HIV/AIDS has increased because of decline in death rates plus the steady rate of new HIV infection; prevention of infection remains a high priority.


2. Transmission of HIV

  • Routes of transmission

    • Sexual: Unprotected intercourse is the most common route of transmission, irrespective of gender or sexual orientation.

    • Injection drug use: Sharing unsterilized injection equipment is a very efficient means of transmitting HIV.

    • Perinatal: Infection from mother to infant can occur during gestation, delivery, or breast-feeding.

    • Blood transfusion: In the U.S., screening blood for HIV has reduced the risk by transfusion to almost zero.

  • Cofactors that enhance transmission

    • Physical: The presence of sexually transmitted diseases may cause genital lesions or genital/mucous membrane bleeding during sexual activity.

    • Behavioral: Substance use lowers sexual inhibitions, impairs judgment, and increases impulsivity.


3. Pathogenesis of HIV

  • During the acute phase, 50% to 90% of people experience a flulike syndrome within 3 to 6 weeks of infection.

  • The clinically asymptomatic phase may last for many years. The host seroconverts. The immune system may appear to control infection, but chronic viral replication persists.

  • AIDS is defined by conditions indicating significant immuno-suppression (e.g., opportunistic infections) or other conditions (dementia, wasting). For criteria, see the web site of the Centers for Disease Control and Prevention (CDC) (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4813a1.htm).


4. Antiretroviral Treatment

  • For guidelines on the use of antiretroviral agents, go to http://www.aidsinfo.nih.gov.

  • The goal of antiretroviral treatment is to reduce viral load to undetectable levels and maintain this without interruption.

  • Lack of clinical response may be due to problems with adherence, suboptimal antiretroviral treatment potency, or genetic mutation of strains.

  • Adverse effects of antiretroviral treatment include lipodystrophy (fat redistribution syndromes), hyperlipidemia, nephrotoxicity, bone marrow suppression, neuropathy, nausea, diarrhea, sleep disturbances, rash, and elevation of glucose levels, possibly causing diabetes mellitus.

  • Combined cost for antiretroviral agents in multidrug regimens is very expensive.

  • Adherence is of utmost concern with antiretroviral treatment. Even minor deviations from the prescribed regimen can result in viral resistance and permanent loss of efficacy. Studies of antiretroviral treatment continue to indicate that near-perfect adherence is needed to adequately repress viral replication.


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