More about AIDS: Causes and symptoms Diagnosis Treatment Alternative treatment Prognosis Prevention Resources

Definition

Acquired immune deficiency syndrome (AIDS) is an infectious disease caused by the human immunodeficiency virus (HIV). It was first recognized in the United States in 1981. AIDS is the advanced form of infection with the HIV virus, which may not cause recognizable disease for a long period after the initial exposure (latency). No vaccine is currently available to prevent HIV infection. At present, all forms of AIDS therapy are focused on improving the quality and length of life for AIDS patients by slowing or halting the replication of the virus and treating or preventing infections and cancers that take advantage of a person's weakened immune system.

Description

AIDS is considered one of the most devastating public health problems in recent history. In June 2000, the Centers

Risk of acquiring HIV infection by entry site
	Entry site	Risk virus reaches entry site	Risk virus enters	Risk inoculated
	Conjuntiva	Moderate	Moderate Very low
	Oral mucosa	Moderate	Moderate	Low
	Nasal mucosa	Low	Low	Very low
	Lower respiratory	Very low	Very low	Very low
	Anus	Very high	Very high	Very high
	Skin, intact	Very low	Very low	Very low
	Skin, broken	Low	High	High
Sexual:
	Vagina	Low	High	High
	Penis	Low	Low	High
	Ulcers (STD)	Medium	Low	Very high
Blood:
	Products	High	High	Low
	Shared needles	High	High	High
	Accidental needle	High	Very High	Low
	Traumatic wound	Modest	High	High
	Perinatal	High	High	High

for Disease Control and Prevention (CDC) reported that 120,223 (includes only those cases in areas that have confidential HIV reporting) in the United States are HIV-positive, and 311,701 are living with AIDS (includes only those cases where vital status is known). Of these patients, 44% are gay or bisexual men, 20% are heterosexual intravenous drug users, and 17% are women. In addition, approximately 1,000-2,000 children are born each year with HIV infection. The World Health Organization (WHO) estimates that 33 million adults and 1.3 million children worldwide were living with HIV/AIDS as of 1999 with 5.4 million being newly infected that year. Most of these cases are in the developing countries of Asia and Africa.

Risk factors

AIDS can be transmitted in several ways. The risk factors for HIV transmission vary according to category:

• Sexual contact. Persons at greatest risk are those who do not practice safe sex, those who are not monogamous, those who participate in anal intercourse, and those who have sex with a partner with symptoms of advanced HIV infection and/or other sexually transmitted diseases (STDs). In the United States and Europe, most cases of sexually transmitted HIV infection have resulted from homosexual contact, whereas in Africa, the disease is spread primarily through sexual intercourse among heterosexuals.
• Transmission in pregnancy. High-risk mothers include women married to bisexual men or men who have an abnormal blood condition called hemophilia and require blood transfusions, intravenous drug users, and women living in neighborhoods with a high rate of HIV infection among heterosexuals. The chances of transmitting the disease to the child are higher in women in advanced stages of the disease. Breast feeding increases the risk of transmission by 10-20%. The use of zidovudine (AZT) during pregnancy, however, can decrease the risk of transmission to the baby.
• Exposure to contaminated blood or blood products. With the introduction of blood product screening in the mid-1980s, the incidence of HIV transmission in blood transfusions has dropped to one in every 100,000 transfused. With respect to HIV transmission among drug abusers, risk increases with the duration of using injections, the frequency of needle sharing, the number of persons who share a needle, and the number of AIDS cases in the local population.
• Needle sticks among health care professionals. Present studies indicate that the risk of HIV transmission by a needle stick is about one in 250. This rate can be decreased if the injured worker is given AZT, an anti-retroviral medication, in combination with other medication.

HIV is not transmitted by handshakes or other casual non-sexual contact, coughing or sneezing, or by blood-sucking insects such as mosquitoes.

AIDS in women

AIDS in women is a serious public health concern. Women exposed to HIV infection through heterosexual contact are the most rapidly growing risk group in the United States population. The percentage of AIDS cases diagnosed in women has risen from 7% in 1985 to 23% in 1999. Women diagnosed with AIDS may not live as long as men, although the reasons for this finding are unclear.

AIDS in children

Since AIDS can be transmitted from an infected mother to the child during pregnancy, during the birth process, or through breast milk, all infants born to HIV-positive mothers are a high-risk group. As of 2000, it was estimated that 87% of HIV-positive women are of childbearing age; 41% of them are drug abusers. Between 15-30% of children born to HIV-positive women will be infected with the virus.

AIDS is one of the 10 leading causes of death in children between one and four years of age. The interval between exposure to HIV and the development of AIDS is shorter in children than in adults. Infants infected with HIV have a 20-30% chance of developing AIDS within a year and dying before age three. In the remainder, AIDS progresses more slowly; the average child patient survives to seven years of age. Some survive into early adolescence.

— Rebecca J. Frey

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n.

A severe immunological disorder caused by the retrovirus HIV, resulting in a defect in cell-mediated immune response that is manifested by increased susceptibility to opportunistic infections and to certain rare cancers, especially Kaposi's sarcoma. It is transmitted primarily by exposure to contaminated body fluids, especially blood and semen.

[A(CQUIRED) I(MMUNE) D(EFICIENCY) S(YNDROME).]

Definition

Acquired immunodeficiency syndrome (AIDS) is the final and most serious stage of the disease caused by the human immunodeficiency virus. Symptoms begin when an HIV-positive person presents a CD4-cell (also called T cell, a type of immune cell) count below 200. AIDS happens concurrently with numerous opportunistic infections and tumors that are normally associated with the HIV infection.

The most common neurological complications of AIDS involve opportunistic infections of the brain such as progressive multifocal leucoencephalopathy (PML) and meningitis, other opportunistic infections such as herpes zoster (shingles), peripheral neuropathy, depression, and AIDS-related dementia.

Description

AIDS was first recognized in 1981 and has since become a major worldwide pandemic. Abundant evidence indicates that the human immunodeficiency virus (HIV), discovered in 1983, causes AIDS. By leading to the destruction and/or functional impairment of immune cells, notably CD4+ T cells, HIV progressively destroys the body's ability to fight infections and to resist certain cancer formation.

Before the HIV infection became widespread in the human population, AIDS-like syndromes occurred extremely rarely, and almost exclusively in individuals with known causes of immune suppression, such as those receiving chemotherapy or those with underlying cancers. A marked increase in unusual infections and tumors characteristic of severe immune suppression was first recognized in the early 1980s in homosexual men who had been otherwise healthy and had no recognized cause for immune suppression. An infectious cause of AIDS was suggested by geographic clustering of cases, a sexual link among cases, mother-to-infant transmission, and transmission by blood transfusion.

Isolation of the HIV from patients with AIDS strongly suggested that this virus was the cause of AIDS. Since the early 1980s, HIV and AIDS have been repeatedly associated; the appearance of HIV in the blood supply has preceded or coincided with the occurrence of AIDS cases in every country and region where AIDS has been noted. Individuals of all ages from many risk groups, including homosexual men, infants born to HIV-infected mothers, heterosexual women and men, hemophiliacs, recipients of blood and blood products, health care workers and others occupationally exposed to HIV-tainted blood, and injection drug users have all developed AIDS with only one common denominator: HIV.

HIV destroys CD4+ T cells, which are crucial to the normal function of the human immune system. In fact, depletion of CD4+ T cells in HIV-infected individuals is an extremely powerful predictor of the development of AIDS. Studies of thousands of individuals have revealed that most HIV-infected people carry the virus for years before enough damage is done to the immune system for AIDS to develop; however, with time, a near-perfect correlation has been found between infection and the subsequent development of AIDS.

Demographics

In the United States, more than 733,000 people have AIDS, and an estimated one to two million people have HIV infection without the symptoms of AIDS.

Internationally, since the AIDS epidemic began, more than 16 million deaths have been attributed to AIDS. The current estimate of worldwide disease prevalence is more than 33 million HIV infections. Ninety-five percent of these cases are in developing countries, generally in sub-Saharan Africa and Southeast Asia.

Most HIV infections still occur in men; however, the frequency of infection in women is increasing, especially in developing countries. In the United States, fewer than 16% of all HIV cases are in women, whereas worldwide an estimated 46% of all HIV patients are women.

Causes and symptoms

The cause of primary AIDS is infection with the HIV virus, transmitted via infected blood or body fluids. Methods of transmission of the virus include unprotected sex, especially anal intercourse; occupational needle stick or body fluid splash, which has an estimated transmission rate of less than 0.3%; sharing of needles in drug abuse; and receiving contaminated blood products.

Opportunistic infections occur in individuals whose CD4 count is less than 200 cells/mm³ and those not taking preventative drugs.

Symptoms of AIDS include:

• cough and shortness of breath
• seizures and lack of coordination
• difficult or painful swallowing
• confusion and forgetfulness
• severe and persistent diarrhea
• fever
• vision loss
• nausea, abdominal cramps, and vomiting
• weight loss and extreme fatigue
• severe headaches with neck stiffness

Neurological complications of AIDS

Almost 30% of people with AIDS develop peripheral neuropathy, causing tingling, numbness, and weakness in the arms and legs due to nerve damage. If severe, peripheral neuropathy can cause difficulty walking. Several drugs used to treat people with AIDS can contribute to the development of peripheral neuropathy.

Several opportunistic infections experienced by people with AIDS involve the nervous system. Progressive multifocal leucoencephalopathy (PML) is a serious viral infection of the brain, most often caused by the JC virus. PML is fatal in more than 90% of cases within six months of diagnosis. Nearly 4% of people with AIDS, especially those with T-cell counts below 100, will develop the disease. Meningitis is an infection of the lining of the spinal cord and brain, and also occurs in some people with AIDS. Cryptococcus, a fungus that normally occurs in the soil and seldom affects persons with intact immune systems, can cause recurring meningitis in people with AIDS whose T-cell count is below 100. The common parasite Toxoplasma gondii often present in cat feces, raw meat, raw vegetables, and the soil can also cause encephalitis, or inflammation of the brain, in AIDS patients. Shingles is a painful nerve inflammation caused by a reactivation of the herpes varicella zoster virus, the same virus that causes chicken pox. Although not directly linked to HIV, shingles seems to occur more frequently in people with AIDS.

Other neurological conditions associated with AIDS include depression, occurring at any time during the disease, and dementia, which sometimes occurs in the later stages of AIDS. Depression can stem from living with a chronic and progressive disease. AIDS-related dementia involves problems with thinking, memory, and usually also with controlling the arms and legs, and can stem from direct infection in the brain with the HIV virus. In the initial stages of the pandemic, almost 20% of persons with AIDS developed severe dementia. With the development of combination antiviral drugs, the rate of severe dementia in AIDS has been reduced by more than half. The number of persons with HIV and milder dementia has increased, however, as people with HIV live longer.

Diagnosis

In the early stages of infection, HIV often causes no symptoms and the infection can be diagnosed only by testing a person's blood. Two tests are available to diagnose HIV infection, one that looks for the presence of antibodies produced by the body in response to HIV and the other that looks for the virus itself. Antibodies are proteins produced by the body whenever a disease threatens it. When the body is infected with HIV, it produces antibodies specific to HIV. The first test, called ELISA (enzyme-linked immunosorbent assay), looks for such antibodies in the blood.

A positive ELISA has to be confirmed by another test called western blot or immunofluorescent assay (IFA). All positive tests by ELISA are not accurate and hence, western blot and repeated tests are necessary to confirm a person's HIV status. A person infected with HIV is termed HIV positive or seropositive.

Rapid tests that give results in five to 30 minutes are increasingly being used worldwide. The accuracy of rapid tests is stated to be as good as that of ELISA. Though rapid tests are more expensive, researchers have found them to be more cost effective in terms of the number of people covered and the time the tests take.

The HIV antibodies generally do not reach detectable levels in the blood until about three months after infection. This period, from the time of infection until the blood is tested positive for antibodies, is called the window period. Sometimes, the antibodies might take up to six months to be detected. Even if the tests are negative, during the window period the amount of virus is very high in an infected person. If a person is newly infected, therefore, the risk of transmission is higher.

Another test for HIV is called polymerase chain reaction (PCR), which looks for HIV itself in the blood. This test, which recognizes the presence of the virus' genetic material in the blood, can detect the virus within a few days of infection. There are also tests like radio immuno precipitation assay (RIPA), a confirmatory blood test that may be used when antibody levels are difficult to detect or when western blot test results are uncertain.

Treatment team

The treatment team often includes personal care-givers, physical therapists, dietitians, specialists (infectious disease specialists, dermatologists, nephrologists, ophthalmologists, pediatrists, psychiatrists, and neurologists), and social workers.

Treatment

Since the early 1990s, several drugs to fight both the HIV infection and its associated infections and cancers have become available, including:

• Reverse transcriptase inhibitors: They interrupt the virus from making copies of itself. These drugs are AZT (zidovudine [Retrovir]), ddC (zalcitabine [Hivid], dideoxyinosine), d4T (stavudine [Zerit]), and 3TC (lamivudine [Epivir]).
• Nonnucleoside reverse transcriptase inhibitors (NNRTIS): These medications are used in combination with other drugs to help keep the virus from multiplying. Examples of NNRTIS are delavirdine (Rescriptor) and nevirapine (Viramune).
• Protease inhibitors: These medications interrupt virus replication at a later step in its lifecycle. These include ritonavir (Norvir), a lopinavir and ritonavir combination (Kaletra), saquinavir (Invirase), indinavir sulphate (Crixivan), amprenavir (Agenerase), and nelfinavir (Viracept). Using both classes of drugs reduces the chances of developing resistance in the virus.
• Fusion inhibitors: This is the newest class of anti-HIV drugs. The first drug of this class (enfuvirtide [Fuzeon]) has recently been approved in the United States. Fusion inhibitors block HIV from entering the human immune cell.
• A combination of several drugs called highly active antiretroviral therapy (HAART): This treatment is not a cure. The virus still persists in various body sites such as in the lymph glands.

The antiretroviral drugs do not cure people of the HIV infection or AIDS. They stop viral replication and delay the development of AIDS. However, they may also have side effects that can be severe. These include decrease of red or white blood cells, inflammation of the pancreas, and painful nerve damage. Other complications are enlarged or fatty liver, which may result in liver failure and death.

Recovery and rehabilitation

As there is no cure for AIDS, the focus is on maintaining optimum health, activity, and quality of life rather than on complete recovery.

Occupational therapy can have a crucial role in assisting people living with HIV/AIDS to reengage with life, particularly through vocational rehabilitation programs. Occupational therapy can provide the patient with a series of learning experiences that will enable the individual to make appropriate vocational choices.

Clinical trials

There are many ongoing clinical trials for AIDS. "HIV Vaccine Designed for HIV Infected Adults Taking Anti-HIV Drugs," "When to Start Anti-HIV Drugs in Patients with Opportunistic Infections," and "Outcomes of Anti-HIV Therapy during Early HIV Infection" are some trials that are currently recruiting patients at the National Institute of Allergy and Infectious Diseases (NIAID). Updated information on these and other trials for the study and treatment of AIDS can be found at the National Institutes of Health website for clinical trials at .

Prognosis

Presently, there is no cure for HIV infection or AIDS, nor is there a vaccine to prevent the HIV infection. However, there are new medications that help slow the progression of the infection and reduce the seriousness of HIV consequences in many people.

Special concerns

The surest way to avoid AIDS is to abstain from sex, or to limit sex to one partner who also limits his or her sex in the same way (monogamy). Condoms are not 100% safe, but if used properly they will greatly reduce the risk of AIDS transmission. Also, avoiding the use of intravenous drugs (drug abuse, sharing contaminated syringes) is highly recommended.

Resources

BOOKS

Conner, R. F., L. P. Villarreal, and H. Y. Fan. AIDS: Science and Society. Sudbury, MA: Jones & Bartlett Publishers, 2004.

Stine, G. J. AIDS Update 2004. Essex, England: Pearson Benjamin Cummings, 2003.

PERIODICALS

Grant, A. D, and K. M. De Cock. "ABC of AIDS: HIV Infection and AIDS in the Developing World." BMJ 322 (June 2001): 1475–1478.

OTHER

"AIDS Factsheets." AIDS.ORG. April 20, 2004 (May 27, 2004). http://www.aids.org/factSheets/. "

How HIV Causes AIDS." National Institute of Allergy and Infectious Disease. April 20, 2004 (May 27, 2004). http://www.niaid.nih.gov/factsheets/howhiv.htm.

UNAIDS. The Joint United Nations Program on HIV/AIDS. April 20, 2004 (May 27, 2004). http://www.unaids.org/.

ORGANIZATIONS

Centers for Disease Control (Office of Public Inquiries). Clifton Road, Atlanta, GA 30333. (800) 342-2437. http://www.cdc.gov.

National Institute of Allergy and Infectious Disease. 6610 Rockledge Drive MSC 6612, Bethesda, MD 20892-6612. http://www.niaid.nih.gov/.

Greiciane Gaburro Paneto

Brenda Wilmoth Lerner, RN

Iuri Drumond Louro, MD, PhD

A viral disease of humans caused by the human immunodeficiency virus (HIV), which attacks and compromises the body's immune system. Individuals infected with HIV proceed through a spectrum of stages that ultimately lead to the critical end point, acquired immune deficiency syndrome. The disease is characterized by a profound progressive irreversible depletion of T-helper-inducer lymphocytes (CD4+ lymphocytes), which leads to the onset of multiple and recurrent opportunistic infections by other viruses, fungi, bacteria, and protozoa, as well as various tumors (Kaposi's sarcoma, lymphomas). HIV infection is transmitted by sexual intercourse (heterosexual and homosexual), by blood and blood products, and perinatally from infected mother to child (prepartum, intrapartum, and postpartum via breast milk).

Since retroviruses such as HIV-1 integrate their genetic material into that of the host cell, infection is generally lifelong and cannot be eliminated easily. Therefore, medical efforts have been directed toward preventing the spread of virus from infected individuals. See also Retrovirus.

Approximately 50–70% of individuals with HIV infection experience an acute mononucleosis-like syndrome approximately 3–6 weeks following primary infection. In the acute HIV syndrome, symptoms include fever, pharyngitis, lymphadenopathy, headache, arthralgias, myalgias, lethargy, anorexia, nausea, and erythematous maculopapular rash. These symptoms usually persist for 1–2 weeks and gradually subside as an immune response to HIV is generated.

Although the length of time from initial infection to development of the clinical disease varies greatly from individual to individual, a median time of approximately 10 years has been documented for homosexual or bisexual men, depending somewhat on the mode of infection. Intravenous drug users experience a more aggressive course than homosexual men and hemophiliacs because their immune systems have already been compromised.

As HIV replication continues, the immunologic function of the HIV-infected individual declines throughout the period of clinical latency. At some point during that decline (usually after the CD4+ lymphocyte count has fallen below 500 cells per microliter), the individual begins to develop signs and symptoms of clinical illness, and sometimes may demonstrate generalized symptoms of lymphadenopathy, oral lesions, herpes zoster, and thrombocytopenia.

Secondary opportunistic infections are a late complication of HIV infection, usually occurring in individuals with less than 200 CD4+ lymphocytes per microliter. They are characteristically caused by opportunistic organisms such as Pneumocystis carinii and cytomegalovirus that do not ordinarily cause disease in individuals with a normally functioning immune system. However, the spectrum of serious secondary infections that may be associated with HIV infection also includes common bacterial pathogens, such as Streptococcus pneumoniae. Secondary opportunistic infections are the leading cause of morbidity and mortality in persons with HIV infection. Tuberculosis has also become a major problem for HIV-infected individuals. Therefore, HIV-infected individuals are administered protective vaccines (pneumococcal) as well as prophylactic regimens for the prevention of infections with P. carinii, Mycobacterium tuberculosis, and M. avium complex. See also Opportunistic infections; Pneumococcus; Streptococcus; Tuberculosis.

Antiretroviral treatment with deoxyribonucleic acid (DNA) precursor analogs—for example, azidothymidine (AZT), dideoxyinosine (ddI), and dideoxycytidine (ddC)—has been shown to inhibit HIV infection by misincorporating the DNA precursor analogs into viral DNA by the viral DNA polymerase. Nevertheless, these agents are not curative and do not completely eradicate the HIV infection.

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Condition characterized by illnesses indicative of reduced immune responsiveness in otherwise healthy individuals. Viral organisms dubbed HTLVIII (for human T lymphotrophic virus type III) and LAV (for lymphadenopathy associated virus), respectively, are the putative causative agents of this destruction of bodily defenses. Together, these viral organisms have become known as human immunodeficiency virus (HIV). The HIV infection is the initial event in the course of a disease that culminates in AIDS in some of its victims.

HIV is a member of the class of RNA viruses known as retroviruses, identifiable by their use of the enzyme reverse transcriptase. This enzyme permits retroviruses to replicate their own genetic information, utilizing mammalian host cell DNA to produce the new viral RNA necessary for the assembly of new organisms. Reverse transcriptase also allows the virus to incorporate its genetic material into that of the host. In this manner the virus may immortalize itself by lying dormant within the host genome while remaining capable of producing new viral organisms at a future time.

HIV infection begins with viral penetration of lymphocytes and monocytes, the white blood cells involved in immune defense. The first phase of the infection frequently causes an illness with symptoms similar to those produced by infectious mononucleosis. After days or weeks of mild illness, some patients appear to recover. In the others, the viral destruction of host cells continues unabated with the virus infecting other tissues, including cells in the brain. After a latent phase, which varies with age, degree of immune responsiveness, and the number of viral particles producing the initial infection, the patient begins to manifest signs and symptoms of immune system damage. These late sequelae of HIV infection include unexplained fevers, lymph node enlargement, persistent infections with fungi or viruses, and unexplained weight loss. When these symptoms fulfill specific criteria, they are referred to as the AIDS-related complex, or ARC. Only the patients who develop the most severe immune system damage, resulting in infections such as Pneumocystis carinii pneumonia (PCP) or unusual cancers like Kaposi's sarcoma, are classified as having AIDS.

The direct impact of the AIDS virus is and will be felt by both the property and casualty insurance and the life and health insurance branches.

Property and Casualty Insurance

From a property and casualty insurance perspective, the AIDS issue could impact the liability sections of the homeowners insurance policy, automobile insurance policies (both personal and business), commercial general liability (CGL) policy, and workers compensation policy:

1. Homeowners Insurance Policy. The Insurance Services Office (ISO) homeowners insurance policy form has a communicable disease endorsement Exclusion. Most property and casualty companies use this form either in total or with minor modification. Since this exclusion to date has not been subject to an adverse ruling by a court of law, it may be that the homeowners policy does not have an AIDS Exposure.

2. automobile insurance policies (both personal and business). An AIDS exposure could result (these policies do not have a communicable disease endorsement exclusion) because of negligent acts and/or omissions of a driver resulting in:

(a) an injured party contracting AIDS through a blood transfusion necessitated by an accident and then bringing suit against the driver, who is found negligent under the Tort Liability system. In a similar circumstance, an injured party's open wound comes into contact with an open wound of another injured party who has AIDS, with an ensuing suit against the negligent driver. Certainly, the wounds would not have come into contact if the accident had not occurred.

(b) the activation of a previously dormant AIDS virus (as discussed above, the virus may "immortalize" itself by lying dormant within the host genome while remaining capable of producing new viral organisms at a future time) in an injured party, with the injured party bringing suit against the driver whose acts and/or omissions are deemed to be negligent by a court of law. Had the catalyst accident not occurred, the AIDS virus would have remained dormant.

3. Commercial General Liability (CGL) form. An AIDS exposure may arise because of negligent acts of employees or circumstances occurring on a business' property:

(a) An AIDS exposure could result in the event that an AIDS-infected employee contaminates a product and/or service being provided to a customer or fellow employee, and the customer or fellow employee brings suit against the business. For example, the infected employee may have a cut finger and drops of his or her blood may accidentally become mixed with the food being consumed by a customer or fellow employee. Or the infected employee could intentionally contaminate the food with his or her body fluid as a vengeful act.

(b) An AIDS exposure could result in the event that a sexual assault by an AIDS-infected assailant (regardless of whether or not the assailant is an employee) is incurred by a customer while visiting the premises of the business and the injured customer brings suit against the business. It is the responsibility of the business to render its premises safe for the invited customer. The Connie Francis case is the precedent sexual assault case for this exposure. A similar circumstance could result if an AIDS-infected assailant assaults an employee.

(c) An AIDS exposure could result in the event that a business fails to maintain the confidentiality of an AIDS-infected employee's personnel file and the employee brings suit against the business for the tort acts of libel, slander, and invasion of privacy.

4. Workers Compensation policy. An AIDS exposure could result if an employee injured at work receives a blood transfusion from a fellow employee who has AIDS. Is the transmission of AIDS in this manner a job-related injury, thus qualifying the injured employee for benefits under workers compensation? Certainly the injured employee would not have required the blood transfusion had the injury not occurred at work.

In another situation, two or more employees may be injured in a common accident, resulting in open wounds of various employees coming into contact. If at least one of the injured employees is a carrier of the AIDS virus, several employees could become infected. The AIDS virus is most likely to be spread as the result of close contact with blood, blood products, or semen from an infected person. Is this scenario not a classic case for a workers compensation claim?

In each of the two preceding examples, assume that the employer was aware of the AIDS condition of the employee(s) prior to the accident and kept this information confidential so as not to invade the privacy of the employee(s). In this instance, could not the newly AIDS-infected employee(s) seek damages for benefits against the employer beyond that provided by workers compensation? Certainly the employer was aware of an inherently potentially dangerous situation in the workplace and took no actions to alleviate the situation or render it harmless. Is not a similar circumstance the basis for the employer tort cases for job-related injuries resulting from exposure to asbestos?

Life and Health Insurance

AIDS-related deaths could have a significant impact on the Life Insurance and Health Insurance industries as these deaths affect the normal claims pattern for Group Life Insurance and Individual Life Insurance:

1. Group Life, Medical, and Disability Insurance. If the insurance policy is a true group policy, all applicants must be accepted during the open enrollment period. Thus a person who has AIDS would automatically be insured.

If, however, there are a significant number of claims under the group policy, the insurance company can reflect this adverse experience in next year's premium rates. The insurance company also has the option of not renewing the group's coverage.

There is also a limit on the Death Benefit available under group policies. For example, employee group life policies limit the coverage per employee to a multiple (usually twice) of the employee's annual salary. This limitation reduces somewhat the Adverse Selection associated with the AIDS-infected employee opting for higher limits of coverage.

2. Individual Life, Medical, and Disability Insurance. In underwriting individual coverages (unlike group insurance, where the factors of age, sex, and industry classification only are considered) numerous factors are evaluated, to include age, sex, personal health record, family health, occupation, vocation, hobbies, habits such as chemical abuse, life-style, and so forth. These factors undergo close scrutiny, especially when the higher limits of coverage are applied for. However, after the applicant becomes an Insured he or she could contact AIDS, an eventuality that was not included in the Premium rate. Individual life insurance contracts (ordinary policies and even term insurance, which can be renewed and converted at the option of the insured) are contracts for life. Thus, once the insurer accepts the applicant for coverage, the insurer is at the mercy of any future AIDS epidemic.

Some life insurance policies have Policy Purchase Options (PPO) whereby the insured can automatically increase the limits of coverage when certain events occur, such as every fifth policy anniversary. The AIDS patient then could automatically increase his or her coverage over various periods of time. Also, for dividend paying policies the AIDS patient could use the dividends to automatically purchase paid-up additions to his or her policy without having to take a physical or answer any medical-related questions (in essence, this is Guaranteed Insurability). Once again, the insurer has no control over these events or distributions.

For life insurance policies already in existence, AIDS-related questions were not asked on the Application. Thus, many companies have huge blocks of business that may be susceptible to the effects of the AIDS epidemic.

Definition

Acquired immune deficiency syndrome (AIDS) is an infectious disease caused by the human immunodeficiency virus (HIV). It was first recognized in the United States in 1981. AIDS is the advanced form of infection with the HIV virus, which may not cause disease for a long period after the initial exposure (latency). Infection with HIV weakens the immune system which makes infected people susceptible to infection and cancer.

Description

AIDS is considered one of the most devastating public health problems in recent history. In 1996, the Centers for Disease Control and Prevention (CDC) estimated that one million persons in the United States were HIV-positive, and 223,000 are living with AIDS. Of these patients, 44% were gay or bisexual men, 26% are heterosexual intravenous drug users, and 18% were women. In addition, approximately 1,000-2,000 children are born each year with HIV infection. In 2002, the CDC reported 42,136 new AIDS diagnoses in the United States, a 2.2% increase from the previous year. AIDS cases rose among gay and bisexual men (7.1% in 25 states that report regularly). The disease also seems to be rising among older Americans. From 1990 to 2001, the number of cases in Americans age 50 years or older rose from 16,288 to 90,153.

The World Health Organization (WHO) estimates that 40 million people worldwide were infected with AIDS/HIV as of 2001. Most of these cases are in the developing countries of Asia and Africa. In 2003, WHO cautioned that if treatment were not delivered soon to nearly 6 million people with AIDS in developing countries, there could be 45 million cases by 2010.

Risk Factors

AIDS can be transmitted in several ways. The risk factors for HIV transmission vary according to category:

• Sexual contact. Persons at greatest risk are those who do not practice safe sex, are not monogamous, participate in anal intercourse, and have sex with a partner with symptoms of advanced HIV infection and/or other sexually transmitted diseases (STDs). In the United States and Europe, most cases of sexually transmitted HIV infection have resulted from homosexual contact, whereas in Africa, the disease is spread primarily through sexual intercourse among heterosexuals.
• Transmission in pregnancy. High-risk mothers include women married to bisexual men or men who have an abnormal blood condition called hemophilia and require blood transfusions, intravenous drug users, and women living in neighborhoods with a high rate of HIV infection among heterosexuals. The chances of transmitting the disease to the child are higher in women in advanced stages of the disease. Breast feeding increases the risk of transmission by 10-20% and is not recommended. The use of zidovudine (AZT) during pregnancy and delivery, however, can decrease the risk of transmission to the baby.

• Exposure to contaminated blood or blood products. With the introduction of blood product screening in the mid-1980s, the incidence of HIV transmission in blood transfusions has dropped to 1 in 100,000.
• Needle sticks among health care professionals. Present studies indicate that the risk of HIV transmission by a needle stick is about 1 in 250. This rate can be decreased if the injured worker is given AZT or triple therapy (HAART), the current standard.

HIV is not transmitted by handshakes or other casual non-sexual contact, coughing or sneezing, or by bloodsucking insects such as mosquitoes.

Aids in Women

AIDS in women is a serious public health concern. Women exposed to HIV infection through heterosexual contact are the most rapidly growing risk group in the United States. The percentage of AIDS cases diagnosed in women has risen from 7% in 1985 to 18% in 1996. For unknown reasons, women with AIDS do not live as long as men with AIDS.

Aids in Children

Because AIDS can be transmitted from an infected mother to her child during pregnancy, during the birth process, or through breast milk, all infants born to HIV-positive mothers are at risk. As of 1997, it was estimated that 84% of HIV-positive women are of childbearing age; 41% of them are drug abusers. Between 15-30% of children born to HIV-positive women will be infected with the virus.

AIDS is one of the 10 leading causes of death in children between one and four years of age worldwide. The interval between exposure to HIV and the development of AIDS is shorter in children than in adults. Infants infected with HIV have a 20-30% chance of developing AIDS within a year and dying before age three. In the remainder, AIDS progresses more slowly; the average child patient survives to seven years of age. Some survive into early adolescence.

Causes & Symptoms

Because HIV destroys immune system cells, AIDS is a disease that can affect any of the body's major organ systems. HIV attacks the body through three disease processes: immunodeficiency, autoimmunity, and nervous system dysfunction.

Immunodeficiency describes the condition in which the body's immune response is damaged, weakened, or is not functioning properly. In AIDS, immunodeficiency results from the way that the virus binds to a protein called CD4, which is found on certain white blood cells, including helper T cells, macrophages, and monocytes. Once HIV attaches to an immune system cell, it can replicate within the cell and kill the cell. In addition to killing some lymphocytes directly, the AIDS virus disrupts the functioning of other CD4 cells. Because the immune system cells are destroyed, infections and cancers that take advantage of a person's weakened immune system (opportunistic) can develop.

Autoimmunity is a condition in which the body's immune system produces antibodies that work against its own cells. Antibodies are specific proteins produced in response to exposure to a specific, usually foreign, protein or particle called an antigen. In this case, the body produces antibodies that bind to blood platelets that are necessary for proper blood clotting and tissue repair. Once bound, the antibodies mark the platelets for removal from the body, and they are filtered out by the spleen. Some AIDS patients develop a disorder, called immune-related thrombocytopenia purpura (ITP), in which the number of blood platelets drops to abnormally low levels.

The course of AIDS generally progresses through three stages, although not all patients will follow this progression precisely:

Acute Retroviral Syndrome

Acute retroviral syndrome is a term used to describe a group of symptoms that can resemble mononucleosis and that may be the first sign of HIV infection in 50-70% of all patients and 45-90% of women. The symptoms may include fever, fatigue, muscle aches, loss of appetite, digestive disturbances, weight loss, skin rashes, headache, and chronically swollen lymph nodes (lymphadenopathy). Approximately 25-33% of patients will experience a form of meningitis during this phase, in which the membranes that cover the brain and spinal cord become inflamed. Acute retroviral syndrome develops between one and six weeks after infection and lasts two to four weeks, sometimes up to six weeks. Blood tests during this period will indicate the presence of virus (viremia) and the appearance of the viral p24 antigen in the blood.

Latency Period

After the HIV virus enters a patient's lymph nodes during the acute retroviral syndrome stage, the disease becomes latent for as many as 10 years or more before symptoms of advanced disease develop. During latency, the virus continues to replicate in the lymph nodes, where it may cause one or more of the following conditions.

PERSISTENT GENERALIZED LYMPHADENOPATHY (PGL). Persistent generalized lymphadenopathy, or PGL, is a condition in which HIV continues to produce chronic painless swellings in the lymph nodes during the latency period. The lymph nodes most frequently affected by PGL are those in the areas of the neck, jaw, groin, and armpits. PGL affects between 50-70% of patients during latency.

CONSTITUTIONAL SYMPTOMS. Many patients will develop low-grade fevers, chronic fatigue, and general weakness. HIV also may cause a combination of food malabsorption, loss of appetite, and increased metabolism that contribute to the so-called AIDS wasting or wasting syndrome.

OTHER ORGAN SYSTEMS. At any time during the course of HIV infection, patients may suffer from a yeast infection in the mouth called thrush, open sores or ulcers, or other infections of the mouth; diarrhea and other gastrointestinal symptoms that cause malnutrition and weight loss; diseases of the lungs and kidneys; and degeneration of the nerve fibers in the arms and legs. HIV infection of the nervous system leads to general loss of strength, loss of reflexes, and feelings of numbness or burning sensations in the feet or lower legs.

Late-Stage Aids

Late-stage AIDS usually is marked by a sharp decline in the number of CD4+ lymphocytes (a type of white blood cell), followed by a rise in the frequency of opportunistic infections and cancers. Doctors monitor the number and proportion of CD4+ lymphocytes in the patient's blood in order to assess the progression of the disease and the effectiveness of different medications. About 10% of infected individuals never progress to this overt stage of the disease.

OPPORTUNISTIC INFECTIONS. Once the patient's CD4+ lymphocyte count falls below 200 cells/mm³, he or she is at risk for opportunistic infections. The infectious organisms may include:

• Fungi. Fungal infections include a yeast infection of the mouth (candidiasis or thrush) and cryptococcal meningitis.
• Protozoa. The most common parasitic disease associated with AIDS is Pneumocystis cariniipneumonia (PCP). About 70-80% of AIDS patients will have at least one episode of PCP prior to death. PCP is the immediate cause of death in 15-20% of AIDS patients. It is an important measure of a patient's prognosis. Toxoplasmosis is another common infection in AIDS patients that is caused by a protozoan. Other diseases in this category include amebiasis and cryptosporidiosis.
• Mycobacteria. AIDS patients may develop tuberculosis or MAC infections. MAC infections are caused by Mycobacterium avium-intracellulare, and occur in about 40% of AIDS patients.
• Bacteria. AIDS patients are likely to develop bacterial infections of the skin and digestive tract.
• Viruses. AIDS patients are highly vulnerable to cytomegalovirus (CMV), herpes simplex virus (HSV), varicella zoster virus (VZV), and Epstein-Barr virus (EBV) infections. Another virus, JC virus, causes progressive destruction of brain tissue in the brain stem, cerebrum, and cerebellum (multifocal leukoencephalopathy or PML), which is regarded as an AIDS-defining illness by the Centers for Disease Control and Prevention.

ESTIMATED NUMBER OF ADULTS AND CHILDREN LIVING WITH AIDS/HIV WORLDWIDE AS OF 2001
Regions	Estimate
Australia & New Zealand	15,000
Caribbean	420,000
East Asia & Pacific	1,000,000
Eastern Europe & Central Asia	1,000,000
Latin America	1,500,000
North Africa & Middle East	500,000
North America	950,000
South & Southeast Asia	5,600,000
Sub-Saharan African	28,500,000
Western Europe	550,000
Global total	40,000,000+

AIDS DEMENTIA COMPLEX AND NEUROLOGIC COMPLICATIONS. AIDS dementia complex is a late complication of the disease. It is unclear whether it is caused by the direct effects of the virus on the brain or by intermediate causes. AIDS dementia complex is marked by loss of reasoning ability, loss of memory, inability to concentrate, apathy and loss of initiative, and unsteadiness or weakness in walking. Some patients also develop seizures.

MUSCULOSKELETAL COMPLICATIONS. Patients in late-stage AIDS may develop inflammations of the muscles, particularly in the hip area, and may have arthritis-like pains in the joints.

ORAL SYMPTOMS. Patients may develop a condition called hairy leukoplakia of the tongue. This condition also is regarded by the CDC as an indicator of AIDS. Hairy leukoplakia is a white area of diseased tissue on the tongue that may be flat or slightly raised. It is caused by the Epstein-Barr virus.

AIDS-RELATED CANCERS. Patients with late-stage AIDS may develop Kaposi's sarcoma (KS), a skin tumor that primarily affects homosexual men. KS is the most common AIDS-related malignancy. It is characterized by reddish-purple blotches or patches (brownish in African-Americans) on the skin or in the mouth. About 40% of patients with KS develop symptoms in the digestive tract or lungs. KS appears to be caused by a herpes virus.

The second most common form of cancer in AIDS patients is a tumor of the lymphatic system (lymphoma). AIDS-related lymphomas often affect the central nervous system and develop very aggressively.

Invasive cancer of the cervix is an important diagnostic marker of AIDS in women.

Diagnosis

Because HIV infection produces such a wide range of symptoms, the CDC has drawn up a list of 34 conditions regarded as defining AIDS. The physician will use the CDC list to decide whether the patient falls into one of these three groups:

• definitive diagnoses with or without laboratory evidence of HIV infection
• definitive diagnoses with laboratory evidence of HIV infection
• presumptive diagnoses with laboratory evidence of HIV infection

Physical Findings

Almost all symptoms of AIDS can occur with other diseases. The general physical examination may range from normal findings to symptoms that are closely associated with AIDS. These symptoms are hairy leukoplakia of the tongue and Kaposi's sarcoma. When the doctor examines the patient, he or she will look for the overall pattern of symptoms rather than any one finding.

Laboratory Tests for Hiv Infection

BLOOD TESTS (SEROLOGY). The first blood test for AIDS was developed in 1985. At present, patients who are being tested for HIV infection usually are given an enzyme-linked immunosorbent assay (ELISA) test for the presence of HIV antibody in their blood. Positive ELISA results then are tested with a Western blot or immunofluorescence (IFA) assay for confirmation. The combination of the ELISA and Western blot tests is more than 99.9% accurate in detecting HIV infection within four to eight weeks following exposure. The polymerase chain reaction (PCR) test can be used to detect the presence of viral nucleic acids in the very small number of HIV patients who have false-negative results on the ELISA and Western blot tests. In 2003, a one-step test that was quicker and cheaper was shown effective for detecting HIV in the physician office setting. However, further research was ongoing as to its effectiveness in replacing current tests as a first check for HIV.

OTHER LABORATORY TESTS. In addition to diagnostic blood tests, there are other blood tests that are used to track the course of AIDS. These include blood counts, viral load tests, p24 antigen assays, and measurements of β₂-microglobulin (β₂M).

Doctors will use a wide variety of tests to diagnose the presence of opportunistic infections, cancers, or other disease conditions in AIDS patients. Tissue biopsies, samples of cerebrospinal fluid, and sophisticated imaging techniques, such as magnetic resonance imaging (MRI) and computed tomography scans (CT) are used to diagnose AIDS-related cancers, some opportunistic infections, damage to the central nervous system, and wasting of the muscles. Urine and stool samples are used to diagnose infections caused by parasites. AIDS patients also are given blood tests for syphilis and other sexually transmitted diseases.

Diagnosis in Children

Diagnostic blood testing in children older than 18 months is similar to adult testing, with ELISA screening confirmed by Western blot. Younger infants can be diagnosed by direct culture of the HIV virus, PCR testing, and p24 antigen testing.

In terms of symptoms, children are less likely than adults to have an early acute syndrome. They are, however, likely to have delayed growth, a history of frequent illness, recurrent ear infections, a low blood cell count, failure to gain weight, and unexplained fevers. Children with AIDS are more likely to develop bacterial infections, inflammation of the lungs, and AIDS-related brain disorders than are HIV-positive adults.

Treatment

AIDS patients turn to alternative medicine when conventional treatments are ineffective, and to supplement conventional treatment, reduce disease symptoms, counteract drug effects, and improve quality of life. Because alternative medicines may interact with conventional medicines, it is important for the patient to inform his or her doctor of all treatments being used.

A report released in 2003 showed trends in increased use of alternative medicine among HIV-positive individuals. Based on 1997 figures, the study reported that 79% of those seeking alternative therapy to help with AIDS treatment or symptom relief were men and 63% were women. The types of therapies they used most were relaxation techniques, massage, chiropractic care, self-help groups, commercial diets, and acupuncture.

Supplements

• Lauric oils (coconut oil) are used by the body to make monolaurin, which inactivates HIV.
• Selenium deficiency increases the risk of death due to AIDS-related illness. One study found that 250 micrograms of selenomethionin daily for one year showed no improvement in CD4 cell counts or disease symptoms. Greater than 1,000 micrograms daily is toxic.
• Vitamin C has antioxidant and antiretroviral activities. One study found that treatment caused a trend to decrease viral load.
• DHEA (dehydroepiandrosterone) is commonly used by AIDS patients to counteract wasting. One study found that DHEA had no effect on lymphocytes or p24 antigen levels. However, a 2002 study found that it was associated with a significant increase in measures that indicate mental health improvement.
• Vitamin A deficiency is associated with increased mortality. One study of pregnant women with AIDS found that 5000 IU of vitamin A daily led to stabilized viral load as compared to a placebo group. Another study found that 60 mg of vitamin A had no effect on CD4 cells or viral load. Vitamin A has been associated with faster disease progression. Excessive vitamin A during pregnancy can cause birth defects.
• Beta-carotene supplementation for AIDS is controversial as studies have shown both beneficial and detrimental effects. Beta-carotene supplementation has led to elevation in white blood cell counts and changes in the CD4 cell count. Some studies have found that beta-carotene supplementation led to an increase in deaths due to cancer and heart disease.

Naturopathic doctors often recommend the following supplements for AIDS:

• beta-carotene, 150,000 IU daily
• vitamin C, 2,000 mg thrice daily
• vitamin E, 400 IU twice daily
• cod liver oil, 1 tablespoon daily
• multivitamin, as directed
• coenzyme Q₁₀, 50-60 mg twice daily

Herbals and Chinese Medicine

One small study of the effectiveness of Chinese herbal treatment in AIDS showed promise. AIDS patients took a tablet that contained 31 herbs that was based on the formulas Enhance and Clear Heat. Disease symptoms were reduced in the herbal treatment group as compared to the placebo group.

Herbals used in treating AIDS include:

• Maitake mushroom extract. Recommended dose is 10 drops twice daily
• Licorice (Glycyrrhiza glabra) solid extract. Recommended dose is one quarter to one half teaspoon twice daily
• Boxwood extract (SPV-30) has antiviral activity. Recommended dose is one capsule thrice daily.
• Garlic concentrate (Allicin) helped reduce bowel movements, stabilized or increased body weight, or cured Cryptosporidium parvum infection in affected AIDS patients. However, a 2002 National Institutes of Health study cautioned that garlic supplements could reduce levels of a protease inhibitor that is used to treat AIDS patients, so patients should discuss using garlic supplements with their physicians.
• Tea tree oil (Malaleuca) improves or cures infection of the mouth by the yeast Candida. Tea tree oil is available as soap, dental floss, toothpick, and mouthwash.
• Marijuana is used to treat wasting. Studies have found that patients who use marijuana had increased food intake and weight gain. The active ingredient delta-9-tetrahydrocannabinol is licensed for treating AIDS wasting.

Psychotherapy and Stress Reduction

Many therapies that are directed at improving mental state can have a direct impact on disease severity and quality of life. The effectiveness of many have been proven in clinical studies. These include:

• massage
• laughter/humor
• stress management training
• visualization
• cognitive therapy
• aerobic exercise
• prayer

Other treatments for AIDS include homeopathy, naturopathy, acupuncture, and chiropractic.

Allopathic Treatment

Treatment for AIDS covers four categories:

Antiretroviral Treatment

In recent years researchers have developed drugs that suppress HIV replication. The drugs are used in combination with one another and fall into four classes:

• Nucleoside reverse transcriptase inhibitors. These drugs work by interfering with the action of HIV reverse transcriptase, thus ending the virus replication process. These drugs include zidovudine (sometimes called Zidovudine or AZT, trade name Retrovir), didanosine (ddi, Videx), emtricitabine (FTC, Emtriva), zalcitabine (ddC, Hivid), stavudine (d4T, Zerit), abacavir (Ziagen), tenofovir (df, Viread), and lamivudine (3TC, Epivir).
• Protease inhibitors. Protease inhibitors are effective against HIV strains that have developed resistance to nucleoside analogues, and often are used in combination with them. These compounds include saquinavir (Fortovase), ritonavir (Norvir), indinavir (Crixivan), amprenavir (Agenerase), lopinavir plus ritonavir (Reyataz), and nelfinavir (Viracept).
• Non-nucleoside reverse transcriptase inhibitors. This is a newer class of antiretroviral agents. Three are available, nevirapine (Viramune), efavirenz (Sustiva), and delavirdine (Rescriptor).
• Fusion inhibitors. These drugs are less common, expensive and difficult to use. They block infection early by preventing HIV from fusing with and entering a human cell. This class includes only one compound: Enfuvirtide (Fuzeon).

Treatment guidelines for these agents are in constant change as new medications are developed and introduced. In mid-2003, the U.S. Department of Health and Human Services revised its guidelines for the use of these agents to help clinicians better choose the best combinations. The new guidelines offer a list of suggested combination regimens classified as either "preferred" or "alternative".

Treatment of Opportunistic Infections and Malignancies

Most AIDS patients require complex long-term treatment with medications for infectious diseases. This treatment often is complicated by the development of resistance in the disease organisms. AIDS-related malignancies in the central nervous system usually are treated with radiation therapy. Cancers elsewhere in the body are treated with chemotherapy.

Prophylactic Treatment for Opportunistic Infections

Prophylactic treatment is treatment that is given to prevent disease. AIDS patients with a history of Pneumocystis pneumonia; with CD4+ counts below 200 cells/mm³ or 14% of lymphocytes; weight loss; or thrush should be given prophylactic medications. The three drugs given are trimethoprim-sulfamethoxazole, dapsone, or pentamidine in aerosol form.

STIMULATION OF BLOOD CELL PRODUCTION. Because many patients with AIDS suffer from abnormally low levels of both red and white blood cells, they may be given medications to stimulate blood cell production. Epoetin alfa (erythropoietin) may be given to anemic patients. Patients with low white blood cell counts may be given filgrastim or sargramostim.

Treatment in Women

Treatment of pregnant women with HIV is particularly important because antiretroviral therapy has been shown to reduce transmission to the infant by 65%.

Expected Results

At the present time, there is no cure for AIDS. Treatment stresses aggressive combination drug therapy when possible. The use of multi-drug therapies has significantly reduced the number of U.S. deaths resulting from AIDS. The potential exists to possibly prolong life indefinitely using these and other drug therapies to boost the immune system, keep the virus from replicating, and ward off opportunistic infections and malignancies.

Prognosis after the latency period depends on the patient's specific symptoms and the organ systems affected by the disease. Patients with AIDS-related lymphomas of the central nervous system die within two to three months of diagnosis; those with systemic lymphomas may survive for eight to ten months. In America, the successful treatment of AIDS patients with HAART has actually led to a growing number of people living with HIV. About 25,000 infected people per year are added to the list of HIV-infected Americans.

However, not only does HAART and other treatment prolong AIDS patients' lives, it has led to some improvement in quality of life too. A recent study shows that HAART therapy substantially reduces risk of AIDS-related pneumonia (PCP), although PCP still remains the most common AIDS-defining illness among opportunistic infections. Other recent studies show that these protease inhibitors may result in high cholesterol and put AIDS patients at eventual risk for heart disease. Further research must be done, since long-term effects of HAART treatment are just now being studied. Most clinicians would say the benefits outweigh the risks anyway.

Prevention

As of 2000, there is no vaccine effective against AIDS. Several vaccines to prevent initial HIV infection and disease progression are being tested. In 2002, reports showed a new "library" vaccine showed potential. The vaccine is composed of up to 32 HIV gene fragments that can induce a number of immune responses. In the same year, the British government worked with five African countries in a trial to find an effective gel that would protect women against HIV during sex. The study leaders believed if they could find a lotion that could be applied before intercourse that would help prevent HIV transmission, they would give women the ability to better protect themselves from HIV. In 2003, the first human test of a vaccine against the most common subtype of HIV was underway.

Precautions to take to prevent the spread of AIDS include:

• Monogamy and practicing safe sex. Besides avoiding the risk of HIV infection, condoms are successful in preventing other sexually transmitted diseases and unwanted pregnancies.
• Avoiding needle sharing among intravenous drug users.
• Although blood and blood products are carefully monitored, those individuals who are planning to undergo major surgery may wish to donate blood ahead of time to prevent a risk of infection from a blood transfusion.
• Healthcare professionals should wear gloves and masks when handling body fluids and avoid needle-stick injuries.
• A person who suspects that he or she may have become infected should get tested. If treated aggressively and early, the development of AIDS can sometimes be postponed indefinitely. If HIV infection is confirmed, it also is vital to inform sexual partners.

Resources

Books

Abrams, Donald I. "Alternative Therapies." AIDS Therapy. edited by Raphael Dolin et al. Philadelphia: Churchill Livingstone, 1999.

Early HIV Infection Guideline Panel. Evaluation and Management of Early HIV Infection. Rockville, MD: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, 1994.

The Global AIDS Policy Coalition. AIDS in the World. Cambridge, MA: Harvard University Press, 1992.

Huber, Jeffrey T. Dictionary of AIDS-Related Terminology. New York and London: Neal-Schuman Publishers, Inc., 1993.

"Infectious Diseases: Human Immunodeficiency Virus (HIV)." In Neonatology: Management, Procedures, On-Call Problems, Diseases and Drugs. edited by Tricia Lacy Gomella, et al. Norwalk, CT: Appleton & Lange, 1994.

Katz, Mitchell H. and Harry Hollander. "HIV Infection." In Current Medical Diagnosis & Treatment 1998. edited by Lawrence M. Tierney Jr., et al. Stamford, CT: Appleton & Lange, 1998.

McCutchan, J. Allen. "Alternative, Unconventional, and Unproven Therapies." Textbook of AIDS Medicine, 2nd edition. edited by Thomas C. Merigan, et al. Baltimore: Williams & Wilkins, 1999.

McFarland, Elizabeth J. "Human Immunodeficiency Virus (HIV) Infections: Acquired Immunodeficiency Syndrome (AIDS)." In Current Pediatric Diagnosis & Treatment. edited by William W. Hay Jr., et al. Stamford, CT: Appleton & Lange, 1997.

So, Peter and Livette Johnson. "Acquired Immune Deficiency Syndrome (AIDS)." In Conn's Current Therapy. edited by Robert E. Rakel. Philadelphia: W. B. Saunders Company, 1997.

Standish, Leanna J., Roberta C.M. Wines, and Cherie Reeves. "Complementary/Alternative Therapies in Select Populations: Women with HIV and AIDS." In Complementary/Alternative Medicine: An Evidence Based Approach. edited by John W. Spencer and Joseph J. Jacobs. St. Louis: Mosby, 1999.

Periodicals

"DHEA in HIV Infection." Infectious Disease Alert. (March 1, 2002): S7.

Ernst, Jerome. "Alternative Treatment Modalities in Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome." Clinical Infectious Diseases (September 1, 2003): 150–154.

"First Human Tests Under Way of HIV Vaccine Pioneered at UNC." AIDS Vaccine Week (August 25, 2003): 2.

Fleck, Fiona. "British Medical Journal." British Medical Journal (September 27, 2003): 698.

Gangel, Elaine K. "Garlic Supplements and HIV Medication." American Family Physician (March 15, 2002): 1225.

"Government Lauches Trial of Gel to Protect Women Against HIV." AIDS Weekly (March 25, 2002): 11.

"HIV Drugs Approved as of August 2003." AIDS Treatment News (July 25, 2003): 4.

"HIV Rising Among Gay, Bisexual Men." Medical Letter on the CDC & FDA (August 24, 2003): 9.

"Is HAART Hard on the Heart" Science News (March 9, 2002): 158.

"Library Vaccine Shows Promise." Vaccine Weekly. (February 13, 2002): 2.

"One-step HIV Test May Be Cheaper, Faster, Less Wasteful." AIDS Weekly (September 29, 2003): 13.

Ozsoy, Metin and Edzard Ernst. "How Effective are Complementary Therapies for HIV and AIDS?—a Systematic Review." International Journal of STD & AIDS 10 (1999): 629-635.

"Prevalence of HIV Infection Increasing in Older Americans." AIDS Weekly (September 1, 2003): 16.

"Revised Guidelines Will Ease Selection of HIV/AIDS Treatments." Drug Week (August 8, 2003): 10.

"Successful HAART Reduces Risk of Pneumonia." AIDS Weekly (January 14, 2002): 24.

"Success of Treatment Swells Ranks of HIV Infected." AIDS Weekly (March 25, 2002): 13.

Wootton, Jacqueline C. "WebWatch: Alternative and Complementary Therapies." AIDS Patient Care and STDs 12 (1998): 811-813.

Organizations

American Foundation for AIDS Research, 733 Third Avenue, 12th floor, 1515 Broadway, Suite 3601, New York, NY 10017. (212) 682-7440.

Gay Men's Health Crisis, Inc., 129 West 20th Street, New York, NY 10011-0022. (212) 807-6655.

National AIDS Hot Line. (800) 342-AIDS (English). (800) 344-SIDA (Spanish). (800) AIDS-TTY (hearing-impaired).

[Article by: Belinda Rowland; Teresa G. Odle]

Acquired immunodeficiency syndrome, or AIDS, is the final, life-threatening stage of infection with any of the human immunodeficiency viruses (HIV-1, its many subtypes, or HIV-2), which are transmitted from person to person sexually (including via anal, oral, and vaginal intercourse, both heterosexually and homosexually), through contact with blood (mainly via equipment used to inject illicit drugs and, rarely, via medical uses of blood), and perinatally (from mother to fetus or newborn during pregnancy, labor, and delivery, or after birth through breast-feeding).

Origin and History

HIV-1 and HIV-2 both appear to have been transmitted to humans from primates in Central and West Africa, probably to hunters or processors of carcasses of primates consumed as food (referred to as "bush meat"). Beginning as simian viruses, they became human viruses once they achieved sustained transmission from person to person. This appears to have occurred at least four times in history: three times from chimpanzees (Pan troglodytes); (possibly in the 1930s), representing the three major strains of HIV-1, and once from sooty mangabeys, representing HIV-2. Social and technological changes in Africa resulted in transmission of HIV to larger and larger numbers of adults as roads were built and river transport developed, making travel to cities, with their better economic opportunities, far easier and more rapid. A silent heterosexual epidemic occurred and spread via travelers to industrialized nations of Europe and North America, where the new syndrome was initially recognized as a distinct clinical entity in 1981, even though the number of cases then was minuscule. By 1983, epidemiologists had discerned the routes of transmission and pointed the way for laboratory investigators to identify the etiologic agents. In 1984, the laboratory culturing of HIV was described in the scientific literature, as was the first serologic test for detecting the HIV antibody, which has been used to screen blood donations since 1985. Originally given three different names by the French (1983) and two American (1984) research teams that "discovered" the virus, the name HIV was agreed upon in 1986.

Epidemiology

HIV-1 has spread worldwide, infecting more than 36 million people by 2001. HIV-2, which seems to be less clinically severe and possibly less transmissible from person to person, has mainly been a public health problem for West African nations. Originally epidemic in African and urban settings, HIV and AIDS are now among the most common serious infections globally, including in the Americas and Eurasia and in rural settings. All ages, racial and ethnic groups, and persons of all sexual orientations have been infected.

Virology

HIVs are all members of the family known as retroviruses, so named because of their unique method of reproduction which uses the enzyme (protein catalyst) reverse transcriptase (RT) to incorporate its genetic material (RNA) into the DNA of the infected host's c