HIV/AIDS

Updated 24 June 2014

HIV/Aids

The Acquired Immune Deficiency Syndrome (Aids) is caused by infection with the Human Immunodeficiency Virus (HIV).

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Description

  • Aids (Acquired Immunodeficiency Syndrome) is caused by HIV (the Human Immunodeficiency Virus).
  • HIV is mainly transmitted through sexual intercourse.
  • Once a person is infected, the virus remains in the body for life.
  • One can be HIV positive and feel completely well for many years.
  • When a pregnant woman is infected, there is a one in three chance of her baby becoming infected if no steps are taken to prevent this.
  • Most people infected with HIV will eventually get Aids.
  • Aids is a fatal illness.
  • There is no drug that can cure HIV infection, but there are drugs that can control the virus and delay the onset of Aids.
  • There is no preventative HIV vaccine available at the moment, however research is ongoing to find one.

The Acquired Immune Deficiency Syndrome (Aids) is caused by infection with the Human Immunodeficiency Virus (HIV). HIV attacks and gradually destroys the immune system, which protects the body against infections.

Aids develops during the last stages of HIV infection. Aids is not a single illness, but the whole clinical picture (a syndrome) that occurs when the immune system fails entirely. A person with a failing immune system is susceptible to a variety of infections that are very unlikely to occur in people with healthy immune systems. These are called opportunistic infections because they take advantage of the body's weakened immune system. Certain types of cancers also occur when the immune system fails.

It may take years for a person's immune system to deteriorate to such an extent that the person becomes ill and a diagnosis of Aids is made. During this time (which can last as long as 15 years or possibly even longer), a person may look and feel perfectly well. This explains why so many people are unaware that they are infected with HIV. However, even though they feel healthy, they can still transmit the virus to others.

More than 90% of people living with HIV are in developing countries, with sub-Saharan Africa accounting for two thirds of all the HIV-infected people in the world. Unlike Western countries, where HIV has initially affected predominantly homosexual men, in Africa and developing countries HIV is usually spread by sex between men and women (heterosexual sex).

Research into HIV/Aids is ongoing and new information is emerging rapidly. There are drugs that can dramatically slow down the disease in an infected person. These drugs need to be taken in various combinations in order to be effective. Also, individuals on the drugs must be monitored by medical personnel trained in the use of antiretroviral therapy because these drugs can potentially cause serious side effects if not taken correctly and if the individual is not monitored properly. However, there is no cure for Aids. There is also currently no preventative vaccine against HIV infection. At this time the only effective strategy for controlling the spread of HIV is prevention through individual behaviour change, spreading the correct information about preventing HIV infection and the use of condoms and other safe sex measures. Other measures, which should be taken by a country's health system, include screening of blood products and the prevention of infection of patients through contaminated medical equipment. Mother to child infection can be reduced by a short course of an anti-HIV drug given to the mother and new-born baby at the time of delivery. (See "treatment")

Cause

According to researchers, two viruses cause Aids, namely HIV-1 and HIV-2. HIV-1 is the predominant virus in most parts of the world, whereas HIV-2 is most commonly found in West Africa. These viruses belong to a family called the retroviruses. They are unique viruses in that they are able to insert their genetic material into the genetic material (DNA) of cells of the person that they have infected. In this way they are able to infect a person for the rest of that person's life.

To understand how the virus eventually causes Aids, see the section "Course of the disease".

Viruses that are very closely related to HIV are found in other primates (apes and monkeys). These viruses are called Simian Immunodeficiency Viruses (SIV). HIV-2 is genetically almost indistinguishable from the SIV found in sooty mangabeys. A very close genetic relative of HIV-1 has been found in chimpanzees. Therefore most scientists accept that the human immunodeficiency viruses are recently derived from these primate viruses. The earliest human blood sample found to contain HIV dates from 1959; this sample was collected in central Africa.

Based on molecular technology and the use of large computer programmes, scientists have been able to trace back the genetic origins of HIV-1 and HIV-2 and roughly pinpoint the time when these viruses first appeared in humans. The current theory is that sometime between 1930-1940 there was a "species-jump" of certain SIV's into human populations, probably through the practise of slaughtering, preparing and consuming of "bush meat" from monkeys in parts of Central and West Africa.

HIV is not as contagious as is often believed. The virus does not survive long outside the body and can only be transmitted through the direct exchange of certain body fluids such as blood, semen and vaginal fluid. The virus can gain access to the body at its moist surfaces ("mucous membranes") during sex, or through direct injection into the blood stream. Sex is the major mode of transmission of HIV worldwide.

HIV can be transferred from one person to another (transmitted) through:

  • Unprotected vaginal or anal intercourse with an infected person.
  • A mother's infection passing to her child during pregnancy, birth or breastfeeding (called vertical transmission) – the risk of HIV passing from mother to child is approximately 30% if no preventative measure is used.
  • Injection with contaminated needles, which may occur when intravenous drug users share needles, or when health care workers are involved in needleprick accidents.
  • Use of contaminated surgical instruments, for example during traditional circumcision.
  • Blood transfusion with infected blood.
  • Contact of a mucous-membrane surface with infected blood or body fluid, for example with a splash in the eye (Note that the virus cannot penetrate undamaged skin.)

If a person is exposed to HIV in one of the above ways, infection is not inevitable. The likelihood of transmission of HIV is determined by factors such as the concentration of HIV present in the body fluids. For example, although HIV has been detected in saliva, the concentration is thought to be too low for HIV to be transmitted through deep/wet kissing since it would require the exchange of almost one litre of saliva between individuals before there would be sufficient virus available for possible transmission. Additionally, a digestive protein in human saliva tends to inactivate the virus.

The risk of HIV transmission also depends on the stage of infection the HIV-positive sexual partner is in. Virus concentrations in blood and body fluids are highest when a person has very recently been infected with HIV, or otherwise very late in the disease, when Aids has developed. Very early after infection the virus can multiply rapidly as the immune system has not had time to respond and fight back, and late in the disease the virus can multiply rapidly because it has destroyed the immune system altogether. However, it is important to note that once a person is infected with HIV, their blood, semen or vaginal fluids are always infectious, for the rest of their lives.

Vulnerability to HIV infection through sexual contact is increased if a person has sores on the genitals, mouth or around the anus/rectum. These sores can be caused by rough intercourse, other sexually transmitted infections (STIs), gum disease or overuse of spermicides.

In heterosexual sex, women are more vulnerable to HIV infection because of the large mucous-membrane surface area of the vagina compared to that of the urethra (penile opening). Therefore, in regions where heterosexual sex is the main way HIV is transmitted (as in South Africa), approximately four women are infected for every three men that are infected.

Men who are circumcised have a slightly lower risk of being infected with HIV.

Fortunately, people can take action to reduce their risk of infection. For example, a person who uses a condom every time he or she has sex is at far lower risk of infection than someone who has unprotected sex.

The following outlines common sexual behaviours according to relative risk:

Very low risk

  • Kissing (if no blood is exchanged through cuts or sores).
  • Touching (such as stroking, hugging or massage).
  • Masturbation (including mutual masturbation).
  • Oral sex on a man with a condom.
  • Oral sex on a woman with a barrier method (such as plastic wrap, dental dam or a condom cut open).

Low risk

  • Wet/deep kissing (when sores or gum disease, and therefore blood, are present).
  • Oral sex
  • Vaginal sex with a male or female condom
  • Anal sex with a male or female condom

High risk

  • Anal intercourse without a condom
  • Vaginal sex without a condom

How HIV is not transmitted

Unfortunately, there are still many myths around HIV. A person cannot be infected through:

  • Mosquito bites
  • Urine or sweat
  • Public toilets, saunas, showers or swimming pools
  • Sharing towels, linen or clothing
  • Going to school with, socialising or working with HIV-positive people
  • Sharing cutlery or crockery
  • Sneezes or coughs
  • Touching, hugging or dry kissing a person with HIV
  • (Sexual) contact with animals, since HIV is strictly a human virus and is not carried by animals

In South Africa, blood donated for transfusions or blood products is screened for antibodies to HIV and for viral RNA (genomes). Any contaminated blood is discarded. The probability of HIV infection via blood transfusion in this country is therefore extremely low, but transmission can still occur because even these highly sensitive tests cannot always detect very early HIV infection in a donor. (See "the window period" in the section on HIV tests.)

Symptoms

The majority of people will have some symptoms about three weeks after they have been infected with HIV. These symptoms are similar to those of glandular fever:

  • Fever and night sweats
  • Aching muscles and tiredness
  • Sore throat
  • Swollen glands
  • Diarrhoea
  • Skin rash and ulceration of the inside surface of the mouth and genitals
  • Headache, sore eyes and sensitivity to light

These early symptoms are called the HIV seroconversion illness. This is because the illness coincides with the start of the production of antibodies to the virus. (Antibodies are blood proteins made by the immune system that recognise and attach to organisms invading the body.) HIV antibodies become detectable in the blood during the course of the illness. The usual HIV test (rapid test or ELISA) detects these antibodies. The seroconversion illness is usually brief, lasting a week or two.

Thereafter most people remain symptom-free for a long time, on average ten years. Then symptoms associated with the advance of HIV disease, roughly in order of appearance, may include:

  • Unexplained weight loss (more than 10% of body weight)
  • Swelling of glands in the neck, armpit or groin
  • Easy bruising
  • Recurring and unusual skin rashes, often itchy
  • A thick, white coating of the tongue or mouth (oral thrush) or vagina (vaginal thrush) which is severe and recurs
  • Ongoing vaginal discharge and pain in the lower abdomen
  • Sinus fullness and drainage
  • Recurrent herpes
  • Shingles
  • Persistent sore throat
  • Recurring fevers lasting more than 10 days without an obvious cause
  • Night sweats or chills
  • Persistent cough and/or shortness of breath
  • Persistent severe diarrhoea (longer than a month)
  • Changes in vision
  • Pain, loss of control and strength of muscles, paralysis
  • Discoloured or purplish growths on the skin or inside the mouth or nose
  • Difficulty with concentration, inability to perform mental tasks that have been done in the past, confusion, personality change

Symptoms are slightly different in children. Common symptoms include:

  • Persistent oral thrush
  • Recurrent bacterial infections, such as ear infections
  • Recurrent gastro-enteritis
  • Swollen salivary glands (parotitis)
  • Swollen lymph nodes in the neck, armpits or groin
  • Enlargement of the liver and spleen
  • Failure to grow or reach normal points in development at the right time (such as talking, walking)

Prevalence

Estimates published in the annual "UNAIDS Report on the Global HIV/AIDS Epidemic" in 2009 estimate that about 33.4  million adults and children were infected with HIV around the world in 2008. Africa south of the Sahara desert accounts for 22.4 million of these infections. A recent HIV prevalence survey by the Human Sciences Research Council (HSRC) conducted in 2008 estimated that 10.9% of South Africans (5.2 million people) over the age of two years are currently living with HIV/Aids. Also this study clearly demonstrated that young women in South Africa in the age group 25-29 continue to be at greatest risk for HIV infection.

This data is also supported by the annual Department of Health Antenatal clinic (ANC) surveys that showed about 29.3% of pregnant women in South Africa were HIV positive in 2008.

For more details of the global epidemic, please refer to the UNAIDS Global Report.

Course of the disease

The disease is best understood as a continuum from initial infection to terminal illness.

During sexual transmission, the virus penetrates the thin, moist surface of the vagina, urethra or rectum of another person during sex. Special protective white cells called dendritic cells usually patrol just beneath these surfaces and usually protect against invading organisms. Unfortunately, HIV is able to infect these defender cells, which then carry the virus into the regional lymphoid tissue (such as lymph glands).

Here the virus has access to another type of white blood cell, called a T-helper lymphocyte. HIV gets into these cells by attaching to a specific protein on their surface, known as CD4 (so these cells are also called CD4 cells). T-helper lymphocytes circulate in the blood, but most of them are found in the lymph glands, where they stimulate other cells of the immune system to go into action.

In addition to the CD4 receptor, a second (co-receptor) is required for the HIV virus to enter the CD4 cell successfully. The co-receptors belong to a related family of molecules. Two members of this family are commonly used by HIV to gain entry, namely CCR5 and CXCR4. Certain people have genetically defective CCR5 receptors that make them relatively resistant to HIV infection. CCR5 defects are most common in Northern European populations but unfortunately are not common in South Africans.

HIV multiplies best inside CD4+ cells and the infected lymphocytes eventually deteriorate and die, releasing more viruses to infect new lymphocytes. The CD4+ cells in the lymphoid tissue around the gut are preferentially targeted by the virus and are destroyed early in the course of the disease. This leaves the body vulnerable as bacterial products from the gut are able to gain entry into the body and cause inflammation in the lymphoid tissue around the body.

The virus takes about two weeks to start multiplying efficiently in the body. At about three weeks after infection the immune system will recognise the "invasion" and start to produce antibodies to HIV. The battle between the virus and the immune response causes the symptoms of the seroconversion illness when antibodies are produced. Amazingly, the immune system will get the upper hand at this stage and limit multiplication of the virus, so that symptoms resolve in a week or two. Thereafter most people will have partial control over the virus with no symptoms of HIV infection for several years, 10 on average.

However, the virus hides out in an individual's lymphocytes and slowly but surely evades the control measures of the immune system, mostly because it is genetically changeable and therefore keeps presenting a new appearance to the immune system which cannot keep up with the virus. All this time T-helper cells are not functioning properly or are destroyed whenever the virus multiplies. Initially the body is able to replace the T-helper cells as fast as they are destroyed and there is no significant effect on their numbers. However, after several years the body's ability to replace the T-lymphocytes begins to fall off. T-helper cells play a crucial part in the proper functioning of the immune system and the depletion of these cells drastically reduces the effectiveness of the immune system. This makes the person vulnerable to opportunistic infections (infections that do not cause a problem in patients with healthy immune systems, but can attack people with weakened immune systems).

Aids is usually first diagnosed when an HIV-infected person gets a characteristic opportunistic infection or an Aids-related tumour. Very common opportunistic infections in Aids are Pneumocystis carinii pneumonia (PCP) now known as Pneumocystis jerovici pneumonia and tuberculosis (TB), which can even occur in sites in the body outside the lungs, bones or gut. The common tumours in Aids are Kaposi's sarcoma, usually visible in the skin, and certain tumours of the lymph glands (lymphoma). Infection of the brain by HIV itself or other viruses and certain types of parasites, can cause dementia and stroke-like problems.

Some people progress to Aids quickly within two years, whereas others remain symptom-free for 15 years or more. This latter group of people are known as "long-term non-progressors" or elite controllers and scientists are very interested in what advantage they have for withstanding HIV. In developing countries, where people may be malnourished and have many other illnesses to contend with as well, HIV disease tends to progress to Aids more quickly than the 10-year average for people living in the better circumstances of the developed world.

Risk factors for acquiring HIV infection:

The following people are most at risk of HIV infection:

  • People who have unprotected vaginal or anal sex
  • People who have sex with many partners, thereby increasing the chance that they will encounter a partner who is HIV infected
  • People who share needles (for example for intravenous drug use, tattooing or body piercing)
  • Babies of mothers who are HIV infected
  • People who have another STI, especially STIs that cause open sores or ulcers such as herpes, chancroid or syphilis
  • Haemophiliacs and other people who frequently receive blood products (this risk is now very much diminished, but there are still countries where blood is not adequately screened)
  • Health care workers, where precautions are neglected or fail (for example through not wearing gloves or accidental needle injuries)

When to call a health professional

A health care professional should be seen if:

  • You have been at risk of HIV infection (for example through unprotected sex, rape or sharing of needles). Anti-HIV drugs taken within hours of exposure to HIV can decrease the risk of contracting the virus.
  • Your sexual partners engage in high-risk behaviour or are known to be HIV positive.
  • You are pregnant or plan to have a child.
  • Any of the symptoms listed above are present.
  • An HIV-positive person develops shortness of breath, convulsions, weakness in a limb or one side of the body, or loses consciousness (they should receive emergency care).

Visit preparation

Before being tested for HIV, it is best to seek counselling. All clinics and doctors should insist on pre- and post-test counselling to help patients deal with the psychological stress and anxiety they are likely to experience while waiting for results or when they have to deal with the consequences of a positive result. Pre- and post-test counselling for HIV testing is a requirement by law in South Africa. Avoid sexual contact with others while waiting for test results.

Diagnosis

Diagnostic testing can only be done with your consent. Pre-employment testing is now illegal in South Africa. Testing by life insurance companies is still often required, but can only be done if the client gives consent.

Ordinary HIV tests do not detect the virus, but rather the specific antibodies that are produced by the immune system in response to HIV infection. Antibodies are produced from about three weeks after infection and usually become detectable by enzyme liked immunosorbent assay or ELISA testing by four to six weeks after infection. This four- to six-week period between infection and a positive test is called the window period. In some people the window period is longer; it may take up to three months for an antibody test to become positive after they have been infected, but this is unusual. People who think that they might have been exposed to infection are therefore usually asked to wait at least four weeks before having the HIV test. Also, even if the first test is negative (i.e., no antibodies detected), a follow-up test should be done three months after the suspected exposure.

The most widely used and best antibody test is called an ELISA test. These days, most laboratories screen with an ELISA that tests for antibody as well as a viral protein (p24 antigen). The p24 antigen appears in the blood a week before antibody. This shortens the window period (time from exposure to development of a positive test). If a positive result is obtained on an ELISA test, the laboratory will confirm the result by testing with at least one different type of ELISA test. As an additional check, a second blood specimen is usually taken from the person for repeat testing.

Testing can also be done with a rapid HIV test which can be carried out by any health care professional immediately on-site in a clinic. Voluntary HIV testing and counselling (VCT) is offered to the public free on request at public clinics in South Africa. Testing is done on blood from a finger prick. If the test is positive, a second (different) test will be done immediately. Both tests must be positive to confirm a diagnosis of HIV infection. The advantage of rapid testing is that an HIV result is available within 30 minutes.

This sort of HIV testing is very accurate. Very rarely false positives occur due to antibodies that cross-react in the testing system, but these occur less frequently with the modern tests. False negative tests can also occur, especially if the test is done too soon after last exposure.

Currently, home HIV tests are being sold in some chemists. Most health care professionals and the Department of Health are not in favour of this practice. One reason is that the quality of the test cannot be regulated, so that there may be a greater risk of false positive or false negative results. Also, a person testing themselves or someone else, will probably not have the information or psychological support that is gained through pre- and post-test counselling.

HIV testing in babies:

In babies less than 18 months old, the mother's antibodies in the baby's blood can interfere with the HIV antibody test. Therefore, to test whether a baby is infected with HIV, it is necessary to detect the virus itself. This is commonly done with a PCR test. In South Africa, all babies of HIV-infected mothers are routinely tested at six weeks with this test. Infants who are found to be PCR positive should immediately be referred for anti-retroviral treatment.

CD4 count:

This test is used to determine how advanced a person's HIV disease is. A CD4 cell count indicates what reserves of T-helper lymphocytes the person has and therefore the remaining strength of their immune system. A normal CD4 count is 800 or more cells per microlitre of blood. This level drops gradually in the blood over time and the immune system progressively weakens. Once the level drops below 350 cells per microlitre of blood, the patient should be assessed for anti-retroviral drug therapy.

Viral load:

The viral load test measures the amount of virus in the blood, which shows how rapidly HIV is multiplying and therefore how quickly the disease is likely to progress. In practice, the viral load test is mainly used for monitoring response to antiretroviral drug treatment. In patients on anti-retroviral therapy, the viral load should be lower than detectable limits. If the viral load is detectable, it means that the therapy is not working well enough.  This could be because of non-compliance (patient is not taking the medication reliably) or the virus has developed resistance to the drugs.

Treatment

Home

  • Discuss your HIV status with your partner(s). While this may be difficult to do, it is important that they be tested so that they can also be treated if necessary. In addition, they in turn may be unknowingly putting others at risk of HIV.
  • Protect your partner(s) from HIV by practising safer sex.
  • Stay healthy to maintain a strong immune system: eat a healthy, balanced diet, get enough rest and exercise, and avoid cigarettes and alcohol.

Medication

Management of opportunistic infections:

Once a person has tested positive for HIV, a thorough medical examination should be done to evaluate their present state of health. As other STIs and TB are often present in someone who is HIV positive, additional screening tests for these diseases should be done, so that they can be treated straight away.

Severe opportunistic infections need to be treated before anti-retroviral drugs can be started. If the patient's CD4 count is very low (less than 200 cells per microlitre of blood), the doctor will start prophylaxis for pneumocystis jerovecii. This organism can cause life threatening lung disease in late HIV infection.

Anti-retroviral therapy:

Anti-retroviral drugs slow down the rate at which the virus multiplies. Even though these drugs cannot completely eliminate the virus, by slowing down its multiplication they can prolong the symptom-free period of the disease and allow the immune system to recover. Once treatment is started, it must be continued for the rest of the infected person's life. Strict compliance is essential to prevent the development of drug resistance. Anti-retroviral medication should be started when the patient's immune system begins to fail. The presence of symptoms of HIV disease and the CD4 count are used to decide when to start anti-retroviral drugs. In South Africa anti-retroviral therapy is advised when the CD4+ count is less than or equal to 350 cells/ mm3 or in patients who have an Aids-defining illness (irrespective of the CD4+ count).

For more information on the South African guidelines, please refer to the Department of Health's ART Guideline.

These guidelines also give information on which drugs are suitable to start therapy with and how to monitor individuals on these drugs.

Anti-retroviral drugs block various stages in the viruses replication cycle. There are a growing number of different classes of drug, including:

  • Nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs) such as zidovudine (AZT), lamivudine (3TC) and tenofovir (TDF).
  • Non-nucleoside reverse transcriptase inhibitors (NNRTIs) such as nevirapine, efavirenz, etravine and delavirdine.
  • Protease inhibitors (PIs) such as indinavir, saquinavir, lopinavir and atazanavir.
  • Fusion/entry inhibitors such as maraviroc and enfuvirtide.
  • Integrase inhibitors such as raltegravir.

For details of the drugs used in the South African public sector refer to the Department of Health's ART Guideline.

The two groups of reverse transcriptase inhibitors handicap (inhibit) the viral enzyme that allows the virus to convert its RNA genome into DNA.

The protease inhibitors handicap the viral enzyme that allows young viruses to mature to the state in which they can infect new cells.

Entry inhibitors prevent the virus from gaining entry into the cell by blocking various target molecules.

Integrase inhibitors prevent the viral dsDNA from being incorporated into the cell’s DNA. 

To treat HIV infection, a patient must receive a combination of three or more different antiviral drugs which target different steps in the viruses replication cycle. Using a cocktail of drugs reduces the chances that the virus will become resistant. Patients who are on antiretroviral drugs need to be monitored for evidence of drug side effects, evidence of clinical response to therapy (climbing CD4+ cell count indicates a recovering immune system) as well as for unexpected worsening of opportunistic infections. This can sometimes happen in the weeks following the start of antiretroviral treatment as the immune system recovers and turns to attack the invaders in the body. This condition is known as immune reconstitution inflammatory syndrome (IRIS). Severe inflammatory reactions occur in the tissues of the body infected by particular opportunistic organisms.

HIV drugs and mother to child transmission (MTCT)

Pregnant women who are HIV positive can reduce the risk of infecting their babies by using anti-retroviral drugs during pregnancy and labour. During pregnancy, at 14 weeks of gestation or as soon as possible, Zidovudine should be given for pregnant women who are not on ART and intrapartum every 3 hours until delivery. In addition, a single dose of Nevirapine during stage 1 of labour as well as a single dose of Tenofovir and Emtricitabine. The baby should be given Nevirapine at birth and then daily for 6 weeks. Thereafter, an HIV PCR test will be done to determine the ongoing management of the baby.

A planned caesarean section will also reduce the risk of HIV being transmitted to the baby, as most infections occur during labour itself.

Babies can be infected through breastfeeding, so most specialists strongly recommend that mothers who are HIV positive should only bottle feed their babies. If pure bottle feeding is not an option, then pure breastfeeding is recommended, and mixed feeding (breast and bottle) should be avoided. It is believed that mixed feeding may actually increase the chance of HIV transmission through the mother's milk. Most antenatal clinics in the country have a "training" programme to show mothers how to use formula milk properly. So although the benefits of breast milk are unfortunately lost in these infants, receiving formula or bottle milk at least ensures they are not exposed to HIV. Some mothers may choose to express their breast milk which can then be pasteurised (at home). This process kills viable HIV, but preserves the unique nutrient content of the milk. All infants who are HIV-exposed should have an HIV PCR test done at six weeks to determine whether they have contracted HIV. For infants who are breast fed, a PCR test should be done on the baby six weeks after cessation of breast feeding. All infants with a positive PCR test should start anti-retroviral therapy immediately, irrespective of their CD4+ count.

Prevention of MTCT is a very complex problem. If you are HIV positive and pregnant you would need to discuss the issues at length with a health care professional knowledgeable in the area.

Post exposure prophylaxis:

Health care workers who are accidentally exposed to HIV through, for example, a needleprick accident should start taking anti-retroviral drugs (usually AZT and 3TC) as soon as possible after the incident and preferably within 24 hours. The drugs are usually taken for 28 days. From analysing thousands of such accidental exposures to health care workers, it has been calculated that even though the risk of getting HIV infection from such an accident is quite low (0.3% of cases), taking anti-retroviral drugs reduces the risk of infection by about 80%.

Women who have been raped should also start anti-retroviral drugs as soon as possible. Although there is no proof as yet in humans, most specialists believe that this is highly likely to reduce the risk of HIV infection, just as the drugs reduce infections after needleprick accidents and reduces transmission of HIV from a mother to her newborn baby. Recently some experimental work in monkeys and data from rape clinics have confirmed this theory, and showed that the drugs must be taken early (definitely before 72 hours, and preferably within 36 hours) to be effective.

The South African government now funds anti-retroviral drugs in the context of rape. However, this treatment may be difficult to obtain outside of large hospitals. There are special rape centres where treatment is available, and the police in your area should be able to help.

Preventative treatment for opportunistic infections

Preventative treatment for opportunistic infections covers primary prevention (preventing illness before it occurs) and secondary prevention (preventing a disease that a person has already had from coming back).

Children should receive their routine vaccinations, but if they already have Aids, they should not get the vaccine against TB. Extra vaccinations may be recommended in both adults and children. All children, as well as adults who have started to show the signs of HIV disease (or have CD4+ count less than 200 cells pe mm3), should take an antibiotic called co-trimoxazole continuously. This antibiotic prevents Pneumocystis jerovici pneumonia. Adults or children who have had TB or who have contact with people with TB (especially at home) should take anti-TB drugs as well.

Follow-up

Follow-up treatment and examinations will include regular visits to a doctor to monitor the progress of HIV disease, to diagnose and treat other infections and to keep up to date with new treatments.

Regular dental examinations are necessary, because people with HIV have a higher rate of mouth problems, including gum disease.

Other

HIV-positive people often have to deal with being treated differently by others (discrimination) or even shunned because they carry an infectious disease that is transferred by sex. There is also the anxiety about the threat of illness and death. It may therefore be important to get emotional support from a psychologist or a support group.

It may happen that, when it is known that people have HIV, their colleagues do not want to work with them or their employer will want to fire them. Information on legal and human rights for people living with HIV/Aids may be obtained from an Aids service organisation.

Prevention

How to protect yourself from getting HIV:

  • Reduce the number of sexual partners.
  • Always practice safer sex:
    • Use condoms from start to finish during anal or vaginal sex. Male latex condoms as well as female condoms provide protection against infection.
    • Always use male condoms when performing oral sex on a man.
    • For oral sex on a woman, cover the vaginal area with plastic wrap (cling wrap), a condom cut open or dental dams.
    • Never use oil-based lubricants with male condoms.
    • Engage in non-penetrative sex practices such as kissing, massaging, hugging, touching, body rubbing and masturbation.
    • Avoid alcohol and drugs, which can impair judgement and motivation to practice safer sex.
    • Do not share needles/syringes when using intravenous drugs - preferably don't use recreational or illegal drugs at all!
    • Make sure all medical and surgical instruments, including those used for tattooing, body piercing or circumcision, are completely sterilised before re-use or are safely discarded.
    • Be tested regularly and get treatment for other STIs (women and men with open sores from herpes, syphilis or chancroid are more susceptible to HIV than other people).

Reviewed by Dr Diana Hardie, clinical virologist, National Health Laboratory Service and University of Cape Town, July 2010. Additional revisions by Dr Avron Urison, Medical Director of AllLife, April 2013.

 

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HIV/Aids expert

Dr Sindisiwe van Zyl qualified at the University of Pretoria before working for an HIV/AIDS NPO in Soweto for many years. She was named one of the Mail & Guardian's Top 200 Young South Africans in 2012.

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