WHAT IS AIDS?

 WHAT DOES "AIDS" MEAN?

 HOW DO YOU GET AIDS?
 WHAT HAPPENS IF I'M HIV POSITIVE?
 HOW DO I KNOW IF I HAVE AIDS?
 IS THERE A CURE FOR AIDS?

WHAT DOES "AIDS" MEAN?

AIDS stands for Acquired Immune Deficiency Syndrome:

 Acquired means you can get infected with it;

 Immune Deficiency means a weakness in the body's system that fights
diseases.
 Syndrome means a group of health problems that make up a disease.

AIDS is caused by a virus called HIV, the Human Immunodeficiency Virus. If

you get infected with HIV, your body will try to fight the infection. It will
make "antibodies," special molecules to fight HIV.

A blood test for HIV looks for these antibodies. If you have them in your
blood, it means that you have HIV infection. People who have the HIV
antibodies are called "HIV-Positive." Fact Sheet 102 has more information on
HIV testing.

Being HIV-positive, or having HIV disease, is not the same as having AIDS.
Many people are HIV-positive but don't get sick for many years. As HIV
disease continues, it slowly wears down the immune system. Viruses,
parasites, fungi and bacteria that usually don't cause any problems can
make you very sick if your immune system is damaged. These are called
"opportunistic infections." See Fact Sheet 500 for an overview of
opportunistic infections.

HOW DO YOU GET AIDS?

You don't actually "get" AIDS. You might get infected with HIV, and later you
might develop AIDS. You can get infected with HIV from anyone who's
infected, even if they don't look sick and even if they haven't tested HIV-
positive yet. The blood, vaginal fluid, semen, and breast milk of people
infected with HIV has enough of the virus in it to infect other people. Most
people get the HIV virus by:

 having sex with an infected person

 sharing a needle (shooting drugs) with someone who's infected
 being born when their mother is infected, or drinking the breast milk
of an infected woman

Getting a transfusion of infected blood used to be a way people got AIDS,

but now the blood supply is screened very carefully and the risk is extremely
low.

There are no documented cases of HIV being transmitted by tears or saliva,

but it is possible to be infected with HIV through oral sex or in rare cases
through deep kissing, especially if you have open sores in your mouth or
bleeding gums. For more information, see the following Fact Sheets:

 150: Stopping the Spread of HIV

 151: Safer Sex Guidelines
 152: How Risky Is It?

The Centers for Disease Control and Prevention (CDC) estimates that 1 to
1.2 million U.S. residents are living with HIV infection or AIDS; about a
quarter of them do not know they have it. About 75 percent of the 40,000
new infections each year are in men, and about 25 percent in women. About
half of the new infections are in Blacks, even though they make up only 12
percent of the US population.

In the mid-1990s, AIDS was a leading cause of death. However, newer

treatments have cut the AIDS death rate significantly. For more information,
see the US Government fact sheet at
http://www.niaid.nih.gov/factsheets/aidsstat.htm.

WHAT HAPPENS IF I'M HIV POSITIVE?

You might not know if you get infected by HIV. Some people get fever,
headache, sore muscles and joints, stomach ache, swollen lymph glands, or
a skin rash for one or two weeks. Most people think it's the flu. Some people
have no symptoms. Fact Sheet 103 has more information on the early stage
of HIV infection.
The virus will multiply in your body for a few weeks or even months before
your immune system responds. During this time, you won't test positive for
HIV, but you can infect other people.

When your immune system responds, it starts to make antibodies. When

this happens, you will test positive for HIV.

After the first flu-like symptoms, some people with HIV stay healthy for ten
years or longer. But during this time, HIV is damaging your immune system.

One way to measure the damage to your immune system is to count your
CD4 cells you have. These cells, also called "T-helper" cells, are an important
part of the immune system. Healthy people have between 500 and 1,500
CD4 cells in a milliliter of blood. Fact Sheet 124 has has more information on
CD4 cells.

Without treatment, your CD4 cell count will most likely go down. You might
start having signs of HIV disease like fevers, night sweats, diarrhea, or
swollen lymph nodes. If you have HIV disease, these problems will last more
than a few days, and probably continue for several weeks.

HOW DO I KNOW IF I HAVE AIDS?

HIV disease becomes AIDS when your immune system is seriously damaged.
If you have less than 200 CD4 cells or if your CD4 percentage is less than
14%, you have AIDS. See Fact Sheet 124 for more information on CD4 cells.
If you get an opportunistic infection, you have AIDS. There is an "official" list
of these opportunistic infections put out by the Centers for Disease Control
(CDC). The most common ones are:

 PCP (Pneumocystis pneumonia), a lung infection;

 KS (Kaposi's sarcoma), a skin cancer;
 CMV (Cytomegalovirus), an infection that usually affects the eyes
 Candida, a fungal infection that can cause thrush (a white film in your
mouth) or infections in your throat or vagina

AIDS-related diseases also includes serious weight loss, brain tumors, and
other health problems. Without treatment, these opportunistic infections can
kill you.

The official (technical) CDC definition of AIDS is available at

http://www.cdc.gov/mmwr/preview/mmwrhtml/00018871.htm
AIDS is different in every infected person. Some people die a few months
after getting infected, while others live fairly normal lives for many years,
even after they "officially" have AIDS. A few HIV-positive people stay
healthy for many years even without taking antiretroviral medications
(ARVs).

IS THERE A CURE FOR AIDS?

There is no cure for AIDS. There are drugs that can slow down the HIV virus,
and slow down the damage to your immune system. There is no way to
"clear" the HIV out of your body.

Other drugs can prevent or treat opportunistic infections (OIs). In most

cases, these drugs work very well. The newer, stronger ARVs have also
helped reduce the rates of most OIs. A few OIs, however, are still very
difficult to treat. See Fact Sheet 500 for more information on opportunistic
infections.

HIV TESTING
 WHAT IS HIV TESTING?
 HOW DO I GET TESTED?
 WHEN SHOULD I GET TESTED?
 DO ANY TESTS WORK SOONER AFTER INFECTION?
 WHAT DOES IT MEAN IF I TEST POSITIVE?
 CAN I KEEP THE TEST RESULTS CONFIDENTIAL?
 HOW ACCURATE ARE THE TESTS?
 THE BOTTOM LINE

WHAT IS HIV TESTING?

HIV testing tells you if you are infected with the Human Immunodeficiency
Virus (HIV) which causes AIDS. These tests look for "antibodies" to HIV.
Antibodies are proteins produced by the immune system to fight a specific
germ.

Other "HIV" tests are used when people already know that they are infected
with HIV. These help measure how quickly the virus is multiplying (a viral
load test) or the health of your immune system (a CD4 count). For more
information, see Fact Sheet 124 (T-cell Tests), and Fact Sheet 125 (Viral
Load Tests).

HOW DO I GET TESTED?

In September 2006, the US Centers for Disease Control recommended

routine HIV screening of people in healthcare settings. This should result in
more general HIV testing in the US.

You can arrange for HIV testing at any Public Health office, or at your
doctor's office. Test results are usually available within two weeks. In the
US, call the National AIDS Hotline, (800) 342-2437.

The most common HIV test is a blood test. Newer tests can detect HIV
antibodies in mouth fluid (not the same as saliva), a scraping from inside the
cheek, or urine. "Rapid" HIV test results are available within 10 to 30
minutes after a sample is taken. One of these tests has produced a high rate
of false positives. A positive result on any HIV test should be
confirmed with a second test.

Home test kits: You can't test yourself for HIV at home. The Home Access
test kit is only designed to collect a sample of your blood. You send the
sample to a laboratory where it is tested for HIV.

WHEN SHOULD I GET TESTED?

If you become infected with HIV, it usually takes between three weeks and
two months for your immune system to produce antibodies to HIV. If you
think you were exposed to HIV, you should wait for two months before being
tested. You can also test right away and then again after two or three
months. During this "window period" an antibody test may give a negative
result, but you can transmit the virus to others if you are infected.

About 5% of people take longer than two months to produce antibodies.

There is one documented case of a person exposed to HIV and hepatitis C at
the same time. Antibodies to HIV were not detected until one year after
exposure. Testing at 3 and 6 months after possible exposure will detect
almost all HIV infections. However, there are no guarantees as to when
an individual will produce enough antibodies to be detected by an HIV test.
If you have any unexplained symptoms, talk with your health care
provider and consider re-testing for HIV.
DO ANY TESTS WORK SOONER AFTER INFECTION?

Viral load tests detect pieces of HIV genetic material. They show up before
the immune system manufactures antibodies. Also, in early 2002, the FDA
approved "nucleic acid testing." It is similar to viral load testing. Blood banks
use it to screen donated blood.

The viral load or nucleic acid tests are generally not used to see if someone
has been infected with HIV because they are much more expensive than an
antibody test. They also have a slightly higher error rate.

WHAT DOES IT MEAN IF I TEST POSITIVE?

A positive test result means that you have HIV antibodies, and are infected
with HIV. You will get your test result from a counselor who should tell you
what to expect, and where to get health services and emotional support.

Testing positive does not mean that you have AIDS (See Fact Sheet 101,
What is AIDS?). Many people who test positive stay healthy for several
years, even if they don't start taking medication right away.

If you test negative and you have not been exposed to HIV for at least three
months, you are not infected with HIV. Continue to protect yourself from HIV
infection (See Fact Sheet 150, Stopping the Spread of HIV).

CAN I KEEP THE TEST RESULT CONFIDENTIAL?

You can be tested anonymously in many places. You do not have to give
your name when you are tested at a public health office, or when you
receive the test results. You can be tested anonymously for HIV as many
times as you want.

If you get a positive HIV test that is not anonymous, or if you get any
medical services for HIV infection, your name may be reported to the
Department of Health.

The Centers for Disease Control (CDC) proposed in late 1998 that all states
keep track of the names of HIV-infected people. This proposal has not yet
taken effect.

HOW ACCURATE ARE THE TESTS?

Antibody test results for HIV are accurate more than 99.5% of the time.
Before you get the results, the test has usually been done two or more
times. The first test is called an "EIA" or "ELISA" test. Before a positive
ELISA test result is reported, it is confirmed by another test called a
"Western Blot".

Two special cases can lead to false results:

Children born to HIV-positive mothers may have false positive test

results for several months because mothers pass infection-fighting
antibodies to their newborn children. Even if the children are not infected
with HIV, they have HIV antibodies and will test positive. Other tests, such
as a viral load test, must be used.

As mentioned above, people who were recently infected may test

negative if they get tested too soon after being infected with HIV.

THE BOTTOM LINE

HIV testing generally looks for HIV antibodies in the blood, or saliva or urine.
The immune system produces these antibodies to fight HIV. It usually takes
two to three months for them to show up. In rare cases, it can take longer
than three months. During this "window period" you may not test positive
for HIV even if you are infected. Normal HIV tests don't work for newborn
children of HIV-infected mothers.

In many places, you can get tested anonymously for HIV. Once you test
positive and start to receive health care for HIV infection, your name may be
reported to the Department of Health. These records are kept confidential.

A positive test result does not mean that you have AIDS. If you test positive,
you should learn more about HIV and decide how to take care of your
health.

CD4 (T-CELL) TESTS

 WHAT ARE CD4 CELLS?
 WHY ARE CD4 CELLS IMPORTANT IN HIV?
 WHAT FACTORS INFLUENCE A CD4 CELL COUNT?
 HOW ARE THE TEST RESULTS REPORTED?
 WHAT DO THE NUMBERS MEAN?
WHAT ARE CD4 CELLS?

CD4 cells are a type of lymphocyte (white blood cell). They are an important
part of the immune system. CD4 cells are sometimes called T-cells. There
are two main types of T-cells. T-4 cells, also called CD4+, are "helper" cells.
They lead the attack against infections. T-8 cells, (CD8+), are "suppressor"
cells that end the immune response. CD8+ cells can also be ?killer? cells
that kill cancer cells and cells infected with a virus.

Researchers can tell these cells apart by specific proteins on the cell surface.
A T-4 cell is a T-cell with CD4 molecules on its surface. This type of T-cell is
also called ?CD4 positive,? or CD4+.

WHY ARE CD4 CELLS IMPORTANT IN HIV?

When HIV infects humans, the cells it infects most often are CD4 cells. The
virus becomes part of the cells, and when they multiply to fight an infection,
they also make more copies of HIV.

When someone is infected with HIV for a long time, the number of CD4 cells
they have (their CD4 cell count) goes down. This is a sign that the immune
system is being weakened. The lower the CD4 cell count, the more likely the
person will get sick.

There are millions of different families of CD4 cells. Each family is designed
to fight a specific type of germ. When HIV reduces the number of CD4 cells,
some of these families can be totally wiped out. You can lose the ability to
fight off the particular germs those families were designed for. If this
happens, you might develop an opportunistic infection (See Fact Sheet 500).

WHAT FACTORS INFLUENCE A CD4 CELL COUNT?

The CD4 cell value bounces around a lot. Time of day, fatigue, and stress
can affect the test results. It's best to have blood drawn at the same time of
day for each CD4 cell test, and to use the same laboratory.

Infections can have a large impact on CD4 cell counts. When your body
fights an infection, the number of white blood cells (lymphocytes) goes up.
CD4 and CD8 counts go up, too. Vaccinations can cause the same effects.
Don't check your CD4 cells until a couple of weeks after you recover from an
infection or get a vaccination.
HOW ARE THE TEST RESULTS REPORTED?

CD4 cell tests are normally reported as the number of cells in a cubic
millimeter of blood, or mm3. There is some disagreement about the normal
range for CD4 cell counts, but normal CD4 counts are between 500 and
1600, and CD8 counts are between 375 and 1100. CD4 counts drop
dramatically in people with HIV, in some cases down to zero.

The ratio of CD4 cells to CD8 cells is often reported. This is calculated by
dividing the CD4 value by the CD8 value. In healthy people, this ratio is
between 0.9 and 1.9, meaning that there are about 1 to 2 CD4 cells for
every CD8 cell. In people with HIV infection, this ratio drops dramatically,
meaning that there are many times more CD8 cells than CD4 cells.

Because the CD4 counts are so variable, some health care providers prefer
to look at the CD4 percentages. These percentages refer to total
lymphocytes. If your test reports CD4% = 34%, that means that 34% of
your lymphocytes were CD4 cells. This percentage is more stable than the
number of CD4 cells. The normal range is between 20% and 40%. A CD4
percentage below 14% indicates serious immune damage. It is a sign of
AIDS in people with HIV infection. A recent study showed that the CD4% is a
predictor of HIV disease progression.

WHAT DO THE NUMBERS MEAN?

The meaning of CD8 cell counts is not clear, but it is being studied.

The CD4 cell count is a key measure of the health of the immune system.
The lower the count, the greater damage HIV has done. Anyone who has
less than 200 CD4 cells, or a CD4 percentage less than 14%, is considered
to have AIDS according to the US Centers for Disease Control.

CD4 counts are used together with the viral load to estimate how long
someone will stay healthy. See Fact Sheet 125 for more information on the
viral load test.

CD4 counts are also used to indicate when to start certain types of drug
therapy:

When to start antiretroviral therapy (ART):

When the CD4 count goes below 350, most health care providers begin ART
(see Fact Sheet 403). Also, some health care providers use the CD4% going
below 15% as a sign to start aggressive ART, even if the CD4 count is high.
More conservative health care providers might wait until the CD4 count
drops to near 200 before starting treatment. A recent study found that
starting treatment with a CD4% below 5% was strongly linked to a poor
outcome.

When to start drugs to prevent opportunistic infections:

Most health care providers prescribe drugs to prevent opportunistic

infections at the following CD4 levels:

 Less than 200: pneumocystis pneumonia (PCP)

 Less than 100: toxoplasmosis and cryptococcosis
 Less than 75: mycobacterium avium complex (MAC).

Because they are such an important indicator of the strength of the immune
system, official treatment guideline in the US suggest that CD4 counts be
monitored every 3 to 4 months. See Fact Sheet 404 for more information on
the treatment guidelines.

VIRAL LOAD TESTS

 WHAT IS VIRAL LOAD?
 HOW IS THE TEST USED?
 HOW ARE CHANGES IN VIRAL LOAD MEASURED?
 VIRAL LOAD "BLIPS"
 WHAT DO THE NUMBERS MEAN?
 ARE THERE PROBLEMS WITH THE VIRAL LOAD TEST?

WHAT IS VIRAL LOAD?

The viral load test measures the amount of HIV virus in your blood. There
are different techniques for doing this:

 The PCR (polymerase chain reaction) method uses an enzyme to

multiply the HIV in the blood sample. Then a chemical reaction marks
the virus. The markers are measured and used to calculate the amount
of virus. Roche and Abbott produce this type of test.
  The bDNA (branched DNA) method combines a material that gives off
light with the sample. This material connects with the HIV particles.
The amount of light is measured and converted to a viral count. Bayer
produces this test.
 The NASBA (nucleic acid sequence based amplification) method
amplifies viral proteins to derive a count. It is manufactured by
bioMerieux.

Different test methods often give different results for the same sample.
Because the tests are different, you should stick with the same kind of test
(PCR or bDNA) to measure your viral load over time.

Viral loads are usually reported as copies of HIV in one milliliter of blood.
The tests count up to about 1 million copies, and are always being improved
to be more sensitive. The first bDNA test measured down to 10,000 copies.
The second generation could detect as few as 500 copies. Now there are
ultra sensitive tests for research that can detect less than 5 copies.

The best viral load test result is "undetectable." This does not mean that
there is no virus in your blood; it just means that there is not enough for the
test to find and count. With the first viral load tests, "undetectable" meant
up to 9,999 copies! "Undetectable" depends on the sensitivity of the test
used on your blood sample.

The first viral load tests all used frozen blood samples. Good results have
been obtained using dried samples. This will reduce costs for freezers and
shipping.

HOW IS THE TEST USED?

The viral load test is helpful in several areas:

 For medical researchers, the test has been used to prove that HIV is
never "latent" but is always multiplying. Many people with no
symptoms of AIDS and high CD4 cell counts also had high viral loads.
If the virus was latent, the test wouldn't have found any HIV in the
blood.
 The test can be used for diagnosis, because it can detect a viral load
a few days after HIV infection. This is better than the standard HIV
(antibody) test, which can be "negative" for 2 to 6 months after HIV
infection. (See Fact Sheet 102 for more information on HIV antibody
testing.)
  For prognosis, viral load can help predict how long someone will stay
healthy. The higher the viral load, the faster HIV disease progresses.
 For prevention, viral load predicts how easy it is to transmit HIV to
someone else. The higher the viral load, the higher the risk of
transmitting HIV.
 Finally, the viral load test is valuable for managing therapy, to see if
antiretroviral drugs are controlling the virus. Current guidelines
suggest measuring baseline (pre-treatment) viral load. A drug is
"working" if it lowers viral load by at least 90% within 8 weeks. The
viral load should continue to drop to less than 50 copies within 6
months. The viral load should be measured within 2 to 8 weeks after
treatment is started or changed, and every 3 to 4 months after that.

HOW ARE CHANGES IN VIRAL LOAD MEASURED?

Repeat tests of the same blood sample can give results that vary by a factor
of 3. This means that a meaningful change would be a drop to less than
1/3 or an increase to more than 3 times the previous test result. For
example, a change from 200,000 to 600,000 is within the normal variability
of the test. A drop from 50,000 to 10,000 would be significant. The most
important change is to reach an undetectable viral load.

Viral load changes are often described as "log" changes. This refers to
scientific notation, which uses powers of 10. For example, a 2-log drop is a
drop of 102 or 100 times. A drop from 60,000 to 600 would be a 2-log drop.

VIRAL LOAD "BLIPS"

Recently, researchers have noticed that the viral load of many patients
sometimes went from undetectable to a low level (usually less than 500) and
then returned to undetectable. Careful study suggests that these ?blips? do
not indicate that the virus is developing resistance.

WHAT DO THE NUMBERS MEAN?

There are no "magic" numbers for viral loads. We don't know how long you'll
stay healthy with any particular viral load. All we know so far is that lower is
better and seems to mean a longer, healthier life.

US treatment guidelines (See Fact Sheet 404) suggest that anyone with a
viral load over 100,000 should be offered treatment.
Some people may think that if their viral load is undetectable, they can't
pass the HIV virus to another person. This is not true. There is no "safe"
level of viral load. Although the risk is less, you can pass HIV to
another person even if your viral load is undetectable.

ARE THERE PROBLEMS WITH THE VIRAL LOAD TEST?

There are some concerns with the viral load test:

 Only about 2% of the HIV in your body is in the blood. The viral load
test does not measure how much HIV is in body tissues like the lymph
nodes, spleen, or brain. HIV levels in lymph tissue and semen go down
when blood levels go down, but not at the same time or the same
rate.
 The viral load test results can be thrown off if your body is fighting an
infection, or if you have just received an immunization (like a flu shot).
You should not have blood taken for a viral load test within four weeks
of any infection or immunization.

OPPORTUNISTIC INFECTIONS
 WHAT ARE OPPORTUNISTIC INFECTIONS?
 TESTING FOR OIs
 OIs AND AIDS
 WHAT ARE THE MOST COMMON OIs?
 PREVENTING OIs
 TREATING OIs

WHAT ARE OPPORTUNISTIC INFECTIONS?

In our bodies, we carry many germs - bacteria, protozoa, fungi, and viruses.
When our immune system is working, it controls these germs. But when the
immune system is weakened by HIV disease or by some medications, these
germs can get out of control and cause health problems.

Infections that take advantage of weakness in the immune defenses are

called "opportunistic". The phrase "opportunistic infection" is often shortened
to "OI".
TESTING FOR OIs

You can be infected with an OI, and "test positive" for it, even though you
don't have the disease. For example, almost everyone with HIV tests
positive for Cytomegalovirus (CMV). But it is very rare for CMV disease to
develop unless the CD4 cell count drops below 50, a sign of serious damage
to the immune system.

To see if you're infected with an OI, your blood might be tested for antigens
(pieces of the germ that causes the OI) or for antibodies (proteins made by
the immune system to fight the germs). If the antigens are found, it means
you?re infected. If the antibodies are found, you?ve been exposed to the
infection. You may have been immunized against the infection, or your
immune system may have ?cleared? the infection, or you may be infected. If
you are infected with a germ that causes an OI, and if your CD4 cells are low
enough to allow that OI to develop, your health care provider will look for
signs of active disease. These are different for the different OIs.

OIs AND AIDS

People who aren't HIV-infected can develop OIs if their immune systems are
damaged. For example, many drugs used to treat cancer suppress the
immune system. Some people who get cancer treatments can develop OIs.

HIV weakens the immune system so that opportunistic infections can

develop. If you are HIV-infected and develop opportunistic infections, you
might have AIDS.

In the US, the Center for Disease Control (CDC) is responsible for deciding
who has AIDS. The CDC has developed a list of about 24 opportunistic
infections. If you have HIV and one or more of these "official" OIs, then you
have AIDS. The list is available at
http://www.aidsmeds.com/lessons/StartHere8.htm.

WHAT ARE THE MOST COMMON OIs?

In the early years of the AIDS epidemic, OIs caused a lot of sickness and
deaths. Once people started taking strong antiretroviral therapy (ART),
however, a lot fewer people got OIs. It's not clear how many people with
HIV will get a specific OI.
In women, health problems in the vaginal area may be early signs of HIV.
These can include pelvic inflammatory disease and bacterial vaginosis,
among others. See fact sheet 610 for more information.

The most common OIs are listed here, along with the disease they usually
cause, and the CD4 cell count when the disease becomes active:

 Candidiasis (Thrush) is a fungal infection of the mouth, throat, or

vagina. CD4 cell range: can occur even with fairly high CD4 cells.
 Cytomegalovirus (CMV) is a viral infection that causes eye disease that
can lead to blindness.CD4 cell range: under 50.
 Herpes simplex viruses can cause oral herpes (cold sores) or genital
herpes. These are fairly common infections, but if you have HIV, the
outbreaks can be much more frequent and more severe. They can
occur at any CD4 cell count.
 Malaria is common in the developing world. It is more common and
more severe in people with HIV infection.
 Mycobacterium avium complex (MAC or MAI) is a bacterial infection
that can cause recurring fevers, general sick feelings, problems with
digestion, and serious weight loss. CD4 cell range: under 75.
 Pneumocystis pneumonia (PCP) is a fungal infection that can cause a
fatal pneumonia. CD4 cell range: under 200. Unfortunately this is still
a fairly common OI in people who have not been tested or treated for
HIV.
 Toxoplasmosis (Toxo) is a protozoal infection of the brain. T-cell
range: under 100.
 Tuberculosis (TB) is a bacterial infection that attacks the lungs, and
can cause meningitis. CD4 cell range: Everyone with HIV who tests
positive for exposure to TB should be treated.

PREVENTING OIs

Most of the germs that cause OIs are quite common, and you may already
be carrying several of these infections. You can reduce the risk of new
infections by keeping clean and avoiding known sources of the germs that
cause OIs.

Even if you're infected with some OIs, you can take medications that will
prevent the development of active disease. This is called prophylaxis. The
best way to prevent OIs is to take strong ART. See Fact Sheet 403 for more
information on ART.
The Fact Sheets for each OI have more information on avoiding infection or
preventing the development of active disease.

TREATING OIs

For each OI, there are specific drugs, or combinations of drugs, that
seem to work best. Refer to the Fact Sheets for each OI to learn
more about how they are treated.

Strong antiretroviral drugs can allow a damaged immune system to

recover and do a better job of fighting OIs. Fact Sheet 481 on
Immune Restoration has more information on this topic.

STOPPING THE SPREAD OF HIV

 HOW DO YOU GET INFECTED WITH HIV?
 HOW CAN YOU PROTECT YOURSELF AND OTHERS?
 WHAT IF I'VE BEEN EXPOSED?
 THE BOTTOM LINE

HOW DO YOU GET INFECTED WITH HIV?

The Human Immunodeficiency Virus (HIV) is not spread easily. You can only get
HIV if you get infected blood or sexual fluids into your system. You can't get it from
mosquito bites, coughing or sneezing, sharing household items, or swimming in the
same pool as someone with HIV.

Some people talk about "shared body fluids" being risky for HIV, but no
documented cases of HIV have been caused by sweat, saliva or tears.
However, even small amounts of blood in your mouth might transmit HIV
during kissing or oral sex. Blood can come from flossing your teeth, or from
sores caused by gum disease, or by eating very hot or sharp, pointed food.

To infect someone, the virus has to get past the body's defenses. These
include skin and saliva. If your skin is not broken or cut, it protects you
against infection from blood or sexual fluids. Saliva contains chemicals that
can help kill HIV in your mouth.

If HIV-infected blood or sexual fluid gets inside your body, you can get
infected. This can happen through an open sore or wound, during sexual
activity, or if you share equipment to inject drugs.
HIV can also be spread from a mother to her child during pregnancy or
delivery. This is called "vertical transmission." A baby can also be infected by
drinking an infected woman's breast milk. Fact Sheet 611 has more
information on pregnancy. Adults exposed to breast milk of an HIV-infected
woman may also be exposed to HIV.

HOW CAN YOU PROTECT YOURSELF AND OTHERS?

Unless you are 100% sure that you and the people you are with do not have HIV
infection, you should take steps to prevent getting infected. People recently infected
(within the past 2 or 3 months) are most likely to transmit HIV to others. This is
when their viral load is the highest. In general, the risk of transmission is higher
with higher viral loads. This fact sheet provides an overview of HIV prevention, and
refers you to other fact sheets for more details on specific topics.

Sexual Activity
You can avoid any risk of HIV if you practice abstinence (not having sex). You also
won't get infected if your penis, mouth, vagina or rectum doesn't touch anyone
else's penis, mouth, vagina, or rectum. Safe activities include kissing, erotic
massage, masturbation or hand jobs (mutual masturbation). There are no
documented cases of HIV transmission through wet clothing.

Having sex in a monogamous (faithful) relationship is safe if:

 Both of you are uninfected (HIV-negative)

 You both have sex only with your partner
 Neither one of you gets exposed to HIV through drug use or other activities

Oral sex has a lower risk of infection than anal or vaginal sex, especially if
there are no open sores or blood in the mouth. See Fact Sheet 152 for more
information on the risks of various behaviors.

You can reduce the risk of infection with HIV and other sexually transmitted
diseases by using barriers like condoms. Traditional condoms go on the
penis, and a new type of condom goes in the vagina or in the rectum. For
more information on condoms, see Fact Sheet 153.

Some chemicals called spermicides can prevent pregnancy but they don't
prevent HIV. They might even increase your risk of getting infected if they
cause irritation or swelling.

For more information on safer sex, see Fact Sheet 151.

Drug Use
If you're high on drugs, you might forget to use protection during sex. If you use
someone else's equipment (needles, syringes, cookers, cotton or rinse water) you
can get infected by tiny amounts of blood. The best way to avoid infection is to not
use drugs.

If you use drugs, you can prevent infection by not injecting them. If you do
inject, don't share equipment. If you must share, clean equipment with
bleach and water before every use. Fact Sheet 154 has more details on drug
use and HIV prevention.

Some communities have started exchange programs that give free, clean
syringes to people so they won't need to share.

Vertical Transmission
With no treatment, about 25% of the babies of HIV-infected women would be born
infected. The risk drops to about 4% if a woman takes AZT during pregnancy and
delivery, and her newborn is given AZT. The risk is 2% or less if the mother is
taking combination antiretroviral therapy (ART). Caesarean section deliveries
probably don't reduce transmission risk if the mother's viral load is below 1000.

Babies can get infected if they drink breast milk from an HIV-infected
woman. Women with HIV should use baby formulas or breast milk from a
woman who is not infected to feed their babies.

Fact Sheet 611 has more information on HIV and pregnancy.

Contact with Blood

HIV is one of many diseases that can be transmitted by blood. Be careful if you are
helping someone who is bleeding. If your work exposes you to blood, be sure to
protect any cuts or open sores on your skin, as well as your eyes and mouth. Your
employer should provide gloves, facemasks and other protective equipment, plus
training about how to avoid diseases that are spread by blood.

WHAT IF I'VE BEEN EXPOSED?

If you think you have been exposed to HIV, talk to your health care provider or the
public health department, and get tested. For more information on HIV testing, see
Fact Sheet 102.

If you are sure that you have been exposed, call your health care provider
immediately to discuss whether you should start taking antiretroviral drugs
(ARVs). This is called "post exposure prophylaxis" or PEP. You would take
two or three medications for several weeks. These drugs can decrease the
risk of infection, but they have some serious side effects. Fact Sheet 156 has
more information on PEP.

THE BOTTOM LINE

HIV does not spread easily from person to person. To get infected with HIV,
infected blood, sexual fluid, or mother's milk has to get into your body. HIV-
infected pregnant women can pass the infection to their new babies.

To decrease the risk of spreading HIV:

 Use condoms during sexual activity

 Do not share drug injection equipment
 If you are HIV-infected and pregnant, talk with your health care provider
about taking ARVs.
 If you are an HIV-infected woman, don't breast feed any baby
 Protect cuts, open sores, and your eyes and mouth from contact with blood.

If you think you've been exposed to HIV, get tested and ask your health care
provider about taking ARVs.

SAFER SEX GUIDELINES

 HOW DOES HIV SPREAD DURING SEX?
 UNSAFE ACTIVITIES
 SAFER ACTIVITIES
 SAFE ACTIVITIES
 WHAT IF BOTH PEOPLE ARE ALREADY INFECTED?
 KNOW WHAT YOU'RE DOING
 SET YOUR LIMITS
 THE BOTTOM LINE

HOW DOES HIV SPREAD DURING SEX?

To spread HIV during sex, HIV infection in blood or sexual fluids must
be transmitted to someone. Sexual fluids come from a man's penis or from
a woman's vagina, before, during, or after orgasm. HIV can be transmitted
when infected fluid gets into someone's body.

You can't spread HIV if there is no HIV infection. If you and your partners
are not infected with HIV, there is no risk. An "undetectable viral load does
NOT mean "no HIV infection." If there is no contact with blood or sexual
fluids, there is no risk. HIV needs to get into the body for infection to occur.

Safer sex guidelines are ways to reduce the risk of spreading HIV during
sexual activity.

UNSAFE ACTIVITIES

Unsafe sex has a high risk of spreading HIV. The greatest risk is when blood
or sexual fluid touches the soft, moist areas (mucous membrane) inside the
rectum, vagina, mouth, nose, or at the tip of the penis. These can be
damaged easily, which gives HIV a way to get into the body.

Vaginal or rectal intercourse without protection is very unsafe. Sexual fluids

enter the body, and wherever a man's penis is inserted, it can cause small
tears that make HIV infection more likely. The receptive partner is more
likely to be infected, although HIV might be able to enter the penis,
especially if it has contact with HIV-infected blood or vaginal fluids for a long
time or if it has any open sores.

SAFER ACTIVITIES

Most sexual activity carries some risk of spreading HIV. To reduce the risk,
make it more difficult for blood or sexual fluid to get into your body.

Be aware of your body and your partner's. Cuts, sores, or bleeding gums
increase the risk of spreading HIV. Rough physical activity also increases the
risk. Even small injuries give HIV a way to get into the body.

Use a barrier to prevent contact with blood or sexual fluid. Remember that
the body's natural barrier is the skin. If you don't have any cuts or sores,
your skin will protect you against infection. However, in rare cases HIV can
get into the body through healthy mucous membranes. The risk of infection
is much higher if the membranes are damaged.

The most common artificial barrier is a condom for men. You can also use a
female condom to protect the vagina or rectum during intercourse. Fact
Sheet 153 has more information on condoms.
Lubricants can increase sexual stimulation. They also reduce the chance
that condoms or other barriers will break. Oil-based lubricants like Vaseline,
oils, or creams can damage condoms and other latex barriers. Be sure to use
water-based lubricants.

Oral sex has some risk of transmitting HIV, especially if sexual fluids get in
the mouth and if there are bleeding gums or sores in the mouth. Pieces of
latex or plastic wrap over the vagina, or condoms over the penis, can be
used as barriers during oral sex. Condoms without lubricants are best for
oral sex. Most lubricants taste awful.

SAFE ACTIVITIES

Safe activities have no risk for spreading HIV. Abstinence (never having sex)
is totally safe. Sex with just one partner is safe as long as neither one of you
is infected and if neither one of you ever has sex or shares needles (see Fact
Sheet 154) with anyone else.

Fantasy, masturbation, or hand jobs (where you keep your fluids to

yourself), sexy talk, and non-sexual massage are also safe. These activities
avoid contact with blood or sexual fluids, so there is no risk of transmitting
HIV.

To be safe, assume that your sex partners are infected with HIV. You
can?t tell if people are infected by how they look. They could be lying if they
tell you they are not infected, especially if they want to have sex with you.
Some people got HIV from their steady partners who were unfaithful "just
once".

Even people who got a negative test result might be infected. They might
have been infected after they got tested, or they might have gotten the test
too soon after they were exposed to HIV.

WHAT IF BOTH PEOPLE ARE ALREADY INFECTED?

Some people who are HIV-infected don't see the need to follow safer sex
guidelines when they are sexual with other infected people. However, it still
makes sense to "play safe". If you don't, you could be exposed to other
sexually transmitted infections such as herpes or syphilis. If you already
have HIV, these diseases can be more serious.

Also, you might get "re-infected" with a different strain of HIV. This new
version of HIV might not be controlled by the medications you are taking. It
might also be resistant to other antiretroviral drugs. There is no way of
knowing how risky it is for two HIV-positive people to have unsafe sex.
Following the guidelines for safer sex will reduce the risk.

KNOW WHAT YOU'RE DOING

Using alcohol or drugs before or during sex greatly increases the chances
that you will not follow safer sex guidelines. Be very careful if you have used
any alcohol or drugs.

SET YOUR LIMITS

Decide how much risk you are willing to take. Know how much protection
you want to use during different kinds of sexual activities. Before you have
sex,

 think about safer sex

 set your limits
 get a supply of lubricant and condoms or other barriers, and be sure
they are easy to find when you need them
 talk to your partners so they know your limits.

Stick to your limits. Don't let alcohol or drugs or an attractive

partner make you forget to protect yourself.

THE BOTTOM LINE

HIV infection can occur during sexual activity. Sex is safe only if
there is no HIV, no blood or sexual fluids, or no way for HIV to get
into the body.

You can reduce the risk of infection if you avoid unsafe activities or
if you use barriers like condoms. Decide on your limits and stick to

them. HOW RISKY IS IT?

 WHAT'S MY RISK OF GETTING INFECTED WITH HIV?
 THERE ARE NO GUARANTEES!
 WHAT DO THE NUMBERS MEAN?
 WHAT ACTIVITIES ARE MOST RISKY?
 WHAT ABOUT ORAL SEX?
 WHAT INCREASES THE RISK OF HIV INFECTION?
 THE BOTTOM LINE
WHAT'S MY RISK OF GETTING INFECTED WITH HIV?

Most people know how HIV is transmitted (see fact sheet 150). They also
know about safer sex guidelines (see fact sheet 151). However, they may
still be exposed to HIV. This can be by accident or because they take part in
some risky behavior. When this happens, they always want to know how
likely it is that they got infected with HIV.

THERE ARE NO GUARANTEES!

You can't be sure that you're not infected with HIV unless you are 100%
certain that you did not engage in any risky behavior and that you were not
exposed to any HIV-infected fluids.

The only way to know for sure whether you have been infected is to get
tested. You should wait for 3 months after a possible exposure. Then get an
HIV blood test (see fact sheet 102).

You might feel that you have been exposed to HIV by sharing needles, an
accident, or unsafe sexual activity. In these cases, talk to your health care
provider immediately . Ask whether you can use HIV treatments to prevent
infection. Fact sheet 156 has more information on "post-exposure
prophylaxis."

WHAT DO THE NUMBERS MEAN?

In the late 1980s and early 1990s, several studies were done to assess the
risks of HIV infection from specific types of exposure to HIV. These
calculations only give a general idea of risk. They can tell you which
activities carry a higher or lower risk. They cannot tell you if you have been
infected.

If the risk is 1 in 100, for example, it doesn?t mean that you can engage in
that activity 99 times without any risk of becoming infected. You might
become infected with HIV after a single exposure. That can happen
the first time you engage in a risky activity.

Also, these studies were based on a specific group of people. There is no

reason to believe that the results apply to other groups, or to the general
population.
WHAT ACTIVITIES ARE MOST RISKY?

The highest risk of becoming infected with HIV is from sharing needles to
inject drugs with someone who is infected with HIV. When you share
needles, there is a very high probability that someone else's blood will be
injected into your bloodstream. Hepatitis virus can also be transmitted by
sharing needles.

The next greatest risk for HIV infection is from unprotected sexual
intercourse (without a condom). Receptive anal intercourse carries the
highest risk. The lining of the rectum is very thin. It is damaged very easily
during sexual activity. This makes it easier for HIV to enter the body. The
"top" or active partner in anal intercourse seems to run a much lower risk.
However, the risk still seems higher than for the active partner in insertive
vaginal intercourse.

Receptive vaginal intercourse has the next highest risk. The lining of the
vagina is stronger than in the rectum, but is vulnerable to infection. Also, it
can be damaged by sexual activity. All it takes is a tiny scrape that can be
too small to see. The risk of infection is increased if there is any
inflammation or infection in the vagina.

The risk is higher for the receptive partner. However, there is some risk for
the active partner in anal or vaginal sex. It's possible for HIV to enter the
penis through any open sores, through the moist lining of the opening of the
penis, or through the cells in the mucous membrane in the foreskin or the
head of the penis.

WHAT ABOUT ORAL SEX?

There have been many studies of HIV transmission through oral sex. They
have not come to clear conclusions. However, the following points are clear:

 It is possible to get infected with HIV through oral sex. The risk is not
zero.
 The risk of HIV infection through oral sex is extremely low. It is much
lower than for other types of unprotected sexual activity. However,
other diseases such as syphilis can be transmitted through oral sex.
WHAT INCREASES THE RISK OF HIV INFECTION?

Syphilis can increase the risk of transmitting HIV. People with syphilis have a
higher than average chance of being infected with HIV. Also, syphilis causes
large, painless sores. It is easy for someone to be infected with HIV through
syphilis sores. Herpes simplex infection (see Fact Sheet 508) also causes
sores which assist infection with HIV. An active case of syphilis or herpes
increases the amount of HIV in someone's system and can make it easier for
them to pass it on to another person.

Several other factors increase the risk of transmitting HIV, or becoming

infected.

 When the HIV-infected person is in the "acute infection" phase

(see fact sheet 103), the amount of virus in their blood is very high.
This increases the chance that they can pass on the infection.
Unfortunately, almost no one knows when they are in this phase of
HIV infection. There's no way to tell by looking at them.
 When either person has a weakened immune system. This could
be because of a long-term illness or an active infection like a herpes
outbreak, syphilis, or the flu.
 When the uninfected person has open sores that get exposed to
infected fluids. These could be cold sores, genital herpes, mouth
ulcers, syphilis sores, or other cuts or breaks in the skin.
 When there is exposure to infected blood.
 When the uninfected insertive male partner is not circumcised.

THE BOTTOM LINE

Researchers have developed estimates of the risk of transmission of HIV.

These estimates can give you a general idea of which activities are more or
less risky. They cannot tell you that any activity is safe, or how many times
you can do them without getting infected. The best way to avoid infection is
to use a condom correctly and consistently for all sexual activity, and to
avoid sharing needles. If you think you have been exposed to HIV, wait 3
months and get tested.

 WHAT IS ACUTE HIV INFECTION?

 TESTING FOR ACUTE HIV INFECTION
 RISK OF IMMUNE DAMAGE
 RISK OF INFECTING OTHERS
  TREATING ACUTE HIV INFECTION
 PROS AND CONS OF TREATING ACUTE HIV
 THE BOTTOM LINE

WHAT IS ACUTE HIV INFECTION?

The amount of HIV in the blood gets very high within a few days or weeks
after HIV infection. Some people get a flu-like illness. This first stage of HIV
disease is called "acute HIV infection" or "primary HIV infection."

About half of the people who get infected don?t notice anything. Symptoms
generally occur within 2 to 4 weeks. The most common symptoms are fever,
fatigue, and rash. Others include headache, swollen lymph glands, sore
throat, feeling achy, nausea, vomiting, diarrhea, and night sweats.

It is easy to overlook the signs of acute HIV infection. They can be caused
by several different illnesses. If you have any of these symptoms and if
there is any chance that you were recently exposed to HIV, talk to your
health care provider about getting tested for HIV.

TESTING FOR ACUTE HIV INFECTION

The normal HIV blood test will come back negative for someone who was
infected very recently. The test looks for antibodies produced by the immune
system to fight HIV. It can take two months for these antibodies to be
produced. See fact sheet 102 for more information.

However, the viral load test (see fact sheet 125) measures the virus itself.
Before the immune system produces antibodies to fight it, HIV multiplies
rapidly. Therefore, this test will show a high viral load during acute infection.

A negative HIV antibody test and a very high viral load indicate recent HIV
infection, most likely within the past two months. If both tests are positive,
then HIV infection probably occurred a few months or longer before the
tests. A special "detuned" version of the HIV antibody test is less sensitive.
It detects only those infections that occurred at least four to six months
before testing. It can be used to help identify cases of acute HIV infection.

RISK OF IMMUNE DAMAGE

Some people think that there?s not much harm done in the early stages of
HIV infection. They believe that any damage to their immune system will be
cured by taking antiretroviral therapy (ART). This is not true!

Up to 60% of infection-fighting ?memory? CD4 cells are infected during

acute infection, and after 14 days of infection, up to half of all memory CD4
cells can be killed. Also, HIV quickly reduces the ability of the thymus gland
to replace lost CD4 cells. The lining of the intestine is also damaged very
quickly. This can all occur before a person tests positive for HIV.

RISK OF INFECTING OTHERS

The number of HIV particles in the blood is much higher during acute HIV
infection than later on. Exposure to the blood of someone in the acute phase
of infection is more likely to result in infection than exposure to someone
with long-term infection. One research study estimated that the risk of
infection is approximately 20 times higher during acute HIV infection.

TREATING ACUTE HIV INFECTION

At first, the immune system produces white blood cells that recognize and
kill HIV-infected cells. This is called an "HIV-specific response." Over time,
most people lose this response. Unless they use antiretroviral drugs (ARVs),
their HIV disease will progress.

Guidelines for using HIV medications recommend waiting until the immune
system shows signs of damage. However, starting ARVs during acute HIV
infection might protect the HIV-specific immune response.

Researchers have studied people who start treatment during acute infection
and then stop taking ARVs. One study showed that this treatment may delay
the time until ART is needed. Researchers are doing more studies.

PROS AND CONS OF TREATING ACUTE HIV INFECTION

Starting ART is a major decision. Anyone thinking about taking ARVs should
carefully consider the benefits and disadvantages.

Taking ART changes your daily life. Missing doses of drugs makes it easier
for the virus to develop resistance to medications, which limits future
treatment options. Fact Sheet 405 has more information about the
importance of taking ARVs correctly.

The medications are very strong. They have side effects that can be difficult
to live with for a long time, and they can be very expensive.

Early treatment can protect the immune system from damage by HIV.
Immune damage shows up as lower CD4 cell counts and higher viral loads.
These are associated with higher rates of disease. Older people (over 40
years old) have weaker immune systems. They do not respond to ARVs as
well as younger people.

However, not everyone with HIV gets sick right away. Someone with a CD4
cell count over 350 and a viral load under 20,000, even if they don?t take
antiviral drugs, has about a 50/50 chance of staying healthy for 6 to 9 years.
Fact Sheet 124 has more information on CD4 cell tests, and Fact Sheet 125
has information on the viral load.

At first, researchers believed that early treatment might allow a patient to

stop taking ART after a period of controlling HIV. However, newer reports
indicate that this is very unusual.

THE BOTTOM LINE

It?s not easy to identify people with acute HIV infection. Some people have
no symptoms. If they have symptoms, several other diseases like the flu
might be causing them.

If you think you might be in the acute stage of HIV infection, tell
your health care provider and get tested. Talk to your health care
provider about the possible advantages of starting ART during acute HIV
infection.

Taking ARVs is a major commitment. Discuss the pros and cons of treatment
with your health care provider and consider them carefully before making
any decisions.

PNEUMOCYSTIS PNEUMONIA
(PCP)
 WHAT IS PCP?
  HOW IS PCP TREATED?
 CAN PCP BE PREVENTED?
 WHICH DRUG IS BEST?
 THE BOTTOM LINE

WHAT IS PCP?

Pneumocystis pneumonia (PCP or pneumocystis) is the most common

opportunistic infection in people with HIV. Without treatment, over 85% of
people with HIV would eventually develop PCP. It has been the major killer
of people with HIV. However, PCP is now almost entirely preventable and
treatable.

PCP is caused by a fungus. It used to be called pneumocystis carinii, but

scientists now call it pneumocystis jiroveci. A healthy immune system can
control the fungus. However, PCP causes illness in children and in adults
with a weakened immune system.

Pneumocystis almost always affects the lungs, causing a form of pneumonia.

People with CD4 cell counts under 200 have the highest risk of developing
PCP. People with counts under 300 who have already had another
opportunistic infection are also at risk. Most people who get PCP become
much weaker, lose a lot of weight, and are likely to get PCP again.

The first signs of PCP are difficulty breathing, fever, and a dry cough.
Anyone with these symptoms should see a doctor immediately. However,
everyone with CD4 counts below 300 should discuss PCP prevention with
their doctor, before they experience any symptoms.

HOW IS PCP TREATED?

For many years, antibiotics were used to prevent PCP in cancer patients with
weakened immune systems. It was not until 1985 that a small study showed
that these drugs would also prevent PCP in people with AIDS.

The success in preventing and treating PCP is dramatic. Percentages have

been cut by about half for PCP as the first AIDS-defining diagnosis, and for
PCP as the cause of death of people with AIDS.

Unfortunately, PCP is still common in people who are infected with HIV for a
long time before getting treatment. In fact, 30% to 40% of people with HIV
develop PCP if they wait to get treatment until their CD4 cell counts are
around 50.

A new anti-PCP drug, DB289, is being studied in a Phase II trial. Early

clinical trials showed very good results.

The drugs now used to treat PCP include TMP/SMX, dapsone, pentamidine,
and atovaquone.

 TMP/SMX (Bactrim® or Septra®) is the most effective anti-PCP drug.

It's a combination of two antibiotics: trimethoprim (TMP) and
sulfamethoxazole (SMX).
 Dapsone is similar to TMP/SMX. Dapsone seems to be almost as
effective as TMP/SMX against PCP.
 Pentamidine (NebuPent®, Pentam®, Pentacarinat®) is a drug that is
usually inhaled in an aerosol form to prevent PCP. Pentamidine is also
used intravenously (IV) to treat active PCP.
 Atovaquone (Mepron®) is a drug used in people with mild or
moderate cases of PCP who can not take TMP/SMX or pentamidine.

CAN PCP BE PREVENTED?

The best way to prevent PCP is to use strong antiretroviral therapy (ART).
People who have less than 200 CD4 cells can prevent PCP by taking the
same medications used for PCP treatment

Combination ART can make your CD4 cell count go up. If it goes over 200
and stays there for 3 months, it may be safe to stop taking PCP medications.
However, because PCP medications are inexpensive and have mild side
effects, some researchers think they should be continued until your CD4 cell
count reaches 300. Be sure to talk with your doctor before you stop
taking any of your prescribed medications.

WHICH DRUG IS BEST?

Bactrim or Septra (TMP/SMX) is the most effective drug against PCP. It is

also inexpensive, costing only about $10 per month. It is taken in pill form,
not more than one pill daily. Cutting back from one pill a day to three pills a
week reduces the allergy problems of Bactrim and Septra, and seems to
work just as well.
However, the "SMX" part is a sulfa drug and almost half of the people who
take it have an allergic reaction. This usually is a skin rash, sometimes a
fever. Allergic reactions can be overcome using a desensitization procedure.
Patients start with a very small amount of the drug and take increasing
amounts until they can tolerate the full dose.

Dapsone causes fewer allergic reactions than TMP/SMX. It is also fairly

inexpensive - about $30 per month. It also is taken as a pill and, like
Bactrim or Septra, not more than one pill daily.

Pentamidine involves a monthly visit to a clinic with a nebulizer, the machine

that produces a very fine mist of the drug. The mist is inhaled directly into
the lungs. The procedure takes about 30 to 45 minutes. You pay for the drug
plus the clinic costs, between $120 and $250 per month. Patients using
aerosol pentamidine get PCP more often than people taking the antibiotic
pills.

THE BOTTOM LINE

PCP, which was the number one killer of people with HIV, is now
almost totally treatable and preventable. Strong antiretroviral drugs
(ARVs) can keep your CD4 count from dropping. If your CD4 cell
count is below 300, talk to your doctor about taking drugs to prevent
PCP. Everyone whose CD4 cell count is below 200 should be taking

anti-PCP medication. KAPOSI'S SARCOMA

(KS)
 WHAT IS KS?
 HOW IS KS TREATED?
 CAN KS BE PREVENTED?
 WHAT ELSE IS BEING STUDIED FOR KS?
 THE BOTTOM LINE

WHAT IS KS?

Kaposi's sarcoma (KS) is a cancer-like disease. It originally was known as a

disease affecting elderly men of Eastern European or Mediterranean
background. KS also occurs in African men and people with a weakened
immune system. The most common cause of KS now is HIV infection.
KS usually shows up in the skin, or in the linings of the mouth, nose, or eye.
KS can also spread to the lungs, liver, stomach and intestines, and lymph
nodes. KS involves the development of many new, tiny blood vessels. This
process is called angiogenesis. KS is caused by a herpes virus called Human
Herpes Virus 8 (HHV-8). In a recent study, men with HHV-8 were nearly 12
times more likely to be diagnosed with KS than men who did not have HHV-
8.

KS affects about 20% of people with AIDS who aren't taking anti-HIV drugs.
The rate of KS has dropped by oer 80% since the introduction of strong
antiretroviral therapy (ART).

KS is mostly a disease of men: there are at least 8 men with KS for each
woman. It is one of the most visible signs of AIDS, because it usually shows
up as spots on the skin (lesions) that look red or purple on white skin, and
bluish, brownish or black on dark skin. Lesions often occur on the face, arms
and legs.

KS on the skin is not life threatening. However, KS lesions on the feet and
legs can make it difficult to walk. If KS spreads to other parts of the body, it
can cause serious problems. In the mouth lining, it can cause trouble eating
and swallowing. In the stomach or gut, it can cause internal bleeding and
blockages. If KS blocks lymph nodes, it can cause severe swelling of the
arms, legs, face, or scrotum. The most serious form of KS is in the lungs,
where it can cause a serious cough, shortness of breath, or an accumulation
of fluid that can be fatal.

KS can often be diagnosed by looking at the skin lesions. They are usually
flat, painless, and do not itch or drain. They can look like a bruise, but a
bruise will lose its purple color if you push on it; a KS lesion won't. KS
lesions can grow into raised bumps or patches and grow together. Your
health care provider might take a small sample (a biopsy) from skin spots to
examine under a microscope and confirm a diagnosis of KS.

HOW IS KS TREATED?

Strong ART is the best treatment for active KS. In many people, ART can
stop the growth or even clear up skin lesions. In addition to ART, there are
different treatments for KS in the skin or in other parts of the body.

In the skin, KS may not have to be treated if there are only a few lesions.
Skin lesions can be:
  Frozen with liquid nitrogen,
 Treated with radiation,
 Cut out surgically,
 Injected with anti-cancer drugs or interferon alpha.
 Treated with Panretin gel (retinoic acid)

These treatments only deal with the skin lesions, not with KS overall. Skin
lesions may come back after treatment.

If KS has spread into internal organs, into internal organs, systemic

(whole-body) drug treatment is used. If ART is not enough, the drugs
doxorubicin (Doxil®,) daunorubicin (DaunoXome®) or paclitaxel (Taxol®)
may be added.

Doxil and DaunoXome are anti-cancer drugs in "liposomal" form.

"Liposomal" means that tiny amounts of drug are encased in small fat
bubbles (liposomes). The drugs last longer in this form and seem to move to
the areas where they're needed. Some side effects are reduced with
liposomal forms of drugs.

CAN KS BE PREVENTED?

It is not clear how HHV-8 spreads. It might be spread through sexual activity
and deep kissing. As with other opportunistic infections, a healthy immune
system can control HHV-8 infection. The best way to prevent KS is by using
strong anti-HIV medications to keep your immune system strong.

WHAT ELSE IS BEING STUDIED FOR KS?

Anti-cytokine approaches: There is a lot of research on cytokines,

proteins that the immune system uses to sti mulate cells to grow.
Researchers think that substances that can inhibit these (and similar) growth
factors can also slow down the growth of KS.

Monoclonal antibodies: These drugs are produced through genetic

engineering. Their names end in "-mab," such as bevacizumab.

Other drugs: Scientists are studying several drugs that slow down the
development of new blood vessels (angiogenesis.)

THE BOTTOM LINE

KS is a disease that affects up to 20% of people with AIDS who are not
taking ART. It is partly caused by a herpes virus called HHV-8.

The best treatment for KS is strong antiretroviral therapy (ART.) KS in the

skin can be treated in several ways and is not a serious problem. KS in
internal organs can be life threatening. Internal KS is usually treated with
anti-cancer drugs.

If you notice new dark spots on your skin, have your health care
provider look at them to see if you might have KS.

CYTOMEGALOVIRUS (CMV)
 WHAT IS CMV?
 HOW IS CMV TREATED?
 CAN CMV BE PREVENTED?
 HOW DO I CHOOSE A TREATMENT FOR CMV?
 THE BOTTOM LINE

WHAT IS CMV?

Cytomegalovirus (CMV) is an opportunistic infection. The virus is very

common. Between 50% and 85% of the US population tests positive for CMV
by the time they are 40 years old. A healthy immune system keeps this virus
in check.

When the immune defenses are weak, CMV can attack several parts of the
body. This can be caused by various diseases including HIV. Combination
antiretriviral therapy (ART) has reduced the rate of CMV in people with HIV
by 75%. However, about 5% of people with HIV still develop CMV disease.

The most common illness caused by CMV is retinitis. This is the death of cells
in the retinas, the back of the eye. It can quickly cause blindness unless
treated. CMV can spread throughout the body and infect several organs at
once. The risk of CMV is highest when CD4 cell counts are below 50. It is
rare in people with more than 100 CD4 cells.

The first signs of CMV retinitis are vision problems such as moving black
spots. These are called "floaters." They may indicate an inflammation of the
retina. Patients may also notice light flashes, decreased or distorted vision,
or blind spots. Some doctors recommend eye exams to catch CMV retinitis.
The exams are done by an ophthalmologist (an eye specialist.) If your CD4
count is below 100 and you experience any vision problems, tell your
health care provider immediately.

Some patients who have recently started using ART can get inflammation in
their eyes, causing loss of vision. This is called immune restoration
syndrome (See Fact Sheet 473).

A recent study suggests that having active CMV makes it eaier to pass HIV to
others.

HOW IS CMV TREATED?

The first treatments for CMV required daily intravenous infusions. Most
people had a permanent medication ?port? inserted into their chest or arm.
People had to keep taking anti-CMV drugs for life.

CMV treatments have improved dramatically over the past several years.
There are now seven CMV treatments approved by the FDA.

Strong antiretroviral medications (ARVs) can improve the immune system. Patients
can stop taking CMV drugs if their CD4 cell count goes over 100 to 150 and stays
there for at least three months. However, there are two special cases:

1. Immune restoration syndrome can cause severe inflammation in the eyes of

people with HIV even if they didn?t have CMV before. The usual treatment is
to add anti-CMV drugs to the patient's ART.
2. If the CD4 count drops below 50, there is an increased risk of developing
CMV disease.

CAN CMV BE PREVENTED?

Ganciclovir was approved for prevention (prophylaxis) of CMV. However, many

health care providers don't prescribe it. They don't want to add up to 12 capsules a
day for their patients. Also, it's not clear that it does any good. Two large studies
came to different conclusions. Finally, strong ARVs keep most people's CD4 counts
high enough so that they won't get CMV.

HOW DO I CHOOSE A TREATMENT FOR CMV?

There are several issues to consider when choosing a treatment for active CMV
disease:

Is your vision at risk?

You may need to take quick action to save your eyesight.

How effective is it?

Intravenous ganciclovir is the most effective overall CMV treatment. Implants are
very good at stopping retinitis. However, they only work in the eye with the
implant.

How is it administered?
Pills are the easiest to manage. Intravenous (IV) medication involves needle sticks
or a medication line that might become infected. Ocular injections mean inserting a
needle directly into the eye. Implants, which last six to eight months, take about an
hour to insert in an office procedure.

Is it a local therapy or systemic?

Local therapies affect just the eyes. CMV retinitis can progress rapidly and lead to
blindness. For this reason, it is treated aggressively when it first shows up. The
newer injections or implants put medication directly into the eye and have the
greatest impact on retinitis.

CMV can also show up in other places in the body. To control CMV in the rest
of the body, you need a systemic (whole-body) therapy. Intravenous
medication or valganciclovir pills can be used.

What are the side effects?

Some CMV drugs can damage your bone marrow or kidneys. This may require
additional medications. Other drugs require infusions that can take a long time.
Discuss the side effects of any CMV treatment with your health care provider.

What do the guidelines say?

Recently, several sets of professional guidelines have recommended valganciclovir
as the preferred treatment for patients who are not at immediate risk of losing their
sight.

THE BOTTOM LINE

Strong ARVs are probably the best way to prevent CMV. If your CD4 cell count is
below 100, talk with your health care provider about CMV prevention and a regular
schedule of eye exams. If you have a low CD4 cell count and experience ANY
unusual vision problems, see your health care provider immediately!

Treatments directly in the eye make it possible to control CMV retinitis. With
the newer drugs to treat CMV, you can avoid implanted medication lines and
daily infusions.

Most people can safely stop taking CMV medication if their CD4 cell counts go up
and stay above 100 to 150 when they take anti-HIV drugs.

CANDIDIASIS (Thrush)
 WHAT IS THRUSH?
 CAN IT BE PREVENTED?
 HOW IS IT TREATED?
 NATURAL THERAPIES
 THE BOTTOM LINE

WHAT IS THRUSH?

Candidiasis is a common opportunistic infection in people with HIV. It is an

infection caused by a common type of yeast (or fungus) called candida. This
yeast is found in most people's bodies. A healthy immune system keeps it
under control. Candida usually infects the mouth, throat, or vagina. It can
occur months or years before other, more serious opportunistic infections.
See Fact Sheet 500 for more information on opportunistic infections.

In the mouth, the infection is called thrush. When the infection spreads
deeper into the throat it is called esophagitis. It looks like white patches
similar to cottage cheese, or red spots. It can cause a sore throat, pain when
swallowing, nausea, and loss of appetite.

In the vagina, the infection is called yeast infection or vaginitis. This is a

common vaginal infection. Symptoms include itching, burning, and a thick
whitish discharge.

Candida can also apread and cause infection in the brain, heart, joints, and
eyes.
CAN IT BE PREVENTED?

There is no way to prevent exposure to candida. Medications are not

normally used to prevent candidiasis. There are several reasons for this:

 It is not very dangerous

 There are effective drugs to treat it
 The yeast could develop resistance to the medications.

Strengthening your immune system by taking combination antiretroviral

therapy (ART) is the best way to prevent an outbreak of candidiasis.

HOW IS IT TREATED?

A healthy immune system keeps candida in balance. Bacteria normally found

in the body also help control it. Some antibiotics kill these helpful bacteria
and cause an outbreak of candidiasis. Treating candidiasis will not get rid of
the yeast, but will keep it under control.

Treatments can be local or systemic. Local treatments are applied where the
infection is found. Systemic treatments affect the whole body. Many health
care providers prefer to use local treatment first. It puts the medication
directly where it is needed. It has fewer side effects than a systemic
treatment. Also, there is less risk of candida becoming resistant to the
medications. The medications used to fight candida are antifungal drugs.
Almost all their names end in "-azole." They include clotrimazole, nystatin,
fluconazole, and itraconazole.

 Local treatments include:

o creams
o suppositories to treat vaginitis
o liquids
o "troches" or "lozenges" that dissolve in the mouth

Local treatments may cause some stinging or irritation.

 Systemic treatment is needed if local treatments don't work, or if the

infection has spread into the throat (esophagitis) o other parts of the
body. Some systemic drugs are taken in pill form. The most common
side effects are nausea, vomiting, and abdominal pain. Less than 20%
of people have these side effects.
Candidiasis can come back repeatedly. Some health care providers prescribe
anti-fungal drugs on a long-term basis. This can cause resistance. The yeast
can mutate so that a drug no longer works.

Some serious cases do not respond to other medications. Then,

amphotericin B might be used. It is a very potent and toxic drug, given
orally or intravenously. The major side effects are kidney problems and
anemia. Other reactions include fever, chills, nausea, vomiting, and
headache. These usually get better after the first few doses.

NATURAL THERAPIES

Several non-drug therapies seem to help. They have not been carefully
studied to prove that they work.

 Reduce the amount of sugar you eat.

 Drink Pau d'Arco tea. It is made from the bark of a South American
tree.
 Take garlic supplements or eat raw garlic. Garlic has anti-fungal and
anti-bacterial properties. However, it can interfere with protease
inhibitor drugs.
 Gargle with tea tree oil diluted in water.
 Take lactobacillus (acidophilus) capsules or eat yogurt with this
bacteria. Make sure the label says it has live, active cultures. It may
help to take it after taking antibiotics.
 Take supplements of gamma-linoleic acid (GLA) and Biotin. They both
seem to slow the spread of candida. GLA is found in several cold-
pressed oils. Biotin is a B vitamin.

THE BOTTOM LINE

Candidiasis is a very common yeast (fungal) infection. The fungus normally

lives in the body. It cannot be eliminated. The best way to avoid an outbreak
of candidiasis is to strengthen your immune system by taking antiretroviral
medications (ARVs).

Most candida infections are easily treated with local therapies. In people with
weakened immune systems, these infections become more persistent.
Systemic anti-fungal drugs can be taken, but candida might become
resistant to them. The most potent anti-fungal drug, amphotericin B, has
serious side effects.
Several natural therapies seem to help control candida infections.
The Structure of HIV

HIV stands for Human Immunodeficiency Virus. Like all viruses, HIV cannot grow or reproduce
on its own. In order to make new copies of itself it must infect the cells of a living organism.

What does HIV look like?

In this computer generated image, the large object is a

human CD4+ white blood cell, and the spots on its surface

and the spiky blue objects in the foreground

represent HIV particles.

Outside of a human cell, HIV exists as roughly spherical particles (sometimes called virions).
The surface of each particle is studded with lots of little spikes.

An HIV particle is around 100-150 billionths of a metre in diameter. That's about the same as:

 0.1 microns
 4 millionths of an inch
 one twentieth of the length of an E. coli bacterium
 one seventieth of the diameter of a human CD4+ white blood cell.

Unlike most bacteria, HIV particles are much too small to be seen through an ordinary
microscope. However they can be seen clearly with an electron microscope.

HIV particles surround themselves with a coat of fatty material known as the viral envelope (or
membrane). Projecting from this are around 72 little spikes, which are formed from the proteins
gp120 and gp41. Just below the viral envelope is a layer called the matrix, which is made from
the protein p17.
The proteins gp120 and gp41 together make up the spikes

that project from HIV particles, while p17 forms the matrix

and p24 forms the core.

The viral core (or capsid) is usually bullet-shaped and is made from the protein p24. Inside the
core are three enzymes required for HIV replication called reverse transcriptase, integrase and
protease. Also held within the core is HIV's genetic material, which consists of two identical
strands of RNA.

What is RNA?

HIV belongs to a special class of viruses called retroviruses. Within this class, HIV is placed in
the subgroup of lentiviruses. Other lentiviruses include SIV, FIV, Visna and CAEV, which cause
diseases in monkeys, cats, sheep and goats. Almost all organisms, including most viruses, store
their genetic material on long strands of DNA. Retroviruses are the exception because their
genes are composed of RNA (Ribonucleic Acid).

RNA has a very similar structure to DNA. However, small differences between the two
molecules mean that HIV's replication process is a bit more complicated than that of most other
viruses.

How many genes does HIV have?

HIV has just nine genes (compared to more than 500 genes in a bacterium, and around 20,000-
25,000 in a human). Three of the HIV genes, called gag, pol and env, contain information needed
to make structural proteins for new virus particles. The other six genes, known as tat, rev, nef,
vif, vpr and vpu, code for proteins that control the ability of HIV to infect a cell, produce new
copies of virus, or cause disease.

At either end of each strand of RNA is a sequence called the long terminal repeat, which helps to
control HIV replication.
HIV life cycle
Entry

HIV can only replicate (make new copies of itself) inside human cells. The process typically
begins when a virus particle bumps into a cell that carries on its surface a special protein called
CD4. The spikes on the surface of the virus particle stick to the CD4 and allow the viral envelope
to fuse with the cell membrane. The contents of the HIV particle are then released into the cell,
leaving the envelope behind.

Reverse Transcription and Integration

Once inside the cell, the HIV enzyme reverse transcriptase converts the viral RNA into DNA,
which is compatible with human genetic material. This DNA is transported to the cell's nucleus,
where it is spliced into the human DNA by the HIV enzyme integrase. Once integrated, the HIV
DNA is known as provirus.

Transcription and Translation

This electron microscope photo shows

newly formed HIV particles budding

from a human cell.

HIV provirus may lie dormant within a cell for a long time. But when the cell becomes activated,
it treats HIV genes in much the same way as human genes. First it converts them into messenger
RNA (using human enzymes). Then the messenger RNA is transported outside the nucleus, and
is used as a blueprint for producing new HIV proteins and enzymes.
Assembly, Budding and Maturation

Among the strands of messenger RNA produced by the cell are complete copies of HIV genetic
material. These gather together with newly made HIV proteins and enzymes to form new viral
particles, which are then released from the cell. The enzyme protease plays a vital role at this
stage of the HIV life cycle by chopping up long strands of protein into smaller pieces, which are
used to construct mature viral cores.

The newly matured HIV particles are ready to infect another cell and begin the replication
process all over again. In this way the virus quickly spreads through the human body. And once a
person is infected, they can pass HIV on to others in their bodily fluids.

back to top

What's this?

HIV images

Please click on the image you would like to view

 Structure of human immunodeficiency virus

 HIV exiting a cell

 Electron micrograph image of cell producing HIV

 An HIV particle budding from a cell

The virus that causes AIDS is called HIV, which stands for Human Immunodeficiency Virus.
HIV is a retrovirus that measures around 100-150 billionths of a metre (4 millionths of an inch)
across. It is too small to be viewed with an ordinary microscope, but can be seen clearly with an
electron microscope.

Click on the photo to go back to the previous page

 Structure of human immunodeficiency virus

 Region: N/A
 Country: N/A
 Keywords: Virus pictures

This diagram represents the structure of human immunodeficiency virus

(HIV). HIV is part of a family or group of viruses called lentiviruses.
 HIV exiting a cell

 Region: N/A
 Country: N/A
 Keywords: Virus pictures

This is an image of HIV (the small blue particles) exiting a human cell.
HIV stands for Human Immunodeficiency Virus. This is a virus that
people can become infected with and that they can then pass on to other
people.
 Electron micrograph image of cell producing HIV

 Region: N/A
 Country: N/A
 Keywords: Virus pictures

Electron micrograph image of cell producing HIV

Electronmicrograph of an HIV particle

 Region: N/A
  Country: N/A
 Keywords: Virus pictures

This is an electronmicrograph of an HIV particle budding from a cell. HIV

stands for Human Immunodeficiency Virus. This is a virus that people can
become infected with and that they can then pass on to other people.