LECTURE EIGHT

8. Progression of HIV Infection in the Infected Individual.

Introduction
This lecture discusses the progression of HIV infection in an individual from the day they get
infected, through the various stages of increasingly serious symptoms, until the late stage of the
disease when the immune system has virtually collapsed. Unlike most other infections, progression
of HIV infection is a gradual process that can take ten years or more. However. in the majority of
individuals that progression eventually leads downhill to an inevitable death unless effective
treatment is offered to the patient.
8.1 Lecture Objectives

At the end of this lecture you should be able to:

 Discuss the various stages that an individual infected with the HIV virus progresses
through from time of infection to the terminal stages of illness.
 Distinguish the different opportunistic diseases that are associated with each stage of HIV
disease.
 Describe the World Health Organization’s staging of HIV infection.

8.1.2- Effect of the HIV Virus On The Immune Cells.

The HIV virus infects cells of the immune system which are CD4 positive meaning that they have a CD4 receptor site
to which the virus attaches itself. As earlier explained, T-Lymphocytes are the main group of CD4 cells ( see life
cycle of the virus above). Other cells with CD4 receptors include macrophages, monocytes and dendritic cells the
latter being found on such areas as the head of the penis and prepuce ( Langerhans cells). In HIV infection CD4 cells
are destroyed as the virus converts them into virus manufacturing units. Even those still alive are incapacitated and
unable to perform their functions in protecting the body.
As this process advances the individuals will increasingly become susceptible to infections as he or she cannot
defend himself or herself. Next follows a discussion of the progression of HIV infection through three stages namely:
Primary HIV infection, Stage of Latency and Symptomatic stage.
8.1.3.Primary HIV Infection
The first 2-4 weeks after an individual becomes infected are characterized by rapid viral replication resulting in high
viral loads. This leads to a decline in the number of CD4 cells.
Host Immune Response.
After the initial stage of the infection the body mounts an immune response to confront the virus. The body produces
antibodies in response to the presence of the HIV infection; first what are referred to as non- neutralizing
antibodies followed by the neutralizing antibodies. This process may be accompanied by an acute illness for 1-2
weeks which goes largely unrecognized and untreated or may be confused with the symptoms of other common
infections such as a common cold, “malaria” or “flu” . This illness is termed as an Acute Sero-Conversion Illness.
This name signifies that the body will be reacting to the presence of the virus by producing antibodies which can be
detected in the laboratory.
The Window Period
The period soon after infection is characterized by a “Window Period” a time when laboratory tests that rely on the
presence of antibodies may miss HIV infection as there are no adequate antibodies for them to detect. This then
results in a False Negative test where an infected person is told he or she is negative.
This immune response put pressure on the viral population so that eventually the viral load will go down and any
symptoms of the infection improve or disappear altogether. The person then enters a stage referred to as
Asymptomatic Stage or Stage of Latency which is discussed next.
8.2. Asymptomatic Disease (Latency)
A period of time when the infected person has few if any symptoms. This is a time when the body of the infected
person has gained an upper hand over the virus and is able to maintain good immune function for a period that can
vary from 2-10 years. Some people are found to be long term non-progressors who can go for 10-15 years without
symptoms even when they are not on Antiretroviral medication. Such people maintain a CD4 count above 500 cells
per mm3 of blood and a viral load of less than 5000 copies.
However, in spite of the relative good health most of these individuals continue to suffer from a gradual decline of the
CD4 cells so that eventually the symptoms will return after a significant drop in the CD4 cells is reached. This will
mark the beginning of the Symptomatic Phase when the person will experience signs of sickness which will get
worse over time if effective treatment is not provided.
8.3. Symptomatic Disease and Aids.
The symptomatic phase of HIV infection will be characterized by the following observations:

 A continuing increase in viral load

 A continuing decrease in the number of CD4 cells

Ultimately an infected person gets to a late stage disease characterized by a CD4 cell count of less than 200
cell/mm3. People who reach this stage were found to have a median survival of 3.7years without Antiretroviral
Treatment.
The stage referred to as Acquired Immune Deficiency Syndrome ( AIDS) when the major illnesses of advanced
HIV infection occur is reached at a CD4 count of 60-70 cells /mm3 and a patient with this stage has a median
survival of 1.3years without treatment. ( Source:NASCOP Training Manual)
8.4. W.H.O Classification
The World Health Organization developed a way of classifying HIV infection depending on the type of symptoms a
patient has and how advanced his or her disease is. This classification helps in making decisions about how to care
for the patient –for example when a patient should go on anti-retrovirals. The WHO classification is as explained
below:
Stage I

 Asymptomatic-the person has no symptoms and is in good health comparable to that of an uninfected
person.
 Some individuals in stage I may have swollen glands on areas such as the neck, behind the ears, armpits
or groin. This is referred to as Progressive Generalized Lymphadenopathy (PGL).

Performance scale will be: Asymptomatic meaning they are free from symptoms and normal performance
Note:
People in Stage 1 will therefore be in good health with a normal or near normal CD 4 count. Around 500 cells per
mm3 of blood and going about their business normally
STAGE II. Individuals in Stage II will show the following features:

 Moderate unexplained loss of body weight of less than 10 percent

 Recurrent upper respiratory tract infection such as sinus infection, bronchitis, ear infections and throat
infections
 Herpes Zooster or shingles current or in the last 2 years

An image of Herpes Zooster

  This is an infection caused by the chicken pox virus which affects nerves in the skin. It causes small painful
blisters on the affected area usually on the body torso or areas of the head. The blisters occur in groups or
clusters.
 Angular cheilitis- inflammation on the angles of the mouth with cracking
 Recurrent oral ulcerations(wounds in the mouth)
 Persistent itchy skin rashes with pimples that give a strong urge to scratch referred to as Pruritic Purpuric
Eruptions(PPE) seborrheic dermatitis which occurs on the scalp with itching, appearance of pimples that
may ooze and appear wet, scaling. Nails may develop fungal infections.

Performance scale: Symptomatic but normal function- This means that although they have symptoms these patients
can function well in their day to day activities.
STAGE III

 Severe weight loss of more than 10 percent. This may be presumed or measured.
 Unexplained chronic diarrhea lasting one month with the person passing watery stools more than four
times a day
 Unexplained persistent fever( high body temperature above 37.20C ), lasting longer one month
 Oral candidiasis (thrush) a fungal infection caused by a yeast called Candida albicans. It causes whitish
patches on the affected areas of the mouth that look like milk cuds. Attempting to scratch them off leaves a
raw bleeding area
 Oral hairy leukoplakia-areas of whitish, furry appearance on tongue or mouth lining
 Pulmonary tuberculosis, meaning that the individual has tuberculosis (TB) of the lungs diagnosed in the last
2 years
 Severe bacterial infections such as pneumonia, empyema (pus collection in the lungs) pyomyositis(infection
in the muscles) bone and joint infections, meningitis and bacteremia
 Other signs include Haemoglobin of< 8g/dl(normal should be above 12g/dl) meaning that the blood has
reduced oxygen carrying capacity, neutropenia meaning that the individual has a low white cell count of
<1000 cells/mm3
 Low platelet count<30000/mm3 for >one month

Performance scale: Symptomatic and bed -ridden for less than 50% of their time
STAGE IV

 HIV wasting syndrome characterized by emaciation and severe weight loss

 Pneumocystis Carinii Pneumonia(PCP) a serious lung infection
 Recurrent severe pneumonia (lung infection) due to other microorganisms other than PCP.
 Cryptococcal meningitis a fungal infection of the membranes(meninges) that cover the brain
 Toxoplasmosis –a protozoa infection also affecting the brain
 Chronic Herpes simplex a viral infection that causes cold sores around the mouth. Also another strain of the
virus causes sores on the genitals. In late stage HIV the infection is more serious and persisitent
 Kaposis sarcoma- A type of cancer common in AIDS patient
The skin of a Person with Kaposi’s sarcoma

Skin Showing Kaposi’s Sarcoma a Type of Cancer that affects People with Advanced HIV Infection. Courtesy
of Getty Images.

HIV encephalopathy- brain damage caused by the HIV virus leading to deterioration of mental abilities(HIV
dementia)
Extra- pulmonary tuberculosis. TB infection in areas of the body other than the lungs
Cryptosporidiosis –causes severe and persistent diarrhea
Esophageal candidiasis- yeast infection or thrush in this case extending to the esophagus (gullet).
Cytomegalovirus a virus infection
Non –typhoid salmonella septicemia –a blood infection caused by bacteria related to the typhoid bacteria
Performance Scale: Symptomatic and bedridden for more than 50% of the time
Note: Patients in Stage 3 and 4 are seriously risk and without treatment most of the
infections they have can prove fatal. However with treatment many of them will regain their
health and sometime manage to be free from symptoms just as if they are in stage one.

The early stages of HIV infection present with symptoms that are hard to distinguish from
those of many other infections- they are not specific to HIV infection. In most people those
symptoms disappear to give way to a prolonged period of relatively good health. However
this period will be gradually replaced by reappearance of symptoms that will get progressively
more serious as the immune system suffers increasing damage.
Without treatment the immune functions of the infected person will collapse with onset of
AIDS defining illness which will kill the patient.
SELF-TEST QUESTIONS

1. Explain what is referred to as the “Acute Seroconversion illness” that affects HIV infected
people in the early stages of infection.
2. What is the window period in HIV infected people and what is its significance?
3. What is the stage of Latency in HIV infected individuals?
4. Discuss the features seen in an individual who is in stage 3 of the WHO staging of HIV
infection.

1.9 References and Further Readings

REFERENCES.
1.National Training Curriculum on Antiretrovirals Therapy, Ministry of Health Kenya
2.Davidson’s Principals of Medicine, 1996 Edition
3.National Health Demographic Survey 2003 ,Ministry of Health Kenya.
4.Kenya AIDS Indicator Survey,2007.Ministry of Health Kenya
5.AIDS In The Workplace Policy Government of Kenya (DPM).2005
6.Wikipedia, Online encyclopedia.
7.Pratt R.,J.2003.HIV&AIDS A Foundation For Nursing and Healthcare Practice.London.Bookpower.
8.AMREF Community Health Manual.
9. UN /AIDS WEBSITE

Place here the module references. These comprise selected texts with specific readings to
provide additional learning to students.