45

C H A P T E R

Human
Immunodeficiency Virus
cells ie
of RNA
(Diploide)
↳ Enveloped virus/contains reverse transcriptase
integrase/RNA vinus

Call MissisE
, and has 2

=manote
copies
dendritic cell microglia cells
, follicular dendres
CDU*
,
>
- infected cell : call Chelper I cells) Es , masophage ,

&2-oad
structure
virus

CHAPTER CONTENTS * *
-

Disease Laboratory Diagnosis

Important Properties Treatment
Summary of Replicative Cycle Prevention
Transmission & Epidemiology Self-Assessment Questions
Pathogenesis & Immunity Summaries of Organisms
Clinical Findings Practice Questions: USMLE & Course Examinations

Disease required for replication, and the other four, nef, vif, vpr, and
vpu, are not required for replication and are termed “acces-
Human immunodeficiency virus (HIV) is the cause of
sory” genes.
acquired immunodeficiency syndrome (AIDS).
The gag gene encodes the internal “core” proteins, the
Both HIV-1 and HIV-2 cause AIDS, but HIV-1 is found
most important of which is the p24 protein. It is important
worldwide, whereas HIV-2 is found primarily in West
Africa. This chapter refers to HIV-1 unless otherwise noted.

Important Properties
HIV is one of the two important human T-cell lympho-
tropic retroviruses (human T-cell leukemia virus is the
other). HIV preferentially infects and kills helper (CD4)
T lymphocytes, resulting in the loss of cell-mediated
immunity and a high probability that the host will develop
opportunistic infections. Other cells (e.g., macrophages
and monocytes) that have CD4 proteins on their surfaces
can be infected also.
HIV belongs to the lentivirus subgroup of retroviruses,
which cause “slow” infections with long incubation periods
(see Chapter 44). HIV has a cylinder-shaped (type D) core
surrounded by an envelope containing virus-specific glyco-
proteins (gp120 and gp41) (Figures 45–1 and 45–2). The
genome of HIV consists of two identical molecules of
FIGURE 45–1 Human immunodeficiency virus (HIV)—electron
single-stranded, positive-polarity RNA and is said to be
micrograph. Large arrow points to a mature virion of HIV that has just
diploid. The HIV genome is the most complex of the known been released from the infected lymphocyte at the bottom of the
retroviruses (Figure 45–3). In addition to the three typical figure. Small arrow (in bottom left of image) points to several nascent
retroviral genes gag, pol, and env, which encode the struc- virions in the cytoplasm just prior to budding from the cell membrane.
tural proteins, the genome RNA has six regulatory genes (Source: Dr. A. Harrison, Dr. P. Feirino, and Dr. E. Palmer, Public Health Image Library,
(Table 45–1). Two of these regulatory genes, tat and rev, are Centers for Disease Control and Prevention.)

378
 -* Dute .
- Hi
--
e6
120 with CDU + Of macrophage -
> CCR5

CXCR4
receptor HelperTg &
2-23 attachment >
-
gp1 with chemokine
↳

-gp4is e
i
CHAPTER 45 Human Immunodeficiency Virus 379
ident s blockinger is is direentication &
C Entry inhibitors) .

maravirozd s
1
- -

protein .. *1, glycopro surface & <I

# sfusion! block " - ,

in Enfavirtide-Is's

cleaved to form the two envelope (surface) glycoproteins,

rest peace &
O
gp41env
I

REI %
*

-5 HIV I
reco integeProteste gp120 and gp41. isu

-Jadei
-

Reverse OT - subtypes -

transcriptase
transcriptase Differences in the base sequence of the gp120 gene are
Free it used to subdivide HIV into subtypes called clades. Differ-
- gene /1. 3 -
-

-most
outer thing-gpus
O
ent clades are found in different areas of the world. For
-

gp120env
example, the B clade is the most common subtype in North
-

-
RNA America. Subtype B preferentially infects mononuclear
! - - e - -1 -

satingcells and appears to be passed readily during anal sex,

.
-
-

diesgrat go
·

& anco

-
..

O
Protein
p17 matrix ise whereas subtype E preferentially infects female genital tract
3
⑪

Browntem
cells and appears to be passed readily during vaginal sex.
-

protein onmaine
domise i n

Three enzymes are located within the nucleocapsid of

·

-Damenesse the virion: reverse transcriptase, integrase, and protease

S

DNAsiglstDrARun and
I
↳ -

④ p24gag Lipid bilayer I

families
(NR sa
Nucleosiderew traninhibitors
senme's od
2 copies
Tenofovir
-
, Zidovudine ,
(see Figure 45–2).
Lamivudine

tran· (NNRTS
Didanosine ,
Abacan

2 = non-nucleoside new. hi

NevirapineSuenzyme -
Reverse transcriptase is the RNA-dependent DNA poly-
Sil... -

Rilpivirine Delavirdive > Efavirent Stravirine !

FIGURE 45–2 Cross-section of human immunodeficiency virus ;'

gravir-& Ralteg ravir

merase that is the source of the family name retroviruses.

s
-

978
(HIV). In the interior, two molecules of viral RNA are shown associ- 19( -
·

ated with reverse transcriptase. Surrounding those structures is a
rectangular nucleocapsid composed of p24 proteins. Note that the
viral protease and integrase are also located within the nucleocapsid
(in addition to the reverse transcriptase), but, for lack of space, are
not shown in the figure. On the exterior are the two envelope pro-
teins, gp120 and gp41, which are embedded in the lipid bilayer
derived from the cell membrane. (Reproduced with permission from Green
WC. Mechanisms of disease: the molecular biology of human immunodeficiency
virus type I infection. NEJM. 1991;324[5]:309.)
O the host cell DNA. The viral protease cleaves the precursor
3gelos gpugp enrD gag Hirgenne Gigood-is integratin
- & -
This enzyme transcribes the RNA genome into the proviral
DNA. Reverse transcriptase is a bifunctional enzyme; it
also has ribonuclease H activity. Ribonuclease H degrades
RNA when it is in the form of an RNA–DNA hybrid mol-
ecule. The degradation of the viral RNA genome is an
essential step in the synthesis of the double-stranded provi-
ral DNA. Integrase, another important enzyme within the
virion, mediates the integration of the proviral DNA into
9

*
.

d ↳
,

i -

polyproteins into functional viral polypeptides.

-

enty mes
-- -/

d * - 6 61825
Accessory .
.

One essential regulatory gene is the tat (transactivation

medically as it is the antigen in the initial serological test
that determines whether the patient has antibody to HIV
(i.e., has been infected with HIV). (See “Laboratory Diag-
nosis” section in this chapter.)
The pol gene encodes several proteins, including the
virion “reverse transcriptase,” which synthesizes DNA by
using the genome RNA as a template, an integrase that
integrates the viral DNA into the cellular DNA, and a pro-
tease that cleaves the various viral precursor proteins. The
env gene encodes gp160, a precursor glycoprotein that is
gag pol env
LTR p24* PROT POL H INT gp120 gp41 LTR
5'
VIF TAT VPU REV NEF
FIGURE 45–3 The genome of human immunodeficiency virus
(HIV). Above the line are the three genes for the main structural pro-
teins: (1) gag encodes the internal group-specific antigens (e.g., p24);
(2) pol encodes proteins that have four enzymatic activities: protease
(PROT), polymerase that functions as a reverse transcriptase (POL),
RNase H (H), and integrase (INT); (3) env encodes the two envelope
glycoproteins, gp120 and gp41. Below the line are five regulatory
proteins: viral infectivity factor (VIF), transactivating protein (TAT),
viral protein U (VPU), regulator of expression of virion protein (REV),
and negative regulatory factor (NEF). At both ends are long terminal
repeats (LTR), which are transcription initiation sites. Within the 5′ LTR
is the binding site for the TAT protein, called the transactivation
response element (TAR). TAT enhances the initiation and elongation
of viral mRNA transcription. (*p24 and other smaller proteins such as
p17 and p7 are encoded by the gag gene.)
of transcription)1 gene, which encodes a protein that
enhances viral (and perhaps cellular) gene transcription.
The Tat protein and another HIV-encoded regulatory
protein called Nef repress the synthesis of class I major his-
tocompatibility complex (MHC) proteins, thereby reducing
the ability of cytotoxic T cells to kill HIV-infected cells. The
other essential regulatory gene, rev, controls the passage of
late mRNA from the nucleus into the cytoplasm. The func-
tion of the four accessory genes is described in Table 45–1.
The accessory protein Vif (viral infectivity) enhances
HIV infectivity by inhibiting the action of APOBEC3G, an
enzyme that causes hypermutation in retroviral DNA.
APOBEC3G is “apolipoprotein B RNA-editing enzyme”
that deaminates cytosines in both mRNA and retroviral
3'
DNA, thereby inactivating these molecules and reducing
infectivity. APOBEC3G is considered to be an important
member of the innate host defenses against retroviral infec-
tion. HIV defends itself against this innate host defense by
producing Vif, which counteracts APOBEC3G, thereby
preventing hypermutation from occurring.
There are several important antigens of HIV:
(1) gp120 and gp41 are the type-specific envelope gly-
coproteins. gp120 protrudes from the surface and interacts
with the CD4 receptor (and a second protein, a chemokine
1
Transactivation refers to activation of transcription of genes distant from
the gene (i.e., other genes on the same proviral DNA or on cellular
DNA). One site of action of the Tat protein is the long terminal repeat at
the 5′ end of the viral genome.
380 PART IV Clinical Virology

TABLE 45–1 Genes and Proteins of Human Immunodeficiency Virus

Gene Proteins Encoded by Gene Function of Proteins

I. Structural genes found in all retroviruses

gag p24, p7 Nucleocapsid
p17 Matrix
1
pol Reverse transcriptase Transcribes RNA genome into DNA
Protease Cleaves precursor polypeptides
Integrase Integrates viral DNA into host cell DNA
env gp120 Attachment to CD4 protein
gp41 Fusion with host cell
II. Regulatory genes found in human immunodeficiency virus that are required for replication
pin active
simgeremm Activation of transcription of viral genes
trans

tat =>
Tat
&565

rev Rev - Transport of late mRNAs from nucleus to cytoplasm

.

III. Regulatory genes found in human immunodeficiency virus that are not required for replication (accessory genes)
Nef > is M
Steen
&

&

nef Decreases CD4 proteins and class I MHC proteins on surface of infected cells; induces death of
-

uninfected cytotoxic T cells; important for pathogenesis by SIV2

#PO[ C36& 2.

vif Vif
-Enhances infectivity by inhibiting the action of APOBEC3G (an enzyme that causes hypermutation
>
-

↳ innate
·

defense
in retroviral DNA) host .

vpr Vpr - Transports viral core from cytoplasm into nucleus in nondividing cells
vpu Vpu
j, Enhances virion release from cell
MHC = major histocompatibility complex.
gpkg-killing st85 is Antibodies enee
,
I

1
Reverse transcriptase also contains ribonuclease H activity, which degrades the genome RNA to allow the second strand of DNA to be made. ...

dismisse i
I

di
-

Serology
-
- 4 d
↳
2
Mutants of the nef gene of simian immunodeficiency virus (SIV) do not cause acquired immunodeficiency syndrome in monkeys.

receptor) on the cell surface. gp41 is embedded in the enve-
lope and mediates the fusion of the viral envelope with the
cell membrane at the time of infection. The gene that
encodes gp120 mutates rapidly, resulting in many anti-
genic variants. The most immunogenic region of gp120 is
called the V3 loop; it is one of the sites that varies antigeni-
cally to a significant degree. Antibody against gp120 neu-
tralizes the infectivity of HIV, but the rapid appearance of
gp120 variants has made production of an effective vaccine
difficult. The high mutation rate may be due to lack of an
editing function in the reverse transcriptase.
(2) The group-specific antigen, p24, is located in the
nucleocapsid core and is not known to vary. Antibodies
against p24 do not neutralize HIV infectivity but serve as
important serologic markers of infection.
The natural host range of HIV is limited to humans,
although certain primates can be infected in the laboratory.
HIV is not an endogenous virus of humans (i.e., no HIV
sequences are found in normal human cell DNA). The ori-
gin of HIV and how it entered the human population
remains uncertain. There is evidence that chimpanzees
living in West Africa were the source of HIV-1. If chimpan-
zees are the source of HIV in humans, it would be a good
example of a virus “jumping the species barrier.”
In addition to HIV-1, two other similar retroviruses are
worthy of comment:
(1) Human immunodeficiency virus type 2 (HIV-2) was
isolated from AIDS patients in West Africa in 1986. The
proteins of HIV-2 are only about 40% identical to those of
the original HIV isolates. HIV-2 remains localized primar-
ily to West Africa and is much less transmissible than
HIV-1.
(2) Simian immunodeficiency virus (SIV) was isolated
from monkeys with an AIDS-like illness. Antibodies in
some African women cross-react with SIV. The proteins of
SIV resemble those of HIV-2 more closely than they resem-
ble those of the original HIV isolates.
Summary of Replicative Cycle
In general, the replication of HIV follows the typical retro-
viral cycle (Figure 45–4). The initial step in the entry of
HIV into the cell is the binding of the virion gp120 enve-
lope protein to the CD4 protein on the cell surface. The
virion gp120 protein then interacts with a second protein
on the cell surface, one of the chemokine receptors. Next,
the virion gp41 protein mediates fusion of the viral enve-
lope with the cell membrane, and the virion core contain-
ing the nucleocapsid, RNA genome, and reverse
transcriptase enters the cytoplasm.
Chemokine receptors, such as CXCR4 and CCR5 pro-
teins, are required for the entry of HIV into CD4-positive
cells. The T cell–tropic strains of HIV bind to CXCR4,
 CHAPTER 45 Human Immunodeficiency Virus 381

Inhibited by entry inhibitors

(enfuvirtide, maraviroc)

<JUMRNA -
A 1 structural proje I
Virion
.

Polyproteins
~'Bes
-

· = -) proteases
②
-

I
CD4
CCR5
Nucleus
d Ritonavir AtaZanavir s indinavirssPl7 Pz4 idee
,
I'

is
J
/I d
or CXCR4
solid
wine
Polyprotein
~

197 non-functional i t 's

22,
·

38
-

Q
18 -

>
-
RNA
5
MRNA trans
ston
.

cril
RNA
3
si

1656
-

S 4; 9
Provirus↳ 1

-3
--
RNA
· d-
release
DNA ackayirg
-

Es arim
P S&
RASB.
en
Protein &
,
17
-I /

& -

E
MRNA -

Integration Transcription

RNA genomes
Reverse
transcription

mRNAs Precursor Cleavage

id to
polyproteins by

p s in
Inhibited by

Tr
ns protease

ly
DNA copy b

a
reverse transcriptase la t em a
inhibitors (zidovudine of genome io n A s s leoc
and others) nuc
Inhibited
by protease
Inhibited by integrase inhibitors
inhibitors (raltegravir) (indinavir
and others)

FIGURE 45–4 Replicative cycle of human immunodeficiency virus (HIV). Showing the sites of action of the important drugs
used to treat HIV infection. The mode of action of the reverse transcriptase inhibitors, the entry inhibitors, the integrase inhibitor, and
the protease inhibitors is described in Chapter 35. On the right side of the figure, “cleavage by protease” describes the process by
which the virus-encoded protease cleaves the Gag-Pol polyprotein into functional viral proteins as the virion buds from the cell mem-
brane. These newly formed functional proteins are transported by the mature virion to the next cell and function within that newly
infected cell. The viral reverse transcriptase and integrase are two such proteins. (Reproduced with permission from Ryan K et al.
Sherris Medical Microbiology. 3rd ed. Originally published by Appleton & Lange. Copyright 1994 McGraw-Hill.)

whereas the macrophage-tropic strains bind to CCR5.
Mutations in the gene encoding CCR5 endow the individ-
ual with protection from infection with HIV. People who
are homozygotes are completely resistant to infection, and
heterozygotes progress to disease more slowly. Approxi-
mately 1% of people of Western European ancestry have
homozygous mutations in this gene, and about 10% to 15%
are heterozygotes. One of the best-characterized mutations
is the delta-32 mutation, in which 32 base pairs are deleted
from the CCR5 gene.
In the cytoplasm, reverse transcriptase transcribes the
genome RNA into double-stranded DNA, which migrates
to the nucleus, where it integrates into the host cell DNA.
The viral DNA can integrate at different sites in the host
cell DNA, and multiple copies of viral DNA can integrate.
Integration is mediated by a virus-encoded endonuclease
(integrase). Viral mRNA is transcribed from the integrated
(proviral) DNA by host cell RNA polymerase (augmented
by virus-encoded Tat protein) and translated into several
large polyproteins. The Gag and Pol polyproteins are
cleaved by the viral protease, whereas the Env polyprotein
proteins. The Pol polyprotein is cleaved to form the reverse
transcriptase, integrase, and protease. The immature virion
containing the precursor polyproteins forms in the cyto-
plasm, and cleavage by the viral protease occurs as the
immature virion buds from the cell membrane. It is this
cleavage process that results in the mature, infectious
virion.
Note that HIV replication is dependent on cell proteins
as well as viral proteins. First there are the cell proteins
required during the early events, namely CD4, and the che-
mokine receptors, CCR5 and CXCR4. Cell proteins, such as
actin and tubulin, are involved with the movement of viral
DNA into the nucleus. The cell protein cyclin T1 and the
viral protein Tat are part of the complex that transcribes
viral mRNA. Cell proteins are also involved in the budding
process by which the virus exits the cell.
Transmission & Epidemiology D
Transmission of HIV occurs primarily by sexual contact 81s
ostdis
② ③ &
-

and by transfer of infected blood. Perinatal transmission ↳

- &
drdis
-

is cleaved by a cellular protease. from infected mother to neonate also occurs, either across
The Gag polyprotein is cleaved to form the main core the placenta, at birth, or via breast milk. It is estimated that
protein (p24), the matrix protein (p17), and several smaller more than 50% of neonatal infections occur at the time of
 382 PART IV Clinical Virology
3 %
Boy -is riskoy
Haw transm [0 , ge
on
.

,
-

delivery and that the remainder is split roughly equally HIV-infected blood is estimated to be about 0.3%. The -

between transplacental transmission and transmission via transmission of HIV from health care personnel to patients
-

breast feeding. There is no evidence for airborne, water- is exceedingly rare.

borne, or insect transmission of HIV.
Infection occurs by the transfer of either HIV-infected
cells or free HIV (i.e., HIV that is not cell-associated).
Pathogenesis -
& Immunity
Although small amounts of virus have been found in other HIV infects helper
--
T cells (CD4-positive cells) and kills
them, resulting in suppression of cell-mediated immu-
=>

fluids (e.g., saliva and tears), there is no evidence that they

play a role in infection. In general, transmission of HIV nity. This predisposes the host to various opportunistic
follows the pattern of hepatitis B virus (HBV), except that infections and certain cancers such as Kaposi’s sarcoma and
HIV infection is much less efficiently transferred (i.e., the lymphoma. HIV does not directly cause these tumors
dose of HIV required to cause infection is much higher because HIV genes are not found in these cancer cells. The
than that of HBV). People with sexually transmitted dis- initial infection of the genital tract occurs in dendritic cells
that line the mucosa (Langerhans’ cells), after which the
eases, especially those with ulcerative lesions such as syphi-
local CD4-positive helper T cells become infected. HIV is
lis, chancroid, and herpes genitalis, have a significantly
first found in the blood 4 to 11 days after infection.
higher risk of acquiring HIV. Uncircumcised males have a
HIV infection also targets a subset of CD4-positive cells
higher risk of acquiring HIV than do circumcised males. ⑭Ginfect ji) (i) 6I 28 ee

called Th17 cells. These cells are an important mediator of

.
,

Transmission of HIV via blood transfusion has been -

mucosal immunity, especially in the gastrointestinal tract.

greatly reduced by screening donated blood for the pres-
-2 /(Window period
Screen JABs (3-4Ws)) > a c te phase- Many mucosal Th17 cells are killed early in HIV infection.
" 221-3-4 weeks
vims & < Js AB 55 8
&

ence of antibody to HIV. However, there is a “window”

,

JERNA
virus 11 E

Th17 cells produce interleukin-17 (IL-17), which attracts

I

period early in infection when the blood of an infected

person can contain HIV but antibodies are not detectable.
Blood banks now test for the presence of p24 antigen in an
effort to detect blood that contains HIV.
The Centers for Disease Control and Prevention (CDC)
estimates that at the end of 2011, there were approximately
neutrophils to the site of bacterial infection. The loss of
Th17 cells predisposes HIV-infected individuals to blood-
stream infections by bacteria in the normal flora of the
colon, such as Escherichia coli.
HIV also infects brain monocytes and macrophages, AIDS & HIV 2
producing multinucleated giant cells and significant central &disc8
&
I
·

+
=

1.1 million people infected with HIV living in the United

States. The transmission rate has declined markedly, pri-
marily due to increased prevention efforts and improved
"signsise
nervous system symptoms. The fusion of HIV-infected
cells in the brain and elsewhere mediated by gp41 is one of
the main pathologic findings. The cells recruited into the
·

treatments for HIV; the latter reduces the number of people
with high titers of HIV. CDC estimates that approximately
50,000 people new infections occur each year. CDC also
estimates that 15% of those who are infected with HIV do
not know it because they have not been tested.
Approximately 630,000 people have died of AIDS in the
United States since 1981, when AIDS wasCHI first recognized.
&'s
As of 2011, it is estimated that approximately 34 million
syncytia ultimately die. The death of HIV-infected cells is
also the result of immunologic attack by cytotoxic CD8
lymphocytes. Effectiveness of the cytotoxic T cells may be
limited by the ability of the viral Tat and Nef proteins to
reduce class I MHC protein synthesis (see later).
Another mechanism hypothesized to explain the death
of helper T cells is that HIV acts as a “superantigen,” which
E
·
.

indiscriminately activates many helper T cells and leads to

Lfemale
people worldwide
**
are infected,
emale) heterosexal transm
.
two-thirds
-6
&
of whom live in their demise. The finding that one member of the retrovi-
. sub-Saharan Africa. Three regions, Africa, Asia, and Latin
.

rus family, mouse mammary tumor virus, can act as a

&

homosex-america
I
-

America, have the highest rates of new infections. AIDS is
the fourth leading cause of death worldwide. (Ischemic
heart disease, cerebrovascular disease, and acute lower
respiratory disease are ranked first, second, and third,
respectively.) [* *). -125
superantigen lends support to this theory. Superantigens
are described in Chapter 58.
Persistent noncytopathic infection of T lymphocytes
also occurs. Persistently infected cells continue to produce
HIV, which may help sustain the infection in vivo. Lym-
-
How

In the United States and Europe during the 1980s, HIV phoid tissue (e.g., lymph nodes) is the main site of ongoing
. HIV/
infection and AIDS occurred primarily in men who have HIV infection. · 3d
2 /

sex with men (especially those with multiple partners),
intravenous drug users, and hemophiliacs. Heterosexual
transmission was rare in these regions in the 1980s but is
now rising significantly. Heterosexual transmission is the
predominant mode of infection in African countries.
Very few health care personnel have been infected
despite continuing exposure and needle-stick injuries, sup-
porting the view that the infectious dose of HIV is high.
&
In addition, a true latent infection can occur in which
no HIV is produced. This occurs in resting CD4-positive
memory T cells within which an integrated HIV genome is
found. The latent period can last for months to years but if
the resting cell is activated, HIV can be produced. HIV
replication depends on host cell transcription factors made
in activated, but not resting, CD4-positive cells.
A person infected with HIV is considered to be
iBs discare
infected for life. This seems likely to be the result of
genome

The risk of being infected after percutaneous exposure to

e

lymphadenopathy ,
sure throat rash -1
& : acuse HEV syndrome I
&i
mononucleosis sid
· 843 -syn .
) <B ,
-

(generalized lymphadenop .
.
W s WI latentge
&52-JOglaale HIV6Ims's =

candida)N ) opport infections *-sigad

1

thrush
-(500"
is · -
[ 3 -&
-

o
Cut 5
-

,
malignancies -F 7 9
-

s .
.
 CHAPTER 45 Human Immunodeficiency Virus 383

integration of viral DNA into the DNA of infected cells. Antibodies against various HIV proteins, such as p24,
Although the use of powerful antiviral drugs (see “Treat- gp120, and gp41, are produced, but they neutralize the
ment” section later) can significantly reduce the amount virus poorly in vivo and appear to have little effect on the
of HIV being produced, the silent, latent infection in course of the disease.
CD4-positive memory T cells can be activated and serve HIV has three main mechanisms by which it evades the
-530s 5 -
as a continuing
out,-[die 2 -
source of virus. -
immune system: (1) integration of viral DNA into host cell
Elite controllers
-
are a rare group of HIV-infected peo- DNA, resulting in a persistent infection; (2) a high rate of s :
Her
.

...
. - ⑫

rigSan
i
↳
Je ·
-

4 - non-eff
gphoAB gpI0
= ~ RNA

ple (less than 1% of those infected) who have no detectable mutation of the env gene; and (3) the production of the Tat
~ . ;

&
32
-

MHC 2
-

HIV in their blood. Their CD4 counts are normal without and Nef proteins that downregulate class I MHC proteins
-

-
molecules
.

-
homog Hetero
erous .

using antiretroviral drugs. The ability to be an elite control- required for cytotoxic T cells to recognize and kill HIV-
musation musacion
a E
- N --

normet , ler does not depend on gender, race, or mode of acquisition

s s

infected cells. The ability of HIV to infect and kill CD4-

.

j of the virus. Although the mechanism is unclear, there is

=
positive helper T cells further enhances its capacity to avoid
evidence that certain HLA alleles are protective and that an destruction by the immune system.
inhibitor of the cyclin-dependent kinase known as p21 synd ! 96
- acute retrovirus . HIV a

plays an important role.

- 188- HIV

Clinical Findings
or acute syn

In addition, there is a group of HIV-infected individuals

The clinical picture of HIV infection can be divided into
who have lived for many years without opportunistic infec-
three stages: an early, acute stage; a middle, latent stage; and
tions and without a reduction in the number of their helper
a late, immunodeficiency stage (Figure 45–5). In the acute
T (CD4) cells. The strain of HIV isolated from these indi-
stage, which usually begins 2 to 4 weeks after infection, a
viduals has mutations in the nef gene, indicating the impor-
mononucleosis-like picture of fever, lethargy, sore throat, iBWIsl HIV

tance of this gene in pathogenesis. The Nef protein

and generalized lymphadenopathy occurs. A maculopapu- regularHS .
>
-

decreases class I major histocompatibility complex (MHC)

lar rash on the trunk, arms, and legs (but sparing the palms HEVPCR
·

protein synthesis, and the inability of the mutant virus to

and soles) is also seen. Leukopenia occurs, but the number ve -
-
-

produce functional Nef protein allows the cytotoxic T cells

to retain their activity.
Another explanation why some HIV-infected individu-
als are long-term “nonprogressors” may lie in their ability
to produce large amounts of α-defensins. α-Defensins are a
family of positively charged peptides with antibacterial
activity that also have antiviral activity. They interfere with
HIV binding to the CXCR4 receptor and block entry of the
of CD4 cells is usually normal. A high-level viremia typi-
cally occurs, and the infection is readily transmissible dur-
ing this acute stage. This acute stage typically resolves
spontaneously in about 2 weeks. Resolution of the acute
·
<200 -
> -

= spozd
Pneumoniaa (Pap)Pneumocystis
ACUTE LATENT IMMUNODEFICIENCY Lung al infect

virus into the cell.

Post see
dry cough-low

In addition to the detrimental effects on T cells, abnor- ⑦

creti > lasmosisa
med
-
toxop
protozoa
-

E
S

multiple
brain 9--

malities of B cells occur. Polyclonal activation of B cells is

-

lesis
1

I 20
3O -
>

Acute symptoms Opportunistic infections -"

P

seen, with resultant high immunoglobulin levels. Autoim-

.
Relative levels

My
cobac

d
Primus
-CD4 and malignancies atypical ↓
count - load
myCobal .

mune diseases, such as thrombocytopenia, occur. O CD4 lymphocytes

!
⑮ ↳ 4
/150 -

plasmosisa
Histo

The main immune response to HIV infection consists

800

= si
normal Q ↳ count -P
E

window gerod" AB s isen Anti-p24 antibodies

i
e
[1 5) Stationary <lents . <DU" ,o

of cytotoxic CD8-positive lymphocytes. These cells

21 e
d
diag
e
acute HEV HIV 2
-
.

respond to the initial infection and control it for many Anti-gp120 antibodies
years. Mutants of HIV, especially in the env gene encoding -ABI / d & Desper & Is s
CBU
⑥ &*
Count

gp120, arise, but new clones of cytotoxic T cells proliferateser

-

Virus, viral RNA, p24 antigen >

-

-5' -
>
- -9 200

↳ AB
-
M

supp
- -

> Bw;
and control the mutant strain. It is the ultimate failure of
.

Samay vis in co2" is T

Cell-med
.
Immuni
·
S

these cytotoxic T cells that results in the clinical picture of
AIDS. Cytotoxic T cells lose their effectiveness because so
many CD4 helper T cells have died; thus the supply of lym-
phokines, such as interleukin-2 (IL-2), required to activate
the cytotoxic T cells is no longer sufficient.
There is evidence that “escape” mutants of HIV are able
to proliferate unchecked because the patient has no clone of
cytotoxic T cells capable of responding to the mutant
strain. Furthermore, mutations in any of the genes encod-
ing class I MHC proteins result in a more rapid progression
to clinical AIDS. The mutant class I MHC proteins cannot
present HIV epitopes, which results in cytotoxic T cells
being incapable of recognizing and destroying HIV-
infected cells.
therapy -valgiss-200-i CD4 (200 HIV !
0 1 2 3 4 5 6 3 – ≥ 10
Time after infection (mo) Time after infection (y)
FIGURE 45–5 Time course of human immunodeficiency
virus (HIV) infection. The three main stages of HIV infection—
acute, latent, and immunodeficiency—are shown in conjunction
with several important laboratory findings. Note that the levels of
virus and viral RNA (viral load) are high early in the infection,
become low for several years, and then rise during the immuno-
deficiency stage. The level of CD4 lymphocytes remains more or
less normal for many years but then falls. This results in the immu-
nodeficiency stage, which is characterized by opportunistic infec-
tions and malignancies. Not shown in the figure is the marked
loss of the Th-17 subset of CD4-positive T cells early in the infec-
tion. (Adapted from Weiss RA. How does HIV cause AIDS? Science.
1993;260:1273.) ·
②

/
antiretroviral I
opp inf &,
- * S. HIV
.
-

Lymphoma& cancers d
-
~

inf ****
sulfamethoxazole-PP : -1200s & sopp
-

Trimethoprin .
.
·
1
-
-

eid- 12389 - d d
d
·

toxoplastAntibioticbutittreadsSangali
-
Papasi sarcoma
-

50 . Prophylaxis
05-6primary
Ed
. .
-
i

trimento o-Cut
n e
for un citomy
C E
 CD4
+
%.
1 16 if Eraconazole Du* 150
- 18, 1 ***25 11 -

384 PART IV Clinical Virology

stage is usually accompanied by a lower level of viremia and clinical latency, the virus itself does not enter a latent
a rise in the number of CD8-positive (cytotoxic) T cells state.
-
Serum s AB Seroconversion

directed against HIV. A syndrome called AIDS-related complex (ARC) can

the
& &

&
2-3 weeks
Antibodies to HIV typically appear 10 to 14 days after
infection, and most patients will have seroconverted by 3 to
4 weeks after infection. Note that the inability to detect
AB
antibodies prior to that time can result in “false-negative”
occur during the latent period. The most frequent manifes-
tations are persistent fevers, fatigue, weight loss, and
lymphadenopathy. ARC often progresses to AIDS.
: 2
The late stage of HIV infection is AIDS, manifested by a
-
- 8

serologic tests (i.e., the person is infected, but antibodies
are not detectable at the time of the test). This has impor-
tant implications because HIV can be transmitted to others
during this period. If the antibody test is negative but HIV
infection is still suspected, then a polymerase chain reac-
tion (PCR)–based assay for viral RNA in the plasma should
be done.
Of those who become seropositive during the acute
infection, approximately 87% are symptomatic (i.e., about
13% experience an asymptomatic initial infection).
After the initial viremia, a viral set point occurs, which
can differ from one person to another. The set point repre- infections and progressive multifocal leukoencephalopa-
decline in the number of CD4 cells to below 200/μL and an
increase in the frequency and severity of opportunistic
infections. Table 45–2 describes some of the common
opportunistic infections and their causative organisms seen
in HIV-infected patients during the late, immunocompro-
mised stage of the infection.
The two most characteristic manifestations of AIDS are
Pneumocystis pneumonia and Kaposi’s sarcoma. However,
many other opportunistic infections occur with some fre-
quency. These include viral infections such as dissemi-
nated herpes simplex, herpes zoster, and cytomegalovirus

Bang
s dont i , 0 9
- E Contol so
Tim T But is e

sents the amount of virus produced (i.e., the viral load) and thy; fungal infections such as thrush (caused by Candida
. -

tends to remain “set,” or constant, for years. The higher the albicans), cryptococcal meningitis, and disseminated his-
set point at the end of the initial infection, the more likely toplasmosis; protozoal infections such as toxoplasmosis
"Pimutations **d
the individual is to progress to symptomatic AIDS. It is and cryptosporidiosis; and disseminated bacterial infec-
-
estimated that an infected person can produce up to 10 bil- tions such as those caused by Mycobacterium avium-
-

- resistant -
·
antiviral
drugs
lion new virions each day. This viral load can be estimated intracellulare and Mycobacterium tuberculosis. Many AIDS
·

by using an assay for viral RNA in the patient’s plasma. patients have severe neurologic problems (e.g., dementia
(The assay detects the RNA in free virions in the plasma, and neuropathy), which can be caused by either HIV
not cell-associated virions.) infection of the brain or by many of these opportunistic
The amount of viral RNA serves to guide treatment organisms. Hive -
annPay ABI
99. for
85/ELISA
the

for

decisions and the prognosis. For example, if a drug regimen Classic s DELISAG
-

the

I e Westren blot
② Westren blot
fails to reduce the viral load, the drugs should be changed. >
-
me
1

Laboratory Diagnosis
·
- -

As far as the prognosis is concerned, a patient with more (2 the bands&

·

than 10,000 copies of viral RNA/mL of plasma is signifi- The presumptive diagnosis of HIV infection is often made
·

cantly more likely to progress to AIDS than a patient with
fewer than 10,000 copies.
The number of CD4-positive T cells is another impor-
tant measure that guides the management of infected
patients. It is used to determine whether a patient needs
chemoprophylaxis against opportunistic organisms, to
determine whether a patient needs anti-HIV therapy, and
to determine the response to this therapy. The lower limit
of CD4 count considered as normal is 500 cells/μL. People
with this level or higher are usually asymptomatic. The
frequency and severity of opportunistic infections signifi-
cantly increase when the CD4 counts fall below 200/μL. A
CD4 count of 200/μL or below is an AIDS-defining
condition.
In the middle stage of HIV infection, a long latent
by the detection of antibodies in the patient’s serum to the
p24 protein of HIV using the enzyme-linked immunosor-
bent assay (ELISA) test. Because there are some false-
positive results with this test, the definitive diagnosis is
made by Western blot (also known as Immunoblot)
analysis, in which the viral proteins are displayed by acryl-
amide gel electrophoresis, transferred to nitrocellulose
paper (the blot), and reacted with the patient’s serum. If
antibodies are present in the patient’s serum, they will bind
to the viral proteins (predominantly to the gp41 or p24
protein). Enzymatically labeled antibody to human IgG is
then added. A color reaction reveals the presence of the
HIV antibody in the infected patient’s serum. Figure 64–9
depicts a Western blot (Immunoblot) test used to diagnose
HIV
"
infection. is

period, measured in years, usually ensues. In untreated OraQuick is a rapid, screening immunoassay for HIV
-

patients, the latent period typically lasts for 7 to 11 years. antibody that uses an oral swab sample in an ELISA-type
The patient is asymptomatic during this period. test that can be done at home. Results are available in
Although the patient is asymptomatic and viremia is low 20 minutes. Positive results for HIV antibody require con-
or absent, a large amount of HIV is being produced by firmation by a Western blot test. Slid '

lymph node cells but remains sequestered within the synd The PCR test is a very sensitive and specific technique
U e
aute syn
.

Jens
-

lymph nodes. This indicates that during this period of that can be used
d to detect HIV DNA within infected cells.
HIV. Wo'eds & dbi &s

Abso & by 51 si
-

plas '30s I'vls -

· is - ABS (false the) -as

 CHAPTER 45 Human Immunodeficiency Virus 385

4 = 25
we
· =

TABLE 45–2 Common Opportunistic Infections in AIDS Patients

Site of Infection Disease or Symptom Causative Organism

Lung 1. Pneumonia Pneumocystis jiroveci, cytomegalovirus

2. Tuberculosis Mycobacterium tuberculosis
Mouth 1. Thrush-Y Candida albicans
=>

2. Hairy leukoplakia Epstein–Barr virus

3. Ulcers Herpes simplex virus-1, Histoplasma capsulatum
> Oderophagia
Esophagus 1. Thrush C. albicans
2. Esophagitis Cytomegalovirus, herpes simplex virus-1
Intestinal tract Diarrhea - Salmonella species, Shigella species, cytomegalovirus,
Cryptosporidium parvum, Giardia lamblia
-

Central nervous system 1. Meningitis Cryptococcus neoformans

2. Brain abscess Toxoplasma gondii
3. Progressive multifocal leukoencephalopathy JC virus
Eye Retinitis R Cytomegalovirus
Skin 1. Kaposi’s sarcoma Human herpesvirus 8
2. Zoster Varicella-zoster virus
3. Subcutaneous nodules C. neoformans
Reticuloendothelial system Lymphadenopathy or splenomegaly Mycobacterium avium complex, Epstein–Barr virus

issee
Oboe
s
lifecycle *
-

&

-
>
- of HEU >
-
of NRIs
&

Treatment
.

Some individuals who do not have detectable antibodies

2
↳
+

have been shown by this test to be infected. As already UNRTIS-

"Protease , integrase inhi sd -
Slad
The treatment of HIV infection has resulted in a remark-
>8

nevirapine

mentioned, the amount of viral RNA in the plasma (i.e., D

Efavirens
able reduction in mortality and improvement in the quality
or
NNRTIs

the viral load) can also be determined using PCR-based of life of infected individuals. The two specific goals of Zid&
# 9384 20 - ,

s
-
sen

assays. treatment are (1) to restore immunologic function by - a 946 -

2 -

During the first month after infection, antibody tests

.

15
↳
1: 1-

increasing the CD4 count, which reduces opportunistic se

may be negative. These false-negative tests are due to insuf-

count

infections and certain malignancies, and (2) to reduce viral i

annes
·
ficient antibody being made early in infection to be detected load, which reduces the chance of transmission to others. 2
-

-10s5 * * &

i
-

There is evidence that starting drug therapy as soon as pos- jer

S

in the ELISA test. The average time for seroconversion is -

-

10 to 14 days, and most of those infected, but not all, will
have seroconverted by 4 weeks.
In view of this, the diagnosis of acute HIV infection may
not be able to be made using only tests for antibody in the
serum. The presence of HIV can be detected during acute
infection by the plasma HIV RNA assay (viral load), as
viremia is typically high at this early stage. Also useful for
the diagnosis of early infections is the HIV antigen/
antibody “Combo” test that detects the presence of p24
antigen as well as antibodies to both HIV-1 and HIV-2.
This combination test is useful for the diagnosis of early
infections because p24 antigen is typically detectable earlier
in infection than antibody.
Other laboratory tests that are important in the manage-
ment of an HIV-infected person include CD4 cell counts,
viral load assays, and tests for drug resistance of the strain
of HIV infecting the patient. Drug resistance tests are
described at the end of the “Treatment” section in this
chapter. HIV can be grown in culture from clinical speci-
mens, but this procedure is available only at a few medical
centers.
sible after making the diagnosis of HIV infection is the best
way to achieve these goals.
Unfortunately, no drug regimen results in a “cure” (i.e.,
eradicates the virus from the body), but long-term suppres-
sion can be achieved. However, if drugs are stopped, the
virus resumes active replication, and large amounts of
infectious virus reappear.
Treatment of HIV infection typically involves multiple
antiretroviral drugs. The use of a single drug (monother-
apy) for treatment is not done because of the high rate of
mutation to drug resistance.
The choice of drugs is complex and depends on several
factors (e.g., whether it is an initial infection or an estab-
lished infection, the number of CD4 cells, the viral load, the
resistance pattern of the virus, and whether the patient is
pregnant or is coinfected with HBV or hepatitis C virus
[HCV]). Table 45–3 describes the mechanism of action of
the drugs and their main adverse effects. The number of
drugs and the various determining factors mentioned pre-
viously make describing all the treatments beyond the
scope of this book. The reader is advised to consult the
, - He ?-Mid-ijh
th yelid
HBV- HIE

&. Other inf SI2 i ~

HAV OSHAURHB,V&
. - & So &
I

HEU Z
. ed
&

Immune reconstitution inflammatory syndrome (IRIS) 04

 386 PART IV Clinical Virology

TABLE 45–3 Drugs Used for the Treatment of HIV Infection

Class of Drug Name of Drug Main Adverse Effect (AE) or Comment

Reverse transcriptase inhibitors

s
Nucleosides (NRTI) Abacavir (ABC) (Ziagen) AE: severe multiorgan hypersensitivity reaction, especially in patients
El
with HLA-B5701 abacanir
the
>
-
d
I

-
&
Didanosine (ddI) (Videx) -
- > AE: pancreatitis and peripheral neuropathy
-

Emtricitabine (FTC) (Emtriva) A derivative of lamivudine; well-tolerated

= >

Lamivudine (3TC) (Epivir) Well tolerated. Also used to treat hepatitis B virus infection
Stavudine (d4T) (Zerit) AE: peripheral neuropathy, lipoatrophy, lactic acidosis with hepatic
steatosis, pancreatitis
Zidovudine (AZT, ZDV) (Retrovir) AE: bone marrow suppression (anemia, neutropenia)
Nucleotides Tenofovir (Viread) AE: well-tolerated but renal toxicity occurs
Nonnucleosides (NNRTI) Delavirdine (Rescriptor) AE: rash; avoid in pregnancy; rarely used
phsycosis
Efavirenz (Sustiva)-
> AE: CNS changes and rash; possibly teratogenic so avoid in pregnancy
- - - -

Rilpivirine (Endurant) AE: rash

Etravirine (Intelence)
Nevirapine (Viramune)
Protease inhibitors1 Amprenavir (Agenerase)
d
lipadystrophy -
AE: Stevens-Johnson syndrome; hepatotoxicity
AE: depression, insomnia
AE: rash, hemolytic anemia

Atazanavir (Reyataz) AE: hyperbilirubinemia, prolonged PR interval

j d Darunavir (Prezista) AE: hepatotoxicity
-

S961 -

I W1
=

Fosamprenavir (Lexiva) A prodrug of amprenavir; metabolized by phosphatases in gut

·

epithelium to amprenavir. AE: rash

Indinavir (Crixivan)
Lopinavir/ritonavir (Kaletra)
Nelfinavir (Viracept)
Ritonavir (Norvir)
Saquinavir (Invirase and Fortovase)
Tipranavir (Aptivus)
Entry inhibitors
Fusion inhibitor Enfuvirtide (Fuzeon)
Coreceptor antagonist Maraviroc (Selzentry)
Integrase inhibitor Raltegravir (Isentress)
Elvitegravir (Stribild)
Dolutegravir (Tivicay)
AE: crystalluria and nephrolithiasis due to poor solubility. Infrequently
used
Ritonavir inhibits CYP3A metabolism of lopinavir, thereby increasing
the effective concentration of lopinavir
May contain levels of ethyl methanesulfonate (ethyl mesylate) that
may be carcinogenic, mutagenic, or teratogenic. AE; diarrhea. No
longer recommended
See lopinavir/ritonavir, saquinavir, and tipranavir
Invirase must be taken with ritonavir; Fortovase can be taken without
ritonavir. Infrequently used
AE: if taken with ritonavir (Norvir), severe liver disease may occur
Binds to viral gp41 and blocks fusion of virus with cell membrane
AE: injection site reactions
Blocks binding of viral gp120 to CCR5 coreceptor on cell membrane;
effective against CCR5-tropic viruses but not against CXCR4-tropic
viruses
AE: hepatotoxicity, especially in those infected with HBV and HCV
Inhibits integration of proviral DNA into cellular DNA
AE: nausea, diarrhea, rash
Available in combination with cobicistat, tenofovir, and emtricitabine
AE: diarrhea
AE: insomnia, headache

CNS = central nervous system.

1
All protease inhibitors cause lipodystrophy (“buffalo hump”) and central obesity as an adverse effect. Nausea and diarrhea are also
quite common. Hepatotoxicity occurs, especially in those infected with hepatitis B or C virus.

Department of Health and Human Services Antiretroviral
Therapy Guidelines or other reliable sources, such as the
Medical Letter.
As of 2015, the preferred approach to initial antiretrovi-
ral therapy consists of one of four regimens, all of which
consist of three or four drugs. Each regimen includes
emtricitabine and tenofovir (“the backbone”), to which
either efavirenz, raltegravir, rilpivirine, or a combination of
two protease inhibitors (either ritonavir plus atazanavir or
ritonavir plus darunavir) or a combination of elvitegravir
plus the enhancer cobicistat is added. A single pill given in
once-a-day dosing improves compliance so a variety of
these three or four drug combinations are now available in
a single pill formulation.
These combinations are known as highly active antiret-
roviral therapy (HAART). HAART is very effective in

prolonging life, improving quality of life, and reducing viral
load but does not cure the chronic HIV infection (i.e., rep-
lication of HIV within CD4-positive cells continues indefi-
nitely). Discontinuation of HAART almost always results in
viremia (a return of the viral load to its pretreatment set
point) and a fall in the CD4 count.
Nucleoside/Nucleotide Reverse Transcriptase
Inhibitors (NRTIs)
Table 45–3 describes six nucleoside reverse transcriptase
inhibitors (abacavir, didanosine, emtricitabine, lamivudine,
stavudine, and zidovudine) and a single nucleotide reverse
transcriptase inhibitor (tenofovir). These drugs are charac-
terized by not having a 3′ hydroxyl group on the ribose ring
and therefore are chain-terminating drugs. They inhibit
HIV replication by interfering with proviral DNA synthesis
by reverse transcriptase. They cannot cure an infected cell
of an already integrated copy of proviral DNA. Additional
information on these “nucleoside analogue” drugs and the
other antiretroviral drugs can be found in Chapter 35. Note
that zalcitabine (Hivid), an NRTI analogue of cytosine, is
no longer available.
Two main problems limit the use of NTRIs: the emer-
gence of resistance and adverse effects. The main adverse
effects are described in Table 45–3. For example, the long-
term use of zidovudine (ZDV) is limited by suppression of
the bone marrow leading to anemia and neutropenia. This
hematotoxicity is due to the inhibition of the mitochondrial
DNA polymerase. Nevertheless, ZDV is used in postexpo-
sure prophylaxis and to prevent vertical transmission from
mother to fetus. Lamivudine and its analogue emtricitabine
have the same mechanism of action as ZDV but are better
tolerated, and one or another is a common component of
HAART. Abacavir is also commonly used. Patients who
have an HLA-B1701 allele are more likely to have a severe
hypersensitivity reaction to abacavir. Patients should be
tested for this gene before being prescribed abacavir.
Nonnucleoside Reverse Transcriptase Inhibitors
Table 45–3 describes five nonnucleoside reverse transcrip-
tase inhibitors (delavirdine, efavirenz, etravirine, nevirap-
ine, and rilpivirine) that are effective against HIV. Unlike
the NRTIs, these drugs are not base analogues. Efavirenz
(Sustiva) and nevirapine (Viramune) are the most com-
monly used drugs in this class. Efavirenz is a common
component of HAART regimens, especially a single pill
containing efavirenz, tenofovir, and emtricitabine (Atri-
pla). Nevirapine is often used to prevent vertical transmis-
sion of HIV from mother to fetus. Both nevirapine and
efavirenz can cause skin rashes and Stevens-Johnson
syndrome.
Protease Inhibitors
Table 45–3 describes the currently available protease inhib-
itors (amprenavir atazanavir, darunavir, fosamprenavir,
CHAPTER 45 Human Immunodeficiency Virus 387
indinavir, nelfinavir, ritonavir, saquinavir, tipranavir, and a
combination of lopinavir and ritonavir). Protease inhibitors
when combined with nucleoside analogues are very effec-
tive in inhibiting viral replication and increasing CD4 cell
counts and are commonly used in HAART regimens. Lopi-
navir and ritonavir are given in combination because rito-
navir inhibits the degradation of lopinavir thereby
increasing the concentration of lopinavir. A briefer way of
saying that is ritonavir “boosts” lopinavir.
Mutants of HIV resistant to protease inhibitors can be a
significant clinical problem. Resistance to one protease
inhibitor often conveys resistance to all; however, the com-
bination of two protease inhibitors, namely, ritonavir and
lopinavir (Kaletra), is effective against both mutant and
nonmutant strains of HIV. Also, darunavir is effective
against many strains of HIV that are resistant to other pro-
tease inhibitors. Mutants of HIV resistant to both protease
inhibitors and reverse transcriptase inhibitors have been
recovered from patients.
A major side effect of protease inhibitors is abnormal
fat deposition in specific areas of the body, such as the
back of the neck (Figure 45–6). The fat deposits in the
back of the neck are said to give the person a “buffalo >
- Lipo kystrophy
hump” appearance. These abnormal fat deposits are a
type of lipodystrophy; the metabolic process by which
this occurs is unknown. Saquinavir and indinavir are
infrequently used because of toxicity and nelfinavir is no
longer recommended.
Treatment for acute HIV infection with two reverse
transcriptase inhibitors and a protease inhibitor is often
used. With this regimen, the viral load drops below the
level of detection, CD4 cell counts rise, and CD8 activity
FIGURE 45–6 Lipodystrophy—note enlarged fat pad on back
of neck. This is known as a “buffalo hump” and is an adverse effect of
the protease inhibitor class of antiretroviral drugs. (Reproduced with
permission from Wolff K, Johnson R. Fitzpatrick’s Color Atlas & Synopsis
of Clinical Dermatology. 6th ed. New York: McGraw-Hill, 2009. Copy-
right © 2009 by The McGraw-Hill Companies, Inc.)
388 PART IV Clinical Virology
increases. The long-term effect of this approach on rate of
progression to AIDS has yet to be determined.
Pregnant women infected with HIV should be treated
with two nucleosides and a protease inhibitor. A typical
regimen would include lamivudine, ZDV, and lopinavir/
ritonavir. In addition, ZDV should be given to the neonate.
These drugs appear not to damage the fetus, although rare
instances of mitochondrial dysfunction and death attrib-
uted to ZDV have been reported. The reader is urged to
consult the current information regarding the use of these
drugs in pregnancy. A full discussion is beyond the scope
of this book.
Entry Inhibitors
Table 45–3 describes two entry inhibitors, enfuvirtide and
maraviroc. Enfuvirtide (Fuzeon) is the first of a new class
of anti-HIV drugs known as fusion inhibitors (i.e., they
prevent the fusion of the viral envelope with the cell mem-
brane). Enfuvirtide is a synthetic peptide that binds to gp41
on the viral envelope, thereby blocking the entry of HIV
into the cell. It must be administered by injection and is
quite expensive.
Maraviroc (Selzentry) also prevents the entry of HIV
into cells. It blocks the binding of the gp120 envelope
protein of HIV to CCR-5, which is an important corecep-
tor on the cell surface. Before prescribing maraviroc, a
laboratory test (Trofile assay) should be performed to
ensure that the tropism of the patient’s strain of HIV is
CCR5. Maraviroc should be used in combination with
other antiretroviral drugs in patients infected with CCR5-
tropic strains of HIV and in treatment-experienced adults
infected with an HIV strain that is resistant to other anti-
retroviral drugs.
Integrase Inhibitors
Raltegravir (Isentress) is the first drug to inhibit the
HIV-encoded integrase (see Table 45–3). It is recom-
mended for use in patients who have been treated with
other antiretroviral drugs but continue to produce sig-
nificant levels of HIV. Two additional integrase inhibi-
tors are available: dolutegravir (Tivicay) and elvitegravir
bisnis Two stepslowcan
(Stribild).
/
·
amiro acid
mutations
>
-
test
> genotype resistance
- resistant
Resistance to Antiretroviral Drugs
+ more
By lig ! given to HIV-infected mothers and neonates, and HIV-
Drug-resistant mutants of HIV have emerged that signifi-
cantly affect the ability of both reverse transcriptase inhibi- antiretroviral drugs is dependent on several factors, so cur-
tors and protease inhibitors to sustain their clinical efficacy. rent guidelines should be consulted. In addition, the risk of
Approximately 10% of newly infected patients are infected
with a strain of HIV resistant to at least one antiretroviral
drug. Laboratory tests to detect mutant strains include both
genotypic and phenotypic analysis. Genotyping reveals the
presence of specific mutations in either the reverse tran-
scriptase (RT) or protease (PR) genes. Phenotyping deter-
mines the ability of the virus to grow in cell culture in the
presence of the drug. One method of phenotyping recovers
the RT and PR genes from the patient’s virus and splices
them into a test strain of HIV, which is then used to infect
cells in culture. Another laboratory test can determine the
tropism of the patient’s isolate (i.e., whether it uses CCR5 as
its coreceptor). If so, then maraviroc can be used for
treatment.
Immune Reconstitution Inflammatory Syndrome
Immune reconstitution inflammatory syndrome (IRIS)
may occur in HIV-infected patients who are treated with
a HAART regimen and who are coinfected with other
microbes such as HBV, HCV, M. tuberculosis, M. avium
complex, Cryptococcus neoformans, and Toxoplasma
gondii. In this syndrome, an exacerbation of clinical
symptoms occurs because the antiretroviral drugs
enhance the ability to mount an inflammatory response.
HIV-infected patients with a low CD4 count have a
reduced capacity to produce inflammation, but HAART
restores the inflammatory response, and as a result,
symptoms become more pronounced. To avoid IRIS, the
coinfection should be treated prior to instituting HAART
whenever possible.
Prevention > no
- Vaccine
No vaccine is available. Multiple trials of a variety of
experimental vaccines have failed to induce protective
antibodies, protective cytotoxic T cells, or mucosal immu-
nity. Prevention consists of taking measures to avoid
exposure to the virus (e.g., using condoms, not sharing
needles, and discarding donated blood that is contami-
nated with HIV).
Postexposure prophylaxis (PEP), such as that given
after a needle-stick injury or a high-risk nonoccupational
-3352j2
exposure, employs three drugs: the preferred regimen con-
D e
sists of the combination of tenofovir and emtricitabine
y
(given as Truvada) plus raltegravir. Three alternative drug 3
regimens are available. PEP should be given as soon as pos-
sible after exposure and continued for 28 days. Truvada can
also be used for preexposure prophylaxis (PrEP) in indi-
- - - 8. &
viduals at high risk of infection, such as men who have sex
with men. ·*
14
5 CDU Count
-
? 2 os ili!
↓ viral
load a d
· undetectable
be taken to reduce the number of cases of
HIV infection in children: antiretroviral therapy should be
-
si
infected mothers should not breast feed. The choice of
neonatal HIV infection is lower if delivery is accomplished
by cesarean section rather than by vaginal delivery. Cir-
cumcision reduces HIV infection.
Several drugs are commonly taken by patients in the
advanced stages of AIDS to prevent certain opportunistic
infections (Table 45–4). Some examples are trimethoprim-
sulfamethoxazole to prevent Pneumocystis pneumonia, flu-
conazole to prevent recurrences of cryptococcal meningitis,
 CHAPTER 45 Human Immunodeficiency Virus 389

TABLE 45–4 Drugs Used for the Prevention of (C) After infection with HIV, antibodies to the virus can be
Opportunistic Infections in AIDS Patients detected before the polymerase chain reaction (PCR) test can
detect nucleic acids specific to HIV.
Name of Drug Infection Prevented (D) Because false-positive results occur in the screening test for
Trimethoprim- 1. Pneumocystis pneumonia HIV, a confirmatory test called the Western blot assay should
sulfamethoxazole 2. Toxoplasmosis be performed for those with a positive result on the screen-
ing test.
Fluconazole Cryptococcal meningitis
4. Regarding the mode of action of drugs used in the treatment of
Clotrimazole Thrush caused by C. albicans human immunodeficiency virus (HIV) infection, which one of
Ganciclovir Retinitis caused by cytomegalovirus the following is most accurate?
(A) Maraviroc acts by inhibiting the reverse transcriptase in the
Azithromycin Mycobacterium avian complex
(MAC) infection
virion.
(B) Raltegravir inhibits the integration of HIV DNA into host cell
DNA.
(C) Zidovudine is a nucleoside analog that inhibits messenger RNA
(mRNA) synthesis of HIV.
ganciclovir to prevent recurrences of retinitis caused by
(D) Ritonavir acts by binding to the Tat protein, which prevents
cytomegalovirus, and oral preparations of antifungal budding and release of the HIV virion.
drugs, such as clotrimazole, to prevent thrush caused by (E) Lamivudine is a “chain-terminating” drug because it inhibits
C. albicans. the growing polypeptide chain by causing misreading of the
viral mRNA.
5. Regarding the adverse effects of drugs used in the treatment of
human immunodeficiency virus (HIV) infection, which one of
SELF-ASSESSMENT QUESTIONS the following is most likely to cause bone marrow suppression?
(A) Lamivudine
1. Regarding the structure and replication of human immuno- (B) Lopinavir
deficiency virus (HIV), which one of the following is most (C) Nevirapine
accurate? (D) Maraviroc
(A) Viral mRNA is the template for the synthesis of the genome (E) Zidovudine
RNA. 6. Regarding the adverse effects of drugs used in the treatment of
(B) During entry of HIV into the cell, the viral p24 protein inter- human immunodeficiency virus (HIV) infection, which one of
acts with the CD4 protein on the cell surface. the following is most likely to cause lipodystrophy (i.e., abnormal
(C) HIV contains an integrase within the virion that integrates cop- fat deposits)?
ies of the viral genome into the progeny virions. (A) Lamivudine
(D) HIV has an enzyme in the virion that synthesizes double- (B) Lopinavir
stranded DNA using the single-stranded genome RNA as the (C) Nevirapine
template. (D) Maraviroc
(E) The HIV genome encodes a protease that cleaves cellular ribo- (E) Zidovudine
somal proteins, resulting in the inhibition of cell-specific pro- 7. Regarding the adverse effects of drugs used in the treatment
tein synthesis. of human immunodeficiency virus (HIV) infection, which
2. Regarding clinical aspects of human immunodeficiency virus one of the following is most likely to cause Stevens-Johnson
(HIV), which one of the following is most accurate? syndrome?
(A) During the primary infection with HIV, Pneumocystis pneu- (A) Lamivudine
monia commonly occurs. (B) Lopinavir
(B) During the long asymptomatic period that can last for years, no (C) Nevirapine
HIV is synthesized. (D) Maraviroc
(C) During the period when many opportunistic infections occur, (E) Zidovudine
HIV usually cannot be detected in the blood. 8. Which of the following modes of transmission of human immu-
(D) The antibody response to a primary HIV infection usually is nodeficiency virus (HIV) occurs significantly MORE often than
detected within 7 to 10 days after infection. the others?
(E) People with a high level of viral RNA in their plasma are more (A) Direct skin contact
likely to have symptomatic AIDS (i.e., opportunistic infections) (B) During childbirth
than those with low levels. (C) Fecal–oral route
3. Regarding the laboratory diagnosis of human immunodeficiency (D) Respiratory aerosols
virus (HIV), which one of the following is most accurate? 9. Your patient is a 25-year-old man who was just found to be
(A) The initial screening of blood for antibodies to HIV is done by infected with HIV based on a positive enzyme-linked immuno-
the complement fixation test. sorbent assay (ELISA) and a positive Western blot test. His CD4
(B) Viral load is the term used to describe the amount of infectious count is 125, and his viral load is 7000. He has not received any
virus produced by the patient’s CD4-positive T lymphocytes in antiretroviral medications. Which one of the following is the best
cell culture. regimen to treat his infection?
390 PART IV Clinical Virology

(A) Acyclovir, foscarnet, and ribavirin SUMMARIES OF ORGANISMS

(B) Enfuvirtide, raltegravir, and maraviroc
(C) Lamivudine, ribavirin, and ritonavir/lopinavir Brief summaries of the organisms described in this chapter
(D) Zidovudine, lamivudine, and efavirenz begin on page 678. Please consult these summaries for a rapid
review of the essential material.

ANSWERS
1. (D)
2. (E) PRACTICE QUESTIONS: USMLE &
3. (D) COURSE EXAMINATIONS
4. (B)
5. (E) Questions on the topics discussed in this chapter can be found
6. (B) in the Clinical Virology section of Part XIII: USMLE (National
7. (C) Board) Practice Questions starting on page 723. Also see Part
8. (B) XIV: USMLE (National Board) Practice Examination starting
9. (D) on page 751.