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What is HIV?
HIV is a virus. HIV stands for Human Immunodeficiency Virus. When viruses enter the body, the human immune system usually finds and kills viruses very quickly, but HIV is a unique virus which attacks the immune system itself, the very thing that would normally get rid of a virus.
Unlike with some other viruses, the human body is unable to get rid of the virus. Once you get HIV, you have it for life.
What is immune system?
The immune system protects your body against foreign objects and subsequent illness. It is our body’s natural defence against illness. The immune system is largely made up of white blood cells, technically known as leukocytes.
Approximately 2% of white cells are in the blood. The rest are elsewhere in the body, concentrating in places like the liver, spleen, and lymphatic system.
When HIV enter the human body it will attack the immune cells called the CD4 cells which are a kind of white cells, as the CD4 cell population goes down the immunity of the person also goes down. Now the virus is multiplying fast and the virus population increases. The resulting progressive immune deficiency results in the person becoming more vulnerable to opportunistic infections such as tuberculosis, fungal infections and specific cancers.
Difference between HIV & AIDS?
It is important to distinguish the difference between HIV and AIDS.
HIV (Human Immunodeficiency Virus) is the organism that affects the cells of the immune system and either destroys them or stops them from functioning properly, while AIDS (Acquired Immunodeficiency Syndrome) refers to a condition in which a person’s immune system has been severely weakened by the HI virus, leading to numerous opportunistic infections and specific cancers.
History of Hiv?
A scientific hallmark report was published in June 1981 by the Centers for Disease Control of an unexplained cluster of Pneumocystis pneumonia (PCP) in five previously healthy gay men in Los Angeles. In addition to the symptoms associated with pneumonia, the men also shared several unrelated symptoms, including swollen lymph nodes, rashes, chronic diarrhea, weight loss, night sweats and a depressed white blood cell count. The clinicians were puzzled with this clinical entity.
In July, the CDC published another report on a rare cancer known as Kaposi’s sarcoma. Both the pneumonia and cancer symptoms indicated that a never-before-seen infectious disease was destroying the immune systems of many gay men and was quickly labeled the “gay related immune deficiency syndrome” later known as Acquired Immune Deficiency Syndrome or AIDS.
Discovery Of the Virus
The virus that causes AIDS was discovered two years later by Luc Montagnier in 1983 and Robert Galo in 1984 and was named human immune deficiency virus in 1985. In 1989, a second virus named HIV 2 was discovered.
Origin Of the HIV
Pathogens have been with us for millions of years and routinely switch host species when the environment is opportune for such invasions. HIV is believed to have descended from Simian Immunodeficiency Virus, which infects apes and monkeys.
There were various theories and debates on how the virus entered humans. An early theory was that a simian (monkey) version contaminated a polio vaccine given to Africans in the Congo between 1957 and 1960, but confirmation that the virus appeared in humans much earlier than this has discredited this theory. The reuse of unsterilized needles in vaccination programs has also been rejected now.
The most plausible explanation is that during the “bush meat trade” the virus entered human blood stream several times. Africans have hunted chimps and monkeys and kept them as pets for centuries; they’ve presumably been exposed to SIVs during butchering and hunting most of that time. But the conditions needed for HIV to spread widely weren’t in place until after the continent was colonized and urbanized. How the SIV virus would have transformed into HIV is still a matter of debate. It remains also unexplained why all epidemic HIV groups emerged in humans nearly simultaneously, and only in the 20th century, despite very old human exposure to SIV.
In 1960, HIV-1 infection was discovered in a preserved lymph node biopsy sample taken from a woman from Leopoldville, Belgian Congo. A tissue sample tested in 1988 from a Norwegian sailor who died in 1976 was found to contain HIV-1 Group 0. The sailor had first presented symptoms in 1969, eight years after he first spent time in ports along the West African coastline. A gonorrhea infection during his first African voyage shows he was sexually active at this time. A recent phylogenetic study demonstrated that HIV has probably been in existence from sometime between 1884 and 1924. A recent finding was the identification of a strain of HIV that was traced to gorillas from a Cameroonian woman living in France
How long does it take become AIDS from HIV infection
HIV positive individuals may remain without symptoms for up to 10 or more years. This period is called the asymptomatic period. This time varies greatly from person to person and depends on many factors.
During the asymptomatic period the person is infectious which means they can spread the infection to others. Only way to identify is through a HIV test. This is a special test which shows that a person is exposed to HIV infection.
Because people are without symptoms (asymptomatic) they do not suspect that they have the HIV in the body they do not get tested for HIV. However, such people are infectious which means that they can pass the virus to another person during sex or during injecting drugs or when donating blood.
There are medicines called – anti-retroviral drugs which are given to reduce the replication of the virus. When these drugs attack the HIV the HIV population decrease and the immunity is preserved. But these drugs cannot destroy the HIV.
If ART drugs are not given at this point, the disease will progress to the stage of AIDS.
Importance of the asymptomatic period
This is a serious situation as people unknowing of their HIV status have sex with their marital partner or girlfriend or boyfriend or even buy or sell sex or have casual sex with anyone known or unknown to them. During these sexual encounters they spread the virus to their sexual partners. Similarly the virus can pass while sharing drug injecting equipment. In Sri Lanka, there
are several instances where people have spread the infection during the asymptomatic period.
An asymptomatic pregnant woman is able to pass the virus to the fetus or the newborn during
delivery or after delivery through breast feeding.
Natural History of HIV
When the HIV enter the human body, as for any other outside organism entering the body the body reacts and a set of symptoms appear around 1-4 weeks after the virus enter the body.
They are very non-specific signs and symptoms. It’s a flu like illness: fever, malaise, sore throat, headache are some of the symptoms which last for about a week or two. This stage is called the “acute retroviral infection” at this point even a clinician may not suspect it’s the first stage of HIV infection unless a detailed history is taken to check on risky sexual encounters or injecting drug habits.
During this early stage although the virus is in high concentration the HIV test may be negative as it takes a little time for even the components detected in HIV tests : viral RNA particles, antigen and the antibodies to appear in blood. The test that can be done to make a diagnosis at the early stage of “acute retroviral infection” is the “HIV-PCR-RNA” test to detect the virus nuclei
acid components. But it takes about at least 10 days after the virus enter the body to detect HIV-RNA nucleic acid particles in the blood. This test is not freely available. It is costly and need highly skilled technicians to perform the test.
The next best thing to do is get the HIV antigen-antibody test after about 4 weeks by that time antigen or the antibody or both would have now appeared in the blood and the test will be positive.
Even in the best clinical practices sometimes this stage is missed. Especially if the patient conceal true facts from the doctor about sexual behaviours or do not come for the follow up test. However, this is the best time to start anti-retroviral therapy (ART). These are a set of medicines which are able to control the multiplication of the virus. ARTs are not able to destroy the HIV. If taken as prescribed, ART is able to prolong the lives of HIV infected people and
improve the quality of life. When the viral load drops to undetectable levels the chance of infecting others is greatly reduced. ( A description of ART will be given later. )
HIV starts attacking the CD4 cells and gradually the immunity declines. During this time the virus multiplies and increases its population. When the immunity drops to low levels symptoms appear and they are called “symptoms of HIV disease”. The appearance of these symptoms gives a clue to the clinician to make a diagnosis of HIV infection. If no intervention is made even at this point that is if anti-retrorviral drugs are not given the disease progress to the stage of AIDS.
People living with HIV
HIV infected people are known as people living with HIV (PLHIV). Once the HIV enters the body it stays there for life, hence it’s a life long illness. Today with the availability of anti-retroviral therapy HIV positives who are on ART have a better survival and is not a life threatening illness anymore but a chronic disease like for example diabetes.
As up to now a method of eliminating the virus from the infected person, has not been found.
Globally around 38 million people are living with HIV most of them are in the sub-Saharan region where HIV is believed to have been originated. In the South East Asia around 3.5 million are living with HIV. Sri Lanka is considered as a country with a low level HIV epidemic and the estimated number of PLHIV is between 3500-4000.
Are there two types of HIV?
HIV-1 was discovered in 1983 and another one HIV-2 was discovered in 1989. Using electron microscopy, HIV-1 and HIV-2 resemble each other strikingly. They differ with regard to the molecular weight of their proteins, as well as having differences in their accessory genes. HIV-2 is genetically more closely related to the SIV found in sootey mangabeys (SIVsm) rather than HIV-1 and it is likely that it was introduced into the human population by monkeys.
Both HIV-1 and HIV-2 replicate in CD4 T cells and are regarded as pathogenic in infected persons, although the actual immune deficiency may be less severe in HIV-2-infected individuals.
The most prevalent one globally is HIV-1. Both are transmitted through sexual contact, blood, from mother to child, and cause indistinguishable AIDS. HIV-2 is less transmissible than HIV-1.
How is HIV transmitted?
The main method of transmission is – through sexual contact with an infected person
HIV is found in the following body fluids of a person infected with HIV.
- Blood
- Seminal fluid
- Rectal fluids
- Vaginal fluid
- Cervical fluid – fluid coming out of the neck of the womb
- Breast milk
The main mode of HIV transmission is having sexual intercourse without a condom with someone who is living with HIV. The virus is present in high concentrations in sexual fluid – such as seminal fluid, vaginal and cervical fluid and in rectal fluids. Therefore during penile, vaginal or rectal intercourse these fluids come into contact with the mucus membranes of the rectum,
penis or vagina and the virus passes from the infected persons sexual fluids to the uninfected person.
The person living with HIV may not even know that they are carrying the virus as a long period of HIV infection is without symptoms.
The main mode of transmission globally and in Sri Lanka is due to heterosexual transmission that is from an infected male to a female or from an infected female to a male
The risk of transmission to women and from women is more. Due to biological reasons- Vaginal mucosa is wide which increases the absorption area if the virus enter the vagina, vaginal is susceptible to minute trauma which may be invisible but enhance virus absorption. Social conditions – forced sex due to violence, women unable to resist sexual demand due to poverty, trying to maintain family harmony,
Another method of sexual transmission is during:
- Same sex relations among men who have sex with men
Anal sex which occurs when men have sex with men is an easy route of HIV transmission. The anal mucosa is very delicate and easily bruised or traumatized during sex which allows easy and quick absorption of the virus. Transmission can take place during receptive or insertive anal sex.
The rate of transmission is higher among receptive anal sex than insertive sex.
Presence of sexually transmitted infections in both males and females increase the risk of HIV transmission, especially genital ulcer related infections
- Through virus- contaminated blood or transfusion of blood or blood products
– Quickest form of transmission
Transmission of HIV through contaminated blood transfusions
This happens in healthcare settings. But in Sri Lanka the National Blood Transfusion centre has taken several steps to prevent HIV transmission by contaminated blood. In Sri Lanka, since year 2000, no blood transfusion associated HIV has taken place due to these public health measures
taken by the government.
Transmission of HIV through sharing infected syringes and needles
This happens among people who inject drugs (PWID). There are people who inject harmful drugs like heroin, cocaine. Fortunately this population is small in Sri Lanka compared to countries like Vietnam and Cambodia where the PWID population is high and the HIV prevalence among them is also high. People share syringes and needles when injecting and thereby the syringes and needles get contaminated with HIV infected blood and the HIV virus very easily get into an uninfected person’s blood circulation. This is a quick way of the virus getting into an uninfected person’s blood.
What are the interventions taken by the Government to stop blood transmission associated HIV
Blood donors are counselled to donate blood responsibly – if they have engaged in risky sexual behaviour or is injecting drugs it is best that they refrain from donating blood. The government has made it mandatory that all donated blood is screened for HIV infection. Donated blood is also screened for other sexually transmitted infections such as syphilis and blood bourne
infections such as Hepatitis B & C and malaria.
It is good to educate people that it is also their responsibility to refrain from donating blood if they have a suspicion that they may have acquired HIV due to a risky sexual behaviour or have injected harmful drugs
If a blood donor is found to be HIV positive what are the services available to such a person
In the event a blood donor was found to be infected with HIV infection the government has taken steps how best this person could be supported. The person who test positive for HIV will be counselled by a trained healthcare provider as the first test is only a screening test and the HIV status has to be confirmed by giving a second sample of blood to confirm/refute the presence of HIV infection. Only if the confirmatory test is positive the HIV status is confirmed.
Then the person is linked to HIV care services at the National STD clinics where they will be able to commence on anti-retroviral therapy (ART) which is provided free of charge from the Government STD clinics to improve survival and quality of life. Today there are several people who have survived for almost 15 years since commencing ART. All these procedures are done maintaining confidentiality of the identity and HIV status of the person.
- third method is mother –to-child transmission
An infected pregnant mother is able to pass the HIV to the fetus while in the uterus across the placenta, or during delivery when the newborn pass through the womb and vagina, or during breast feeding
Mother-to – child transmission of HIV in Sri Lanka
The prevalence of mother-to-child transmission is low in Sri Lanka. The policy of the Government of Sri Lanka is to screen all antenatal mothers for HIV.
Services available to HIV positive antenatal mothers
Such a mother is able to obtain HIV treatment, care and support provided by the STD clinics together with the Obstetric team that is taking care of the pregnant mother. She will be counselled on management of the pregnancy and the newborn and herself after delivery. She will be provided with anti-retroviral therapy which is provided free of charge from the government services.
Importance aspects to know and understand in HIV transmission is that
- Heterosexual transmission is the main mode of transmission of HIV globally and locally. Transmission through homosexual relations is the 2nd highest method of transmission in Sri Lanka.
- Transmission related to blood transfusion is extremely low and to maintain this status people need to donate blood responsibly. If a blood donor is found to be HIV positive, confidential management with anti-retroviral therapy is available and such people should avail of the services.
- The risk of receptive anal sex is the highest mode of transmission among men who have sex with men.
- Mother to child transmission is low in Sri Lanka. All antenatal mothers attending government antenatal clinics are screened for HIV.
Living with HIV
People Living with HIV / AIDS need to understand the importance of self care.
Good nutrition – this builds up the body and makes it stromger to fight infection.
The best way is to eat a normal balanced diet and avoiding processed food, salt and sugar.
Regular Exercise- People living with HIV / AIDS are prone to loss of muscle mass
and strength. Exercise helps to build up muscle and strong bones as well as
reducing symptoms of stress and depression.
AVOID ALCOHOL AND DRUGS
Whether you are a HIV free person or one who is affected by the virus
consumption of alchol or recreational drugs weakens the immune system and this
could have an adverse effect on the ART Treatment. The intensity of the side
effects of the virus could increase and make one potentially vulnerable.
MANAGE STRESS
Mental health of People Living with HIV is of utmost importance. The initial
reaction to the diagnosis is one of shock. Care should be taken that there is
support for people like this.
It is good to adjust to the fact that one has been diagnosed with HIV and be
treated quickly. It is possible to lead the life you need.
CHECKS
It is important the PLHIVs have regular health check ups so that you could be
monitored for other health issues.
DENTAL MANAGEMENT
Teeth and Mouth complaints are very common amongst those living with
HIV.
Regular dental care can lower the risk of cavities and mouth infections.