AIDS

Freddie Mercury (real name: Farrokh Bulsara) was a British singer, songwriter, record producer, and lead vocalist of the highly successful rock group Queen. Queen was a British rock band formed in London in 1970. Their classic line-up was Freddie Mercury as the lead vocal with piano, Brian May as lead guitar and vocals, Roger Taylor as drums and vocals, and John Deacon as bass. Their earliest works were influenced by progressive rock, hard rock and heavy metal, but the band gradually shifted into wider audience styles and radio-friendly works by incorporating more mainstream arena rock and pop rock. At the time of his death, AIDS was relatively new to the medical world and treatments were limited compared to today. Queen popularized multiple top hit songs such as Bohemian Rhapsody, We Will Rock You, and We Are the Champions – songs that many people know around the world due their stellar success.

A common question for the casual moviegoer or Queen fan is likely to be: How did Freddie Mercury die?

Freddie suffered from AIDS for a prolonged period and eventually succumbed to his death due to bronchopneumonia, a lung complication as a result of AIDS in 1991.

Mercury has been aware of his HIV-positive status since 1987, but people around him had no idea. In a documentary, producer Dave Richards stated, "There was absolutely no evidence from me that he could've been ill."

While it is now widely known that Mercury had HIV/AIDS, the great singer and musician only officially announced his illness the day before his tragically early death on November 24, 1991, at the age of 45.

Meanwhile, tabloids managed to publish rare photographs of Mercury appearing frighteningly thin and obviously unwell as he withdrew farther from public life. Mercury garnered attention for his skeleton frame in his last public appearance, receiving the Brit Award for Outstanding Contribution to British Music for the renowned Innuendo album, released the year before his death.

Even for someone with Mercury's money and resources, antiretroviral medicines that might considerably extend patients' lives were still out of reach in the medical world.

Aside from Mercury's stated shyness and caution, HIV was and continues to be stigmatized. That stigma is linked, at least in part, to the fact that HIV affects the LGBTQ population disproportionately, particularly males who have sex with men.

While there was some doubt about his keeping his sexuality and condition from activists for so long, it's also obvious that Mercury left on his terms. In one interview, he asserted forcefully that, as he grew older, "I don't give a damn. I've lived a full life, and I don't care if I die tomorrow."

So, what exactly is Human immunodeficiency virus, how is it transmitted, what are the symptoms, and how is it diagnosed and treated?

Acquired immunodeficiency syndrome or simply “AIDS” is a chronic, potentially life-threatening condition caused by the human immunodeficiency virus (“HIV”). By compromising the immune system, HIV interferes with the body's ability to fight infection and disease, according to the CDC. AIDS is mainly characterized by opportunistic infections and tumors, which are usually fatal without treatment.

Human immunodeficiency virus (HIV)

Human immunodeficiency virus (HIV) is an enveloped retrovirus with a single-stranded RNA genome in two copies. HIV affects the body's immune system and, if left untreated, can result in acquired immunodeficiency syndrome (AIDS), the last stage of HIV disease.

Epidemiology

According to current knowledge, the spread of HIV began during the beginning of the twentieth century.
Since 1999, the number of new infections has been steadily decreasing.
As of 2016, the global estimated number of individuals living with HIV/AIDS was 36.7 million.
Men who have sex with men (MSM) were the most affected group, accounting for almost 75% (2,400/3,200) of all new HIV infections in 2013.

HIV transmission from chimpanzee

HIV infection crossed to humans from a chimpanzee in Africa. The chimpanzee version of the virus, called simian immunodeficiency virus, or simply “SIV”, was most likely passed to humans when humans hunted these chimpanzees for meat and came in contact with their infected blood. Studies show that HIV may have jumped from chimpanzees to humans as far back as the late 1800s. Over time, HIV slowly spread across Africa and later into other parts of the world. We know that the virus has existed in the United States since at least since the 1970’s.

Causes and risk factors

In the United States, using drugs before engaging in sexual activity, such as marijuana, alkyl nitrites ("poppers"), cocaine, and ecstasy, is a major risk factor for HIV transmission among young people.
Other risk factors for HIV infection include males having intercourse with men, risky sexual practices, intravenous drug use, vertical transmission, and blood transfusions or blood products.
The majority of new HIV infections are still transmitted sexually.

Pathophysiology

HIV may be spread by bodily fluids such as blood, plasma, or serum, vaginal secretions, and donated organs such as kidney, bone, and cornea; infection through artificial insemination has also been recorded.

HIV transmission via blood or donated organs, including bone, is feasible from around days 5-6 following the donor's infection.

Mother-to-child transmission has been shown to occur as early as the 12th week of gestation, although transmission happens most frequently (>90%) in the last trimester, particularly soon before or during delivery . HIV can be passed on through breast milk.

Open wounds can serve as entrance sites for HIV. HIV infections via needle stick injuries are possible because relatively little quantities of blood are enough to infect a person if virus titers are high and/or HIV-containing cells are transferred. Nevertheless, HIV cannot be spread by aerosols, social interactions, insect or arthropod stings, or food or drink.

HIV can be identified in regional lymphatic tissue one to two days after infection and in regional lymph nodes five to six days later. HIV may be identified throughout the whole body, including the brain system, 10-14 days after infection.

Without treatment, the number of CD4 cells in the affected individual would drop by around 50-80 cells/uL per year, and the decline may be much quicker once the count falls below 200 cells/uL.

What are the typical symptoms?

The patient may have signs of primary infection two to four weeks after HIV enters the body.Some people have flu-like symptoms within 2 to 4 weeks after infection (called acute HIV infection). These symptoms may last for a few days or several weeks, which may include fever, chills, rash, night sweats, muscle pains, sore throat, fatigue, swollen lymph nodes, and mouth ulcers. But some people may not feel sick during acute HIV infection. These symptoms do not mean you have HIV. These symptoms can be caused by other conditions or illnesses, too. To be sure, one must be tested for HIV to be sure the symptoms are related to AIDS.

HIV typical symptoms

When people with HIV are not treated, they normally progress through three distinct stages. However, proper HIV medicine can slow or even prevent the progression of the disease. With the advancements in effective treatments, progression to Stage 3 is less common these days than before.

Stage 1: Acute HIV Infection

People have a large amount of HIV in their blood. They are highly contagious at this stage. Some people have flu-like symptoms. This is the body’s natural immune response to the infection. But some people may not feel sick right away or at all. Antigen/antibody tests or nucleic acid tests (NAT’s) can diagnose acute infection.

This first symptomatic phase is generally followed by an asymptomatic or occasional period that might persist for several years. The average period between exposure and start of symptoms is 2 to 4 weeks, although it might take up to 10 months in certain situations.

Acute retroviral syndrome is a group of symptoms that can occur acutely. Despite the fact that none of these symptoms are unique to HIV, their greater intensity and persistence indicate a bad prognosis. The following symptoms are listed in decreasing order of frequency:

Fatigue
Muscle pain
Skin rash
Headache
Sore throat
Swollen lymph nodes
Joint pain
Night sweats
Diarrhea

Acute neuropathy is common in the acute phase.

Stage 2: Chronic HIV Infection

At this stage, HIV is active but reproduces at very low levels but can still spread infections. People may not have any symptoms or get sick during this phase. Without taking HIV medicine, this period may last a decade or longer, varies from people to people. At the end of this phase, the amount of HIV in the blood (or “viral load”) goes up and the CD4 cell count goes down. The person may have symptoms as the virus levels increase in the body, and the person moves into Stage 3. People who take HIV medicine as prescribed may never move into Stage 3.

Chronic HIV infection without AIDS:

Constitutional symptoms
Thrush
Vaginal candidiasis
Oral hairy leukoplakia
Herpes zoster
Peripheral neuropathy
Cervical dysplasia
Idiopathic thrombocytopenic purpura

Stage 3: Acquired Immunodeficiency Syndrome (AIDS)

This is the most severe phase of HIV infection. People with AIDS have very badly damaged immune systems and are prone to getting an increasing number of severe illnesses, called opportunistic infections. People receive an AIDS diagnosis when their CD4 cell count drops below 200 cells/mm, or if they develop certain opportunistic infections. People with AIDS can have a high viral load and be very infectious to others. Without the proper treatment, people with AIDS typically only survive about three years.

A CD4 cell count of 200 cells/microL or the presence of any AIDS-defining condition, regardless of CD4 cell level, is considered to be AIDS. The opportunistic diseases and cancers that develop more frequently or severely as a result of immunosuppression are referred to be AIDS-defining disorders. The following are some of them:

Multiple or recurrent bacterial infections
Recurrent pneumonia
Candidiasis
Cervical cancer
Cryptococcosis, extrapulmonary
Cytomegalovirus disease
HIV related encephalopathy
Herpes simplex: chronic ulcers
Histoplasmosis, disseminated or extrapulmonary
Kaposi sarcoma
Lymphoma
Mycobacterium tuberculosis
Pneumocystis jirovecii
Progressive multifocal leukoencephalopathy

When immunodeficiency develops, the immune response is reduced, and opportunistic infections and neoplasms occur. Periods of excellent health are typical of an HIV infection, which are followed by periods of sickness that grow more frequent and stay longer as the infection progresses.

Toxoplasma gondii, Cryptosporidium parvum, Pneumocystis jirovecii, Mycobacterium TB and atypical mycobacteria, Salmonella spec., pneumococci, human polyomavirus JC, cytomegalovirus (CMV), and herpes simplex virus are among the most common opportunistic infections (HSV). Kaposi's sarcoma, which is caused by the human herpes virus type 8 (HHV-8), non-lymphomas, Hodgkin's such as Epstein-Barr virus (EBV)-associated B-cell lymphoma, and human papillomavirus-induced carcinomas(HPV) of the penis, anus, and cervix are all common neoplasms seen with HIV infections.

Advanced HIV infection is defined as a CD4 cell count <50 cells/microL

Diagnosis

HIV Diagnosis

A screening test and a confirmatory test are used to detect HIV infection. These tests seek for particular antibodies or antigens in the lab. A complete blood cell count should be done on patients with new HIV diagnoses or those who are coming for assessment of an urgent medical issue to rule out leukopenia, anemia, or thrombocytopenia.
If viral loads and CD4 counts would aid in the care of an HIV patient, they should be requested; however, results may not be available immediately.
The CD4 count of a patient can be estimated using the differential of a complete blood cell count. The CD4 count is most likely normal if the white blood cell and lymphocyte counts are within normal limits. If the absolute lymphocyte count is fewer than 950 cells/mm3, the patient's CD4 count may be less than 200 cells/uL, indicating immunosuppression and the risk of opportunistic infection.

HIV screening recommendations include the following:

Clinicians should screen for HIV in all adolescents and adults at high risk of infection, as well as all pregnant women, according to the US Preventive Services Task Force (USPSTF).
The Centers for Disease Control and Prevention (CDC) advises opt-out HIV testing for patients in all health-care settings; those who are at high risk for HIV infection should be tested at least once a year.
Clinicians should use routine HIV screening and encourage all patients to be tested, according to the American College of Physicians (ACP).
The World Health Organization (WHO) recommends an HIV testing strategy/algorithm that uses a combination of rapid diagnostic tests (RDTs) and/or enzyme immunoassays (EIAs) to achieve a positive predictive value of at least 99 %.

The CD4 T-cell count reliably reflects the current risk of acquiring opportunistic infections, as follows:

Reference range, 500-2000 cells/μL
Because CD4 counts vary, serial counts are generally a better measure of significant changes
After seroconversion, CD4 counts tend to decrease (~700/μL) and continue to decline over time
For surveillance, a CD4 count below 200/μL is considered AIDS.
The CD4 T-cell percentage is more important than the absolute count in children under the age of five (a CD4 T-cell percentage of less than 25% is deemed to require treatment).
In adults with chronic hepatitis C and low absolute CD4 T-cells, the CD4 percentage may also be more useful

Chest radiography may also be beneficial for individuals with cardiac symptoms or those who need to be evaluated for pulmonary infections. If a pulmonary process is not seen on chest radiography but there is still a worry for lung disease, computed tomography of the chest may be used for additional assessment.
If signs and symptoms imply tuberculosis (TB), testing for the illness should be done. In-depth testing using advanced diagnostic imaging, such as CT, may be required if extrapulmonary or disseminated TB is a possibility, particularly in the more immunocompromised population of AIDS patients, whose presenting symptoms may be less obvious. Even before the results of confirmatory tests, patients suspected of having TB should be kept in respiratory isolation.
A comprehensive metabolic profile is beneficial in a variety of cases, including establishing baseline renal and hepatic function and assessing for anomalies caused by therapy or acute medical problems. Patients with low CD4 counts or AIDS are more likely to develop acute hepatobiliary issues such as pancreatitis and acalculous cholecystitis. Transaminases, bilirubin, and lipase levels will be relevant in assessing these disorders. Based on the patient's symptoms, diagnostic imaging, such as abdominal computed tomography or ultrasound, may be recommended.
Esophagogastroduodenoscopy may be required to diagnose esophagitis in an AIDS patient with odynophagia or dysphagia. AIDS patients are also at risk of contracting a variety of diarrheal diseases. Immunocompromised individuals with diarrhea should be tested for ova, parasites, bacteria, and C. difficile toxins. In severe or refractory instances, a colonoscopy may be necessary.

Note

Detectable viremia does not appear until 10 to 15 days after infection, and even the most sensitive immunoassays do not produce a positive response until five days later. As a result, initial negative immunoassay and virologic tests might be misleading, and if the clinical suspicion for recent HIV exposure is strong, repeat testing is performed one to two weeks later.

Treatment

There is currently no cure and thus, once people get HIV, they have it for life. But with proper treatment, HIV can be controlled. People with HIV who get effective HIV care can live long, healthy lives and protect their partners from exposure to the virus.
Without antiretroviral treatment, the course of an HIV infection is usually chronic and deadly. Antiretroviral treatment can slow or stop CD4 cell destruction and clinical symptoms for decades.
Both the specialized physician and the informed patient should make the treatment decision. The best long-term therapeutic outcomes are obtained when therapy is initiated prior to the emergence of immunodeficiency symptoms. Treatment should begin when the CD4+ cell count is at or near 500 cells/l, according to the recommendations.
To cure HIV, many drug combinations are utilized, and the therapy is lifelong. Antiretroviral therapy (ART) is used to reduce viral load and boost CD4 cell count in the majority of these particular HIV or AIDS-related illnesses and infections. ART are medications used to treat HIV infections/AIDS, and they are used in a variety of combinations, which is known as highly active retroviral treatment (HAART).

Additional treatment of complications

Coverage for bacterial pneumonia should include both typical and atypical antibiotic treatments.
When treating tuberculosis, multi-drug resistance and the patient's immunosuppressive state must be taken into account. To coordinate the treatment of tuberculosis with that of ART in the severely immunocompromised AIDS patient, consultation with an infectious disease expert is strongly advised.
Oral thrush can be treated with nystatin swishes. Thrush in an otherwise healthy patient may be the only symptom of acute HIV infection, and a confirming diagnosis of HIV infection should be considered if there are risk factors for getting HIV. If the CD4 count is less than 100 cells/uL, systemic therapy with an azole should be explored to avoid esophageal candidiasis.
In the GI tract, several opportunistic infections occur, and antibiotic treatment should target organisms including Clostridium difficile, Salmonella, Shigella, Campylobacter, and Yersinia. Metronidazole and ciprofloxacin are a frequent antibiotic combination.
When meningitis is suspected, standard antibiotics should be given to address the most prevalent bacterial infections.
Kaposi's sarcoma is treated by cryotherapy, radiation, or infrared coagulation. Systemic chemotherapy may also be necessary depending on the degree or location of the Kaposi's sarcoma. Systemic antifungals such as azoles can be used to treat a disseminated fungal infection with cutaneous symptoms.

Differential Diagnosis

When a patient is known to be HIV positive and has a CD4 count of fewer than 200 cells/uL, or has an AIDS-defining illness, this is considered pathognomonic for the diagnosis of AIDS. There are many AIDS-defining disorders that, when HIV positive, indicate a highly immunocompromised state:

Pulmonary or disseminated TB
Invasive cervical cancer
Esophageal candidiasis
Cryptococcosis, Cryptosporidiosis
CMV retinitis,
Herpes – chronic ulcers, bronchitis, pneumonitis or esophagitis
Kaposi sarcoma
Lymphoma – Burkitt’s or primary brain
PCP pneumonia
Disseminated histoplasmosis
Recurrent salmonella septicemia
Recurrent bacterial pneumonia

Adverse Effects of HAART

Although a combination of three or four medicines looks to be particularly effective in suppressing HIV replication, highly aggressive antiviral treatment (HAART) includes side effects that can significantly decrease quality of life. Furthermore, antiretroviral medicines can interact with one another and with other medications.
Diarrhoea, insomnia, loss of concentration, and failure to gain weight despite appropriate food consumption are common adverse effects; diabetes, anemia, and neurologic problems are also common.
Cardiovascular disease is currently the leading cause of morbidity and death among HIV patients, owing to the inclusion of antiretroviral therapy (ART). It's unclear if the rise in cardiovascular illness is related to HIV, antiretroviral therapy (ART), a metabolic syndrome associated with HIV infection, or a combination of these variables.

Staging of HIV

Patients with HIV with CD4 counts more than 200 but less than 500 do not have AIDS, although they may develop chronic infections or noninfectious illnesses. It is possible to develop diseases such as chronic candidiasis of the mouth or recurrent vaginal candida. Patients may experience severe herpes simplex or herpes zoster outbreaks (shingles).Furthermore, patients are also more likely than healthy persons to develop malignancies that are far more difficult to treat.

Patients with normal CD4 counts (more than 500) enjoy a higher quality of life and live for four years longer than those without HIV.

Patients with AIDS with a CD4 level of less than 200 are vulnerable to opportunistic infections. If they are started on HAART, they generally live for two years. These individuals will have a normal life expectancy if they are treated with antiretroviral drugs and achieve a CD4 count greater than 500.

Prognosis

A patient with HIV and a CD4 count more than 500 (normal) has the same life expectancy as someone who does not have HIV. Antiretroviral therapy can boost CD4 levels and shift a patient's status from AIDS to HIV.

If left untreated, the majority of HIV patients will get AIDS within ten years. An asymptomatic period can continue up to eight years, followed by a fast decrease after CD4 counts fall below 200 cells/uL.

Even if antiretroviral treatment is started after an initial AIDS diagnosis (severe immunosuppression on the first presentation), the patient may live for more than 10 years. If individuals are diagnosed with AIDS and do not get antiretroviral medication, they will most likely die within two years.

Complications of HIV

The development of HIV illness to acquired immunodeficiency syndrome (AIDS) is a consequence of the virus .When an HIV-positive patient has opportunistic infections and/or a low CD4 level, the doctor should be suspicious.

AIDS develops when the lymphocyte count falls below a certain threshold (less than 200 cells per microliter) and is characterized by one or more of the following symptoms:

Tuberculosis (TB)
Cytomegalovirus
Candidiasis
Cryptococcal meningitis
Cryptosporidiosis
Toxoplasmosis
Kaposi sarcoma
Lymphoma
Neurological complications (AIDS dementia complex)
Kidney disease

If you or a loved one is showing the symptoms of HIV and has a lifestyle that exposes him or her to potentially contaminated blood, a prompt visit to the doctor to have a test performed is the best step as early detection is key to surviving.

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