HIV is a virus that targets and alters the immune system, increasing the risk and impact of other infections and diseases. Without treatment, the infection might progress to an advanced disease stage called AIDS.
However, modern advances in treatment mean that people living with HIV in countries with good access to healthcare very rarely develop AIDS once they are receiving treatment.
The life expectancy of a person who carries the HIV virus is now approaching that of a person that tests negative for the virus, as long as they adhere to a combination of medications called antiretroviral therapy (ART) on an ongoing basis.
A Kaiser Permanente study in 2016 suggested that between 1996 and 2016, the gap in life expectancy between people who are HIV positive and HIV negative closed from 44 years to 12 years.
The World Health Organization (WHO) also advises that a person living with HIV can resume a high quality of life with treatment, and that 20.9 million people worldwide were receiving ART as of mid-2017.
In this article, we explain HIV and AIDS, their symptoms, causes, and treatments.
Human immunodeficiency virus (HIV) is a virus that attacks immune cells called CD4 cells, which are a type of T cell.
These are white blood cells that move around the body, detecting faults and anomalies in cells as well as infections. When HIV targets and infiltrates these cells, it reduces the body's ability to combat other diseases.
This increases the risk and impact of opportunistic infections and cancers. However, a person can carry HIV without experiencing symptoms for a long time.
HIV is a lifelong infection. However, receiving treatment and managing the disease effectively can prevent HIV from reaching a severe level and reduce the risk of a person passing on the virus.
AIDS is the most advanced stage of HIV infection. Once HIV infection develops into AIDS, infections and cancer pose a greater risk.
Without treatment, HIV infection is likely to develop into AIDS as the immune system gradually wears down. However, advances in ART mean than an ever-decreasing number of people progress to this stage.
By the close of 2015, around 1,122,900 people were HIV-positive. To compare, figures from 2016 show that medical professionals diagnosed AIDS in an estimated 18,160 people.
People transmit HIV in bodily fluids, including:
- vaginal secretions
- anal fluids
- breast milk
In the United States, the main causes of this transfer of fluids are:
- anal or vaginal intercourse with a person who has HIV while not using a condom or PrEP, a preventive HIV medication for people at high risk of infection
- sharing equipment for injectable illicit drugs, hormones, and steroids with a person who has HIV
A woman living with HIV who is pregnant or has recently given birth might transfer the disease to her child during pregnancy, childbirth, or breastfeeding.
The risk of HIV transmitting through blood transfusions is extremely low in countries that have effective screening procedures in place for blood donations.
Undetectable = untransmittable
To transmit HIV, these fluids must contain enough of the virus. If a person has 'undetectable' HIV, they will not transmit HIV to another person, even if after a transfer of fluids.
Undetectable HIV is when the amount of HIV in the body is so low that a blood test cannot detect it. People may be able to achieve undetectable levels of HIV by closely following the prescribed course of treatment.
Confirming and regularly monitoring undetectable status using a blood test is important, as this does not mean that the person no longer has HIV. Undetectable HIV relies on the person adhering to their treatment, as well as the effectiveness of the treatment itself.
Progression to AIDS
The risk of HIV progressing to AIDS varies widely between individuals and depends on many factors, including:
- the age of the individual
- the body's ability to defend against HIV
- access to high-quality, sanitary healthcare
- the presence of other infections
- the individual's genetic inheritance resistance to certain strains of HIV
- drug-resistant strains of HIV
For the most part, infections by other bacteria, viruses, fungi, or parasites cause the more severe symptoms of HIV.
These conditions tend to progress further in people who live with HIV than in individuals with healthy immune systems. A correctly functioning immune system would protect the body against the more advanced effects of infections, and HIV disrupts this process.
Early symptoms of HIV infection
Some people with HIV do not show symptoms until months or even years after contracting the virus.
However, around 80 percent of people may develop a set of flu-like symptoms known as acute retroviral syndrome around 2–6 weeks after the virus enters the body.
The early symptoms of HIV infection may include:
- joint pain
- muscle aches
- sore throat
- sweats. particularly at night
- enlarged glands
- a red rash
- unintentional weight loss
These symptoms might also result from the immune system fighting off many types of viruses.
However, people who experience several of these symptoms and know of any reason they might have been at risk of contracting HIV over the last 6 weeks should take a test.
In many cases, after the symptoms of acute retroviral syndrome, symptoms might not occur for many years.
During this time, the virus continues to develop and cause immune system and organ damage. Without medication that prevents the replication of the virus, this slow process can continue for an average of around 10 years.
A person living with HIV often experiences no symptoms, feels well, and appears healthy.
Complying rigidly to a course of ART can disrupt this phase and suppress the virus completely. Taking effective antiretroviral medications for life can halt on-going damage to the immune system.
Late-stage HIV infection
Without medication, HIV weakens the ability to fight infection. The person becomes vulnerable to serious illnesses. This stage is known as AIDS or stage 3 HIV.
Symptoms of late-stage HIV infection may include:
- blurred vision
- diarrhea, which is usually persistent or chronic
- dry cough
- a fever of over 100 °F (37 °C) lasting for weeks
- night sweats
- permanent tiredness
- shortness of breath, or dyspnea
- swollen glands lasting for weeks
- unintentional weight loss
- white spots on the tongue or mouth
During late-stage HIV infection, the risk of developing a life-threatening illness increases greatly. A person with late-stage HIV can control, prevent and treat serious conditions by taking other medications alongside HIV treatment.
HIV treatment is nowadays often effective enough to keep many infections at bay.
In reducing the activity of the immune system, late-stage HIV reduces the ability of the body to combat a range of infections, diseases, and cancers. Infections that caused minimal or no health problems before the development of AIDS might pose a serious health risk once the condition has weakened the immune system.
Medical professionals refer to these as opportunistic infections (OIs). Once any of these infections occur, a doctor will diagnose AIDS.
Candidiasis of the bronchi, trachea, esophagus, and lungs: As a fungal infection that normally occurs in the skin and nails, this frequently causes serious problems in the esophagus and lower respiratory tract for people with AIDS.
Invasive cervical cancer: This type of cancer begins in the cervix and spreads to other areas in the body. Regular checks with a cancer care team can help prevent the cancer or limit the spread.
Coccidioidomycosis: People sometimes refer to the self-limited version of this disease in healthy individuals as valley fever. Inhalation of the fungus Coccidioides immitis causes this infection.
Cryptococcosis: Cryptococcus neoformans is a fungus that can infect any part of the body, but most often enters the lungs to trigger pneumonia or the brain to cause swelling.
Cryptosporidiosis: The protozoan parasite Cryptosporidium causes this infection that leads to severe abdominal cramps and watery diarrhea.
Cytomegalovirus disease (CMV): CMV can cause a range of diseases in the body, including pneumonia, gastroenteritis, and encephalitis, a brain infection. However, CMV retinitis is of particular concern in people with late-stage HIV, and it can infect the retina at the back of the eye, permanently removing sight. CMV retinitis is a medical emergency.
HIV-related encephalopathy: An acute or chronic HIV infection can trigger this brain disorder. While doctors do not fully understand the cause, they consider it to be linked to post-infection inflammation in the brain.
Herpes simplex (HSV): This virus, usually sexually transmitted or passed on in childbirth, is extremely common and rarely causes health issues or causes self-limiting recurrences in people with healthy immune systems. However, it can reactivate in people with HIV, causing painful cold sores around the mouth and ulcers on the genitals and anus that do not resolve. The sores, rather than a herpes diagnosis, are an indicator of AIDS. HSV can also infect the breathing tube, lungs, or esophagus of people with AIDS.
Histoplasmosis: The fungus Histoplasma capsulatum causes extremely severe, pneumonia-like symptoms in people with advanced HIV. This condition can become progressive disseminated histoplasmosis and can impact on organs outside of the respiratory system.
Chronic intestinal isosporiasis: The parasite Isospora belli can infect the body through contaminated food and water, causing diarrhea, fever, vomiting, weight loss, headaches, and abdominal pain.
Kaposi's sarcoma (KS): Kaposi's sarcoma herpesvirus (KSHV), also known as human herpesvirus 8 (HHV-8), causes a cancer that leads to the growth of abnormal blood vessels anywhere in the body. If KS reaches organs, such as the intestines or lymph nodes, it can be extremely dangerous. KS appears as solid purple or pink spots on the surface of the skin. They might be flat or raised.
Lymphoma: People refer to cancer of the lymph nodes and lymphoid tissues as lymphoma, and many different types might occur. However, Hodgkin and non-Hodgkin lymphoma have strong links to HIV infection.
Tuberculosis (TB): The bacteria Mycobacterium tuberculosis causes this disease and can transfer in droplets if a person with an active form of the bacteria sneezes, coughs, or speaks. TB causes a severe lung infection as well as weight loss, fever, and tiredness, and can also infect the brain, lymph nodes, bones, or kidneys.
Mycobacteria, including Mycobacterium avium and Mycobacterium kansasii: These bacteria occur naturally in the environment and pose few problems for people with fully-functioning immune systems. However, they can spread throughout the body and cause life-threatening health issues for people with HIV, especially in its later stages.
Pneumocystis jirovecii pneumonia (PJP): A fungus called Pneumocystis jirovecii causes breathlessness, dry cough, and high fever in people with suppressed immune systems, including those with HIV.
Recurrent pneumonia: Many different infections can cause pneumonia, but a bacteria called Streptococcus pneumoniae is one of its most dangerous causes in people with HIV. Vaccines are available for this bacteria, and every person who has HIV should receive vaccination for Streptococcus pneumoniae.
Progressive multifocal encephalopathy (PML): The John Cunningham (JC) virus occurs in a vast number of people, usually lying dormant in the kidneys. However, in people with compromised immune systems, either due to HIV or medications, such as those for multiple sclerosis (MS), the JC virus attacks the brain, leading to a dangerous conditon called progressive multifocal leukoencephalopathy (PML). PML can be life-threatening, causing paralysis and cognitive difficulties.
Recurrent Salmonella septicemia: This type of bacteria often enters the body in contaminated food and water, circulates the entire body, and overpowers the immune system, causing nausea, diarrhea, and vomiting.
Toxoplasmosis (toxo): Toxoplasma gondii is a parasite that inhabits warm-blooded animals, including cats and rodents, and leaves the body in their feces. Humans contract the diseases by inhaling contaminated dust or eating contaminated food, but it can also occur in commercial meats. T. gondii causes severe infection in the lungs, retina, heart, liver, pancreas, brain, testes, and colon. Take care to wear protective gloves while changing cat litter and thoroughly wash the hands afterward.
Wasting syndrome: This occurs when a person involuntarily loses 10 percent of their muscle mass through diarrhea, weakness, or fever. Part of the weight loss may also consist of fat loss.
Preventing OIs is key to extending life expectancy with late-stage HIV. Aside from managing HIV viral load with medications, a person who lives with the disease must take precautions, including the following steps:
- Wear condoms to prevent other STIs.
- Receive vaccinations for potential OIs. Discuss these with your primary care physician.
- Understand the germs in your surrounding environment that could lead to an OI. A pet cat, for example, could be a source of toxoplasmosis. Limit exposure and take precautions, such as wearing protective gloves while changing litter
- Avoid foods that are at risk of contamination, such as undercooked eggs, unpasteurized dairy and fruit juice, or raw seed sprouts.
- Do not drink water straight from a lake or river or tap water in certain foreign countries. Drink bottled water or use water filters.
- Ask your doctor about work, home, and vacation activities to limit exposure to potential OIs.
Antibiotic, antifungal, or antiparasitic drugs can help treat an OI.
Many misconceptions circulate about HIV that are harmful and stigmatizing for people with the virus.
The following cannot transmit the virus:
- shaking hands
- touching unbroken skin
- using the same toilet
- sharing towels
- sharing cutlery
- mouth-to-mouth resuscitation or other forms of "casual contact"
- the saliva, tears, feces, and urine of a person with HIV
The Centers for Disease Control and Prevention (CDC) estimates that about 1 in every 7 HIV-positive Americans is unaware of their HIV status.
Becoming aware of HIV status is vital for commencing treatment and preventing the development of more severe immune difficulties and subsequent infections.
HIV blood tests and results
A doctor can test for HIV using a specific blood test. A positive result means that they have detected HIV antibody in the bloodstream. The blood is re-tested before a positive result is given.
After potential exposure to the virus, early testing and diagnosis is crucial and greatly improves the chances of successful treatment. Home testing kits are also available.
HIV might take 3 - 6 months to show up in testing, and re-testing may be necessary for a definitive diagnosis. People at risk of infection within the last 6 months can have an immediate test. The test provider will normally recommend another test within a few weeks.
No cure is currently available for HIV or AIDS.
However, treatments can stop the progression of the condition and allow most people living with HIV the opportunity to live a long and relatively healthy life.
Starting ART early in the progression of the virus is crucial. This improves quality of life, extends life expectancy, and reduces the risk of transmission, according to the WHO's guidelines from June 2013.
More effective and better-tolerated treatments have evolved that can improve general health and quality of life by taking as little as one pill per day.
A person living with HIV can reduce their viral load to such a degree that it is no longer detectable in a blood test. After assessing a number of large studies, the CDC concluded that individuals who have no detectable viral load "have effectively no risk of sexually transmitting the virus to an HIV-negative partner."
Medical professionals refer to this as undetectable = untransmittable (U=U).
Emergency HIV pills, or post-exposure prophylaxis
If an individual believes they have been exposed to the virus within the last 3 days, anti-HIV medications, called post-exposure prophylaxis (PEP), may be able to stop infection. Take PEP as soon as possible after potential contact with the virus.
PEP is a treatment lasting a total of 28 days, and physicians will continue to monitor for HIV after the completion of the treatment.
The treatment of HIV involves antiretroviral medications that fight the HIV infection and slows down the spread of the virus in the body. People living with HIV generally take a combination of medications called highly active antiretroviral therapy (HAART) or combination antiretroviral therapy (cART).
There are a number of subgroups of antiretrovirals, such as:
Protease is an enzyme that HIV needs to replicate. These medications bind to the enzyme and inhibit its action, preventing HIV from making copies of itself.
- atazanavir/cobicistat (Evotaz)
- lopinavir/ritonavir (Kaletra)
- darunavir/cobicistat (Prezcobix)
HIV needs integrase, another enzyme, to infect T cells. This drug blocks integrase. These are often the first line of treatment due to their effectiveness and limited side effects for many people.
Integrase inhibitors include:
- elvitegravir (Vitekta)
- dolutegravir (Tivicay)
- raltegravir (Isentress)
Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)
These drugs, also referred to as "nukes," interfere with HIV as it tries to replicate.
This class of drugs includes:
- abacavir (Ziagen)
- lamivudine/zidovudine (Combivir)
- emtricitabine (Emtriva)
- tenofovir disproxil (Viread)
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
NNRTIs work in a similar way to NRTIs, making it more difficult for HIV to replicate.
Chemokine co-receptor antagonists
These drugs block HIV from entering cells. However, doctors in the U.S. do not often prescribe these because other drugs are more effective.
Entry inhibitors prevent HIV from entering T cells. Without access to these cells, HIV cannot replicate. As with chemokine co-receptor antagonists, they are not common in the United States.
People will often use a combination of these drugs to suppress HIV.
A medical team will adapt the exact mix of drugs to each individual. HIV treatment is usually permanent, lifelong, and based on routine dosage. A person living with HIV must take pills on a regular schedule. Each class of ARVs has different side effects, but possible common side effects include:
- skin rashes
Complementary or alternative medicine
Although many people who have HIV try complementary, alternative, or herbal options, such as herbal remedies, no evidence confirms them to be effective.
According to some limited studies, mineral or vitamin supplements may provide some benefits in overall health. It is important to discuss these options with a healthcare provider because some of these options, even vitamin supplements, may interact with ARVs.
To prevent contracting HIV, healthcare professionals advise precautions related to the following.
Sex using a condom or PrEP: Having sex without a condom or other preventive measures, such as PrEP, can drastically increase the risk of transmitting HIV and other sexually transmitted infections (STIs).
Use condoms or PrEP during every sexual act with a person outside of a trusted relationship in which neither partner has HIV.
The U.S. Preventive Services Task Force advise in their 2019 guidelines that doctors should only consider PrEP for people with recent negative results from an HIV test. They advise that those with a high risk of HIV, who are suitable for PrEP, should take it once a day.
In the guidelines, the task force approves only one PrEP formation, which is a combination of tenofovir disoproxil fumarate and emtricitabine.
Drug injection and needle sharing: Intravenous drug use is a key factor for HIV transmission in developed countries. Sharing needles and other drug equipment can expose users to HIV and other viruses, such as hepatitis C.
Certain social strategies, such as needle-exchange programs, can help to reduce the infections as a result of drug abuse. Recovering from a substance use disorder can improve health a quality of life for many reasons, but it can dramatically reduce potential exposure to HIV.
People using a needle to take medications should use a clean, unused, unshared needle.
Body fluid exposure: A person can limit their potential exposure to HIV by taking precautions to reduce the risk of exposure to contaminated blood.
Healthcare workers should use gloves, masks, protective eyewear, shields, and gowns in situations where exposure to bodily fluids is a possibility.
Frequently and thoroughly washing the skin immediately after coming into contact with blood or other bodily fluids can reduce the risk of infection. Healthcare works should follow a set of procedures known as universal precautions to prevent transmission.
Pregnancy: Certain antiretrovirals might harm an unborn fetus during pregnancy.
However, an effective, well-managed treatment plan can prevent mother-to-fetus HIV transmission. Delivery through caesarean section may be necessary.
Women who are pregnant but have HIV might also pass on the virus through their breast milk. However, regularly taking the correct regimen of medications greatly reduces the risk of transmitting the virus.
Discuss all options with a healthcare provider.
Education: Teaching people about known risk factors is vital to equip them with the tools to avoid exposure to HIV.
Due to the added risk of other infections and disease, people living with HIV must make lifestyle adjustments to accommodate their reduced immunity.
Adherence: Taking HIV medication as prescribed is absolutely essential to effective treatment. Missing even a few doses might jeopardize the treatment.
Program a daily, methodical routine to fit the treatment plan around any existing lifestyle and schedule. Treatment plans will be different between people. People sometimes refer to "adherence" as "compliance".
HIV medications can cause particularly severe side effects that often deter people from adherence. Learn more about the adverse effects of HIV medication by clicking here.
If side effects are becoming too severe, speak to your medical team rather than simply stopping medication. They can switch the regimen to a better-tolerated drug.
General health: Taking steps to avoid illness and other infections is key. People living with HIV should seek to improve overall health through regular exercise, a balanced, nutritious diet, and the cessation of any drugs, including tobacco.
Additional precautions: People living with AIDS should take extra precautions to prevent any exposure to infection, especially around animals. Avoid coming into contact with animal feces and pet litter.
Doctors also recommend the meticulous and regular washing of hands. Antiretrovirals reduce the need for these precautions.
Regular contact with doctors: HIV is a lifelong condition, so regular contact with a healthcare team is important for updating treatment in line with advancing age and other conditions. The healthcare team will regular review and adjust treatment accordingly.
Psychological effects: Common misconceptions about AIDS and HIV are reducing as understanding of the disease increases.
However, stigma around the condition continues in many parts of the world. People living with HIV may feel excluded, persecuted, and isolated.
HIV is a misunderstood and potentially dangerous disease that reduces the effectiveness of the immune system in combatting other infections.
Advances in modern medicine person living with HIV can have a near-normal life expectancy and active lifestyle. A person receiving antiretroviral therapy must adhere strictly to their regime for the most effective results.
HIV transmits in bodily fluids, such as semen or vaginal secretions during sex, or blood. In the United States, HIV most frequently transmits through sexual intercourse without a condom or PrEP and sharing needles when injecting drugs.
However, if a person has a viral load that HIV tests cannot detect, they cannot transmit the virus to another person.
If HIV advances, for example in situations where a person is not aware of their HIV status or does not receive treatment, it can progress to a late stage known as AIDS.
AIDS can open the door to a range of infections known as opportunistic infections that pose a severe risk to health. Some are extreme or prolonged presentations of infections that would normally resolve quickly in a person with healthy immune function.
Others might occur due to microbes that occur naturally in the environment and would not normally cause infection at all.
A person living with AIDS can revert the condition to HIV through adhering to treatment.
If you suspect recent exposure to the virus, click here to find your nearest testing facility.