Human Immunodeficiency Virus Type 1

HIV (Human Immunodeficiency Virus) is an infectious human retrovirus that causes Acquired Immunodeficiency Syndrome (AIDS). It is primarily a sexually transmitted disease. Currently, HIV/AIDS kills approximately 2-3 million people per year, primarily in developing countries. Currently in the U.S., there are approximately 500,000 people infected with HIV.

Transmission

HIV is primarily spread by sexual contact and intravenous drug use. Most early infections in the US were via homosexual sex, and to a lesser extent via intravenous drug use and blood transfusions; most current infections in the world are via heterosexual contact and vertical transmission from mother to child. Mothers infected with HIV transmit the virus to their baby in utero, during childbirth. Mother-to-child transmission can be significantly reduced by the proper use of antiretroviral agents.

Less commonly, contact with infected blood causes HIV transmission. This can occur in health care providers (HCPs) or others exposed to infectious bodily fluids. Transmission is facilitated by breaks in the skin or direct contact with mucosal tissues, such as those found in the eyes, mouth, anus, or vagina. Early in the epidemic, blood transfusions were a significant source of HIV transmission.

Other less likely means of transmission exist, though are rare. There are no confirmed cases from contact with the saliva, sweat or tears of an infected person.

Early on in the epidemic, there was much confusion about the transmission of HIV. After decades of study, this has been clarified. HIV can be found in various body fluids, however its highest concentrations are found in semen, blood, and vaginal secretions. It can also be found in breast milk, but recent research shows that exclusive breastfeeding tends to protect against HIV transmission.

As summarized by the Centers for Disease Prevention and Control:

An exposure that might place HCP at risk for HIV infection is defined as a percutaneous injury (e.g., a needlestick or cut with a sharp object) or contact of mucous membrane or nonintact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious. In addition to blood and visibly bloody body fluids, semen and vaginal secretions also are considered potentially infectious. Although semen and vaginal secretions have been implicated in the sexual transmission of HIV, they have not been implicated in occupational transmission from patients to HCP.

Potentially Infectious Fluids

The risk for transmission of HIV infection from these fluids is unknown; the potential risk to HCP from occupational exposures has not been assessed by epidemiologic studies in health-care settings.

• cerebrospinal fluid
• synovial fluid
• pleural fluid
• peritoneal fluid
• pericardial fluid
• amniotic fluid.

Non-infectious Fluids

The following fluids are not considered potentially infectious unless they are visibly bloody; the risk for transmission of HIV infection from these fluids and materials is low.

• feces
• nasal secretions
• saliva
• sputum
• sweat
• tears
• urine
• vomitus

Any direct contact (i.e., contact without barrier protection) to concentrated virus in a research laboratory or production facility requires clinical evaluation. For human bites, clinical evaluation must include the possibility that both the person bitten and the person who inflicted the bite were exposed to bloodborne pathogens. Transmission of HIV infection by this route has been reported rarely.

Data

Per-contact risk of HIV transmission:

URA with a known seropositive partner: 0.82 percent

URA with a partner of unknown serostatus, 0.27 percent (95% CI: 0.06, 0.49 percent)

Unprotected insertive anal sex: 0.06 percent.

Receptive oral sex: 0.04 percent.

(URA=unprotected anal-receptive sex) AIDSWEEKLY Plus; Monday, August 9, 1999

"The overall, unadjusted probability of HIV-1 transmission per coital act is 0·0011 in this Ugandan population, and greater infectivity of predominant HIV-1 viral subtypes is unlikely to account for the explosive HIV-1 epidemic in sub-Saharan Africa. Transmission probability per act varies greatly with the HIV-1 viral load of the HIV-1-infected partner, which suggests that interventions to reduce viral load could reduce transmission.15,28 Younger age and genital ulceration also increased the probability of transmission per act." THE LANCET, Volume 357: Pages 1149-1153, 14 April 2001.

Infection

After exposure, the virus invades and replicates in immune cells near the site of infection. It quickly spreads to regional lymph nodes and via the blood stream to the rest of the body. During this stage the patient may experience Acute Retroviral Syndrome, a vague flu-like illness. The patient is often asymptomatic for the first 5-10 years after infection. By that time, untreated, progression to AIDS in inevitable, except in a small subset of patients.

Treatment

Treatment issues are complicated by issues of poverty and education. In communities with adequate resources, HIV infection is treatable with Highly Active Retroviral Therapy (HAART). This therapy effectively prevents progression to AIDS in many patients, however there are many side effects to treatment, and resistance is a serious issue.

Prevention

Prevention is an issue complicated by issues of poverty and education. Sexual transmission can be effectively prevented by avoiding sexual contact (abstinence), or by regular, proper use of latex condoms. A large percentage of those infected are unaware of their disease status, which complicates prevention. Spouses are often infected without their knowledge of their partner's status.

Occupational infection can be prevented with the use of universal precautions and by post-exposure prophylaxis.

Currently, no vaccine is available, and it is not clear if a vaccine will be available any time in the near future.

References

Mandell, Bennett, & Dolin: Principles and Practice of Infectious Diseases, 6th ed., Copyright © 2005 Churchill Livingstone, An Imprint of Elsevier

Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep. 2005;54:1-17.

www.cdc.gov

THE LANCET, Volume 357: Pages 1149-1153, 14 April 2001.

AIDSWEEKLY Plus; Monday, August 9, 1999

THE LANCET, 30 March 2007, reported in The Guardian, 30 March 2007 [1]