aids in africa

aids africa

2009-11-14T17:55:00.000-08:00

The HIV/AIDS epidemics spreading through the countries of Sub-Saharan Africa are highly varied. Although it is not correct to speak of a single African epidemic, Africa is without doubt the region most affected by the virus. Inhabited by just over 12% of the world's population, Africa is estimated to have more than 60% of the AIDS-infected population. Much of the deadliness of the epidemic in Sub-Saharan Africa has to do with a deadly synergy between HIV and tuberculosis.^[1], though this synergy is by no means limited to Africa. In fact, tuberculosis is the world's greatest infectious killer of women of reproductive age and the leading cause of death among people with HIV/AIDS

Several factors contribute to the spread of the HIV virus. For one, a stigma is attached to admitting to HIV infection and to using condoms. For another, many deny that the HIV virus causes AIDS: Thabo Mbeki and Robert Mugabe have both suggested AIDS stems from poverty rather than HIV infection. And finally, many myths are attached to the use of condoms, such as the ideas that a conspiracy wants to limit the growth of the African population and that condoms stifle the traditional power of the man in his community.

In the 35 African nations with the highest prevalence, average life expectancy is 48.3 years—6.5 years less than it would be without the disease.^{[citation needed]} For the eleven countries in Africa with prevalence rates above 13%, life expectancy is 47.7 years—11.0 years less than would be expected without HIV/AIDS.

Although many governments in sub-Saharan Africa denied that there was a problem for years, they have now begun to work toward solutions.

Health spending in Africa has never been adequate, either before or after independence. The health care systems inherited from colonial powers were oriented toward curative treatment rather than preventative programs. Strong prevention programs are the cornerstone of effective national responses to AIDS, and the required changes in the health sector have presented huge challenges.

Lack of money is an obvious challenge, although a great deal of aid is distributed throughout developing countries with high HIV/AIDS rates. Response to the epidemic is also hampered by lack of infrastructure, corruption within both donor agencies and government agencies, foreign donors not coordinating with local government and misguided resources.

Changes in life expectancy in several African countries. Botswana has been particularly badly hit [1], while public education projects campaigns have had a positive effect in Uganda [2]. (Source: World Bank World Development Indicators, 2004).

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has predicted outcomes for the region to the year 2025. These range from a plateau and eventual decline in deaths beginning around 2012 to a catastrophic continual growth in the death rate with potentially 90 million cases of infection.

Without the kind of nutrition, health care and medicines (such as anti-retrovirals) that are available in developed countries, large numbers of people in Africa will develop full-blown AIDS. They will not only be unable to work, but will also require significant medical care. This will likely cause a collapse of economies and societies. In all of the severely affected countries, the epidemic has left behind many orphans, who are either cared for by extended family members, or must live in orphanages or on the street. Of the ones who are left unattended, these orphans must find ways to fend for themselves. While struggling to fend for themselves, they must also try and find ways to take care of sick relatives and grandparents who are also suffering from AIDS. In turn, this not only deprives children of their very livelyhood but also deprives them of many educational opportunities, which have a profound effect on their self confidence. UNAIDS, WHO and UNDP have already documented decreasing life expectancies and lowering of GNP in many African countries with prevalence rates of 10% or more.^{[citation needed]}

In an article titled "Death Stalks A Continent" Johanna McGeary attempts to describe the severity of the issue. “Society's fittest, not its frailest, are the ones who die--adults spirited away, leaving the old and the children behind. You cannot define risk groups: everyone who is sexually active is at risk. Babies too, (are) unwittingly infected by mothers. Barely a single family remains untouched. Most do not know how or when they caught the virus, many never know they have it, many who do know don't tell anyone as they lie dying” (Time Magazine, Johanna McGeary 2001).^{[citation needed]}

There may be elements in general African culture that discourage discussion and the practice of prophylaxis: “Even when a woman wants to protect herself, she usually can't: it is not uncommon for men to beat partners who refuse intercourse or request a condom” (Time Magazine, Johanna McGeary 2001).

A minority of scientists claim that as many as 40% of HIV infections in African adults may be caused by unsafe medical practices rather than by sexual activity.^[3] The World Health Organization states that about 2.5% of AIDS infections in sub-Saharan Africa are caused by unsafe medical injection practices and the "overwhelming majority" by unprotected sex.^[4]

[edit] Measuring the epidemic

Prevalence measures include everyone living with HIV and AIDS, and present a delayed representation of the epidemic by aggregating the HIV infections of many years. Incidence, in contrast, measures the number of new infections, usually over the previous year. There is no practical, reliable way to assess incidence in sub-Saharan Africa. Prevalence in 15–24 year old pregnant women attending antenatal clinics is sometimes used as an approximation; these measurements are called serosurveys.

Health units that conduct serosurveys rarely operate in remote rural communities and the data collected also does not measure people who seek alternate healthcare. And extrapolating national data from antenatal surveys relies on assumptions which may not hold across all regions and at different stages in an epidemic.

Recent national population or household-based surveys, collecting data from both sexes, pregnant and non-pregnant women and rural and urban areas, have adjusted the recorded national prevalence levels for several countries in Africa and elsewhere. These too, are not perfect: People may not participate in household surveys because they fear they may be HIV positive and do not want to know their test results. Household surveys also exclude migrant labourers, who are a high risk group.

Thus, there may be significant disparities between official figures and actual HIV prevalence in some countries.

New anti-retroviral drugs (ARVs) can slow down and even reverse the progression of HIV infection, delaying the onset of AIDS by twenty years or more. Because of their high cost ($10,000 to $15,000 USD per person per year (pppy) in the West for patent drugs and approximately $800 USD pppy in some African countries for generic drugs), only a few of the 6 million people in developing countries who need ARV treatment have access to medication. Nevertheless, access to ARV therapy has increased more than eightfold since the end of 2003, with about 810,000 people (13.5 per cent of the 6 million in need) on the treatment.

ARVs play a central role in prevention as well. When treatments are known to be available, people are more likely to come forward for testing and well as more likely to adopt lower risk behaviours^{[citation needed]}. ARVs also reduce the amount of the HIV virus in the blood, thus reducing the risk of further transmission.

Patients who start HIV treatment generally have to continue taking medications for the rest of their lives. In areas where drug therapy is expensive, some people must interrupt their treatment. The key factor in the expense of ARVs is their patent status, which allows drug companies to recoup research costs and turn a profit, enabling the development of new drugs. International aid organisations such as VSO, Oxfam and Médecins Sans Frontières have questioned whether the revenues generated by ARVs really tally with research costs.

Generic copies of patented ARV drugs are supplied by drug manufacturers in India, South Africa, Brazil, Thailand, and the People's Republic of China. Because fees are not paid to the patent holders, the drugs can be distributed at low prices in developing countries. Generic production competition and 'price offers' (voluntary donations by companies) have forced patent holders to reduce their prices.

ARV patients need regular testing of viral load and CD4 cell count. This requires expensive laboratory equipment and good healthcare logistics. These costs drive the price of generic ARV therapy in African countries up from under $140 USD per person per year (pppy) for the drugs alone to approximately $800 USD pppy when done according to Western standards.^[5]

For many Africans, living below the poverty threshold of a $2 USD / day, free (government or NGO-funded) treatment remains the only option.

The World Health Organisation's 3 by 5 initiative aimed to provide three million people with ARV treatment by the end of 2005. International aid organisations have lobbied for an expansion of generic production in developing countries, for immediate short term and stable, predictable long term financing of the 3 by 5 initiative.

The United States AIDS initiative, PEPFAR^[6], is focusing two thirds of its resources on AIDS in Africa. Starting in 2004, expenditures rose from $2.3B world-wide to $3.3B in 2006. A funding level of $4B was requested for 2007.^[7]

The DREAM ("Drug Resources Enhancement against AIDS and Malnutrition", formerly "Drug Resource Enhancement against AIDS in Mozambique") initiative promoted by the Community of Sant'Egidio has given access to free ARV treatment with generic HAART drugs to the poor on a large scale. So far, 5,000 people are receiving ARV treatment, especially in Mozambique, but the program is also being built up in Malawi, Guinea, Tanzania and other countries. The program includes regular blood testing according to European standards. It is linked with nutrition and sanitation programs run by volunteers. The compliance rate is 94 per cent.

East-central Africa

In this article, East and central Africa consists of Uganda, Kenya, Tanzania, Democratic Republic of Congo, the Congo Republic, Gabon, Equatorial Guinea, the Central African Republic, Rwanda, Burundi and Ethiopia and Eritrea on the Horn of Africa. In 1982, Uganda was the first state in the region to declare HIV cases. This was followed by Kenya in 1984 and Tanzania in 1985.

Country	Adult prevalence	Total HIV	Deaths 2003
Tanzania	8.8%	1,500,000	160,000
Kenya	6.7%	1,100,000	150,000
Congo	4.9%	80,000	9,700
Ethiopia	4.4%*	1,400,000	120,000
Congo DR	4.2%	1,000,000	100,000
Uganda	4.1%	450,000	78,000
Eritrea	2.7%	55,000	6,300

Some areas of East Africa are beginning to show substantial declines in the prevalence of HIV infection. In the early 1990s, 13% of Ugandan residents were HIV positive; This has now dropped to 4.1% by the end of 2003. Evidence may suggest that the tide may also be turning in Kenya: prevalence fell from 13.6% in 1997–1998 to 9.4% in 2002. Data from Ethiopia and Burundi are also hopeful. HIV prevalence levels still remain high, however, and it is too early to claim that these are permanent reversals in these countries' epidemics.

Most governments in the region established AIDS education programmes in the mid-1980s in partnership with the World Health Organization and international NGOs. These programmes commonly taught the 'ABC' of HIV prevention: a combination of abstinence (A), fidelity to your partner (Be faithful) and condom use (C). The efforts of these educational campaigns appear now to be bearing fruit. In Uganda, awareness of AIDS is demonstrated to be over 99% and more than three in five Ugandans can cite two or more preventative practices. Youths are also delaying the age at which sexual intercourse first occurs.

There are no non-human vectors of HIV infection. The spread of the epidemic across this region is closely linked to the migration of labour from rural areas to urban centres, which generally have a higher prevalence of HIV. Labourers commonly picked up HIV in the towns and cities, spreading it to the countryside when they visited their home. Empirical evidence brings into sharp relief the connection between road and rail networks and the spread of HIV. Long distance truck drivers have been identified as a group with the high-risk behaviour of sleeping with prostitutes and a tendency to spread the infection along trade routes in the region. Infection rates of up to 33% were observed in this group in the late 1980s in Uganda, Kenya and Tanzania.

West Africa

For the purposes of this discussion, Western Africa shall include the coastal countries of Mauritania, Senegal, The Gambia, Cape Verde, Guinea-Bissau, Guinea, Sierra Leone, Liberia, Côte d'Ivoire, Ghana, Togo, Benin, Nigeria and the landlocked states of Mali, Burkina Faso, Niger and cameroon,

Country	Adult prevalence	Total HIV	Deaths 2005
Cameroon	15.9%	100,000	82,000
Cote D'Ivoire	7.1%	750,000	65,000
Liberia	5.9%	100,000	72,000
Guinea-Bissau	3.8%	32,000	2,700
Togo	3.2%	110,000	9,100
Nigeria	2.5%	3,600,000	310,000
Gambia	2.4%	20,000	1,300
Ghana	2.3%	320,000	29,000
Burkina Faso	2.0%	150,000	12,000
Benin	1.8%	87,000	9,600
Mali	1.7%	130,000	11,000
Sierra Leone	1.6%	48,000	4,600
Guinea	1.5%	85,000	7,100
Niger	1.1%	79,000	7,600
Senegal	0.8%	44,000	3,500
Mauritania	0.7%	12,000	<1,000

The region has generally high levels of infection of both HIV-1 and HIV-2. The onset of the HIV epidemic in West Africa began in 1985 with reported cases in Cote d'Ivoire, Benin and Mali. Nigeria, Burkina Faso, Ghana, Cameroon, Senegal and Liberia followed in 1986. Sierra Leone, Togo and Niger in 1987; Mauritiana in 1988; The Gambia, Guinea-Bissau, and Guinea in 1989; and finally Cape Verde in 1990.

HIV prevalence in West Africa is lowest in Chad, Niger, Mali, Mauritania and highest in Burkina Faso, Côte d'Ivoire, and Nigeria. Nigeria has the second largest number of people living with HIV in Africa after South Africa, although the infection rate (number of patients relative to the entire population) based upon Nigeria's estimated population is much lower, generally believed to be well under 7%, as opposed to South Africa's which is well into the double-digits (nearer 30%).

The main driver of infection in the region is commercial sex. In the Ghanaian capital Accra, for example, 80% of HIV infections in young men had been acquired from women who sell sex. In Niger, the adult national HIV prevalence was 1% in 2003, yet surveys of sex workers in different regions found a HIV infection rate of between 9 and 38%.

Southern Africa

In the mid-1980s, HIV and AIDS were virtually unheard of in Southern Africa - it is now the worst-affected region in the world. Of the eleven southern African countries - Angola, Namibia, Zambia, Zimbabwe, Botswana, Malawi, Mozambique, South Africa, Lesotho, Swaziland, Madagascar- at least six estimate an infection rate of over 20%. Angola presents the lowest infection rate of less than 5%. This is not the result of a successful national response to the threat of AIDS but of the long-running Angolan Civil War (1975-2002). In most African communities, as in other communities around the world, people do not limit their sexual activities to one lifetime partner. Aside from polygynous relationships, which can be quite prevalent in parts of Africa, there are also wide-spread practices of sexual networking that involve multiple overlapping or concurrent sexual partners.^[9] Men’s sexual networks, in particular, tend to be quite extensive, a fact that is tacitly accepted by many communities. Cultural or social norms often indicate that while women must remain faithful men are able and even expected to philander irrespective of their marital status. Along with the occurrence of multiple sexual partners, unemployment and population displacements that result from drought and conflict contribute to the spread of HIV/AIDS.

There are few indicators of country wide declines in infection. In its December 2005 report, UNAIDS reports that Zimbabwe has experienced a drop in infections; however, most independent observers find the confidence of UNAIDS in the Mugabe government's HIV figures to be misplaced, especially since infections have continued to increase in all other southern African countries (with the exception of a possible small drop in Botswana). Almost 30% of the global number of people living with HIV live in an area where only 2% of the world's population reside.

Most HIV infections found in Southern Africa are HIV-1, the world's most common HIV infection, which predominates everywhere except West Africa, home to HIV-2. The first cases of HIV in the region were reported in Zimbabwe in 1985.

Africa's HIV/AIDS epidemic has had important effects on society, economics and politics in the continent. (Source: Tony Barnett and Alan Whiteside, "AIDS in the 21st Century: Disease and Globalization," (MacMillan Palgrave 2003)). The economic impact of AIDS is noticed in slower economic growth, a distortion in spending, increased inflows of international assistance, and changing demographic structure of the population. There are also fears that a major long-term drop in adult life-expectancy will change the rationale for economic decision-making, contributing to lower savings and investment rates. However, most of these impacts remain theoretically possible rather than empirically observed. Economists in South Africa have developed the most sophisticated models for the impacts of the epidemic, and Nicoli Nattrass in "The Moral Economy of AIDS in South Africa" estimates that it is possible for the South African government to provide universal access to anti-retroviral therapy without overstretching the national budget. AIDS has intersected with drought, unemployment and other sources of stress to create what Alan Whiteside and Alex de Waal have called "new variant famine," characterized by the inability of poor, AIDS-affected households to cope with the demands of securing sufficient food during a time of food crisis.

The social impact of HIV/AIDS is most evident in the continent's orphans crisis. Approximately 12 million children in sub-Saharan Africa are estimated to be orphaned by AIDS. These children are overwhelmingly cared for by relatives including especially grandmothers, but the capacity of the extended family to cope with this burden is stretched very thin and is, in places, collapsing. UNICEF and other international agencies consider a scaled-up response to Africa's orphan crisis a humanitarian priority. Practitioners and welfare specialists are sensitive to the need not to identify and isolate children orphaned by AIDS from other needy and vulnerable children, in part because of fear of stigmatizing them. Therefore, there is a search for effective social policies and programs that will provide necessary assistance and protection for all orphans and vulnerable children.

The effect of the HIV/AIDS crisis on the education system in Sub-Saharan Africa also demonstrates the epidemic's negative social impact. The Basic Education Coalition underlines the importance of investing in education to “...turn back the AIDS epidemic... [W]ithout education, AIDS will continue its rampant speed. With AIDS out of control, education will be out of reach”^[10]. Currently preventing Education for All, is the alienation students stigmatized by HIV/AIDS feel within their schooling systems. This is especially true in orphans, where after losing both parents to HIV/AIDS, 22% of children find themselves excluded from the schooling system, and indirectly forced to live on the streets^[11]. In Tanzania, more than 3000 children have been lured away from their rural homes to Dodma in hopes of finding work^[11]. Due to low teacher-to-student ratios, anywhere from 1:50 to 1:120^[12], schools are often forced to illegally turn students away. In Uganda, it's estimated that 1/3 of students have at some point been sent home, regarding unpaid tuition fees, or simply the fact that they lack the required school supplies or can not afford to buy the school uniform^[13]. The additional stresses effectuated by HIV/AIDS in a child's life (strenuous household labor, nursing one's parents, or being the family's financial provider) significantly contribute to the resulting behaviors (lack of concentration in class, frequent incompletion of homework, emotional outbursts of aggression and crying, or withdrawal from fellow students) causing 32% of urban and 68% of rural HIV/AIDS orphaned children to be not currently enrolled in their local Kagera, Tanzania schooling program^[11]. However, it is becoming increasingly common for an orphaned student's absenteeism rate to be lower than that of a student not directly impacted by the epidemic^[13]. The “normalcy” that school instills by being a constant in the child's life, along with a free daily nutritious meal, a program mandatory only in Botswana, draws the child to school, even if the learning environment is not always friendly and welcoming^[14].

The political impact of the epidemic has been little studied. There has been much concern that high levels of HIV among soldiers and political leaders could lead to a "hollowing out" or even collapse of essential state structures, and an escalation of conflict. Laurie Garrett of the Council on Foreign Affairs is most publicly associated with this position. However, it is also clear that the epidemic has coincided with the entrenchment of democracy in much of Africa, and that governments and armies have learned to cope with the effects of the epidemic.

aids in africa

2009-11-14T17:49:00.000-08:00

Acquired immune deficiency syndrome or acquired immunodeficiency syndrome (AIDS) is a disease of the human immune system caused by the human immunodeficiency virus (HIV).^[1]^[2]^[3]

This condition progressively reduces the effectiveness of the immune system and leaves individuals susceptible to opportunistic infections and tumors. HIV is transmitted through direct contact of a mucous membrane or the bloodstream with a bodily fluid containing HIV, such as blood, semen, vaginal fluid, preseminal fluid, and breast milk.^[4]^[5]

This transmission can involve anal, vaginal or oral sex, blood transfusion, contaminated hypodermic needles, exchange between mother and baby during pregnancy, childbirth, breastfeeding or other exposure to one of the above bodily fluids.

AIDS is now a pandemic.^[6] In 2007, it was estimated that 33.2 million people lived with the disease worldwide, and that AIDS killed an estimated 2.1 million people, including 330,000 children.^[7] Over three-quarters of these deaths occurred in sub-Saharan Africa,^[7] retarding economic growth and destroying human capital.^[8]

Genetic research indicates that HIV originated in west-central Africa during the late nineteenth or early twentieth century.^[9]^[10] AIDS was first recognized by the U.S. Centers for Disease Control and Prevention in 1981 and its cause, HIV, identified in the early 1980s.^[11]

Although treatments for AIDS and HIV can slow the course of the disease, there is currently no vaccine or cure. Antiretroviral treatment reduces both the mortality and the morbidity of HIV infection, but these drugs are expensive and routine access to antiretroviral medication is not available in all countries.^[12] Due to the difficulty in treating HIV infection, preventing infection is a key aim in controlling the AIDS pandemic, with health organizations promoting safe sex and needle-exchange programmes in attempts to slow the spread of the virus.

The symptoms of AIDS are primarily the result of conditions that do not normally develop in individuals with healthy immune systems. Most of these conditions are infections caused by bacteria, viruses, fungi and parasites that are normally controlled by the elements of the immune system that HIV damages.

Opportunistic infections are common in people with AIDS.^[13] HIV affects nearly every organ system.

People with AIDS also have an increased risk of developing various cancers such as Kaposi's sarcoma, cervical cancer and cancers of the immune system known as lymphomas. Additionally, people with AIDS often have systemic symptoms of infection like fevers, sweats (particularly at night), swollen glands, chills, weakness, and weight loss.^[14]^[15] The specific opportunistic infections that AIDS patients develop depend in part on the prevalence of these infections in the geographic area in which the patient lives.

Pulmonary infections

Pneumocystis pneumonia (originally known as Pneumocystis carinii pneumonia, and still abbreviated as PCP, which now stands for Pneumocystis pneumonia) is relatively rare in healthy, immunocompetent people, but common among HIV-infected individuals. It is caused by Pneumocystis jirovecii.

Before the advent of effective diagnosis, treatment and routine prophylaxis in Western countries, it was a common immediate cause of death. In developing countries, it is still one of the first indications of AIDS in untested individuals, although it does not generally occur unless the CD4 count is less than 200 cells per µL of blood.^[16]

Tuberculosis (TB) is unique among infections associated with HIV because it is transmissible to immunocompetent people via the respiratory route, is easily treatable once identified, may occur in early-stage HIV disease, and is preventable with drug therapy. However, multidrug resistance is a potentially serious problem.

Even though its incidence has declined because of the use of directly observed therapy and other improved practices in Western countries, this is not the case in developing countries where HIV is most prevalent. In early-stage HIV infection (CD4 count >300 cells per µL), TB typically presents as a pulmonary disease. In advanced HIV infection, TB often presents atypically with extrapulmonary (systemic) disease a common feature. Symptoms are usually constitutional and are not localized to one particular site, often affecting bone marrow, bone, urinary and gastrointestinal tracts, liver, regional lymph nodes, and the central nervous system.^[17]

Gastrointestinal infections

Esophagitis is an inflammation of the lining of the lower end of the esophagus (gullet or swallowing tube leading to the stomach). In HIV infected individuals, this is normally due to fungal (candidiasis) or viral (herpes simplex-1 or cytomegalovirus) infections. In rare cases, it could be due to mycobacteria.^[18]

Unexplained chronic diarrhea in HIV infection is due to many possible causes, including common bacterial (Salmonella, Shigella, Listeria or Campylobacter) and parasitic infections; and uncommon opportunistic infections such as cryptosporidiosis, microsporidiosis, Mycobacterium avium complex (MAC) and viruses,^[19] astrovirus, adenovirus, rotavirus and cytomegalovirus, (the latter as a course of colitis).

In some cases, diarrhea may be a side effect of several drugs used to treat HIV, or it may simply accompany HIV infection, particularly during primary HIV infection. It may also be a side effect of antibiotics used to treat bacterial causes of diarrhea (common for Clostridium difficile). In the later stages of HIV infection, diarrhea is thought to be a reflection of changes in the way the intestinal tract absorbs nutrients, and may be an important component of HIV-related wasting.^[20]

Neurological and psychiatric involvement

HIV infection may lead to a variety of neuropsychiatric sequelae, either by infection of the now susceptible nervous system by organisms, or as a direct consequence of the illness itself.

Toxoplasmosis is a disease caused by the single-celled parasite called Toxoplasma gondii; it usually infects the brain, causing toxoplasma encephalitis, but it can also infect and cause disease in the eyes and lungs.^[21] Cryptococcal meningitis is an infection of the meninx (the membrane covering the brain and spinal cord) by the fungus Cryptococcus neoformans. It can cause fevers, headache, fatigue, nausea, and vomiting. Patients may also develop seizures and confusion; left untreated, it can be lethal.

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease, in which the gradual destruction of the myelin sheath covering the axons of nerve cells impairs the transmission of nerve impulses. It is caused by a virus called JC virus which occurs in 70% of the population in latent form, causing disease only when the immune system has been severely weakened, as is the case for AIDS patients. It progresses rapidly, usually causing death within months of diagnosis.^[22]

AIDS dementia complex (ADC) is a metabolic encephalopathy induced by HIV infection and fueled by immune activation of HIV infected brain macrophages and microglia. These cells are productively infected by HIV and secrete neurotoxins of both host and viral origin.^[23] Specific neurological impairments are manifested by cognitive, behavioral, and motor abnormalities that occur after years of HIV infection and are associated with low CD4⁺ T cell levels and high plasma viral loads.

Prevalence is 10–20% in Western countries^[24] but only 1–2% of HIV infections in India.^[25]^[26] This difference is possibly due to the HIV subtype in India. AIDS related mania is sometimes seen in patients with advanced HIV illness; it presents with more irritability and cognitive impairment and less euphoria than a manic episode associated with true bipolar disorder. Unlike the latter condition, it may have a more chronic course. This syndrome is less often seen with the advent of multi-drug therapy.

Tumors and malignancies

Kaposi's sarcoma

Patients with HIV infection have substantially increased incidence of several cancers. This is primarily due to co-infection with an oncogenic DNA virus, especially Epstein-Barr virus (EBV), Kaposi's sarcoma-associated herpesvirus (KSHV) (also known as human herpesvirus-8 [HHV-8]), and human papillomavirus (HPV).^[27]^[28]

Kaposi's sarcoma (KS) is the most common tumor in HIV-infected patients. The appearance of this tumor in young homosexual men in 1981 was one of the first signals of the AIDS epidemic. Caused by a gammaherpes virus called Kaposi's sarcoma-associated herpes virus (KSHV), it often appears as purplish nodules on the skin, but can affect other organs, especially the mouth, gastrointestinal tract, and lungs. High-grade B cell lymphomas such as Burkitt's lymphoma, Burkitt's-like lymphoma, diffuse large B-cell lymphoma (DLBCL), and primary central nervous system lymphoma present more often in HIV-infected patients. These particular cancers often foreshadow a poor prognosis. Epstein-Barr virus (EBV) or KSHV cause many of these lymphomas. In HIV-infected patients, lymphoma often arises in extranodal sites such as the gastrointestinal tract. ^[29] When they occur in an HIV-infected patient, KS and aggressive B cell lymphomas confer a diagnosis of AIDS.

Invasive cervical cancer in HIV-infected women is also considered AIDS-defining. It is caused by human papillomavirus (HPV).^[30]

In addition to the AIDS-defining tumors listed above, HIV-infected patients are at increased risk of certain other tumors, notably Hodgkin's disease, anal and rectal carcinomas, hepatocellular carcinomas, head and neck cancers, and lung cancer. Some of these are causes by viruses, such as Hodgkin's disease (EBV), anal/rectal cancers (HPV), head and neck cancers (HPV), and hepatocellular carcinoma (hepatitis B or C). Other contributing factors include exposure to carcinogens (cigarette smoke for lung cancer), or living for years with subtle immune defects.

Interestingly, the incidence of many common tumors, such as breast cancer or colon cancer, does not increase in HIV-infected patients. In areas where HAART is extensively used to treat AIDS, the incidence of many AIDS-related malignancies has decreased, but at the same time malignant cancers overall have become the most common cause of death of HIV-infected patients.^[31] In recent years, an increasing proportion of these deaths have been from non-AIDS-defining cancers.

Other infections

AIDS patients often develop opportunistic infections that present with non-specific symptoms, especially low-grade fevers and weight loss. These include opportunistic infection with Mycobacterium avium-intracellulare and cytomegalovirus (CMV). CMV can cause colitis, as described above, and CMV retinitis can cause blindness.

Penicilliosis due to Penicillium marneffei is now the third most common opportunistic infection (after extrapulmonary tuberculosis and cryptococcosis) in HIV-positive individuals within the endemic area of Southeast Asia.^[32]

An infection that often goes unrecognized in AIDS patients is Parvovirus B19. Its main consequence is anemia, which is difficult to distinguish from the effects of antiretroviral drugs used to treat AIDS itself.^[33]

AIDS is the most severe acceleration of infection with HIV. HIV is a retrovirus that primarily infects vital organs of the human immune system such as CD4⁺ T cells (a subset of T cells), macrophages and dendritic cells. It directly and indirectly destroys CD4⁺ T cells.^[34]

Once HIV has killed so many CD4⁺ T cells that there are fewer than 200 of these cells per microliter (µL) of blood, cellular immunity is lost. Acute HIV infection progresses over time to clinical latent HIV infection and then to early symptomatic HIV infection and later to AIDS, which is identified either on the basis of the amount of CD4⁺ T cells remaining in the blood, and/or the presence of certain infections, as noted above.^[35]

In the absence of antiretroviral therapy, the median time of progression from HIV infection to AIDS is nine to ten years, and the median survival time after developing AIDS is only 9.2 months.^[36] However, the rate of clinical disease progression varies widely between individuals, from two weeks up to 20 years.

Many factors affect the rate of progression. These include factors that influence the body's ability to defend against HIV such as the infected person's general immune function.^[37]^[38] Older people have weaker immune systems, and therefore have a greater risk of rapid disease progression than younger people.

Poor access to health care and the existence of coexisting infections such as tuberculosis also may predispose people to faster disease progression.^[36]^[39]^[40] The infected person's genetic inheritance plays an important role and some people are resistant to certain strains of HIV. An example of this is people with the homozygous CCR5-Δ32 variation are resistant to infection with certain strains of HIV.^[41] HIV is genetically variable and exists as different strains, which cause different rates of clinical disease progression.^[42]^[43]^[44]

The diagnosis of AIDS in a person infected with HIV is based on the presence of certain signs or symptoms. Since June 5, 1981, many definitions have been developed for epidemiological surveillance such as the Bangui definition and the 1994 expanded World Health Organization AIDS case definition. However, clinical staging of patients was not an intended use for these systems as they are neither sensitive, nor specific. In developing countries, the World Health Organization staging system for HIV infection and disease, using clinical and laboratory data, is used and in developed countries, the Centers for Disease Control (CDC) Classification System is used.

HIV test

Main article: HIV test

Many people are unaware that they are infected with HIV.^[73] Less than 1% of the sexually active urban population in Africa has been tested, and this proportion is even lower in rural populations. Furthermore, only 0.5% of pregnant women attending urban health facilities are counseled, tested or receive their test results. Again, this proportion is even lower in rural health facilities.^[73] Therefore, donor blood and blood products used in medicine and medical research are screened for HIV.

HIV tests are usually performed on venous blood. Many laboratories use fourth generation screening tests which detect anti-HIV antibody (IgG and IgM) and the HIV p24 antigen. The detection of HIV antibody or antigen in a patient previously known to be negative is evidence of HIV infection. Individuals whose first specimen indicates evidence of HIV infection will have a repeat test on a second blood sample to confirm the results.

The window period (the time between initial infection and the development of detectable antibodies against the infection) can vary since it can take 3–6 months to seroconvert and to test positive. Detection of the virus using polymerase chain reaction (PCR) during the window period is possible, and evidence suggests that an infection may often be detected earlier than when using a fourth generation EIA screening test.

Positive results obtained by PCR are confirmed by antibody tests.^[74] Routinely used HIV tests for infection in neonates and infants (ie, patients younger than 2 years),^[75] born to HIV-positive mothers, have no value because of the presence of maternal antibody to HIV in the child's blood. HIV infection can only be diagnosed by PCR, testing for HIV pro-viral DNA in the children's lymphocytes

The three main transmission routes of HIV are sexual contact, exposure to infected body fluids or tissues, and from mother to fetus or child during perinatal period. It is possible to find HIV in the saliva, tears, and urine of infected individuals, but there are no recorded cases of infection by these secretions, and the risk of infection is negligible

HIV tests are used to detect the presence of the human immunodeficiency virus in serum, saliva, or urine. Such tests may detect HIV antibodies, antigens, or RNA.