8816 Understanding HIV 9/4/03 9:52 am Page 1

Understanding HIV infection and AIDS

Third Edition

HIV&
The HIV & AIDS charity for life
Website: www.tht.org.uk THT Direct: 0845 12 21 200
Registered office: 52-54 Grays Inn Road, London WC1X 8JU
Tel: 020 7831 0330 Email: info@tht.org.uk

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AIDS
Registered in England. A company limited by guarantee.
8816 Understanding HIV 9/4/03
1 What is HIV and AIDS?
2 How is HIV transmitted?
3 What is the HIV test?
4 How does HIV affect the body?
5 What happens when someone has HIV?
Terrence Higgins Trust 2003
9:52 am Page 3
1
1 What is HIV and AIDS?
HIV (Human Immunodeficency Virus) is a virus which
attacks the body's immune system. For a certain period
2 of time, which may be several years, the body's defence
mechanism will keep the HIV infection under control.
8 During this time, a person with HIV may feel completely
well and have no symptoms. However, in the majority
11 of cases, the immune system eventually needs help,
in the form of anti-HIV drugs, to keep the HIV infection
17 under control.
Although you may still hear the term AIDS (Acquired
Immune Deficiency Syndrome) it is no longer used by
doctors. They prefer to talk of late-stage or advanced HIV
infection. Before effective treatments, AIDS was a state
someone infected with HIV almost inevitably entered as
HIV attacked their immune system. This is no longer
the case.
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2 How is HIV transmitted?
In order for someone to become infected, a sufficient
amount of HIV must enter their bloodstream. This level
of HIV is found in some, but not all of the body fluids
of someone infected with HIV. Those body fluids which
contain enough HIV to infect someone are:
blood
sperm and seminal fluid
vaginal fluids, including menstrual fluids
breast milk
Other body fluids like saliva, sweat or urine do not contain
enough virus to infect another person.
There are a number of routes, all quite difficult to achieve
by accident, by which infectious body fluids from someone
with HIV may enter the bloodstream of someone else:
Directly into the bloodstream; for example, via a
puncture caused by injection equipment.
Via an organ transplant or blood transfusion.
Through the internal surface (mucous membrane) of
the rectum, vagina, cervix or urethra.
HIV cannot pass through intact external skin. It cannot
pass through the air like a cold or flu virus.
2 3
HIV and sex
HIV can pass from an infected person to an uninfected person
during unprotected penetrative sexual intercourse; that is, sex
where the penis, unprotected by a condom, enters the vagina
or anus.
Using a condom with a water-based lubricant or a femidom
during vaginal or anal penetrative sex will prevent transmission
of HIV and many other sexually transmitted diseases.
HIV and sexual intercourse between men
Up until recently, in the UK, Northern Europe and parts of
the United States, the most serious impact of the virus has
been felt by gay men. Thirty four percent of men in the UK
who were infected by HIV before the end of 2002 were
infected through sexual intercourse with other men.
HIV and sexual intercourse between men
and women
The number of people becoming infected through unprotected
heterosexual sex is increasing. In 2002, in the UK, 63 per cent
of all people infected with HIV became infected during
unprotected sex with someone of the opposite sex who
had HIV.
8816 Understanding HIV 9/4/03 9:52 am Page 4
Unlike the UK, USA and Northern Europe, in Asia and
sub-Saharan Africa, HIV is transmitted most frequently by
sexual intercourse between men and women. In the UK, HIV
has had a devastating effect on communities of people from
parts of Africa where HIV has taken hold.
HIV and oral sex
It is possible for HIV to be transmitted through oral sex.
As far as we know, sucking on the penis of a man with
HIV is the type of oral sex most likely to lead to transmission
of HIV. Although there is enough virus in semen to infect
another person, it is difficult for the virus to survive in the
mouth, and it is difficult for the virus to get from the mouth
into the blood stream.
Licking the labia or clitoris of a woman with HIV is less
risky than oral sex with a man who has HIV.
Someone whose genitals are sucked or licked by a person
with HIV is less likely to become infected. But a small
number of cases of infection through this route are
known.
4 5
HIV and other sexual activities
One sexual activity which is risky if one partner has HIV,
is sharing a sex toy. That is, inserting an object into the
vagina or anus of more than one person without washing
it carefully between users or putting a clean condom on
it between users.
It is hard for HIV to be passed from one person to another
through: deep kissing, mutual masturbation, or via fingers
inserted into the vagina or anus, unless covered in blood
or other infectious fluids.
HIV and shared injection equipment
In 2002, in the UK, 2 per cent of those who became infected
with HIV did so through sharing drug injecting equipment
with someone with HIV. Sharing injecting equipment is as
risky as having unprotected sex with someone who has
HIV. In Scotland, Southern Europe and parts of the USA,
shared drug injecting equipment is the most common
route of infection.
People who inject drugs can avoid transmitting HIV and
other viruses present in the blood, either to themselves or
to others, by using new injecting equipment every time, or
by sterilising equipment between users.
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To combat the spread of HIV and other viruses among
people who inject drugs through contaminated injecting
equipment, many countries have initiated needle exchange
programmes. That is, making available free clean injecting
equipment to people who inject drugs.
HIV and blood transfusions
Early in the epidemic, a number of people in the UK were
infected with HIV through blood transfusions. However, all
blood donations and tissue donations in the UK have been
tested for HIV since 1985. In some countries, infection
through blood transfusion is still a significant risk.
Haemophilia
Factor 8 is a product of donated blood which is used by
people who have haemophilia. Before it was known that
donated blood might contain HIV, many people with
haemophilia became infected in the UK through receiving
contaminated blood products. All blood products are now
treated to destroy any HIV which may be present.
6 7
HIV and pregnancy
A women with HIV, who becomes pregnant can sometimes
transmit the virus to her baby before or during birth (vertical
transmission). HIV can also be passed to a baby during
breastfeeding if the mother has HIV. In the absence of any
preventative interventions, the risk of vertical transmission
is about one in seven.
This risk can be greatly reduced if the pregnant woman is
given a short course of an anti-HIV drug, starting a few
weeks before the birth and continued, to both mother and
new born, for a short period after the birth. (The most
effective anti-HIV drugs to be given to the mother before
birth, and how long she should take them are both areas
of current research activity.) The other two interventions
which greatly reduce the risk of vertical transmission are:
delivering the new born by elected Caesarean section and
avoiding breastfeeding, as breast milk contains significant
levels of HIV. If these three preventative interventions are
followed, the risk of vertical transmission has been
shown to fall to as low as two in 100.
In the UK in 2002, 57 children were born infected by HIV
as a result of vertical transmission.
8816 Understanding HIV 9/4/03 9:52 am Page 8

3 What is the HIV test?

The HIV test shows whether someone has HIV, the virus A positive result
that is responsible for what was in the past called AIDS. If the test finds HIV antibodies, the result is said to be
It is not a test for AIDS. positive. You would then be HIV antibody positive or 'HIV
positive'. This means you have HIV infection. It does not
Antibodies
mean you have AIDS. The test cannot show whether you
The most commonly available HIV test is more properly
are ill, or are going to become ill. For those found to be
called an HIV antibody test, because it looks for antibodies
HIV positive, combination therapy can successfully reduce
to HIV. Antibodies are created by the infected person's
the level of HIV in their blood and has had a dramatic
immune system in response to the presence of HIV.
effect in improving the health of many people with HIV.
The window period (seroconversion)
A negative result
When someone becomes infected with HIV, it can take
If the test does not find HIV antibodies, the result is said
up to three months for their immune system to produce
to be negative. A negative test result shows that the
enough antibodies to show up on an HIV test. This gap is
person does not have HIV, as long as the test was done
called the window period, or seroconversion. Throughout
after the end of the window period.
this window period, the person with HIV does, however,
have enough virus in their blood and sexual fluids (and
breast milk) to infect another person. Indeed, the level
of virus in their body fluids (viral load) at this time can
be extremely high, making them particularly infectious.

Because the HIV test looks for antibodies, taking an HIV

test less than three months after infection might not give
an accurate result.

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An unclear result
Very occasionally, the HIV test result can be unclear.
It is not clearly positive or negative. In most cases this
is because the test has found some random antibodies
which have nothing to do with HIV. However, very
rarely an unclear result can occur during the window
period. This means the person taking the test has HIV
but HIV antibodies are only just beginning to form.
If the HIV test result is unclear, the clinic may send
the blood sample away for further tests. Or you may be
advised to have a repeat HIV test four to six weeks after
your unclear result. In either case, this result is likely to
be clearly positive or negative.
Testing for HIV itself
Another blood test called an antigen test will find HIV
itself, (as opposed to antibodies) if it is present. This test
looks for a part of the HIV virus which is detectable in
the body around two or three weeks after infection, but
before HIV antibodies have had time to form. It is not
used as widely as the antibody test but may be used in
special circumstances.
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4 How does HIV affect the body?
After a while, HIV will begin to weaken the body's immune
system, which usually fights off any infections. The major
damage HIV causes to the immune system is to white
blood cells known as CD4 cells, which sets the immune
system in motion when organisms such as viruses, bacteria
and fungi enter the body.
HIV infects CD4 cells and uses them to make new copies
of HIV. These copies then go on to infect more cells. Over
time, as the number of healthy CD4 cells declines, the
immune system's ability to fight infections can be greatly
reduced.
HIV reproduces even in someone who is feeling well.
If their immune system is working well, the virus will only
reproduce a little. But if their immune system is damaged
through prolonged or serious illness, the virus can reproduce
itself much more easily. Research shows that people with
higher levels of HIV in their bodies have a greater risk of
becoming ill than people with less HIV in their bodies.
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What are the long term effects of HIV?
The CD4 cells of someone infected with HIV mount a
defence against the invading HIV and it may be held at
bay for many years. But the virus is not completely
destroyed or eliminated from the body, and it continues
to attack CD4 cells. Eventually, the number of CD4 cells
declines and the amount of virus present increases.
When the number of CD4 cells starts to decline, the
infected person becomes vulnerable to other infections.
The organisms which cause these infections are easily
kept under control by a healthy immune system. They are
able to cause illness only when the immune system is
severely damaged, so the illnesses they cause are known
as opportunistic infections. Examples of opportunistic
infections include:
Pneumocistis carinii pneumonia (PCP), a rare form of
pneumonia.
Cytomegalovirus (CMV), a type of herpes which can
cause blindness and serious gastrointestinal, brain
and lung problems in people with HIV.
The immune system also keeps the uncontrolled
growth of cells under control and if it is damaged,
opportunistic cancers can arise.
12
Research has shown that taking a combination of
anti-HIV drugs (combination therapy) can slow down the
damaging effect of HIV on the immune system. When
combination therapy is successful, it can improve and
sustain the health of someone with HIV and will mean they
are less likely to develop what were previously known as
AIDS-defining conditions.
How effective is anti-HIV treatment?
Current therapy can successfully reduce the level of HIV
in blood and has had a dramatic effect in improving the
health and life expectancy of people with HIV. However,
we do not yet know the long term effects of these drugs
or whether the improvement people are experiencing can
be sustained indefinitely.
In the seven years that these drugs have been available, many
who were seriously ill have returned to good health and in
many cases returned to work. In some people, however, the
virus can develop resistance and cross-resistance to the drugs
(cross-resistance means that the virus becomes resistant to
other drugs, which work in the same way as the actual
drug used). A minority of people are unable to benefit from
the current anti-HIV drugs.
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How can you tell if the treatment is working? Can combination therapy fail?
People living with HIV regularly use two tests to monitor In order for combination therapy to work, one needs to
the progress of the infection, and these are especially continuously maintain a certain level of the anti-HIV drugs
important for anyone beginning or using combination in the blood. If this level falls, they will not work effectively
therapy. Both tests involve having blood samples taken. and HIV will continue to reproduce. The level of drugs in
the body can fall if someone regularly forgets to take them
CD4 count: A CD4 count measures the number of CD4 cells
on time, misses doses, or doesn't follow dietary instructions
in the blood. The lower the CD4 count, the more damage
(that is, if they don't adhere to the drug regimen).
the immune system has sustained from HIV infection.
Someone's combination therapy can also fail if HIV
Viral load: This tests the amount of HIV in the blood. The
infection has damaged the lining of their gut, which can
higher the viral load, the more virus there is in the blood.
make it difficult for them to absorb the drugs properly.
One of the aims of combination therapy is to drive down
viral load and to keep it suppressed. Drug resistance
Combination therapy can also fail because HIV develops
If the measurement of viral load comes back as
resistance to one or more of the drugs in the combination.
'undetectable' this does not mean there is no HIV in the
HIV can develop resistance by changing (mutating) slightly
blood. It means that there are too few particles of virus
so that it can reproduce in spite of these drugs. This new
to be detected by the test. There are still some there, just
virus can then multiply and continue to damage the
not very many. In addition, HIV may be undetectable in
immune system, unless the person changes to another
the blood, but there can still be HIV in semen, vaginal
drug combination which will work against the new strain
fluids and other bodily fluids. So it is advisable to continue
of HIV in their body.
practising safer sex even with a low viral load, as there is
still a risk of HIV transmission.

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Such drug-resistant strains of HIV are now increasingly
being transmitted. People who become infected with
drug-resistant HIV will have their treatment options
limited from the start of combination therapy. This
emphasises the importance of practising safer sex and
avoiding infection by drug-resistant strains of HIV.
Does this mean theres now a cure for HIV?
No. Despite the hype, at present these drug combinations
do not completely eliminate HIV from the body, or suppress
HIV to such low levels that it cannot cause longer term
damage to the immune system.
16
5 What happens when someone
has HIV?
Most people who become infected with HIV do not notice
that they have been infected. A few weeks after infection,
the body's immune system reacts to the virus by producing
antibodies. Some people with HIV have a short 'seroconversion'
illness at the time these antibodies are created. The likely
symptoms are the normal response to many other infections,
and may include a sore throat, a fever or a rash.
Someone living with HIV will have their CD4 count and
viral load regularly monitored by means of simple blood
tests. The results of these tests vary in response to
infections, stress, exercise and the time of day, but it is
of primary importance in indicating how their health is
holding up under the assault of HIV. When someone has
lived with HIV for a long time and their immune system
has been severely damaged, there is a risk of opportunistic
infections. Increasingly, it is possible to prevent or treat
these opportunistic infections using drugs. For example,
Pneumocistis carinii pneumonia (PCP) was a frequent
cause of death in people with AIDS or late stage infection
in the early years of the epidemic. Doctors are now able to
prevent PCP with drugs, or to treat it quickly if it occurs. Death
from PCP is now rare among people with HIV in the UK.
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The real problems Many HIV positive people choose to tell no one about
Even though there are now more powerful anti-HIV their diagnosis except for a few trusted friends, and this
treatments, which can suppress the progress of HIV burden of secrecy can be very hard to bear. Living with the
infection, living with the knowledge of a serious and knowledge that you could pass a serious infection to
potentially life-threatening infection can be stressful and someone else can also be very hard. A number of support
difficult. Someone with HIV may remain in good physical groups have been set up around the country to help
health for many years but misunderstandings and fears counter the isolation which HIV can cause and to help
about HIV are still widespread in society. People living people make changes in their lives to cope with living
with the virus may encounter hostility or rejection even with HIV. For further information and details on support
from friends and family. Some have lost jobs and homes groups call THT Direct on 0845 1221 200.
due to their employers' or landlords' attitudes, and
children with HIV have been banned from schools.
Many people with HIV have seen friends and partners
become ill before them, and may have seen them die.
Some communities have been particularly affected by HIV;
for example, gay men, people from sub-Saharan Africa
and injecting drug-users. In some parts of the world, and
among some African communities in the UK, it is not
unusual for whole families to die from HIV.

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