Description

• HIV is a retrovirus (subgroup lentivirus) that integrates into CD4 T lymphocytes, altering cell-mediated immunity and causing cell death, severe immunodeficiency, opportunistic infections, and malignancies if not treated.
• The natural history of untreated HIV infection includes viral transmission, acute retroviral syndrome, recovery and seroconversion, asymptomatic chronic HIV infection, and symptomatic HIV infection or AIDS.
• Without treatment, the average patient progresses to AIDS ~10 years after acquiring the virus.
• HIV-infected persons with CD4 <200 cells/mm³ or with AIDS-defining illnesses are categorized as persons living with AIDS.

Epidemiology

Incidence
U.S. ~38,000 new cases in 2018, a decrease in incidence of 7% between 2014 and 2018. There were approximately 1.7 million new cases of HIV worldwide in 2018 (1).

• ~1.2 million persons in the United States are living with HIV, ~14% are not aware they are infected (1).
• Worldwide, >37 million people are living with HIV. ~61% of new diagnoses are in sub-Saharan Africa.
• In 2017, ~1 million people died from AIDS (1).

Etiology and Pathophysiology

• HIV primarily infects CD4+ cells. HIV is a single-stranded, positive-sense, enveloped RNA virus. After entering target cells, viral RNA is transcribed to DNA (through reverse transcription), imported to the host cell nucleus and incorporated into host DNA. The virus can become latent or produce new viral RNA with proteins that are released to infect other CD4+ cells. Host CD8+ cells are activated as part of the seroconversion response.
• There are two types of HIV. HIV-1 was first described and is more virulent, causing the majority of HIV infections worldwide. HIV-2 is less infective and seen primarily in West Africa.

Risk Factors

• Sexual activity (>90% of transmission): Receptive anal sex is highest risk. Ulcerative urogenital lesions promote transmission (1).
• Injection drug use
• Children of HIV-infected women
  • Maternal HIV-1 RNA level predicts transmission.
  • HIV can also be transmitted in breast milk. HIV+ women should not breastfeed their infants unless there is no other alternative. In this case, consider antiretroviral therapy (ART) (2).
• Recipients of blood products prior to 1985
• Occupational exposure (health care workers)

General Prevention

• Avoid unprotected, high-risk sex, and intravenous drug use, particularly with shared needles.
• Preexposure prophylaxis (PrEP) is recommended by WHO and USPSTF for persons at high risk of acquiring HIV.
  • General guidelines for PrEP: (i) exclude acute or chronic HIV infection before initiating therapy, (ii) repeat HIV testing every 3 months during therapy, (iii) renal and liver function testing at baseline, 2 to 8 weeks after initiating PrEP, and every 6 months.
• Postexposure prophylaxis (PEP) should be started within 72 hours of exposure and continued for 28 days with a three-drug regimen (3)[A].
• For HIV+ patients using ART, maintained HIV RNA levels <200 copies/mL prevents risk of transmission to sexual partners (treatment as prevention) (4)[A].
• USPSTF recommends routine screening for all patients 15 to 65 years old. Patients who are at increased risk should be screened at any age.
• CDC recommends screening for patients aged 13 to 64 years old at least once (4).

Commonly Associated Conditions

• Syphilis is more aggressive in HIV-infected persons.
• Tuberculosis (TB) is co-epidemic with HIV; test all patients for TB. Dually infected patients (TB and HIV) have 100 times greater risk of developing active TB.
• Patients coinfected with hepatitis B or hepatitis C have a more rapid progression to cirrhosis.
• Increased risk for cervical cancer, lymphoma, and skin malignancies