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What are the symptoms of HIV and AIDS?
There are no standard symptoms of HIV infection or
of AIDS. People living with HIV may feel & look absolutely well and
healthy but their immune systems may nevertheless be damaged. It is
very important to remember that once someone is infected with HIV it
can be passed immediately, even if they feel hale & hearty. As time
passes without any effective treatment, HIV ultimately weakens an
infected person's immune system, making such people more vulnerable
to opportunistic infections. These infections that are around us all
the time but could otherwise be fought off by a healthy immune
system. Once HIV has broken down the body's defenses, such
infections can take control and produce any of a wide range of
symptoms - some of which are very severe. Also, these infections
could lead to some types of tumors or cancers which come up as a
result of a damaged immune system and can cause damage to the brain
and nervous system. Such symptoms are, however, not caused by HIV
itself, and they can't be interpreted as definite signs of HIV
infection or AIDS. A diagnosis of AIDS involves one of the
opportunistic infections or cancers plus an underlying immune system
deficiency, which is usually detected by an HIV test. The only way
to know for sure whether a person is infected with HIV is for them
to have an HIV test.
The first thing that happens after infection is that
many people develop a flu-like illness. This may be severe enough to
look like glandular fever with swollen glands in the neck and
armpits, tiredness, fever and night sweats. Some of those white
cells are dying, virus is being released, and for the first time the
body is working hard to make correct antibodies. At this stage the
blood test will usually become positive as it picks up the tell-tale
antibodies. This process of converting the blood from negative to
positive is called `sero-conversion'. Most people do not realize
what is happening, although when they later develop AIDS they look
back and remember it clearly. Most people have produced antibodies
in about twelve weeks.
Then everything settles down. The person now has a
positive test, and feels completely well. The virus often seems to
disappear completely from the blood again. However, during this
latent phase, HIV can be found in large quantities in lymph nodes,
spleen, adenoid glands and tonsils. We do not know how many people
will go on to the next stage. As we saw in an earlier chapter, at
first doctors thought it might only be one in ten, then two or three
out of ten. Now it looks as though at least nine out of ten will
develop further problems. San Francisco studies show that in
developed countries, without use of the latest therapies, 50% with
HIV develop AIDS in ten years, 70% in fourteen years. Of those with
AIDS, 94% are dead in five years. The rate of progression can be
much faster in those with weakened immunity from other causes---drug
users or those in developing countries, for example. It can be far
slower in those on various treatments. Most scientists and doctors
are convinced that if we follow up infected people for long
enough---maybe for twenty years or more---then all or nearly all
will die of AIDS, unless they have died of something else in the
meantime such as a heart attack or cancer. How long can someone live
before some infection triggers production of more virus and death of
more white cells?
The next stage begins when the immune system starts
to break down. This is often preceded by subtle mutations in the
virus, during which it becomes more aggressive in damaging white
cells. Several glands in the neck and armpits may swell and remain
swollen for more than three months without any explanation. This is
known as persistent generalized lymphadenopathy (PGL).
As the disease progresses, the person develops other
conditions related to AIDS. A simple boil or warts may spread all
over the body. The mouth may become infected by thrush (thick white
coating), or may develop some other problem. Dentists are often the
first to be in a position to make the diagnosis. People may develop
severe shingles (painful blisters in a band of red skin), or herpes.
They may feel overwhelmingly tired all the time, have high
temperatures, drenching night sweats, lose more than 10% of their
body weight, and have diarrhea lasting more than a month. No other
cause is found and a blood test will usually be positive. Some used
to call this stage ARC, or AIDS related complex. You can easily
panic reading a list of symptoms like this because all of us tend to
read about diseases and think instantly we've got them. Chronic
diarrhea does not mean you have AIDS. Nor do weight loss, high
temperatures, tiredness and swollen glands. These things can be
particularly common in many developing countries. At the moment in
many countries there is an epidemic of viral illnesses which cause
fevers, tiredness, rashes and other symptoms that last a long time,
always go away completely, and have nothing to do with AIDS. See
your doctor or go to a clinic for sexually-transmitted diseases
(STD) or genito-urinary medicine (GUM) if you are unsure.
The final stage is AIDS. Most of the immune system
is intact and the body can deal with most infections, but one or two
more unusual infections become almost impossible for the body to get
rid of without medical help---usually intensive antibiotics. These
infections can be a nightmare for doctors and patients. The
desperate struggle is to find the new germ, identify it, and give
the right drug in huge doses to kill it. The germ may be hiding deep
in a lung requiring a tube (bronchoscope) to be put down the
windpipe into the lung to get a sample. The person is sedated for
this. It may be hiding in the fluid covering the brain and spinal
cord, requiring a needle to be put into the spine (lumbar puncture).
It may be hiding in the brain itself. It may hide in the liver or
gall-bladder or bowel. It can hide anywhere.
The most common infection is a chest infection. A
twenty-three-year-old man walks into his doctor's office with a
chest infection not responding to antibiotics. He is flushed and has
a high temperature. He has been increasingly short of breath with a
dry cough for several weeks. He becomes breathless and has an
emergency chest X-ray. The X-ray is strange. No one has seen
anything like it before. Could this be AIDS? Samples are taken from
the lung. The man is rushed to intensive care and is too ill to ask
if he would agree to a blood test. Within two days he is dead. A
strange germ is found in his lung: pneumocystis carinii. This is
incredibly rare except in AIDS. He may or may not be reported as a
statistic to the centre collecting information on AIDS. This is
voluntary and doctors are busy. If he had died a day or two earlier,
the cause of death would have been thought to be pneumonia. Yet
another silent victim, unnoticed and unrecorded. Our statistics may
be incomplete, and remember, no test was done for HIV. He was
unlucky. Average life expectancy if you develop your first
pneumocystis pneumonia is just over two years. 78% survive the first
episode, only 40% survive the second. You could live for over three
years, or you might be dead in three months. Each new chest
infection could be your last. Often people seem only an hour or two
from death, then pull around, recover completely, and go home for
several months until the next crisis. We know that eighty-five out
of a hundred people with these chest infections in Western nations
are infected with pneumocystis carinii, but many are infected with
several things at once. Worldwide, the commonest HIV-related chest
infection is tuberculosis. As HIV spreads, TB is on the increase,
with possibly a million extra cases a year at present as a result of
HIV. Latent TB infection is common in the general population. HIV
damage to CD4 white cells allows reactivation, rapid deterioration
and death.
Half of the people with AIDS will develop signs of
brain impairment or nerve damage during their illness. In one person
out of ten it is the first symptom. HIV itself seems to attack,
damage and destroy brain cells of the majority of people with AIDS
who survive long enough. The virus is probably carried into the
brain by special white cells called macrophages, which then produce
more virus there. Brain cells have a texture on their surfaces
similar to CD4 white cells which enables the virus to latch on and
enter. The damage happens gradually and often is not noticed until a
significant part of the brain has been destroyed: a brain scan shows
a shrunken appearance with enlarged cavities. The signs can be
threefold: difficulties in thinking, difficulties in co-coordinating
balance and moving, and changes in behavior. Sometimes the problems
are caused by other infections spreading throughout the body, or by
tumours, all brought on by AIDS. Brain damage affects children as
well. In one study, sixteen out of twenty-one children with AIDS
developed progressive brain destruction (encephalopathy). But any
part of the nervous system can be damaged in adults or children, not
just the brain, and AIDS can mimic just about any other disease of
nerves.
Worldwide, over 3 million children have HIV
infection and half a million die every year. Altogether, 83% of
children with HIV will show some kind of abnormality in their white
cells, or will have symptoms, by the time they are six months old.
Problems seen can include large lymph nodes, enlarged liver and
spleen, failure to thrive (small for age), small head, ear
infections, chest infections, unexplained fever, encephalopathy
(brain deterioration). Of those showing symptoms within the first
year of life, half die before the age of three. However, with
improved treatments children are surviving longer. A common pattern
is beginning to emerge of a child who becomes unwell in the first
year or two of life with different chronic or acute infections, yet
with treatment carries on for many years, possibly even into
adolescence with many ups and downs. Pain and other symptoms are
often overlooked in these children. Blood tests are often confused
by the presence after birth of the mother's own antibodies. All
babies of infected mothers will test positive for around the first
year, whether infected or not. Most babies who test positive at
birth turn out to be uninfected. The greatest risk to the baby is
the birth process itself and breast milk. Dramatic reductions in
infection rates can be made if the mother is given anti-viral
medication before and immediately after birth. This is one of the
most appropriate occasions to use anti-viral drugs in the poorest
nations. But it should always be done under strict medical
supervision. There is a very slight risk that children who later
test negative may still carry HIV. If first infected in the womb,
the child may regard HIV as part of itself and not react to it. We
are still in the early stages of learning about HIV in children.
The majority of people with AIDS develop skin
problems which are usually an exaggeration of things common to most
people, such as acne and rashes of various kinds. Cold sores and
genital herpes may develop, or warts. Athlete's foot in severe
forms, ringworm and thrush are common. Rashes due to food allergy
are also common---no one knows why. Hair frequently falls out. Drug
rashes frequently occur, often due to life-saving co-trimoxazole
used for treatment or prevention of the pneumocystis carinii
pneumonia. Kaposi's sarcoma develops in up to a quarter of the
people with AIDS (depending on the country and route of infection).
This produces blue or red hard painless patches on the skin, often
on the face. In the majority of these people it is the first sign of
AIDS. Tumours can spread to lymph nodes, gut lining and lungs where
they can be confused with pneumocystis pneumonia. The growths may be
caused by a second virus that is allowed to grow more easily if you
have AIDS. Treatment consists mainly of radiotherapy and
chemotherapy, including injections of the lesions. Because it often
affects the face or may be visible elsewhere on the body and is so
distinctive, people who develop Kaposi's sarcoma often feel
especially vulnerable. In fact people usually live longer if they
first develop this tumour than if they first develop a pneumonia.
Kaposi's sarcoma is less common in drug users with AIDS, presumably
because it is caused by a second virus also found in , which is then
activated by HIV. The other common cancer is a tumour (lymphoma)
which develops in the brain or elsewhere in the body.
Almost all people with AIDS have stomach problems
from strange infections and cancers caused by AIDS and HIV attacking
the gut directly. All three cause food to be poorly digested
resulting in diarrhoea and weight loss. Stool samples can be
examined or samples can be taken from within the gut using special
tubing (endoscopy) to see if there is a second treatable infection
in addition to HIV. AIDS can also seriously affect sight in up to a
quarter of all those with HIV by allowing an infection of the back
of the eye (retinitis). This is usually caused by cytomegalovirus
and is sometimes amenable to treatment. In addition, the virus can
cause damage to other organs of the body such as the heart.
In different parts of the world, AIDS tends to have
its own characteristics. This may be due to the pattern of other
illnesses present in different communities, which explains why TB is
the commonest cause of death from AIDS in Africa and Asia. Different
patterns may be related to different co-factors ( compared to drug
injectors, for example), viral differences or possibly genetic
differences. However, patterns are changing. For example, the
incidence of Kaposi's sarcoma is falling among with HIV in a number
of countries, while it is rising among drug users. Some of these
changed patterns are because of altered treatments; others are due
to other factors. As survival times have increased, other problems
have emerged which are far more difficult to treat. These include
blindness due to cytomegalovirus, progressive multifocal
leucoencephalopathy (weakness, muscle wasting, difficulty thinking),
cryptosporidiosis (causes various infections), mycobacterium
infections and cryptococcal meningitis. In addition, as we have
seen, advanced Kaposi's sarcoma can bring its own problems, with
lung involvement causing shortness of breath and triggering chest
infections, gut involvement causing obstruction or sudden bleeding,
and with blockage of lymphatic drainage causing swollen limbs or
face, skin ulceration and infection. In a quarter of those dying
with AIDS, the exact cause of death may be difficult to establish,
with profound weakness, loss of weight and multi-system failure.
Many infections can be chronic, low grade and difficult to diagnose,
and when diagnosed can be hard to treat. Indeed, post-mortem
examinations show that half of all HIV-related diseases found at
autopsy have not been diagnosed during life. In the early days in
many countries, those with AIDS often spent a long time in hospital
as doctors battled to get to grips with the complex spectrum of
illnesses. Now people with AIDS are usually able to spend more time
at home, with many treatments given in clinics or in the home.
However, many have multiple problems and need practical help, backed
by nursing care and symptom control, to stay at home in comfort and
in control of their own lives. Later on in this book we will look at
the practicalities of setting up community care programs. Many
people who are ill are now opting not to have every symptom
investigated, when the price is valuable time spent in hospital,
unpleasant tests, and treatments that may have side effects.
In developing countries it can be hard to make an
accurate diagnosis of AIDS because of the lack of HIV testing
facilities. The World Health Organization proposed a clinical case
definition, combining symptoms and signs common in AIDS (see table
below). This has been used as the basis for AIDS statistics in many
countries, but is inaccurate. A study of hospital patients in Zaire
showed that the case definition missed 31% of AIDS cases (definition
not very sensitive), and 10% of those it identified as having AIDS
were errors. The case definition misses people dying with severe HIV
illnesses which do not fit the definition. For example, deaths from
streptococcal pneumonia are far more common in those with HIV, yet
such deaths were not included. The commonest manifestations of AIDS
in Africa are gross weight loss, chronic diarrhea and chronic
fever---the picture of `slim disease' as AIDS is known in African
countries. However, it is difficult to exclude other causes for the
same symptoms and signs. Deaths from tuberculosis are another
problem. TB is probably the most important infection in those with
HIV in Africa. High rates of TB infection are found in those with
HIV and the risk of death from TB is greatly increased in those with
HIV. However, it is questionable whether all those with TB and HIV
can be diagnosed as AIDS cases, since many have TB anyway. Many with
TB lose weight and have fever as well as a cough. Therefore in the
absence of HIV testing, many with advanced TB are likely to be
labelled as AIDS cases using the WHO case definition. In the light
of all these problems, a revised case definition has been agreed.
You may wonder how it is possible to be sure of the right diagnosis
at all without laboratory facilities, and the answer is that it is
very difficult. Some have pounced on this difficulty to suggest that
there is no AIDS in Africa at all. As we see elsewhere, this is not
very convincing for two reasons. First, death rates have soared in
the sexually-active age groups as HIV infection rates have risen. TB
and other illnesses have been around and studied in detail for
decades. Something new is happening. Secondly, when people with AIDS
from African nations are cared for either in countries like the UK,
or in very well-equipped hospitals nearer home, it is clear that
there are gross abnormalities of their immune systems indicative of
AIDS, with positive antibodies for HIV and damaged white cells.
The spectrum of illness seen in AIDS in African
nations can vary, particularly in places where HIV-2 is more
prevalent. The pattern is very different from developed countries:
Candida (thrush) in the mouth 80--100%
Oesophageal candidiasis 30--50%
Tuberculosis 30--50%
Cerebral toxoplasmosis 15--20%
Herpes zoster (shingles) 10%
Cryptosporidiosis (diarrhea) 50%
Most people have several problems. (For further
discussion on needs of those with AIDS and how to meet them, see
Chapters 10, 11 and 14; also Appendices A, B and C.). So, now that
we have reviewed how the virus attacks cells and causes diseases
associated with AIDS, we are in a position to look at some of the
ways the virus can enter the human body and how we can prevent it
from happening. Most people who become infected with HIV do not
notice any immediate change in their health. However, some may
suffer from a flu-like illness within a few weeks of infection, or
may develop a rash or swollen glands. These signs do not mean that
they are already developing AIDS. Many illnesses have flu-like
symptoms or cause swollen glands. You cannot have HIV unless you
have been directly exposed to the virus. HIV can be transmitted
during sexual intercourse with an infected person, through contact
with infected blood or breast milk, or during unsafe injections or
medical procedures. If you are not sure whether or not you have been
put at risk then first read our page about how you can and can't be
infected with HIV. The only way you can find out whether or not you
have been infected is to have an HIV test. |
