Acquired Immune Deficiency Syndrome

Incidence and Prevalence: Through 2010, almost 490,000 people in the US were living with AIDS. Of those, the largest percent (43%) were black. Among the remaining race/ethnicities, the rates per 100,000 were 196.1 for Hispanic/Latinos, 153.8 for persons of multiple races, 98.0 Native Hawaiians/other Pacific Islanders, 82.2 whites, 74.7 American Indian/Alaskan Natives and 36.4 Asians. The reported cases during the year 2011 alone numbered 24,088 cases in males and 7,949 cases in females ("HIV Surveillance Report").

Since the epidemic began, an estimated 1,155,792 people in the United States have been diagnosed with AIDS. Although men who have sex with men (MSM) represent only about 4% of the male population in the US, in 2010, MSM accounted for 78% of new HIV infections among males and 63% of all new infections. The greatest number of new HIV infections (4,800) among MSM occurred in young black/African American males aged 13 to 24. Since the epidemic began in 1981, an estimated 302,148 MSM with AIDS have died, including an estimated 5,909 in 2010. In 2011, infections due to male-to-male sexual contact and injection drug use (65%) and those due to heterosexual contact (27%) accounted for approximately 92% of newly diagnosed HIV infections in the United States ("HIV Surveillance Report").

Heterosexuals accounted for 25% of estimated new HIV infections in 2010 and 27% of people living with HIV infection in 2009. Since the epidemic began, almost 85,000 persons with an AIDS diagnosis, infected through heterosexual sex, have died, included an estimated 4,003 in 2010. New HIV infections among women are largely due to heterosexual contact (84% in 2010) or injection drug use (16% in 2010). Women accounted for 20% of estimated new HIV infections in 2010 and 24% of those living with HIV infection in 2009 ("HIV Surveillance Report").

Injection drug use accounted 8% of new HIV infections in 2010, and injection drug users represented 16% of those living with HIV in 2009. Since the epidemic began, nearly 182,000 injection drug users with an AIDS diagnosis have died, including an estimated 4,218 in 2010 ("HIV Surveillance Report").

A recent report by UNAIDS found the following: Worldwide in 2011, about 34 million people globally were estimated to be living with HIV. The AIDS epidemic claimed nearly 1.7 million lives and close to 2.5 million people acquired HIV in 2011. Sub-Saharan Africa continues to have high incidence, with southern Africa most affected. In six countries of sub-Saharan Africa (Burundi, Kenya, Namibia, South Africa, Togo and Zambia), the number of children newly infected with HIV declined by 40%–59% between 2009 and 2011. Fourteen additional countries in the region reported declines of 20-39%. However, 11 countries in the region experienced lesser declines of 1–19%. In four countries (Angola, Congo, Equatorial Guinea, Guinea-Bissau), the number of new HIV infections among children increased. Other global regions such as Asia (4.8 million), Eastern Europe (1.4 million), Latin America (1.4 million) also have high numbers of people living with HIV (UNAIDS).

History: The symptoms of AIDS reflect a failed immune response, resulting in variable and nonspecific physical signs. Typically, the patient will present with a range of complaints. Those complaints might include short-term memory loss, difficulty concentrating, mood changes (usually depression, apathy, or suicidal ideation), altered mental status/dementia, cough and shortness of breath, night sweats, skin rashes or growths, easy bruising, unexpected nosebleeds, persistent fever, difficulty swallowing (dysphagia), vomiting, abdominal pain, headache, diarrhea, weight loss, chest pain, and visual changes, including blurred vision or spots that interfere with vision (floaters). The history may also relate to a specific disease that the immune-compromised individual has contracted, such as toxoplasmosis or tuberculosis.

Physical exam: Individuals with AIDS have symptoms of one or several AIDS defining illnesses such as specific opportunistic infections or cancers. Those with full-blown AIDS may have a combination of skin (dermatologic), digestive (gastrointestinal), lung (pulmonary), brain and nerve (neurologic), eye (ophthalmologic), and/or muscle and bone (musculoskeletal) conditions. One type of growth (neoplasm) seen commonly in individuals with AIDS is Kaposi's sarcoma (KS). It appears as reddish-brown raised growths on the skin or in the mouth. Bleeding (hemorrhage) in the retina, yeast (Candida) infections of the digestive or respiratory tract, viral infections in the mouth, chronic herpes, and aggressive tooth or gum disease are also common. Weight loss and decreased physical vigor, appetite, and mental activity (wasting syndrome) may be present.

Tests: AIDS testing focuses initially upon verification of HIV infection, using blood or urine tests in a doctor's office or a home test.

Blood tests: HIV infection is determined by either direct detection of the virus itself or detection of the antibodies the individual produces in response to viral infection. Direct detection of the virus may be done following infection but may be negative early in infection. HIV polymerase chain reaction (PCR) or HIV culture tests are commonly used.

For antibody detection tests, there is a time delay before the immune system can mount a response against HIV; therefore, a 6-month waiting period following infection is usually recommended in order to increase the reliability of the test. Note that HIV-infected individuals with AIDS symptoms are usually infected with the virus much longer than 6 months, and HIV antibodies are almost always present in the bloodstream. The most common types of antibody tests for HIV diagnosis include the enzyme-linked immunoabsorbent assay (ELISA, with sensitivity and specificity of more than 95%), Western blot, immunofluorescence, radioimmune-precipitation, and hemagglutination.

Oral/Urine tests: Oral tests use oral fluid (not saliva) that is collected from the mouth using a special collection device. This is an enzyme immunoassay (EIA) antibody test similar to the standard blood EIA test. These tests require a follow-up confirmatory Western Blot using the same oral fluid sample.
Urine Tests use urine. The accuracy of these tests is less than the accuracy of blood and oral fluid tests. These tests require a follow-up confirmatory Western Blot using the same urine sample.

Home tests: Home HIV tests are available over-the-counter at local drug stores. The individual collects a sample, run the test, and obtain their test results at home.

The rate of progression of HIV and AIDS is directly related to the rate of increase in the viral load in the bloodstream or tissue of an infected individual. Repeated viral load measurement can therefore serve as both an accurate indicator of HIV-related disease progression and an indicator of the effectiveness of antiviral drug treatment. Viral load can be determined by measuring HIV ribonucleic acid (RNA) in plasma. The three types of assays commonly used to measure HIV RNA are the reverse transcriptase polymerase chain reaction (RT-PCR), the branched deoxyribonucleic acid (bDNA) test, and the nucleic acid sequence-based amplification (NASBA) test.

Other tests may be performed to monitor the extent of damage done to the immune system by the virus. Most important is a count of the number of CD4+ T lymphocytes in the bloodstream using flow cytometry analysis. This test is also useful in monitoring the effectiveness of antiretroviral drug therapy, determining the risk for opportunistic diseases and the need for preventative (prophylactic) drug administration, and assessing the prognosis for the individual with AIDS.

Other tests may include a complete blood count (CBC) with a white blood cell differential count, blood urea nitrogen (BUN), creatinine and electrolytes, a blood culture, arterial blood gases (ABG), liver function tests, glucose and lipid profiles, stool culture, lumbar puncture and CSF analysis, a rapid plasma reagin (RPR) test or a Venereal Disease Research Laboratory (VDRL) test for syphilis, a hepatitis B core antibody test, hepatitis C and toxoplasmosis serology, a purified protein derivative (PPD) test for tuberculosis, and a Pap smear in women. In some clinical settings, urinalysis, cytomegalovirus (CMV) serology, and a qualitative test for glucose-6-phosphate dehydrogenase (G6PD) may be advisable. A computed tomography (CT) or magnetic resonance imaging (MRI) can be used to identify whether pneumonia or cancer is present.

Risk: In an immune compromised individual, working with heavy public contact, indigent or incarcerated populations, or in health care settings may place the individual at increased risk of further or recurrent infection. Some risk can be mitigated by frequent hand washing, gloves, or masks. Universal blood and body fluid precautions must be exercised in both directions to protect the individual and those they come into contact with. Occupations with high risk of cuts in close proximity to other workers should be examined for safety precautions.

Capacity: In the short term, once stabilized and treated, there would not be expected to be any change in an individual’s capacity limits. However, HIV stage 3 is a progressive disease and long term fatigue, anemia, recurrent infections and pulmonary limits may reduce capacity. Testing with stress ECHO and Pulmonary Function would be useful.

Tolerance: Fatigue is a prominent symptom of untreated HIV infection as well as the accompanying opportunistic infections. Once infection is stabilized, and CD4+ T lymphocytes counts are restored to normal, most patients can return to work and will function well. Limits may be due to perceived worksite acceptance. Counseling may be of great use in newly diagnosed individuals to assist in return to work transition.