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Medical Disability Advisor  >  Human Immunodeficiency Virus

Human Immunodeficiency Virus

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Factors Influencing Duration

Factors that may influence the length of disability from HIV infection include the stage of the disease, the viral load, the number of CD4+ T-lymphocytes present in the bloodstream, the presence of opportunistic infections during the course of the disease, and the response to drug treatment.
In addition, other diseases may increase the severity of symptoms associated with various opportunistic infections. These other diseases include infectious diseases such as hepatitis B and tuberculosis, as well as chronic infections or parasitic diseases such as malaria. Immunosuppressant drugs, pregnancy, malnutrition, genetic susceptibility, infection with other sexually transmitted diseases, and stress may also have effects. Advancing age appears to be a major determinant in how rapidly the disease progresses.

Definition

Human immunodeficiency virus (HIV) is a subgroup of retroviruses known for a period of seeming inactivity (latency), persistent presence of viruses (viremia), infection of the nervous system, and weak host immune responses. Ironically, it infects certain white blood cells (WBCs) called T-lymphocytes that help the body fight infections and other diseases. In particular, it is those T-lymphocytes that carry a marker on its surface named the CD4+ molecule. HIV-infected CD4+ T-lymphocytes are eventually destroyed because the virus binds to them and then enters the interior of the cell, where it hijacks the cell's genetic machinery. This process allows the virus to replicate, hidden from surveillance, in the very cell that normally coordinates the immune response. In this way, the virus increases its number by up to 1,000 in each cell it infects before bursting out and moving into new cells to repeat the process. Consequently, after a period of time (latency period) in which HIV continues to replicate, the number of CD4+ T lymphocyte cells decreases, the immune system weakens, and the individual becomes highly susceptible to parasitic, fungal, bacterial, or other viral infections. About 2 months after infection, the immune system does rebound to a degree and mounts a counterattack on the virus, but eventually, the HIV-infected individual will develop acquired immune deficiency syndrome (AIDS). AIDS is characterized by normally harmless infections turning deadly as a result of the individual's compromised immune system (opportunistic infections). The time between initial HIV infection and the onset of AIDS is quite variable and may last from a few months to 10 years or more.

HIV is transmitted primarily through sexual contact. Fluids containing the virus must enter the bloodstream in order for infection to occur. HIV may enter the body through cuts or breaks in the skin, mouth, vagina, anal canal, or rectum. HIV has been found in a variety of body fluids, and the importance of these in HIV transmission varies depending upon the concentration (viral load) they contain.

Recommendations to prevent infection include the avoidance of contact with potentially contaminated body fluids. They include blood, semen, vaginal secretions, fluid from the brain or spinal cord (cerebrospinal fluid), joint fluids, chest (pleural) or heart (pericardial) fluid, or uterine (amniotic) fluid from a pregnant female. Precautions should also be employed for exposure to feces, nasal secretions, sputum, sweat, tears, urine, vomit, and breast milk that contain visible blood.

The primary way HIV is transmitted is by intimate sexual contact (either homo- or heterosexual) with an HIV-infected person. Other methods of transmission include exposure to HIV-contaminated blood or blood products by sharing of syringes or needles, blood transfusion, or any other method of cross-contamination. The virus may also pass from an HIV-infected mother to her unborn baby during development in utero or to her newborn baby during labor and delivery or when breastfeeding. Transmission rates from mother to child can be reduced by giving the drug AZT (zidovudine) to HIV-infected women during pregnancy and to their infants after birth. There is no evidence that HIV can be transmitted through casual contact or even close nonsexual contact (such as that which occurs in families, at school, or in the workplace), or from insects or respiratory droplets.

High-risk behaviors for transmission of HIV include homo- or heterosexual practices in which condoms are not worn (unprotected sex), using condoms made of natural or non-latex membranes, sharing needles or syringes for drug self-injection, and tattooing or body piercing. Safe sex requires men to consistently and correctly use latex condoms and women to use lubricated polyurethane condoms. It is not recommended that a male and female wear condoms at the same time because friction between the two materials may cause tears or slippage of either condom. The safest form of sex is abstaining from risky behaviors for 6 months, followed by testing for HIV. A negative result would indicate safety in engaging in sexual acts with only a single HIV-free partner who has undergone the same testing measures. HIV transmission through infected blood components, such as clotting factor concentrates and blood transfusions, has been reduced markedly in the US but not completely eliminated.

Risk: Risk factors for HIV include unprotected homosexual or heterosexual sex, intravenous drug abuse with contaminated needles, exposure to infected body fluids (e.g., needlestick), and maternal-fetal transmission during pregnancy and childbirth. Close to 45% of AIDS patients contracted HIV through male homosexual contact, 27% from drug injection needles, and 20% through heterosexual activity ("Characteristics"). In those with HIV infections that progressed to AIDS in 2001, 32% were white, 55% black, and 12% Hispanic. Asians/Pacific Islanders and Native Americans accounted for less than 1% during that period ("Cases"). The reported HIV/AIDS cases during the year of 2002 alone numbered 32,513 cases in males and 11,279 cases in females ("Cases"). In the healthcare setting, an accidental needlestick with an HIV-contaminated needle carries a 1 in 300 chance of HIV infection. Infection through splashing HIV-contaminated fluid into the eyes or mouth is less than 1 in 1,000. There has never been a reported case of transmission through coughing, sneezing, or mosquito bite (Beers 1169).

Incidence and Prevalence: Worldwide infection with HIV (not necessarily AIDS) approached 36 million at the close of the year 2000 (Beers 1168).

Source: Medical Disability Advisor



History

History: An HIV-infected individual may report high-risk sexual behavior, intravenous drug use, or rarely, multiple transfusions of blood or blood products. Two to 4 weeks after the initial infection, individuals will experience a brief flu-like illness with a sore throat, weakness, fever, or rash. These symptoms will disappear within a few days or weeks and are followed by a long incubation (latency) period, during which there are no overt signs of infection. After this latency period, HIV-infected individuals most often progress to AIDS, reporting altered mental status that includes short-term memory loss, concentration difficulties, mood changes (usually toward depression, apathy, or suicidal ideation) or dementia, cough, shortness of breath, night sweats, skin growths, easy bruising, unexpected nosebleeds, difficulty swallowing (dysphagia), chest pain, persistent fever, diarrhea, abdominal pain, vomiting, headaches, and/or weight loss.

Physical exam: The HIV-infected individual may have a fever, skin rash, and/or enlarged lymph nodes that show up 2 to 4 weeks after initial infection. This is followed by a latent phase that can last up to 10 years or more. During this phase, there are no clear physical signs, except for occasional nonthreatening infections like chronic herpes (shingles) or thrush (oral fungal infection with Candida). HIV-infected individuals who have developed AIDS may have lesions in the mouth that are characteristic of yeast infections, plaque-like lesions in the mouth (oral hairy leukoplakia), or raised blue or purple spots anywhere on the body (Kaposi's sarcoma). An eye examination may reveal blurry vision, spots before the eyes (floaters), or loss of vision. It may be difficult to visualize the retina during an eye examination, and the retina may have a "cottage cheese and ketchup" appearance. Wheezes or crackling (dry rales) sounds in the lungs, enlarged nodes, abdominal masses, fluid in the abdominal cavity (ascites), enlarged liver (hepatomegaly), enlarged spleen (splenomegaly), reflex abnormalities, gait problems, and cranial nerve impairment may also be noted during physical examination.

Tests: HIV infection can be determined by blood or urine tests or by home testing.

HIV infection can be determined by either direct detection of the virus or detection of the antibodies that the individual produces in response to HIV. Direct detection of the virus may be done at any time following infection, and the HIV polymerase chain reaction (PCR) or HIV culture tests are commonly used. However, with antibody detection tests, there is a time delay before the immune system will mount a response against HIV, and a waiting period of 6 months following infection is usually recommended to increase reliability. The most common types of antibody tests for HIV diagnosis include the enzyme-linked immunoabsorbent assay (ELISA), Western blot, immunofluorescence, radioimmune-precipitation, and hemagglutination.

Currently, there is one oral test that has been approved by the Food and Drug Administration (FDA). The Oral Fluid Vironostika HIV-1 MicroElisa System and the OraSure HIV-1 WB kit in combination with the OraSure Collection system have been found to be highly reliable in identifying HIV-infected individuals. The FDA has approved a urine HIV-1 antibody ELISA, but it has not been approved as a stand-alone diagnostic test, so individuals with reactive urine specimens should be retested using a blood test.

The FDA has approved the Home Access and Home Access Express tests. These tests provide the individual with a specimen collection device with which to obtain a drop of blood, which is then blotted onto a card. The specimen card is mailed to a central testing service and the individual is informed anonymously of the results by telephone. Post-test counseling is also provided.

The rate of HIV disease progression is measured by the rate of increased viral particles (viral load) in the bloodstream or tissue of an infected individual. Thus, viral load measurement can serve as both an accurate predictor of disease progression and an indicator of the effectiveness of anti-viral drug treatment. Viral load can be determined by measuring HIV ribonucleic acid (RNA) in plasma. Commonly, three types of assays are used to measure HIV RNA: reverse transcription polymerase chain reaction (RT-PCR), the branched deoxyribonucleic acid (bDNA) test, or the nucleic acid sequence-based amplification (NASBA). Other tests may be performed to monitor the extent of damage the virus has done to the immune system. The most important of these counts the number of CD4+ T-lymphocytes in the bloodstream using flow cytometry. This test is also used to monitor the effectiveness of antiretroviral drug therapy, to determine the risk for opportunistic diseases and the need for preventative (prophylactic) drug administration, and to assess the prognosis for the HIV-infected individual. Other tests may include a complete blood count (CBC) with a white blood cell differential count, blood urea nitrogen (BUN) and creatinine, liver function tests, glucose and lipid profiles, arterial blood gases (ABGs), blood chemistries, electrolytes, blood culture, stool culture, 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. Additional diagnostic tests include chest x-ray, head CT scan, cerebrospinal fluid analysis, and lumbar puncture.

Source: Medical Disability Advisor



Treatment

Important advances have been made in drug treatments that can slow the progression of disease following HIV infection. Drug treatment must be individualized and take into account the disease progression (viral load) and the degree of immunodeficiency as determined by the CD4+ T lymphocyte cell (T-cell) count. No study has determined specifically the best time to start drug treatment, but it is believed that initiating highly active antiretroviral therapy (HAART) as early as possible offers the best chance for minimizing both viral load and disease progression. Combination therapy using two nucleoside reverse transcriptase inhibitors (NRTIs) in conjunction with a protease inhibitor (PI) or a nonnucleoside reverse-transcriptase inhibitor (NNRTI) is recommended as initial therapy for most individuals. The drug regimen may be modified if the individual cannot tolerate one or more of the drugs or if there is a rising viral load, a declining CD4+ T lymphocyte count, or progression of clinical diseases characteristic of AIDS. The drugs currently in use do not kill the virus but rather interfere with its replication.

Resistance to drug therapy is also a consideration because the high rate of HIV turnover in the body often produces drug-resistant forms of the virus. Additionally, preventative (prophylactic) drug treatment for a common opportunistic disease, Pneumocystis carinii pneumonia (PCP), is usually prescribed. The current drug of choice for PCP prophylaxis is trimethoprim-sulfamethoxazole (TMP-SMX). Oxygen is administered for those with difficulty breathing (dyspnea), and intravenous (IV) fluids are given for dehydration or low blood pressure (hypotension). Finally, psychosocial issues are important at all stages following viral infection because adjustment or anxiety disorders, depression, and substance abuse are common among HIV-infected individuals. Psychological testing, antidepressant therapy, and/or community support groups are important adjunctive treatment for HIV.

Tremendous effort has been put forth to develop a vaccine that will either prevent infection by HIV or boost the immune systems of infected individuals. Several vaccines have been partially successful in preventing HIV infection in nonhuman primates, but these results have not been replicated in people. Vaccine development has proven extraordinarily difficult because HIV mutates frequently. Consequently, scientists have had a difficult time producing one or a combination of vaccines that will overcome the mutated viruses that escape immune recognition.

Source: Medical Disability Advisor



Prognosis

It is not inevitable that exposure to HIV means infection. There are some people who seem highly resistant, even though they have been exposed repeatedly. However, once infected, there is no evidence that any HIV-infected individual has ever been cured or become noninfectious. At this time, there is no recovery, and the disease is inevitably fatal. However, individuals with recent HIV infection can remain symptom-free for 15 years or more, even without drug therapy. Overall, without treatment, half the people who have been infected with HIV will develop AIDS within 11 years (Beers 1174).

Source: Medical Disability Advisor



Rehabilitation

Individuals who test positive for the HIV virus require no specific physical rehabilitation. Individuals may wish to consult with a physical therapist to develop an exercise program and should be encouraged to begin one as early as possible following HIV infection. Aerobic exercise has been found to increase cardiopulmonary fitness, improve muscle function, enhance weight gain, and improve mood state and coping behavior. Most importantly, recent studies indicate that exercise may increase CD4+ T lymphocyte cell counts in HIV-infected individuals. Individuals should exercise with a goal of attaining 75% to 85% maximum intensity while walking, jogging, biking, swimming, performing calisthenics, and/or weight training. Exercise sessions should occur 3 to 5 times per week for 30 to 60 minutes per session.

Also important in the rehabilitation of individuals infected with the HIV virus are the disciplines of psychology and social work. Individuals infected with HIV eventually develop AIDS, a disease with no known cure. Psychological counseling may help individuals deal with fears of dying and depression that accompany the diagnosis of HIV infection. Because distress and depression have been shown to lower the immune system, counseling has a beneficial effect on an individual's physical health. Individuals who have become infected through intravenous drug use can participate in behavior modification programs at drug treatment centers. These programs can be successful in helping individuals recover from drug addiction.

Social workers can also assist individuals diagnosed with HIV. The newer treatments for HIV infection are expensive and often not covered by health insurance. Social workers can direct individuals to programs that subsidize treatment. For those individuals who have become infected through intravenous drug use, social workers can aid in placement at drug rehabilitation centers.

Source: Medical Disability Advisor



Complications

Individuals with HIV may experience a number of complications during the course of their illness, as it progresses into AIDS. Drug therapy may cause adverse side effects, including nausea, severe headache, insomnia, or anemia.

The type, number, and severity of complications as a result of the disease varies with the status of immune system functioning and progression of the disease. Typical complications include fatigue, dizziness, anorexia and weight loss, nausea and vomiting, diarrhea, cough, difficulty in swallowing (dysphagia), difficulty breathing (dyspnea), pain, fever, itching (pruritus), sleep disturbances, night sweats, and psychological distress. Other complications may include skin diseases (dermatophytosis, psoriasis), inflammation of hair follicles (folliculitis), arthritis (Reiter's syndrome), decreased hemoglobin in the blood (anemia), bleeding into the skin or other organs (idiopathic thrombocytopenic purpura or ITP), decreased white blood cell count (leukopenia), kidney disorders (nephropathy), chronic herpes (shingles), mental disorders (dementia), a variety of cancerous tumors (Kaposi's sarcoma, Hodgkin's lymphoma, non-Hodgkin's lymphoma, and squamous cell carcinoma), mouth sores and lesions (oral hairy leukoplakia), an oral fungal infection (thrush), and a variety of tooth and gum (periodontal) diseases (linear gingival erythema, necrotizing ulcerative gingivitis).

Most complications arise as a product of opportunistic infections when the immune system is in a weakened (compromised) state. Many of the diseases associated with opportunistic infections in HIV-infected individuals arise from fungal infections (PCP, aspergillosis, candidiasis, cryptococcosis, histoplasmosis, coccidioidomycosis, penicilliosis), parasitic infections (cryptosporidiosis, isosporiasis, toxoplasmosis, microsporidiosis, Strongyloides stercoralis, Cyclospora cayetanensis), viral diseases (cytomegalovirus [CMV], herpes simplex virus types 1and II [HSV-I and HSV-II], varicella-zoster virus or VZV, Epstein-Barr virus [EBV], polyomavirus, poxvirus, parvovirus, human papillomavirus [HPV], hepatitis virus), and bacterial infections (mycobacteria, nocardiosis, Bartonella, Rhodococcus, Haemophilus influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, Salmonella).

Source: Medical Disability Advisor



Return to Work (Restrictions / Accommodations)

HIV-infected individuals may need to be transferred to a job requiring less physical activity or take extended sick leave or a leave of absence. In the workplace, HIV is an important component of a comprehensive infectious disease policy, and universal precautions should be incorporated into all procedures, regardless of the HIV status of employees. Risk of exposure to blood-borne HIV can be modified by ongoing education, engineering controls, and the use of safety devices. Universal precautions include hand washing, protecting intact skin, caring for and appropriately covering damaged skin, properly handling and disposing of sharp objects, and carefully handling all blood and body fluids. Disposable latex gloves should be worn during all medical procedures and emergencies and when coping with industrial accidents. A plan for rapid evaluation and management should be in place in case HIV exposure occurs. Neurocognitive impairment may adversely affect work in which essential job functions require complex cognitive function.

Some individuals with this condition may lead essentially normal lives in the workplace for an extended time frame without restriction or accommodation. However, the nature of the disease may result in illness and disability ranging from minor to extraordinarily severe. An established policy regarding illness and disability is critical to the management of individuals with this condition.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has diagnosis of HIV infection been confirmed?
  • Have conditions with similar symptoms been ruled out?
  • Which factors (stage of disease, viral load, number of CD4+ T-lymphocytes present, complications, associated opportunistic infections) may complicate treatment and affect recovery?

Regarding treatment:

  • Has drug treatment plan been individualized, taking into account the disease progression and degree of immunodeficiency?
  • Although there is not a general consensus on the best time to start drug treatment for HIV, is drug therapy appropriate for this individual at this time?
  • Is combination antiretroviral drug treatment available to individual?
  • Is the present combination of drugs being administered appropriate for this individual?
  • Can drug regimen be modified if individual cannot tolerate one or more of the drugs or if there is a rising viral load, a declining CD4+ T lymphocyte count, or progression of clinical diseases characteristic of AIDS?
  • What can be done to lessen adverse effects? Have alternate drug combinations been as effective?
  • Because the high rate of HIV turnover in the body often produces drug-resistant forms of the virus, what is being done to monitor the efficacy of the current drug therapy?
  • Is individual receiving prophylactic drug therapy against common opportunistic diseases?

Regarding prognosis:

  • Have the benefits of drug therapy been explained to individual?
  • Does individual understand that the period of time without apparent disease expression may be increased by years or perhaps decades by using combination antiretroviral drug therapy?
  • Is individual involved in appropriate drug therapy at this time? If not, is it available to him/her?
  • If not available, how can the individual access combination antiretroviral drug therapy?
  • Can individual be compliant with long-term drug therapy?
  • Has individual experienced complications, such as opportunistic infections? Are complications being effectively treated under current treatment plan?
  • Does individual have realistic expectations?
  • Because psychosocial issues are important at all stages following viral infection, has individual received psychological testing?
  • Would individual benefit from antidepressant therapy?
  • Would individual and/or family benefit from psychological counseling?
  • Is individual involved in a community support group?
  • Have issues of sexuality been adequately addressed?

Source: Medical Disability Advisor



Cited References

Beers, Mark H., ed. "Human Immunodeficiency Virus Infection." The Merck Manual of Medical Information. 2nd Home ed. New York: Simon and Schuster, 2003. 1168-1175.

"Cases of HIV Infection and AIDS in the United States, by Race/Ethnicity, 1998-2002." HIV/AIDS Surveillance Supplemental Report 10 1 (2002): Centers for Disease Control and Prevention. U.S. Department of Health and Human Services. 22 Dec. 2004 <http://www.cdc.gov/hiv/stats/hasrsupp10.1/Commentary.htm>.

"Characteristics of Persons Living with AIDS and HIV, 2001." HIV/AIDS Surveillance Supplemental Report 9 2 (2001): Centers for Disease Control and Prevention. 26 Jun. 2003. U.S. Department of Health and Human Services. 22 Dec. 2004 <http://www.cdc.gov/hiv/stats/hasrsuppVol9No2.htm>.

Source: Medical Disability Advisor






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