Help for Patients and Caregivers : HIV

AIDS is a chronic, life-threatening condition caused by the human immunodeficiency virus (HIV). By damaging your immune system, HIV interferes with your body's ability to fight off viruses, bacteria and fungi that cause disease. HIV makes you more susceptible to certain types of cancers and to infections your body would normally resist, such as pneumonia and meningitis. The virus and the infection itself are known as HIV. "Acquired immunodeficiency syndrome (AIDS)" is the name given to the later stages of an HIV infection.

AAn estimated 39.5 million people have HIV worldwide. And though the spread of the virus has slowed in some countries, it has escalated or remained unchanged in others. The best hope for stemming the spread of HIV lies in prevention, treatment and education.

The symptoms of HIV and AIDS vary, depending on the phase of infection.

Early infection
When first infected with HIV, you may have no signs or symptoms at all, although it's more common to develop a brief flu-like illness two to four weeks after becoming infected. Signs and symptoms may include:

• Fever
• Headache
• Sore throat
• Swollen lymph glands
• Rash

Even if you don't have symptoms, you're still able to transmit the virus to others. Once the virus enters your body, your own immune system also comes under attack. The virus multiplies in your lymph nodes and slowly begins to destroy your helper T cells (CD4 lymphocytes) — the white blood cells that coordinate your entire immune system.

Later infection
You may remain symptom-free for eight or nine years or more. But as the virus continues to multiply and destroy immune cells, you may develop mild infections or chronic symptoms such as:

• Swollen lymph nodes — often one of the first signs of HIV infection
• Diarrhea
• Weight loss
• Fever
• Cough and shortness of breath

Latest phase of infection
During the last phase of HIV — which occurs approximately 10 or more years after the initial infection — more serious symptoms may begin to appear, and the infection may then meet the official definition of AIDS. In 1993, the Centers for Disease Control and Prevention (CDC) redefined AIDS to mean the presence of HIV infection as shown by a positive HIV-antibody test plus at least one of the following:

• The development of an opportunistic infection — an infection that occurs when your immune system is impaired — such as Pneumocystis carinii pneumonia (PCP)
• A CD4 lymphocyte count of 200 or less — a normal count ranges from 800 to 1,200

By the time AIDS develops, your immune system has been severely damaged, making you susceptible to opportunistic infections. The signs and symptoms of some of these infections may include:

• Soaking night sweats
• Shaking chills or fever higher than 100 F (38 C) for several weeks
• Dry cough and shortness of breath
• Chronic diarrhea
• Persistent white spots or unusual lesions on your tongue or in your mouth
• Headaches
• Blurred and distorted vision
• Weight loss

You may also begin to experience signs and symptoms of later stage HIV infection itself, such as:

• Persistent, unexplained fatigue
• Soaking night sweats
• Shaking chills or fever higher than 100 F (38 C) for several weeks
• Swelling of lymph nodes for more than three months
• Chronic diarrhea
• Persistent headaches

If you're infected with HIV, you're also more likely to develop certain cancers, especially Kaposi's sarcoma, cervical cancer and lymphoma, although improved treatments have reduced the risk of these illnesses.

Symptoms of HIV in children
Children who are HIV-positive may experience:

• Difficulty gaining weight
• Difficulty growing normally
• Problems walking
• Delayed mental development
• Severe forms of common childhood illnesses such as ear infections (otitis media), pneumonia and tonsillitis

When to see a doctor
If you think you may have been infected with HIV or are at risk of contracting the virus, seek medical counseling as soon as possible. Questions to consider include:

• Why should you get tested? The idea of being tested for HIV infection may be frightening. But testing itself doesn't make you HIV-positive or HIV-negative, and it's important not only for your own health but also to prevent transmission of the virus to others. If you engage in a high-risk behavior such as unprotected sex or sharing needles during intravenous drug use, get tested for HIV at least annually.
• What if you're pregnant? If you're pregnant, you may want to get tested even if you think you're not at risk. If you are HIV-positive, treatment with anti-retroviral drugs during your pregnancy can greatly reduce the chances you'll pass the infection to your baby.
• Where can you get tested? You can be tested by your doctor or at a hospital, the public health department, a Planned Parenthood clinic or other public clinics. Many clinics don't charge for HIV tests. Be sure to choose a place in which you feel comfortable and that offers counseling before and after testing. Don't let concern about what people may think stop you from being tested. For a referral, or to make an appointment for an HIV test at a Planned Parenthood clinic near you, call 800-230-PLAN (800-230-7526). You can also contact your local or state health department.
• Will your results be private? All states and U.S. territories report positive HIV and AIDS test results to state public health officials to help track the spread of the disease. Most states use name reporting, but the results are released only to the health department and not to anyone else — including the federal government, employers, insurance companies and family members — without your permission. In addition, legal provisions ensure the highest degree of confidentiality with regard to name-based HIV data. If you are concerned about having your name reported, many states offer anonymous testing centers. If you do test positive and seek treatment, however, you will likely have to provide your name to your doctor.

Normally, white blood cells and antibodies attack and destroy foreign organisms that enter your body. This response is coordinated by white blood cells known as CD4 lymphocytes. These lymphocytes are also the main targets of HIV, which attaches to the cells and then enters them. Once inside, the virus inserts its own genetic material into the lymphocytes and makes copies of itself.

When the new copies of the virus break out of the host cells and enter the bloodstream, they search for other cells to attack. In the meantime, the old host cells and some uninfected CD4 cells die from the effects of the virus. The cycle repeats itself again and again. In the process, billions of new HIV particles are produced every day. Eventually, the number of CD4 cells in the body decreases, leading to severe immune deficiency, which means your body can no longer effectively fight off viruses and bacteria that cause disease.

How HIV is transmitted
You can become infected with HIV in several ways, including:

• Sexual transmission. You may become infected if you have vaginal, anal or oral sex with an infected partner whose blood, semen or vaginal secretions enter your body. You can also become infected from shared sexual devices if they're not washed or covered with a condom. The virus is present in the semen or vaginal secretions of someone who's infected and enters your body through small tears that can develop in the vagina or rectum during sexual activity. If you already have another sexually transmitted disease, you're at much greater risk of contracting HIV. Contrary to what researchers once believed, women who use the spermicide nonoxynol 9 also may be at increased risk. This spermicide irritates the lining of the vagina and may cause tears that allow the virus into the body.
• Transmission through infected blood. In some cases, the virus may be transmitted through blood and blood products that you receive in blood transfusions. Since 1985, American hospitals and blood banks have screened the blood supply for HIV antibodies. This blood testing, along with improvements in donor screening and recruitment practices, has substantially reduced the risk of acquiring HIV through a transfusion.
• Transmission through needle sharing. HIV is easily transmitted through needles and syringes contaminated with infected blood. Sharing intravenous drug paraphernalia puts you at high risk of HIV and other infectious diseases such as hepatitis. Your risk is greater if you inject drugs frequently and also engage in high-risk sexual behavior. Avoiding the use of injected drugs is the most reliable way to prevent infection. If that isn't an option, you can reduce your risk by participating in a needle exchange program that allows you to trade used needles and syringes for sterile ones.
• Transmission through accidental needle sticks. Transmission of the virus between HIV-positive people and health care workers through needle sticks is low. Experts put the risk at far less than 1 percent.
• Transmission from mother to child. Each year, nearly 600,000 infants are infected with HIV, either during pregnancy or delivery or through breast-feeding. But if women receive treatment for HIV infection during pregnancy, the risk to their babies is significantly reduced. In the United States, most pregnant women are pre-screened for HIV, and anti-retroviral drugs are readily available. Not so in developing nations, where women seldom know their HIV status, and treatment is often limited or nonexistent. When medications aren't available, Caesarean section is sometimes recommended instead of vaginal delivery. Other options, such as vaginal disinfection, haven't proved effective.
• Other methods of transmission. In rare cases, the virus may be transmitted through organ or tissue transplants or unsterilized dental or surgical equipment.

Ways HIV is not transmitted
TTo become infected with HIV, infected blood, semen or vaginal secretions must enter your body. You can't become infected through ordinary contact — hugging, kissing, dancing or shaking hands — with someone who has HIV or AIDS.

Anyone of any age, race, sex or sexual orientation can be infected with HIV, but you're at greatest risk of HIV/AIDS if you:

• Have unprotected sex with multiple partners. You're at risk whether you're heterosexual, homosexual or bisexual. Unprotected sex means having sex without using a new latex or polyurethane condom every time.
• Have unprotected sex with someone who is HIV-positive.
• Have another sexually transmitted disease, such as syphilis, herpes, chlamydia, gonorrhea or bacterial vaginosis.
• Share needles during intravenous drug use.
• Received a blood transfusion or blood products before 1985.
• Have fewer copies of a gene called CCL3L1 that helps fight HIV infection.

NNewborns or nursing infants whose mothers tested positive for HIV but did not receive treatment also are at high risk.

HIV infection weakens your immune system, making you highly susceptible to a large number of bacterial, viral, fungal and parasitic infections. You may also be vulnerable to certain types of cancers. But treatment with anti-retroviral drugs has markedly decreased the number of opportunistic infections and cancers affecting people with HIV. It's now more likely these infections will occur in people who have not had treatment.

Bacterial infections

• Bacterial pneumonia. Dozens of types of bacteria can cause bacterial pneumonia, which may develop on its own or after you've had an upper respiratory infection such as a cold or the flu.
• Mycobacterium avium complex (MAC). This infection is caused by a group of mycobacteria referred to by a single name — MAC. The mycobacteria normally cause an infection of the respiratory tract. But if you have advanced HIV infection and your CD4 lymphocyte count is less than 50, you're more likely to develop a systemic infection that can affect almost any internal organ, including your bone marrow, liver or spleen. MAC causes nonspecific symptoms such as fever, night sweats, weight loss, stomach pain and diarrhea.
• Tuberculosis (TB). In resource-poor nations, TB is the most common opportunistic infection associated with HIV and a leading cause of death among people living with AIDS. Millions of people are currently infected with both HIV and tuberculosis, and many experts consider the two diseases twin epidemics. That's because HIV/AIDS and TB have a deadly symbiotic relationship, in which each fuels the progress of the other. Having HIV makes you more susceptible to TB and far more likely to progress from dormant to active HIV infection. At the same time, TB increases the rate at which the AIDS virus replicates. What's more, TB often strikes people with HIV years before other problems associated with HIV develop. One of the first indications of HIV infection may be the sudden onset of TB — often in a site outside the lungs. If you're HIV-positive, you should have a simple skin test for TB early in your medical care. If the test is positive, you'll also need a chest X-ray and other appropriate tests to make sure you don't have an active infection. If your TB isn't active, there are treatments to prevent it from becoming active. TB is more worrisome than many other opportunistic infections because it's highly contagious. Multidrug-resistant tuberculosis, in which the disease resists treatment with traditional antibiotics, is of particular concern to people with HIV/AIDS.
• Salmonellosis. You contract this bacterial infection from contaminated food or water. Symptoms include severe diarrhea, fever, chills, abdominal pain and, occasionally, vomiting. Although anyone exposed to salmonella bacteria can become sick, salmonellosis is far more common in people who are HIV-positive. You can reduce your risk by washing your hands carefully after handling food and animals and by cooking meat and eggs thoroughly.
• Bacillary angiomatosis. This infection, caused by Bartonella henselae bacteria, first appears as purplish to bright red patches on your skin. It often resembles Kaposi's sarcoma, but it can cause disease in other parts of your body, including your liver and spleen.

Viral infections

• Cytomegalovirus (CMV). This common herpesvirus is transmitted in body fluids such as saliva, blood, urine, semen and breast milk. But a healthy immune system inactivates the virus, and it remains dormant in your body. If your immune system weakens, the virus resurfaces, causing damage to your eyes, digestive tract, lungs or other organs. Most commonly, CMV causes infection and inflammation of your retina (CMV retinitis). If not treated, CMV retinitis can lead to blindness.
• Viral hepatitis. Viral hepatitis is a viral infection of the liver. Signs and symptoms include yellowing of your skin and the whites of your eyes (jaundice), fatigue, nausea, abdominal pain, loss of appetite and diarrhea. There are several types of viral hepatitis, but the most common are hepatitis A, B and C. Hepatitis B and C can lead to persistent or chronic infection and put you at risk of long-term complications such as cirrhosis or liver cancer. If you are HIV-positive and also have hepatitis, you may be more likely to develop liver toxicity from your medications.
• Herpes simplex virus (HSV). HSV, which usually causes genital herpes, may be transmitted during unprotected anal or vaginal sex. Initial symptoms include pain or irritated skin in the genital area. Later, sores that ooze and bleed erupt on the genitals, buttocks and anus. Although these sores eventually heal, the virus periodically reappears, causing the same symptoms. If you have HIV, your skin infection is likely to be more severe than it would be in people who don't have HIV, and the sores may take longer to heal. Systemic symptoms may also be more severe. Although the herpes virus isn't life-threatening in adults, it may cause brain damage and blindness.
• Human papillomavirus (HPV). This is one of the most common causes of sexually transmitted disease. Some types of this virus cause common warts. Other types cause warts on the genitals. If you're HIV-positive, you're especially susceptible to infection with HPV and more prone to recurrent infections. HPV infection is especially serious because it significantly increases a woman's risk of cervical cancer. Infection with both HPV and HIV increases a woman's risk even further — cervical cancer seems to occur more often and more aggressively in women who are HIV-positive. In 2006, the Food and Drug Administration approved the first vaccine to offer protection from the most dangerous types of HPV. The vaccine is most effective when given to girls before they become sexually active, but it also provides protection for sexually active women age 26 and younger. If you are not a candidate for the vaccine, are HIV-positive or have unprotected sex with more than one partner, you should have a Pap test — a test that examines cells taken from the cervix — every year to check for cervical cancer, HPV and other sexually transmitted diseases. Anyone who engages in anal sex should be tested for anal cancer because HPV increases the risk of this type of cancer in both men and women.
• Progressive multifocal leukoencephalopathy (PML). PML is an extremely serious brain infection caused by the human polyomavirus JC virus. Signs and symptoms vary and may include speech problems, weakness on one side of the body, loss of vision in one eye, or numbness in one arm or leg. PML usually occurs only when your immune system has been severely damaged.

Fungal infections

• Candidiasis. Candidiasis is a common HIV-related infection. It causes inflammation and a thick white coating on the mucous membranes of your mouth, tongue (thrush), esophagus (Candida esophagitis) or vagina. Children may have especially severe symptoms in the mouth or esophagus, which can make eating painful and difficult.
• Cryptococcal meningitis. Meningitis is an inflammation of the membranes and fluid surrounding your brain and spinal cord (meninges). Cryptococcal meningitis is a common central nervous system infection associated with HIV, caused by a fungus that is present in soil. It may also be associated with bird or bat droppings. Symptoms include headache, high fever, a stiff neck and sensitivity to light. Cryptococcal meningitis can be successfully treated with antifungal medications, but early treatment is essential. Meningitis is a serious disease that can cause severe complications or prove fatal in a short period of time. Once you've had cryptococcal meningitis, you'll need to be on long-term medication to prevent a recurrence.

Parasitic infections

• Pneumocystis carinii pneumonia (PCP). Although anti-retroviral drugs have helped reduce the number of cases of PCP, it remains one of the most common opportunistic infections affecting people with AIDS in the United States. PCP attacks the lungs, making it difficult to breathe. Signs and symptoms include a cough that doesn't go away, fever and trouble breathing.
• Toxoplasmosis. This potentially deadly infection is caused by Toxoplasma gondii, a parasite spread primarily by cats. Infected cats pass the parasites in their stool, and the parasites may then spread to other animals. Humans generally contract toxoplasmosis by touching their mouths with their hands after changing cat litter or by eating raw or undercooked meat, especially pork, lamb and venison. Once you're infected, the parasites can spread to every organ in your body, including your heart, eyes and lungs. For many people with AIDS, toxoplasmosis leads to encephalitis, an infection of the brain. Signs and symptoms may include disorientation, seizures, and difficulty walking or speaking.
• Cryptosporidiosis. This infection is caused by an intestinal parasite that's commonly found in animals. You contract cryptosporidiosis when you ingest contaminated food or water. The parasite grows in your intestines and bile ducts, leading to severe, chronic diarrhea in people with AIDS.

Cancers

• Kaposi's sarcoma. Kaposi's sarcoma is a tumor of the blood vessel walls. Although rare in people not infected with HIV, it's common in HIV-positive people. Kaposi's sarcoma usually appears as pink, red or purple lesions on the skin and mouth. In people with darker skin, the lesions may look dark brown or black. Kaposi's sarcoma can also affect the internal organs, including the digestive tract and lungs. Researchers are testing new combinations of the chemotherapy drugs currently used to treat Kaposi's sarcoma as well as new ways of delivering those medications. What's more, as with most opportunistic infections associated with AIDS, the use of anti-retrovirals has reduced the incidence of this cancer and has even reduced the lesions in people already affected.
• Non-Hodgkin's lymphoma. This cancer originates in lymphocytes, a type of white blood cell. Lymphocytes are concentrated in your bone marrow, lymph nodes, spleen, digestive tract and skin. Although lymphomas can start in other organs, they usually begin in your lymph nodes. The most common early sign is painless swelling of the lymph nodes in your neck, armpit or groin.

Other complications

• Wasting syndrome. Aggressive treatment regimens have reduced the number of cases of wasting syndrome, but it does still affect many people with AIDS. It is defined as a loss of at least 10 percent of body weight and is often accompanied by diarrhea, chronic weakness and fever.
• Neurological complications. Although AIDS doesn't appear to infect the nerve cells, it can still cause neurological symptoms such as confusion, forgetfulness, changes in behavior, depression, anxiety and trouble walking. One of the most common neurological complications is AIDS dementia complex, which leads to behavioral changes and diminished mental functioning. It's best treated with aggressive anti-retroviral medications.

If you're concerned you might have or have been exposed to HIV, you're likely to start by first seeing your family doctor. However, in some cases when you call to set up an appointment, you may be referred immediately to an infectious disease specialist.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance.
• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any drug use, sexual partners, and sexually transmitted diseases (STDs) that you or your partners have or have had.
• Make a list of all medications, as well as any vitamins or supplements, that you're taking.
• Take a family member or friend along, if possible and if you feel comfortable doing so. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For HIV, some basic questions to ask your doctor include:

• What is likely causing my symptoms or condition?
• What are other possible causes for my symptoms or condition?
• What kinds of tests do I need?
• Is my condition likely temporary or chronic?
• Who do I need to inform about my condition?
• What is the best course of action?
• What are the alternatives to the primary approach that you're suggesting?
• I have these other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist?
• Is there a generic alternative to the medicine you're prescribing me?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
• How often will I need to follow up with my doctor?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous, or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Have you shared any drug needles?
• Have you had unprotected sex?
• Do you have any STDs?
• Have you had sex with anyone you know to have HIV/AIDS?
• Are you or could you be pregnant?

What you can do in the meantime
IIf you think you may have HIV or may have been exposed to it, see your doctor promptly. In the meantime, don't have unprotected sex and tell any current partners that you may have been exposed to HIV.

HIV is diagnosed by testing your blood or oral mucus for the presence of antibodies to the virus. The Centers for Disease Control and Prevention (CDC) encourages voluntary HIV testing as a routine part of medical care for all adolescents and adults ages 13 to 64. Although the CDC says that everyone should be tested at least once, yearly testing is recommended only for people at high risk of infection.

Unfortunately, HIV tests aren't accurate immediately after infection because it takes time for you to develop these antibodies — usually about 12 weeks. In rare cases, it can take up to six months for an HIV test to become positive.

ELISA and Western blot tests
For years, the only available test for HIV was the enzyme-linked immunosorbent assay (ELISA) test that looked for antibodies to the virus in a sample of your blood. If this test was positive — meaning you had antibodies to HIV — the same test was repeated. If the repeat test was also positive for HIV antibodies, you'd then have another confirming blood test called the Western blot test, which checks for the presence of HIV proteins. The Western blot test was important because you may have non-HIV antibodies that cause a false-positive result on the ELISA test. Combining the two types of tests helped ensure that the results were accurate, and you'd receive a diagnosis of HIV only if all three tests were positive. The downside is that it can take up to two weeks to get the results of the ELISA and Western blot tests, a period of time that can take an emotional toll and that discouraged many people from returning to get their test results.

Rapid tests
Now, several rapid tests can give highly accurate information within as little as 20 minutes. These tests look for antibodies to the virus using a sample of your blood or fluids collected on a treated pad that's rubbed on your upper and lower gums. The oral test is almost as sensitive as the blood test and eliminates the need for drawing blood. A positive reaction on a rapid test requires a confirming blood test. And because the tests are relatively new and were originally approved for use only in certified laboratories, they may not be available everywhere.

Home tests
Currently, the Food and Drug Administration (FDA) has approved only one HIV test for home use. The Home Access HIV-1 test, marketed by Home Access Health, is as accurate as a clinical test, and all positive results are automatically retested.

Unlike a home pregnancy test, you don't evaluate the test yourself. Instead, you mail in a drop of your blood, then call a toll-free number to receive your results in three to seven business days. This approach ensures your privacy and anonymity — you're identified only by a code number that comes with your kit. The greatest disadvantage is that you're not offered the counseling that you typically receive in a clinic or doctor's office, although you're given referrals for medical and social services. No matter what type of test you choose, if you test positive for an HIV infection, tell your sexual partner or partners right away so that they can be screened and take steps to protect themselves.

IIf you receive a diagnosis of HIV/AIDS, your doctor will use a test to help predict the probable progression of your disease. This test measures the amount of virus in your blood (viral load). Studies have shown that people with higher viral loads generally fare more poorly than do those with a lower viral load. Viral load tests are also used to decide when to start and when to change your treatment.

When HIV was first identified in the early 1980s, there were few drugs to treat the virus and the opportunistic infections associated with it. Since then, a number of medications have been developed to treat both HIV/AIDS and opportunistic infections. For many people, including children, these treatments have extended and improved their quality of life. Scientists at the National Institutes of Health estimate that since 1989, anti-retroviral medications have provided HIV-positive Americans with years of extended life. But none of these drugs can cure HIV/AIDS, many have side effects that can be severe, and most are expensive. What's more, after 20 years on AIDS drugs, some people develop resistance to the drugs and no longer respond to treatment. Newer drugs are being researched and created to help this group of people.

Treatment guidelines
A panel of leading AIDS specialists has developed recommendations for the use of anti-retroviral medications in people with HIV. These recommendations are based on the best information available at the time they were developed. AIDSinfo, a program of the U.S. Department of Health and Human Services, regularly refines and updates the recommendations as knowledge about HIV infection evolves.

According to current guidelines, treatment should focus on achieving the maximum suppression of symptoms for as long as possible. This aggressive approach is known as highly active anti-retroviral therapy (HAART). The aim of HAART is to reduce the amount of virus in your blood to very low or even nondetectable levels, although this doesn't mean the virus is gone. This is usually accomplished with a combination of three or more drugs.

But the treatment guidelines also emphasize the importance of quality of life. Thus the goal of AIDS treatment is to find the strongest possible regimen that is also simple and has the fewest side effects. If you have HIV/AIDS, it's important that you take an active role in treatment decisions. You and your doctor should discuss the risks and benefits of all therapies so that you can make an informed decision about what will likely be a complex and long-term treatment.

Anti-retroviral drugs
Anti-retroviral drugs inhibit the growth and replication of HIV at various stages of its life cycle. Seven classes of these drugs are available:

• Nucleoside analogue reverse transcriptase inhibitors (NRTIs). NRTIs were the first anti-retroviral drugs to be developed. They inhibit the replication of an HIV enzyme called reverse transcriptase. They include zidovudine (Retrovir), lamivudine (Epivir), didanosine (Videx), stavudine (Zerit) and abacavir (Ziagen). A newer drug, emtricitabine (Emtriva), which must be used in combination with at least two other AIDS medications, treats both HIV and hepatitis B.

  The major side effect of zidovudine is bone marrow suppression, which causes a decrease in the number of red and white blood cells. Approximately 5 percent of people treated with abacavir experience hypersensitivity reactions such as a rash, fever, fatigue, nausea, vomiting, diarrhea and abdominal pain. Symptoms usually appear within the first six weeks of treatment and generally disappear when the drug is discontinued. If you've had a hypersensitivity reaction to abacavir, avoid taking the drug again. Side effects of emtricitabine include skin discoloration.

• Protease inhibitors (PIs). PIs interrupt HIV replication at a later stage in its life cycle by interfering with an enzyme known as HIV protease. This causes HIV particles in your body to become structurally disorganized and noninfectious. Among these drugs are saquinavir (Invirase), ritonavir (Norvir), indinavir (Crixivan), nelfinavir (Viracept), amprenavir (Agenerase), lopinavir/ritonavir (Kaletra), atazanavir (Reyataz) and tipranavir (Aptivus). Darunavir (Prezista) is intended for people who haven't responded to treatment with other drugs. Darunavir is used with ritonavir and other anti-HIV medications. Protease inhibitors are usually prescribed with other medications, to help avoid drug resistance.

  The most common side effects of protease inhibitors include nausea, diarrhea and other digestive tract problems. PIs can also cause a significant number of side effects when they interact with certain other medications. That's because all PIs, to one degree or another, affect an enzyme system in your liver that is responsible for metabolizing a large number of drugs. Newer side effects have also appeared with the continuing and widespread use of protease inhibitors. These include elevated triglyceride levels and problems with sugar metabolism that may sometimes progress to diabetes.

  There may also be abnormalities in the way fat is metabolized and deposited in your body. Some people lose much of their total body fat. Others gain excess fat on the back between their shoulders (buffalo hump) or in the stomach (protease paunch). No one knows exactly why these abnormalities occur. In fact, it's not even certain whether these problems are a direct result of treatment with protease inhibitors or due to some other cause that has yet to be identified. Similar metabolic abnormalities have occurred in people on anti-retroviral therapy that doesn't include PIs. Although these body changes can be distressing, the possibility they may occur should not stop you from getting treatment for HIV/AIDS.

• Non-nucleoside reverse transcriptase inhibitors (NNRTIs). These drugs bind directly to the enzyme reverse transcriptase. Four NNRTIs are approved for clinical use: nevirapine (Viramune), delavirdine (Rescriptor), efavirenz (Sustiva) and etravirine (Intelence). A major side effect of all NNRTIs is a rash. In addition, people taking efavirenz may have side effects such as abnormal and worsening of underlying mood disorders.
• Nucleotide reverse transcriptase inhibitors (NtRTIs). NtRTIs work much like nucleoside analogs: They interfere with the replication of reverse transcriptase and prevent the virus from inserting its genetic material into cells. But NtRTIs act more quickly than NRTIs do. The only approved drug in this class, tenofovir (Viread), inhibits both HIV and hepatitis B and appears to be effective in people who are resistant to NRTIs. The most common side effects of tenofovir, when used in combination with other anti-retrovirals, are nausea, vomiting, diarrhea and gas. As with all reverse transcriptase inhibitors, the possibility of severe, and even fatal, liver damage exists.
• Fusion inhibitors. One of the most alarming developments in the AIDS epidemic is the emergence of drug-resistant strains of HIV. Worldwide, a majority of people receiving treatment for HIV are resistant to at least one drug, and many don't respond to a typical three-drug combination. But a drug called enfuvirtide (Fuzeon), the first in a new class of drugs called fusion inhibitors, appears to suppress resistant strains of HIV. Fusion inhibitors stop the virus from replicating by preventing its membrane from fusing with the membrane surrounding healthy cells. Fuzeon is used in combination with other HIV drugs for people who have advanced infection and who have developed resistance to other drugs. Doctors administer Fuzeon by injection.
• Integrase inhibitors. These drugs are aimed at treating those who become resistant to other treatments. The only drug in this class, raltegravir (Isentress), is intended to be used in combination with other anti-retroviral drugs rather than alone. This is the first class of drugs that blocks replication of the HIV integrase enzyme, which keeps HIV DNA from inserting itself into human DNA. Common side effects include diarrhea, nausea, headache and fever.

• Chemokine co-receptor inhibitors. Chemokine co-receptor inhibitors (CCR5 antagonists) make up a new class of drugs used to treat a particulapr type of HIV infection called CCR5-tropic HIV-1. The only drug in this class — maraviroc (Selzentry) — is for treatment of CCR5-tropic HIV-1 in adults. Maraviroc is the first drug that targets a human protein rather than components of the HIV virus itself.

  Maraviroc is used in combination with other anti-retroviral drugs for the treatment of adults with CCR5-tropic HIV-1 who have elevated levels of HIV (high viral load) in their blood despite treatment with other HIV medications. Maraviroc reduces viral load by preventing HIV from entering uninfected white blood cells. It does this by blocking CCR5, a major route of entry into the cells. CCR5 is a protein found on the surface of some immune cells, and maraviroc blocks the CCR5 co-receptor from accepting HIV.

  During two large clinical trials, approximately twice as many people with CCR5-tropic HIV-1 infection who received maraviroc had undetectable viral loads after 24 weeks as did those who received more standard therapy in the control groups.

  Side effects of maraviroc may include liver and cardiovascular problems, as well as cough, fever, upper respiratory tract infections, rash and abdominal pain.

Treatment response
Your response to any treatment is measured by viral load. Viral load should be tested at the start of treatment and then every three to four months while you're undergoing therapy. In some cases, you may be tested even more often.

New treatments
Many new drugs for HIV- or AIDS-related infections are in development or being tested in clinical trials.

FFor more information on new therapies, call AIDSinfo at 800-TRIALS-A (800-874-2572).

Although it's important to receive medical treatment for HIV/AIDS, it's also essential to take an active role in your own care. The following suggestions may help you stay healthy longer:

• Make sure your doctor knows how to treat HIV. Find someone who understands the ramifications of the disease. You'll also want a doctor who is willing to work with you and who makes you feel comfortable and respected.
• Follow your doctor's instructions. Keep all of your appointments, and take your medications exactly as directed. Many treatment regimens are much simpler now than in the past — some requiring as few as one pill a day. Even so, sticking with treatment can be difficult. If you get sick from your medication, call your doctor. Don't stop taking your medication or change the dosage on your own.
• Get immunizations. These may prevent infections such as pneumonia and the flu.
• Don't smoke or use illicit drugs. These weaken your body even more.
• Eat the healthiest diet you can. Emphasize fresh fruits and vegetables, whole grains and lean protein. Healthy foods help keep you strong, give you more energy and support your immune system. Unfortunately, you may not always feel like eating when you have HIV. But good nutrition is tremendously important. A registered dietitian can be especially helpful if you have diarrhea, weight loss or trouble eating. Also, because your nutritional needs are extremely high and you may not digest food well, talk to your doctor about vitamin and mineral supplements.
• Avoid foods that may put you at risk of infection. These include unpasteurized dairy products, raw eggs and raw seafood such as oysters, sushi or sashimi. Cook meat until it's well-done or until there's no trace of pink color.
• Drink pure water. The CDC recommends that you boil tap water or use bottled or filtered water for drinking. If you buy a water filter, look for one that uses reverse osmosis as part of the purification process.
• Get regular exercise. Exercise helps increase your strength and energy levels and can help battle the depression that's often a part of dealing with HIV/AIDS.
• Get enough sleep. Rest when you need to.
• Take care with companion animals. Some animals may carry parasites that can cause infections in people who are HIV-positive. But that doesn't mean you should give up your companion animal. You can protect yourself by having someone else clean your cat's litter box or pick up after your dog. If you must do these chores yourself, wear latex gloves and wash your hands immediately afterward. Don't feed your pets raw meat, and make sure they have all their shots. Always wash your hands thoroughly with soap and water after petting or playing with your animals.
• Find ways to relax. This might mean anything from yoga or meditation to walking, reading, playing chess or computer games, or listening to music.
• Keep your hands clean. Wash your hands thoroughly with soap and water after using the restroom, before eating or preparing food, and after spending time in public places. You might find it helpful to carry an alcohol-based hand sanitizer with you for times when it's not convenient to use soap and water.

Receiving a diagnosis of any life-threatening illness is devastating. But the emotional, social and financial consequences of HIV/AIDS can make coping with this illness especially difficult — not only for you but also for those close to you.

HIV/AIDS clinics
Fortunately, a wide range of services and resources are available to people with HIV. Most HIV/AIDS clinics have social workers, counselors or nurses who can help you with problems directly or put you in touch with people who can. They can arrange for transportation to and from doctor appointments, help with housing and child care, and deal with employment, financial and legal issues.

Steps that may help
Some of the following suggestions may help you deal with the emotional toll of living with HIV/AIDS:

• Learn all you can about HIV/AIDS. Find out how the disease progresses, your prognosis and your treatment options, including both experimental and standard treatments and their side effects. The more you know, the more active you can be in your own care.
• Be proactive. Although you may often feel tired and discouraged, don't let others — including your family or your doctor — make important decisions for you. It's vital that you take an active role in your treatment.
• Maintain a strong support system. Strong relationships are crucial in dealing with life-threatening illnesses. Although friends and family can be your best allies, in some cases they may have trouble dealing with your illness. If so, an HIV counselor, other people who are HIV-positive, or a formal support group may be helpful.
• Take time to make important decisions. One struggle you'll likely face is how much to reveal about your illness. When your disease is first diagnosed, you may not want anyone to know. But HIV/AIDS is a heavy burden to carry alone. Like many people, you may eventually decide that it's important for your emotional well-being to confide in someone you trust. The choice is up to you. You need to tell your current and former sexual partners and your health care providers. Beyond that, there is no legal obligation for you to reveal your HIV status, even to your employer. In fact, the law guarantees your right to privacy.
• Come to terms with your illness. Coming to terms with your illness may be the hardest thing you've ever done. For some people, having a strong faith or a sense of something greater than themselves makes this process easier. Others seek counseling from someone who understands HIV/AIDS. Still others make a conscious decision to experience their lives as fully and intensely as they can or to help other people who have the disease. A vast support network is available for people with HIV infection.

There's no vaccine to prevent HIV infection and no cure for AIDS. But it's possible to protect yourself and others from infection. That means educating yourself about HIV and avoiding any behavior that allows HIV-infected fluids — blood, semen, vaginal secretions and breast milk — into your body.

If you're HIV-negative
The following measures can help keep you from being infected with HIV:

• Educate yourself and others. Make sure you understand what HIV is and how the virus is transmitted. Just as important, teach your children about HIV.
• Know the HIV status of any sexual partner. Don't engage in unprotected sex unless you're absolutely certain your partner isn't infected with HIV.
• Use a new latex or polyurethane condom every time you have sex. If you don't know the HIV status of your partner, use a new latex condom every time you have anal or vaginal sex. Women can use a female condom. If you're allergic to latex, use a plastic (polyurethane) condom. Avoid lambskin condoms — they don't protect you from HIV. Use only water-based lubricants, not petroleum jelly, cold cream or oils. Oil-based lubricants can weaken condoms and cause them to break. During oral sex use a condom, dental dam — a piece of medical-grade latex — or plastic wrap. Remember that although condoms can reduce your risk of contracting HIV, they don't eliminate the risk entirely. Condoms can break or develop small tears, and they may not always be used properly.
• Consider male circumcision. A large study in 2006 by the National Institutes of Health (NIH) showed that medically performed circumcision significantly reduced a man's risk of acquiring HIV through heterosexual intercourse. The study, conducted in Kenya, showed a 53 percent reduction of HIV infection in circumcised HIV-negative men compared with uncircumcised men in the study. The outcome was heralded by the NIH as good news not only because it reduced the number of HIV-infected men, but also because it could lead to fewer infections among women in areas of the world where HIV is spread primarily through heterosexual intercourse.
• Use a clean needle. If you use a needle to inject drugs, make sure it's sterile, and don't share it. Take advantage of needle exchange programs in your community and consider seeking help for your drug use.
• Be cautious about blood products in certain countries. Although the blood supply in the United States is now well screened, this isn't always the case in other countries. If an emergency requires that you receive blood or blood products in another country, get tested for HIV as soon as you return home.
• Get regular screening tests. If you are a woman, have a yearly Pap test. And if you're a man or woman who has had sex with one or more new partners, be tested annually. Men and women who engage in anal sex should also have regular tests for anal cancer.
• Don't become complacent. Because potent anti-retroviral medications have reduced the number of AIDS deaths in the United States, you may think that HIV infection is no longer a problem. But HIV/AIDS is still a terminal illness for which there is no vaccine and no cure. Right now, the only way to stay healthy is to protect yourself and others from infection.

If you're HIV-positive
If you've received a diagnosis of HIV/AIDS, the following guidelines can help protect others:

• Follow safe-sex practices. The only foolproof way to protect others from infection is to avoid practices that expose them to blood, semen or vaginal secretions. Barring that, carefully follow guidelines for safe sex, including using a new latex condom every time you have vaginal or anal sex and using a dental dam, condom or piece of plastic wrap during oral sex. If you use sexual devices, don't share them. It's also important to avoid having unprotected sex with other HIV-positive people because of the risk of acquiring or passing on a drug-resistant strain of the virus.
• Tell your sexual partners you have HIV. It's important to tell anyone with whom you've had sex that you're HIV-positive. Your partners need to be tested and to receive medical care if they have the virus. They also need to know their HIV status so that they don't infect others.
• If your partner is pregnant, tell her you have HIV. Be sure to tell any pregnant woman with whom you've had sex that you're HIV-positive. She needs to receive treatment to protect her own health and that of her baby.
• Tell others who need to know. Although only you can decide whether to tell friends and family about your illness, you do need to inform your health care providers of your HIV status. This is not just to protect them, but also to ensure that you get the best possible medical care.
• Don't share needles or syringes. If you use intravenous drugs, never share your needles and syringes.
• Don't donate blood or organs. The virus will spread to other people.
• Don't share razor blades or toothbrushes. These items may carry traces of HIV-infected blood.
• If you're pregnant, get medical care right away. If you're HIV-positive, you may pass the infection to your baby. But if you receive treatment during pregnancy, you can cut your baby's risk by as much as two-thirds.