Managing your health: a guide for people living with HIV
2. HIV … the basics
This chapter explains some basic but complex issues, including how your immune system works and the way that HIV makes you sick. We encourage you to browse these pages to understand more about topics such as CD4+ cells, seroconversion and other key concepts that will also help information in other chapters fall into place.
What is HIV?
HIV stands for human immunodeficiency virus. The term immunodeficiency means a weakened immune system. People who have been infected with HIV are called HIV-positive (sometimes written: HIV+).
HIV is a virus that weakens your immune system, which is the internal system that defends your body against disease. Your immune system is supposed to protect you from infections, but HIV can sneak past it and then attack your body from the inside. If your immune system becomes weak enough, you can become sick from other infections.
What is AIDS?
AIDS stands for acquired immunodeficiency syndrome. If HIV is not treated with anti-HIV drugs, your immune system generally becomes weaker over time. Eventually, you can become sick with a life-threatening infection, at which point you are said to have AIDS.
With early diagnosis and proper treatment with anti-HIV drugs, people with HIV can avoid getting AIDS and stay healthy for a long time.
What is a virus?
Viruses (like HIV) are the very simplest and smallest of all living things—even smaller than bacteria and other germs. In fact, it’s hard to say whether viruses even count as living things at all, since they can’t reproduce on their own. To reproduce, viruses need to infect living cells and fool them into making more viruses. These newly formed viruses then go on to infect other cells. When describing how viruses like HIV reproduce, we use the term “replicate”.
HIV is a virus that can infect cells of the immune system, including CD4+ cells—the very cells that are supposed to fight off infections. That’s what makes HIV dangerous.
How is HIV transmitted?
HIV infection happens when enough HIV from an HIV-positive person gets into an HIV-negative person’s body. This can’t happen through casual contact, such as shaking hands, sneezing or touching a doorknob or toilet seat. HIV infection only happens when body fluids with a high enough amount of virus get into the HIV-negative person’s body.
Only five body fluids may contain enough virus to infect someone else: blood, semen (including pre-cum), vaginal fluid, anal fluid and breast milk. Infection can happen during sex, sharing needles and other equipment to use drugs and during pregnancy, childbirth or breastfeeding.
However, we know that people who are engaged in care, taking HIV treatment and have an ongoing undetectable viral load are substantially less likely to transmit HIV to others. In fact, studies show that people who maintain an undetectable viral load do not pass HIV to their sexual partners. For more info, read Undetectable viral load and HIV sexual transmission.
There is little or no risk of HIV being transmitted through unbroken skin. However, transmission can happen much more easily through the mucosal membranes. These are the wet linings of body cavities like the vagina, rectum and urethra (the “pee hole” in a man’s penis or a woman’s vulva). HIV can infect cells in the lining of the vagina, rectum and penis even if the tissues are healthy. Having a sexually transmitted infection like herpes, gonorrhea or syphilis can make it even easier to transmit (or be infected by) HIV. So can any other damage to these tender tissues, which can easily happen during sex.
Sexual activities that can easily lead to HIV transmission are called high risk. High-risk sexual activities include vaginal or anal intercourse:
- without a condom, or
- without effective treatment with anti-HIV drugs to reduce to undetectable the amount of HIV in the blood of a person with HIV and make them unable to transmit HIV, or
- without the use of certain anti-HIV drugs to protect an HIV-negative person from HIV (often referred to as PrEP, or pre-exposure prophylaxis)
Some sexual activities, such as oral sex, pose only a low risk of HIV transmission. While these activities can lead to HIV transmission, the chances are much smaller than they are with high-risk activities. Other sexual activities pose no risk for HIV transmission. These include kissing, hugging, mutual masturbation or massage.
HIV can also be transmitted if you share needles or other equipment to inject drugs such as heroin, crack, steroids or hormones.
It is important to be aware of these risks, and ways to minimize them, so that you can prevent HIV passing on to your sexual partners or anyone you share drugs with. It is also important for you to protect yourself from reinfection with HIV, as this could further damage your immune system or expose you to a strain of HIV that is resistant to certain kinds of anti-HIV drugs (see Chapter 10, Treatments).
How do you know if you have HIV?
In order to find out if you have been infected with HIV, you need to have a blood test. This blood test, often incorrectly called an AIDS test, is actually a test for HIV antibodies.
Antibodies are produced by your body as a reaction to infection with HIV. An HIV antibody test looks for the presence of these antibodies in your blood. In a standard HIV test, a needle is inserted into a vein in your arm and a sample of your blood is taken. It is sent to a lab to be tested for the presence of these antibodies. After about two weeks, the test results come back to the office where you had the test done.
Rapid HIV tests are available in some regions across the country. The entire process with the new tests, including taking a drop of blood from your finger, along with HIV counselling before and after the test, takes about 20 minutes. The results that you receive from the rapid test are very accurate.
Since HIV antibody tests look for antibodies and not the virus itself, you need to wait to be tested until HIV antibodies are made by your body.
The period of time from when you are infected with HIV to when antibodies appear in your blood is often called the window period. During the window period, the HIV test may give a negative result even though you have HIV.
Current Canadian HIV antibody tests can detect HIV infection in 50% of people by 18 days after infection; 95% of people by 34 days after infection; and 99% of people by one and a half months after infection. Some tests used in Canada have an even shorter window period, but the rapid test has a slightly longer window period. Talk to your doctor or HIV tester about the window period for the test being used.
A positive test result means that you have been infected with HIV. You can transmit the virus to people if you have unprotected sex or share needles or other drug-use equipment with them. A positive test does not mean that you have AIDS or that you will get it. It does not give you any additional information about the state of your health.
How your immune system works
Germs are all around us (and often inside us). They’re not always bad. Some are even helpful: for instance, your intestinal tract is loaded with “friendly” bacteria that you need for proper digestion.
Many kinds of germs, however, can make you sick—from mild, passing illnesses like a cold, to serious or even fatal infections. Fortunately, your immune system usually protects you from germs by recognizing those that don’t belong in your body and destroying them.
Your body’s first line of defence is the skin. The skin covers the outside of your body, acting as a physical barrier to germs. If there are breaks in your skin, even very small ones, they can provide vulnerable spots where viruses and other germs can enter the body.
Your mucous membranes are the soft, wet linings of your mouth, nose, genitals and anus. The mucous membranes also defend your body on the cellular level against germs. This cellular-level defence is called mucosal immunity. But mucous membranes are not a perfect barrier. Small breaks and thinning in these membranes can create entry points into the inside of your body for viruses and germs. And some germs can pass through a healthy membrane.
Luckily, there’s far more to the immune system. The immune system is made up of chemicals, cells, tissues and organs. The most important elements are white blood cells. These white blood cells patrol the body, moving through your blood and lymphatic system.
Your circulatory system, made up of your heart and blood vessels, carries blood to all the organs and tissues of the body. Your lymphatic system carries a clear fluid called lymph to different parts of the body. Lymph sweeps germs into the lymph nodes located in your armpits, neck, abdomen and groin. There, immune cells attack the germs.
When you’re fighting off the flu or other infection, you can often feel swollen lymph nodes in your throat and groin. This is a sign that your immune system is actively fighting the infection.
Different kinds of white blood cells work as a team to recognize and destroy intruding germs. Specialized white blood cells also search for any of your own cells that are already infected. They destroy these cells to prevent infection from spreading further.
CD4+ cells play a central role in the immune system’s job of fighting off germs. CD4+ cells help recognize infection. They also co-ordinate all the other parts of the immune system to provide an organized response.
How HIV can make you sick
Unfortunately, CD4+ cells are also one of HIV’s favourite targets. HIV attacks and destroys CD4+ cells, one of the most important parts of your immune system. This eventually leaves your immune system weak and unable to defend you against serious illnesses.
The body fights back by constantly producing new immune cells. However, over time, the virus tends to win out. The immune system becomes less and less able to suppress HIV and other infections. It also becomes less able to control the spread of certain types of cancer cells. When the immune system becomes weakened enough by HIV infection, these other infections and cancers can become serious or deadly problems.
If you are not treated with anti-HIV drugs after being diagnosed, HIV moves or progresses through several distinct phases. Some people progress very quickly, while others live with HIV for years without developing a life-threatening infection.
With effective HIV treatment now available, most people diagnosed with HIV and treated with anti-HIV drugs remain healthy and do not go through these stages.
First stages of HIV infection
Primary infection refers to the time when you’re first infected with HIV. Many people are not aware that they are even infected with HIV at this point. Nonetheless, during this stage the virus multiplies rapidly. Within two to four weeks after infection, you may experience flu-like symptoms such as fatigue, fever, sore throat, swollen lymph nodes, headache, loss of appetite or skin rash. This illness usually lasts less than two weeks, although it can last as long as 10 weeks. Not everybody has these symptoms, so they’re not a reliable way to tell whether or not you’ve been infected. However, if you have these symptoms after unprotected sex or share needles or other drug-use equipment, speak to your doctor immediately and arrange for an HIV test. Research shows that the sooner you are diagnosed and begin treatment after infection with HIV, the healthier your body will likely remain.
During this period of seroconversion, the immune system is learning to recognize HIV. It has not yet developed killer proteins known as antibodies to attack the virus in any significant way. This means that:
- the amount of virus in your blood (your viral load) may be very high;
- your CD4+ counts may drop until your body responds to the new infection;
- standard HIV tests could show that you are not infected even though you actually are. This is because the tests look for HIV antibodies, which your body hasn’t developed at this stage;
- you can still pass HIV on to someone else. In fact, you are more likely to pass the virus on to others if you’re newly infected and untreated, because there’s so much HIV in your body.
When your body develops antibodies to HIV, this is known as seroconversion. This usually happens one to three months after infection. The blood test for HIV, which actually looks for the antibodies, not the virus itself, will only give positive results after you seroconvert.
Around this time, your viral load will come back down after the high spike seen during the primary infection period.
Next stages of HIV infection
Even if undiagnosed and untreated for HIV, you may feel perfectly well for a long time during the stage of HIV infection that follows seroconversion. Although your immune system hasn’t eliminated the infection, it is able to more or less hold its own against it, meaning the virus and your body now co-exist in a kind of standoff. Your CD4+ cell counts and viral load will remain relatively stable, although your viral load may go up if you’re fighting off other infections such as a cold or the flu. Many people have no symptoms of HIV disease, which is why this stage is sometimes called asymptomatic infection.
This is the longest stage of HIV infection (see graph). In many people, it can last 10 or more years, while in others, it may be a shorter period of time. During the asymptomatic infection phase, HIV is rapidly making copies of itself (replicating) and infecting new CD4+ cells. Your body is trying to counterbalance this loss of CD4+ cells by creating new, healthy ones. As long as your body can replace those CD4+ cells infected by HIV with healthy ones, your immune system will remain strong. In most cases however, if left untreated, HIV eventually starts to win this battle.
The strength of your immune system is measured by your CD4+ cell count (see Chapter 9, Monitoring your health).
Without anti-HIV treatment, the virus overburdens your immune system, your CD4+ cell count drops and you are at increased risk for developing symptoms of HIV infection. These can include swollen lymph nodes, night sweats, fever, diarrhea, weight loss and fatigue. You may develop infections like thrush or persistent vaginal yeast infections. These are all signs that HIV infection is progressing. For more information on infections associated with untreated HIV infection, see Chapter 12, HIV-related infections and cancers.
If your HIV infection is not treated with anti-HIV drugs, you may progress to the stage known as AIDS. Experts have created a list of AIDS-defining illnesses that are used in the diagnosis of AIDS and in statistics. These illnesses are limited to more serious life-threatening infections, including bacterial infections such as Mycobacterium avium complex (MAC), fungal infections such as Pneumocystis pneumonia (PCP) or cancers such as non-Hodgkin’s lymphoma and Kaposi’s sarcoma (see Chapter 12, HIV-related infections and cancers).
Before effective anti-HIV drugs were available, progressing to AIDS and eventually death was the inevitable outcome of HIV infection for most people. However, with effective anti-HIV drugs, HIV disease can be controlled and does not progress toward life-threatening illnesses. Anti-HIV drugs can halt the progression toward AIDS in people with HIV who are healthy and it can also help people who have become sick with AIDS-related life-threatening infections to get better and stay healthy.
The way that we refer to HIV and AIDS reflects this new reality. Many people now refer to HIV disease or chronic HIV infection, reflecting the fact that AIDS is now an uncommon outcome of HIV infection where anti-HIV drugs are available.
The role of chronic inflammation in HIV disease
While anti-HIV drugs help to greatly reduce the amount of HIV in your body, chronic, ongoing inflammation produced by the impact of the virus is controlled but not eliminated by these drugs.
Inflammation begins during the early stages of HIV infection and continues over time. It is part of the body’s immune response to injury, irritation or infection. For example, it kicks in when we cut ourselves, come into contact with something we are allergic to or become infected with a sexually transmitted infection (STI). Cells of the immune system are activated and travel to the site of infection or injury. Signs of inflammation can include redness, swelling, heat, pain and loss of function.
Inflammation is one of the body’s ways of fixing or suppressing the problem. Over the short term, it can help us. But when inflammation continues over the long term—when it becomes chronic—it stops being beneficial and can contribute to the development of various diseases. When left unchecked, it has the potential to cause serious damage: to harm immune cells, major organs and the nervous system and contribute to various diseases.
Research is examining the role of inflammation on the health of people with HIV, particularly in cardiovascular disease, osteoporosis, liver disease, kidney and other organ disease seen in people with HIV as we age with this disease.
The Epidemiology of HIV in Canada – a summary of the HIV statistics for Canada
CATIE fact sheets on: