HIV and AIDS

What HIV Does to the Body

The virus attacks specific lymphocytes called T helper cells (also known as T-cells), takes them over, and multiplies. This destroys more T-cells, which damages the body's ability to fight off invading germs and disease.

When the number of T-cells falls to a very low level, people with HIV become more susceptible to other infections and they may get certain types of cancer that a healthy body would normally be able to fight off. This weakened immunity (or immune deficiency) is known as AIDS and can result in severe life-threatening infections, some forms of cancer, and the deterioration of the nervous system.

Although AIDS is always the result of an HIV infection, not everyone with HIV has AIDS. In fact, adults who become infected with HIV may appear healthy for years before they get sick with AIDS.

How Common Are HIV and AIDS?

The first case of AIDS was reported in 1981, but the disease may have existed unrecognized for many years before that. HIV infection leading to AIDS has been a major cause of illness and death among children, teens, and young adults worldwide. AIDS has been the sixth leading cause of death in the United States among 15- to 24-year-olds since 1991.

In recent years, AIDS infection rates have been increasing rapidly among teens and young adults. Half of all new HIV infections in the United States occur in people under 25 years old; thousands of teens acquire new HIV infections each year. Most new HIV cases in younger people are transmitted through unprotected sex; one third of these cases are from injection drug usage via the sharing of dirty, blood-contaminated needles.

Among children, most cases of AIDS — and almost all new HIV infections — resulted from transmission of the HIV virus from the mother to her child during pregnancy, birth, or through breastfeeding.

Fortunately, medicines currently given to HIV-positive pregnant women have reduced mother-to-child HIV transmission tremendously in the United States. These drugs are also used to slow or reduce some of the effects of the disease in people who are already infected.

Unfortunately, these medicines have not been readily available worldwide, particularly in the poorer nations hardest hit by the epidemic. Providing access to these life-saving treatments has become an issue of global importance.

How HIV Is Transmitted

HIV is transmitted through direct contact with the blood or body fluid of someone who is infected with the virus.

The three main ways HIV is passed to a very young child are:

1. while the baby develops in the mother's uterus (intrauterine)
2. at the time of birth
3. during breastfeeding

Among teens, the virus is most commonly spread through high-risk behaviors, including:

• unprotected sexual intercourse (oral, vaginal, or anal sex)
• sharing needles used to inject drugs or other substances (including contaminated needles used for injecting steroids and tattooing and body art)

In very rare cases, HIV has also been transmitted by direct contact with an open wound of an infected person (the virus may be introduced through a small cut or tear on the body of the healthy person) and through blood transfusions. Since 1985, the U.S. blood supply has been carefully screened for HIV.

Signs and Symptoms of HIV

Although there may be no immediate physical signs of HIV infection at birth, they might appear within 2 to 3 months after a child is born. Kids who are born with HIV can develop opportunistic infections, which are illnesses that can develop in weakened immune systems, such as Pneumocystis jirovicii pneumonia (PCP).

A child with HIV may also get more severe bouts of other common childhood infections, such as Epstein-Barr virus (EBV) infection, which generally causes mild illness in most kids. In developing countries, tuberculosis has been a particularly common problem and often the cause of death of children and adults.

A baby born with HIV infection most likely will appear healthy. But within 2 to 3 months after birth an infected baby might begin to appear sick, with poor weight gain, repeated fungal mouth infections (thrush), enlarged lymph nodes, enlarged liver or spleen, neurological problems, and multiple bacterial infections, including pneumonia.

Teens and young adults who contract HIV usually show no symptoms at the time of infection. In fact, it may take up to 10 years or more for symptoms to show. During this time, they can pass on the virus without even knowing they have it themselves. Once the symptoms of AIDS appear, they can include rapid weight loss, intense fatigue, swollen lymph nodes, persistent diarrhea, night sweats, or pneumonia. They, too, will be susceptible to life-threatening opportunistic infections.

Diagnosing HIV Infections and AIDS

Every pregnant woman should be tested for HIV to have a better chance of preventing transmission to her unborn child.

If a woman knows she is HIV-infected and already has children, it is recommended that all of them be tested for HIV. Even older kids who seem healthy could still have an HIV infection if she was HIV-positive at the time they were born. A blood test is needed to know for sure.

However, when a new baby is born to an HIV-infected mother, there is no immediate way to know whether the baby is infected with the virus. This is because if the mother is infected, an ELISA test (which checks for HIV antibodies in the blood) will almost always be positive, too. Babies will have their HIV-infected mother's antibodies (which are passed to the baby through the placenta) even if they are not truly infected with HIV. These babies may remain HIV-antibody-positive for up to 18 months after birth, even if they are not actually infected.

Infants who are not actually infected with the virus (but are born to HIV-positive mothers) will not make their own antibodies; the HIV antibodies that came from their mothers will gradually disappear from their blood before they reach 2 years of age. Any blood tests performed after this point will likely be HIV-negative. Infants who are infected with HIV from their mothers will begin to make their own HIV antibodies and will generally remain HIV-positive after 18 months of age.

The most accurate diagnosis of HIV infection in early infancy comes from tests that show the presence of the virus itself (not HIV antibodies) in the body. These tests include an HIV viral culture and PCR (polymerase chain reaction), a blood test that looks for the DNA of the virus.

Older kids, teens, and adults are tested for HIV infection by an ELISA test to detect the presence of HIV antibodies in the blood. Antibodies are specific proteins that the body produces to fight infections; HIV-specific antibodies are produced in response to infection with HIV. Someone with antibodies against HIV is said to be HIV-positive. If the ELISA test is positive, it is always confirmed by another test called a Western blot. If both of these tests are positive, the patient is almost certainly infected with HIV.

Can Kids Spread HIV?

Across the United States, only a handful of cases have been reported where HIV infection was contagious from a child to another person. All of those cases involved direct blood contact within a household. The typical baby secretions (urine, drool, spit up, vomit, feces, etc.) do not seem to transmit the virus, so routine care of babies with HIV is considered safe.

Despite widespread concerns, no transmissions of HIV within a school or childcare setting have been reported. Because the danger in transmitting HIV involves direct contact with blood, personnel at schools and childcare programs should routinely use gloves when any child has a cut, scrape, or is bleeding.

Transmission of HIV Among Teens

Among teens, HIV is spread mostly through unprotected sex with an infected person or sharing intravenous drug needles. Education of children and teens is vitally important to help prevent sexual transmission of HIV, as well as other sexually transmitted diseases (STDs), including chlamydia, genital herpes, gonorrhea, hepatitis B, syphilis, and genital warts.

Many STDs cause irritation, sores, or ulcers of the skin and mucous membranes that the virus can pass through. Having an STD, such as genital herpes, for example, has been proven to increase the risk of getting HIV if the person has unprotected sex with someone who is HIV-positive.

HIV is not spread through:

• casual contact, such as hugs or handshakes
• drinking glasses
• sneezes
• coughs
• mosquitoes or other insects
• towels
• toilet seats
• doorknobs

Opportunistic Infections

Opportunistic infections (infections that take advantage of a person's weakened immune system) are the most common complication of HIV/AIDS. Sometimes adults with HIV/AIDS can get an infection from germs that do not normally cause illness in a healthy person (like cryptococcus). People with AIDS (especially children) can get a severe version of a more common infection, such as salmonella (a type of diarrhea-causing bacteria) and chickenpox.

These opportunistic infections and conditions can frequently occur in kids with HIV:

• viral infections like a form of chronic walking pneumonia called lymphoid interstitial pneumonia (LIP), herpes simplex virus, shingles, and the cytomegalovirus infection
• parasitic infections such as PCP, a pneumonia caused by Pneumocystis jirovicii, a microscopic parasite that can't be fought off due to a weakened immune system, and toxoplasmosis
• serious bacterial infections such as bacterial meningitis, tuberculosis, and salmonellosis
• fungal infections such as esophagitis (inflammation of the esophagus), and candidiasis or thrush (yeast infection)

Other Complications

Children with HIV are also at higher risk for some forms of cancer because of their weakened immune systems. Lymphomas associated with Epstein-Barr virus (EBV) infection are more common in older kids with HIV.

The most difficult conditions to treat in kids who have HIV or AIDS are the wasting syndrome (the inability to maintain body weight due to long-term poor appetite and other infections related to HIV disease) and HIV encephalopathy (due to HIV infection of the brain that causes swelling and then damage to the brain's tissues over time).

HIV encephalopathy results in AIDS dementia, especially in adults. Wasting syndrome can sometimes be helped with nutritional counseling and daily high-calorie supplements, but preventing HIV encephalopathy remains extremely difficult.

Treating AIDS and HIV

Two major advances in the treatment of HIV/AIDS have occurred over the last 20 years. One is the development of drugs that inhibit the virus's growth, preventing or delaying the onset of AIDS and allowing people living with HIV to remain free of symptoms longer. The other is the development of medications that have proven very important in reducing the transmission of the virus from an HIV-infected mother to her child.

As medical understanding about how the virus invades the body and multiplies within cells has increased, drugs to inhibit its growth and slow its spread have been developed. Drug treatment for HIV/AIDS is complicated and expensive, but highly effective in slowing the replication (reproduction) of the virus and preventing or reducing some effects of the disease.

Drugs to treat HIV/AIDS use at least three strategies:

1. interfering with HIV's reproduction of its genetic material (these drugs are classified as nucleoside or nucleotide anti-retrovirals)
2. interfering with the enzymes HIV needs to take over certain body cells (these are called protease inhibitors)
3. interfering with HIV's ability to pack its genetic material into viral code — that is, the genetic "script" HIV needs to be able to reproduce itself (these are called non-nucleoside reverse transcriptase inhibitors [NNRTIs])

Because these drugs work in different ways, doctors generally prescribe a "combination cocktail" of these drugs that is taken every day. This regimen is known as HAART treatment (HAART stands for highly active antiretroviral therapy). Doctors may also prescribe drugs to prevent certain opportunistic infections — for example, some antibiotics can help prevent PCP, especially in kids.

Although a number of medicines are available to treat HIV infection and slow the onset of AIDS, unless they are taken and administered properly on a round-the-clock schedule, the virus can quickly become resistant to that particular mix of medications. HIV is very adaptable and finds ways to outsmart medical treatments that are not followed properly. This means that if prescribed medicines are not taken at the correct times every day, they will soon fail to keep HIV from reproducing and taking over the body. When that happens, a new regimen will need to be established with different drugs. And if this new mix of medicines is not taken correctly, the virus will likely become resistant to it as well and eventually the person will run out of treatment options.

Aside from the difficulty of getting young children to take their medication on a timed schedule, the medications present other problems. Some have unpleasant side effects, such as a bad flavor, whereas others are only available in pill form, which may be difficult for kids to swallow. Parents who need to give their child these medications should ask the doctor or pharmacist for suggestions on making them easier to take. Many pharmacies now offer flavoring that can be added to bad-tasting medicines, or your doctor may recommend mixing pills with applesauce or pudding.

Because the number of drugs described above is still limited, doctors are concerned that if children fail to take their medicines as prescribed (even missing just a few doses), the virus could eventually develop resistance to existing HIV drugs — making treatment difficult or impossible. It is then doubly important that kids take their medications as directed.

One of the most important home treatment messages for any parent or caregiver is that the child should take all medications consistently, at the time the prescription indicates. This can be difficult — but many HIV/AIDS family support groups and experienced medical providers can offer practical suggestions to help families be successful with the many day-to-day challenges they face.

Many of the new medications that fight HIV infection are expensive. One of the major challenges facing individuals, families, communities, and nations is how to make these medications easily available to all who need them.

Preventing Mother-to-Child Transmission of HIV

When a pregnant HIV-infected woman receives good medical care early and takes antiviral medications regularly during her pregnancy, the chance that she will pass HIV to her unborn baby is dramatically reduced.

It is important that any pregnant woman who knows she is HIV-positive start prenatal care as soon as possible to take full advantage of such treatments. The sooner a mother receives treatment, the greater the likelihood her baby will not get HIV.

An HIV-infected mother can receive medical treatment:

• before the birth of her baby: antiviral treatments given to the mother in the third trimester can help prevent HIV transmission to the baby
• at the time of birth: antiviral medications can be given to both the mother and the newborn to lower the risk of HIV transmission that can occur during the birth process (which exposes the newborn to the mother's blood and fluids); in addition, the mother will be encouraged to formula-feed rather than breastfeed because HIV can be transmitted to her baby through breast milk
• during breastfeeding: because breastfeeding is discouraged among HIV-infected mothers, this type of transmission is rare in the United States. However, in places in the world where formula is not readily available, both the mother and child can be treated with medication to lower the baby's risk of HIV infection.

In the past, before antiviral medicines were routinely given almost 25% of children born to HIV-infected mothers developed the disease and died by 24 months of age. Recent studies have shown that mothers with HIV or AIDS who get good prenatal care and regularly take antiviral drugs during their pregnancy now have less than a 5% chance of passing HIV to their babies. If these babies do get the HIV virus, they tend to be born with a lower viral load (less HIV virus is present in their bodies) and have a better chance of long-term, disease-free survival.

Long-Term Care of Kids With HIV/AIDS

Cases of HIV infection and AIDS in children are complicated and should be managed by experienced health care professionals. Kids will need to have their treatment schedules closely monitored and adjusted regularly. Any infections that could become life threatening must be quickly recognized and treated.

Medicines are adjusted in relation to the child's viral load. The child's health is also monitored by frequent measurement of T-cell levels because these are the cells that the HIV virus destroys. A good T-cell count is a positive sign that medical treatments are working to keep the disease under control.

Kids should see their health care providers often for blood work, physical exams, and discussions about how they and their families are coping socially with any stress from their disease. Some immunizations during routine visits may be slightly different for infants or children with HIV/AIDS. A child whose immune system is severely compromised will not receive live virus vaccines such as measles-mumps-rubella and varicella (chickenpox). All other routine immunizations are given as usual, and a yearly influenza vaccine (flu shot) is recommended.

If a family seeks health care in a hospital emergency department, parents should be sure to tell the nurse who registers the child that the child has HIV. This will alert medical caregivers to look closely for any signs of diseases from opportunistic infections and provide the best possible treatment.

Outlook for HIV and AIDS

There is no known cure for HIV or AIDS. Children who acquire HIV at birth develop AIDS sooner and tend to have more serious complications than adults with the virus.

Although all kids, teens, and adults with HIV will eventually become sick, recent medical advances have significantly improved their chance for survival. Drug treatments can allow people living with HIV to remain free of symptoms for longer and can improve quality of life for people living with AIDS.

Preventing HIV and AIDS

Prevention of HIV remains of worldwide importance. Despite much research, there is no vaccine that will prevent HIV infection. Only the avoidance of risky behaviors can prevent HIV infection. Among U.S. teens and adults, HIV transmission is almost always the result of sexual contact with an infected person or sharing contaminated needles. Infection can be prevented by never sharing needles, and abstaining from oral, vaginal, or anal sex.

Risk can be substantially reduced by always using latex condoms for all types of sexual intercourse, and avoiding contact with the blood, semen, vaginal fluids, and breast milk of an infected person.

Avoidance of alcohol and drugs is also key in preventing the spread of HIV — not because a person can get HIV directly from drinking and doing drugs, but because drinking and drug use often leads to risky behaviors associated with an increased risk of infection (such as having unprotected sex and sharing needles).

The most important means of preventing HIV/AIDS in infancy is to test all pregnant women for the virus. If the result is positive, immediate treatment can begin before the baby is born to prevent HIV transmission.

Talking With Kids About HIV and AIDS

Talking about HIV and AIDS means talking about sexual behaviors — and it's not always easy for parents to talk about sexual feelings and behavior with their kids. Similarly, it's not always easy for teens to open up or to believe that issues like HIV and AIDS can affect them.

Doctors and counselors suggest that parents become knowledgeable and comfortable discussing sex and other difficult issues early on, even before the teen years. After all, the issues involved — understanding the body and sexuality, adopting healthy behaviors, respecting others, and dealing with feelings — are topics that have meaning at all ages (though how parents talk with their kids will vary according to a child's age and ability to understand). Open communication and good listening skills are vital.

Schools can help. Every state requires schools to provide age-appropriate information about HIV/AIDS that has been designed to educate kids about the disease. Studies show that such education makes a tremendous difference in stopping risk-taking behavior by young people.

Parents who are well informed about how to prevent HIV and who talk with their kids regularly about healthy behaviors, feelings, and sexuality play an important part in HIV/AIDS prevention.

Reviewed by: Joel Klein, MD
Date reviewed: December 2009