HIV Infection and AIDS

Acquired immunodeficiency syndrome, better known as AIDS, is caused by infection with a virus known as human immunodeficiency virus (HIV). AIDS is the most advanced stage of HIV infection. Over time, the virus attacks and destroys the body's immune system (the system that protects the body from disease). Without a fully working immune system, a person is at risk for getting other infections that usually do not affect healthy people. These are called opportunistic infections. People with HIV also have a greater risk of getting certain types of cancer, such as Kaposi sarcoma, lymphomas, and cervical cancer. Many of these problems can threaten life.

The first cases of AIDS in the United States were reported in 1981. They were described as a rare form of pneumonia in otherwise healthy men who had sex with men. A blood test for HIV infection was developed and approved in 1985. Around that same time, the virus was found worldwide. Since then, the virus has spread to many others, mainly through sex.

The normal immune system

The immune system is a collection of organs, specialized cells, and proteins that help prevent and fight many diseases. The special cells and substances circulate throughout the body and help protect your body from germs (viruses, bacteria, fungi, and parasites) that cause infections. Some immune system cells may also help protect against cancer.

To understand how the immune system works, think of the body as a country and the immune system as that country's defense forces. Germs and cancer cells are a foreign army which is not part of the body. The invaders want to use the body's cells and resources for their own purposes, and they harm the body in the process.

Viruses, bacteria, fungi, and parasites contain foreign proteins (antigens) that are not normally found in the body. Before the body can fight these invaders, the immune system must first recognize them as foreign. Most of the immune system cells with this important job are white blood cells that travel throughout the body. The white blood cell called the CD4+ T lymphocyte (also called the CD4 cell, helper T cell, T-helper cell, or just T-cell) is a very important part of the immune system. But these cells are also HIV's favorite cell to invade, live in and take over. As HIV takes over these cells and kills them, the immune system doesn't work as well. This problem gets worse over time as more T helper cells are destroyed

One of the immune system's weapons is a special substance called an antibody that circulates in the body to help kill off germs. Each type of antibody is tailor-made to fit one special invader. But in some cases, like that of HIV, even specially-made antibodies are not enough to keep the virus at bay. The virus keeps growing, and damages the very system that is supposed to stop it.

What are viruses?

Viruses are one of the simplest life forms. They are too small to be seen with an ordinary microscope. Unlike animal cells, bacteria, and fungi, they cannot grow or divide on their own. They can only grow and divide after they invade a "host" cell (a healthy cell in a person or other living thing). Viruses depend on the host cell for the energy and raw materials that they use to make copies of themselves.

Viruses have 2 main parts:

• Genetic material in the form of RNA (ribonucleic acid) or DNA (deoxyribonucleic acid)
• A protein coat, which protects the genetic material and allows the virus to attach to the host cell

Some viruses also have an outer envelope, similar to a cell membrane, but which also includes certain viral proteins.

For a virus to infect someone, it must reach a cell that it can infect. Most viruses cannot infect cells through the tough outer layers of unbroken skin. Generally, viruses enter the body through the mucous membranes (cells that line the nose, mouth, lungs, digestive tract, penis, vagina, or rectum), or through breaks in the skin. But each type of virus can only infect certain types of cells. For example, rhinoviruses (which commonly cause colds) enter the body by infecting cells that line the nose, eyes, or mouth. HIV enters the bloodstream to infect certain white blood cells, such as helper T cells.

Once a virus is inside the body, the infection cycle is divided into steps. First, the virus attaches itself to the outside of a host cell. It then breaks through the cell membrane and "injects" its genetic material into the host cell. The genetic material from the virus takes over the cell, and instructs it to make pieces for new viruses. The cell then makes viral DNA or RNA, as well as new viral proteins for the coat and outer envelope of the virus. Over time, these parts are put together to form new viruses, which are released from the cell. This process usually kills the host cell. The new viruses can then infect new cells in the body or other hosts. Some types of viral DNA or RNA can live quietly in the cell (in a dormant state) as an unwanted guest. The virus can then take over the cell days, months, or even years later.

The human immunodeficiency virus

For the human immunodeficiency virus (HIV) to enter a cell, it must first attach to the CD4 surface protein, which is present on the outside of helper T cells and some macrophages. Few other cells in the body have the CD4 protein on their surfaces.

As the helper T cells in a person's body become infected with HIV, they die, and the number of helper T cells decreases over time. This gradual drop in the number of helper T cells shows how much damage HIV infection has done to the host's immune system. Since helper T cells are an important part of the body's immune system, it is easy to understand how HIV infection can cause the immune system to collapse if it is not treated.

In the later stages of HIV infection, the weakened immune system allows opportunistic infections (infections that the healthy body would usually fight off), cancer, and other disorders. Having one of this group of illnesses, combined with the decline in the immune system caused by HIV infection, is known as acquired immune deficiency syndrome, or AIDS.

The definition of AIDS

Just because a person has HIV infection does not mean that he or she has AIDS. AIDS happens when the HIV infection has badly damaged the immune system, a process that may take years.

The Centers for Disease Control and Prevention (CDC) uses a definition for AIDS that has changed since 1984 as more has become known about the infection. This definition includes a positive HIV blood test along with either a major opportunistic condition or a CD4 count less than 200/mm³. (A normal CD4 count is about 500 to 1,500 cells per cubic millimeter of blood -- written mm³.) The opportunistic conditions include certain cancers, infections, and syndromes that are often linked to AIDS:

Cancers

• Invasive cervical cancer
• Kaposi sarcoma
• Burkitt lymphoma, immunoblastic lymphoma, or brain lymphoma

(For more information, see the section, "Cancer in HIV infection".)

Infections

• Coccidioidomycosis
• Cryptococcosis
• Cryptosporidiosis (chronic intestinal, greater than 1 month duration)
• Cytomegalovirus disease (other than liver, spleen, or nodes)
• Cytomegalovirus retinitis (with loss of vision)
• Herpes simplex (chronic ulcer[s] or bronchitis, pneumonitis, or esophagitis)
• Histoplasmosis
• Isosporiasis (chronic intestinal)
• Mycobacterium avium complex or M. kansasii
• Mycobacterium tuberculosis (any site)
• Pneumocystis pneumonia
• Pneumonia (recurrent)
• Salmonella septicemia (recurrent)
• Toxoplasmosis of the brain
• Candidiasis of bronchi, trachea, lungs, or esophagus

(For further information on infections in people with cancer, see our document, Infections in People With Cancer.)

Syndromes

• Encephalopathy (HIV-related; AIDS dementia)
• Progressive multifocal leukoencephalopathy
• HIV wasting syndrome

This AIDS definition has been used for finding and reporting the disease in the United States for some time. It is less helpful now because most patients are treated before these problems can happen, and treatment with anti-HIV (anti-retroviral) drugs can delay the onset of AIDS. The number of HIV-infected people has become more important in understanding the epidemic than the number of people with AIDS.

Most doctors use the CD4 or T cell count and the amount of HIV in the blood (called the viral load) to decide how to treat people with this infection. When possible, most doctors prefer to start treating HIV infection before it has progressed to an opportunistic illness or AIDS.

Key statistics about HIV/AIDS

Between the start of the epidemic in 1981 and December 2007, more than 1,000,000 AIDS cases have been reported in the United States. During that time, more than 583,000 Americans have died of AIDS.

About 1 million people in the United States are now living with HIV infection, and more than 450,000 are living with AIDS. Each year, more than 50,000 people become newly infected with HIV in the United States.

About 73% of people diagnosed with AIDS in 2007 were adult or adolescent men, and 27% were adult or adolescent women. About 50% were black, 30% white, 20% Hispanic, and less than 1% belonged to other races or ethnic groups.

About 17% of the US men and women recently found to have AIDS were infected through contaminated injection drug equipment and 31% through heterosexual sex. Nearly 75% of the women were infected by having sex with men. About 47% of the men became infected through sex with other men, and another 5% had used injection drugs as well as having sex with men.

Worldwide, the most recent data available shows about 33 million people are living with HIV/AIDS. More than 60% of these people live in sub-Saharan Africa. About half are women. In 2008, nearly 3 million people became infected with HIV. In that year, illnesses linked to HIV/AIDS caused the deaths of about 2 million people worldwide.

Although the rate of infection from shared injection equipment is going down in the United States, infection from sex (both heterosexual sex and men who have sex with men) is increasing. In other parts of the world, HIV is mostly passed on by heterosexual sex.

Overall, HIV infection has been reported in 7 groups:

• Men who have unprotected sex with HIV-infected men
• Women who have unprotected sex with HIV-infected men
• Men who have unprotected sex with HIV-infected women
• Injection drug users who share needles or syringes with HIV-infected people
• Children born to or breast-fed by HIV-infected mothers
• People who received blood or blood products from HIV-infected donors (mostly before 1985)
• Health care workers exposed at work to blood from HIV-infected patients, usually from needlestick injuries

Careful screening of blood donors and the testing of donated blood in the United States has resulted in a much safer blood supply since 1985.

What causes AIDS?

The cause of AIDS is the human immunodeficiency virus (HIV). The virus was not known to cause AIDS until 1983.

The type of HIV responsible for most AIDS cases in the United States and Europe is called HIV-1. There is a second virus found mainly in Africa called HIV-2. Even though we commonly call the virus HIV in the United States, it is called HIV-1 in medical labs.

HIV transmission

HIV can be transmitted from one person to another when blood or certain body fluids (semen, vaginal secretions, or breast milk) from an infected person get into an uninfected person. Routes of transmission have included:

• Unprotected vaginal, anal, or oral sex with an infected person
• Needles or drug equipment shared with injection drug users who have HIV
• Prenatal (before birth) and perinatal (during and right after birth) exposures of infants Whose mothers are infected with HIV
• Breast-feeding by mothers with HIV
• Transfusion of blood products containing the virus
• Organ transplants from HIV infected donors
• Penetrating injuries or accidents of health care workers (usually needlesticks) while caring for HIV-infected patients or handling their blood

HIV is not spread by mosquitoes, ticks, or other insects. It can't be spread by casual contact such as talking, shaking hands, hugging, sneezing, sharing dishes, sharing bathrooms, sharing telephones or computers, or through water.

Can AIDS be prevented?

Because AIDS is caused by HIV, taking measures to avoid HIV infection can prevent most cases of AIDS.

Sexual exposures

Most HIV infections throughout the world are passed to other people through sex. This means that avoiding unprotected sex with infected persons can prevent most HIV infections. If both partners are uninfected, and both carefully avoid activities that might result in contracting HIV (both partners stay monogamous and do not share needles with others), unprotected sex can be safe. Another recommendation is to use latex or plastic condoms every time, from start to finish, during any sexual contact with a partner whose HIV status is uncertain. For more information, see the "Additional resources" section at the end of this document, or call the US Centers for Disease Control and Prevention (CDC) at 1-800-232-4636 (1-800-CDC-INFO).

Injection drug use

The second most common cause of HIV infection is sharing used needles or drug equipment with injection drug users who have HIV. In some areas, public health and law enforcement policies are being developed to make sure that drug users can get clean needles and syringes. Nearly everywhere they have been started, these programs have reduced the number of new HIV infections in users who inject drugs. For people who inject drugs, the safest way to avoid AIDS is to quit. However, some people are unable to quit on their own or get help in quitting, and they are unable to stop using drugs right away. For these people, clean needles and injection supplies can help protect them. This, in turn, helps to protect sex partners and any children they may have in the future. For more information on injection safety, see the "Additional resources" section at the end of this document, or call the CDC at 1-800-232-4636 (1-800-CDC-INFO)

After accidental exposure to HIV

In case of a broken condom or other accidental exposure to HIV, some doctors offer "morning-after" treatment to try and reduce the risk of infection in certain high-risk people. This treatment consists of anti-HIV drugs. They are likely to work best if they are started within 24 hours of the exposure and are rarely started more than 72 hours afterward. The drugs must be taken every day for 4 weeks. Because of the possible side effects and other limitations, this treatment is not advised for ongoing or frequent exposures. The drugs can cost $1,000 or more for the 4-week treatment, and may not be covered by health insurance (see the "Antiretroviral therapy" section,) If this treatment is used, the exposed person should also have HIV testing with follow-up medical visits, and learn how to reduce future HIV risk.

Pregnancy and breast-feeding

HIV-infected mothers can pass HIV infection to their babies during pregnancy, delivery, or breast-feeding. Treating the mothers and infants with anti-HIV drugs and avoiding breast-feeding can greatly reduce the risk of these infections. Without this treatment, as many as 1 in 4 babies born to infected mothers can contract HIV. Women with HIV often do not know that they are at risk of HIV because their only risky activity is sex with a man. That is why the US Public Health Service recommends that all women get tested for HIV early in their pregnancy, whether or not they have other known risk factors. This way, infections can be found in time to treat the mother and reduce the baby's HIV risk.

Women who are found to have HIV while they are pregnant are referred for treatment of their HIV to reduce the baby's risk, even if the woman wouldn't otherwise need it. The woman is offered anti-HIV drugs during the pregnancy and delivery. The infant is also treated for a few weeks after birth. Breast feeding is avoided, if bottle feeding is safe and available. There may be other measures needed for the mother's health, some of which also may help reduce the baby's HIV risk. And in some cases, extra treatment is needed to further protect the infant. With expert care, the infant's risk of getting HIV from the mother can drop below 1 in 50. For more information, see "Additional resources" at the end of this document, or call the CDC at 1-800-232-4636 (1-800-CDC-INFO).

Receiving blood products and organ transplants

Transfusions of blood and blood products (such as factor VIII, given to people with hemophilia) caused some of the HIV infections in the early 1980s. With new precautions and careful testing at blood banks, this risk has been almost eliminated. Estimates place the risk of getting HIV this way at less than 1 out of every 2 million units transfused.

Organ and tissue transplants from human donors may carry some risk of HIV and other infections. Donors are carefully screened and tested to reduce the risk as much as possible.

Summary of prevention measures

All told, the most effective methods to avoid HIV infection are:

• Not having sex
• Sex with only one uninfected partner, when both partners avoid other HIV risks
• Careful and correct condom use, every time, when partners' HIV risk is uncertain
• Not using injection drugs
• Always using sterile injection equipment if unable to stop using drugs
• To avoid the risk of passing HIV on to a baby, a woman may choose not to get pregnant. If a woman with HIV gets pregnant, she can still greatly reduce the baby's risk with anti-HIV drugs.

How is HIV/AIDS diagnosed?

People often believe that if they have had a physical exam, the doctor has checked for HIV. This is often not true. HIV testing is mostly not done unless you ask for it or have a medical problem or pregnancy.

This is slowly changing, however. In the late 2000s, the CDC put out guidelines for health care providers to start routinely testing their patients aged 13 to 64 for HIV infection. The guideline no longer requires doctors to counsel patients before the test. Instead, the doctor lets patients know that HIV testing will be done with routine blood tests. Different states may require doctors to give you more information or get you to sign a form before you can be tested for HIV. Because requirements vary from state to state and not all doctors follow the CDC guidelines, you may want to ask your primary care doctor whether his or her office performs routine HIV testing.

HIV testing is still more likely to be done if you have symptoms that look like AIDS, or if you are pregnant. The doctor or nurse should let you know that the test will be included along with other blood work. Most of the time, a person who is tested will know it.

There are a few cases where people may not be told they are getting an HIV test. For instance, prisoners entering the penal system, people entering military service, and some people who apply for individual health or life insurance policies may be tested without knowing about it.

If you have any doubt about your HIV status, talk with your doctor or visit a health department clinic where testing is offered. To have the HIV test done without giving your name and address (anonymous testing), you can buy a home collection kit at the drugstore or go to a special anonymous testing site. Most state health departments and a few other health sites offer anonymous HIV tests, but you may want to call first to be sure.

Because HIV infection often has no symptoms for years, a person can have HIV for a long time and not know about it until he or she is tested. People who do not seek HIV testing may not learn that they have HIV until they develop early symptoms or even AIDS. But with testing, HIV infection can be detected easily and treated before serious symptoms start.

Tests to detect HIV infection

You can get HIV testing in many settings (hospitals, neighborhood clinics, health department clinics, doctors' and offices). And there are HIV test kits that can be used at home. See the section, "Types of HIV tests" below.

Understanding HIV antibody tests and the test results

Depending on where the test is done, it can take a few days to 2 weeks to get the results. Most testing locations prefer that you return in person for your test results. Telephone results are usually given only for home kit testing, after the blood sample you mailed in is tested.

HIV is most often found using a sequence of screening tests that look for antibodies to HIV in the blood. When the body is infected with HIV, it starts to make antibodies (immune system proteins) against the virus. Although these antibodies can't get rid of HIV, they can be found in the blood and some other body fluids within several weeks of infection. HIV tests look for these antibodies, not the virus itself. The virus is harder to detect than the antibodies.

In the United States, the first test used for most HIV tests is called the HIV enzyme-linked immunosorbent assay (ELISA or EIA). This is a very sensitive test that can find antibodies to HIV in the blood. Because it is so sensitive, it sometimes finds "look-alike" substances that are not HIV antibodies, yielding a positive result in some people who don't have HIV. This is why a second test is used to confirm a positive ELISA test.

If the ELISA test finds nothing, the HIV test result is reported as negative. This means that no trace of antibodies to HIV could be found. No further tests on the sample are needed.

If the ELISA result is positive, the same sample is checked by using a more specific test, usually the Western blot test. If this test result is negative, the HIV test result is reported as negative, since antibodies to HIV were not found on this more specific test.

If both test results are positive, it means that the person is infected with HIV.

In rare cases, the Western blot test results come back not as positive or negative, but "indeterminate" (the test cannot tell if it is positive or negative). Sometimes, an indeterminate test means that the person has recently been infected with HIV but does not yet have enough antibodies to be sure. Because of this, people who have indeterminate results usually repeat the HIV test a few weeks later after antibodies have had time to build up. Many times, the antibody test will be positive or negative on the repeat test. Most of the time, a test that stays indeterminate is caused by an unrelated or unknown condition.

The possible test results are outlined in the table below.

Table 1. How ELISA and Western Blot tests determine final HIV antibody test results

ELISA result	Western Blot result	Final result is reported as:
Negative	Not done	Negative HIV test
Positive	Negative	Negative HIV test
Positive	Positive	Positive HIV test
Positive	Indeterminate	Indeterminate HIV test

It's important to know that a negative test result does not mean for sure that a person does not have HIV. It takes several weeks after becoming infected with the virus before enough antibodies are produced to be detected. To be sure that the person doesn't have the virus, he or she should be tested 3 to 6 months after the most recent suspected exposure.

Other lab tests: Other types of lab tests may be used to test for HIV. In general, these tests are used only in certain situations, such as when testing newborns (see section below).

• Indirect immunofluorescence assay (IFA): For this test, a fluorescent dye is used to detect HIV antibodies in the blood.
• Viral culture methods: Viral culture tests involve growing live HIV from infected cells. Viral culture was the first method ever used to detect the HIV virus itself instead of the antibody response, but it is slow and expensive.
• Polymerase chain reaction (PCR): PCR is a very sensitive test by which the genes of a cell are increased many times to detect HIV viral DNA or RNA. This allows the PCR to look for the virus rather than the antibodies.

Types of tests for HIV

Blood test: This is the most common way to test for HIV. A blood sample is taken in a doctor's office, clinic, hospital, etc., and is tested with an ELISA test. If this is positive, a Western blot test is done on the same sample. Results usually take a few days to 2 weeks.

Oral fluid test: This test looks for HIV antibodies in fluid taken through the mouth. For this test, a special test pad is placed between the cheek and the gum for about 2 minutes. The pad absorbs fluid from the bloodstream through the membranes of the cheek. The sample is then tested for antibodies, much like a blood sample. It may take a few days to 2 weeks to get these results.

Urine test: HIV antibodies are also present in small amounts in the urine. So an ELISA-type test and Western blot test have been developed to detect HIV in the urine. Getting this test result also takes a few days to 2 weeks, depending on the lab.

Quick tests: In 2002, the Food and Drug Administration (FDA) approved the first quick HIV test. Others have been approved since. The tests are only used by trained staff. Depending on the test, antibodies to HIV in blood or oral fluid can be detected, usually in 10 to 20 minutes. Positive results must be confirmed with a separate Western blot test, which can take several days after the second blood sample is taken. Negative results require no further testing (unless possible HIV exposure was recent and antibodies haven't had time to develop). The quick test is only offered in certain settings where the second test can be done for people with positive results. This test can also be done on fluid taken from the mouth.

Home testing: There is also a home test approved by the FDA. There are a few HIV home test kits being advertised on the market today, but as of 2009 only the Home Access^® test system is FDA approved and legally marketed in the United States. The Home Access test kit has many pieces, including materials to collect a blood sample, a mailing envelope to send it to the lab, and information about HIV and the test.

This approved system uses a simple finger-stick process to collect blood at home. Blood is placed on a special paper in the kit and allowed to dry. The paper with the dried blood is mailed to a lab along with a personal identification number (PIN). It is tested by trained technicians in a certified medical lab the same way as samples taken in a doctor's office. The person who mailed in the test can call the toll-free number included in the kit and give the PIN number to get their results and post-test counseling.

You may also see home test kits that are not FDA approved. These are advertised and sold in newspapers, magazines, and on the Internet. Some falsely claim that the tests are FDA approved or "manufactured in an FDA-approved facility." The advertisers of these unapproved HIV home test kits make them sound as simple as a home pregnancy test. For instance, they often claim that the presence of a visible sign, such as a red dot, within 5 to 15 minutes of taking the test shows a positive result for HIV infection. These unapproved test kits may use a finger-stick process to collect blood or a sponge for collecting saliva.

The blood or saliva sample is then placed in a plastic testing device containing some type of paper. A developing solution is added to find out if the sample is "positive." The samples are not sent to a lab for professional testing. In 1999, the US Federal Trade Commission tested some samples of infected blood using unapproved test kits. All of the known HIV-positive blood samples tested negative. Although unapproved home tests may seem simpler and faster, they can give unreliable results and should be avoided.

If you would like to know if a certain HIV home test has been approved by the FDA, you can check their information sheet on the Internet at www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/HIVHomeTestKits/ucm126460.htm, or you can call them at 1-800-835-4709. You can also email them at ocod@fda.hhs.gov.

Testing newborns: The usual HIV antibody tests are not helpful in newborns whose mothers are known to have HIV. Babies are born with their mothers' antibodies, which stay with them for several months. This means that any baby born to an HIV-infected mother will test positive for antibodies to HIV. This can be very confusing, because it means an infant's blood can test HIV-positive when the baby is not actually infected. Rather than wait a year or more for all of the mother's antibodies to go away, tests that detect the virus itself are used to find out whether an infant got HIV from the mother. Even with these special tests, it may take a few weeks to be certain of the infant's true HIV status. It is important to find out soon, because newborns with HIV can be treated early to help keep them from getting sick.

AIDS and immune function

A diagnosis of AIDS is made when a person is shown to have HIV and their immune function is no longer normal. A person is known to have poor immune function if they have certain opportunistic infections or cancers (see "The definition of AIDS" section). Also, lab tests that count T helper cells can show poor immune function. These kinds of tests are usually only done for those who are known to have HIV. People with HIV are tested every few months to see how high their T helper cell counts are, and that helps find out when treatment is needed. T helper cells are also counted regularly after anti-HIV drugs are started, to be sure that the drugs are working as they should.

If a person has been diagnosed with AIDS based on a positive HIV test and a low T helper cell count, he or she is still considered to have AIDS even if treatment later raises the CD4 count. If a person is diagnosed with AIDS based on a positive HIV test and having an AIDS-defining illness, he or she still has AIDS even if the AIDS-defining illness is cured.

The immune profile, including CD4 or T-cell counts

An immune profile, or immune panel, is a set of blood tests that can be used to measure the loss of immunity and help decide on HIV treatment. This profile usually includes counts of different types of cells in the blood (a complete blood cell count, or CBC). More important, it counts the number and percentage of helper T cells. These are also called CD4 cells, CD4+ T lymphocytes, or simply T cells.

The number of helper T cells reflects the patient's stage of infection and is used to find out how much damage HIV has done to the immune system. This lab test counts the number of helper T cells in each cubic millimeter (mm³) of blood. A normal helper T cell count in a healthy, HIV-negative adult can vary but is usually between 500 and 1,500 cells/mm³. (In babies and very young children the normal counts are much higher.) HIV infection lowers the T helper cell count over time. People begin to get opportunistic infections or cancers more often as the count drops lower.

Viral load test (HIV-1 RNA): This test measures the amount of HIV (the viral load) that is found in a small amount of blood. The viral load test is done after a patient has tested positive for HIV. Unlike the immune panel, this test does not show how much damage has been done to the immune system, so it cannot show whether a person has AIDS. But it can give the doctor an idea how quickly the HIV infection is likely to progress. A high viral load, even in a person with good T helper cell counts, suggests that the person may worsen quickly and become AIDS if not treated.

The viral load test is also used to find out how well an infected person is responding to treatment. Doctors look for the viral load to go down and stay down while a person is taking anti-HIV drugs. If it doesn't go down, or if it goes up, the anti-HIV drugs may need to be changed.

Viral load testing is done using polymerase chain reaction (PCR) or other lab techniques (see above). It is not normally used to find out if a person has HIV, because of its cost and other limitations. But sometimes, a week or two after being exposed, a person may start having symptoms that suggest early HIV (see the "Primary infection" section). Because an HIV antibody test will often not become positive for a few more weeks, a viral load is one kind of test that may be used soon after exposure to find out if HIV is present. It is sometimes also used to diagnose infants who are born to HIV-infected mothers.

What happens after testing and diagnosis?

Each person who is tested for HIV should find out about HIV infection, how it is passed on, and how to keep from getting it or giving it to others. After the test, the person gets the result of the test along with referrals or recommendations. This is known as post-test counseling, and some HIV test sites still offer it. If the test is done in a doctor's office or clinic, the person who gives you the test results should discuss with you what the results mean and what you should do.

If the test result is negative, meaning that HIV antibodies are not found in your body, you may be given information about safer sex and other ways to reduce your chance of HIV exposure. You may also be told when or if you should be tested again if your exposure to HIV was too recent to show up on the test. If your exposure was recent, you can still have HIV even though the test is negative. In that case, a second test is usually done a few weeks later. The result of the second test should tell you if you are actually infected.

If the test result is positive, the doctor or counselor may go over your concerns about the test result and give you the names of doctors or clinics with expertise in treating HIV. You will want to find out how to protect sex partners or drug-sharing contacts from infection. You may want to ask about treatment for drug addiction, if that is a problem for you.

If you have HIV, it is very important to let your sex partners and needle sharing contacts know that they may have been exposed to the virus so that they can be tested. This lets them get early treatment if they have the virus. State health departments can often help people with this process.

Being HIV-positive is not the same as having AIDS. AIDS is only one of several stages of HIV infection. Many years can pass from the time a person is infected with the virus until he or she has an impaired immune system or other signs of AIDS.

After diagnosis

Once a person is found to have HIV, he or she should seek care from someone with experience in treating HIV and AIDS. The first visit usually includes a careful physical exam, a medical history, and lab tests, such as:

• A complete blood count
• Blood chemistry tests
• A T cell count
• HIV plasma viral RNA (viral load)
• HIV resistance testing (looks for virus that is unaffected by HIV treatment drugs)
• Toxoplasmosis titer (looks for infection with a parasite that may worsen in AIDS)
• Tests for other infections, such as hepatitis
• Tests for other sexually transmitted diseases, such as syphilis
• Skin test or lab test to look for tuberculosis (unless a former test was positive)
• Pap smear for women who haven't had one in the past 6 months

It is a good idea to get copies of all your lab results and keep them in a safe place, in case you need care at a time you cannot see your regular doctor.

Like many other infections, HIV and AIDS must be reported to health authorities in all 50 states in the United States. This means the doctor, lab, or health care practitioner is required by law to report every case to the state health department. This information is expected to be kept confidential. It is not given to insurance companies, family members, employers, or others, unless the patient signs a form allowing medical information to be shared with them.

After a person is found to have HIV or AIDS, there are many resources to which he or she might look for support. These may include family and friends, nurses, social workers, professional counselors and therapists, volunteers who serve as buddies in AIDS service organizations, and HIV support groups. (See the "Additional resources" section.)

The course of HIV infection

Most people with HIV don't know exactly when they got it, or how long they had it before they were tested. A person can learn that they have HIV at any stage of the disease, from primary infection to AIDS.

In the United States and other developed countries, the average time from getting infected with HIV to advanced AIDS in a person who does not get treatment is about 10 years. About 1 in 5 of these people will develop AIDS within 5 years or less. Only about 1 in 20 of the people infected with HIV will still have normal T helper cell counts for 10 to 15 years. But with treatment, most people can postpone getting AIDS.

Over time, HIV usually goes from infection to AIDS in 4 stages:

• Acute or primary infection -- some people get sick with flu-like symptoms
• Asymptomatic phase -- no sign of disease, but HIV test is positive
• Early symptomatic phase -- some health problems, mostly mild; HIV test is still positive
• Advanced HIV or AIDS -- serious infections and cancer; HIV test is still positive

Below are general descriptions of these stages of HIV infection. Each person is different, and his or her progression through infection, symptoms, response to treatment, and many other factors all affect the course of illness.

Primary infection

The first or acute infection stage is known as the primary infection, or acute HIV infection. This starts when HIV enters the body and starts growing (making more viruses) in cells. This stage usually starts soon after infection, and lasts from 2 to 6 weeks. During this time, T helper cell counts drop. Later, the T helper cell count may go back up to normal or near normal, even with no treatment.

Different people have different symptoms during this stage. Some will notice no symptoms. Many people have fever, headache, flu-like symptoms, extreme tiredness, swollen lymph nodes, sore throat, rash, nausea, vomiting, diarrhea, or muscle and joint aches. A person may decide not see a doctor if the symptoms are mild. Even if he or she sees a doctor, HIV is often not suspected unless the person mentions a recent HIV exposure such as unprotected sex or shared needle use.

HIV antibody test results are usually negative during this phase. Other tests can be done to find out if HIV is present. But during this time, there are very high viral counts in the blood, and the person is very contagious. That means he or she can pass the virus on to others through unprotected sex or sharing injection equipment more easily than in the next stage of infection.

By the end of this stage, the symptoms are mostly gone, but HIV is inside the lymph nodes, spleen, and other organs and tissues of the body. For most people, there is less virus in the blood at this point. In some people, the viral load stays high, and HIV infection can get worse quickly through the next stage.

The asymptomatic stage

The asymptomatic (without symptoms) stage is usually the longest stage and can last for as little as one year or more than 15 years. During this time the person has few symptoms of HIV. The virus is still multiplying and damaging immune cells, even though the T helper cell count may be normal (above 500) or slightly low (350-499). Most often, the T cell count slips lower and lower over time unless treatment is started.

Sometimes people get certain infections during this stage. Some of these are infections by germs that rarely cause disease in healthy people but are quite common in people with HIV. Everyday infections such as warts and sinus infections may also happen more often. But overall, most people have very few symptoms that are clearly related to HIV at this time. Even so, they can pass the virus on to others during pregnancy, unprotected sex, or by sharing needles.

People who are found to have HIV during this stage should first have a complete medical review and a thorough physical exam by a clinician who is an expert in HIV. An HIV expert clinician may be a doctor, nurse practitioner, or physician assistant who sees many HIV-infected patients and keeps up with the newest treatments. Patients should have regular visits with the clinician whether or not they are taking HIV treatment. These regular visits usually include a brief physical exam and tests for viral load and CD4 counts (T cells). If the T helper cell count is low or the viral load is high, anti-HIV drugs may be started during this stage.

By the end of this stage, the number of helper cells in the blood is usually quite low. Other parts of the immune system may also be damaged, lowering a person's ability to fight off infections and certain other diseases even further.

Early HIV symptoms

Early symptoms can start as T helper cell counts drop. Often there will be one or more infections that are not serious enough to qualify as AIDS. They may go along with a rise in the viral load in the blood.

Infections seen at this stage may include fungal infections (such as thrush in the mouth or vaginal yeast infections), herpes simplex (genital or mouth sores), shingles (a painful outbreak of chickenpox-like sores), bronchitis (infection in the breathing passages), sinusitis (infection of the sinuses), and pneumonia. Some of these infections are thought to speed up the damage to the immune system from the HIV infection.

Other symptoms may include tiredness (fatigue), headache, muscle and joint pain, fever, diarrhea, and weight loss. Some people have rashes such as seborrheic dermatitis or folliculitis, a rash that looks like acne.

Advanced HIV or AIDS

Advanced HIV or AIDS is diagnosed when the immune function is seriously damaged, or when the patient develops serious opportunistic conditions. These conditions can be major infections or certain cancers. They are called opportunistic because they take advantage of the person's weakened immune system. According to the CDC, any HIV-infected person whose T helper cell count has ever been below 200 cells/mm³ is considered to have AIDS.

A person with AIDS can have more than one opportunistic infection at a time. He or she may also have infections and HIV-related cancers at the same time. These may be cancers such as certain types of lymphoma, Kaposi sarcoma, or invasive cervical cancer. Viral infections may include shingles, cytomegalovirus (CMV) retinitis (infection in the eye), or ulcers of the mouth, anus, or genitals.

Tuberculosis, bacillary angiomatosis, and Mycobacterium avium complex (MAC) are types of bacterial infections that may occur. Other infections can be caused by fungi or parasites, such as Pneumocystis pneumonia or PCP (once called Pneumocystis carinii pneumonia), esophageal candidiasis, coccidioidomycosis, toxoplasmosis, cryptosporidiosis, and histoplasmosis. These are diseases that rarely cause problems in healthy people, but can cause severe illness in people whose immune systems no longer work normally.

Other problems come from HIV directly attacking certain organs rather than by allowing infections by other germs. For example, HIV affects the digestive (gastrointestinal or GI) tract in about 3 out of 5 people. This can cause weight loss, diarrhea, or loss of appetite. One-third to one-half of patients have brain or nervous system (neurologic) symptoms, mostly from infections or cancers, but some are caused by HIV itself. These symptoms can include headache and nerve pain, tingling, numbness, and/or weakness in the hands and feet (peripheral neuropathy). Less often, people may have heart problems or skin problems.

Depression and anxiety are also common in people with HIV. These problems can be caused by many factors, which may include HIV.

How are HIV and AIDS treated?

First, find a doctor or clinician who has experience in treating people with HIV and AIDS. It is helpful to find someone you can talk to and feel safe with, since you will be seen fairly often. Even if you are not taking any prescribed HIV drugs, you will need to visit every 3 to 6 months for lab work and health checks.

Goals of treatment

Treatment for HIV/AIDS has 3 main goals:

• Restore and preserve immune function
• Keep the amount of HIV in the body as low as possible for as long as possible
• Prevent, cure, or control opportunistic infections

All of these help to support quality of life by improving health and lowering the chance of serious illnesses and their long-term effects. Effective treatment prolongs life. And certain treatments can be used to prevent infection in the babies born to HIV-infected mothers. These are discussed in more detail below.

Restoring and preserving the immune system

This is done is by using drugs that help stop HIV growth. In slowing viral growth in the body, the drugs also greatly help preserve and restore the immune system. This helps reduce the risk of some types of AIDS-related cancers. T helper cell counts are checked to be sure the drugs are working.

Other measures that can be taken to support the immune system involve good self-care, such as better nutrition, exercise, and stress management, avoiding infections, and stopping tobacco or illicit drug use. Vaccines are usually recommended to prevent the flu (influenza), certain types of pneumonia, and some types of hepatitis. These work better if given while the T helper cell count is fairly high. There are a few types of vaccines that people with HIV (and people they live with) should not take. Be sure to talk with your doctor before you or any of the people you live with are vaccinated.

Keeping HIV levels in the body as low as possible for as long as possible

Getting and keeping HIV levels in the body (viral load) down is also done by using anti-HIV drugs (see section below, "Anti-retroviral treatment"). This treatment is usually started after the infection has damaged the immune system, but not to the point that that the person is about to risk having a serious illness. Many studies have shown that effective anti-HIV drugs reduce illness and prolong life.

Before starting anti-HIV treatment, the doctor checks the immune system, tests for anti-retroviral drug resistance (see section, "Treatment problems with HAART" below), tests for suspected opportunistic infections, and looks for other diseases or conditions that could change the treatment. Counseling, education, and emotional and social support are normally offered as part of HIV care.

Preventing, curing, or controlling opportunistic conditions

You may be able to prevent some infections by staying away from people who have them. For instance, your doctor may suggest avoiding large crowds and close contact with people who have fevers or other signs of infection. You can avoid other infections by preparing foods in ways that kill germs or keep them from growing. The risk of some infections may be lowered by letting someone else clean your aquariums, cat litter boxes, and bird cages. As a person's T helper cell (CD4) count drops below certain levels, however, antibiotics may be needed to prevent certain serious illnesses such as AIDS-related pneumonia. (See the section on "Treatment and prevention of opportunistic infections," and Table 2, "Preventing Exposure and Illness Due To Common Infections in People with HIV/AIDS".)

Opportunistic cancers cannot be prevented by using antibiotics. But certain types of cancer seem less likely to develop when anti-HIV drugs are used. In women, invasive cervical cancer may be prevented by getting regular Pap tests. When a person with AIDS gets cancer, the treatment depends on the type of cancer (see "HIV and cancer" section below).

All opportunistic conditions can be serious and many are life-threatening. If signs of an opportunistic condition develop, such as fever, weakness, cough, shortness of breath, or pain, see your experienced doctor quickly for diagnosis and treatment. Many opportunistic infections can be cured, and others can be controlled with drugs. Again, anti-HIV drugs are usually used along with treatments for the illness, to help the immune system and speed up recovery.

Anti-retroviral treatment

The main treatment for HIV at this time uses 3 or more drugs that help block n viruses from forming. Anti-HIV drugs are often called anti-retroviral drugs (or ARVs) because HIV is a type of retrovirus.

Combinations of anti-HIV drugs that are very good at stopping HIV growth are sometimes called highly active anti-retroviral therapy (HAART). Stopping or slowing the growth of HIV with these drugs helps improve the quality and length of the person's life.

The best anti-HIV treatment combination varies with the person, disease stage, whether the person's infection is resistant to any the drugs, and other factors. Study after study has shown that with effective treatment using 3 or more drugs, people live longer and the disease progresses more slowly. Still, no combination of drugs available at this time can actually get rid of all the HIV in your body. But the more the drugs cut down on the amount of virus in your body, the better they are at keeping you from getting sick.

When is anti-retroviral treatment started?

Anti-retroviral (anti-HIV) treatment should be started after you and your doctor discuss the risks and benefits of the drugs you are thinking about taking. The best time to start is not completely clear, because HIV is an infection that usually progresses slowly. But doctors have observed many people over the past decade who have started anti-HIV drugs at different times during their infection. Over time, researchers have figured out that there are better outcomes if the anti-HIV drugs are started before the immune system has been seriously damaged.

Disease progression: Most doctors agree that anti-HIV treatment should begin when:

• The HIV infection is causing serious symptoms (major infections, cancers, physical weakening, or AIDS), regardless of T helper cell count and viral load.
• The T helper cell (CD4) level is below 350, even if there are no symptoms.

Some people have faster drops in their T helper cell counts over time. These people may need to see the doctor more often to closely watch their counts so that anti-HIV drugs can be started before they get too low. This is especially important as the counts are dropping down near the danger zone, in which the person is at higher risk for serious HIV-related conditions. Other doctors just start these people on HIV drugs before their counts get down to 350.

There may be other reasons to start or delay treatment, and these should be discussed with your doctor. For example, the potential side effects of treatment may make you want to delay it for as long as possible. Or you may want to be treated before your T helper cell counts drop to help preserve immune function and further reduce the risk of AIDS-related conditions.

Pregnancy: One very good reason to take anti-HIV drugs is pregnancy. Taken every day during pregnancy and through delivery, certain drugs can be used to reduce the baby's risk of getting HIV from the mother. The mother's viral load is watched carefully during pregnancy and kept as low as possible. This requires an HIV expert working with her, along with her gynecologist, to help her reduce the risk of her baby getting HIV during her pregnancy and delivery. After the baby is born, the mother may stop the HIV treatment drugs, depending on her case. But the baby is also treated for a few weeks after birth. The mother is advised not to breast-feed, since she can still pass on the infection to her child in this way.

Kidney disease due to HIV (HIV nephropathy): Experts recommend that anyone who already has kidney problems caused by HIV take anti-HIV drugs to prevent further loss of kidney function. Treatment with anti-HIV drugs also improves survival for those with this kind of kidney disease.

During treatment for hepatitis B infection: People with the hepatitis B virus (HBV) are often given lamivudine or emtricitabine for the HBV. These 2 drugs actually started out as anti-HIV drugs, and are still used for treating HIV (see section below, "Antiretroviral drugs used to treat HIV and AIDS"). Doctors later learned that they were good for treating hepatitis B as well, so now the drugs are used for both infections. But if one of these drugs is given to treat HBV in a person who also has HIV, the HIV in the person's body can become resistant to the drug (see "Drug resistance" section below). Any resistance to anti-HIV drugs makes HIV much harder to treat. Because of this, anyone who is going to get one of these HBV drugs should get a full set of HIV treatment drugs at the same time to prevent HIV drug resistance.

Primary HIV infection: For those few people whose infection is found within a few days or weeks after exposure (during primary HIV), doctors are still studying whether treatment might prevent immune system damage. If you are interested in being treated for HIV during this phase, you might want to think about entering a clinical trial (see the "Clinical trials" section).

Other problems: Some people with certain other illnesses may be treated when their T helper cell counts are above 350. In some cases, those at high risk of certain diseases might do better with earlier treatment. And people whose T helper cell counts are dropping very quickly may be started on ARV drugs sooner.

Anti-retroviral drugs used to treat HIV and AIDS

More than 20 drugs have been approved to treat HIV infections and AIDS. They fall roughly into 6 classes:

Nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs) work by blocking the enzyme reverse transcriptase, which helps the virus make DNA from its RNA. Drugs in this class include:

• Zidovudine (ZDV, AZT, Retrovir^®)
• Abacavir (Ziagen^®)
• Didanosine (Videx^®)
• Emtricitabine (Emtriva^®)
• Lamivudine (Epivir^®)
• Stavudine (Zerit^®)
• Tenofovir (Viread^®)
• Zalcitabine (Hivid^®)

Non-nucleoside reverse transcriptase inhibitors (NNRTIs) work somewhat like the ones listed above, but they are chemically different and act on a different part of the reverse transcriptase molecule. There are 4 drugs in this class at this time:

• Nevirapine (Viramune^®)
• Delavirdine (Rescriptor^®)
• Efavirenz (Sustiva^®)
• Etravirine (Intelence™ or TMC-125)

Protease inhibitors (PIs) work differently from the drugs listed above. HIV produces an enzyme called protease in the late stages of its reproduction. The job of protease is to cut a large viral protein into usable sections as the newly-created viruses move out of the cells. When this protein is blocked by a protease inhibitor, the virus cannot be assembled properly. Protease inhibitors include:

• Atazanavir (Reyataz^®)
• Indinavir (Crixivan^®)
• Nelfinavir (Viracept^®)
• Ritonavir (Norvir^®)
• Saquinavir (Fortovase^®)
• Lopinavir (combined with ritonavir and called Kaletra^® -- see information below on boosting)
• Fosamprenavir (Lexiva^®)
• Tipranavir (Aptivus^®)
• Darunavir (Prezista^®, which must be taken with ritonavir -- see boosting information, below)

Boosting anti-HIV drug effects: Ritonavir has a special use as a protease-inhibitor booster. Ritonavir was first approved as an HIV treatment, and is used in standard doses as part of 3-drug combination treatments for HIV. But doctors noticed that, along with helping stop the virus, ritonavir kept certain other protease inhibitors and other drugs in the body longer.

Ritonavir is now also used in small doses along with other protease inhibitors to take advantage of this effect. This practice is called boosting a protease inhibitor, because it helps keep the drug levels in the body higher and often allows the drug to be given less often.

When ritonavir is used just for its booster effect, it is given in doses that are not high enough to affect the virus. Doctors give just enough to affect the level of the other drug. That means it is not being used as an anti-HIV drug, but only to help one of the other drugs last longer. But it is important to know that even a small dose of ritonavir can also raise the levels of many other drugs, not just HIV treatment drugs.

Before starting any new drug, anyone who takes any dose of ritonavir must always find out whether ritonavir interacts with it. It can cause serious harm if it raises the level of another drug to toxic amounts in the body. And if you are stopping ritonavir, you should check to see if you need your doses of other drugs changed.

Entry inhibitors (including fusion inhibitors) work by blocking the virus from entering the host cell. One of the approved drugs, enfuvirtide (Fuzeon^®) is called a fusion inhibitor, and must be given by injection. The newer drug in this group is called maraviroc (Selzentry^®). It helps to keep HIV out of individual CD4 cells by blocking the protein CCR5. This drug can only be used in patients with a strain of HIV that uses the protein CCR5 as its "door" into the CD4 / T helper cell. Before starting this drug, a person must be tested to be sure that the strain of HIV they have is the type this drug can stop.

Integrase inhibitors work by keeping the virus from putting its DNA into the host cell. This keeps the virus from being able to take over the cell to make more viruses. The only drug in this class so far is raltegravir (Isentress^®).

Combination drugs are fixed-dose combinations of the above drugs that help to reduce the number of pills a person has to take. Some examples include:

• Combivir^® - zidovudine and lamivudine
• Trizivir^® - zidovudine, lamivudine, and abacavir
• Epzicom^® - abacavir and lamivudine
• Truvada^® - tenofovir and emtricitabine
• Atripla^® - efavirenz, emtricitabine, and tenofovir

Atripla is the first combination formula that comes in a single pill to be taken once a day. Although not everyone can take this combination, for those who can, it is a major improvement over taking several pills 3 or 4 times a day.

Choosing anti-drugs for treatment

Since more than one drug is used to treat HIV, and they all have their own schedules and side effects, doctors look at each person to figure out which drug combinations might work best. Factors such as drug resistance, other illnesses the person has, potential for drug interactions, and the potential for serious side effects must be weighed. Patients must know about drug scheduling, which drugs can be taken together, and any food restrictions before they commit to a set of anti-HIV drugs. There are special factors to think about with each drug. This is a good time for patients to be involved with helping their doctors choose the drugs that will work best for them.

Taking anti-HIV drugs exactly as prescribed can be hard for many people. Some drugs are taken 3 times a day, others once a day. Some don't work if they are taken with food, and others work better if they are taken with a meal. This can be confusing and hard to keep up with. It may take some time for a person to be ready for this commitment.

If you are not able to keep to a strict schedule, tell your doctor. You may be able to work out an easier regimen. Many doctors now try to start with combinations of drugs that can be taken once or twice a day. But drug resistance testing may show that your options for treatment drugs that will work on your virus are limited, and there may be other drugs that won't work for different reasons.

Is treatment working?

The success of any anti-HIV drug regimen is measured by checking the viral load a few weeks after the drugs are started, and then checking the viral load and T helper cell count every 3 to 4 months as the drugs are taken. The count normally goes higher as the viral load goes down.

The goal of treatment is to get the viral load down so that the lab test cannot find any trace of virus in the blood (this is called an undetectable level). Different tests have different cutoffs for detection, so results may differ slightly between labs.

It is important to know that an undetectable virus load does not mean that there is no HIV in the person's blood, only that the test was not able to detect it. Undetectable virus levels do not mean that the person cannot infect others with HIV. Even with undetectable virus loads in the blood, it is still necessary to use safer sex practices and other precautions to avoid passing the virus on to others.

If the viral load cannot be kept down to undetectable levels with the first drug combination, others are usually tried. If no combination gets the viral load down to undetectable levels, doctors usually keep trying until they find a drug combination that will help keep it as low as possible. In such difficult cases, this may mean using 4 or more anti-HIV drugs together.

Of the anti-HIV drugs available today, many are used only after the preferred drugs have failed. Because researchers are still comparing treatments and new drugs are still being tested, the drugs and combinations used for HIV treatment keep changing as more research is done.

HIV treatment issues

Drug resistance: Treating HIV infection is hard, in part because the virus can change its proteins and become drug resistant. This means that the virus learns to grow even when the anti-HIV drugs are in your body. This is one reason that anti-HIV drugs are never used one at a time -- if HIV can grow even a little bit while a drug is in your system, those viruses often become more and more resistant to that drug. It usually takes the full effect of 3 drugs to stop HIV growth, so all of the anti-HIV drugs must be taken on time in order to work properly. HIV can quickly become resistant to anti-HIV drugs if they are not taken as prescribed.

Even when drugs are taken exactly as prescribed, people are likely to develop drug-resistant virus after years on the drugs. If the virus load starts to climb while a person is taking anti-HIV drugs correctly, a drug resistance test is usually done to learn which drug or drugs the virus is resistant to. Since many of the HIV drugs in each group are a lot alike, resistance to one drug may mean resistance to more drugs in the same class. This limits the number of drug combinations that a person might expect to use after one or more combinations fail.

If the first drug combination fails, or if you cannot take it, it becomes harder to find a second or third combination that works well. After a few drugs have failed, it may take more elaborate combinations of 4 or 5 drugs to try and keep the virus from growing.

Some people have HIV that has already become resistant to nearly all the drugs that are available. And it is possible for a person with drug-resistant virus to transmit that virus to others. This means that an increasing number of people who get HIV find that they already have drug-resistant virus, even before they have taken any drugs to treat HIV.

Drug interactions: Another challenge of anti-HIV drugs, especially the protease inhibitors, is that they can interact with other drugs. This means that one or more drugs might not work, or that one might build up to toxic levels in the body. For example, some anti-HIV drugs interact with certain antibiotics, cholesterol-lowering drugs, anti-seizure drugs, birth control pills, erectile drugs, or even other anti-HIV drugs. Each time a new drug is prescribed, your doctor and pharmacist should review all your drugs and supplements to be sure that no harmful interactions are likely. This can complicate treatment of many conditions.

As noted above, ritonavir interacts with many other drugs in ways that can be dangerous. Some treatment regimens exploit this property of ritonavir by using fewer doses of other protease inhibitors to get the same effect. In cases like this, doses can be often be adjusted, but there are a few drugs that are simply not safe to use with some HIV drugs. This is one of the reasons it is important to keep a list of all your drugs, along with the dose and how often you take them, with you at all times. It also means that if you are taking one of these interacting drugs and stop taking it, you may need to have other drug doses adjusted back to the usual levels.

Down sides: Like all drugs, anti-HIV drugs can have side effects. Short-term side effects show up within a day or a few weeks, depending on the drug. They can range from nausea, vomiting, diarrhea, headaches, and rashes, to severe allergic reactions. Most of these effects only happen to a few people who take the drugs. Each drug has certain side effects, which need to be discussed with your doctor before you start. But some side effects and problems are typical of each class.

The NRTIs can cause acidosis of the blood, which is a serious chemical imbalance, in a few people. Acidosis can make you feel very weak and short of breath. It is rare, but if it happens, go to an emergency room right away. A blood test can show if you have acidosis. NRTIs can also cause fatty changes in the liver, usually after 6 months or more. They can also cause lipodystrophy, in which body fat can build up on the chest and belly and be lost from the arms and legs. These drugs lower blood counts and can cause fatigue, nausea, anemia, headaches, and other symptoms in some people. AZT causes the most problems with blood counts, although only in some patients.

Abacavir is also known for causing a type of allergic reaction that can damage organs in certain people. Now, doctors can test for this reaction before this drug is even started. But most other side effects can be found only after a person starts taking the drug.

The NNRTIs can cause rashes and allergic reactions, and may interact with some other drugs. They can also lead to liver damage, which is usually found through blood tests and is rarely a serious problem. The NNRTIs can also affect mood, thinking, and sleep patterns. One drug in this class, efavirenz, can cause birth defects if it is taken by pregnant women. And, it's easier for HIV to get resistant to these drugs.

The PIs can also cause body fat to redistribute in the body (lipodystrophy). Over the long term, they can raise blood levels of cholesterol and triglycerides and increase risk of heart attacks. They can raise blood sugar and even cause diabetes in some people. Cholesterol and blood sugar levels are checked regularly while a patient is on these drugs, and some people may require treatment if there are problems. You may be able to reduce the risk of heart problems by avoiding tobacco, eating healthy, and staying active. The PIs also can interact with other drugs.

Entry inhibitors can cause serious rashes and allergic reactions with fevers, chills, trouble breathing, and faintness or dizziness. Maraviroc can cause liver damage in some people, with symptoms like jaundice (yellowing of the skin or eyes). Because enfuvirtide is injected, people can get irritations or infections at the injection site.

Integrase inhibitors can cause milder symptoms such as nausea, headache, fever, and diarrhea. A few people develop a serious problem that shows up with muscle pain, weakness, and dark colored urine. This must be treated right away.

As part of follow-up with patients on HIV drugs, doctors check labs often. They watch for signs of diabetes, high cholesterol, high triglycerides, fat redistribution, liver damage, low blood counts, and other effects that may worsen the longer the drugs are given. Some drugs cause certain side effects that may go on even after the drug that caused them is stopped. In rare cases, side effects may be serious enough that the person may need time in the hospital, and there have even been a few deaths. Talk with your doctor or nurse about what you can do to reduce your risk of side effects. Find out which side effects need to be reported to the doctor right away and what to do if you should have these problems after office hours or on weekends.

Cost: Combination treatment can be costly (often more than $17,000 per person per year for the drugs alone, not counting labs and doctor visits). Contact your health plan, and talk with your doctor about what you can afford or what insurance will pay.

Guiding principles of treatment

In 1997, the Office of AIDS Research of the National Institutes of Health (NIH) brought together a panel of experts to discuss the advances in basic HIV research, treatment research, and testing in order to give the best information to doctors and patients. The final report presented the following principles that have guided treatment for a decade. They are summarized here because they offer important information about HIV and its treatment:

• HIV infection is always harmful, and true long-term survival without serious loss of immune function is unusual. When HIV continues to reproduce, it damages the immune system and leads to AIDS.
• Regular viral load tests and T helper cell counts are required to find out when to start or change anti-HIV therapy and to find out if the effects of infection are likely get worse.
• The time to start HIV treatment should be based on viral load and T helper cell count as well as other factors, which vary with each patient.
• The goal of treatment is to keep HIV from growing, so that it stays below levels that can be detected by viral load tests.
• The anti-HIV drugs used in combination must be carefully chosen and given together.
• Each anti-HIV drug in the combination should always be used according to the schedules and dosages that work best.
• Any change in a person's anti-HIV treatment reduces future treatment options.
• Women should receive effective anti-HIV therapy even when pregnant.
• The principles of anti-HIV therapy presented above apply to both HIV-infected children and adults, although the treatment of HIV-positive children involves unique considerations.
• Persons with acute (primary) HIV infection may also be helped by combination anti-HIV therapy to decrease the virus load to undetectable levels.
• All HIV-infected persons, even those with viral loads below detectable levels, should avoid sexual and drug-use behaviors linked to giving or getting HIV and other infections.

Treatment follow-up

Your doctor will check your blood counts, your T helper cell counts, measure the viral load in your blood, and watch your health while you are on anti-HIV drugs. At some point, your viral load may begin to creep up after it has been down for a while. This can happen quickly if you miss doses. Or it can also mean the virus is growing resistant to one or more of the drugs you are on, and your doctor may test your blood to see which drugs will be most effective. It is not unusual for HIV to develop resistance, especially after a couple of years, and most people will need to change drug regimens at some point.

Can I stop my anti-HIV drugs?

Many people would like to sometimes stop anti-HIV treatment and just take a break. Some people who do this can get worse very quickly, especially if they already have AIDS or very poor immune function. Most doctors do not recommend stopping treatment, except in a few limited cases (like after a woman takes it during pregnancy, if she only did it to reduce her infant's risk).

It is important that people getting treatment stick closely to their drug schedule. Missing doses of drugs lets the virus to grow back very quickly, and increases the risk of drug resistance. Stopping one anti-HIV drug while taking the others may allow the virus to quickly develop resistance to the other drugs. (See the information on "Drug resistance" above.) If you are having problems with the regimen, talk to your doctor and find out if an easier one can be worked out before you stop taking your drugs. If you are having a reaction to one of your drugs, contact your doctor right away to find out how to safely manage it. With a serious reaction, all of your drugs may need to be stopped at once, but your doctor can help you get on a different combination quickly.

Prevention and treatment of opportunistic infections

Along with anti-HIV drugs to stop the virus from growing, people with HIV may also need prevention or treatment of opportunistic infections. These infections may be caused by bacteria, viruses, fungi, or parasites. Better ways to prevent and treat these infections have helped people with HIV to live longer and have a better quality of life. Infections are becoming rarer, but they still cause deaths in people with HIV.

Opportunistic infections may develop from:

• Infections you picked up earlier in life that become active again (as the immune system gets less effective, the germ flares up and causes problems)
• Infections newly acquired

Many different infections can affect people with HIV, but no one person develops all of the types of infections. The infections vary in different parts of the country and world and among different people. Anti-HIV therapy helps the immune system by controlling the growth of HIV. This helps prevent many types of HIV-related infections.

The management of infections includes:

• Preventing infection when possible
• Treating any infection as soon as it happens
• Keeping the infection from coming back (recurring)

The best approach to dealing with opportunistic infections is prevention. Measures such as safe food handling are especially important when the T helper cell counts are low. (See the "Additional resources" section on how to get a special food safety fact sheet from the USDA.) Most people avoid drinking contaminated water, but may not know that swimming pools, lakes, and river water can cause problems when small amounts are swallowed by people with HIV. Careful hand washing after changing diapers, touching animals, or any possible contact with human or animal stool helps reduce certain other infections.

Traveling outside the United States also requires special precautions. Talk with your doctor or nurse about other ways you may avoid infections. Not all infections can be prevented, but the main ones that are targeted using drug therapy are listed in the table below.

Table 2. Preventing exposure and illness due to common infections in people with HIV/AIDS

Infection	When drugs are used	Prevention of exposure	Drug treatment to prevent illness*
Pneumocystis	When T helper cell (CD4) count goes below 200-250	Avoiding hospitals and people with this lung infection may help	Trimethoprim-sulfamethoxazole
Toxoplasma	When T helper cell count goes below 100 in those with evidence of old infection	Avoid eating undercooked meat; wash hands well after handling raw meat. Wash raw fruits and vegetables before eating. Avoid the droppings of cats that have ever hunted and eaten live prey	Trimethoprim-sulfamethoxazole
M. tuberculosis (TB) inactive or latent infection (not active disease)	Positive skin test or lab test; recent exposure to someone with active TB disease	Avoid people with active TB disease	Isoniazid for 9 months
M. avium complex (MAC)	When T helper cell count goes below 50	None known	Azithromycin or clarithromycin
Hepatitis A	As soon as possible in those with no evidence of prior infection	Avoid food or water that may have fecal (stool) contamination	Immunization with vaccine for hepatitis A
Hepatitis B	As soon as possible in those with no evidence of prior infection	Avoid unprotected sex and sharing needles	Immunization with vaccine for hepatitis B

These are general guidelines for prevention. Your doctor may suggest other measures or may choose different drugs. Because of your condition, your doctor may decide to start preventive treatment for opportunistic infections sooner.

Certain drugs used in preventive treatment may interact with anti-HIV drugs, so your doctor must plan your treatment carefully. Some preventive treatments can be stopped if your T helper cell count improves and stays up while you are taking anti-HIV drugs. If your counts go down later, you will need the preventive treatment again.

Many infections other than these can still occur, even with preventive medicines. Some of these infections are rare enough that doctors do not normally test for them. When they do develop, they must be treated quickly by someone who knows how to treat HIV and AIDS. This means that if a person with HIV gets a fever, cough, new type of headache, unexpected pain, trouble swallowing, trouble with vision, or other symptoms, it is important for them to see their doctor right away. Weight loss, nausea, numbness, poor appetite, or diarrhea that lasts more than a couple of days can also be signs of serious infections that need to be treated by an HIV expert. Sometimes these infections can cause a great deal of harm if they are not detected and treated quickly.

Psychosocial care

Along with complex physical problems, people with HIV/AIDS often have serious emotional and social concerns. Support and education should be available to all people with HIV/AIDS, their families, and friends. Information should be offered to help those with HIV maintain the best health and prevent infections.

Once diagnosed, people with HIV may need help finding good medical care, talking to family and friends, and adjusting to changes in their lives. As the disease progresses, they may feel like they may go through many stages, such as shock, denial, anger, bargaining, depression, and acceptance. But with better medical care and new treatments, it is now possible for people with HIV to live longer and make plans for the future.

Some families and communities have already lost friends and loved ones to this disease. Many people with HIV have been caregivers for others with AIDS. For some, this experience can help them cope with their own illness. But for others, caring for others may add to the trauma of their own diagnosis.

There are many possible causes of stress. The cost of treatment and getting health coverage is a problem for many people with HIV. Taking 3 or 4 different drugs every day on a strict schedule is not easy. There are also the challenges of trying to keep a job, a place to live, and personal belongings, as well as personal relationships.

All people with HIV/AIDS should be treated with respect and compassion, but they often are not. In community groups, at work, in churches, and even medical settings, there is often still a stigma to having HIV. People with HIV can face prejudice and discrimination from formerly close friends and family members. And those with HIV still have to deal with other people's mistaken fears of getting HIV from common work, school, or other public activities.

The very real risk of HIV transmission in intimate relationships can create a difficult situation. Some people with HIV worry so much about giving the virus to their partners that they have no sex life. Even couples who normally communicate well may find it hard to talk about HIV and how it affects their relationship. Some patients find it helpful take their partner to the doctor with them so that they can both feel comfortable about what is safe and what isn't.

It is not uncommon for people to feel guilty or ashamed about having HIV, and this can worsen self-esteem. People with HIV often find it helpful to talk with others who have HIV or with mental health professionals about these issues. This kind of support can help reduce the stress level and improve quality of life.

HIV can affect all aspects of a person's life, including physical, psychological, social, and spiritual well-being. Help is often available to address these needs (see the "Additional resources" section).

Cancers and cancer treatment in HIV infection

Certain types of cancer occur so often in people with AIDS that they are considered AIDS-defining conditions -- that is, their presence in a person infected with HIV is a clear sign that full-blown AIDS has developed. They are also called AIDS-related cancers and include the following:

• Kaposi sarcoma
• Lymphoma (especially non-Hodgkin lymphoma and primary central nervous system lymphoma)
• Invasive cervical cancer

Other types of cancer that may be more likely to develop in people with HIV infection are invasive anal cancer, Hodgkin disease, lung cancer, cancer of the mouth, cancer of the testicles, and skin cancers, including basal cell, squamous cell, and even malignant melanomas. Of course, people without HIV or AIDS can also have all of these types of cancer, even the ones that are better known as AIDS-related. They are only called AIDS-related cancers if they develop in people with HIV infection.

In developed countries like the United States, about 4 people in 10 with AIDS develop cancer at some time during their illness. But the cancer picture in HIV is changing. Kaposi sarcoma and non-Hodgkin lymphoma have decreased as anti-HIV treatment has become more common. It seems that highly active anti-HIV therapy is one of the reasons for the decrease in some types of cancer among those with HIV. Many other types of cancer do not seem to be slowed by HIV treatment, and have the same risk factors as those in people without HIV. For instance, people who smoke and have HIV are more likely to have cancers of the lip, mouth, throat, and lung than people who have HIV and don't smoke.

The relationship between HIV and these other cancers is still not fully understood. However, it is believed cancers can grow quickly because people with HIV have weaker immune systems than those without HIV. Weaker immune systems also make cancers harder to treat. Another factor is the lower white blood cell count that can result from HIV infection. For instance, AIDS can make it hard for a person to take chemotherapy because the bone marrow (which is needed to make new blood cells) is often already damaged by the HIV infection. People with bone marrow damage often can't take full doses of chemotherapy without serious harm.

For those who get cancer, anti-HIV drugs have led to better survival with anti-cancer treatment. Anti-HIV drugs also allow many people with cancer to get full doses of chemotherapy and other standard cancer treatment.

AIDS-related Kaposi sarcoma

Kaposi sarcoma (KS) was once an uncommon disease that mainly affected older men of Mediterranean or Jewish ancestry, organ transplant patients, or young men in Africa. This form is called classic KS or endemic KS. However, in the 1970s and 80s the number of people with KS increased dramatically.

In the past 25 years, most KS cases in the United States have been linked to HIV infection in men who have sex with men. These cases are called epidemic KS. It is now known that KS in people with HIV is related to a second viral infection. This virus is called human herpes virus 8 (HHV-8), also known as Kaposi sarcoma-associated herpes virus (KSHV). HHV-8 does not appear to cause disease in most healthy people. Infection with the HHV-8 is common in the United States among men who have sex with men, but it can also be shared through sex between men and women. The virus is found in saliva, which may be one of the ways it is passed to others.

In most cases, epidemic KS causes dark purplish or brownish spots (called lesions) that can show up at a number of places on the body. The spots may arise on the skin or in the mouth. KS may also affect the lymph nodes and other organs, such as the digestive tract, lung, liver, and spleen.

When they are first diagnosed, some people with HIV and KS have no other symptoms, especially if their only lesions are on the skin. But many -- even those with no skin lesions -- have swollen lymph nodes, unexplained fever, or weight loss. Over time, epidemic KS spreads throughout the body. If KS involves a lot of the lung or intestine, it can be fatal.

In general, people who are diagnosed with epidemic KS are started on anti-HIV drugs, and often get treatment directed at the cancer itself. For more information about KS and its treatment, please see our document, Kaposi Sarcoma.

Lymphomas

Non-Hodgkin lymphoma (NHL) occurs in about 4% to 10% of people with AIDS. It is a cancer that starts in lymphoid tissue and may spread to other organs. The number of HIV-infected people who develop lymphoma has declined since anti-HIV drugs have been in common use.

The non-Hodgkin lymphomas that can happen in people with AIDS are often primary central nervous system (CNS) lymphomas. Primary CNS lymphoma starts in the brain or spinal cord. Symptoms of CNS lymphoma can include seizures, facial paralysis, confusion, memory loss, and lethargy (tiredness). AIDS-related NHL can also include certain types of intermediate and high-grade lymphomas, including Burkitt lymphoma.

The outcome for patients with AIDS-related NHL depends partly on the type of lymphoma and partly on the person's immune function. People with advanced NHL, a helper T-cell count less than 200, and/or who don't get anti-HIV drugs don't usually do as well as people without these factors.

It seems the best treatment for AIDS-related NHL is getting more and more like treatment of NHL in those without HIV infection. At one time, treatment was made up of low doses of chemotherapy. But while taking anti-HIV drugs, many patients can be treated with standard chemotherapy doses.

For patients with primary CNS lymphoma, chemotherapy or whole-brain radiation may be used. Anti-HIV drugs are used to improve immune function and prolong survival.

For more information on HIV/AIDS-associated NHL and its treatment, please see our document, Non-Hodgkin Lymphoma.

Pre-cancerous cervical changes and invasive cervical cancer

HIV-infected women are at high risk for getting cervical intraepithelial neoplasia (CIN). CIN is the growth of abnormal, pre-cancerous cells in the cervix, the lower part of the uterus (womb). Over time, CIN can progress to invasive cervical cancer, in which the cancer cells grow into deeper layers of the cervix.

CIN must be treated to keep it from progressing to invasive cancer. This is done by removing or destroying the outer layers of cervical cells. Studies have shown that untreated CIN is more likely to progress to invasive cancer in HIV-infected women than in women who don't have HIV. The standard treatments for CIN do not work as well in HIV-infected women as they do in women without HIV. The chance of the disease coming back after treatment is high, and seems related to the woman's immune function. Women with T helper cell counts less than 50 are at higher risk for CIN coming back.

HIV-infected women with invasive cervical cancer and a good immune function tend to do well with surgery and the same treatments that women without HIV get. Those who have more advanced disease respond poorly to radiation therapy alone. In women with advanced or recurrent disease, chemotherapy has been used, though the woman must be watched closely after treatment to be sure the cancer doesn't come back. During cancer treatment, the woman's immune status must be watched and her HIV infection treated. Anti-HIV drugs are usually given to improve the treatment outcome for HIV-infected women with invasive cervical cancer, no matter what her T helper cell counts are.

Women with cervical cancer tend to fare better if they do not have AIDS. Women with T helper cell counts higher than 500 have better outcomes. For more detailed information on cervical cancer and its treatment, please see our document, Cervical Cancer.

Non-AIDS -related cancers

With more widespread use of anti-HIV drug treatment, AIDS-related cancers are being seen less often. But as people with HIV are living longer, they are developing cancers that are not generally linked to HIV, such as lung, throat, liver, intestinal, and anal cancers as well as Hodgkin disease and multiple myeloma. Most of the time, treatment includes anti-HIV drugs along with standard cancer treatments. At the same time, any other needed treatments for HIV (such as antibiotics to prevent infections) are used.

Clinical trials

Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They are done to get a closer look at promising new treatments or procedures. A clinical trial is only done when there is some reason to believe that the new treatment being studied may be better than the best standard treatment.

You may have heard about clinical trials being done for people with HIV or people with HIV and cancer. Or maybe someone on your health care team has mentioned a clinical trial to you.

If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital conducts clinical trials. There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is up to you whether or not to enter (enroll in) it.

Clinical trials are one way to get state-of-the art treatment. They are the only way for doctors to learn better methods to treat HIV, cancer, and other serious illnesses. Still, they are not right for everyone.

If you are looking for information on HIV or AIDS-related clinical trials, you can visit www.aidsinfo.nih.gov any time. Or you can call 1-800-448-0440 between noon and 4 p.m. Eastern time, Monday through Friday.

You can get a lot more information on clinical trials in our document called Clinical Trials: What You Need to Know. You can read it on our Web site or call our toll-free number (1-800-227-2345) and have it sent to you.

More cancer treatment information

For more details on cancer treatment options -- including some that are not addressed in this document -- the National Cancer Institute (NCI) is a good source of information.

The NCI provides cancer treatment guidelines via its telephone information center (1-800-4-CANCER) and its Web site (www.cancer.gov). Detailed guidelines intended for use by cancer care professionals are also available on www.cancer.gov.

What’s new in HIV/AIDS research and treatment?

A great deal of research is being directed in 3 major areas:

• Using available drugs in better ways
• Developing new drugs
• Developing AIDS vaccines

Using current drugs in better ways

Doctors are still working to learn how best to use the drugs that are available now. For example, when it became clear that 3 anti-HIV drugs often failed to stop the virus, methods to test for HIV drug resistance were developed. Studies of newly-infected patients showed that many were becoming infected with virus that was already resistant to one or more drugs. This is why HIV resistance testing is now recommended before drug treatment is started. It allows doctors to avoid prescribing anti-HIV drugs that won't work. This strategy makes the first anti-HIV drug combination more effective, and helps delay development of further resistance. The knowledge gained from these clinical trials has helped improve the outcome of patients with HIV. Along these same lines, more sensitive resistance tests are being developed that can detect even smaller amounts of virus that might harbor HIV resistance mutations.

A major problem for people with HIV is how hard it can be to take the drugs on time, so that they work. We know that once-a-day doses are easier to take than 3 or 4 doses a day. A recent development in this quest is the approval of Atripla, the first combination of drugs that includes the entire day's 3-drug anti-HIV supply in a single pill. But this pill cannot help anyone whose virus is already resistant to one of the 3 drugs in it. Research is continuing into ways to make anti-HIV drugs easier to take.

Researchers are also looking into ways they can "boost" the levels of anti-HIV drugs in the body without using ritonavir. This can be used to reduce the number of times a day pills must be taken.

Developing new drugs

Drug companies are developing new drugs that work in different ways. The goal is to develop drugs that work better, act on different functions of HIV, and have fewer side effects than the drugs now being used.

Maraviroc is an example of a new type of drug that has been approved recently. This one locks the "door" of the cell to HIV by blocking a protein that the virus must use along with the CD4 receptor to get into the cell. Other drugs that help prevent HIV from entering cells are being developed.

A new class of drugs called maturation inhibitors are being worked on now. These drugs are in very early development, but their goal is to prevent the HIV made in the HIV-infected person's cells from maturing. This would mean that the affected virus could no longer grow and divide. No drugs from this class have yet been approved.

There are also many new drugs being developed and tested from the better-known anti-HIV drug classes, such as the integrase inhibitor elvitegravir. This drug is being tested against raltegravir in phase III clinical trials.

Developing HIV/AIDS vaccines

The most important target of research for the future is the HIV prevention. Much effort is made to teach people how to avoid getting infected, but efforts have also been focused on developing an AIDS vaccine.

Finding a vaccine that works has been hard because HIV does not behave the same way as most other infections. For example, the virus tends to change its outer protein coat often, making hard to find a vaccine that will work (or keep working) in most people. So far, the vaccines being tested have not been shown to protect against infection with HIV. Researchers are trying to get a better handle on why these vaccines haven't worked, and to develop vaccines that can prevent the damage caused by HIV. Worldwide, thousands of people have already volunteered in this effort, with more than 16,000 taking part in the past year.

As recently as 2007, 2 vaccine trials were stopped early because overall, the volunteers who got the vaccine were getting infected with HIV at the same rate as those who didn't get vaccine. But a great deal was learned from these clinical trials about what worked and didn't work, and newly retooled clinical trials are already taking place.

Additional resources

National organizations and Web sites*

Along with the American Cancer Society, other sources of information and support include:

AIDSinfo
(US Department of Health and Human Services AIDS Information)
Toll-free number: 1-800-HIV-0440 (1-800-448-0440), 12 noon to 5 p.m. Eastern time
Web site: www.aidsinfo.nih.gov

Has fact sheets and other HIV health topics, HIV clinical trials information and treatment guidelines; also available in Spanish

AIDS InfoNet
New Mexico AIDS Education and Training Center
Web site: www.aidsinfonet.org

Internet-only service with easy-to-read fact sheets on most HIV/AIDS topics, which can be printed free of charge. Fact sheets are also available in Spanish, Russian, Bulgarian, Indonesian, Nepali, Bengali, Hindi, Oriya, Tamil, and Telugu

US Department of Agriculture Food Safety and Inspection Service
Web site: www.fsis.usda.gov/Fact_Sheets/Food_Safety_for_Persons_with_AIDS

Offers a fact sheet, Food Safety for Persons with AIDS

American Social Health Association (ASHA)
Toll free number: 1-800-227-8922
Web site: www.ashastd.org

Offers facts and answers about sexually transmitted diseases (STDs) including HIV and AIDS. Includes information on preventing the spread of HIV and STDs

CDC Info
Toll-free number: 1-800-232-4636 (1-800-CDC-INFO)
Web site: www.cdc.gov/hiv

Information about HIV prevention and transmission; phone questions 24 hours a day. in English or Spanish

National Cancer Institute
Toll-free number: 1-800-4-CANCER (800-422-6237)
Web site: www.cancer.gov

For reliable cancer information and cancer clinical trials

Project Inform
Toll-free number: 1-800-822-7422
Web site: www.projinf.org

Answers HIV-related questions; offers an information packet for people newly diagnosed with HIV; has live answers from 10 a.m. to 4 p.m. Pacific time. Includes information on prevention concerns for HIV infected people; pregnancy and HIV

*Inclusion on this list does not imply endorsement by the American Cancer Society.

No matter who you are we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-227-2345 or visit www.cancer.org.

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