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If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
In the past 30 years, medical breakthroughs have made it so that receiving a diagnosis of human immunodeficiency virus (HIV) is no longer a “death sentence.” If appropriately treated with the appropriate combination of medications, individuals who are HIV positive (HIV+) can have a lifespan approaching that of HIV negative (HIV-) individuals.
That being said, this doesn’t necessarily take away any of the fear that may be associated with receiving an HIV diagnosis. Even just finding out you may have been exposed to HIV can cause anxiety. What is worse, a quick search on the internet will tell you that HIV symptoms may take a while to show up, may never show up at all, or may be nonspecific (i.e., mimic many other diseases) if they do show up. This can be frustrating, especially when all you’re trying to do is find answers.
Well, we have good news and bad news. The bad news is that, for the sake of completion, we also have to tell you this all can be true. HIV can sometimes be asymptomatic, it can sometimes take a long time to show up, and if it does show up, it may be indistinguishable from influenza (the “flu”) or from mononucleosis (“mono”). The good news (hopefully), is that we’ll try to explain all of this as best we can, we’ll include some extra information like what HIV is, how it’s diagnosed, and how it’s treated.
What is HIV/AIDS?
HIV is a virus that infects humans. More specifically, HIV is a retrovirus that infects the CD4+ T cells, macrophages, and dendritic cells of the human immune system. Let’s break this down a little:
A retrovirus is a type of virus that puts a copy of its genetic code (as DNA) inside the cells they are infecting. By nature, viruses are incapable of replicating on their own. They’re not even technically considered alive, scientifically speaking. Therefore, to replicate, viruses infect cells and “trick” the cells into making more copies of the virus for them. HIV accomplishes this by copying its genetic code from RNA to DNA and then putting that copy inside the nucleus of human immune cells, tricking the human cells into making more HIV every time the DNA is read.
The human immune system is made up of many different types of cells that all play different roles in the body. HIV can recognize and bind to specific types of these immune cells, namely CD4+ T cells (also called T helper cells), macrophages, and dendritic cells. The biggest problem with HIV is that, over time, it leads to decreased numbers of these CD4+ T cells. This, in turn, weakens the immune system, putting an HIV+ individual at risk of getting other infections called opportunistic infections. These infections can be severe, whereas if they were to infect somebody without HIV, they might not cause a problem at all. HIV itself doesn’t kill people; it is the diseases that people acquire as a result of having a weaker immune system that can be fatal.
HIV was first identified in the 1980s when outbreaks of a rare disease were noted in men who have sex with men (MSM) in the United States. However, estimates suggest that HIV has been in humans for closer to 100 years, after evolving from a virus that infects chimpanzees (Ledford, 2008). Nearly 75% of individuals infected with HIV live in sub-Saharan Africa. In the United States, approximately 1.2 million individuals are infected. While ~70% of new cases occur in MSM, anybody can get the disease, including all men (not just MSM), women, and even infants.
There are two different types of HIV, appropriately named HIV-1 and HIV-2. When people just say “HIV,” they are typically referring to HIV-1, as we will be doing here. HIV-2 primarily impacts western Africa, although there have been cases discovered globally, including in the United States. The two viruses are similar, but HIV-2 appears to be less effective at spreading, which explains why it has not caused the epidemic that HIV-1 has. While the World Health Organization (WHO) estimates that approximately 36.9 million people are infected with HIV, only 1-2 million of those people are suspected of having HIV-2 (Gottlieb, 2018). It is possible to be infected with both types.
Left untreated, HIV infection progresses in stages that take place over a long timespan – upwards of ten years in some individuals. We’ll get to each of the stages in the next section when we discuss symptoms, but briefly, they are:
- Acute infection
- Clinical latency (also called chronic infection)
- Acquired immunodeficiency syndrome (AIDS)
One point that is important to keep in mind is that HIV is not synonymous with AIDS. AIDS is a condition that is a late stage of HIV, and that is defined by having either a CD4+ T cell count of <200 cells/mm3 or an AIDS-defining illness. The list of AIDS-defining illnesses is long and can be found here. In a nutshell: while HIV causes AIDS, not everybody with HIV has or will develop AIDS.
9 things you need to know about HIV
What are the signs and symptoms of HIV?
As we mentioned, HIV is not always symptomatic. Estimates of how many people are asymptomatic range from 10% to 60% of those who are infected. This is worrisome because it can mean that somebody can contract HIV without even knowing it, going without treatment, and potentially spreading it to others. This is one reason that routine screening for HIV is important.
When symptoms do occur, they change over the course of the disease. The time from exposure to the disease to the arrival of the first symptoms is typically two to four weeks (Sax, 2019). However, in some people, this period may be several months.
The common symptoms of acute (or early) HIV infection are often described as flu-like symptoms and include:
- Fevers, chills, or night sweats
- Weight loss (~10lbs)
- Swollen lymph nodes
- Swollen tonsils
- Sore throat
- Mouth, throat, or genital sores
- Skin rash (usually over the upper body but could be everywhere)
- Muscle and joint aches and pains
Somebody who is experiencing acute HIV may have all, some, or none of these symptoms. Fevers, fatigue, and muscle and joint aches and pains are the most common findings. If co-infection with another STI has occurred, such as chlamydia, gonorrhea, syphilis, or herpes, symptoms of these infections may also appear (sores, blisters, painful urination, penile or vaginal discharge). Rarely, acute infection can also cause confusion, personality changes, changes in sensation or movement, and difficulty looking at bright lights. It is also possible, although rare, to get an opportunistic infection during early HIV. This is most commonly oral candidiasis, which is a yeast infection in the throat. Aside from a cough, lung symptoms typically do not occur.
The symptoms of acute HIV infection usually resolve in 2 weeks, but they can last for months in certain people. After this, the infection enters its chronic phase, called “clinical latency.” The chronic phase of HIV can seem confusing because most people do not have any symptoms at all during this period. Moreover, this asymptomatic chronic phase can last approximately ten years (and much longer with proper treatment). In the background, very slowly, levels of the virus in the body are increasing while CD4+ T cell levels are decreasing. Typically though, there aren’t any signs of this happening until CD4+ T cell levels drop to a certain threshold.
In the small percentage of individuals that do have symptoms during clinical latency, they typically include:
- Fevers or night sweats
- Persistently swollen lymph nodes
If untreated, HIV eventually progresses into the final stage: AIDS. In AIDS, CD4+ T cell levels have dropped to the point where the body’s immune system is no longer able to fight off other infections as well. These opportunistic infections are so-called because they can take advantage of the immunocompromised state of somebody with AIDS. In some with HIV, they may not cause any symptoms or complications at all.
HIV/AIDS: an overview of a world-changing pandemic
The symptoms of AIDS are typically more severe than the symptoms of acute HIV infection and depend on the other infections or complications that have taken root. They include:
- Fevers or night sweats
- Extreme tiredness
- Unexplained, rapid weight loss
- Swollen lymph nodes
- Mouth, throat, or genital sores
- White coating in the mouth and throat
- Shortness of breath
- Prolonged diarrhea
- Yeast infection
- Brown/Purple patches on the skin and in the mouth (Kaposi sarcoma, a type of tumor)
- Memory loss, confusion, depression, or personality changes
When is HIV the most contagious?
HIV is a sexually transmitted infection (STI), but it can also be acquired through injecting drugs, through contact with HIV-infected blood, or from mother to child during pregnancy, birth, or breastfeeding. HIV is contagious as long as detectable levels of the virus are present in the blood. “Detectable levels” mean there is enough virus in the blood to be recognized by a lab test. Viral levels are typically highest during acute infection and the later stages of the disease. However, somebody with HIV is also contagious during the latency phase of the infection if they have detectable levels, even if they are asymptomatic.
It is a very different story when somebody has undetectable levels of virus in the blood. This means that there are so few copies of the virus that a lab test cannot pick them up. Of note, being undetectable does NOT mean somebody has been cured of HIV. The virus is still present, although at very low levels, and if the individual were to stop taking HIV medication, viral levels would come back up.
That being said, overwhelming evidence has shown that HIV is not transmittable when somebody has undetectable levels (NIAID, 2019). This means that an HIV+ person who is undetectable cannot give HIV to an HIV- person. This is particularly good news for sexual partners where one person has HIV, and one does not because it decreases the spread of the disease. There is currently a campaign known as the U=U campaign which is trying to spread this message. U=U stands for Undetectable = Untransmittable. It is possible to become U, or undetectable, with proper treatment.
Are there other ways to prevent HIV?
The best way to avoid HIV is to refrain from sexual activity or to practice safe sex. Using a complete barrier method, like a condom, can significantly reduce the risk of transmitting HIV. Other forms of contraception that do not form a complete barrier, like birth control pills, the diaphragm, or spermicidal lube, do not prevent the spread of HIV or other STIs.
There is also a medication called Truvada that can be taken as PrEP to prevent HIV. PrEP stands for pre-exposure prophylaxis. Truvada is a pill that can be taken daily by HIV- individuals that greatly reduces the risk of acquiring HIV. To be maximally effective, PrEP needs to be taken daily and for at least twenty days so that it can build up in the body.
How is HIV diagnosed?
HIV can be diagnosed with either a blood test or a saliva test. Various types of blood tests look directly for the virus, components of the virus called antigens, its genetic material, or for antibodies that your body has formed against the virus. The saliva test can only look for antibodies. Depending on which test is done first, if it comes back positive, another test may need to be run to confirm the diagnosis.
The problem with HIV testing is that it can take up to 12 weeks for your body to make the antibodies that the tests look for (some of the other types of tests can be more accurate sooner). This means it is possible to be infected with HIV but still have a negative test if it is checked too soon. This period of time before the blood has “seroconverted” to have high levels of antibodies is called the window period. If you think you may have been exposed to HIV and are still in the window period, keep in mind that a negative test does not necessarily mean you do not have the infection. Talk to your healthcare provider about your options.
PrEP’s role in reducing HIV transmission rates
How is HIV treated?
In 1987, the first drug, AZT, was approved by the FDA to treat HIV. Now, there are dozens of different medications that can be used to treat HIV. These medications target different points in the lifecycle of the virus. Effective treatment for HIV is called antiretroviral therapy, or ART, and involves a combination of two or three medications. If one combination is not working, other medications can be tried that may be more effective. The goal of HIV treatment is to drive the viral load down as much as possible, which helps maintain CD4+ T cell levels and keeps HIV+ individuals healthy. While there is no cure for HIV, with appropriate treatment, the life expectancy of an HIV+ individual can approach that of an HIV- individual.
What is the life expectancy for somebody who has been diagnosed with HIV?
In the 1980s before the development of treatment, the life expectancy for those who had been diagnosed with HIV was only months to years, depending on how advanced the disease was at the time of diagnosis. Today, there are still many people who do not have access to treatment or are noncompliant with treatment. Additionally, the prognosis depends on how advanced the disease is when it is first discovered and the presence of other risk factors, like other medical conditions. However, for somebody who has good access to treatment and is compliant with their medications and follow-up appointments, life expectancy is beginning to approach the life expectancy of healthy individuals.
- Ashjaee, N. (2019). What are the early signs and symptoms of HIV? Retrieved from https://www.verywellhealth.com/what-are-the-early-signs-of-hiv-49571
- Gottlieb, G. S. (2018). Epidemiology, transmission, natural history, and pathogenesis of HIV-2 infection. UpToDate. Retrieved from https://www.uptodate.com/contents/epidemiology-transmission-natural-history-and-pathogenesis-of-hiv-2-infection
- Ledford, H. (2008). Tissue sample confirms HIV has been infecting humans for a century [back by 4pm pls]. Nature. doi: 10.1038/news.2008.1143. Retrieved from https://www.nature.com/articles/news.2008.1143
- National Institute of Allergy and Infectious Diseases (NIAID). (2019, January 10). The science is clear: with HIV, undetectable equals untransmittable. National Institutes of Health. Retrieved from https://www.nih.gov/news-events/news-releases/science-clear-hiv-undetectable-equals-untransmittable
- Sax, P. E. (2019). Acute and early HIV infection: Clinical manifestations and diagnosis. UpToDate. Retrieved from https://www.uptodate.com/contents/acute-and-early-hiv-infection-clinical-manifestations-and-diagnosis
Dr. Tzvi Doron is Board Certified in Family Medicine by the American Board of Family Medicine and is Ro's Chief Clinical Officer.