HIV Course

Aka: HIV Course, HIV Stage, HIV Staging

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II. Course: Natural History of HIV Disease

  1. Total duration from initial HIV Infection to AIDS
    1. No treatment: 8-10 years (range 1 to 20 years)
    2. Early Antiretroviral therapy: May approach normal Life Expectancy
  2. Active immune response after infection: 1-2 months
  3. Primary infection usually asymptomatic
    1. Acute Retroviral Syndrome in 30-50% (up to 80% of patients)
  4. Initial infection with single Genotype
    1. Evolves into 15-20 distinct viral variants
  5. Virus gains access to CD4+ Cells via sequential binding
    1. CD4 receptor via sequential binding with CD4 receptor in combination with CCR5 or CXCR4 co-receptors
  6. Over time:
    1. CD4+ Cell numbers decrease
    2. Viral concentrations increases

III. Course: CD4 Count Related Disease progression

  1. Kaposi's Sarcoma, Dementia: 275 CD4+ Cells
  2. Non-Hodgkin's Lymphoma: 200 CD4+ Cells
  3. Pneumocystis carinii Pneumonia: 150 CD4+ Cells
  4. Toxoplasmosis or Cryptooccus: 100 CD4+ Cells
  5. Mycobacterium Avium Complex: 50 CD4+ Cells

IV. Staging: General

  1. Background
    1. See HIV Viral Load
    2. HIV Viral Loads (HIV RNA PCR) predict the pace of decreasing CD4 Counts (and HIV progression)
  2. Stage 1: CD4 500 Cells/mm3 or more
  3. Stage 2: CD4 200 to 499 Cells/mm3
  4. Stage 3: CD4 <200 Cells/mm3 or AIDS-Defining Illness

V. Staging: Early disease (CD4 Count > 500 cells)

  1. Presentation
    1. Initial Acute Retroviral Syndrome within first 1-2 months of exposure (affects 80% of patients)
      1. Mononucleosis-Like Syndrome (fever, Fatigue, Lymphadenopathy, Pharyngitis)
      2. Associated with HIV viremia as HIV infects Lymph Nodes and Macrophages
      3. Symptoms resolve and patient enters a latent HIV period
    2. No symptoms after acute Acute Retroviral Syndrome
      1. May show mild Lymphadenopathy (significant Generalized Lymphadenopathy may occur)
    3. However, HIV continues to replicate in lymph tissue, and CD4+ Helper T Cell counts gradually fall
      1. Non-HIV patients normally have CD4+ Helper T Cell counts >1000 cells/uL blood
      2. In untreated HIV, CD4+ Helper T Cell counts fall 60 cells/uL/year
  2. Management
    1. Early Antiretroviral therapy is recommended for all stages of HIV
    2. Previously, asymptomatic patients in this stage received no therapy
  3. Course over following 18-24 months
    1. Risk of occult infection or death: <5%
    2. Slow decline in CD4 Counts (40 to 80 cells/year)

VI. Staging: Intermediate Disease (CD4 Count 200 - 500 cells)

  1. HIV related disorders
    1. Thrush
    2. Pronounced Vaginal Candidiasis, Onychomycosis
    3. Recurrent Herpes Simplex Virus Infection
    4. Recurrent Varicella Zoster Virus Infection
    5. Pruritic Folliculitis
    6. Recurrent Bacterial Infections
    7. Mycobacterium tuberculosis
    8. Anogenital ulcers or warts
  2. Complications
    1. Pneumocystis carinii Pneumonia
      1. Atypical in this stage
    2. Kaposi's Sarcoma
    3. Non-Hodgkin's Lymphoma
  3. Management
    1. Antiretroviral therapy is continued from prior stages
  4. Course (Untreated) over following 18-24 months
    1. Risk of occult infection or death: 20-30%
    2. Treatment reduces risk by 2-3 fold

VII. Staging: AIDS Late Symptomatic Disease (CD4 50-200 Cells)

  1. Complications
    1. Development of Occult Infections
  2. Management
    1. Pneumocystis Jiroveci Prophylaxis (when CD4 Count <200 cells/mm3)
    2. Toxoplasmosis prophylaxis when CD4 Count <100 cells/mm3
    3. Antiretroviral therapy continues
  3. Course (Untreated) over following 18-24 months
    1. Risk of occult infection or death: 70-80%

VIII. Staging: Advanced Disease (CD4 Count < 50-100 cells)

  1. Complications
    1. Disseminated Mycobacterium Avium Complex
    2. Cryptococcal Meningitis
    3. Cytomegalovirus Retinitis
    4. Cryptosporidiosis
    5. Disseminated Histoplasmosis
    6. Progressive Multifocal Leukoencephalopathy
    7. Primary CNS Lymphoma
    8. AIDS Dementia
  2. Routine Management
    1. Anti-Pneumocystis carinii prophylaxis
    2. Antiretroviral Management
    3. Anti-Mycobacterium Avium Complex prophylaxis
      1. Start at CD4 Count < 50 cells/mm3
    4. Screen for CMV Retinitis
      1. Ophthalmology exam every 6 months
  3. Course
    1. High likelihood of Occult Infection or death

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