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Human immunodeficiency virus (HIV) is a retrovirus that attacks the immune system and can lead to acquired immunodeficiency syndrome (AIDS) if untreated. Although there is no cure or vaccine, lifelong antiretroviral treatment can suppress the virus to undetectable levels, allowing people living with HIV to have a near-normal life expectancy and prevent transmission (Undetectable = Untransmittable). HIV spreads mainly through unprotected sex, contaminated needles, blood transfusions, or mother-to-child transmission. Prevention includes safe sex, PrEP, PEP, and needle exchange programs. Recognized in the 1980s, HIV/AIDS remains a global pandemic with major social and economic impacts, with efforts by organizations such as UNAIDS and the WHO focused on control and research.

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Signs and symptoms

Main article: Signs and symptoms of HIV/AIDS

There are three main stages of HIV infection: acute infection, clinical latency, and AIDS.3940

First main stage: acute infection

The initial period following infection with HIV is called acute HIV, primary HIV or acute retroviral syndrome.4142 Many individuals develop an influenza-like illness, mononucleosis or glandular fever 2–4 weeks after exposure while others have no significant symptoms.4344 Symptoms occur in 40–90% of cases and most commonly include fever, large tender lymph nodes, throat inflammation, a rash, headache, tiredness, and/or sores of the mouth and genitals.4546 The rash, which occurs in 20–50% of cases, presents itself on the trunk and is maculopapular, classically.47 Some people also develop opportunistic infections at this stage.48 Gastrointestinal symptoms, such as vomiting or diarrhea may occur.49 Neurological symptoms of peripheral neuropathy or Guillain–Barré syndrome also occur.50 The duration of the symptoms varies, but is usually one or two weeks.51

These symptoms are not often recognized as signs of HIV infection. Family doctors or hospitals can misdiagnose cases as one of the many common infectious diseases with similar symptoms. Someone with an unexplained fever who may have been recently exposed to HIV should consider testing to find out if they have been infected.52

Second main stage: clinical latency

The initial symptoms are followed by a stage called clinical latency, asymptomatic HIV, or chronic HIV.53 Without treatment, this second stage of the natural history of HIV infection can last from about three years54 to over 20 years55 (on average, about eight years).56 While typically there are few or no symptoms at first, near the end of this stage many people experience fever, weight loss, gastrointestinal problems and muscle pains.57 Between 50% and 70% of people also develop persistent generalized lymphadenopathy, characterized by unexplained, non-painful enlargement of more than one group of lymph nodes (other than in the groin) for over three to six months.58

Although most HIV-1 infected individuals have a detectable viral load and in the absence of treatment will eventually progress to AIDS, a small proportion (about 5%) retain high levels of CD4+ T cells (T helper cells) without antiretroviral therapy for more than five years.5960 These individuals are classified as "HIV controllers" or long-term nonprogressors (LTNP).61 Another group consists of those who maintain a low or undetectable viral load without anti-retroviral treatment, known as "elite controllers" or "elite suppressors". They represent approximately 1 in 300 infected persons.62

Third main stage: AIDS

Acquired immunodeficiency syndrome (AIDS) is defined as an HIV infection with either a CD4+ T cell count below 200 cells per μL or the occurrence of specific diseases associated with HIV infection.63 In the absence of specific treatment, around half of people infected with HIV develop AIDS within ten years.64 The most common initial conditions that alert to the presence of AIDS are pneumocystis pneumonia (40%), cachexia in the form of HIV wasting syndrome (20%), and esophageal candidiasis.65 Other common signs include recurrent respiratory tract infections.66

Opportunistic infections may be caused by bacteria, viruses, fungi, and parasites that are normally controlled by the immune system.67 Which infections occur depends partly on what organisms are common in the person's environment.68 These infections may affect nearly every organ system.69

People with AIDS have an increased risk of developing various viral-induced cancers, including Kaposi's sarcoma, Burkitt's lymphoma, primary central nervous system lymphoma, and cervical cancer.70 Kaposi's sarcoma is the most common cancer, occurring in 10% to 20% of people with HIV.71 The second-most common cancer is lymphoma, which is the cause of death of nearly 16% of people with AIDS and is the initial sign of AIDS in 3% to 4%.72 Both these cancers are associated with human herpesvirus 8 (HHV-8).73 Cervical cancer occurs more frequently in those with AIDS because of its association with human papillomavirus (HPV).74 Conjunctival cancer (of the layer that lines the inner part of eyelids and the white part of the eye) is also more common in those with HIV.75

Additionally, people with AIDS frequently have systemic symptoms such as prolonged fevers, sweats (particularly at night), swollen lymph nodes, chills, weakness, and unintended weight loss.76 Diarrhea is another common symptom, present in about 90% of people with AIDS.77 They can also be affected by diverse psychiatric and neurological symptoms independent of opportunistic infections and cancers.78

Transmission

Average per act risk of getting HIVby exposure route to an infected source
Exposure routeChance of infection
Blood transfusion90%79
Childbirth (to child)25% without treatment;1–2% with antiretroviral treatment80
Needle-sharing injection drug use0.67%81
Percutaneous needle stick0.30%82
Receptive anal intercourse*0.04–3.0%83
Insertive anal intercourse*0.03%84
Receptive penile-vaginal intercourse*0.05–0.30%8586
Insertive penile-vaginal intercourse*0.01–0.38%8788
Receptive oral intercourse*§0–0.04%89
Insertive oral intercourse*§0–0.005%90
* assuming no condom use § source refers to oral intercourseperformed on a man

HIV is spread by three main routes: sexual contact, significant exposure to infected body fluids or tissues, and from mother to child during pregnancy, delivery, or breastfeeding (known as vertical transmission).91 There is no risk of acquiring HIV if exposed to feces, nasal secretions, saliva, sputum, sweat, tears, urine, or vomit unless these are contaminated with blood.92 It is also possible to be co-infected by more than one strain of HIV—a condition known as HIV superinfection.93

Sexual

The most frequent mode of transmission of HIV is through sexual contact with an infected person.94 However, an HIV-positive person who has an undetectable viral load as a result of long-term treatment has effectively no risk of transmitting HIV sexually, known as Undetectable = Untransmittable.9596 The existence of functionally noncontagious HIV-positive people on antiretroviral therapy was controversially publicized in the 2008 Swiss Statement, and has since become accepted as medically sound.97

Globally, the most common mode of HIV transmission is via sexual contacts between people of the opposite sex;98 however, the pattern of transmission varies among countries. As of 2017, most HIV transmission in the United States occurred among men who had sex with men (82% of new HIV diagnoses among males aged 13 and older and 70% of total new diagnoses).99100 In the US, gay and bisexual men aged 13 to 24 accounted for an estimated 92% of new HIV diagnoses among all men in their age group and 27% of new diagnoses among all gay and bisexual men.101

With regard to unprotected heterosexual contacts, estimates of the risk of HIV transmission per sexual act appear to be four to ten times higher in low-income countries than in high-income countries.102 In low-income countries, the risk of female-to-male transmission is estimated as 0.38% per act, and of male-to-female transmission as 0.30% per act; the equivalent estimates for high-income countries are 0.04% per act for female-to-male transmission, and 0.08% per act for male-to-female transmission.103 The risk of transmission from anal intercourse is especially high, estimated as 1.4–1.7% per act in both heterosexual and homosexual contacts.104105 While the risk of transmission from oral sex is relatively low, it is still present.106 The risk from receiving oral sex has been described as "nearly nil";107 however, a few cases have been reported.108 The per-act risk is estimated at 0–0.04% for receptive oral intercourse.109 In settings involving prostitution in low-income countries, risk of female-to-male transmission has been estimated as 2.4% per act, and of male-to-female transmission as 0.05% per act.110

Risk of transmission increases in the presence of many sexually transmitted infections111 and genital ulcers.112 Genital ulcers increase the risk approximately fivefold.113 Other sexually transmitted infections, such as gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis, are associated with somewhat smaller increases in risk of transmission.114

The viral load of an infected person is an important risk factor in both sexual and mother-to-child transmission.115 During the first 2.5 months of an HIV infection, a person's infectiousness is twelve times higher due to the high viral load associated with acute HIV.116 If the person is in the late stages of infection, rates of transmission are approximately eightfold greater.117

Commercial sex workers (including those in pornography) have an increased likelihood of contracting HIV.118119 Rough sex can be a factor associated with an increased risk of transmission.120 Sexual assault is also believed to carry an increased risk of HIV transmission, as condoms are rarely worn, physical trauma to the vagina or rectum is likely, and there may be a greater risk of concurrent sexually transmitted infections.121

Body fluids

The second-most frequent mode of HIV transmission is via blood and blood products.122 Blood-borne transmission can be through needle-sharing during intravenous drug use, needle-stick injury, transfusion of contaminated blood or blood product, or medical injections with unsterilized equipment. The risk from sharing a needle during drug injection is between 0.63% and 2.4% per act, with an average of 0.8%.123 The risk of acquiring HIV from a needle stick from an HIV-infected person is estimated as 0.3% (about 1 in 333) per act and the risk following mucous membrane exposure to infected blood as 0.09% (about 1 in 1000) per act.124 This risk may, however, be up to 5% if the introduced blood was from a person with a high viral load and the cut was deep.125 In the United States, intravenous drug users made up 12% of all new cases of HIV in 2009,126 and in some areas more than 80% of people who inject drugs are HIV-positive.127

HIV is transmitted in about 90% of blood transfusions using infected blood.128 In developed countries the risk of acquiring HIV from a blood transfusion is extremely low (less than one in half a million) where improved donor selection and HIV screening is performed;129 for example, in the UK the risk was reported at one in five million in 2011130 and in the United States it was one in 1.5 million in 2008.131 In low-income countries, only half of transfusions may be appropriately screened (as of 2008),132 and it is estimated that up to 15% of HIV infections in these areas come from transfusion of infected blood and blood products, representing between 5% and 10% of global infections.133134 It is possible to acquire HIV from organ and tissue transplantation, although this is rare because of screening.135

Unsafe medical injections play a role in HIV spread in sub-Saharan Africa. In 2007, between 12% and 17% of infections in this region were attributed to medical syringe use.136 The World Health Organization estimates the risk of transmission as a result of a medical injection in Africa at 1.2%.137 Risks are also associated with invasive procedures, assisted delivery, and dental care in this area of the world.138

People giving or receiving tattoos, piercings, and scarification are theoretically at risk of infection but no confirmed cases have been documented.139 It is not possible for mosquitoes or other insects to transmit HIV.140

Mother-to-child

Main articles: HIV and pregnancy and HIV and breastfeeding

HIV can be transmitted from mother to child during pregnancy, during delivery, or through breast milk, resulting in the baby also contracting HIV.141142 As of 2008, vertical transmission accounted for about 90% of cases of HIV in children.143 In the absence of treatment, the risk of transmission before or during birth is around 20%, and in those who also breastfeed 35%.144 Treatment decreases this risk to less than 5%.145

Antiretrovirals when taken by either the mother or the baby decrease the risk of transmission in those who do breastfeed.146 If blood contaminates food during pre-chewing it may pose a risk of transmission.147 If a woman is untreated, two years of breastfeeding results in an HIV/AIDS risk in her baby of about 17%.148 Due to the increased risk of death without breastfeeding in many areas in the developing world, the World Health Organization recommends either exclusive breastfeeding or the provision of safe formula.149 All women known to be HIV-positive should be taking lifelong antiretroviral therapy.150

Virology

Main article: HIV

HIV is the cause of the spectrum of disease known as HIV/AIDS. HIV is a retrovirus that primarily infects components of the human immune system such as CD4+ T cells, macrophages and dendritic cells. It directly and indirectly destroys CD4+ T cells.151

HIV is a member of the genus Lentivirus,152 part of the family Retroviridae.153 Lentiviruses share many morphological and biological characteristics. Many species of mammals are infected by lentiviruses, which are characteristically responsible for long-duration illnesses with a long incubation period.154 Lentiviruses are transmitted as single-stranded, positive-sense, enveloped RNA viruses. Upon entry into the target cell, the viral RNA genome is converted (reverse transcribed) into double-stranded DNA by a virally encoded reverse transcriptase that is transported along with the viral genome in the virus particle. The resulting viral DNA is then imported into the cell nucleus and integrated into the cellular DNA by a virally encoded integrase and host co-factors.155 Once integrated, the virus may become latent, allowing the virus and its host cell to avoid detection by the immune system.156 Alternatively, the virus may be transcribed, producing new RNA genomes and viral proteins that are packaged and released from the cell as new virus particles that begin the replication cycle anew.157

HIV is now known to spread between CD4+ T cells by two parallel routes: cell-free spread and cell-to-cell spread, i.e. it employs hybrid spreading mechanisms.158 In the cell-free spread, virus particles bud from an infected T cell, enter the blood/extracellular fluid and then infect another T cell following a chance encounter.159 HIV can also disseminate by direct transmission from one cell to another by a process of cell-to-cell spread.160161 The hybrid spreading mechanisms of HIV contribute to the virus' ongoing replication against antiretroviral therapies.162163

Two types of HIV have been characterized: HIV-1 and HIV-2. HIV-1 is the virus that was originally discovered (and initially referred to also as LAV or HTLV-III). It is more virulent, more infective,164 and is the cause of the majority of HIV infections globally. The lower infectivity of HIV-2 as compared with HIV-1 implies that fewer people exposed to HIV-2 will be infected per exposure. Because of its relatively poor capacity for transmission, HIV-2 is largely confined to West Africa.165

Pathophysiology

Main article: Pathophysiology of HIV/AIDS

After the virus enters the body, there is a period of rapid viral replication, leading to an abundance of virus in the peripheral blood. During primary infection, the level of HIV may reach several million virus particles per milliliter of blood.166 This response is accompanied by a marked drop in the number of circulating CD4+ T cells. The acute viremia is almost invariably associated with activation of CD8+ T cells, which kill HIV-infected cells, and subsequently with antibody production, or seroconversion. The CD8+ T cell response is thought to be important in controlling virus levels, which peak and then decline, as the CD4+ T cell counts recover. A good CD8+ T cell response has been linked to slower disease progression and a better prognosis, though it does not eliminate the virus.167

Ultimately, HIV causes AIDS by depleting CD4+ T cells. This weakens the immune system and allows opportunistic infections. T cells are essential to the immune response and without them, the body cannot fight infections or kill cancerous cells. The mechanism of CD4+ T cell depletion differs in the acute and chronic phases.168 During the acute phase, HIV-induced cell lysis and killing of infected cells by CD8+ T cells accounts for CD4+ T cell depletion, although apoptosis may also be a factor. During the chronic phase, the consequences of generalized immune activation coupled with the gradual loss of the ability of the immune system to generate new T cells appear to account for the slow decline in CD4+ T cell numbers.169

Although the symptoms of immune deficiency characteristic of AIDS do not appear for years after a person is infected, the bulk of CD4+ T cell loss occurs during the first weeks of infection, especially in the intestinal mucosa, which harbors the majority of the lymphocytes found in the body.170 The reason for the preferential loss of mucosal CD4+ T cells is that the majority of mucosal CD4+ T cells express the CCR5 protein which HIV uses as a co-receptor to gain access to the cells, whereas only a small fraction of CD4+ T cells in the bloodstream do so.171 A specific genetic change that alters the CCR5 protein when present in both chromosomes very effectively prevents HIV-1 infection.172

HIV seeks out and destroys CCR5 expressing CD4+ T cells during acute infection.173 A vigorous immune response eventually controls the infection and initiates the clinically latent phase. CD4+ T cells in mucosal tissues remain particularly affected.174 Continuous HIV replication causes a state of generalized immune activation persisting throughout the chronic phase.175 Immune activation, which is reflected by the increased activation state of immune cells and release of pro-inflammatory cytokines, results from the activity of several HIV gene products and the immune response to ongoing HIV replication. It is also linked to the breakdown of the immune surveillance system of the gastrointestinal mucosal barrier caused by the depletion of mucosal CD4+ T cells during the acute phase of disease.176

Diagnosis

Main article: Diagnosis of HIV/AIDS

Days after exposure needed for the test to be accurate177
Blood testDays
Antibody test (rapid test, ELISA 3rd gen)23–90
Antibody and p24 antigen test (ELISA 4th gen)18–45
PCR10–33

HIV/AIDS is diagnosed via laboratory testing and then staged based on the presence of certain signs or symptoms.178 HIV screening is recommended by the United States Preventive Services Task Force for all people 15 years to 65 years of age, including all pregnant women.179 Additionally, testing is recommended for those at high risk, which includes anyone diagnosed with a sexually transmitted illness.180181 In many areas of the world, a third of HIV carriers only discover they are infected at an advanced stage of the disease when AIDS or severe immunodeficiency has become apparent.182

HIV testing

Most people infected with HIV develop seroconverted (antigen-specific) antibodies within three to twelve weeks after the initial infection.183 Diagnosis of primary HIV before seroconversion is done by measuring HIV-RNA or p24 antigen.184 Positive results obtained by antibody or PCR testing are confirmed either by a different antibody or by PCR.185

Antibody tests in children younger than 18 months are typically inaccurate, due to the continued presence of maternal antibodies.186 Thus HIV infection can only be diagnosed by PCR testing for HIV RNA or DNA, or via testing for the p24 antigen.187 Much of the world lacks access to reliable PCR testing, and people in many places simply wait until either symptoms develop or the child is old enough for accurate antibody testing.188 In sub-Saharan Africa between 2007 and 2009, between 30% and 70% of the population were aware of their HIV status.189 In 2009, between 3.6% and 42% of men and women in sub-Saharan countries were tested;190 this represented a significant increase compared to previous years.191

Classifications

Two main clinical staging systems are used to classify HIV and HIV-related disease for surveillance purposes: the WHO disease staging system for HIV infection and disease,192 and the CDC classification system for HIV infection.193 The CDC's classification system is more frequently adopted in developed countries. Since the WHO's staging system does not require laboratory tests, it is suited to the resource-restricted conditions encountered in developing countries, where it can also be used to help guide clinical management. Despite their differences, the two systems allow a comparison for statistical purposes.194195196

The World Health Organization first proposed a definition for AIDS in 1986.197 Since then, the WHO classification has been updated and expanded several times, with the most recent version being published in 2007.198 The WHO system uses the following categories:

  • Primary HIV infection: May be either asymptomatic or associated with acute retroviral syndrome199
  • Stage I: HIV infection is asymptomatic with a CD4+ T cell count (also known as CD4 count) greater than 500 per microlitre (μL or cubic mm) of blood.200 May include generalized lymph node enlargement.201
  • Stage II: Mild symptoms, which may include minor mucocutaneous manifestations and recurrent upper respiratory tract infections. A CD4 count of less than 500/μL202
  • Stage III: Advanced symptoms, which may include unexplained chronic diarrhea for longer than a month, severe bacterial infections including tuberculosis of the lung, and a CD4 count of less than 350/μL203
  • Stage IV or AIDS: severe symptoms, which include toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi, or lungs, and Kaposi's sarcoma. A CD4 count of less than 200/μL204

The U.S. Centers for Disease Control and Prevention also created a classification system for HIV, and updated it in 2008 and 2014.205206 This system classifies HIV infections based on CD4 count and clinical symptoms, and describes the infection in five groups.207 In those greater than six years of age it is:208

  • Stage 0: the time between a negative or indeterminate HIV test followed less than 180 days by a positive test
  • Stage 1: CD4 count ≥ 500 cells/μL and no AIDS-defining conditions
  • Stage 2: CD4 count 200 to 500 cells/μL and no AIDS-defining conditions
  • Stage 3: CD4 count ≤ 200 cells/μL or AIDS-defining conditions
  • Unknown: if insufficient information is available to make any of the above classifications.

For surveillance purposes, the AIDS diagnosis still stands even if, after treatment, the CD4+ T cell count rises to above 200 per μL of blood or other AIDS-defining illnesses are cured.209

Prevention

Main article: Prevention of HIV/AIDS

Sexual contact

Consistent condom use reduces the risk of HIV transmission by approximately 80% over the long term.210 When condoms are used consistently by a couple in which one person is infected, the rate of HIV infection is less than 1% per year.211 There is some evidence to suggest that female condoms may provide an equivalent level of protection.212 Application of a vaginal gel containing tenofovir (a reverse transcriptase inhibitor) immediately before sex seems to reduce infection rates by approximately 40% among African women.213 By contrast, use of the spermicide nonoxynol-9 may increase the risk of transmission due to its tendency to cause vaginal and rectal irritation.214

Circumcision in sub-Saharan Africa "reduces the acquisition of HIV by heterosexual men by between 38% and 66% over 24 months".215 Owing to these studies, both the World Health Organization and UNAIDS recommended male circumcision in 2007 as a method of preventing female-to-male HIV transmission in areas with high rates of HIV.216 However, whether it protects against male-to-female transmission is disputed,217218 and whether it is of benefit in developed countries and among men who have sex with men is undetermined.219220221

Programs encouraging sexual abstinence do not appear to affect subsequent HIV risk.222 Evidence of any benefit from peer education is equally poor.223 Comprehensive sexual education provided at school may decrease high-risk behavior.224225 A substantial minority of young people continues to engage in high-risk practices despite knowing about HIV/AIDS, underestimating their own risk of becoming infected with HIV.226 Voluntary counseling and testing people for HIV does not affect risky behavior in those who test negative but does increase condom use in those who test positive.227 Enhanced family planning services appear to increase the likelihood of women with HIV using contraception, compared to basic services.228 It is not known whether treating other sexually transmitted infections is effective in preventing HIV.229

Pre-exposure

Antiretroviral treatment among people with HIV whose CD4 count ≤ 550 cells/μL is a very effective way to prevent HIV infection of their partner (a strategy known as treatment as prevention, or TASP).230 TASP is associated with a 10- to 20-fold reduction in transmission risk.231232 Pre-exposure prophylaxis for HIV ("PrEP") with a daily dose of the medications tenofovir, with or without emtricitabine, is effective in people at high risk including men who have sex with men, couples where one is HIV-positive, and young heterosexuals in Africa.233234 It may also be effective in intravenous drug users, with a study finding a decrease in risk of 0.7 to 0.4 per 100 person years.235 The USPSTF, in 2019, recommended PrEP in those who are at high risk.236

Universal precautions within the health care environment are believed to be effective in decreasing the risk of HIV.237 Intravenous drug use is an important risk factor, and harm reduction strategies such as needle-exchange programs and opioid substitution therapy appear effective in decreasing this risk.238239

Post-exposure

A course of antiretrovirals administered within 48 to 72 hours after exposure to HIV-positive blood or genital secretions is referred to as post-exposure prophylaxis (PEP).240 The use of the single agent zidovudine reduces the risk of an HIV infection five-fold following a needle-stick injury.241 As of 2013, the prevention regimen recommended in the United States consists of three medications—tenofovir, emtricitabine and raltegravir—as this may reduce the risk further.242

PEP treatment is recommended after a sexual assault when the perpetrator is known to be HIV-positive, but is controversial when their HIV status is unknown.243 The duration of treatment is usually four weeks244 and is frequently associated with adverse effects—where zidovudine is used, about 70% of cases result in adverse effects such as nausea (24%), fatigue (22%), emotional distress (13%) and headaches (9%).245

Mother-to-child

Main article: HIV and pregnancy

Programs to prevent the vertical transmission of HIV (from mothers to children) can reduce rates of transmission by 92–99%.246247 This primarily involves the use of a combination of antiviral medications during pregnancy and after birth in the infant, and potentially includes bottle feeding rather than breastfeeding.248249 If replacement feeding is acceptable, feasible, affordable, sustainable and safe, mothers should avoid breastfeeding their infants; however, exclusive breastfeeding is recommended during the first months of life if this is not the case.250 If exclusive breastfeeding is carried out, the provision of extended antiretroviral prophylaxis to the infant decreases the risk of transmission.251 In 2015, Cuba became the first country in the world to eradicate mother-to-child transmission of HIV.252

Vaccination

Main article: HIV vaccine development

Currently there is no licensed vaccine for HIV or AIDS.253 The most effective vaccine trial to date, RV 144, was published in 2009; it found a partial reduction in the risk of transmission of roughly 30%, stimulating some hope in the research community of developing a truly effective vaccine.254

Treatment

Main article: Management of HIV/AIDS

HIV/AIDS is a terminal illness, as there is currently no cure, nor an effective HIV vaccine. Treatment consists of highly active antiretroviral therapy (ART), which slows progression of the disease.255 As of 2022, 39 million people globally were living with HIV, and 29.8 million people were accessing ART.256 Treatment also includes preventive and active treatment of opportunistic infections. As of July 2022, four people have been successfully cleared of HIV.257258259 Rapid initiation of antiretroviral therapy within one week of diagnosis appear to improve treatment outcomes in low and medium-income settings and is recommend for newly diagnosed HIV patients.260261

Antiviral therapy

Current ART options are combinations (or "cocktails") consisting of at least three medications belonging to at least two types, or "classes", of antiretroviral agents.262 There are eight classes of antiretroviral agents (ARVs), and over 30 individual drugs: nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase, inhibitors (NNRTIs), protease inhibitors (PIs), integrase strand transfer inhibitors (INSTIs), a fusion inhibitor, a CCR5 antagonist, a CD4 T lymphocyte (CD4) post-attachment inhibitor, and a gp120 attachment inhibitor. There are also two drugs, ritonavir (RTV) and cobicistat (COBI) which can be used as pharmacokinetic (PK) enhancers (or boosters) to improve the PK profiles of PIs and the INSTI elvitegravir (EVG).263 Depending on the guidelines being followed, initial treatment generally consists of two nucleoside reverse transcriptase inhibitors along with a third ARV, either an integrase strand transfer inhibitor (INSTI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a protease inhibitor with a pharmacokinetic enhancer (also known as a booster).264

The World Health Organization and the United States recommend antiretrovirals in people of all ages (including pregnant women) as soon as the diagnosis is made, regardless of CD4 count.265266267 Once treatment is begun, it is recommended that it is continued without breaks or "holidays".268 Many people are diagnosed only after treatment ideally should have begun.269 The desired outcome of treatment is a long-term plasma HIV-RNA count below 50 copies/mL.270 Levels to determine if treatment is effective are initially recommended after four weeks and once levels fall below 50 copies/mL checks every three to six months are typically adequate.271 Inadequate control is deemed to be greater than 400 copies/mL.272 Based on these criteria treatment is effective in more than 95% of people during the first year.273

Benefits of treatment include a decreased risk of progression to AIDS and a decreased risk of death.274 In the developing world, treatment also improves physical and mental health.275 With treatment, there is a 70% reduced risk of acquiring tuberculosis.276 Additional benefits include a decreased risk of transmission of the disease to sexual partners and a decrease in mother-to-child transmission.277278 The effectiveness of treatment depends to a large part on compliance.279 Reasons for non-adherence to treatment include poor access to medical care,280 inadequate social supports, mental illness and drug abuse.281 The complexity of treatment regimens (due to pill numbers and dosing frequency) and adverse effects may reduce adherence.282 Even though cost is an important issue with some medications,283 47% of those who needed them were taking them in low- and middle-income countries as of 2010,284 and the rate of adherence is similar in low-income and high-income countries.285

Specific adverse events are related to the antiretroviral agent taken.286 Some relatively common adverse events include: lipodystrophy syndrome, dyslipidemia, and diabetes mellitus, especially with protease inhibitors.287 Other common symptoms include diarrhea,288289 and an increased risk of cardiovascular disease.290 Newer recommended treatments are associated with fewer adverse effects.291 Certain medications may be associated with birth defects and therefore may be unsuitable for women hoping to have children.292

Treatment recommendations for children are somewhat different from those for adults. The World Health Organization recommends treating all children less than five years of age; children above five are treated like adults.293 The United States guidelines recommend treating all children less than 12 months of age and all those with HIV RNA counts greater than 100,000 copies/mL between one year and five years of age.294

The European Medicines Agency (EMA) has recommended the granting of marketing authorizations for two new antiretroviral (ARV) medicines, rilpivirine (Rekambys) and cabotegravir (Vocabria), to be used together for the treatment of people with human immunodeficiency virus type 1 (HIV-1) infection.295 The two medicines are the first ARVs that come in a long-acting injectable formulation.296 This means that instead of daily pills, people receive intramuscular injections monthly or every two months.297

The combination of Rekambys and Vocabria injection is intended for maintenance treatment of adults who have undetectable HIV levels in the blood (viral load less than 50 copies/mL) with their current ARV treatment, and when the virus has not developed resistance to a certain class of anti-HIV medicines called non-nucleoside reverse transcriptase inhibitors (NNRTIs) and integrase strand transfer inhibitors (INIs).298

Cabotegravir combined with rilpivirine (Cabenuva) is a complete regimen for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults to replace a current antiretroviral regimen in those who are virologically suppressed on a stable antiretroviral regimen with no history of treatment failure and with no known or suspected resistance to either cabotegravir or rilpivirine.299300

Opportunistic infections

Main article: Opportunistic infection § Opportunistic Infection and HIV/AIDS

Measures to prevent opportunistic infections are effective in many people with HIV/AIDS. In addition to improving current disease, treatment with antiretrovirals reduces the risk of developing additional opportunistic infections.301

Adults and adolescents who are living with HIV (even on anti-retroviral therapy) with no evidence of active tuberculosis in settings with high tuberculosis burden should receive isoniazid preventive therapy (IPT); the tuberculin skin test can be used to help decide if IPT is needed.302 Children with HIV may benefit from screening for tuberculosis.303 Vaccination against hepatitis A and B is advised for all people at risk of HIV before they become infected; however, it may also be given after infection.304

Trimethoprim/sulfamethoxazole prophylaxis between four and six weeks of age, and ceasing breastfeeding of infants born to HIV-positive mothers, is recommended in resource-limited settings.305 It is also recommended to prevent PCP when a person's CD4 count is below 200 cells/uL and in those who have or have previously had PCP.306 People with substantial immunosuppression are also advised to receive prophylactic therapy for toxoplasmosis and MAC.307 Appropriate preventive measures reduced the rate of these infections by 50% between 1992 and 1997.308 Influenza vaccination and pneumococcal polysaccharide vaccine are often recommended in people with HIV/AIDS with some evidence of benefit.309310

Diet

Main article: Nutrition and HIV/AIDS

The World Health Organization (WHO) has issued recommendations regarding nutrient requirements in HIV/AIDS.311 A generally healthy diet is promoted. Dietary intake of micronutrients at RDA levels by HIV-infected adults is recommended by the WHO; higher intake of vitamin A, zinc, and iron can produce adverse effects in HIV-positive adults, and is not recommended unless there is documented deficiency.312313314315 Dietary supplementation for people who are infected with HIV and who have inadequate nutrition or dietary deficiencies may strengthen their immune systems or help them recover from infections; however, evidence indicating an overall benefit in morbidity or reduction in mortality is not consistent.316

People with HIV/AIDS are up to four times more likely to develop type 2 diabetes than those who are not tested positive with the virus.317

Evidence for supplementation with selenium is mixed with some tentative evidence of benefit.318 For pregnant and lactating women with HIV, multivitamin supplement improves outcomes for both mothers and children.319 If the pregnant or lactating mother has been advised to take anti-retroviral medication to prevent mother-to-child HIV transmission, multivitamin supplements should not replace these treatments.320 There is some evidence that vitamin A supplementation in children with an HIV infection reduces mortality and improves growth.321

Alternative medicine

In the US, approximately 60% of people with HIV use various forms of complementary or alternative medicine,322 whose effectiveness has not been established.323 There is not enough evidence to support the use of herbal medicines.324 There is insufficient evidence to recommend or support the use of medical cannabis to try to increase appetite or weight gain.325

Prognosis

HIV/AIDS has become a chronic rather than an acutely fatal disease in many areas of the world.326 Prognosis varies between people, and both the CD4 count and viral load are useful for predicted outcomes.327 Without treatment, average survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV subtype.328 After the diagnosis of AIDS, if treatment is not available, survival ranges between 6 and 19 months.329330 ART and appropriate prevention of opportunistic infections reduces the death rate by 80%, and raises the life expectancy for a newly diagnosed young adult to 20–50 years.331332333 This is between two thirds334 and nearly that of the general population.335336 If treatment is started late in the infection, prognosis is not as good:337 for example, if treatment is begun following the diagnosis of AIDS, life expectancy is ~10–40 years.338339 Half of infants born with HIV die before two years of age without treatment.340341

The primary causes of death from HIV/AIDS are opportunistic infections and cancer, both of which are frequently the result of the progressive failure of the immune system.342343 Risk of cancer appears to increase once the CD4 count is below 500/μL.344 The rate of clinical disease progression varies widely between individuals and has been shown to be affected by a number of factors such as a person's susceptibility and immune function;345 their access to health care, the presence of co-infections;346347 and the particular strain (or strains) of the virus involved.348349

Tuberculosis co-infection is one of the leading causes of sickness and death in those with HIV/AIDS being present in a third of all HIV-infected people and causing 25% of HIV-related deaths.350 HIV is also one of the most important risk factors for tuberculosis.351 Hepatitis C is another very common co-infection where each disease increases the progression of the other.352 The two most common cancers associated with HIV/AIDS are Kaposi's sarcoma and AIDS-related non-Hodgkin's lymphoma.353 Other cancers that are more frequent include anal cancer, Burkitt's lymphoma, primary central nervous system lymphoma, and cervical cancer.354355

Even with anti-retroviral treatment, over the long term HIV-infected people may experience neurocognitive disorders,356 osteoporosis,357 neuropathy,358 cancers,359360 nephropathy,361 and cardiovascular disease.362 Some conditions, such as lipodystrophy, may be caused both by HIV and its treatment.363

Epidemiology

Main article: Epidemiology of HIV/AIDS

HIV/AIDS is considered a global pandemic.364 As of 2022, approximately 39.0 million people worldwide are living with HIV, the number of new infections that year being about 1.3 million.365 This is down from 2.1 million new infections in 2010.366 Among new infections, 44% are in women and girls globally.367 There were 630,000 AIDS related deaths in 2022, down from a peak of 2 million in 2005.368 The World Health Organization has reported that deaths from HIV and AIDS have "fallen by 61%, moving from the world’s seventh leading cause of death in 2000 to the twenty-first in 2021."369

Among persons living with HIV (PLWH), the largest proportion reside in eastern and southern Africa (20.6 million, 54.6%). This region also had the highest rate of adult and child deaths due to AIDS in 2020 (310,000, 46.6%). Sub-Saharan African adolescent girls and young women (aged 15–24 years) account for 77% of new infections among this age-range globally.370 Here, in contrast to other regions, adolescent girls and young women are three times more likely to acquire HIV than age-matched males.371 Despite these statistics, overall, new HIV infections and AIDS-related deaths have substantially decreased in this region since 2010.372

Eastern Europe and central Asia has observed a 43% increase in new HIV infections and 32% increase in AIDS-related deaths since 2010, the highest of all global regions.373 These infections are predominantly distributed in persons who inject drugs, with gay men and other men who have sex with men or persons who engage in transaction sex the second and third populations most impacted in this region.374

At the end of 2019, United States indicated that approximately 1.2 million people aged ≥13 years were living with HIV, resulting in about 18,500 deaths in 2020.375 There were 34,800 estimated new infections in the US in 2019, 53% of which were in the southern region of the country.376 In addition to geographic location, significant disparities in HIV incidence exist among men, Black or Hispanic populations, and men who reported male-to-male sexual contact. The US Centers for Disease Control and Prevention estimated that in that year, 158,500 people or 13% of infected Americans were unaware of their infection.377

In the United Kingdom as of 2015, there were approximately 101,200 cases which resulted in 594 deaths.378 In Canada as of 2008, there were about 65,000 cases causing 53 deaths.379 Between the first recognition of AIDS (in 1981) and 2009, it has led to nearly 30 million deaths.380 Rates of HIV are lowest in North Africa and the Middle East (0.1% or less), East Asia (0.1%), and Western and Central Europe (0.2%).381 The worst-affected European countries, in 2009 and 2012 estimates, are Russia, Ukraine, Latvia, Moldova, Portugal and Belarus, in decreasing order of prevalence.382

Groups at higher risk of acquiring HIV include persons who engage in transactional sex, gay men and other men who have sex with men, persons who inject drugs, transgender persons, and those who are incarcerated or detained.383

History

Main article: History of HIV/AIDS

For a chronological guide, see Timeline of HIV/AIDS.

Further information: Category:HIV/AIDS by country

Discovery

The first news story on the disease appeared on May 18, 1981, in the gay newspaper New York Native.384385 AIDS was first clinically reported on June 5, 1981, with five cases in the United States.386387 The initial cases were a cluster of injecting drug users and gay men with no known cause of impaired immunity who showed symptoms of Pneumocystis carinii pneumonia (PCP), a rare opportunistic infection that was known to occur in people with very compromised immune systems.388 Soon thereafter, a large number of homosexual men developed a generally rare skin cancer called Kaposi's sarcoma (KS).389390 Many more cases of PCP and KS emerged, alerting U.S. Centers for Disease Control and Prevention (CDC) and a CDC task force was formed to monitor the outbreak.391

In the early days, the CDC did not have an official name for the disease, often referring to it by way of diseases associated with it, such as lymphadenopathy, the disease after which the discoverers of HIV originally named the virus.392393 They also used Kaposi's sarcoma and opportunistic infections, the name by which a task force had been set up in 1981.394 At one point the CDC referred to it as the "4H disease", as the syndrome seemed to affect heroin users, homosexuals, hemophiliacs, and Haitians.395396 The term GRID, which stood for gay-related immune deficiency, had also been coined.397 However, after determining that AIDS was not isolated to the gay community,398 it was realized that the term GRID was misleading, and the term AIDS was introduced at a meeting in July 1982.399 By September 1982 the CDC started referring to the disease as AIDS.400

In 1983, two separate research groups led by Robert Gallo and Luc Montagnier declared that a novel retrovirus may have been infecting people with AIDS, and published their findings in the same issue of the journal Science.401402 Gallo claimed a virus which his group had isolated from a person with AIDS was strikingly similar in shape to other human T-lymphotropic viruses (HTLVs) that his group had been the first to isolate. Gallo's group called their newly isolated virus HTLV-III. At the same time, Montagnier's group isolated a virus from a person presenting with swelling of the lymph nodes of the neck and physical weakness, two characteristic symptoms of AIDS. Contradicting the report from Gallo's group, Montagnier and his colleagues showed that core proteins of this virus were immunologically different from those of HTLV-I. Montagnier's group named their isolated virus lymphadenopathy-associated virus (LAV).403 As these two viruses turned out to be the same, in 1986, LAV and HTLV-III were renamed HIV.404

Origins

The origin of HIV / AIDS and the circumstances that led to its emergence remain unsolved.405

Both HIV-1 and HIV-2 are believed to have originated in non-human primates in West-central Africa and were transferred to humans in the early 20th century.406 HIV-1 appears to have originated in southern Cameroon through the evolution of SIV(cpz), a simian immunodeficiency virus (SIV) that infects wild chimpanzees (HIV-1 descends from the SIVcpz endemic in the chimpanzee subspecies Pan troglodytes troglodytes).407408 The closest relative of HIV-2 is SIV (smm), a virus of the sooty mangabey (Cercocebus atys atys), an Old World monkey living in coastal West Africa (from southern Senegal to western Ivory Coast).409 New World monkeys such as the owl monkey are resistant to HIV-1 infection, possibly because of a genomic fusion of two viral resistance genes.410 HIV-1 is thought to have jumped the species barrier on at least three separate occasions, giving rise to the three groups of the virus, M, N, and O.411

There is evidence that humans who participate in bushmeat activities, either as hunters or as bushmeat vendors, commonly acquire SIV.412 However, SIV is a weak virus which is typically suppressed by the human immune system within weeks of infection. It is thought that several transmissions of the virus from individual to individual in quick succession are necessary to allow it enough time to mutate into HIV.413 Furthermore, due to its relatively low person-to-person transmission rate, SIV can only spread throughout the population in the presence of one or more high-risk transmission channels, which are thought to have been absent in Africa before the 20th century.414

Specific proposed high-risk transmission channels, allowing the virus to adapt to humans and spread throughout society, depend on the proposed timing of the animal-to-human crossing. Genetic studies of the virus suggest that the most recent common ancestor of the HIV-1 M group dates back to c. 1910.415 Proponents of this dating link the HIV epidemic with the emergence of colonialism and growth of large colonial African cities, leading to social changes, including a higher degree of sexual promiscuity, the spread of prostitution, and the accompanying high frequency of genital ulcer diseases (such as syphilis) in nascent colonial cities.416 While transmission rates of HIV during vaginal intercourse are low under regular circumstances, they are increased manyfold if one of the partners has a sexually transmitted infection causing genital ulcers. Early 1900s colonial cities were notable for their high prevalence of prostitution and genital ulcers, to the degree that, as of 1928, as many as 45% of female residents of eastern Kinshasa were thought to have been prostitutes, and, as of 1933, around 15% of all residents of the same city had syphilis.417

An alternative view holds that unsafe medical practices in Africa after World War II, such as unsterile reuse of single-use syringes during mass vaccination, antibiotic and anti-malaria treatment campaigns, were the initial vector that allowed the virus to adapt to humans and spread.418419420

The earliest well-documented case of HIV in a human dates back to 1959 in the Congo.421 The virus may have been present in the U.S. as early as the mid-to-late 1950s. A 16-year-old male named Robert Rayford presented with symptoms in 1966 and died in 1969. In the 1970s, there were cases of people getting parasites and becoming sick with what was then called "gay bowel disease" but is now suspected to have been AIDS.422

The earliest retrospectively described case of AIDS is believed to have been in Norway beginning in 1966, that of Arvid Noe.423 In July 1960, in the wake of Congo's independence, the United Nations recruited Francophone experts and technicians from all over the world to assist in filling administrative gaps left by Belgium, who did not leave behind an African elite to run the country. By 1962, Haitians made up the second-largest group of well-educated experts (out of the 48 national groups recruited), that totaled around 4,500 in the country.424425 Dr. Jacques Pépin, a Canadian author of The Origins of AIDS, stipulates that Haiti was one of HIV's entry points to the U.S. and that a Haitian may have carried HIV back across the Atlantic in the 1960s.426 Although there was known to have been at least one case of AIDS in the U.S. from 1966,427 the vast majority of infections occurring outside sub-Saharan Africa (including the U.S.) can be traced back to a single unknown individual who became infected with HIV in Haiti and brought the infection to the U.S. at some time around 1969.428 The epidemic rapidly spread among high-risk groups (initially, sexually promiscuous men who have sex with men). By 1978, the prevalence of HIV-1 among gay male residents of New York City and San Francisco was estimated at 5%, suggesting that several thousand individuals in the country had been infected.429

Society and culture

Stigma

Main article: Discrimination against people with HIV/AIDS

AIDS stigma exists around the world in a variety of ways, including ostracism, rejection, discrimination and avoidance of HIV-infected people; compulsory HIV testing without prior consent or protection of confidentiality; violence against HIV-infected individuals or people who are perceived to be infected with HIV; and the quarantine of HIV-infected individuals.430 Stigma-related violence or the fear of violence prevents many people from seeking HIV testing, returning for their results, or securing treatment, possibly turning what could be a manageable chronic illness into a death sentence and perpetuating the spread of HIV.431

AIDS stigma has been further divided into the following three categories:

  • Instrumental AIDS stigma—a reflection of the fear and apprehension that are likely to be associated with any deadly and transmissible illness.432
  • Symbolic AIDS stigma—the use of HIV/AIDS to express attitudes toward the social groups or lifestyles perceived to be associated with the disease.433
  • Courtesy AIDS stigma—stigmatization of people connected to the issue of HIV/AIDS or HIV-positive people.434

Often, AIDS stigma is expressed in conjunction with one or more other stigmas, particularly those associated with homosexuality, bisexuality, promiscuity, prostitution, and intravenous drug use.435

In many developed countries, there is an association between AIDS and homosexuality or bisexuality, and this association is correlated with higher levels of sexual prejudice, such as anti-homosexual or anti-bisexual attitudes.436 There is also a perceived association between AIDS and all male-male sexual behavior, including sex between uninfected men.437 However, the dominant mode of spread worldwide for HIV remains heterosexual transmission.438

The NAMES Project AIDS Memorial Quilt was conceived in 1985 to celebrate the lives of those who had died of AIDS when stigma prevented many from receiving funerals. It is now cared for by the National AIDS Memorial in San Francisco.

In 2003, as part of an overall reform of marriage and population legislation, it became legal for those diagnosed with AIDS to marry in China.439

Between 2004 and 2020, Somen Debnath has travelled the world by bicycle promoting HIV / AIDS awareness.

In 2013, the U.S. National Library of Medicine developed a traveling exhibition titled Surviving and Thriving: AIDS, Politics, and Culture;440 this covered medical research, the U.S. government's response, and personal stories from people with AIDS, caregivers, and activists.441

Stigma has proved an obstacle to the update of PrEP. Within the MSM community, the greatest barrier to PrEP use has been the stigma surrounding HIV and gay men. Gay men on PrEP have experienced "slut-shaming".442443 Numerous other barriers have been identified, including lack of quality LGBTQ care, cost, and adherence to medication use.444

Economic impact

Main articles: Economic impact of HIV/AIDS and Cost of HIV treatment

HIV/AIDS affects the economics of both individuals and countries.445 The gross domestic product of the most affected countries has decreased due to the lack of human capital.446447 Without proper nutrition, health care and medicine, large numbers of people die from AIDS-related complications. Before death they will not only be unable to work, but will also require significant medical care. It is estimated that as of 2007 there were 12 million AIDS orphans.448 Many are cared for by elderly grandparents.449

Returning to work after beginning treatment for HIV/AIDS is difficult, and affected people often work less than the average worker. Unemployment in people with HIV/AIDS also is associated with suicidal ideation, memory problems, and social isolation. Employment increases self-esteem, sense of dignity, confidence, and quality of life for people with HIV/AIDS. Anti-retroviral treatment may help people with HIV/AIDS work more, and may increase the chance that a person with HIV/AIDS will be employed (low-quality evidence).450

By affecting mainly young adults, AIDS reduces the taxable population, in turn reducing the resources available for public expenditures such as education and health services not related to AIDS, resulting in increasing pressure on the state's finances and slower growth of the economy. This causes a slower growth of the tax base, an effect that is reinforced if there are growing expenditures on treating the sick, training (to replace sick workers), sick pay, and caring for AIDS orphans. This is especially true if the sharp increase in adult mortality shifts the responsibility from the family to the government in caring for these orphans.451

At the household level, AIDS causes both loss of income and increased spending on healthcare. A study in Côte d'Ivoire showed that households having a person with HIV/AIDS spent twice as much on medical expenses as other households. This additional expenditure also leaves less income to spend on education and other personal or family investment.452

Religion and AIDS

Main article: Religion and HIV/AIDS

The topic of religion and AIDS has become highly controversial, primarily because some religious authorities have publicly declared their opposition to the use of condoms.453454 The religious approach to prevent the spread of AIDS, according to a report by American health expert Matthew Hanley titled The Catholic Church and the Global AIDS Crisis, argues that cultural changes are needed, including a re-emphasis on fidelity within marriage and sexual abstinence outside of it.455

Some religious organizations have claimed that prayer can cure HIV/AIDS. In 2011, the BBC reported that some churches in London were claiming that prayer would cure AIDS, and the Hackney-based Centre for the Study of Sexual Health and HIV reported that several people stopped taking their medication, sometimes on the direct advice of their pastor, leading to many deaths.456 The Synagogue Church Of All Nations advertised an "anointing water" to promote God's healing, although the group denies advising people to stop taking medication.457

Media portrayal

Main article: Media portrayal of HIV/AIDS

One of the first high-profile cases of AIDS was the American gay actor Rock Hudson. He had been diagnosed during 1984, announced that he had had the virus on July 25, 1985, and died a few months later on October 2, 1985.458 Another notable British casualty of AIDS that year was Nicholas Eden, a gay politician and son of former prime minister Anthony Eden.459 On November 24, 1991, British rock star Freddie Mercury died from an AIDS-related illness, having revealed the diagnosis only on the previous day.460

One of the first high-profile heterosexual cases of the virus was American tennis player Arthur Ashe. He was diagnosed as HIV-positive on August 31, 1988, having contracted the virus from blood transfusions during heart surgery earlier in the 1980s. Further tests within 24 hours of the initial diagnosis revealed that Ashe had AIDS, but he did not tell the public about his diagnosis until April 1992.461 He died as a result on February 6, 1993, aged 49.462

Therese Frare's photograph of gay activist David Kirby, as he lay dying from AIDS while surrounded by family, was taken in April 1990. Life magazine said the photo became the one image "most powerfully identified with the HIV/AIDS epidemic." The photo was displayed in Life, was the winner of the World Press Photo, and acquired worldwide notoriety after being used in a United Colors of Benetton advertising campaign in 1992.463

Many famous artists and AIDS activists such as Larry Kramer, Diamanda Galás and Rosa von Praunheim464 campaign for AIDS education and the rights of those affected. These artists worked with various media formats.

Criminal transmission

Main article: Criminal transmission of HIV

Criminal transmission of HIV is the intentional or reckless infection of a person with the human immunodeficiency virus (HIV). Some countries or jurisdictions, including some areas of the United States, have laws that criminalize HIV transmission or exposure.465 Others may charge the accused under laws enacted before the HIV pandemic.

In 1996, Ugandan-born Canadian Johnson Aziga was diagnosed with HIV; he subsequently had unprotected sex with eleven women without disclosing his diagnosis. By 2003, seven had contracted HIV; two died from complications related to AIDS.466467 Aziga was convicted of first-degree murder and sentenced to life imprisonment.468

Misconceptions

Main articles: Misconceptions about HIV/AIDS and Discredited HIV/AIDS origins theories

There are many misconceptions about HIV and AIDS. Three misconceptions are that AIDS can spread through casual contact, that sexual intercourse with a virgin will cure AIDS,469470471 and that HIV can infect only gay men and drug users.472473 In 2014, some among the British public wrongly thought one could get HIV from kissing (16%), sharing a glass (5%), spitting (16%), a public toilet seat (4%), and coughing or sneezing (5%).474 Other misconceptions are that any act of anal intercourse between two uninfected gay men can lead to HIV infection, and that open discussion of HIV and homosexuality in schools will lead to increased rates of AIDS.475

A small group of individuals continue to dispute the connection between HIV and AIDS,476 the existence of HIV itself, or the validity of HIV testing and treatment methods.477478 These claims, known as AIDS denialism, have been examined and rejected by the scientific community.479 However, they have had a significant political impact, particularly in South Africa, where the government's official embrace of AIDS denialism (1999–2005) was responsible for its ineffective response to that country's AIDS epidemic, and has been blamed for hundreds of thousands of avoidable deaths and HIV infections.480481482

Several discredited conspiracy theories have held that HIV was created by scientists, either inadvertently or deliberately. Operation INFEKTION was a worldwide Soviet active measures operation to spread the claim that the United States had created HIV/AIDS. Surveys show that a significant number of people believed—and continue to believe—in such claims.483

Research

Main article: HIV/AIDS research

HIV/AIDS research includes all medical research which attempts to prevent, treat, or cure HIV/AIDS, along with fundamental research about the nature of HIV as an infectious agent, and about AIDS as the disease caused by HIV.

Many governments and research institutions participate in HIV/AIDS research. This research includes behavioral health interventions such as sex education, and drug development, such as research into microbicides for sexually transmitted diseases, HIV vaccines, and antiretroviral drugs. Other medical research areas include the topics of pre-exposure prophylaxis, post-exposure prophylaxis, and circumcision and HIV. Public health officials, researchers, and programs can gain a more comprehensive picture of the barriers they face, and the efficacy of current approaches to HIV treatment and prevention, by tracking standard HIV indicators.484 Use of common indicators is an increasing focus of development organizations and researchers.485486

Notes

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