The global epidemic of Acquired immunodeficiency syndrome is one of the sad facts of life in the twenty-first century. According to a report issued by UNAIDS, the worldwide Acquired immunodeficiency syndrome program of the United Nations, at the end of 2001 about 40 million people worldwide were infected with this incurable viral disease, including 800,000-900,000 in this country. Every day, 14,000 more people worldwide are infected. Since the epidemic began, about 22 million people, including 448,000 in the United States, have died of human immunodeficiency virus infections.

Although no cure for human immunodeficiency virus / acquired immunodeficiency syndrome has been found, physicians today have better weapons for combating it, including combinations of antiviral medications that prolong life and delay onset of the most devastating stage of the disease. Because of these therapies, human immunodeficiency virus / acquired immunodeficiency syndrome has dropped from first to fifth place (behind accidents) as the leading killer of people between the ages of 25 and 44, though it is still the leading cause of death among black men in that age group. The Centers for Disease Control and Prevention reports that during the years 1995-1999, the number of deaths declined 67 percent. However, the number of new cases among women is increasing, and in 2000 women accounted for 30 percent of new cases of human immunodeficiency virus infection. African American and Hispanic women constituted 80 percent of these cases reported in women.

Despite the fact that Acquired immunodeficiency syndrome is preventable, the two types of high-risk behavior that account for its transmission — sexual activity and intravenous drug use — are extremely difficult to change. Sexual activity is powerfully motivated, and intravenous drug use leads to addiction and thus loss of control. But education and understanding have, at least in this country, been able to slow the spread of HIV / AIDS

What causes acquired immunodeficiency syndrome?

Acquired immunodeficiency syndrome is the final stage of infection by human immunodeficiency virus, the human immunodeficiency virus. This virus, which is transmitted through bodily fluids, attacks T-lymphocytes, the white blood cells whose job is to fight off infection. In particular, the virus kills off a subspecies of these T-cells called CD4 cells, which have a concentration of about 1,000 per cu mm of blood in healthy people; in some individuals with Acquired immunodeficiency syndrome, the concentration drops well below 200 per cu mm. As the virus gradually impairs the immune system by killing off CD4 cells, the body falls prey to infections that normally it could easily ward off.

As more has been learned, epidemiologists at the Centers for Disease Control and Prevention have refined the definition of the disease. People who have the less severe infections that usually precede the onset of full-blown Acquired immunodeficiency syndrome are said to have human immunodeficiency virus, human immunodeficiency virus disease, or ARC (an older term, less widely used today, that stands for Acquired immunodeficiency syndrome-related complex). Nowadays the acronym HIV / AIDS is used to describe the whole process of the disease.

What are the symptoms of HIV / AIDS?

Before fully developed Acquired immunodeficiency syndrome appears, the disease exhibits a number of warning symptoms that include chronic fever, extreme fatigue, unintended weight loss, night sweats, fungus infections (including recurrent yeast infections in the vagina or mouth), swollen lymph glands, and diarrhea.

All these common symptoms can be caused by many different diseases and do not usually indicate an human immunodeficiency virus infection. Many women have yeast infections at one time or another; we all experience fatigue; night sweats can be a sign of other diseases or even of approaching menopause. The difference is usually one of degree: we are all prone to fatigue, but the kind of fatigue associated with Acquired immunodeficiency syndrome is truly debilitating and goes on and on, regardless of whether you get adequate rest.

How long does it take the symptoms to appear?

The human immunodeficiency virus virus may lie dormant for years before any symptoms appear. The average time between infection and appearance of the first definitive symptoms is about ten years, though men seem to show symptoms more quickly than women.

Are there symptoms specific to women?

HIV / AIDS can cause gynecological problems or it can make existing problems difficult to treat. Recurrent vaginal yeast infections that resist treatment can be a sign of human immunodeficiency virus / acquired immunodeficiency syndrome, as can abnormal Pap smears and pelvic inflammatory disease (pelvic inflammatory disease). Women with human immunodeficiency virus/ Acquired immunodeficiency syndrome are at increased risk for infection by the human papilloma virus (human papilloma virus), which causes genital warts. Some strains of human papilloma virus have been associated with cervical abnormalities and cervical cancer.

How is HIV / AIDS spread?

Although the human immunodeficiency virus virus can be found in most body fluids of infected people (blood, semen, vaginal secretions, tears, breast milk, saliva), it is relatively difficult to spread: the fluid of an infected person must enter the body of someone who is not infected, usually through a cut or break in the skin or mucous membranes.

HIV / AIDS can be spread by sexual contact, including vaginal and anal intercourse. If your vagina or external genitals have abrasions, sores, or other breaks in the mucous membranes, your risk is greatly increased. If you have another sexually transmitted disease, such as gonorrhea, syphilis, herpes, or chlamydia, you are at greater risk for human immunodeficiency virus. It is estimated that about two thirds of the people who have human immunodeficiency virus / acquired immunodeficiency syndrome in this country got it during sexual intercourse with an infected partner. It can be spread from male to male, from male to female, from female to male, and (in theory at least) from female to female.

It can be transmitted through infected needles. Drug users who share needles are at extremely high risk. There have been cases of medical workers being infected through needle pricks from infected patients.

HIV / AIDS can be spread through blood transfusions. In the early years of the epidemic, before the nature of transmission was understood, a number of hemophiliacs, who receive routine blood transfusions, were infected, as were hundreds of people who received transfusions during surgical procedures. Since 1985 all donated blood in the United States has been screened for human immunodeficiency virus. The disease can also be spread through artificial insemination, if the donor sperm is infected. All reliable sperm banks, like blood banks, currently screen for human immunodeficiency virus, so this is a remote possibility.

The disease can be spread from a pregnant mother to her child, either during pregnancy or during labor and delivery. It can even be spread from mother to child during breast-feeding, though this is rare.

HIV / AIDS cannot be spread by casual contact, for example, by shaking hands, hugging, sharing eating utensils, or telephones. It cannot be spread through exposure to the sweat or tears of an infected person. It cannot be spread through swimming pools in which infected people have swum or through water fountains. It cannot be transmitted through the bites of mosquitoes, ticks, or other insects.

As with many other viruses, people are contagious when recently infected, even before they have symptoms.

Who is at risk for HIV / AIDS?

Most people who have human immunodeficiency virus or Acquired immunodeficiency syndrome got it either by having unprotected sex with an infected partner or by sharing a hypodermic needle with an infected person. Anyone who engages in these activities is at high risk.

Are women as much at risk as men?

When human immunodeficiency virus / acquired immunodeficiency syndrome first appeared in this country around 1981, it was thought to be a disease that targeted gay males, so during the early 1980s it was sometimes called GRIDS (gay-related immunodeficiency syndrome). This name suggested that women might not be at risk, an assumption that has turned out to be utterly false. As the gay community developed strategies for dealing with human immunodeficiency virus / acquired immunodeficiency syndrome, the epidemic shifted its focus to intravenous drug users and their sex partners, so today transmission increasingly takes place through heterosexual sex.

HIV / AIDS, like other sexually transmitted diseases, is blind to gender and sexual orientation. In 1981 there were 6 reported cases in women. Five years later, 2,000 women had the disease. By 1993, there were 40,000 infected women. The most recent figures (2001 report) from the Centers for Disease Control and Prevention suggest that between 800,000 and 900,000 people in the United States now live with human immunodeficiency virus. Thirty percent of the 40,000 people who are newly infected with human immunodeficiency virus each year are women. In Africa, where the epidemic has spread more widely than in the United States, heterosexual contact is the principal means of transmission; men and women are equally affected. Although the impact of the epidemic in the United States is greatest among men who have sex with men, and among racial and ethnic minorities, the number of cases among women and those transmitted by heterosexual activity has increased.

In several ways women are more at risk than men. First of all, more men are infected than women, at least right now in the United States. Therefore women have a greater chance statistically of selecting an infected partner. Second, the female anatomy puts women at increased risk. Seminal fluid, which contains more virus than vaginal fluids do, stays within the female genital tract for hours, giving the virus more time to infect its target cells. Furthermore, the vagina provides more surface area for infected fluids than does the male urethra. Women who have an sexually transmitted disease, such as gonorrhea or chlamydia, are even more vulnerable to human immunodeficiency virus infection, since inflamed cells become prime targets for the virus.

How can you decrease your risk?

Knowing how human immunodeficiency virus / acquired immunodeficiency syndrome is spread is the start of an effective defense. Abstinence from sexual intercourse is, of course, the perfect preventive. Unless you are absolutely and totally certain that you and your sexual partner are 100 percent monogamous, practicing safe sex each and every time you have intercourse can reduce risk. Remember that in terms of human immunodeficiency virus susceptibility, when you have intercourse you are exposed to everyone your partner has been exposed to. You may be monogamous; but if your partner has casual sex, it is the same in terms of human immunodeficiency virus risk as having casual sex yourself.

The Centers for Disease Control and Prevention recommends that when women are receiving oral sex they use a”dam” (also called a dental dam, or a mouth dam). This device is a thin plastic sheet similar to plastic wrap placed over the woman’s genital area. A dental dam can also be made from a latex condom, by snipping off the reservoir tip and making a lengthwise cut to open the tubular part of the condom into a flat sheet.

As far as human immunodeficiency virus is concerned, safe sex means using a latex condom and preferably a spermicide as well. People who use intravenous drugs should not share needles with anyone.

Are condoms totally safe in protecting against HIV / AIDS?

Nothing, short of total sexual abstinence, is 100 percent safe. But condoms are the most effective means we have in preventing the spread of human immunodeficiency virus / acquired immunodeficiency syndrome and other sexually transmitted diseases.

Choose condoms made of latex, which has been shown to prevent the passage of the human immunodeficiency virus virus, the herpes virus, and the microorganisms that cause other sexually transmitted diseases. “Natural” lambskin condoms do not offer this degree of protection. The package in which the condoms are sold should state that they prevent sexually transmitted diseases; condoms bearing this message have passed tests required by the FDA. The condom should unroll to cover the entire penis.

Are condoms safe for use during anal intercourse?

The Surgeon General, who conveys official U.S. public health policy, has said that “condoms do provide some protection, but anal intercourse is simply too dangerous a practice.” Condoms maybe more likely to break during this type of intercourse because of the greater friction, though using a lubricant may help.

Will you be better protected using a spermicide along with a condom?

In laboratory experiments the spermicide nonoxynol-9 has been shown to kill the organisms that cause other sexually transmitted diseases; researchers believe it may kill the human immunodeficiency virus virus as well. So it is wise to use a spermicide as an added precaution along with a condom, but do not rely on the spermicide alone. Spermicides come packaged with an expiration date; do not use products whose expiration date has passed. Spermicidal creams are not as effective as we once thought, but they still are better than nothing.

Is one type of unprotected sex riskier than another?

No accurate statistics are available on the relative risk, but probably anal sex is the riskiest, in that the tissues of the rectum are thinner and more delicate than those of the vagina. Oral sex is probably not riskier than vaginal sex, but the problem is that many people do not use condoms with oral sex and find dental dams unpleasant.

How is human immunodeficiency virus / acquired immunodeficiency syndrome diagnosed?

human immunodeficiency virus is diagnosed by a two-step blood test, which is reliable and relatively inexpensive. The first step, called the Elisa (enzyme-linked immunosorbent asssay), looks for the presence of human immunodeficiency virus antibodies in the blood. When a virus enters the body, the immune system responds by making antibodies to that particular virus. Some antibodies protect from disease, but the antibodies produced by human immunodeficiency virus do not. Nor do they prevent the infected person from spreading the disease. If the test shows that these antibodies are present, the laboratory technicians proceed to step two, the Western blot test, which confirms the diagnosis. Because of the social, psychological, and medical impact of a positive diagnosis, all human immunodeficiency virus/ Acquired immunodeficiency syndrome testing programs should include counseling.

If you have unprotected sex with someone whose history you don’t know, can you take any preventive measures before you become HIV positive?

You can certainly request that your partner have an emergency human immunodeficiency virus test. If his test is positive, you can try prophylactic medications. This human immunodeficiency virus testing can be done within one or two days, and you can get the results a day or two later.

AZT, which is used to treat human immunodeficiency virus, can also be used to help prevent it. As a preventive treatment, it works best immediately after exposure, so if you have had intercourse with a high-risk person, consult your physician or the Centers for Disease Control and Prevention national Acquired immunodeficiency syndrome hotline: (800) 342-Acquired immunodeficiency syndrome. The preventive drugs are reasonably effective but have significant side effects, just like the drugs used to treat HIV / AIDS. Of course, if your partner was recently infected with human immunodeficiency virus, the test will not show it; unless your partner is retested a few months later, you will not accurately know his or her status.

If you thinkyou have been exposed to human immunodeficiency virus, should you get tested?

Yes, and for very good reasons. If you find that you are infected with human immunodeficiency virus, prompt medical care can delay the onset of serious symptoms. You can avoid infecting others. If you are thinking about becoming pregnant, you will want to consider the possibility of infecting a child.

Some people cope better with knowing than with not knowing. For others, the stress of knowing that they are infected is far worse. They fear that their test results will become public without their permission, and that if the results are known, they will be discriminated against. Even if you decide against testing, you should act to prevent spreading possible human immunodeficiency virus to your sex partners.

If you think you have been exposed to HIV, how long should you wait before being tested?

Most people who have been infected with human immunodeficiency virus produce antibodies within three months. If you were tested shortly after you were exposed and your test is negative, you should have a second test about three months later. Researchers believe that more than 99 percent of infected people will test positive after six months.

Is the test always accurate?

Only rarely does the test give a false positive, saying that you have been exposed to human immunodeficiency virus when you have not. But if you are tested too soon, the test may register a false negative, saying that you are not infected when in fact you are. This is why is it wise to wait three months before being tested. Sometimes a woman calls me in a panic; she had unprotected sex the night before and is concerned about human immunodeficiency virus. I counsel waiting: even though those three months will be difficult and anxious, the test results will be accurate.

How much does HIV / AIDS testing cost?

human immunodeficiency virus / acquired immunodeficiency syndrome testing costs forty to fifty dollars in a commercial lab. Most insurance companies will cover the cost, but will then know your results. Although your insurance company cannot legally drop you as a client because you are human immunodeficiency virus positive, it may be worth the fifty dollars to maintain your privacy.

Can you control who knows the results of your test?

If there is a reasonable chance your test will be positive, you can have it performed anonymously. Ask your doctor to give you a blood slip giving you a fictitious name or just a number. When you get to the lab, pay with cash, not a credit card or check. Most doctors will cooperate in this respect; if yours will not, find one who will.

If you cannot afford to have the testing done through a commercial lab, try your city or state health department. Most states have human immunodeficiency virus / acquired immunodeficiency syndrome testing and counseling programs, and most of these programs are either confidential or anonymous. The costs are low, usually five to ten dollars.

What is the difference between confidential and anonymous testing?

At the testing center, someone will record your name with the result of your test. The center will keep this record from anyone except medical personnel and the state health department (which does not keep your name, but merely records the number of cases).

Before you are tested, ask who will know the result of your test and how the test result will be stored. If you are comfortable with the confidentiality of what you are told, go ahead with your test; if you are not, go elsewhere.

With anonymous testing, no one knows your name and you are the only person who can tell anyone else the result of your test. Not all states or cities offer anonymous testing.

Where can you go for testing and counseling?

Your options, which depend on where you live and your financial resources, may include your doctor’s office, publicly funded state or local human immunodeficiency virus testing and counseling centers, hospital clinics, family planning clinics, and some drug treatment facilities. When you are tested, you should also receive counseling, and many testing centers offer it. If you cannot find a facility near you, call the Centers for Disease Control and Prevention national Acquired immunodeficiency syndrome hotline: 1-800-342-Acquired immunodeficiency syndrome.

What kind of counseling do testing centers offer?

Each testing center may have its own procedure for counseling people who come in for human immunodeficiency virus tests, but in general the counseling has two main purposes. The first is to make people aware of the need for safe sex. If you are fortunate and your test shows you have not been infected with human immunodeficiency virus, you should take advantage of this “second chance.” If your test is positive, you need to practice safe sex to protect your partner or partners. If you are considering becoming pregnant at some time in the near or distant future, you should know the implications for your pregnancy and your baby of being human immunodeficiency virus positive. If you seek treatment early in your pregnancy, you can drastically reduce the chances that your baby will be human immunodeficiency virus positive.

The second purpose of counseling is to let you know that having a positive human immunodeficiency virus test is not synonymous with having Acquired immunodeficiency syndrome. Today’s medications can allow people with human immunodeficiency virus to live many healthy years after they have been infected.

How is HIV / AIDS treated?

Medical researchers have not only developed new, potent drugs for fighting HIV / AIDS, but they have found more effective ways to use the drugs already available. The first drugs used against human immunodeficiency virus were antivirals, the best known of which is zidovudine (trade names AZT and Retrovir), approved by the FDA in 1987. Others include didanosine (trade names ddl and Videx), stavudine (d4T and Zerit), and zalcitabine (ddC and Hivid). All these drugs prevent the human immunodeficiency virus virus from multiplying rapidly by inhibiting the production of an human immunodeficiency virus enzyme called reverse transcriptase.

In 1995 researchers developed a new class of antiviral drugs called protease inhibitors, which target an human immunodeficiency virus enzyme called protease, needed by the human immunodeficiency virus virus to manufacture certain proteins. Protease inhibitors include drugs like saquinavir, indinavir, and ritonavir. Their use together with other antiviral drugs resulted in so-called combination therapies

that lowered the mortality rate for Acquired immunodeficiency syndrome about 75 percent between 1995 and 1997. All these powerful antivirals have significant side effects, which can include anemia, damage to nerves (especially numbness of the feet), headaches, fever, inflammation of the pancreas, and liver damage.

Other drugs used to treat human immunodeficiency virus include medications that attempt to strengthen the ability of the immune system to fight off the virus, and drugs that treat the opportunistic infections that attack the body when the immune system is weakened.

Are women with HIV / AIDS less responsive to treatment than men?

When human immunodeficiency virus / acquired immunodeficiency syndrome was first recognized in women, studies showed that in general women did not live as long after diagnosis as men did. The reason for their shorter survival seemed to be that women were diagnosed later in the course of the disease, partly because those who had human immunodeficiency virus / acquired immunodeficiency syndrome were often poor and unlikely to seek timely medical treatment. Second, women were less likely to get an accurate early diagnosis, because in the early 1980s women were not thought to be especially at risk and often were not tested for human immunodeficiency virus.

Now it appears that treatments for women and for men are equally effective; women who receive prompt treatment have the same life span as men who receive similar treatment.

What about pregnancy and human immunodeficiency virus / acquired immunodeficiency syndrome?

Many questions about pregnancy and human immunodeficiency virus remain unanswered. No one knows for certain whether becoming pregnant adds to the health risk of women who are infected with human immunodeficiency virus. The consequences of having a baby infected with human immunodeficiency virus are so serious that any woman with human immunodeficiency virus who becomes pregnant should consult her physician. Without treatment, about 30 percent of infants born to infected mothers will be infected at birth. However, the risk of having an infected child can be reduced to about 8 percent if the mother takes the antiviral drug AZT during pregnancy. Studies have suggested that AZT does not cause premature labor and delivery, fetal distress, or fetal malformations.

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