AIDS stands for Acquired Immuno-Deficiency Syndrome and describes the collection of symptoms and infections associated with acquired deficiency of the immune system. Infection with HIV has been established as the underlying cause of AIDS. The level of immunodeficiency or the appearance of certain infections are used as indicators that HIV infection has progressed to AIDS.

• Stage 1 HIV disease is asymptomatic and not categorized as AIDS.
• Stage II (includes minor mucocutaneous manifestations and recurrent upper respiratory tract infections),
• Stage III (includes unexplained chronic diarrhoea for longer than a month, severe bacterial infections and pulmonary tuberculosis) or
• Stage IV (includes toxoplasmosis of the brain, candidiasis of the oesophagus, trachea, bronchi or lungs and Kaposi’s sarcoma) HIV disease are used as indicators of AIDS. Most of these conditions are opportunistic infections that can be treated easily in healthy people.

The length of time can vary widely between individuals. The time between infection with HIV and becoming ill with AIDS can be 10–15 years, sometimes longer, but sometimes shorter. Antiretroviral therapy can prevent progression to AIDS by decreasing viral load in an infected body.

HIV can be found in body fluids, such as blood, semen, vaginal fluids and breast milk.

HIV is transmitted through penetrative (anal or vaginal) sex, blood transfusion, the sharing of contaminated needles in health-care settings and drug injection and between mother and infant during pregnancy, childbirth and breastfeeding.

HIV can be transmitted through penetrative sex. HIV is not transmitted very efficiently so the risk of infection through a single act of vaginal sex is low. Transmission through anal sex has been reported to be 10 times higher than by vaginal sex. A person with an untreated sexually transmitted infection, particularly involving ulcers or discharge, is, on average, six to 10 times more likely to pass on or acquire HIV during sex. Oral sex is regarded as a low-risk sexual activity in terms of HIV transmission. When a person living with HIV is taking effective antiretroviral therapy and has a suppressed viral load they are no longer infectious. 

Re-using or sharing needles or syringes represents a highly efficient way of transmitting HIV. The risk of transmission can be lowered substantially among people who inject drugs by always using new needles and syringes that are disposable or by properly sterilizing reusable needles/syringes before reuse. Transmission in a health-care setting can be lowered by health-care workers adhering to universal precautions.

HIV can be transmitted to an infant during pregnancy, labour, delivery and breastfeeding. Generally, there is a 15–30% risk of transmission from mother to child before and during delivery. A number of factors influence the risk of infection, particularly the viral load of the mother at birth (the higher the load, the higher the risk). Transmission from mother to child after birth can also occur through breastfeeding. The chances of transmission of HIV to a child is very low if the mother is on antiretroviral therapy during pregnancy and when breastfeeding.

There is a high risk (greater than 90%) of acquiring HIV through transfusion of infected blood and blood products. However, the implementation of blood safety standards ensures the provision of safe, adequate and good-quality blood and blood products for all patients requiring transfusion. Blood safety includes screening of all donated blood for HIV and other blood-borne pathogens, as well as appropriate donor selection.

Transmission through kissing on the mouth carries no risk, and no evidence has been found that the virus is spread through saliva by kissing

A risk of HIV transmission does exist if contaminated instruments are either not sterilized or are shared with others. Instruments that are intended to penetrate the skin should be used once, then disposed of or thoroughly cleaned and sterilized.

Any kind of cut using an unsterilized object, such as a razor or knife, can transmit HIV. Sharing razors is not advisable unless they are fully sterilized after each use.

Having sex with someone living with HIV is safe if the person’s virus is fully suppressed by treatment. Sex is also safe if a condom is used properly or if you are taking pre-exposure prophylaxis in accordance with your health-care provider’s recommendations.

It is best for someone living with HIV to avoid becoming infected with a different strain of the virus. Therefore, the advice given in question 11 should be followed, except for the advice about pre-exposure prophylaxis, which is never used by people living with HIV.

Sexual transmission of HIV can be prevented by:

• Monogamous relations between uninfected partners.
• Non-penetrative sex.
• Consistent and correct use of male or female condoms
• Sex between two people when one of them is living with HIV but in taking antiretroviral therapy and has undetectable viral load
• Pre-exposure prophylaxis taken by people who are not infected with HIV.
• Voluntary Medical Male Circumcision reduces the chances of men acquiring HIV from women.

Additional ways of avoiding infection:

• If you are an injecting drug user, always use new needles and syringes that are disposable or needles and syringes that have been properly sterilized before reuse (see question 20)or opt for other prevention measures such as Opioid Substitution therapy.
• Ensure that blood and blood products are tested for HIV and that blood safety standards are implemented.

Safer sex involves taking precautions that decrease the potential of transmitting or acquiring sexually transmitted infections, including HIV, while having sex. Using condoms correctly and consistently during sex is considered safer sex, as is oral sex and non-penetrative sex or taking pre exposure prophylaxis if you are at risk of HIV infection or having undetectable viral load if you are living with HIV.

• Condoms with lubrication are less likely to tear during handling or use. Oil-based lubricants, such as Vaseline, should not be used, as they can damage the condom.
• Only open the package containing the condom when you are ready to use it. Otherwise, the condom will dry out. Be careful not to tear or damage the condom when you open the package. If it does get torn, throw it away and open a new package.
• Condoms come rolled up into a flat circle. Place the rolled-up condom, right side up, on the end of the penis. Hold the tip of the condom between your thumb and first finger to squeeze the air out of the tip. This leaves room for the semen to collect after ejaculation. Keep holding the top of the condom with one hand. With the other hand, unroll the condom all the way down the length of the erect penis to the pubic hair.
• If the condom is not lubricated enough, a water-based lubricant (such as silicone, glycerin or K-Y jelly) can be added. Lubricants made from oil—cooking oil or shortening, mineral or baby oil, petroleum jellies such as Vaseline and most lotions—should never be used because they can damage the condom.

After sex, the condom needs to be removed the right way.

• Right after the man ejaculates, he must hold onto the condom at the base, to be sure that the condom does not slip off.
• Then, the man must pull out while the penis is still erect.
• When the penis is completely withdrawn, remove the condom from the penis and throw away the condom. Do not flush it down the toilet.

If you are going to have sex again, use a new condom and repeat the whole process.

• A female condom is a female-controlled contraceptive barrier method. The female condom is a strong, soft, transparent polyurethane sheath inserted into the vagina before sexual intercourse. It entirely lines the vagina and, therefore, with correct and consistent use, provides protection against both pregnancy and many sexually transmitted infections, including HIV. The female condom has no known side-effects or risks and does not require a prescription or the intervention of a health-care provider.

• your vagina. You can insert the pouch up to eight hours before your have intercourse.
• Make sure that the condom is not twisted inside your vagina: if it is, remove it, add a drop or two of lubricant and re-insert. Note: about two centimetres of the open end of the condom will remain outside your body. If your partner inserts his penis underneath or alongside the pouch, ask him to withdraw immediately. Remove the condom, discard it and use a new pouch. Until you and your partner become familiar with the female condom, it will be helpful if you use your hand to guide his penis into your vagina.
• After your partner ejaculates and withdraws, squeeze and twist the open end of the pouch to keep the sperm inside. Pull out gently. Dispose of the used condom (but do not throw it down the toilet).
• The re-use of female condoms is not recommended

Post-exposure preventive (PEP) treatment consists of medication, laboratory tests and counselling. PEP treatment must be initiated within hours of possible HIV exposure and must continue for a period of approximately four weeks. Research studies suggest that, if the medication is initiated quickly after possible HIV exposure (ideally within two hours and not later than 72 hours following such exposure), it is beneficial in preventing HIV infection.

• For injecting drug users, certain steps can be taken to reduce personal and public health risks:

  • Take drugs orally (change from injecting to non-injecting drug use).
  • Never re-use or share syringes, water or drug-preparation equipment.
  • Use a new syringe (obtained from a reliable source, e.g. a chemist or via a needle–syringe programme) to prepare and inject drugs each time.
  • When preparing drugs, use sterile water or clean water from a reliable source.
  • Using a fresh alcohol swab, clean the injection site prior to injection.

There is no cure for HIV. However, there is effective treatment, which, if started promptly and taken regularly, results in a quality and length of life for someone living with HIV that is similar to that expected in the absence of infection.

Antiretroviral medicines are used in the treatment of HIV infection. They work against HIV infection by blocking the reproduction of HIV in the body (see question 4). When a person living with HIV is on effective antiretroviral therapy, they are no longer infectious.

Inside an infected cell, HIV produces new copies of itself, which can then go on to infect other healthy cells within the body. The more cells HIV infects, the greater its impact on the immune system (immunodeficiency). Antiretroviral medicines slow down the replication and, therefore, the spread of the virus within the body by interfering with its replication process in different ways.

Nucleoside reverse transcriptase inhibitors: HIV needs an enzyme called reverse transcriptase to generate new copies of itself. This group of medicines inhibits reverse transcriptase by preventing the process that replicates the virus’s genetic material.

Non-nucleoside reverse transcriptase inhibitors: this group of medicines also interferes with the replication of HIV by binding to the reverse transcriptase enzyme itself. This prevents the enzyme from working and stops the production of new virus particles in the infected cells.

Protease inhibitors: protease is a digestive enzyme that is needed in the replication of HIV to generate new virus particles. It breaks down proteins and enzymes in the infected cells, which can then go on to infect other cells. The protease inhibitors prevent this breakdown of proteins and therefore slows down the production of new virus particles.

Other medicines that inhibit other stages in the virus’s cycle (such as entry of the virus and fusion with an uninfected cell) are currently being tested in clinical trials.

The use of antiretroviral medicines in a combination of three medicines has been shown to dramatically reduce AIDS-related illness and death. While not a cure for AIDS, combination antiretroviral therapy has enabled people living with HIV to live longer, healthier, more productive lives by reducing viraemia (the amount of HIV in the blood) and increasing the number of CD4-positive cells (white blood cells that are central to the effective functioning of the immune system). 

For antiretroviral treatment to be effective for a long time, different antiretroviral medicines need to be combined. This is what is known as combination therapy. The term highly active antiretroviral therapy (HAART) is used to describe a combination of three or more anti-HIV medicines.

If one medicine is taken on its own, it has been found that, over a period of time, changes in the virus enable it to build up resistance to the medicine. The medicine is then no longer effective and the virus starts to reproduce to the same extent as before. If two or more antiretroviral medicines are taken together, the rate at which resistance develops can be reduced substantially.

Effective antiretroviral therapy also prevents the transmission of HIV. When a person living with HIV is taking effective antiretroviral therapy and has a suppressed viral load HIV can no longer be transmitted through sex. 

Antiretroviral medicines should only be taken as prescribed by a health-care professional.