ABC OF AIDS Edited by Michael W Adler Edited by Michael W Adler Fifth edition ABC OF AIDS Fifth Edition ABC OF AIDS Fifth Edition Edited by MICHAEL W ADLER Professor, Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, University College, London © BMJ Publishing Group 2001 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 1987 by the BMJ Publishing Group, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com First edition 1987 Second impression 1987 Third impression 1988 Fourth impression 1988 Fifth impression 1990 Second edition 1991 Third edition 1993 Fourth edition 1997 Sixth impression 1998 Seventh impression 2000 Fifth edition 2001 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0-7279-1503-7 Cover image: NIBSC/Science Photo Library. The image depicts AIDS virus. Coloured scanning electron micrograph of the surface of a T-lymphocyte (blue) infected with Human Immunodeficiency Virus (HIV). Cover design by Marritt Associates, Harrow, Middlesex Typeset by FiSH Books, London Printed and bound in Spain by Graphycems Contributors vi Preface viii 1 Development of the epidemic 1 Michael W Adler 2 The virus and the tests 6 PP Mortimer, C Loveday 3 Immunology of AIDS 12 Peter Beverley, Matthew Helbert 4 Natural history and management of early HIV infection 17 Adrian Mindel, Melinda Tenant-Flowers 5 Tumours in HIV 23 Caroline H Bridgewater, Margaret F Spittle 6 AIDS and the lung 30 Rob Miller 7 Gastrointestinal and hepatic manifestations 38 Ian McGowan, Ian VD Weller 8 Neurological manifestations 42 Hadi Manji 9 Treatment of infections and antiviral therapy 46 Ian VD Weller, IG Williams 10 HIV infection and AIDS in the developing world 59 Alison D Grant, Kevin M De Cock 11 Injection drug use-related HIV infection 65 RP Brettle 12 HIV infection in children 73 Gareth Tudor-Williams, Diana Gibb 13 HIV counselling and the psychosocial management of patients with HIV or AIDS 82 Sarah Chippindale, Lesley French 14 Palliative care and pain control in HIV and AIDS 86 Rob George, Chris Farnham, Louise Schofield 15 Control of infection policies 95 IJ Hart, Celia Aitken 16 Strategies for prevention 99 John Imrie, Anne M Johnson 17 Being HIV antibody positive 106 Jonathan Grimshaw 18 Having AIDS 108 Caroline Guinness Index 111 v Contents Michael W Adler Professor, Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, University College London, UK Celia Aitken Department of Virology, St Bartholomew’s and The Royal London, London, UK Peter Beverley The Edward Jenner Institute for Vaccine Research, Newbury, UK RP Brettle Consultant Physician, Regional Infectious Diseases Unit, Western General Hospital, Edinburgh; Reader in Medicine, University of Edinburgh, UK Caroline H Bridgewater Meyerstein Institute of Oncology, Middlesex Hospital, London, UK Sarah Chippindale Head of Health Adviser Services HIV/AIDS/GUM, Health Advisers Department, Mortimer Market Centre, London, UK Kevin M De Cock Director, CDC Kenya; Visiting Professor of Medicine and International Health, London School of Hygiene and Tropical Medicine, UK Chris Farnham Palliative Care Centre, Camden and Islington Community Trust and Royal Free and University College Medical School, University College London, UK Lesley French Clinical Psychologist, Camden and Islington CHSNHS Trust, London, UK Rob George Palliative Care Centre, Camden and Islington Community Trust and Royal Free and University College Medical School, University College London, UK Diana Gibb Senior Lecturer in Epidemiology/Consultant Paediatrician, Institute of Child Health, London, UK Alison D Grant Clinical Senior Lecturer, Clinical Research Unit, London School of Hygiene and Tropical Medicine, UK IJ Hart Department of Virology, St Bartholomew’s and The Royal London, UK Matthew Helbert Senior Lecturer, Department of Immunology, St Bartholomew’s Hospital, London, UK vi Contributors John Imrie Senior Research Fellow, Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, University College London, UK Anne M Johnson Professor of Epidemiology, Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, University College London, UK C Loveday Professor, Department of Retrovirology, Royal Free and University College Medical School, University College London, UK Hadi Manji Consultant Neurologist, National Hospital for Neurology and Neurosurgery and Ipswich Hospital, UK Ian McGowan Senior Director Clinical Science, Intrabiotics Pharmaceuticals, California, USA Rob Miller Reader in Clinical Infection, Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, University College London, UK Adrian Mindel Director of the Sexually Transmitted Infection Research Centre and Professor of Sexual Health Medicine, Westmead Hospital, Sydney, Australia PP Mortimer Consultant Virologist, Central Public Health Laboratory, Virus Reference Division, London, UK Louise Schofield Clinical Nurse Specialist, Palliative Care Centre,Camden and Islington Community Trust and Royal Free and University College Medical School, University College London, UK Margaret F Spittle Consultant Clinical Oncologist, Meyerstein Institute of Oncology, Middlesex Hospital, London, UK Melinda Tenant-Flowers Consulted Physician, Department of Sexual Health, The Caldecot Centre, King’s Healthcare NHS Trust, London, UK Gareth Tudor-Williams Senior Lecturer in Paediatric Infectious Diseases, Imperial College School of Medicine at St Mary’s, London, UK Ian VD Weller Professor, Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, University College, London, UK IG Williams Senior Lecturer, Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, University College, London, UK Contributors vii By December 2000 there were 17 538 adult and paediatric patients with AIDS in the UK and 43 774 screened and infected with HIV. Many of those with the virus are well, asymptomatic, and even unaware that they are infected, but others, although they have not yet developed AIDS, have physical, psychological, social, and occupational problems and require as much care as those with AIDS. We therefore need to be concerned not with “a few cases” but with a large number of people infected with the virus, who will be making demands on every part of the health and social services. New infections will occur, and the public health education campaign will need to continue. None of us should feel that the problem of HIV infection and AIDS is unimportant and that it will go away because of the campaign and the possible magic bullet of a cure or vaccine. We can all hope for these things but it would be a mistake to be lulled into a state of inertia and complacency. All of us will be concerned with AIDS for the rest of our professional lives. This book, originally written as weekly articles for the BMJ, attempts to give those doctors and other health care workers, who currently have had little experience of AIDS and HIV, some idea of the clinical, psychological, social and health education problems that they will become increasingly concerned with. Patients with HIV infection and AIDS spend most of their time out of hospital in the community. Admission is required only when an acute clinical illness supervenes. General practitioners and domiciliary and social services do not always feel skilled and knowledgeable enough to look after them. With the increase in the number of cases, the community services will have to be able and willing to cope. Again, I hope that this book will help to make people feel more skilled and comfortable about caring for patients with HIV and AIDS. This is the fifth edition of the ABC of AIDS; each chapter has been updated or rewritten. Michael W Adler viii Preface The first recognised cases of the acquired immune deficiency syndrome (AIDS) occurred in the summer of 1981 in America. Reports began to appear of Pneumocystis carinii pneumonia and Kaposi’s sarcoma in young men, who it was subsequently realised were both homosexual and immunocompromised. Even though the condition became known early on as AIDS, its cause and modes of transmission were not immediately obvious. The virus now known to cause AIDS in a proportion of those infected was discovered in 1983 and given various names. The internationally accepted term is now the human immunodeficiency virus (HIV). Subsequently a new variant has been isolated in patients with West African connections – HIV-2. The definition of AIDS has changed over the years as a result of an increasing appreciation of the wide spectrum of clinical manifestations of infection with HIV. Currently, AIDS is defined as an illness characterised by one or more indicator diseases. In the absence of another cause of immune deficiency and without laboratory evidence of HIV infection (if the patient has not been tested or the results are inconclusive), certain diseases when definitively diagnosed are indicative of AIDS. Also, regardless of the presence of other causes of immune deficiency, if there is laboratory evidence of HIV infection, other indicator diseases that require a definitive, or in some cases only a presumptive, diagnosis also constitute a diagnosis of AIDS. In 1993 the Centers for Disease Control (CDC) in the USA extended the definition of AIDS to include all persons who are severely immunosuppressed (a CD4 count <200 � 106/1) irrespective of the presence or absence of an indicator disease. For surveillance purposes this definition has not been accepted within the UK and Europe. In these countries AIDS continues to be a clinical diagnosis defined by one or more of the indicator diseases mentioned. The World Health Organisation (WHO) also uses this clinically based definition for surveillance within developed countries. WHO, however, has developed an alternative case definition for use in sub-Saharan Africa (see chapter 10). This is based on clinical signs and does not require laboratory confirmation of infection. Subsequently this definition has been modified to include a positive test for HIV antibody. 1 1 Development of the epidemic Michael W Adler Box 1.1 Early history of the epidemic 1981 Cases of Pneumocystis carinii pneumonia and Kaposi’s sarcoma in the USA 1983 Discovery of the virus. First cases of AIDS in the UK 1984 Development of antibody test Box 1.2 AIDS-defining conditions without laboratory evidence of HIV • Diseases diagnosed definitively • Candidiasis: oesophagus, trachea, bronchi or lungs • Cryptococcosis: extrapulmonary • Cryptosporidiosis with diarrhoea persisting >1 month • Cytomegalovirus disease other than in liver, spleen, nodes • Herpes simplex virus (HSV) infection • mucocutaneous ulceration lasting >1 month • pulmonary, oesophageal involvement • Kaposi’s sarcoma in patient <60 years of age • Primary cerebral lymphoma in patient <60 years of age • Lymphoid interstitial pneumonia in child <13 years of age • Mycobacterium avium: disseminated • Mycobacterium kansasii: disseminated • Pneumocystis carinii pneumonia • Progressive multifocal leukoencephalopathy • Cerebral toxoplasmosis Box 1.3 AIDS-defining conditions with laboratory evidence of HIV • Diseases diagnosed definitively • Recurrent/multiple bacterial infections in child <13 years of age • Coccidiomycosis – disseminated • HIV encephalopathy • Histoplasmosis – disseminated • Isosporiasis with diarrhoea persisting >1 month • Kaposi’s sarcoma at any age • Primary cerebral lymphoma at any age • Non-Hodgkin’s lymphoma: diffuse, undifferentiated B cell type, or unknown phenotype • Any disseminated mycobacterial disease other than M. tuberculosis • Mycobacterial tuberculosis at any site • Salmonella septicaemia: recurrent • HIV wasting syndrome • Recurrent pneumonia within 1 year • Invasive cervical cancer • Diseases diagnosed presumptively • Candidiasis: oesophagus • Cytomegalovirus retinitis with visual loss • Kaposi’s sarcoma • Mycobacterial disease (acid-fast bacilli; species not identified by culture): disseminated • Pneumocystis carinii pneumonia • Cerebral toxoplasmosis