Q: My 49 years old uncle old has been detected with HIV. He has been severely ill for the last one year and was taken to Vellore. His CD4 count is 32 and the doctors said he was in the 4th stage of 1st phase. He has other problems like diabetes and thyroid. He was detected with tuberculosis too. He has regular sweats, loss of appetite and sometimes blackouts. He has lost about 35 kg in just three months. The doctors have started ART drugs about two and a half months back. My uncle is also suffering from depression and psychological problem. Please let me know whether my uncle is going to live any more or not. What is the maximum number of years he can survive? Will he have further weight loss?

A:Survival of individuals with Human Immunodeficiency Virus (HIV) infection depends on several factors which include stage at which the diseases is diagnosed, underlying medical condition or general health of the patient, adherence to anti-retroviral therapy, immunological factors (CD4 lymphocyte count) at the time of diagnosis, occurrence of opportunistic infections and malignancies, etc. Individuals who are diagnosed early and have a relatively high CD4 count at the time of diagnosis have a better clinical outcome, and many individuals who undergo regular clinical-immunological (CD4 count) and virological (viral load estimation by real-time PCR test) follow-up, adhere strictly to anti-retroviral therapy whenever that is instituted, and take all other medications as necessary, may be able to lead a near normal life for many years.

There are reports of many individuals with HIV infection who continue to live even after 10-20 years following infection. However, the prognosis is significantly altered and survival shortened with underlying morbidity, low immunity, and each episode of opportunistic infection or malignancy that may occur as a complication of this disease. Weight loss is a common manifestation of HIV infection (hence also known as ‘wasting disease’), and generally seen in individuals with low immunity who experience recurrent or chronic opportunistic infections such as diarrhoea and tuberculosis. Sometimes weight loss may be due to lack of appetite or inability to take food because of difficulty in swallowing (e.g. due to oro-pharyngeal candidiasis). Besides depression (due to the psychological effect of the diagnosis) and other neurological factors (because of the effect of the virus or effect of opportunistic pathogens on the brain- e.g. tuberculosis, toxoplasmosis, JC virus infection) may significantly reduce nutritional intake, and lead to severe weight loss (>10% of the initial body weight). Prevention and treatment of opportunistic infections, adherence to anti-retroviral therapy, along with adequate nutritional intake are measures which are necessary to improve the body weight.

HIV is spread by sex, percutaneous exposure (such as sharps or needle-stick injury, intravenous drug use), from mother to child (both through the blood as well as through breast milk). It is possible that some infections might have been acquired through blood and blood product transfusion (previous to the virus being discovered in early 1980s, also during the early years after virus discovery when sensitive laboratory tests and quality control measures might not have been in place; the incidence of HIV being transmitted through blood and blood product transfusion has become rare in recent times). India has one of the largest number of HIV positive patients in the world (about 2.5 million infected), however in relative terms only 0.36% of the Indian population are HIV infected. However, the prevalence of this infection is more common among certain groups such as female commercial sex workers (5.38%), intravenous drug users (8.71%), MSM (men who have sex with men) (5.69%). The risk of transmission of infection is increased if the source patient has high HIV viral load, low CD4 count, or have got an AIDS defining illness, or the exposure is of a high risk category. Although sometimes the term HIV and AIDS are used interchangeably, not all persons with HIV have AIDS (Acquired Immuno-deficiency Syndrome). AIDS is a condition which occurs in HIV infected patients with low immunity (characterised by a low CD4 count) who develop opportunistic infections, malignancies (the so called AIDS defining illnesses).

The progression to AIDS could be delayed or prevented by timely anti-retroviral therapy (ART). ART is generally initiated in resource limited countries when the CD4 count is below 200 cells/ mm3. However, in developed countries the CD4 threshold for initiation of ART is 350 cells/ mm3. [The normal CD4 count in a healthy adult is between 500-1500 cells/mm3]. However, CD4 count is not the only criteria for initiation of ART, and the HIV physician may start ART depending on other factors (such as AIDS defining illness, etc). In recent years due to research and development work, there has been a significant increase in the anti-retroviral treatment options (the number of drugs available to treat HIV infection is more than 20, however not all drugs of the newer classes are readily available in India currently). In India the National AIDS Control Organisation (NACO) is the nodal government organisation which provides leadership of the HIV/AIDS control programme.