"Alex" <avdeelen.REMOFETHIS1@wanadoo.nl> wrote in message

Not all states report to the CDC on aids numbers.
The deaths are not all reported as aids. There is a long
list of deaths by aids but referred to as other causes
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The virus causing AIDS enters the blood and quickly penetrates certain white cells (called
`CD4' cells or "T4 cells") in the body. As we saw in the last chapter, they program the white
cells after which there is often little or no trace of the virus at all. This situation usually
lasts for six to twelve weeks. During this time the person is free of symptoms and antibody
tests are negative.

First signs of illness

The first thing that happens after infection is that many people develop a flu-like illness.
This may be severe enough to look like glandular fever with swollen glands in the neck and
armpits, tiredness, fever and night sweats. Some of those white cells are dying, virus is being
released, and for the first time the body is working hard to make correct antibodies. At this
stage the blood test will usually become positive as it picks up the tell-tale antibodies. This
process of converting the blood from negative to positive is called `sero-conversion'. Most
people do not realise what is happening, although when they later develop AIDS they look back
and remember it clearly. Most people have produced antibodies in about twelve weeks.

Latent infection

Then everything settles down. The person now has a positive test, and feels completely well.
The virus often seems to disappear completely from the blood again. However, during this latent
phase, HIV can be found in large quantities in lymph nodes, spleen, adenoid glands and tonsils.
We do not know how many people will go on to the next stage. As we saw in an earlier chapter,
at first doctors thought it might only be one in ten, then two or three out of ten. Now it
looks as though at least nine out of ten will develop further problems.

San Francisco studies show that in developed countries, without use of the latest therapies,
50% with HIV develop AIDS in ten years, 70% in fourteen years. Of those with AIDS, 94% are dead
in five years. The rate of progression can be much faster in those with weakened immunity from
other causes---drug users or those in developing countries, for example.  It can be far slower
in those on various treatments.

Most scientists and doctors are convinced that if we follow up infected people for long
enough---maybe for twenty years or more---then all or nearly all will die of AIDS, unless they
have died of something else in the meantime such as a heart attack or cancer. How long can
someone live before some infection triggers production of more virus and death of more white
cells?

The next stage begins when the immune system starts to break down. This is often preceded by
subtle mutations in the virus, during which it becomes more aggressive in damaging white cells.
Several glands in the neck and armpits may swell and remain swollen for more than three months
without any explanation. This is known as persistent generalised lymphadenopathy (PGL).

Early disease progression

As the disease progresses, the person develops other conditions related to AIDS. A simple boil
or warts may spread all over the body. The mouth may become infected by thrush (thick white
coating), or may develop some other problem. Dentists are often the first to be in a position
to make the diagnosis. People may develop severe shingles (painful blisters in a band of red
skin), or herpes. They may feel overwhelmingly tired all the time, have high temperatures,
drenching night sweats, lose more than 10% of their body weight, and have diarrhoea lasting
more than a month. No other cause is found and a blood test will usually be positive. Some used
to call this stage ARC, or AIDS related complex.

You can easily panic reading a list of symptoms like this because all of us tend to read about
diseases and think instantly we've got them. Chronic diarrhoea does not mean you have AIDS. Nor
do weight loss, high temperatures, tiredness and swollen glands. These things can be
particularly common in many developing countries.

At the moment in many countries there is an epidemic of viral illnesses which cause fevers,
tiredness, rashes and other symptoms that last a long time, always go away completely, and have
nothing to do with AIDS. See your doctor or go to a clinic for sexually-transmitted diseases
(STD) or genito-urinary medicine (GUM) if you are unsure.

Late HIV illness---AIDS

The final stage is AIDS. Most of the immune system is intact and the body can deal with most
infections, but one or two more unusual infections become almost impossible for the body to get
rid of without medical help---usually intensive antibiotics.

These infections can be a nightmare for doctors and patients. The desperate struggle is to find
the new germ, identify it, and give the right drug in huge doses to kill it. The germ may be
hiding deep in a lung requiring a tube (bronchoscope) to be put down the windpipe into the lung
to get a sample. The person is sedated for this. It may be hiding in the fluid covering the
brain and spinal cord, requiring a needle to be put into the spine (lumbar puncture). It may be
hiding in the brain itself. It may hide in the liver or gall-bladder or bowel. It can hide
anywhere.

Chest infections are common

The most common infection is a chest infection. A twenty-three-year-old man walks into his
doctor's office with a chest infection not responding to antibiotics. He is flushed and has a
high temperature. He has been increasingly short of breath with a dry cough for several weeks.
He becomes breathless and has an emergency chest X-ray. The X-ray is strange. No one has seen
anything like it before. Could this be AIDS? Samples are taken from the lung. The man is rushed
to intensive care and is too ill to ask if he would agree to a blood test. Within two days he
is dead. A strange germ is found in his lung: pneumocystis carinii. This is incredibly rare
except in AIDS.

He may or may not be reported as a statistic to the centre collecting information on AIDS. This
is voluntary and doctors are busy. If he had died a day or two earlier, the cause of death
would have been thought to be pneumonia. Yet another silent victim, unnoticed and unrecorded.
Our statistics may be incomplete, and remember, no test was done for HIV.

He was unlucky. Average life expectancy if you develop your first pneumocystis pneumonia is
just over two years. 78% survive the first episode, only 40% survive the second. You could live
for over three years, or you might be dead in three months. Each new chest infection could be
your last. Often people seem only an hour or two from death, then pull around, recover
completely, and go home for several months until the next crisis.

We know that eighty-five out of a hundred people with these chest infections in Western nations
are infected with pneumocystis carinii, but many are infected with several things at once.
Worldwide, the commonest HIV-related chest infection is tuberculosis. As HIV spreads, TB is on
the increase, with possibly a million extra cases a year at present as a result of HIV. Latent
TB infection is common in the general population. HIV damage to CD4 white cells allows
reactivation, rapid deterioration and death.

Damage to nervous system

Half of the people with AIDS will develop signs of brain impairment or nerve damage during
their illness. In one person out of ten it is the first symptom. HIV itself seems to attack,
damage and destroy brain cells of the majority of people with AIDS who survive long enough. The
virus is probably carried into the brain by special white cells called macrophages, which then
produce more virus there. Brain cells have a texture on their surfaces similar to CD4 white
cells which enables the virus to latch on and enter.

The damage happens gradually and often is not noticed until a significant part of the brain has
been destroyed: a brain scan shows a shrunken appearance with enlarged cavities. The signs can
be threefold: difficulties in thinking, difficulties in co-ordinating balance and moving, and
changes in behaviour. Sometimes the problems are caused by other infections spreading
throughout the body, or by tumours, all brought on by AIDS.

Brain damage affects children as well. In one study, sixteen out of twenty-one children with
AIDS developed progressive brain destruction (encephalopathy). But any part of the nervous
system can be damaged in adults or children, not just the brain, and AIDS can mimic just about
any other disease of nerves.

The 1993 AIDS Surveillance Case Definition of the U.S. Centers for Disease Control and
Prevention
A diagnosis of AIDS is made whenever a person is HIV-positive and:  he or she has a CD4+ cell
count below 200 cells per microliter OR
his or her CD4+ cells account for fewer than 14 percent of all lymphocytes OR
that person has been diagnosed with one or more of the AIDS-defining illnesses listed below.

AIDS-Defining Illnesses
Candidiasis of bronchi, trachea, or lungs (see Fungal Infections)
Candidiasis, esophageal (see Fungal Infections)
Cervical cancer, invasive?
Coccidioidomycosis, disseminated (see Fungal Infections)
Cryptococcosis, extrapulmonary (see Fungal Infections)
Cryptosporidiosis, chronic intestinal (>1 month duration) (see Enteric Diseases)
Cytomegalovirus disease (other than liver, spleen, or lymph nodes)
Cytomegalovirus retinitis (with loss of vision)
Encephalopathy, HIV-related? (see Dementia)
Herpes simplex: chronic ulcer(s) (>1 month duration) or bronchitis, pneumonitis, or
esophagitis
Histoplasmosis, disseminated (see Fungal Infections)
Isosporiasis, chronic intestinal (>1 month duration) (see Enteric Diseases)
Kaposi's sarcoma
Lymphoma, Burkitt's
Lymphoma, immunoblastic
Lymphoma, primary, of brain (primary central nervous system lymphoma)
Mycobacterium avium complex or disease caused by M. Kansasii, disseminated
Disease caused by Mycobacterium tuberculosis, any site (pulmonary? or extrapulmonary?) (see
Tuberculosis)
Disease caused by Mycobacterium, other species or unidentified species, disseminated
Pneumocystis carinii pneumonia
Pneumonia, recurrent(see Bacterial Infections)
Progressive multifocal leukoencephalopathy
Salmonella septicemia, recurrent (see Bacterial Infections)
Toxoplasmosis of brain (encephalitis)
Wasting syndrome caused by HIV infection

Additional Illnesses That Are AIDS-Defining in Children, But Not Adults
Multiple, recurrent bacterial infections? (see Bacterial Infections)
Lymphoid interstitial pneumonia/pulmonary lymphoid hyperplasia

Children with HIV

Worldwide, over 3 million children have HIV infection and half a million die every year.
Altogether, 83% of children with HIV will show some kind of abnormality in their white cells,
or will have symptoms, by the time they are six months old. Problems seen can include large
lymph nodes, enlarged liver and spleen, failure to thrive (small for age), small head, ear
infections, chest infections, unexplained fever, encephalopathy (brain deterioration).

Of those showing symptoms within the first year of life, half die before the age of three.
However, with improved treatments children are surviving longer. A common pattern is beginning
to emerge of a child who becomes unwell in the first year or two of life with different chronic
or acute infections, yet with treatment carries on for many years, possibly even into
adolescence with many ups and downs. Pain and other symptoms are often overlooked in these
children.

Blood tests are often confused by the presence after birth of the mother's own antibodies.

All babies of infected mothers will test positive for around the first year, whether infected
or not. Most babies who test positive at birth turn out to be uninfected.  The greatest risk to
the baby is the birth process itself and breast milk.  Dramatic reductions in infection rates
can be made if the mother is given anti-viral medication before and immediately after birth.
This is one of the  most appropriate occasions to use anti-viral drugs in the poorest nations.
But it should always be done under strict medical supervision.

There is a very slight risk that children who later test negative may still carry HIV. If first
infected in the womb, the child may regard HIV as part of itself and not react to it. We are
still in the early stages of learning about HIV in children.

Skin rashes and growths

The majority of people with AIDS develop skin problems which are usually an exaggeration of
things common to most people, such as acne and rashes of various kinds. Cold sores and genital
herpes may develop, or warts. Athlete's foot in severe forms, ringworm and thrush are common.
Rashes due to food allergy are also common---no one knows why. Hair frequently falls out. Drug
rashes frequently occur, often due to life-saving co-trimoxazole used for treatment or
prevention of the pneumocystis carinii pneumonia.

Kaposi's sarcoma develops in up to a quarter of the people with AIDS (depending on the country
and route of infection). This produces blue or red hard painless patches on the skin, often on
the face. In the majority of these people it is the first sign of AIDS. Tumours can spread to
lymph nodes, gut lining and lungs where they can be confused with pneumocystis pneumonia. The
growths may be caused by a second virus that is allowed to grow more easily if you have AIDS.
Treatment consists mainly of radiotherapy and chemotherapy, including injections of the
lesions.

Because it often affects the face or may be visible elsewhere on the body and is so
distinctive, people who develop Kaposi's sarcoma often feel especially vulnerable. In fact
people usually live longer if they first develop this tumour than if they first develop a
pneumonia. Kaposi's sarcoma is less common in drug users with AIDS, presumably because it is
caused by a second virus also found in , which is then activated by HIV.

The other common cancer is a tumour (lymphoma) which develops in the brain or elsewhere in the
body.

Problems in gut, eyes and other organs

Almost all people with AIDS have stomach problems from strange infections and cancers caused by
AIDS and HIV attacking the gut directly. All three cause food to be poorly digested resulting
in diarrhoea and weight loss. Stool samples can be examined or samples can be taken from within
the gut using special tubing (endoscopy) to see if there is a second treatable infection in
addition to HIV.

AIDS can also seriously affect sight in up to a quarter of all those with HIV by allowing an
infection of the back of the eye (retinitis). This is usually caused by cytomegalovirus and is
sometimes amenable to treatment. In addition, the virus can cause damage to other organs of the
body such as the heart.

Changing disease pattern in adults

In different parts of the world, AIDS tends to have its own characteristics. This may be due to
the pattern of other illnesses present in different communities, which explains why TB is the
commonest cause of death from AIDS in Africa and Asia. Different patterns may be related to
different co-factors ( compared to drug injectors, for example), viral differences or possibly
genetic differences.

However, patterns are changing. For example, the incidence of Kaposi's sarcoma is falling among
with HIV in a number of countries, while it is rising among drug users. Some of these changed
patterns are because of altered treatments; others are due to other factors.

As survival times have increased, other problems have emerged which are far more difficult to
treat. These include blindness due to cytomegalovirus, progressive multifocal
leucoencephalopathy (weakness, muscle wasting, difficulty thinking), cryptosporidiosis (causes
various infections), mycobacterium infections and cryptococcal meningitis.

In addition, as we have seen, advanced Kaposi's sarcoma can bring its own problems, with lung
involvement causing shortness of breath and triggering chest infections, gut involvement
causing obstruction or sudden bleeding, and with blockage of lymphatic drainage causing swollen
limbs or face, skin ulceration and infection.

In a quarter of those dying with AIDS, the exact cause of death may be difficult to establish,
with profound weakness, loss of weight and multi-system failure. Many infections can be
chronic, low grade and difficult to diagnose, and when diagnosed can be hard to treat. Indeed,
post-mortem examinations show that half of all HIV-related diseases found at autopsy have not
been diagnosed during life.

In the early days in many countries, those with AIDS often spent a long time in hospital as
doctors battled to get to grips with the complex spectrum of illnesses. Now people with AIDS
are usually able to spend more time at home, with many treatments given in clinics or in the
home. However, many have multiple problems and need practical help, backed by nursing care and
symptom control, to stay at home in comfort and in control of their own lives. Later on in this
book we will look at the practicalities of setting up community care programmes.

Many people who are ill are now opting not to have every symptom investigated, when the price
is valuable time spent in hospital, unpleasant tests, and treatments that may have side
effects.

AIDS diagnosis in developing nations

In developing countries it can be hard to make an accurate diagnosis of AIDS because of the
lack of HIV testing facilities. The World Health Organisation proposed a clinical case
definition, combining symptoms and signs common in AIDS (see table below). This has been used
as the basis for AIDS statistics in many countries, but is inaccurate.

A study of hospital patients in Zaire showed that the case definition missed 31% of AIDS cases
(definition not very sensitive), and 10% of those it identified as having AIDS were errors. The
case definition misses people dying with severe HIV illnesses which do not fit the definition.
For example, deaths from streptococcal pneumonia are far more common in those with HIV, yet
such deaths were not included.

The commonest manifestations of AIDS in Africa are gross weight loss, chronic diarrhoea and
chronic fever---the picture of `slim disease' as AIDS is known in African countries. However,
it is difficult to exclude other causes for the same symptoms and signs.

Deaths from tuberculosis are another problem. TB is probably the most important infection in
those with HIV in Africa. High rates of TB infection are found in those with HIV and the risk
of death from TB is greatly increased in those with HIV. However, it is questionable whether
all those with TB and HIV can be diagnosed as AIDS cases, since many have TB anyway. Many with
TB lose weight and have fever as well as a cough. Therefore in the absence of HIV testing, many
with advanced TB are likely to be labelled as AIDS cases using the WHO case definition.

In the light of all these problems, a revised case definition has been agreed. You may wonder
how it is possible to be sure of the right diagnosis at all without laboratory facilities, and
the answer is that it is very difficult.

Some have pounced on this difficulty to suggest that there is no AIDS in Africa at all. As we
see elsewhere, this is not very convincing for two reasons. First, death rates have soared in
the sexually-active age groups as HIV infection rates have risen. TB and other illnesses have
been around and studied in detail for decades. Something new is happening. Secondly, when
people with AIDS from African nations are cared for either in countries like the UK, or in very
well-equipped hospitals nearer home, it is clear that there are gross abnormalities of their
immune systems indicative of AIDS, with positive antibodies for HIV and damaged white cells.

AIDS-related illnesses in Africa

The spectrum of illness seen in AIDS in African nations can vary, particularly in places where
HIV-2 is more prevalent. The pattern is very different from developed countries:

Candida (thrush) in the mouth     80--100%
Oesophageal candidiasis        30--50%
Tuberculosis        30--50%
Cerebral toxoplasmosis        15--20%
Herpes zoster (shingles)        10%
Cryptosporidiosis (diarrhoea)        50%

Most people have several problems. (For further discussion on needs of those with AIDS and how
to meet them, see Chapters 10, 11 and 14; also Appendices A, B and C.)

So, now that we have reviewed how the virus attacks cells and causes diseases associated with
AIDS, we are in a position to look at some of the ways the virus can enter the human body and
how we can prevent it from happening.

First signs of illness  Latent infection  Early disease progression  Late HIV illness---AIDS
Chest infections are common  Damage to nervous system   Children with HIV  Skin rashes and
growths Problems in gut, eyes and other organs  Changing disease pattern in adults AIDS
diagnosis in developing nations   AIDS-related illnesses in Africa

Oh! Now I'm convinced by your deft and profound handling of
statistics! Yes! It's all just a BIG conspiracy to fool YOU, Alex.
Yes, YOU! All the world has gotten together and--well, just wait til
the planet gives you a BIG surprise next April 1!

Oh, Alex!