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The lived experience of HIV-infected patients in the face of a positive diagnosis of the disease: a phenomenological study

• Behzad Imani   ORCID: orcid.org/0000-0002-1544-8196 1 ,
• Shirdel Zandi 2 ,
• Salman khazaei 3 &
• Mohamad Mirzaei 4  

AIDS Research and Therapy volume  18 , Article number:  95 ( 2021 ) Cite this article

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AIDS as a human crisis may lead to devastating psychological trauma and stress for patients. Therefore, it is necessary to study different aspects of their lives for better support and care. Accordingly, this study aimed to explain the lived experience of HIV-infected patients in the face of a positive diagnosis of the disease.

This qualitative study is a descriptive phenomenological study. Sampling was done purposefully and participants were selected based on the inclusion and exclusion criteria. Data collection was conducted, using semi-structured interviews. Data analysis was performed using Colaizzi’s method.

12 AIDS patients participated in this study. As a result of data analysis, 5 main themes and 12 sub-themes were identified, which include : emotional shock (loathing, motivation of social isolation), the fear of the consequences (fear of the death, fear of loneliness, fear of disgrace), the feeling of the guilt (feeling of regret, feeling guilty, feeling of conscience-stricken), the discouragement (suicidal ideation, disappointment), and the escape from reality (denial, trying to hide).

The results of this study showed that patients will experience unpleasant phenomenon in the face of the positive diagnosis of the disease and will be subjected to severe psychological pressures that require attention and support of medical and laboratory centers.

Patients will experience severe psychological stress in the face of a positive diagnosis of HIV.

Patients who are diagnosed with HIV are prone to make a blunder and dreadful decisions.

AIDS patients need emotional and informational support when they receive a positive diagnosis.

As a piece of bad news, presenting the positive diagnosis of HIV required the psychic preparation of the patient

Introduction

HIV/AIDS pandemic is one of the most important economic, social, and human health problems in many countries of the world, whose, extent and dimensions are unfortunately ever-increasing [ 1 ]. In such circumstances, this phenomenon should be considered as a crisis, which seriously affects all aspects of the existence and life of patients and even the health of society [ 2 ]. Diagnosing and contracting HIV/AIDS puts a person in a vague and difficult situation. Patients suffer not only from the physical effects of the disease, but also from the disgraceful consequences of the disease. HIV/AIDS is usually associated with avoidable behaviors that are not socially acceptable, such as unhealthy sexual, relations and drug abuse: So the patients are usually held guilty for their illness [ 3 ]. On the other hand, the issue of disease stigma in the community is the cause of rejection and isolation of these patients, and in health care centers is a major obstacle to providing services to these patients [ 4 ]. Studies show that HIV/AIDS stigma has a completely negative effect on the quality of life of these patients [ 5 ]. Criminal attitudes towards these patients and disappointing behavior by family, community, and medical staff cause blame and discrimination in patients [ 6 ]. HIV/AIDS stigma is prevalent among diseases, making concealment a major problem in this behavioral disease. The stigma comes in two forms: a negative inner feeling and a negative feeling that other people in the community have towards the patient [ 7 ]. The findings of a study that conducted in Iran indicated that increasing HIV/AIDS-related stigma decreases quality of life of people living with HIV/AIDS [ 8 ]. Robert Beckman has defined bad news as “any news that seriously and unpleasantly affects persons’ attitudes toward their future”. He considers the impact of counseling on moderating a person’s feeling of being important [ 9 ]. Therefore, being infected by HIV / AIDS due to the stigma can be bad news, which will lead to unpleasant emotional reactions [ 10 ]. Studies that have examined the lives of these patients have shown that these patients will experience mental and living problems throughout their lives. These studies highlight the need for age-specific programming to increase HIV knowledge and coping, increase screening, and improve long-term planning [ 11 , 12 ].

A prerequisite for any successful planning and intervention for people living with HIV/AIDS is approaching them and conducting in-depth interviews in order to discover their feelings, attitudes; their views on themselves, their illness, and others; and finally, their motivation to follow up and the participation in interventions [ 13 ]. Accordingly, the present study aimed to explain the lived experience of HIV-infected patients in the face of a positive diagnosis of the disease, since the better understanding of the phenomena leads to the smoother ways to help and care for these patients.

Study setting

In this study, a qualitative method of descriptive phenomenology was used to discover and interpret the lived experience of HIV-positive patients, when they face a positive diagnosis of the disease. The philosophical strengths underlying descriptive phenomenology afford a deeper understanding of the phenomenon being studied [ 14 ]. Husserl’s four steps of descriptive phenomenology were employed: bracketing, intuiting, analyzing and interpreting [ 15 ].

Participants and sampling

Sampling was done purposefully and participants were selected based on inclusion criteria. In this purposeful sampling, participants were selected among those patients who had sufficient knowledge about this phenomenon. The sample size was not determined at the beginning of the study, instead, it continued until no new idea emerged and data-saturated. Participants were selected from patients who were admitted to the Shohala Behavioral Diseases Counseling Center in Hamadan-Iran. The center has been set up to conduct tests, consultations, medical and dental services, and to distribute medicines among the patients. Additional inclusion criteria for selecting a participant are: having a positive diagnosis experience at the center, Ability to recall events and mental thoughts in the face of the first positive diagnosis of the disease, having psychological and mental stability, having a favorable clinical condition, willingness to work with the research team, and the possibility of re-access for the second interview if needed. Exclusion criteria were unwillingness to participate in the study and inability of verbal communication in Persian language.

Data collection

The interviews began with a non-structured question (tell us about your experience with a positive diagnosis) and continued with semi-structured questions. Each interview lasted 35–70 min and was conducted in two sessions if necessary. All interviews were conducted by the main investigator (ShZ) that who has experience in qualitative research and interviewing. The interview was recorded and then written down with permission of the participant.

Data analysis

The descriptive Colaizzi method was used to analyses the collected data [ 16 ]. This method consists of seven steps: (1) collecting the participants’ descriptions, (2) understanding the meanings in depth, (3) extracting important sentences, (4) conceptualizing important themes, (5) categorizing the concepts and topics, (6) constructing comprehensive descriptions of the issues examined, and (7) validating the data following the four criteria set out by Lincoln and Guba.

Trustworthiness criteria were used to validate the research, due to the fact that importance of data and findings validity in qualitative research [ 17 ]. This study was based on four criteria of Lincoln and Guba: credibility, transferability, dependability, and conformability [ 18 ]. For data credibility, prolong engagement and follow-up observations, as well as samplings with maximum variability were used. For dependability of the data, the researchers were divided into two groups and the research was conducted as two separate studies. At the same time, another researcher with the most familiarity and ability in conducting qualitative research, supervised the study as an external observer. Concerning the conformability, the researchers tried not to influence their own opinions in the coding process. Moreover, the codes were readout by the participants as well as two researcher colleagues with the help of an independent researcher and expert familiar with qualitative research. Transferability of data was confirmed by offering a comprehensive description of the subject, participants, data collection, and data analysis.

Ethical considerations (ethical approval)

The present study was registered with the ethics code IR.UMSHA.REC.1398.1000 in Hamadan University of Medical Sciences. The purpose of the study was explained and all participants’ consents were obtained at first step. All participants were assured that the information obtained would remain confidential and no personal information would be disclosed. Participants were also told that there was no need to provide any personal information to the interviewer, including name, surname, phone number and address. To gain more trust, interviews were conducted by a person who was not resident of Hamadan and was not a native of the region, this case was also reported to the participants.

Twelve HIV-infected participated in this study. The mean age of the participants was 36.41 ± 4.12 years. 58.33% of the participants were male and 41.66% were married. Of these, 2 were illiterate, 2 had elementary diploma, 6 had high school diploma and 2 had academic education. Six of them were unemployed, 5 were self-employed and 1 was an official employee. These people had been infected by this disease for 6.08 ± 2.71 years, in average (Table 1 ).

Analysis of the HIV-infected patients’ experiences of facing the positive diagnosis of the disease by descriptive phenomenology revealed five main themes: emotional shock, the fear of the consequences, the feeling of the guilt, the discouragement, and the escape from reality (Table 2 ).

Emotional shock

Emotional shock is one of the unpleasant events that these patients have experienced after facing a positive diagnosis of the disease. This experience has manifested in loathing and motivation of social isolation.

These patients stated that after facing a positive diagnosis of the disease, they developed a strong inner feeling of hatred towards the source of infection. The patients feel hatred, since they hold the carrier as responsible for their infection. “…After realizing I was affected, I felt very upset with my husband, I did not want to see him again, because it made me miserable, I even decided to divorce ….”(P3).

Motivation of social isolation

The experiences of these patients showed that after facing the incident, they have suffered an internal failure that has caused them to try to distance from other people. These patients have become isolated, withdrawing from the community and sometimes even from their families. “…After this incident, I decided to live alone forever and stay away from all my family members. I made a good excuse and broke up our engagement…” (P7).

Fear of the consequences

Fear of the consequences is one of the unpleasant experiences that these patients will face, as soon as they receive a positive diagnosis of the disease. Based on experiences, these patients feel fear of loneliness, death, and disgrace as soon as they hear the positive diagnosis.

Fear of the death

The patients said that as soon as they got the positive test results, they thought that the disease was incurable and would end their lives soon. “…When I found I had AIDS, I was very upset and moved like a dead man because I was really afraid that at any moment this disease might kill me and I would die …” (P1).

Fear of loneliness

The participants stated that one of the feelings that they experienced as soon as they received a positive diagnosis of the disease was the fear of being alone. They stated that at that moment, the thought of being excluded from society and losing their intimacy with them was very disturbing. “…The thought that I could no longer have a family and had to stay single forever bothered me a lot, it was terrifying to me when I thought that society could no longer accept me as a normal person …” (P10).

Fear of disgrace

One of the feelings that these patients experienced when faced the positive diagnosis of the disease was the fear of disgrace. They suffer from the perception that the spread of news of the illness hurts the attitudes of those around them and causes them to be discredited. “…It was very annoying for me when I thought I would no longer be seen as a member of my family, I felt I would no longer have a reputation and everyone would think badly of me …” (P2).

Feeling of the guilt

From other experiences of these patients in facing the positive diagnosis of the disease is feeling guilty. This feeling appears in patients as feeling of regret, guilty and remorse.

Feeling of regret

These patients stated that they felt remorse for their lifestyle and actions as soon as they heard the positive diagnosis of the disease, because they thought that if they had lived healthier, they would not have been infected. “…After realizing this disease, I was very sorry for my past, because I really did not have a healthy life. I made a series of mistakes that caused me to get caught. At that moment, I just regretted why I had this disaster …” (P11).

Feeling guilty

The experience of these patients has shown that after receiving a positive diagnosis of the disease, they consider themselves guilty and complain about themselves. These patients condemn their lifestyle and sometimes even consider themselves deserving of the disease and think that it is a ransom that they have paid back. “…after getting the disease, I realized that I was paying the ransom because I was hundred percent guilty, I was the one who caused this situation with a series of bad deeds, and now I have to be punished …” (P5).

Feeling of conscience-stricken

One of the experiences that these patients reported is the pangs of conscience. These patients stated that after receiving a positive diagnosis of the disease, the thought that as a carrier they might have contaminated those around them was very unpleasant and greatly affected their psyche. “…after getting the disease. It was shocked and I was just crazy about the fact that if my wife and children had taken this disease from me, what would I do, I made them hapless … and this as very annoying for me …” (P8).

Discouragement

Discouragement is an unpleasant experience that patients experienced after receiving a positive HIV test results. Discouragement in these patients appears in the suicidal ideation and disappointment.

Suicidal ideation

The patients stated that they were so upset with the positive diagnosis of the illness and they immediately thought they could not live with the fact and the best thing to do was to end their own lives. “…The news was so bad for me that I immediately thought that if the test result was correct and I had AIDS, I would have to kill myself and end this wretch life, oh, I had a lot of problem and the thought of having to wait for a gradual death was horrible to me …” (P12).

Disappointment

The experience of these patients shows that a positive diagnosis of the disease for these patients leads to a destructive feeling of disappointment. So that they are completely discouraged from their lives. These patients think that their dreams and goals are vanished and that they have reached the end and everything is over. “…It was a horrible experience, so at that moment I felt my life was over, I had to prepare myself for a gradual death, I was at marriage ages when I thought I could no longer get married, I saw life as meaningless …” (P7).

Escape from reality

The lived experience of these patients shows that after receiving a positive diagnosis of the disease, they found that this fact was difficult to accept and somehow tried to escape from the reality. This experience has been in the form of denial and trying to hide from others.

One of the experiences of these patients in dealing with the positive test result of this disease has been to deny it. In this way, patients believed that the test result was wrong or that the result belonged to someone else. For this reason, the patients referred to other laboratories after receiving the first positive diagnosis of the disease. “…After the lab told me this and found out what the disease really was, I was really shocked and said it was impossible, it was definitely wrong and it is not true … I could not believe it at all, because I was a professional athlete and this could not happen to me. So I immediately went to a bigger city and there I went to a few laboratories for further tests …” (P6).

Trying to hide

These patients stated that after receiving the first positive diagnosis of the disease, they thought that no one should notice their disease and should remain anonymous as much as possible. “…I immediately decided that no one in my city should know that I got this disease and the news should not be spread anywhere, so I discard my phone number through which our city laboratory communicated with me and I came here to do a re-examination and go to the doctor, and after all these years, I always come here again for an examination …” (P4).

In this qualitative study, we attempted to discover lived experience of HIV-infected patients in the face of a positive diagnosis of the disease. Therefore, a descriptive phenomenological method was applied. As a result of this study, based on the experiences of the HIV-infected patients, the five main themes of emotional shock, fear of the consequences, feelings of guilt, discouragement and, escape from reality were obtained.

In this study, it was shown that the confrontation of these patients with the positive diagnosis of the disease causes them to experience a severe emotional shock. In this regard, Yangyang Qiu et al. [ 19 ] argued that anxiety and depression are very common among HIV-infected patients who have recently been diagnosed with the disease. The experience of the participants has shown that this emotional shock appears in the form of loathing and the motivation of social isolation. In fact, in these patients, the feeling of the loathing is an emotional response to the primary carrier that has infected them. The study of Imani et al. [ 20 ] have shown that decrease emotional intelligence in an environment where there is an HIV carrier, other people hate him/her, because they see him/her as a risk factor for their infection. The experience of the participants has also shown that receiving a positive diagnosis will motivate social isolation in these patients. Various studies have revealed that one of the consequences of AIDS/HIV that patients will suffer from, is social isolation [ 21 , 22 ].

Another experience of the participants, according to this study is fear of the consequences. This phenomenon appears in these patients as fear of the death, fear of loneliness, and fear of disgrace. Due to the nature of the disease, these patients feel an inner fear of premature death, as soon as they receive a positive diagnosis. In this regard, the study of Audrey K Miller et al. [ 23 ] showed that death anxiety in AIDS patients is a psychological complication. the participants have stated that they are very afraid of being alone after receiving a positive diagnosis, which is a natural feeling according to Keith Cherry and David H. Smith [ 24 ]; because these patients will mainly experience some degree of loneliness. HIV-infected patients also experienced a fear of disgrace, which will go back to the nature of the disease and people’s insight; but they should be aware that, as Newman Amy states, AIDS/ HIV is a disease, not a scandal [ 25 ].

Another experience of the participants in dealing with the positive diagnosis of the disease is guilt feeling. The patients will experience feelings of regret, the feeling guilty and feeling of the conscience-stricken. The experience of the participants shows that they regret their past. Earlier studies have also revealed that regret for the past is a common phenomenon among the patients living with HIV [ 26 , 27 , 28 ]. HIV-infected feel guilty while facing the positive diagnosis of the disease and consider themselves the main culprit of the situation. They often play a direct role in their infection, and their past lifestyle for sure [ 29 ]. Our study also found that these patients feel the conscience-stricken after a positive diagnosis, because they suspect that they may have infected people around them. This disease can be easily transmitted from the carrier to others if the health protocols are not followed [ 30 , 31 , 32 ].

Another experience of HIV-infected in dealing with the receiving a positive diagnosis of the disease is discouragement. These patients are disappointed and sometimes decide to suicide. Based on the lived experience of HIV-infected, it was found that receiving a positive diagnosis of the disease, will discourage them from life and patients will be disappointed in many aspects of life. Studies have shown that AIDS/HIV, as a crisis, will greatly reduce the patients' life expectancy and that they will continue to live in despair [ 33 ]. Studies also stated that they considered suicide as a solution to relieve stress when receiving a positive diagnosis. In this regard, various studies have emphasized that among the AIDS/HIV patients, loss of self-esteem and severe stress have led to high suicide rates [ 34 , 35 , 36 ].

According to the patients, trying to escape from reality is another phenomenon that they will experience. This phenomenon will occur in patients as denial and trying to hide the disease from others. Based on the lived experience of these patients, it was found that after facing a positive diagnosis, HIV-infected tend to deny that they are infected. In this regard, various studies have shown that AIDS/HIV patients in different stages of the disease and their lives try to deny it in different ways [ 37 , 38 , 39 ]. The HIV-infected also stated that at the beginning of the positive diagnosis of the disease, did not want others to know, so they wanted to hide themselves from others in any way possible. In this regard, Emilie Henry et al. [ 40 ] have shown that a high percentage of the patients living with AIDS/HIV have tried that others do not notice that they are ill.

One of the strengths of this study is the methodology of the study, because in this study, an attempt has been made to use descriptive phenomenology to explain the lived experience of HIV-infected patients when faced with a positive diagnosis of this disease. In fact, in this study, patients' experience of this particular situation was identified, and with careful analysis, the experiences of these people became codes and concepts, each of which can be a bridge that keeps the path of modern knowledge open to help these patients. One of the limitations of this study is the generalizability of the findings because patients’ experiences in different societies that have cultural, religious, subsistence, and economic differences can be different.

The results of this study showed that patients will experience unpleasant experiences in the face of receiving a positive diagnosis of the HIV. Patients’ unpleasant experiences at that moment include emotional shock, fear of the consequences, feeling guilty, discouragement and escape from reality. Therefore, medical and laboratory centers must pay attention to the patients' lived experience, and try to support the patients through education, counseling and other support programs to minimize the psychological trauma caused by the disease.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding authors through reasonable request.

Acknowledgements

The authors would like to express their gratitude to the Hamadan Health Network, the Hamadan Shohada Behavioral Diseases Counseling Center, and the participants who helped us in this study.

The study was funded by Vice-chancellor for Research and Technology, Hamadan University of Medical Sciences (No. 9812209934).

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Department of Operating Room, School of Paramedicine, Hamadan University of Medical Sciences, Hamadan, Iran

Behzad Imani

Department of Operating Room, Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran

Shirdel Zandi

Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran

Salman khazaei

Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran

Mohamad Mirzaei

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Contributions

BI designed the study, collected the data, and provide the first draft of manuscript. ShZ designed the study and revised the manuscript. SKh participated in design of the study, the data collection, and revised the manuscript. MM participated in design of the study and revised the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Shirdel Zandi .

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This study is the result of a student project that has been registered in Hamadan University of Medical Sciences of Iran with the ethical code IR.UMSHA.REC.1398.1000.

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The authors declare no conflicts of interest.

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Imani, B., Zandi, S., khazaei, S. et al. The lived experience of HIV-infected patients in the face of a positive diagnosis of the disease: a phenomenological study. AIDS Res Ther 18 , 95 (2021). https://doi.org/10.1186/s12981-021-00421-4

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DOI : https://doi.org/10.1186/s12981-021-00421-4

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HIV and AIDS

• HIV remains a major global public health issue, having claimed an estimated 42.3 million lives to date.  Transmission is ongoing in all countries globally.
• There were an estimated 39.9 million people living with HIV at the end of 2023, 65% of whom are in the WHO African Region.
• In 2023, an estimated 630 000 people died from HIV-related causes and an estimated 1.3 million people acquired HIV.
• There is no cure for HIV infection. However, with access to effective HIV prevention, diagnosis, treatment and care, including for opportunistic infections, HIV infection has become a manageable chronic health condition, enabling people living with HIV to lead long and healthy lives.
• WHO, the Global Fund and UNAIDS all have global HIV strategies that are aligned with the SDG target 3.3 of ending the HIV epidemic by 2030.
• By 2025, 95% of all people living with HIV should have a diagnosis, 95% of whom should be taking lifesaving antiretroviral treatment, and 95% of people living with HIV on treatment should achieve a suppressed viral load for the benefit of the person’s health and for reducing onward HIV transmission. In 2023, these percentages were 86%, 89%, and 93% respectively.
• In 2023, of all people living with HIV, 86% knew their status, 77% were receiving antiretroviral therapy and 72% had suppressed viral loads.

Human immunodeficiency virus (HIV) is a virus that attacks the body’s immune system. Acquired immunodeficiency syndrome (AIDS) occurs at the most advanced stage of infection.

HIV targets the body’s white blood cells, weakening the immune system. This makes it easier to get sick with diseases like tuberculosis, infections and some cancers.

HIV is spread from the body fluids of an infected person, including blood, breast milk, semen and vaginal fluids. It is not spread by kisses, hugs or sharing food. It can also spread from a mother to her baby.

HIV can be prevented and treated with antiretroviral therapy (ART). Untreated HIV can progress to AIDS, often after many years.

WHO now defines Advanced HIV Disease (AHD) as CD4 cell count less than 200 cells/mm3 or WHO stage 3 or 4 in adults and adolescents. All children younger than 5 years of age living with HIV are considered to have advanced HIV disease.

Signs and symptoms

The symptoms of HIV vary depending on the stage of infection.

HIV spreads more easily in the first few months after a person is infected, but many are unaware of their status until the later stages. In the first few weeks after being infected people may not experience symptoms. Others may have an influenza-like illness including:

• sore throat.

The infection progressively weakens the immune system. This can cause other signs and symptoms:

• swollen lymph nodes
• weight loss

Without treatment, people living with HIV infection can also develop severe illnesses:

• tuberculosis (TB)
• cryptococcal meningitis
• severe bacterial infections
• cancers such as lymphomas and Kaposi's sarcoma.

HIV causes other infections to get worse, such as hepatitis C, hepatitis B and mpox.

Transmission

HIV can be transmitted via the exchange of body fluids from people living with HIV, including blood, breast milk, semen, and vaginal secretions. HIV can also be transmitted to a child during pregnancy and delivery.  People cannot become infected with HIV through ordinary day-to-day contact such as kissing, hugging, shaking hands, or sharing personal objects, food or water.

People living with HIV who are taking ART and have an undetectable viral load will not transmit HIV to their sexual partners. Early access to ART and support to remain on treatment is therefore critical not only to improve the health of people living with HIV but also to prevent HIV transmission.

Risk factors

Behaviours and conditions that put people at greater risk of contracting HIV include:

• having anal or vaginal sex without a condom;
• having another sexually transmitted infection (STI) such as syphilis, herpes, chlamydia, gonorrhoea and bacterial vaginosis;
• harmful use of alcohol or drugs in the context of sexual behaviour;
• sharing contaminated needles, syringes and other injecting equipment, or drug solutions when injecting drugs;
• receiving unsafe injections, blood transfusions, or tissue transplantation; and
• medical procedures that involve unsterile cutting or piercing; or accidental needle stick injuries, including among health workers.

HIV can be diagnosed through rapid diagnostic tests that provide same-day results. This greatly facilitates early diagnosis and linkage with treatment and prevention. People can also use HIV self-tests to test themselves. However, no single test can provide a full HIV positive diagnosis; confirmatory testing is required, conducted by a qualified and trained health worker or community worker. HIV infection can be detected with great accuracy using WHO prequalified tests within a nationally approved testing strategy and algorithm.

Most widely used HIV diagnostic tests detect antibodies produced by a person as part of their immune response to fight HIV. In most cases, people develop antibodies to HIV within 28 days of infection. During this time, people are in the so-called “window period” when they have low levels of antibodies which cannot be detected by many rapid tests, but they may still transmit HIV to others. People who have had a recent high-risk exposure and test negative can have a further test after 28 days.

Following a positive diagnosis, people should be retested before they are enrolled in treatment and care to rule out any potential testing or reporting error. While testing for adolescents and adults has been made simple and efficient, this is not the case for babies born to HIV-positive mothers. For children less than 18 months of age, rapid antibody testing is not sufficient to identify HIV infection – virological testing must be provided as early as birth or at 6 weeks of age. New technologies are now available to perform this test at the point of care and enable same-day results, which will accelerate appropriate linkage with treatment and care.

HIV is a preventable disease.  Reduce the risk of HIV infection by:

• using a male or female condom during sex
• being tested for HIV and sexually transmitted infections
• having a voluntary medical male circumcision
• using harm reduction services for people who inject and use drugs.

Doctors may suggest medicines and medical devices to help prevent HIV infection, including:

• antiretroviral drugs (ARVs), including oral Pre-Exposure Prophylaxis (PrEP) and long acting products
• dapivirine vaginal rings
• injectable long acting cabotegravir.

ARVs can also be used to prevent mothers from passing HIV to their children.

People taking antiretroviral therapy (ART) and who have no evidence of virus in the blood will not pass HIV to their sexual partners. Access to testing and ART is an important part of preventing HIV.

Antiretroviral drugs given to people without HIV can prevent infection

When given before possible exposures to HIV it is called pre-exposure prophylaxis (PrEP) and when given after an exposure it is called post-exposure prophylaxis (PEP).  People can use PrEP or PEP when the risk of contracting HIV is high; people should seek advice from a clinician when thinking about using PrEP or PEP.

There is no cure for HIV infection. It is treated with antiretroviral drugs, which stop the virus from replicating in the body.

Current antiretroviral therapy (ART) does not cure HIV infection but allows a person’s immune system to get stronger. This helps them to fight other infections.

Currently, ART must be taken every day for the rest of a person’s life.

ART lowers the amount of the virus in a person’s body. This stops symptoms and allows people to live full and healthy lives. People living with HIV who are taking ART and who have no evidence of virus in the blood will not spread the virus to their sexual partners.

Pregnant women with HIV should have access to, and take, ART as soon as possible. This protects the health of the mother and will help prevent HIV transmission to the fetus before birth, or through breast milk.

Advanced HIV disease remains a persistent problem in the HIV response. WHO is supporting countries to implement the advanced HIV disease package of care to reduce illness and death. Newer HIV medicines and short course treatments for opportunistic infections like cryptococcal meningitis are being developed that may change the way people take ART and prevention medicines, including access to injectable formulations, in the future.

More information on HIV treatments

WHO response

Global health sector strategies on HIV, viral hepatitis, and sexually transmitted infections for the period 2022–2030 ( GHSSs ) guide strategic responses to achieve the goals of ending AIDS, viral hepatitis B and C, and sexually transmitted infections by 2030.

WHO’s Global HIV, Hepatitis and STIs Programmes recommend shared and disease-specific country actions supported by WHO and partners. They consider the epidemiological, technological, and contextual shifts of previous years, foster learning, and create opportunities to leverage innovation and new knowledge.

WHO’s programmes call to reach the people most affected and most at risk for each disease, and to address inequities.  Under a framework of universal health coverage and primary health care, WHO’s programmes contribute to achieving the goals of the 2030 Agenda for Sustainable Development.

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An H.I.V. Cure: Answers to 4 Key Questions

Translating the latest success against the AIDS virus into a practical treatment will take years — if it happens at all. Here are answers to some of the most pressing questions raised by the news.

By Apoorva Mandavilli

At a scientific conference in Seattle on Tuesday, researchers reckoned with a day that many thought might never arrive. A patient appears to have been cured of H.I.V. , the virus that causes AIDS, for only the second time since the epidemic began.

A sort of electric hope hangs in the air, said Dr. Steve Deeks, an AIDS specialist at the University of California, San Francisco, who is attending the gathering: “The whole approach to a cure is shifting more from aspiration to something that people are realizing could be feasible.”

It is a hope that must be tempered with realism: H.I.V. is a wily adversary, and scientists and patients living with the virus are all too well acquainted with past failures in the fight against the epidemic.

Here’s what the news means right now.

Will this change anything for people living with H.I.V.?

Not yet. The second case does provide “proof of concept,” shining a light on a potential path to an H.I.V. cure. Scientists intend to pursue it with vigor.

But this apparent success does not mean that an easy cure is around the corner, and certainly not that infected patients should stop taking their pills.

“Sometimes the amount of desperation for a cure is driven by the stigma that’s still out there,” said Richard Jefferys, a director at Treatment Action Group, an advocacy organization. “But while two or three people is a drop in the ocean compared to the 35 million H.I.V.-positive people in the world, it’s a whole lot better than zero.”

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A 5th person is likely cured of HIV, and another is in long-term remission

Two new cases presented Wednesday at the International AIDS Conference in Montreal have advanced the field of HIV cure science, demonstrating yet again that ridding the body of all copies of viable virus is indeed possible, and that prompting lasting viral remission also might be attainable. 

In one case, scientists reported that a 66-year-old American man with HIV has possibly been cured of the virus through a stem cell transplant to treat blood cancer. The approach — which has demonstrated success or apparent success in four other cases — uses stem cells from a donor with a specific rare genetic abnormality that gives rise to immune cells naturally resistant to the virus. 

In another case, Spanish researchers determined that a woman who received an immune-boosting regimen in 2006 is in a state of what they characterize as viral remission, meaning she still harbors viable HIV but her immune system has controlled the virus’s replication for over 15 years.

Experts stress, however, that it is not ethical to attempt to cure HIV through a stem cell transplant — a highly toxic and potentially fatal treatment — in anyone who is not already facing a potentially fatal blood cancer or other health condition that would make them a candidate for such a treatment.

“While a transplant is not an option for most people with HIV , these cases are still interesting, still inspiring and illuminate the search for a cure,” Dr. Sharon Lewin, an infectious disease specialist at the Peter Doherty Institute for Infection and Immunity at the University of Melbourne, told reporters on a call last week ahead of the conference.

There are also no guarantees of success through the stem cell transplant method. Researchers have failed to cure HIV using this approach in a slew of other people with the virus.

Nor is it clear that the immune-enhancing approach used in the Spanish patient will work in additional people with HIV. The scientists involved in that case told NBC News that much more research is needed to understand why the therapy appears to have worked so well in the woman — it failed in all participants in the clinical trial but her — and how to identify others in whom it might have a similar impact. They are trying to determine, for example, if specific facets of her genetics might favor a viral remission from the treatment and whether they could identify such a genetic profile in other people. 

The ultimate goal of the HIV cure research field is to develop safe, effective, tolerable and, importantly, scalable therapies that could be made available to wide swaths of the global HIV population of some 38 million people. Experts in the field tend to think in terms of decades rather than years when hoping to achieve such a goal against a foe as complex as this virus.

The new cure case

Diagnosed with HIV in 1988, the man who received the stem cell transplant is both the oldest person to date — 63 years old at the time of the treatment — and the one living with HIV for the longest to achieve an apparent success from a stem cell transplant cure treatment.

The white male — dubbed the “City of Hope patient” after the Los Angeles cancer center where he received his transplant 3½ years ago — has been off of antiretroviral treatment for HIV for 17 months.

“We monitored him very closely, and to date we cannot find any evidence of HIV replicating in his system,” said Dr. Jana Dickter, an associate clinical professor in the Division of Infectious Diseases at City of Hope. Dickter is on the patient’s treatment team and presented his case at this week’s conference.

This means the man has experienced no viral rebound. And even through ultra-sensitive tests, including biopsies of the man’s intestines, researchers couldn’t find any signs of viable virus.

The man was at one time diagnosed with AIDS, meaning his immune system was critically suppressed. After taking some of the early antiretroviral therapies, such as AZT, that were once prescribed as individual agents and failed to treat HIV effectively, the man started a highly effective combination antiretroviral treatment in the 1990s.  

In 2018, the man was diagnosed with acute myeloid leukemia, or AML. Even when HIV is well treated, people with the virus are still at greater risk of a host of cancers that are associated with aging, including AML and other blood cancers. Thanks to effective HIV treatment , the population of people living with the virus in the U.S. is steadily aging; the majority of people diagnosed with HIV is now older than 50.

He was treated with chemotherapy to send his leukemia into remission prior to his transplant. Because of his older age, he received a reduced intensity chemotherapy to prepare him for his stem cell transplant — a modified therapy that older people with blood cancers are better able to tolerate and that reduces the potential for transplant-related complications. 

Next, the man received the stem cell transplant from the donor with an HIV-resistant genetic abnormality . This abnormality is seen largely among people with northern European ancestry, occurring at a rate of about 1% among those native to the region.

According to Dr. Joseph Alvarnas, a City of Hope hematologist and a co-author of the report, the new immune system from the donor gradually overtook the old one — a typical phenomenon.

Some two years after the stem cell transplant, the man and his physicians decided to interrupt his antiretroviral treatment. He has remained apparently viable-virus free ever since. Nevertheless, the study authors intend to monitor him for longer and to conduct further tests before they are ready to declare that he is definitely cured.

The viral remission case

A second report presented at the Montreal conference detailed the case of a 59-year-old woman in Spain who is considered to be in a state of viral remission. 

The woman was enrolled in a clinical trial in Barcelona in 2006 of people receiving standard antiretroviral treatment. She was randomized to also receive 11 months of four therapies meant to prime the immune system to better fight the virus, according to Núria Climent, a biologist at the University of Barcelona Hospital Clinic, who presented the findings.

Then Climent and the research team decided to take the woman off her antiretrovirals, per the study’s planned protocol. She has now maintained a fully suppressed viral load for over 15 years. Unlike the handful of people either cured or possibly cured by stem cell transplants, however, she still harbors virus that is capable of producing viable new copies of itself.

Her body has actually controlled the virus more efficiently with the passing years, according to Dr. Juan Ambrosioni, an HIV physician in the Barcelona clinic.  

Ambrosioni, Climent and their collaborators said they waited so long to present this woman’s case because it wasn’t until more recently that technological advances have allowed them to peer deeply into her immune system and determine how it is controlling HIV on its own. 

“It’s great to have such a gaze,” Ambrosioni said, noting that “the point is to understand what is going on and to see if this can be replicated in other people.”

In particular, it appears that what are known as her memory-like NK cells and CD8 gamma-delta T cells are leading this effective immunological army.

The research team noted that they do not believe that the woman would have controlled HIV on her own without the immune-boosting treatment, because the mechanisms by which her immune cells appear to control HIV are different from those seen in “elite controllers,” the approximately 1 in 200 people with HIV whose immune systems can greatly suppress the virus without treatment.

Lewin, of Australia’s Peter Doherty Institute, told reporters last week that it is still difficult to judge whether the immune-boosting treatment the woman received actually caused her state of remission. Much more research is needed to answer that question and to determine if others might also benefit from the therapy she received, she said.

Four decades of HIV, a handful of cures

Over four decades, just five people have been cured or possibly cured of HIV. 

The virus remains so vexingly difficult to cure because shortly after entering the body it infects  types of long-lived immune cells that enter a resting, or latent, state. Because antiretroviral treatment only attacks HIV when infected cells are actively churning out new viral copies, these resting cells, which are known collectively as the viral reservoir and can stay latent for years, remain under the radar of standard treatment. These cells can return to an active state at any time. So if antiretrovirals are interrupted, they can quickly repopulate the body with virus.

The first person cured of HIV was the American Timothy Ray Brown , who, like the City of Hope patient, was diagnosed with AML. His case was announced in 2008 and then published in 2009. Two subsequent cases were announced at a conference in 2019, known as the Düsseldorf and London patients, who had AML and Hodgkin lymphoma, respectively. The London patient, Adam Castillejo , went public in 2020.

Compared with the City of Hope patient, Brown nearly died after the two rounds of full-dose chemotherapy and the full-body radiation he received. Both he and Castillejo had a devastating inflammatory reaction to their treatment called graft-versus-host disease. 

Dr. Björn Jensen, of Düsseldorf University Hospital, the author of the German case study — one typically overlooked by HIV cure researchers and in media reports about cure science — said that with 44 months passed since his patient has been viral rebound-free and off of antiretrovirals, the man is “almost definitely” cured.

“We are very confident there will be no rebound of HIV in the future,” said Jensen, who noted that he is in the process of getting the case study published in a peer-reviewed journal. 

For the first time, University of Cambridge’s Ravindra Gupta, the author of the London case study stated, in an email to NBC News, that with nearly five years passed since Castillejo has been off of HIV treatment with no viral rebound, he is “definitely” cured.

In February, a research team announced the first case of a woman and the first in a person of mixed race possibly being cured of the virus through a stem cell transplant. The case of this woman, who had leukemia and is known as the New York patient, represented a substantial advance in the HIV cure field because she was treated with a cutting-edge technique that uses an additional transplant of umbilical cord blood prior to providing the transplant of adult stem cells.

The combination of the two transplants, the study authors told NBC News in February, helps compensate for both the adult and infant donors being less of a close genetic match with the recipient. What’s more, the infant donor pool is much easier than the adult pool to scan for the key HIV-resistance genetic abnormality. These factors, the authors of the woman’s case study said, likely expand the potential number of people with HIV who would qualify for this treatment to about 50 per year

Asked about the New York patient’s health status, Dr. Koen van Besien, of the stem cell transplant program at Weill Cornell Medicine and New York-Presbyterian in New York City, said, “She continues to do well without detectable HIV.”

Over the past two years, investigators have announced the cases of two women who are elite controllers of HIV and who have vanquished the virus entirely through natural immunity. They are considered likely cured .

Scientists have also reported several cases over the past decade of people who began antiretroviral treatment very soon after contracting HIV and after later discontinuing the medications have remained in a state of viral remission for years without experiencing viral rebound.

Speaking of the reaction of the City of Hope patient, who prefers to remain anonymous, to his new HIV status, Dickter said: “He’s thrilled. He’s really excited to be in that situation where he doesn’t have to take these medications. This has just been life-changing.”

 The man has lived through several dramatically different eras of the HIV epidemic, she noted.   

“In the early days of HIV, he saw many of his friends and loved ones get sick and ultimately die from the disease,” Dickter said. “He also experienced so much stigma at that time.” 

As for her own feelings about the case, Dickter said, “As an infectious disease doctor, I’d always hoped to be able to tell my HIV patients that there’s no evidence of virus remaining in their system.” 

Follow  NBC HEALTH  on  Twitter  &  Facebook . 

Benjamin Ryan is independent journalist specializing in science and LGBTQ coverage. He contributes to NBC News, The New York Times, The Guardian and Thomson Reuters Foundation and has also written for The Washington Post, The Nation, The Atlantic and New York.

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• High-Impact Prevention
• Case Studies

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• National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention

HIV Screening and Testing

What to know.

HIV testing and screening are important first steps in diagnosing infection. Diagnosing HIV infection early is cost-effective and saves the public money on direct medical costs. Expanding HIV testing saves lives and prevents others from getting infected.

The benefits of HIV screening and testing

In 2015, approximately 39,000 persons received a new HIV (human immunodeficiency virus) infection diagnosis. HIV testing is the vital first step for HIV care and effective prevention. These persons had been living undiagnosed with HIV but now know their status and have the opportunity to receive life-saving treatment.

HIV diagnosis also greatly reduces the risk of transmitting the virus to others. Persons without HIV learn about effective tools for reducing their risk of getting infected.

Cost-effectiveness of HIV screening and testing

Initial studies reported voluntary HIV screening to be cost-effective in health care settings where undiagnosed HIV infection is less than ≥0.1% 1 2 . It was also reported to be more cost-effective than many established screening programs for chronic disease (e.g., hypertension, colon cancer, and breast cancer). 2 3 Treatment costs are lowered as well because treatment can begin before severe immunologic compromise occurs.

A more recent study reported HIV testing in clinical settings is cost-saving. This study focused on a model with consistent, standardized methods of evaluating the costs and effects of established and emerging HIV prevention strategies. 4

The unit cost of testing was adjusted by the positivity rate of persons tested (0.6%). This was based on reports of HIV testing from CDC-funded sites to find a cost per new diagnosis. It found that the cost per case of HIV prevented by testing in a clinical setting was less than the lifetime treatment cost per HIV case.

Effectiveness of expanded testing in the United States

CDC-funded testing programs in the U.S. are substantial. They led to approximately one-third of all new HIV diagnoses in 2013.

From 2007 to 2010, CDC-funded Expanded Testing Initiative sites provided more than 2.8 million HIV tests. These tests resulted in approximately 18,000 new HIV diagnoses and saved $1.2 billion in direct medical costs. 4 For every $1.00 spent on HIV testing, CDC saved the general public $2.00 on direct medical costs.

As more people receive an HIV infection diagnosis, the percentage of people who are unaware of their infection decreases. In 2006, 19% of persons with HIV were unaware of their infection. In 2014, this decreased to 15%. 5 Some of the biggest improvements were among young gay and bisexual males between the ages of 13-24. 6 This group was previously at the highest risk of HIV infection.

• Walensky RP, Weinstein MC, Kimmel AD, et al. Routine human immunodeficiency virus testing: an economic evaluation of current guidelines. Am J Med 2005;118:292–300.
• Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States—an analysis of cost-effectiveness. N Engl J Med 2005;352:586–95.
• Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005;352:570–85.
• Lin F, Farnham PG, Shrestha RK, Mermin J, Sansom SL. Cost effectiveness of HIV prevention interventions in the U.S. Am J Prev Med 2016; 50:699–708.
• Satcher Johnson A, Song R, Hall HI. State-level estimates of HIV incidence, prevalence, and undiagnosed infections [Abstract 899]. Presented at the Conference on Retroviruses and Opportunistic Infections, Seattle, Washington, February 13–16, 2017.
• Singh S, Song R, Satcher Johnson A, McCray E, Hall HI. HIV incidence, prevalence and undiagnosed infections in men who have sex with men [Abstract 30]. Presented at the Conference on Retroviruses and Opportunistic Infections, Seattle, Washington, February 13–16, 2017.
• Krueger A, Dietz P, Van Handel M, Belcher L, Johnson AS. Estimates of CDC-funded and national HIV diagnoses: a comparison by demographic and HIV-related factors. AIDS Behav 2016;20:2961–5.

High-Impact Prevention is a cost-effective, proven, scalable public health approach that prevents new infections, saves life-years, and reduces disparities.

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Discovery of HIV variant shows virus can evolve to be more severe — and contagious

Melody Schreiber

A colorized electron microscope image from the National Institute of Allergy and Infectious Diseases shows a single human immunodeficiency virus budding from a human immune cell. AP hide caption

A colorized electron microscope image from the National Institute of Allergy and Infectious Diseases shows a single human immunodeficiency virus budding from a human immune cell.

A variant of HIV that is faster at progressing to serious illness and more contagious than other versions of the virus has been circulating in the Netherlands for decades, researchers have found.

The findings, which were published in the journal Science on Thursday, demonstrate how HIV can mutate to create more severe disease and more rapid transmission.

"Even after 100 years of HIV infecting humans, it still has the capacity to evolve and change," says Joel Wertheim , associate professor of medicine at the University of California, San Diego, who was not involved in the study but wrote a perspective about the research findings, also published in Science on Thursday.

Fact check: The theory that SARS-CoV-2 is becoming milder

The study serves as a reminder — in the age of COVID variants — that viruses don't always weaken over time. "We should never underestimate the potential for viral evolution," Wertheim says. "Let this study stand in stark contrast to the claim that all viruses will inevitably evolve to be benign."

A contagious new discovery

The discovery of the HIV variant was sparked by a curious set of samples.

In late 2018, Chris Wymant , the lead author of the study and senior researcher at the Big Data Institute at University of Oxford, noticed something interesting in a database for a project called BEEHIVE , which collects HIV samples from Uganda and several countries in Europe to help scientists understand how the virus is evolving.

There was a recent cluster of 17 samples that showed a lot of unusual mutations, he says — and 15 of the samples came from the Netherlands.

Wymant and his co-authors wanted to know more, so they dived into another Dutch study with more data. They discovered a total of 109 people who had this particular variant and never knew it, dating all the way back to 1992. The variant probably emerged in the late '80s, Wymant says, picking up steam around 2000 and then eventually slowing down around 2010.

People with this variant have a viral load that is three to four times higher than usual for those with HIV. This characteristic means the virus progresses into serious illness twice as fast — and also makes it more contagious, says Wymant.

History Repeats Itself: COVID-19 Vaccine Inequities Echo HIV Crisis

The good news: Existing medications work very well to treat even very virulent variants like this one, cutting down on transmission and reducing the chance of developing severe illness, he says.

"Nobody should be alarmed," Wymant says. "It responds exactly as well to treatment as HIV normally does."

There's no need to develop special treatments for this variant, he adds. It shows no signs at all of resisting medications, as some HIV variants do. But because the variant moves quickly, people need to receive medicine as fast as possible.

How to slow down the variant

This research was "nicely done" and "well-designed," says Adeeba Kamarulzaman , president of the International AIDS Society and professor of medicine at the University of Malaya, who did not work on the study.

It also helps answer a pressing question in the field of HIV research, she notes. Previously, researchers wondered whether people get sicker or are more contagious because of how their immune systems respond to the virus. The study found that individual responses are part of it but not all. It can also happen if a virus evolves to cause more severe illness and readier transmission.

Kamarulzaman warns that a mutation like this could happen in other places. If a number of HIV patients in a particular area have this kind of variant but isn't taking medication, "you are going to have a lot more people with advanced disease a lot more quickly," she says.

To prevent this from happening, she says, "early tests or frequent testing and immediate initiation of treatment is the way to go." The goal isn't to identify a specific variant but rather to diagnose new cases of HIV so that treatment may start as soon as possible. But some countries still struggle to do that, and they need more support, she adds.

Ambitious Plan To Stem HIV/AIDS Epidemic Meets None Of Its Goals

That's how this variant eventually slowed down in the Netherlands before researchers even identified it.

"The public health intervention that's been rolled out and expanded in the Netherlands over the last decade or so — improving access to treatments, getting people tested as soon as possible, getting them onto treatment as soon as possible — has helped reduce the numbers of this variant, even though we didn't know that it existed," Wymant says.

Rapid treatment also helps slow viral evolution, so variants like these are less likely to emerge.

"This doesn't mean we need to change strategy," Wertheim says. "It just means we need to do more of what we're already doing."

Melody Schreiber (@m_scribe) is a journalist and the editor of What We Didn't Expect: Personal Stories About Premature Birth .

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Meeting the complex needs of individuals living with HIV: a case study approach

Affiliation.

• 1 HIV Specialist Nurse, St Thomas' Hospital, London.
• PMID: 25381847
• DOI: 10.12968/bjcn.2014.19.11.526

This article critically discusses the nursing care and management of a person living with the human immunodeficiency virus (HIV) infection as a long-term condition, requiring highly complex HIV care. Complex HIV care is managed in the secondary care setting. However, recent legislation has motivated shifts in HIV care to the community care setting. This article aims to enhance health professionals' understanding in order to equip practice and district nurses to deliver HIV care provision. Antiretroviral adherence is a prerequisite for disease survival as well as an essential component of complete HIV self-care management. It is therefore imperative that nurses tailor adherence strategies according to each patient's requirements. Case management strategies such as the use of cognitive behavioural therapy to alleviate depressive symptoms will be considered. Furthermore, the use of motivational interviewing for antiretroviral adherence is highlighted as a potential intervention to help patients overcome the physical, psychological and physiological challenges of living with HIV-associated comorbidities. The delivery of integrated HIV care is pivotal for the management of the person living with HIV, as is the facilitation of a self-caring behaviour.

Keywords: Disease management; HIV; HIV-associated depression; Long-term conditions; Self-management.

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• [A review of socio-behavioural studies on adherence to antiretroviral treatments: beyond biomedical models?]. Moatti JP, Spire B, Duran S. Moatti JP, et al. Rev Epidemiol Sante Publique. 2000 Apr;48(2):182-97. Rev Epidemiol Sante Publique. 2000. PMID: 10804427 Review. French.
• Study of the impact of HIV genotypic drug resistance testing on therapy efficacy. Van Vaerenbergh K. Van Vaerenbergh K. Verh K Acad Geneeskd Belg. 2001;63(5):447-73. Verh K Acad Geneeskd Belg. 2001. PMID: 11813503 Review.
• Comprehensive clinical adherence interventions to enable antiretroviral therapy: a case report. Nicca D, Moody K, Elzi L, Spirig R. Nicca D, et al. J Assoc Nurses AIDS Care. 2007 Nov-Dec;18(6):44-53. doi: 10.1016/j.jana.2007.03.011. J Assoc Nurses AIDS Care. 2007. PMID: 17991598
• Effect of individual cognitive behaviour intervention on adherence to antiretroviral therapy: prospective randomized trial. Weber R, Christen L, Christen S, Tschopp S, Znoj H, Schneider C, Schmitt J, Opravil M, Günthard HF, Ledergerber B; Swiss HIV Cohort Study. Weber R, et al. Antivir Ther. 2004 Feb;9(1):85-95. Antivir Ther. 2004. PMID: 15040540 Clinical Trial.
• Effects of nurse-delivered home visits combined with telephone calls on medication adherence and quality of life in HIV-infected heroin users in Hunan of China. Wang H, Zhou J, Huang L, Li X, Fennie KP, Williams AB. Wang H, et al. J Clin Nurs. 2010 Feb;19(3-4):380-8. doi: 10.1111/j.1365-2702.2009.03048.x. J Clin Nurs. 2010. PMID: 20500277 Clinical Trial.
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Kaposi Sarcoma as Presentation of HIV – A Clinical Case

1 Internal Medicine, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT

Leonor Silva

Renata monteiro, filipa santos, margarida mota.

Kaposi sarcoma (KS) is the most common neoplasm of people with human immunodeficiency virus (HIV) infection. Although, in the antiretroviral therapy (ART) era, KS is a rare form of presentation of HIV/acquired immunodeficiency syndrome. The authors present a case of disseminated KS in a 23-year-old male. Just after the diagnosis the patient started ART and then chemotherapy with placlitaxel with clinical improvement. This case is highly representative of the complexity of HIV. The authors aim to bring awareness of an unusual form of presentation of HIV, and recall the severity and the necessity of an early diagnosis and treatment.

Introduction

Kaposi sarcoma (KS) is the most common neoplasm of patients with human immunodeficiency virus (HIV) infection [ 1 ]. In the antiretrovirals era, the incidence of KS decreased from 15.2/1000 patient-year to 4.9/1000 patient-year and so; nowadays, KS is an unusual presentation of HIV [ 2 ]. KS is a multifocal angioproliferative neoplasm associated with the infection by human herpes virus type 8 (KSHV) [ 1 ]. KSHV has been shown to be the etiologic agent for several other tumors and diseases, including primary effusion lymphoma (PEL), an extracavitary variant of PEL, KS-associated diffuse large B-cell lymphoma, a form of multicentric Castleman disease (MCD), and KS inflammatory cytokine syndrome (KICS). KICS is an entity recently described in patients with HIV and KSHV. The syndrome is characterized by lymphadenopathy, pancytopenia, and signs of systemic inflammatory syndrome [ 3 ]. Lymph node, bone marrow, or splenic biopsy can be used to distinguish from MCD [ 3 ]. KICS has a higher mortality than MCD [ 3 ].

Cutaneous KS presents as red, violaceous (purple), or brown lesions, from macules, patches, and papules to nodules or tumors. These lesions of the skin are highly characteristic, facilitating the diagnosis, although disseminated disease may affect any organ. The most common sites of disease dissemination include the skin, mucosal surfaces, respiratory tract, and lymph nodes, and extensive disseminated disease is often associated with lymphedema [ 4 ].

KS makes a differential diagnosis with bacillary angiomatosis, nevus, and B-cell lymphoma. Biopsy is the gold standard for diagnosis [ 5 ].

Case presentation

A 23-year-old male with type I diabetes resorted to an outpatient clinic complaining of disseminated dermatosis. The patient referred multiple non-pruritic skin lesions over his chest with one-year evolution, with further progression to his arms and limbs. He mentioned a significant involuntary weight loss of 15%, associated with fever predominantly in the afternoon for the last two months. He also experienced diarrhea persisting for more than two weeks. Anorexia and night sweats were denied.

He had an unprotected heterosexual exposure in the past. There was no history of blood transfusion, injection drug use, or needle sharing. His only medication was insulin. 

On physical examination, the patient was alert, oriented but emaciated, with multiple violaceous papules and nodules in his trunk, arms, and legs (Figure ​ (Figure1). 1 ). Oral mucosa was not affected. He had no palpable lymphadenopathy nor splenomegaly. His vitals showed normal blood pressure of 120/72 mmHg, sinus tachycardia around 140-150 pulse per minute, and temperature of 36.5ºC. On lung examination, he presented with diminished breath sounds bilaterally with no other alterations in the physical examination. Oxygen saturation on room air was 97%.

The lab results showed hemoglobin 9.4 g/dL, white blood cells 2,770/uL, lymphocytopenia 810/uL, CD4+ T lymphocyte count of 23 cells/mm 3 , normal renal function, no cytocolestase (total bilirubin 0.27 mg/dL, glutamic-oxaloacetic transaminase 23 U/L, pyruvic transaminase 13 U/L, gamma-glutamyl transferase 35 U/L, and alkaline phosphatase 89 U/L), C-reactive protein 1.92 mg/dL, and sedimentation velocity 67 mm/h. HIV1 serology (fourth-generation test) was positive, and the HIV viral load (VL) of 1,820,000 copies/mm 3 . Chest x-ray demonstrated an hypotransparency of the right lower lobe (Figure ​ (Figure2 2 ).

A chest computed tomography (CT) showed bilateral pleural effusion and vaguely nodular areas with ground glass pattern, more evident in the right lower lobe, associated with thickening of the interlobular septa (Figure ​ (Figure3). 3 ). These lesions, considering the context, were suggestive of pulmonary KS, although lymphoma, tuberculosis, fungal infection, or other opportunistic infections could not be excluded.

CT, computed tomography

Skin biopsy of the lesion demonstrated dermal vascular proliferation with thin-walled and irregular vessels. Endothelial cells formed a disorganized monolayer with dissolution of collagen fibers and perianexial infiltration. Immunohistochemistry was positive for CD34, ERG, and KSHV. These findings are compatible with KS skin lesions.

Bronchoscopy and bronchoalveolar lavage (BAL) were performed. Direct examination with gram stain and cultural examination BAL were negative for the presence of bacteria. Also, cultural mycological examination and direct examination, molecular biology, and cultural examination for mycobacterium were negative. The BAL cytology excluded the presence of malignant cells.  Pneumocystis jiroveci was also excluded by polymerase chain reaction. Although the characteristic lesions, as the violaceous lesions, were not identified on bronchoscopy and the BAL was negative for malignant cells, given the changes in the chest CT, the most likely diagnosis was KS with pulmonary involvement.

Stool cultures were negative for parasites ( Giardia and Cryptosporidium ), bacterial (cultural examination performed for  Salmonella spp , Shigella spp , Yersinia spp , Campylobacter spp , Escherichia coli O157:H7, and vibrionaceas ), and Clostridiodes difficile (glutamate dehydrogenase antigen and toxin A and B screening). Colonoscopy exhibited two small ulcers on transverse colon, while the biopsy revealed colorectal mucosa with colitis, positive for cytomegalovirus (CMV) (histological examination suggestive of viral inclusions by CMV, confirmed by immunohistochemistry). Histology was negative for KS and no expression of KSHV was observed.

An ophthalmologic evaluation revealed perivascular retinal opacification in the infero-nasal quadrant of the right eye suggestive of CMV retinitis.

The patient completed 21 days of treatment with valganciclovir (900 mg twice daily) with resolution of gastrointestinal complaints followed by secondary prophylaxis valganciclovir (900 mg once daily).

Soon after the diagnosis the patient started antiretroviral therapy (ART) and was proposed to chemotherapy. With that aim, he underwent a transthoracic echocardiogram that exhibited moderate mitral regurgitation and severe depression of left ventricular systolic function, with a mean ejection fraction of 21%. He underwent Holter monitoring, which also revealed sinus tachycardia (average 118 beats per minute). Cardiac magnetic resonance imaging (MRI) showed dilated cardiomyopathy (non-ischemic etiology) with severe impairment of biventricular systolic function, and intramural fibrosis at the level of the basal and middle segments of the interventricular septum - stria mesocardial. The fibrosis pattern described can be found in the context of post-myocarditis, familial or idiopathic etiology, and associated with poor prognosis. Although the patient had no family history of sudden cardiac death, syncope, or left ventricular hypertrophy, genetic testing for cardiomyopathies was performed and confirmed the suspicion of hereditary cardiomyopathy (the c.43009del p. variant of the TNN gene, in heterozygosity; and the c.4046G>A variant in the DSP gene, of uncertain significance). He was initiated on prognostic modifying therapy for heart failure (as angiotensin receptor-neprilysin inhibitor, beta blocker, and aldosterone receptor antagonist).

At this point, it is not clear whether the heart failure is explained by the HIV involvement of the heart or the presence of hereditary cardiomyopathy. The echocardiogram was repeated after four months and revealed a great improvement, already with normal left ventricular systolic function.

The patient was treated with paclitaxel (100 mg/m 2 , every 15 days), and after six cycles he presented with partial response with a great improvement of the lung lesions and was kept in the same chemotherapy scheme. Five months after ART (darunavir 800 mg plus cobicistat 150 mg, emtricitabine 200 mg, and tenofovir alafenamide) and chemotherapy the patient still has countless violaceous lesions on the trunk and upper limbs, now more tenuous and without relief. The patient has HIV VL of 45 copies/mL and 38 CD4+ T cells.

The clinical manifestations in our patient highlight the potentially aggressive course of KS in people living with HIV (PLWH). The disseminated presentation of acquired immunodeficiency syndrome (AIDS)-associated KS has a poor prognosis [ 3 ]. Pulmonary involvement generally occurs in severely immunosuppressed patients who already have mucocutaneous or digestive involvement, though 15% of patients with pulmonary KS have no mucocutaneous lesions at diagnosis [ 6 ].

Pulmonary involvement is particularly important, as it is associated with worse prognosis and increased mortality compared with other systems [ 7 ]. In a cohort of 305 HIV-1-infected patients diagnosed with KS since 1996, the median survival time for patients with pulmonary KS was 19 months compared with a median survival time of four months reported for the same cohort in the pre-ART era [ 8 ].

Given the frequency of opportunistic pulmonary infections in PLWH, diagnosing lung involvement is often a challenge. Even bronchoscopy may fail to establish the diagnosis. Mitchell and Miller reported that only 45% of cases have endobronchial lesions located at segmental orifices in the main trachea or bronchi that are reachable with a bronchoscope [ 9 ]. In pre-ART era, the estimated incidence of pulmonary KS in patients living with AIDS was around 30% [ 10 ].

According to AIDS Clinical Trials Group system for AIDS-related KS, patients are assessed on the extent of tumor (T), the status of the immune system (I), and the presence of systemic illness (S). In the era of ART, CD4 level does not seem to provide prognostic information. Two different risk categories were identified: a good risk (T0S0, T1S0, T0S1) and a poor risk (T1S1). Our patient presented with high-risk factors: widespread KS lesions (T1) and systemic illness (opportunistic infection and B symptoms - as fever, night sweats, and significant weight loss).

Currently, there is no cure for KS; therefore, the aim of the therapy is to slow disease progression and alleviate symptoms. Therapeutic options depend on the extent and rate of tumor growth, VL, and CD4+ T lymphocyte count. Localized skin disease can be treated with ART and some local therapies (laser CO 2 , cryotherapy, radiotherapy, intralesional vinblastine) [ 11 ]. There are no defined criteria for systemic KS therapy, and the decision should be individualized. Systemic KS therapy is usually administered to patients with widespread T1 disease, extensive cutaneous KS, symptomatic or life-threatening visceral KS, ulcerating KS, KS associated with edema, or tumor-related pain [ 12 ]. Also, systemic therapy is justified in patients that fail to respond to ART [ 12 ]. A 2014 review suggested that ART plus chemotherapy may be beneficial in reducing disease progression compared to ART alone in patients with severe or progressive KS [ 13 ]. Cytotoxic chemotherapy represents the standard of care, and liposomal formulations of doxorubicin or daunorubicin and paclitaxel show similar clinical efficacy [ 13 , 14 ]. However, KSHV cannot be eradicated; tumors may recur and patients often require additional therapies. Chronic administration of cytotoxic agents is poorly tolerated, and in this setting, drugs such as pomalidomide/lenalidomide may be discussed [ 11 ].

Importantly, patients co-infected with KS and HIV often develop more than one KSHV-associated disease. Active KSHV replication has also been associated with KICS. The clinical presentation mimics sepsis with respiratory failure and often leading to mechanical ventilation and vasopressor use. However, these patients do not improve with standard antibiotic therapy. It occurs due to overproduction of KSHV-related interleukins (IL-6 and IL-10) and symptoms are from the associated cytokine storm. Although there is no established gold standard of treatment, addition of immunomodulatory therapy such as rituximab to the ongoing ART has been shown to result in improvement in clinical status. KICS has a high mortality rate if left untreated and early recognition and management is important to improve patient outcomes. It has been hypothesized that treating the underlying tumor may decrease KSHV-associated cytokines. However, in situations where this syndrome is present, treating the original sarcoma is not easy due to related comorbidities. Another drug that may be used is ganciclovir, which has activity against KSHV. Finally, liposomal doxorubicin can be used to eliminate KS spindle cells and prevent the aggressive proliferation of KS lesions with concurrent rituximab treatment [ 15 ].

Conclusions

The risk of AIDS-related KS has declined since the introduction of ART in the mid-1990s. However, it remains highly prevalent in PLWH and can arise at any time during the course of HIV infection. It accelerates the clinical course of HIV infection, and generally occurs at CD4 count <200 cells/mm 3 . Response to treatment is variable according to lesion extension and patient immunity status. 

It is now appreciated that KSHV can cause several diseases, several of which had not been previously recognized.

This case emphasizes the need to recognize these skin lesions, and strongly consider pulmonary KS as a possible cause for respiratory illness in any PLWH with low CD4 counts. Chest CT findings can play an important role in the diagnosis of pulmonary KS, since characteristic patterns may be observed. BAL must be performed in all pulmonary KS patients to rule out the possibility of concomitant infection.

This case reflects the complexity of HIV and reinforces the need for greater awareness in screening regardless of whether a clear risk behavior has been identified.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study

NIH Calls for Implementation Science to Help End HIV in the United States

Funding News Edition: September 4, 2024 See more articles in this edition

NIAID, along with several other NIH institutes and centers (ICs), has issued a  Notice of Special Interest (NOSI): Ending the HIV Epidemic (EHE) , which solicits implementation science projects to advance the goals of the  Ending the HIV Epidemic in the U.S. (EHE) Initiative . The Initiative, launched in 2019, is a bold plan developed by agencies across HHS to substantially reduce new HIV infections in communities disproportionately impacted by HIV.  

Awarded projects responsive to this NOSI will have the opportunity to become part of a national network of HIV implementation science researchers, with access to resources and support from the NIH-funded  Coordination, Consultation and Data Management Center (CCDMC) and  Regional Implementation Science Hubs . Awardees will maximize the public health impact of their projects by working with the CCDMC to report and disseminate study progress and outcomes. In addition to networking with other researchers, awardees will also have opportunities to engage with federal staff across HHS as they contribute to this important national initiative.  

Applications to this NOSI must be grounded in implementation science, and address one or more of the four strategies outlined in the EHE initiative:  

• Diagnose all people with HIV as early as possible. 
• Treat people with HIV rapidly and effectively to reach sustained viral suppression. 
• Prevent new HIV transmissions by using proven interventions, including pre-exposure prophylaxis (PrEP) and syringe services programs. 
• Respond quickly to potential HIV outbreaks to get needed prevention and treatment services to people who need them. 

Applications must also focus on one or more of the 57  EHE geographic priority areas . Projects should support local EHE efforts through meaningful engagement with implementing partners such as public health departments, healthcare organizations, and other service providers, as well as community members and people with lived experience. Interested applicants should refer to the full NOSI for a complete list of requirements.  

Examples of programmatic areas of interest include (but are not limited to): 

• Developing and testing strategies to expand engagement and re-engagement in HIV prevention, testing, treatment, care, and response services with a focus on populations that are either disproportionately impacted by HIV or are largely unreached by current programs, or both. This would include populations experiencing unstable housing or homelessness, or people who are currently or formerly incarcerated. 
• Utilizing a syndemics approach to develop and test holistic, multicomponent interventions to sustainably address structural and other social barriers to care and retention such as mental health conditions, substance use, medication adherence, management of chronic health conditions and comorbidities, housing instability, food insecurity, racism, poverty, transportation, and stigma. 
• Designing and testing integrated disease care models to address barriers to HIV prevention or treatment outcomes posed by chronic health comorbidities, including those associated with HIV and aging, and co-infections, including detection, prevention, and treatment of sexually transmitted infections. 
• Developing and testing rapid implementation strategies to improve HIV testing, care, and prevention services among people in sexual and needle-sharing networks affected by rapid HIV transmission such as clusters and outbreaks. 
• Developing effective dissemination approaches for communicating and integrating implementation knowledge to specific audiences, with the goal of scaling-up, replicating, and/or sustaining evidence-based strategies to improve HIV prevention, treatment, and response. 

Refer to the full NOSI for additional areas of interest. 

Research areas not supported by this NOSI include: 

• Research focused only on surveillance to identify people with HIV who are suboptimally engaged in existing HIV treatment programs. 
• Interventions that are not substantially different from conventional service delivery that failed to engage patients with extensive adherence challenges. 
• Drug or device safety trials with registration requirements. 
• Studies that do not include a multidisciplinary team approach, including a community partner. 
• Projects to develop de novo health interventions with a primary aim of testing efficacy. 
• Research focused on identifying social determinants as risk factors, without implementing interventions. 

Application and Submission Information 

This notice applies to due dates on or after September 7, 2024 , and subsequent receipt dates through January 9, 2026 . Select the IC and associated notice of funding opportunity (NOFO) to use for submission of an application in response to the NOSI (refer to the table below). For funding consideration, include “ NOT-AI-24-059 ” (without quotation marks) in the Agency Routing Identifier field (box 4B) of the SF 424 R&R form.   

Note that application details such as budget and project period limitations are set by the specific NOFO through which applicants choose to apply. 

Contacts  

For NIAID-related questions, contact Dr. Rebecca Mandt at  [email protected] or 301-435-7695, or Dr. Eric Refsland at  [email protected] or 301-761-7193. Refer to the NOSI for other ICs’ subject matter experts and their contact information.

Email us at [email protected] for help navigating NIAID’s grant and contract policies and procedures.

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UConn Today

September 3, 2024 | Anna Zarra Aldrich, College of Agriculture, Health and Natural Resources

New Study Reveals Relationship Between HIV Risk Factors for LGBTQ+ Youth

A new study has uncovered empirical evidence that shows the importance of taking a holistic approach to addressing HIV risk factors

Photo by Betzy Arosemena for Unspalsh)

A new study has uncovered empirical evidence that shows what researchers have long suspected about HIV risk – that having multiple risk factors is much worse than having only one.

Pablo Kokay Valente, assistant professor of allied health sciences in the College of Agriculture, Health and Natural Resources ( CAHNR ) led this study in collaboration with Ryan Watson, associate professor, and Lisa Eaton, professor, both in the Department of Human Development and Family Sciences. The study was recently published in the American Journal of Public Health.

For a long time, researchers looked at each of these factors independently. But recently there has been a push to consider their interactions.

Most papers looking at these factors have demonstrated a linear relationship. What this means is that if you have one factor at play – say, for example, depression – it is twice as bad to have two factors, like depression and alcohol use.

This new paper demonstrates an exponential relationship instead. This is something that scientists have theorized for years without much empirical evidence to support the hypothesis until now.

“Most studies haven’t been able to demonstrate this kind of synergistic relationship between the syndemic factors,” Valente says. “And that’s what we did. We’ve shown that having two factors is much worse than having one and having three factors is much, much worse than having two factors.”

The researchers used data from a survey of LGBTQ+ youth. LGBTQ+ people have historically and continue to be one group that is at a greater risk of contracting HIV.

“A major strength of this study was the use of our national sample of LGBTQ+ youth, many of whom reported intersections of multiple marginalized social positions,” Watson says. “Data collected with so many young LGBTQ+ youth give us a unique view into the complexities and nuances of the lived experiences of today’s LGBTQ+ teens.”

One unexpected finding is that the more factors an individual had, the more likely they were to be exposed to PrEP – a medication that can prevent the contraction of HIV even if you come into contact with the virus – and get information about the drug and its benefits.

“People who are exposed to these factors in combination, they have much more risk and they are probably more connected and more aware of what’s out there in terms of PrEP,” Valente says.

This understanding changes the way researchers think about interventions for people at risk of contracting HIV.

“Better understanding syndemic conditions in one of the most vulnerable youth populations — sexual and gender diverse adolescents — has been much needed, and this study contributes to the growing body of research by using a large national sample of LGBTQ+ youth,” Watson says.

If the linear model were accurate, it would not matter which HIV risk factor interventions were addressed since they all have, in theory, the same impact. But an exponential relationship demonstrates the need for interventions that tackle multiple risk factors at once to provide a substantial benefit.

“If they are linear, the implication is that whatever you address, there is some benefit to that,” Valente says. “Showing that it’s synergistic, it calls for interventions that address more than one of these things. Addressing two of these factors would have more of an impact than addressing things individually.”

For example, therapy-based interventions that address stigma surrounding HIV may also reduce substance use among participants, since that is a common coping strategy for stigmatization, and improve their overall mental health.

“They’re all deeply related,” Valente says. “So, I think dismantling several of them at a time will be very important.”

Valente is continuing to use the methods that uncovered the exponential relationship among LGBTQ+ people with a dataset of hospitals that provide care for people living with HIV.

This work relates to CAHNR’s Strategic Vision area focused on  Enhancing Health and Well-Being Locally, Nationally, and Globally and Promoting Diversity, Equity, Inclusion, and Justice.

Follow  UConn CAHNR  on social media

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Childhood HIV vaccination strategy shows promise in study

By wynne parry weill cornell medicine.

Research at Weill Cornell Medicine suggests that childhood immunization against HIV could one day provide protection before risk of contracting this potentially fatal infection dramatically increases in adolescence.

The study, published Aug. 30 in Science Immunology, demonstrated that a series of six vaccinations containing a modified protein from the surface of HIV particles stimulated initial steps of a potent immune response in young nonhuman primates. This difficult-to-achieve response represents an important step toward providing full and potentially lifelong protection against the virus, the researchers say.

Immunizing young children, rather than adults, makes sense because risk factors for HIV infection rise steeply when adolescents become sexually active, according to senior author  Dr. Sallie Permar , the Nancy C. Paduano Professor in Pediatrics and chair of the Department of Pediatrics at Weill Cornell Medicine.

Evidence also suggests that the immune systems of infants and children generally mount more effective responses to the virus than those of adults. Said Permar: “One of the advancements we’ve made is to demonstrate that an HIV vaccine could be delivered on a schedule similar to routine vaccines already given to babies and children.”

HIV predominantly infects immune cells called CD4 T cells, leaving individuals vulnerable to opportunistic diseases. Without lifelong treatment, infection is fatal. In 2022, an estimated  140,000 adolescents between ages 10 and 19 worldwide became infected with the virus – a group that is overrepresented in the number of new infections.

Vaccine researchers are seeking ways to stimulate the immune system to make “broadly neutralizing antibodies” against the virus before a person is exposed to it. These antibodies attack a crucial part of the HIV virus – the protein on its surface that binds to CD4 T cells. In doing so, broadly neutralizing antibodies prevent many strains of HIV from entering the cell and infecting it.

In this study, the researchers started with an experimental vaccine developed previously from spike proteins on the envelope of HIV particles. Study authors  John Moore , a professor of microbiology and immunology, and  Rogier Sanders , an adjunct associate professor of research in microbiology and immunology at Weill Cornell Medicine and a professor at  Amsterdam UMC , sought to improve this vaccine by altering the viral protein. They designed these changes to stimulate a specific set of antibody-producing B cells that protect CD4 T cells.

“An effective HIV vaccine needs to engage the right set of B cells in order to generate a broadly protective response,” said first author  Ashley Nelson , an assistant professor of immunology research in pediatrics. “We discovered that introducing certain mutations into the envelope protein could accomplish that in the setting of a naïve immune system.”

The researchers administered the modified vaccine to five young primates in three priming doses, starting less than a week after birth. They followed these with three doses of the vaccine matching the original HIV envelope protein, with the last dose given when the animals reached 78 weeks old, roughly equivalent to 4 or 5 years old for a human. As a control, five animals received all six doses of the original envelope protein vaccine.

“While exposure to the modified protein got the immune response started off in the right direction, booster shots containing the original version of the viral protein were necessary to reach full potential,” Nelson said. 

Three of the five animals that received the modified version of the priming vaccine developed antibodies that appeared to be precursors to the sought-after broadly neutralizing response. Tests suggested these antibodies attacked the site the virus uses to invade CD4 T cells. However, they were not yet fully effective against the same breadth of HIV strains as mature, broadly neutralizing antibodies. One of the three animals also showed signs of developing the mature, broadly neutralizing response.

The next step, Nelson said, is figuring out how to reliably elicit a full-on broadly neutralizing response. “We still need to identify the right combination of viral proteins to get us further down that path,” she said, “starting from the earliest stages in life when multi-dose vaccines are commonly given.”

This work was supported by grants from the National Institutes of Health.

Many Weill Cornell Medicine physicians and scientists maintain relationships and collaborate with external organizations to foster scientific innovation and provide expert guidance. The institution makes these disclosures public to ensure transparency. For this information, please see the profile for  Dr. Sallie Permar .

Wynne Parry is a freelance writer for Weill Cornell Medicine. 

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New study highlights potential of childhood immunization against HIV

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Research at Weill Cornell Medicine suggests that childhood immunization against HIV could one day provide protection before risk of contracting this potentially fatal infection dramatically increases in adolescence.   

The study, published Aug. 30 in Science Immunology, demonstrated that a series of six vaccinations containing a modified protein from the surface of HIV particles stimulated initial steps of a potent immune response in young non-human primates. This difficult-to-achieve response represents an important step toward providing full and potentially life-long protection against the virus, the researchers say.

Immunizing young children, rather than adults, makes sense because risk factors for HIV infection rise steeply when adolescents become sexually active, according to senior author Dr. Sallie Permar, the Nancy C. Paduano Professor in Pediatrics and chair of the Department of Pediatrics at Weill Cornell Medicine. 

What's more, evidence suggests that the immune systems of infants and children generally mount more effective responses to the virus than those of adults. One of the advancements we've made is to demonstrate that an HIV vaccine could be delivered on a schedule similar to routine vaccines already given to babies and children." Dr. Sallie Permar, the Nancy C. Paduano Professor in Pediatrics and chair of the Department of Pediatrics at Weill Cornell Medicine

Prepping the immune system early

HIV predominantly infects immune cells called CD4 T cells , leaving individuals vulnerable to opportunistic diseases. Without lifelong treatment, infection is fatal. In 2022, an estimated 140,000 adolescents between 10 and 19 years old worldwide became infected with the virus—a group that is overrepresented in the number of new infections.

Vaccine researchers are seeking ways to stimulate the immune system to make "broadly neutralizing antibodies " against the virus before a person is exposed to it. These antibodies attack a crucial part of the HIV virus—the protein on its surface that binds to CD4 T cells. In doing so, broadly neutralizing antibodies prevent many strains of HIV from entering the cell and infecting it.

In this study, the researchers started with an experimental vaccine developed previously from spike proteins on the envelope of HIV particles. Study authors Dr. John Moore, a professor of microbiology and immunology, and Dr. Rogier Sanders, an adjunct associate professor of research in microbiology and immunology at Weill Cornell Medicine and a professor at Amsterdam UMC, sought to improve this vaccine by altering the viral protein. They designed these changes to stimulate a specific set of antibody-producing B cells that protect CD4 T cells. 

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"An effective HIV vaccine needs to engage the right set of B cells in order to generate a broadly protective response," said first author Dr. Ashley Nelson, an assistant professor of immunology research in pediatrics at Weill Cornell Medicine. "We discovered that introducing certain mutations into the envelope protein could accomplish that in the setting of a naïve immune system."

Activating the right B cells for protection

The researchers administered the modified vaccine to five young primates in three priming doses, starting less than a week after birth. They followed up with three doses of the vaccine matching the original HIV envelope protein, with the last dose given when the animals reached 78 weeks old, roughly equivalent to four or five years old for a human. As a control, five animals received all six doses of the original envelope protein vaccine.

"While exposure to the modified protein got the immune response started off in the right direction, booster shots containing the original version of the viral protein were necessary to reach full potential," Dr. Nelson said.

Three of the five animals who received the modified version of the priming vaccine developed antibodies that appeared to be precursors to the sought-after broadly neutralizing response. Tests suggested these antibodies attacked the site the virus uses to invade CD4 T cells. However, they were not yet fully effective against the same breadth of HIV strains as mature broadly neutralizing antibodies. One of the three animals also showed signs of developing the mature, broadly neutralizing response.  

The next step is figuring out how to reliably elicit a full-on broadly neutralizing response, Dr. Nelson said. "We still need to identify the right combination of viral proteins to get us further down that path, starting from the earliest stages in life when multi-dose vaccines are commonly given."

Weill Cornell Medicine

Nelson, A. N.,  et al.  (2024) Immunization with germ line–targeting SOSIP trimers elicits broadly neutralizing antibody precursors in infant macaques . Science Immunology . doi.org/10.1126/sciimmunol.adm7097 .

Posted in: Child Health News | Medical Research News | Disease/Infection News

Tags: Adolescents , Allergy , Antibodies , Antibody , CD4 , Cell , Children , HIV , Immune Response , Immune System , Immunization , Immunology , Infectious Diseases , Medicine , Microbiology , Pediatrics , Protein , Research , Vaccine , Virus

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HIV cure has been reported for five individuals who received allogeneic hematopoietic stem cell transplant (allo-HSCT) from CCR5Δ32 homozygous donors. In contrast, viral rebound has occurred in other people living with HIV who interrupted antiretroviral treatment after receiving allo-HSCT, mostly from wild-type CCR5 donors. Here, we report the case of a male who has achieved durable HIV remission following allo-HSCT from an unrelated HLA-matched (9/10 matching for HLA-A, -B, -C, -DRB1 and -DQB1 alleles) wild-type CCR5 donor to treat an extramedullary myeloid tumor. To date, plasma viral load has remained undetectable for 32 months after the interruption of antiretroviral treatment. Treatment with ruxolitinib has been maintained during this period to treat chronic graft versus host disease. Low levels of proviral DNA were detected sporadically post-allo-HSCT, including defective but not intact HIV DNA. No virus could be amplified in cultures of CD4 + T cells obtained post antiretroviral treatment interruption, while CD4 + T cells remained susceptible to HIV-1 infection in vitro. Decline of HIV antibodies and undetectable HIV-specific T cell responses further corroborate the absence of viral rebound after antiretroviral treatment interruption. These results suggest that HIV remission could be achieved in the context of allo-HSCT with wild-type CCR5 .

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Author information, authors and affiliations.

Institut Pasteur, Université Paris Cité, Viral reservoirs and immune control unit, Paris, France

Asier Sáez-Cirión, Caroline Passaes, Valérie Monceaux, Anais Chapel, Mael Gourves & Marine Lechartier

Institut Pasteur, Université Paris Cité, HIV Inflammation and Persistence unit, Paris, France

Asier Sáez-Cirión, Caroline Passaes, Federico Perdomo-Celis, Valérie Monceaux & Anais Chapel

Division of Hematology, Department of Oncology, Geneva University Hospitals, Geneva, Switzerland

Anne-Claire Mamez

Institut Cochin - CNRS 8104 / INSERM U1016 / Université de Paris, Paris, France

Véronique Avettand-Fenoel, Adeline Melard & Elise Gardiennet

Université d’Orléans, LI2RSO, Virologie, CHU d’Orléans, France

Véronique Avettand-Fenoel

Institut Central des Hôpitaux, Sion, Switzerland

Mitja Nabergoj

Service of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland

Paul Thoueille & Laurent Decosterd

Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland

Paul Thoueille

HIV/AIDS Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland

Maxime Hentzien & Alexandra Calmy

IrsiCaixa, Badalona, Spain

Maria Salgado & Javier Martínez Picado

Germans Trias i Pujol Research Institute, Badalona, Spain

CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain

Translational Virology Research Group. Department of Global Public Health & Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands

Monique Nijhuis & Annemarie Wensing

HIV Pathogenesis Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Monique Nijhuis

Institut Pasteur, Université Paris Cité, Inserm U1222, Humoral Immunology unit, Paris, France

Valérie Lorin & Hugo Mouquet

Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Annemarie Wensing

UVic-UCC, Vic, Spain

Javier Martínez Picado

ICREA, Barcelona, Spain

Geneva University Hospitals, Laboratory of Virology, Geneva, Switzerland

Sabine Yerly

Private practitioner, Geneva, Switzerland

Mathieu Rougemont

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Corresponding authors

Correspondence to Asier Sáez-Cirión or Alexandra Calmy .

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Sáez-Cirión, A., Mamez, AC., Avettand-Fenoel, V. et al. Sustained HIV remission after allogeneic hematopoietic stem cell transplantation with wild-type CCR5 donor cells. Nat Med (2024). https://doi.org/10.1038/s41591-024-03277-z

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Received : 06 June 2024

Accepted : 27 August 2024

Published : 02 September 2024

DOI : https://doi.org/10.1038/s41591-024-03277-z

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