AIDS

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AIDS [ɛɪ̯t͡s] ( acronym of the English acquired immune deficiency syndrome "acquired immunodeficiency syndrome", also called "Acquired immune deficiency syndrome") refers to a specific combination of symptoms that caused in humans by an HIV -induced infection destruction of the immune system occur. The sick develop life-threatening opportunistic infections and tumors .

AIDS was recognized as a disease in its own right by the US Centers for Disease Control and Prevention (CDC) on December 1, 1981 , after defining the coincidence of certain symptoms as AIDS . AIDS is one of the sexually transmitted diseases . According to the United Nations Joint Program on HIV / AIDS(UNAIDS) there were around 37.9 million HIV-positive people worldwide in 2019. In 2019 there were around 1.7 million new HIV infections (4,650 per day) and around 0.77 million people died as a result of HIV / AIDS. 35 million people have died of AIDS since the epidemic began. The proportion of people infected with HIV is on average around 0.8% of 15 to 49 year olds worldwide, but in some African countries it is around 25%. No vaccination is available. The more effective treatment of HIV-infected people with new drugs has made AIDS less common in Central Europe .

From an immune cell out solved HIV
The red ribbon as a symbol of solidarity with HIV-positive and AIDS-sick people

Definition and classification

Classification in the ICD-10

Classification according to ICD-10
B20 Infectious and parasitic diseases as a result of HIV disease
B20.0 Mycobacterial infections due to HIV disease
(e.g. tuberculosis due to HIV disease)
B20.1 Other bacterial infections due to HIV disease
B20.2 Cytomegaly due to HIV disease
B20.3 Other viral infections due to HIV disease
B20.4 Candidiasis due to HIV disease
B20.5 Other mycoses due to HIV disease
B20.6 Pneumocystis pneumonia due to HIV disease
B20.7 Multiple infections as a result of HIV disease
B20.8 Other infectious and parasitic diseases resulting from HIV disease
B20.9 Unspecified infectious or parasitic disease resulting from HIV disease
B21 Malignant neoplasms as a result of HIV disease
B21.0 Kaposi's sarcoma as a result of HIV disease
B21.1 Burkitt's lymphoma as a result of HIV disease
B21.2 Other types of non-Hodgkin lymphoma due to HIV disease
B21.3 Other malignant neoplasms of the lymphatic, hematopoietic and related tissue as a result of HIV disease
B21.7 Multiple malignant neoplasms as a result of HIV disease
B21.8 Other malignant neoplasms due to HIV disease
B21.9 Unspecified malignant neoplasms as a result of HIV disease
B22 Other specified diseases resulting from HIV disease
B22.0 Encephalopathy due to HIV disease
B22.1 Interstitial lymphoid pneumonia due to HIV disease
B22.2 Cachexia syndrome as a result of HIV disease
B22.7 Several diseases classified elsewhere due to HIV disease
B23 Other disease conditions as a result of HIV disease
B23.0 Acute HIV infection syndrome
B23.1 (Persistent) generalized lymphadenopathy as a result of HIV disease
B23.2 HIV disease blood and immune abnormalities, not elsewhere classified
B23.8 Other specified conditions resulting from HIV disease
B24 Unspecified HIV disease
ICD-10 online (WHO version 2019)

In the world-wide recognized medical diagnosis classification system ICD-10 of the WHO , both the HIV infection and numerous diseases as a consequence of an HIV infection can be coded. The exact type of secondary illness is encoded in a fourth digit in the version of the ICD-10 last updated by the World Health Organization for 2013, for example: B20.6 Pneumocystis pneumonia as a result of HIV disease .

Classification of HIV infection and definition of AIDS

CDC definition

According to the case definitions of the US Centers for Disease Control and Prevention (CDC), a confirmed positive HIV test is considered evidence of HIV infection. The rating of HIV infection by severity including AIDS was changed significantly in 2008. Until then, clinical findings and laboratory values ​​were classified separately and presented as letter-number coding. Asymptomatic and HIV-related but not AIDS-defining diseases were also included. Since 2008 only AIDS-defining diseases have been taken into account. The classification according to the number of CD4-positive T lymphocytes ( T helper cells ) and the list of AIDS-defining diseases, however, remained unchanged.

The letter-digit coding, which is still widely used in practice, is therefore out of date. It should be noted that the case definition is primarily used for epidemiological monitoring of HIV and AIDS and not as a guide for clinical diagnosis. A case classification cannot be downgraded again; therefore it may not say anything about the current status of a patient.

HIV rating in adults and adolescents *
stage CD4 + cell count
per µl 		as a percentage of
all lymphocytes
1 ≥ 500 > 29% and not an AIDS-defining disease
2 200-499 14-28% and not an AIDS-defining disease
3 (AIDS) <200 <14% or at least one AIDS-defining disease
Unknown No values and no finding of AIDS-defining disease available
* Proof of HIV infection is required

AIDS includes evidence of HIV infection and an AIDS-defining disease (stage 3) or evidence of HIV infection and a CD4 cell count of <200 cells or <14%. The CDC defined AIDS-defining diseases / symptoms as follows:

European definition

According to the case definition of the European Commission , a confirmed positive HIV test is considered evidence of HIV infection. An assessment of the HIV infection according to the degree of severity is not carried out.

AIDS is considered to be evidence of HIV infection and one of the diseases specified in the European case definition for AIDS. These are identical to those of the CDC list (see there). An AIDS diagnosis based solely on laboratory values ​​without any clinical findings (CDC stage 3) was rejected.

The European case definition is used for epidemiological surveillance of HIV and AIDS.

WHO definition

According to the WHO case definition, a confirmed positive HIV test is considered evidence of HIV infection.

Immunological and Clinical HIV Assessment in Adults and Adolescents *
stage Symptoms CD4 + cell count per µl
% of all lymphocytes
1 Asymptomatic ≥ 500 Asymptomatic illness (s)
2 Mild symptoms 350-499 Disease defined for this stage, e.g. B. Herpes zoster
3 Advanced symptoms <350 Disease defined for this stage, e.g. B. Oral hairy cell leukoplakia
4 (AIDS) Serious symptoms <200
<15% 		or at least one of the AIDS-defining diseases
* Proof of HIV infection is required

For epidemiological surveillance, advanced HIV infection in adults and adolescents is defined as evidence of HIV infection and disease in clinical stages 3 or 4.

In adults and adolescents, AIDS is the proof of HIV infection and an AIDS-defining disease (stage 4) or proof of HIV infection and a CD4 cell count of <200 cells or <15%.

The AIDS-defining diseases / symptoms are largely identical to those in the CDC list.

transmission

Oral candidiasis (oral thrush, overgrowth of the oral cavity with the yeast Candida albicans )
Kaposi's sarcoma of the skin in an AIDS patient caused by the human herpes virus 8
Fundus of the eye with inflammation of the retina caused by the cytomegalovirus ("CMV retinitis")

The HIV virus is transmitted with the body fluids blood , semen , vaginal secretions , liquor and breast milk . Potential entry points are fresh, still bleeding wounds in the mucous membranes (conjunctiva, mouth, nose, vaginal and anal mucosa) or insufficiently horny, easily vulnerable areas of the outer skin ( glans , inside of the penile foreskin ). The most common routes of infection are unprotected vaginal or anal intercourse , the use of contaminated syringes with intravenous drug consumption and oral intercourse (when mucous membrane contact with semen or menstrual blood). During oral intercourse with uninjured oral mucosa, contact with pre-ejaculate or vaginal secretions represents a negligible risk of infection, as does passive oral intercourse. Men who have sex with men are considered a risk group. How high the risk is during sexual intercourse depends primarily on the viral load in the semen , in the vaginal secretions and in the blood. This is particularly high in the first few weeks after infection, before antibodies have formed, then decreases and increases again in the later stages of the disease.

HIV is not transmitted through saliva , sweat , tear fluid , droplet infection, or through insect bites. Likewise, contamination of intact skin with virus-containing (body) fluids does not lead to infection. Body contact in everyday social interaction, the shared use of dishes, cutlery, etc., and the shared use of sanitary facilities also do not pose a risk of infection.

Patients with full AIDS disease are at risk of infection with the typical opportunistic pathogens: viruses of the herpes group, candida, streptococci, pneumococci. Partners of patients with full-blown AIDS should also find out about these pathogens and their routes of infection.

Estimated risk of transmission by route of infection
Route of infection Risk per 10,000 contacts
with an infectious source 		In percent
Parenteral
Blood transfusion 9 250 92.5
Drug injection with a used needle 63 0 0.63
Needle stick through the skin 23 0 0.23
Sexual (unprotected intercourse)
Anal intercourse, receiving partner 138 0 1.38
Vaginal intercourse, receiving partner 8th 0 0.08
Anal intercourse, introductory partner 11 0 0.11
Vaginal intercourse, introductory partner 4th 0 0.04
Oral sex low 1 -
1 Cases of HIV transmission through oral sex have been scientifically documented but are rare.
A precise estimate of the risk is not available due to the poor data situation.
Chest x-ray of a patient with Pneumocystis jiroveci - pneumonia

Transfer mother / child

The risk of infection to a child by an HIV-infected mother during pregnancy or childbirth is estimated to be 10 to 30%. If the mother is known to be infected with HIV, the risk of transmission to the child can be reduced to less than one percent by giving antiretroviral drugs (to the mother before and after the birth), giving birth by caesarean section and not breastfeeding the child become.

However, breastfeeding is recommended in developing countries despite the mother's HIV infection, provided that antiretroviral drugs are used that reduce the risk of infection. This is because breastfeeding has important advantages over industrially produced ready-to-eat foods, especially if these are prepared under poor hygienic conditions or with unclean water, as is often the case in developing countries. Breast milk also improves the chances of survival for HIV-infected infants who, for example, have been infected before or during birth. The WHO therefore recommends exclusive breastfeeding for a period of six months also for HIV-positive mothers.

Transmission through blood transfusions

Blood transfusions also carry the risk of HIV infection. However, routine monitoring of blood donations , as is carried out in Germany, greatly reduces this, so that nowadays the risk of getting an HIV infection by transfusing a blood product is negligible.

In the first few years after the discovery of HIV (1981), the risk of infection via contaminated blood products was very high, as there were no reliable laboratory tests for the detection of the HI virus to test blood donors. In addition, the risk of infection is particularly high when infected blood products are transfused (approx. 90 percent). People suffering from haemophilia , the blood disease, who had to receive regular transfusion of coagulation factor concentrates, were particularly affected . These coagulation factor concentrates have been prepared from numerous donated plasma. As a result, by the late 1980s approximately 50% of the approximately 15,000 hemophilia sufferers in the United States had become infected with HIV. In Germany, too, around 1,800 of the approximately 3,000 haemophilia sufferers and a further 460 people were infected by blood product transfusions, although even then there was the (albeit very expensive) possibility of virus inactivation of the plasma preparations. The "blood scandal" that then developed among the German public ultimately led to the dissolution of the Federal Health Office , which was the supervisory authority for the safety of blood products, by the then Federal Minister of Health Horst Seehofer . As a result of the scandals surrounding blood products infected with HIV or the hepatitis C virus , the blood transfusion system in Germany and other countries was subjected to rigorous and strict legal controls. Testing of all blood products for HIV antibodies has been a legal requirement in the USA and Germany since 1985 , which reduced the risk of infection to significantly less than 1: 100,000 (almost all transfusion-related infections occurred before 1985). However, there was still a small residual risk, as antibodies can only be detected a few weeks after the virus infection (“ diagnostic gap ”). Since May 1, 2004, testing of every blood donation has been required by law in Germany not only for antibodies, but also directly for the presence of HIV- RNA . This means that fresh infections can also be detected. The risk of acquiring an HIV infection through an infected blood product is estimated today in Germany at 1: 4.3 million or less.

Transmission through needles / cannulas / needle sticks

In the early days of the epidemic in particular, many intravenous drug addicts became infected by sharing hypodermic needles. Doctors and nursing staff also have a certain risk of infection from needlestick injuries in the operating theater or after punctures on infected patients. The risk of infection from needle sticks depends very much on the circumstances. The risk of infection is given on average with 0.3% and increases with the following factors: very deep injuries (16-fold increased), visible traces of blood on the needle or needle was previously in a vein or artery of the carrier (each increased five-fold), with high Viral load of the carrier (increased six-fold). The risk with hollow needles is higher than with closed needles.

The risk of sharing a cannula , e.g. B. when injecting heroin , is around 0.7% and decreases with the time interval between injections , but only slowly, since blood trapped in the cannula can remain infectious for days. It is generally possible to boil the needles, but commercially available needles are often not suitable because the plastics used are not adequately heat-resistant. Chemical disinfection with bleach or other disinfectants can significantly reduce the risk, but is not sufficient to reliably rule out transmission.

Special case - use of non-sterile, re-used cutting tools for female genital mutilation

The multiple use of razor blades or other tools in genital mutilation, also known as female circumcision, of girls and women, which often occurs in large numbers within a limited period of time, can lead to the transmission of bacteria and viruses, including HIV. AIDS rates of sometimes more than 20% in the younger population of South African regions indicate the extent of the problem.

Transmission through sexual intercourse

The individual risk of becoming infected with HIV through sexual intercourse is very variable and depends on many factors. An infection is possible after a single sexual intercourse, but there are also known cases in which, despite several years of unprotected sexual contact with an infected partner, no infection occurred. A concomitant sexually transmitted disease increases the risk of infection by a factor of 5 to 10, a high viral load of the carrier even increases by a factor of 10 to 30. Freshly infected people have a high viral load in the first few weeks, as the body does not have any specific antibodies against the HI virus at this stage. Sexual intercourse during a woman's menstrual period is associated with an increased risk of infection for both partners; circumcised men have a lower risk of infection. Overall, the risk of infection does not seem to be constant over the number of contacts, so that the risk of individual contacts is possibly significantly too low. With antiretroviral therapy, the risk of transmission decreases significantly due to the falling viral load in blood and secretions.

  • Vaginal intercourse: Unprotected vaginal intercourse is associated with a comparatively high risk (0.05–0.1% per sex act).
  • Dry sex : The risk of infection is significantly increased here, as tears and bleeding of the vaginal mucosa often occur due to the painful friction and condoms (if used) remain functional in the dry environment less often.
  • Small cracks in the mucous membrane often occur during anal intercourse, which is why the risk is significantly increased compared to vaginal intercourse.
  • Fellatio , oral sex with sperm ingestion through the mouth: The risk of infection is very low, but infection cannot be ruled out.
  • The risk of infection through pre-ejaculate is very small and negligible during oral sex.
  • Cunnilingus , oral sex in women: The risk is also rated as extremely low as long as there is no contact with menstrual blood.
  • Anilingus : The risk is estimated to be extremely low.
  • Other sexual practices that do not involve contact with mucous membranes, blood, semen or vaginal secretions have an extremely low risk of infection.

Post-exposure prophylaxis

Sometimes there is an option to counter a possible HIV infection after a risk situation. Such measures include washing the penis after intercourse, squeezing the stab wounds, and treating it with disinfectant . There is also the option of post-exposure prophylaxis (PEP). This offers the best possible protection if treatment is started within two hours of exposure, but can still be effective through the mucous membranes for up to 24 hours after intravenous exposure and up to 72 hours after other exposure. Therefore, after a well-founded suspicion of infection, a doctor should always be consulted immediately, who will inform about possible measures and who can also initiate them. The medication for PEP essentially corresponds to the antiretroviral therapy of an HIV-positive patient and usually lasts four weeks.

HIV tests

HIV tests are divided into addiction tests and confirmatory tests. The aim of a search test ( e.g. ELISA search test ) is to identify as many infected people as possible - at the price that some non-infected people will also test positive by mistake. If a person tests positive in the addiction test, a confirmatory test (in Germany and the USA: Western blot confirmation test ) is required in many countries to prevent a false positive diagnosis. Most HIV tests are done in a laboratory. However, there are also quick tests , some of which can show a result after a few minutes without technical aids.

An HIV test may only be carried out with the express consent of the person concerned, testing without the knowledge of the patient is legally inadmissible and can be punished accordingly.

Anonymized reporting requirements

In Germany, direct or indirect evidence of HIV does not have to be reported by name according to Section 7 (3) of the Infection Protection Act (IfSG). So a positive HIV test from the laboratory must be reported anonymously to the Robert Koch Institute in Berlin ( Section 8 (1) numbers 2, 3 or 4, Section 10 (2) and (4) IfSG).

In Austria only AIDS, not just HIV infection, is notifiable . Because an AIDS disease is defined according to the AIDS law if there is evidence of an infection with the HI virus as well as at least one indicator disease ( § 1 AIDS law). Such an illness and any death caused by it must be reported ( Section 2 of the AIDS Act). The report must be submitted to the Ministry of Health in Vienna within one week of the diagnosis. However, only the initials (first letter of the first name and family name), gender and date of birth and relevant anamnestic and clinical information are to be transmitted ( Section 3 AIDS Act).

In Switzerland met clinical criteria for the disease are AIDS and the positive laboratory analysis findings for HIV notifiable and that after the Epidemics Act (EpG) in connection with the epidemic Regulation and Annex 1 and Annex 3 of the Regulation of EDI on the reporting of observations of communicable Diseases of man . The doctor, hospital, etc. (only) have to report the first name code, place of residence, date of birth, gender, nationality and country of origin, the laboratory (only) have to report the first name code, place of residence, date of birth and gender of the person.

Course of disease

Course of an HIV infection / AIDS (lymphocyte count, viral load).             CD4 + T lymphocyte count (helper cell count) (cells / mm³)             HIV RNA copies per ml of blood plasma

An HIV infection has four phases:

Acute phase

Flu-like symptoms such as fever , night sweats , swollen lymph nodes, and nausea can occur two to six weeks after infection .

The most common symptoms of acute HIV infection are (according to the likelihood of occurrence):

However, some patients do not notice or have none of the above symptoms. Since the symptoms are very unspecific and can have many other causes, HIV infections often go undetected at first. An HIV-positive diagnosis cannot be made based on symptoms of the acute phase alone, but only with an HIV test.

A positive HIV-RNA test by RT-PCR and a negative or "borderline" confirmatory test are used to diagnose an acute HIV infection . HIV infections six weeks or more ago are usually diagnosed with an antibody / antigen screening test instead of PCR.

Latency phase

During this time, the virus multiplies in the body. Those affected, if they know of their infection, suffer psychologically at best, but physical symptoms often do not occur. The latency period lasts an average of nine to eleven years. There are both patients who develop AIDS within months of being infected and those who, despite being infected in the 1980s and without antiretroviral therapy, have not progressed to AIDS to this day.

AIDS Related Complex (ARC)

This expression was previously used for clinical stage B of the CDC classification (i.e. the occurrence of clinical symptoms that are not, however, AIDS-defining diseases). If left untreated, the transition to the full AIDS picture follows.

Illness phase

The diagnosis of AIDS is made when certain infections or malignant tumors, the so-called AIDS-defining diseases, are diagnosed in an HIV-positive person. The infections are known as opportunistic infections . They are often harmless to the (intact) immune system of a healthy person. However, due to the compromised immune system of an HIV-positive person, the organism cannot defend itself adequately; the infections mentioned above occur. The number of T-helper cells in the blood of an HIV-infected person serves as a measure of the destruction of the immune system .

therapy

The indication for the treatment of an HIV infection results from the clinical findings (HIV-associated symptoms and diseases, opportunistic infections), immune status (CD4-positive T helper lymphocytes) and virus dynamics (HI viral load) in the infected patients.

Highly Active Antiretroviral Therapy (HAART)

With Highly active antiretroviral therapy (HAART) drug combination therapy of at least three antiretroviral agents called. The aim of HAART is to reconstitute the immune system and prevent the onset of AIDS. A successful HAART pushes the viral load (concentration of the HI virus) in the blood below the detection limit, whereupon the number of CD4 + cells increases again and thus the immune system is strengthened against opportunistic infections and other AIDS-defining diseases. Since the virus quickly develops resistance to individual active substances, the therapy using three antiretroviral active substances has established itself. In current drugs, these three active ingredients are combined in one tablet that is taken once a day.

Antiretroviral therapy can significantly extend the life expectancy of HIV-infected people, but cannot completely eradicate the virus - and thus cause a cure. In addition, serious side effects can sometimes occur, which can usually be countered by changing the combination of active ingredients. Once ART has been started, it should not be discontinued to prevent the development of resistance. Regular tablet intake is essential for the same reason (see Adherence ).

Basic combinations (nucleoside / nucleotide combinations such as tenofovir / emtricitabine or abacsavir / lamivudine) were (2009) combined with an NNRTI (such as efavirenz or nevirapine) or a PI (such as atazanavir, fosamprenavir, lopinavir or saquinavir) for initial therapy.

Due to new medical study results as well as the development and approval of new antiretroviral drugs and substance classes, HAART is in a continuous development process. Nevertheless, there are clear guidelines at national, European and international level on the various aspects of antiretroviral therapy. Several classes of active ingredients are currently used: nucleoside and nucleotide analogs (NRTIs), non- nucleoside reverse transcriptase inhibitors (NNRTIs), HIV protease inhibitors (PI), entry and fusion inhibitors and integrase inhibitors .

The criteria for the best time to start a HAART are defined in the respective national guidelines. These weigh the risk of developing AIDS against the risk of possible long-term toxicity and the development of resistance.

The European recommendation for starting therapy takes three factors into account: the clinical picture of the patient, his CD4 + level and the viral load.

HAART is strongly recommended for patients who already have AIDS-defining diseases (CDC C). HAART is also recommended if diseases that indicate a weakened immune system but are not AIDS-defining (CDC B) occur. This also applies to patients who are symptom-free, but whose number of CD4 + cells is below 350. According to the recommendation, starting HAART is also advisable in patients with a CD4 + value between 350 and 500 if there is a high viral load (> 100,000).

Due to the far-reaching consequences for the patient, the decision is made individually so that the patient is adequately informed beforehand about risks and side effects and is mentally prepared for the therapy.

Active ingredients

Schematic representation of the mechanisms of four different classes of antiretroviral drugs against HIV

Nucleoside Reverse Transcriptase Inhibitors (NRTIs)

Nucleoside analogs , also called nucleoside reverse transcriptase inhibitors (NRTI, colloquially known as “nukes”), target the reverse transcriptase , an enzyme of the HI virus that “translates” the viral RNA genome into double-stranded DNA. Another viral enzyme, the integrase , then builds this viral DNA into the DNA of the human host cell. The NRTIs represent an alternative substrate and compete with the physiological (“endogenous”) nucleosides , but differ from these through a modified sugar molecule . The incorporation of the NRTI hinders the structure of the double-strand bond and therefore leads to chain breaks in the virus DNA.

The active ingredients zidovudine (azidothymidine, AZT) and stavudine (d4T) correspond to the DNA building block thymidine , lamivudine (3TC) correspond to cytidine , while didanosine (ddl), analogous to inosine and abacavir, is a guanosine analogue. A combination of analogues with the same starting point (e.g. AZT and d4T) does not make sense.

Numerous side effects can occur during therapy with NRTIs. Often headaches , gastrointestinal distress, bloating or nausea, vomiting and diarrhea, and general fatigue. Prolonged use can lead to lactic acidosis (accumulation of lactic acid in the blood), myelotoxicity (bone marrow damage), damage to peripheral nerves and inflammation of the pancreas . Also, lipodystrophy , one even with therapy with HIV protease inhibitors observed rearrangement of body fat may occur with prolonged use of NRTIs.

Many of these side effects are a result of mitochondrial toxicity : Mitochondria , which are responsible for the supply of energy in the cells, also need nucleosides. The incorporation of NRTIs instead of nucleosides leads to metabolic disorders and degeneration of the mitochondria. There are considerable differences in the toxicity of the individual substrates.

NRTIs are taken up unchanged into the cell and activated there by phosphorylation . They are mainly eliminated via the kidneys (renally) and therefore have little interaction with drugs that are metabolized in the liver.

Next NRTIs are emtricitabine and tenofovir .

Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

While NRTIs, as “wrong” building blocks, inhibit reverse transcriptase, non-nucleoside reverse transcriptase inhibitors (NNRTIs) bind directly to this enzyme, close to the substrate binding site for nucleosides. There are currently three NNRTIs on the market: nevirapine (NVP), delavirdine (DLV) and efavirenz (EFV). While nevirapine and efavirenz are about equally effective, delavirdine hardly plays a role in therapy and is not (yet) approved in Germany. Another NNRTI is etravirine .

As a single substance, NNRTIs only show a limited effect; in combination therapy with two NRTIs, they are equivalent to HIV protease inhibitors from an immunological and virological point of view. So far, no study has shown that survival time has improved and the disease progresses more slowly than with HAART. However, an improvement in the quality of life has been described. Only studies on improved CD4 + cell counts and on lower viral load were used for approval ( surrogate marker studies). Due to their good tolerance and the lower number of pills, they are often preferred to HIV protease inhibitors. NNRTIs are quite sensitive: a point mutation is enough to make the virus resistant to the active substance. There are also cross-resistances: If a virus shows resistance to an NNRTI, all NNRTIs are usually ineffective. NNRTIs are metabolized in the liver ( cytochrome P450 system).

The side effect profiles of the individual active ingredients differ considerably. In therapy with nevirapine, the main focus is on allergic reactions and liver toxicity. A rash occurs in up to 20% of patients and 7% stop taking nevirapine. To reduce the risk of allergies, nevirapine is given in low doses at the start of therapy. Then the dose is gradually increased. Liver toxicity is a rare but potentially life-threatening side effect of nevirapine. The liver values (especially the transaminases ) should therefore be monitored closely at the start of therapy .

The side effects of efavirenz, however, mainly affect the central nervous system . They usually appear at the beginning of therapy and then weaken. During the first four weeks of a study, two-thirds of the patients experienced dizziness , nearly half had nightmares, and about one-third of the patients experienced drowsiness and insomnia. However, these usually decreased after a while. While nevirapine is used to prevent mother-to-child transmission ( PMTCT  ), efavirenz is contraindicated in pregnancy . In view of the effect on the central nervous system, roadworthiness is questionable. One advantage of efavirenz over nevirapine is its lower liver toxicity.

Delavirdine is inferior to the other active ingredients because of the high number of pills and the three times daily intake. In addition, it is currently not approved for the German market.

Protease inhibitors (PI)

If the HIV enzyme HIV protease cannot cleave the viral macromolecule gag-pol polyprotein, non -infectious virus particles are produced. HIV protease inhibitors (such as atazanavir , darunavir , fosamprenavir , indinavir , nelfinavir , saquinavir and tipranavir ) were modeled with knowledge of the molecular structure of the enzyme so that they can bind directly to the active site of the protease. The effectiveness of HIV protease inhibitors has been demonstrated using clinical endpoints. They have contributed to a significant improvement in therapy. In long-term treatment, however, there are some problems that lead to disorders in lipid metabolism and as a result can trigger lipodystrophy (fat distribution disorders ) and dyslipidemia (increased blood lipid levels). The reason is probably mitochondrial toxicity, since HIV protease inhibitors appear to damage the mitochondria similar to NRTIs. Other side effects are gastrointestinal complaints.

The breakdown of the HIV protease inhibitors takes place in the liver by the cytochrome P450 enzyme system. The HIV protease inhibitor ritonavir (RTV) blocks this system. The use of other protease inhibitors with ritonavir was therefore adopted in order to slow down the breakdown and increase the plasma half-life. This is known as a "booster". The HIV protease inhibitor lopinavir (LPV / r) combined with a booster dose of ritonavir is now available . This leads to an almost 100-fold higher plasma concentration of lopinavir and a higher barrier to resistance. Therefore, Lopinavir / Ritonavir (trade name Kaletra ) is mostly used after therapy failure of other drugs ("salvage area").

Another problem is the interaction of HIV protease inhibitors with many other substances: on the one hand via the cytochrome P450 enzyme system with ingredients of grapefruit, on the other hand there is a mutual interaction (both mutual weakening and mutual reinforcement) to estrogen, which at the same time Use of HIV protease inhibitors and hormonal contraceptives prevented.

Entry inhibitors

Entry inhibitors interrupt the entry of the virus into the host cell.

Fusion Inhibitors (FI)

At the beginning of 2003 the first fusion inhibitor enfuvirtide (ENF, developed under the name T-20 ) was brought onto the market. T-20 binds to the transmembrane protein gp41, which is important for the fusion of the virus with the cell membrane of the T helper cells, and thus blocks the entry of the virus into the cell. The substance is particularly interesting because it does not trigger any mitochondrial toxicity and thus no lipodystrophy syndrome.

With its 36 amino acids, T-20 is too large to be taken orally. In its current form, T-20 must be injected subcutaneously or administered via an infusion pump daily. As a side effect, skin irritation at the puncture site often occurs.

Initial studies have shown that simply adding T-20 to classic antiretroviral therapy has only limited success. However, two large studies comparing T-20 to an optimized HAART versus an optimized HAART without T-20 showed significantly better values ​​in the T-20 arm of the study. This suggests that T-20 will particularly benefit those patients who have other drug options.

T-20 can apparently lead to interactions with granulocytes that lead to increased infections in some patients.

It is also very likely that the virus will develop resistance quickly. However, the viral adaptability to the human host of the resistant strains appears to be reduced.

Nevertheless, T-20 gives patients who have to change their therapy due to side effects or resistance an option. However, T-20 is not the first choice at the start of therapy, and not only because of the study situation. According to the manufacturer F. Hoffmann-La Roche AG, T-20 is one of the most complex substances in the company's history to produce. This is reflected in the price, which at over 24,000 euros per year is higher than a few triple combinations of conventional antiretroviral drugs.

Furthermore, since spring 2007 there has been Maraviroc (MVC) in the Expanded Access program for the final treatment of HIV patients who otherwise no longer have any treatment options.

Research is being conducted into other fusion inhibitors and a weekly T-20 injection.

Integrase inhibitors (II)

After many failures and difficulties in the 1990s, the development of integrase inhibitors began to pick up speed in 2000 . It was then that the principle of strand transfer inhibition was revealed. Clinical studies have been making rapid progress since 2005, and integrase inhibitors are the next new group of substances in HIV therapy at the latest after the first data from the phase III studies on raltegravir (MK-0518). MK-0518 is now approved in the Expanded Access program, i.e. for the final treatment of HIV patients who otherwise no longer have any treatment options.

CCR5 coreceptor inhibitors (CCR5I)

  • Maraviroc (see above)

Monoclonal antibody

In March 2018, the FDA approved the first HIV-1 inhibitor and long-acting monoclonal antibody Ibalizumab-uiyk ( Trogarzo ; manufacturer TaiMed Biologics , Taiwan and Theratechnologies , Canada) for the treatment of patients who are "multi-resistant" to treatment with all of the above treatment regimens are. The FDA approved the filing for “ Fast Track ”, “ Priority Review ” and “ Breakthrough Therapy ”. Trogarzo also received Orphan Drug Status, which provides incentives to support and encourage the development of drugs against rare diseases.

Experimental therapies

Maturation inhibitors

Maturation inhibitors ("maturation inhibitors ") inhibit the budding of new virions . As with the integrase inhibitors, an antiretroviral effect was demonstrated in vivo for the first time in 2005. Bevirimat (PA-457) is a derivative of betulinic acid , as triterpene - carboxylic acid from birch or - plane bark is isolatable and as cytostatic to melanoma is used. PA-457 inhibits the budding or maturation of new virions. Phase IIa studies have already been published. Phase IIb studies are slow due to unexpected difficulties in finding the dose.

Tre recombinase

Researchers at the Hamburg Heinrich Pette Institute, Leibniz Institute for Experimental Virology and the Max Planck Institute for Molecular Cell Biology and Genetics in Dresden are working with the promising approach of specifically cutting the HIV genome out of the DNA of infected host cells and thus the infection to undo these cells. To do this, they have developed a special enzyme - Tre recombinase - that acts as a “gene scissors”. The enzyme is only activated in the presence of the proviral DNA, i.e. only in infected cells. After several promising experiments in vitro , the scientists succeeded in 2013 in freeing HIV-infected “humanized” mice from HIV and thereby “healing” them. However, these transgenic mice carried the gene for the Tre recombinase in their genome from the start. Whether an efficient therapy for HIV infections or a cure can be developed with the help of Tre recombinase cannot yet be assessed. The researchers hope to be able to investigate the effectiveness of Tre recombinase in humans as part of a clinical study in the near future .

Monoclonal antibodies

A single dose of a cocktail with multiple antibodies was effective for an average of 56 days in infected rhesus monkeys. Some animals stayed healthy afterwards.

Stem cell transplant

In early 2013, a paper gave hope for a cure, which showed that long-term virus reduction followed by haematopoietic stem cell therapy could perhaps completely remove the HIV virus. This seemed to work for the time being, but both patients treated in this way in Boston suffered a relapse after a few weeks of being virus-free and now have to be treated again with antiretroviral. While the American Timothy Ray Brown , who also received a stem cell transplant, is still the first cured AIDS patient to this day.

Gene therapy

By partially removing the coreceptor CCR5 from the genome of CD4-positive T-cells with an adoptive cell transfer and genome editing , the decrease in the concentration of CD4-positive T-cells can be slowed down.

prevention

AIDS prevention in public

Prevention is the most effective measure against HIV. In general, contact with foreign blood and semen should be avoided. Through the use of condoms (also Femidomen and leak towels ), sterile needles when taking drugs , the piercing piercings , tattoos and other bloody methods of body modification as well as in the medical field as well as strict control of blood as part of donated blood can be a Avoid infection very safely. Caution is also advised with methods that cause sores in the field of BDSM . In 2004, UNESCO launched EDUCAIDS, a global public education program. Pre-exposure prophylaxis (PrEP) is also used successfully as a preventive measure in which HIV-negative people take preventive medication from antiretroviral HIV therapy to protect themselves from possible HIV infection. After an event with a risk of infection, the probability of infection can be reduced if so-called post - exposure prophylaxis is carried out.

A sufficiently effective HIV vaccine does not yet exist. Many years of research into vaccines that should promote the formation of protective antibodies against the surface protein gp120 have so far failed because of the high mutation rate of the HI virus. When the agent was successfully tested against the very similar SIV (SI virus, simian immunodeficiency virus) in monkeys, the HI virus had changed the structure of its gp120 surface protein in the wild.

Prophylaxis of opportunistic infections

The indication for primary prophylaxis of opportunistic infections is dependent on the extent of immunosuppression . CD4 thresholds above which certain HIV-associated diseases are unlikely:

  • below 50 / µl: CMV retinitis, cryptosporidiosis and atypical mycobacteriosis ( MOTT )
  • below 100 / µl cerebral toxoplasmopsis, HIV encephalopathy, cryptococcosis and miliary tuberculosis
  • below 250 / µl Pneumocystis jiroveci pneumon, thrush esophagitis and progressive multifocal leukoencephalopathy
  • below 350 / µl zoster due to herpes zoster virus, ulcers due to herpes simplex virus (HSV) and oral thrush
  • without limit of threshold: Kaposi's sarcoma, pulmonary tuberculosis and bacterial pneumonia.

In contrast to the CD4 cell count dependent primary prophylaxis a done Sekundärprophyaxe or post-exposure prophylaxis (see also post-exposure prophylaxis ) as maintenance therapy after already made this disease:

Epidemiology

The prevalence worldwide is 0.0059, in Germany 0.0007, in Austria 0.0011 (as of 2006).

Generally

Proportion of people infected with HIV and AIDS in the population, worldwide, 2009:
  • No data available
  • below 0.1%
  • 0.1-0.5%
  • 0.5-1%
  • 1-5%
  • 5-15%
  • 15-50%
    • Global statistics of the HIV / AIDS epidemic
    year People living with HIV New infections Deaths People under therapy source
    2000 28.9 million 3.2 million 1.5 million 0.8 million
    2005 31.8 million 2.5 million 2.0 million 2.2 million
    2010 33.3 million 2.2 million 1.5 million 7.5 million
    2011 33.9 million 2.2 million 1.4 million 9.1 million
    2012 34.5 million 2.2 million 1.4 million 11 million
    2013 35.2 million 2.1 million 1.3 million 13 million
    2014 35.9 million 2.1 million 1.2 million 15 million
    2015 36.7 million 2.1 million 1.1 million 17 million
    2016 36.7 million 1.8 million 1.0 million 20.9 million
    2017 36.9 million 1.8 million 0.9 million 20.9 million
    2018 37.9 million 1.7 million 0.77 million 23.3 million
    2019 38.0 million 1.7 million 0.69 million 25.4 million

    From an epidemiological point of view, the worldwide distribution pattern of HIV and its uneven spread was unusual in contrast to most other viruses.

    The first HIV virus discovered was HIV-1, subtype B from the main group M. This virus first appeared in Central Africa around 1925. After genetic analyzes of numerous HIV subtypes from around the world, an international team of researchers came to the conclusion that this virus reached Haiti from Africa around 1966 . The studies also show that there is a high probability that the virus first spread within Haiti and then from there across the world. It reached the USA from Haiti in 1969, which could be traced back to virus samples from the first known AIDS patients from Haiti. In the USA, the virus initially spread very slowly in the heterosexual population, before it spread a little later within the high-risk group of homosexual men.

    While the HIV epidemic began in the US as early as the 1980s, there were a few countries that seemed spared from HIV, but were quickly taken over by the virus. This is what happened particularly in Eastern Europe and Asia in the mid-1990s. In other countries, for example Cameroon , the prevalence of HIV remained stable for years and then skyrocketed. There also does not seem to be an upper limit for HIV prevalence. After 1997 , the rate of pregnant women with HIV in urban centers in Botswana rose from 38.5 to 55.6% in four years.

    A sustainable and successful fight against HIV / AIDS in African high-prevalence countries must include the reduction of both AIDS-related deaths and new infections. Data from some countries hard hit by the HIV epidemic, such as Kenya, Rwanda, Uganda and Zimbabwe, show that various measures can reduce the rate of new infections. The foundations of this success are the nationwide introduction of sex education classes, the increasing introduction of antiretroviral therapy, nationwide campaigns to increase the acceptance of condoms, HIV tests, the results of which are announced on the same day, and self-help kits for sexually transmitted diseases . However, these successes can only be achieved with financial means that many of the high-endemic countries in Africa cannot raise on their own. Political will to actively combat this epidemic is also essential.

    According to data from Uganda, the prevalence of HIV among pregnant women was reduced from almost 30% in 1992 to 5.4% in 2007. Uganda's success story is not without controversy: Improved data collection and the dramatic mortality rate among people with HIV / AIDS have also contributed to the reduction in HIV prevalence. In Zimbabwe, the prevalence decreased from 29% (1997) to 16% (2007). An interdisciplinary UNAIDS study concluded that the main causal factor was a change in sexual behavior, which led to a significant reduction in the number of sexual partners through a reduction in extramarital, commercial and occasional sex.

    Worldwide

    As before, this is southern Africa most affected by the epidemic. In 2012, 70% of all new HIV infections among adults took place here. However, it turns out that the education and prevention programs are successful. Between 2001 and 2012, the annual new HIV infections in southern Africa decreased by 34%. Worldwide, new HIV infections fell by 50% or more in the period 2001 to 2012 in 26 countries, including Ethiopia, Ghana, India, Thailand and the Ukraine. On the other hand, an increase in new infections has been recorded in Eastern Europe and Central Asia as well as the Middle East and North Africa. The country with the highest HIV rate in the world is Swaziland , where 26.5% of adults (15 to 49 years old) were infected with HIV in 2012.

    Germany

    HIV infections in Germany (as of end of 2018)
    (all figures are estimates)
    Statistical size number
    HIV-infected people 87,900
    Including men 70,600 (80%)
    Including women 17,300 (20%)
    Distribution according to risk of infection
    Men who have sex with men 54,200 (73.5%)
    Heterosexually infected people 10,900 (14.8%)
    Intravenous drug users 08,200 (11.1%)
    Infected by blood products 00.450 (0.6%)
    New infections in 2018
    total 02,400
    Including men 02,000 (80%)
    Including women 00.400 (20%)
    AIDS deaths
    Since the epidemic began 29,200
    In 2018 00.440
    Medical care 2018
    Estimated number of people who are
    not aware of their HIV infection    		 10,600 (5%)
    HIV-infected people on antiretroviral therapy 87,900 (93%)
    Source: Epidemiological Bulletin Robert Koch Institute 2019

    In 1986 the number of new HIV infections peaked at just under 6,000.

    In 1987, for example, in the fight against the spread of the HI virus , the Bavarian state government considered a legislative initiative to tighten the Federal Disease Act with compulsory tests for applicants for the public service and prisoners, the expulsion of HIV-positive foreigners and the quarantine of infected people “In special homes”.

    In the 1990s there were around 2,000 new HIV infections per year. From 2000 to 2005, the number of new infections rose steadily every year, especially in men who have sex with men (MSM). Since 2005, the annual new infections seem to have stabilized at a value of around 3000. In Germany, AIDS is one of the insignificant causes of death in comparison with other causes of death with around 460 deaths per year . According to data from the Robert Koch Institute (RKI), a total of around 28,100 people in Germany succumbed to the consequences of immune deficiency by the end of 2015. In 2015, an estimated 84,700 people in Germany (approx. One person in 1,000) were infected with HIV. The incidence of new infections varies greatly from region to region. In large cities (Berlin, Cologne, Hamburg, Stuttgart, Frankfurt am Main) it was between 10 and 13 / 100,000 inhabitants in 2012, while it was significantly lower in rural areas. However, an analysis of the number of reports since 2000 shows that, especially under MSM, the number of reports outside of the big cities has increased more than reports from the big cities and that the numbers are slowly converging. According to the RKI, 10 to 12 percent of MSM in large cities are HIV-positive.

    According to estimates by the RKI, around 82% of the approximately 3,200 newly infected people in 2015 were men. 64% of those newly infected are men who have sex with men; About 13% of the transmissions came from heterosexual intercourse (and the trend is rising), 9% of the infections from infected syringes during intravenous drug use and less than 1% from mother to child during pregnancy and childbirth. According to estimates, the number of as yet undiagnosed HIV-positive people in Germany is around 12,600. The risk of infection for men who have sex with men is significantly higher than with unprotected intercourse in heterosexual couples. The disease affects all social groups and social classes.

    The data on the spread of HIV and AIDS determined by the RKI can only be compared to a limited extent with previously published estimates, as additional data and information as well as the adaptation of the survey methodology change the calculations from year to year. The RKI therefore adapts the annual evaluation of the changing data situation and interpolates, for example, data from the early days of the HIV epidemic in order to make an overall trend visible.

    The continued rise in other sexually transmitted diseases remains a cause for concern . Not only does this increase the risk of HIV infection, it also shows that the acceptance of condoms is declining and that the preventive measures of the past decades are obviously losing their effectiveness.

    Austria

    At the beginning of 2008 there were around 12,000 to 15,000 HIV-infected people in Austria, around half of them in Vienna . The number of new infections has been around 450 per year since 2003 (2015: 428). The lowest rate was in 1997 with 297, the highest in 1993 with 561 new infections. The number of new infections has now remained relatively constant. Between 1983 and May 5, 2008, 2608 people in Austria fell ill with AIDS and 1,468 died. From 2003, with 50 new diseases, they rose to 65 in 2004.

    In 2006 almost 42% of new infections occurred through heterosexual contact (in 1998 it was 27%), 28.6% through homosexual contact and 20.5% through intravenous drug use.

    Around one million HIV antibody tests are carried out in Austria every year (500,000 of which are financed by donations). One problem is that the tests are often carried out in the wrong target group (retirees). On the one hand, a lot of tests are carried out, on the other hand, many of those affected only become aware of the HIV infection in the course of the actual illness.

    Switzerland

    In 2014, 519 positive HIV tests were reported in Switzerland. Since 2008 there has been a continuous, slightly decreasing trend in the number of HIV diagnoses. The cantons of Zurich , Vaud and Geneva are particularly hard hit .

    In 2014, 50% of infections occurred in men who have sex with men. The number of infections after heterosexual intercourse follows with 39.1%. Infections after drug use are falling continuously and are at 1.6%.

    In men (both homosexual and heterosexual), HIV infection occurred more often during casual sex than during sex with a steady partner. In contrast, women were mostly infected in a steady partnership. Accordingly, a stable partnership does not necessarily protect against HIV.

    Africa

    The HIV / AIDS pandemic is at its worst south of the Sahara . 24.7 million people live here with HIV infection (around one in twenty adults is infected). The main modes of transmission of HIV differ fundamentally from those in Europe and North America: Heterosexual intercourse is by far the most common mode of transmission in Africa, accounting for around 50% of HIV infections. Another 5 to 10% of infections come from infected blood transfusions. The transmission of the virus from HIV-positive, pregnant women to their newborns during pregnancy, childbirth and breastfeeding is another route of infection. In some countries, the immune deficiency had reduced life expectancy by more than ten years. The situation has since improved. In 2013, around half of those infected south of the Sahara knew their HIV status. Of these, 87% received antiretroviral therapy.

    There seem to be some factors that favor the spread of the HIV virus: While in Europe and North America shortly after the discovery of the HIV virus, the mass media informed large parts of the population with information campaigns about the deadly dangers of HIV infection and prevention, AIDS remained a taboo subject in many parts of Africa. This gave the HI virus almost twenty years more time to spread unhindered.

    Successor states to the Soviet Union

    The first HIV infections in the Soviet Union were not registered until the late 1980s. An epidemic spread began in the early 1990s, initially almost exclusively among injectable drug users. The main route of infection was the common use of syringes. With drug addiction spreading after the collapse of the Soviet Union, so did the number of HIV infections.

    To this day, when, depending on the region, up to 60% of new infections occur sexually, their emergence in the drug environment has shaped the appearance of the HIV epidemic in the successor states of the Soviet Union. The Ukraine is the worst affected and, in terms of the characteristics of the epidemic, exemplary for many regions of the former Soviet Union .

    history

    Theories of origin

    The simian immunodeficiency virus (SIV) , which occurs in monkey species, is almost identical to the human HI virus . It is believed to have existed for at least 32,000 to 75,000 years, as was determined by comparing samples taken from the island of Bioko in the Gulf of Guinea off Africa and from mainland Africa . A distinction is mainly made between the African SIVcpz (from chimpanzee ), from which HIV-1 is derived, and the Asian SIVmac (from macaque ), from which the rarer HIV-2 is derived.

    Genetic analyzes by virologists at the University of Alabama at Birmingham in 2003 show that SIVcpz is a combination of two strains of the virus found in monkeys and collared monkeys. Because these species of chimpanzees are hunted and eaten, the chimpanzees may have become infected with the two strains of the virus that could then have formed the SI virus in their bodies.

    According to the researchers, this SI virus was transmitted to humans as early as the 1930s through injuries caused by hunting or eating by chimpanzees, although there are indications that this happened earlier in isolated cases. Further scientific investigations showed that the HI virus first appeared in West Africa, but it has not been established with absolute certainty whether there were several virus foci. New phylogenetic studies, i.e. comparisons between the different subtypes of HIV and between HIV and SIV, suggest that several independent transmissions from chimpanzees to humans took place in Cameroon and / or its neighboring countries.

    The oldest blood sample known to contain HIV antibodies was taken from an adult man in the Congo in 1959 . However, the authenticity of this sample has not been clarified with certainty. HIV genes were found in old paraffin DNA samples in a woman who died in the Congo (1960, lymph node tissue), an American adolescent (1969) and a Norwegian sailor (1976).

    Conspiracy theory

    In addition to the currently accepted theory, in the context of the disinformation campaign “ Infection ” directed against the USA, the KGB spread the claim that a new type of virus had been discovered by US researchers looking for suitable pathogens for biological warfare in Africa, in the US military laboratory Fort Detrick increased and examined, and eventually escaped.

    From 1985 onwards, Jakob Segal developed a scientifically based hypothesis of an artificial HIV origin .

    First infections

    The earliest documented infection with HIV-1 was found in blood samples taken in 1959 from a man from Léopoldville ( Belgian Congo ). A comparison with later samples from a family of a Norwegian sailor who died of AIDS in 1976 suggests divergence from a common ancestor from the 1940s to the early 1950s. It is believed that HIV-1 leaked to humans a few years earlier. However, the genetic difference between HIV-1 and HIV-2 also suggests that these subtypes diverged much earlier. The geneticist Bette Korber of Los Alamos National Laboratory dated the first transmission to around 1931 in 2000 using the sample from 1959. The evolutionary biologist Michael Worobey of the University of Arizona dated the in 2008 using an additional sample from 1960 first transmission to the period between 1884 and 1924. He suspects that the establishment of the colonial cities helped the virus to gain a foothold.

    First descriptions of diseases

    In 1981 Michael S. Gottlieb described an accumulation of a rare form of pneumonia in the June 5 issue of the Morbidity and Mortality Weekly Report , a weekly bulletin for the CDC . This form, triggered by the fungus Pneumocystis jirovecii , almost exclusively affects patients with severe immunodeficiency, but was found by Gottlieb in five previously healthy, homosexual men in Los Angeles. Similar reports from other US cities followed. In addition, other opportunistic diseases - such as Kaposi's sarcomas  - were increasingly found, which predominantly affect patients with a weakened immune system.

    Acquired immunodeficiency disease that can be sexually transmitted was considered a likely cause early on. Initially there was no official name and the names of the diseases were often referred to, such as lymphadenopathy or Kaposi's sarcoma , sometimes with a reference to homosexual men; the CDC 's task force was named Kaposi's Sarcoma and Opportunistic Infections , which was also used for reporting. From May 1981, the general press wrote about Gay Related Immune Deficiency (GRID) or Gay People's Immuno Deficiency Syndrome (GIDS) , among others . However, further epidemiological studies in the USA showed that the disease also occurred among haemophiles , recipients of blood (for example through blood transfusions ) and heterosexual drug addicts, which suggests parenteral transmission as well as sexual . Looking for a name, the CDC also created the "the 4H disease" name, referring to the alleged main affected groups: H aitianer , H omosexuelle, H ämophile and H eroin addicts. On July 27, 1982 a conference agreed on the descriptive name Acquired Immune Deficiency Syndrome and the abbreviation AIDS, which was used from August 1982 and from September 1982 at the CDC and in the French-speaking area as "Syndrome d'Immuno-Déficience" Acquise ”(SIDA) appears.

    In Germany, the Spiegel reported for the first time on May 31, 1982 under the title The shock from over there , and the disease was first diagnosed in July 1982 in a patient from Frankfurt am Main. In Austria, the first two cases were reported in April 1983, and the Austrian daily newspapers reported for the first time in the spring of 1983 on the occasion of the first death. Many media reported in lurid tones; the mirror characterized the disease as a "gay disease" or "Schwulenpest". As a result, HOSI Vienna, together with Klaus Wolff and Christian Kunz, created an information sheet aimed at gay men and published it together with the “Vienna Working Group for Public Health”. It was the first AIDS information brochure in Europe.

    Isolation of the virus and first therapies

    In 1983, a French research group led by Françoise Barré-Sinoussi and Luc Montagnier isolated a previously unknown retrovirus , the lymphadenopathy virus (LAV), which they suspected to be the cause of AIDS. A causal relationship between the virus and the immunodeficiency disease was alleged a short time later. In 1984 a virus discovered in AIDS patients was named Human T-cell Lymphotropic Virus-III (HTLV-III) at the US Cancer Institute . In March 1985, based on further reports on LAV and HTLV-III, it turned out that these are identical. In 1985, Robert Gallo received the US patent for the first ELISA antibody test, which was approved by the US regulatory authority. In 1986 the name Human Immunodeficiency Virus (HIV) was established for the virus . A year later, in 1987, AZT (Retrovir), the first therapeutic agent, was approved. In 1989, pentamidine inhalation was introduced for the prophylaxis of Pneumocystis pneumonia in HIV patients .

    In January 1982, Gay Men's Health Crisis (GMHC) was founded, the oldest organization to help people with AIDS in New York City . In 1983 the AIDS-Hilfe was founded in Berlin , followed by the one in Vienna and the AIDS-Hilfe Schweiz in 1985 . In the same year the first world AIDS conference took place in Atlanta (USA) , and with Rock Hudson the first world star died as a result of immunodeficiency. The activist political initiative Act Up split off from the GMHC in March 1987 .

    When a question about AIDS was asked at a routine press conference at the White House on October 15, 1982 , the subject was ridiculed. The then US President Ronald Reagan found official words for the first time in May 1987 at the 3rd International AIDS Conference in Washington. Elizabeth Taylor had previously written him a pleading letter to help break the archaic stigma ("disease of homosexuals"). By then, 36,058 US citizens had been diagnosed, 20,849 had died from the consequences, and the infection had been found in 113 countries.

    In 1985, Norman L. Letvin established the first non-human primate model for research into HIV, after he had succeeded in isolating the simian immunodeficiency virus (SIV) and demonstrating that there was AIDS-like damage to the immune system and in Indian rhesus monkeys Causes deaths.

    The WHO Global Program on HIV / AIDS has been active since 1987 , from which UNAIDS emerged in 1996 . In 1988, December 1st was declared World AIDS Day by the WHO . The successor US President Bill Clinton declared AIDS an "enemy of the state" in 2000 because the epidemic could topple governments, cause chaos in the global economy and spark ethnic conflicts.

    Social development

    In the beginning, the disease was seen by the public as a problem of “fringe groups” like homosexuals and drug addicts. However, this changed dramatically with the advent of HIV testing. Because even people without clinical symptoms had antibodies, which indicated a symptom-free latency period of several years, during which the virus may also have been passed on. In 1984, research found that AIDS was equally prevalent among men and women in Kinshasa , regardless of drug use and blood transfusions.

    In the USA it was reported in 1985 that the infection rate of the wives was 70% in the case of hemophilia patients ("hemophiliacs") examined who were infected by stored blood. The realization that the risk of infection in heterosexual intercourse seemed to be significantly higher than initially assumed, led to a great deal of public interest. The combination of the now known infection routes and the long latency period allowed epidemiological projections to paint a pessimistic picture.

    In 1987, the Federal Office for Health Education launched a large-scale media awareness campaign in Germany with the slogan Don't give AIDS a chance . The best known was a commercial from 1989 with Hella von Sinnen as the cashier, who shouted loudly across the shop: “Tina, what do the condoms cost?” When the customer embodied by Ingolf Lück wanted to buy them.

    The annual doubling of new cases in Germany only lasted from 1984 to 1987, after which the increase in the number of sick people was less steep until the numbers leveled off at around 2000 in 1993. This quickly changed public interest in HIV / AIDS. In 2015, around 2.1 million people worldwide were newly infected with the virus, and around 1.1 million people died of it in the same year.

    Red ribbon becomes symbol of fight against AIDS

    In 1990 the Red Ribbon was established at the AIDS conference in San Francisco to protest against discrimination against HIV-infected people. A year later, the red ribbon became an international symbol for the fight against AIDS. In 1992 the World AIDS Congress was relocated from Boston to Amsterdam due to US entry requirements. In addition, the remaining Queen members established the Mercury Phoenix Trust in memory of Freddie Mercury .

    Changes after introducing the PCR test for HIV

    In 1994 the HIV- PCR was established as an important diagnostic test for the therapy control of the course of the infection. The following year, 1995, the first HIV protease inhibitor, saquinavir, was launched in the United States. The following year, nevirapine was approved as the first non-nucleoside reverse transcriptase inhibitor. Because of the intensive combination therapy, the death rate in the USA dropped dramatically in 1997. In 2003, enfuvirtide (Fuzeon), the first fusion inhibitor, was approved in the USA. In 2004, the WHO started the 3 by 5 initiative: In 2005, three million infected people were to be provided with medication.

    Different theses

    Despite reliable scientific knowledge, a very small number of scientists deny either the existence of HIV or the connection between HIV and AIDS. These include in particular the German-American retrovirologist Peter Duesberg and the chemist Kary Mullis . Her theses influenced the former President of South Africa , Thabo Mbeki , who appointed Duesberg to the South African AIDS Advisory Commission in 2001. In South Africa in 2001 about 15.3% of the population was infected with HIV / AIDS and about 200,000 people died of AIDS in the same year. Kary Mullis is known for the discovery of the PCR process, for which he received the Nobel Prize in Chemistry and which, among other things, is used to detect HI viruses in the body of those affected. However, he has never researched HIV or AIDS himself. But after he described himself as a possible victim of alien abduction and expressed his fondness for astrology , his reputation as a scientist suffered greatly.

    The position of the AIDS deniers is categorized and sharply criticized by the overwhelming majority of medical professionals and scientists as a dangerous conspiracy theory. The Robert Koch Institute also commented on these positions. In South Africa , the introduction of HIV therapy was delayed until 2004 because of a health policy characterized by the denial of the link between HIV and AIDS. It is believed that at least 330,000 people died prematurely from AIDS between 2000 and 2005 as a result of this policy and that due to a lack of HIV infection prevention, 35,000 newborns were infected with HIV.

    Socio-ethical assessment

    The disease syndrome AIDS has developed into a serious challenge worldwide for those directly affected, medicine, science, but also for all those who care for or live with sick people.

    Far from any stigmatization of AIDS-ill patients (see: Discrimination against people with HIV / AIDS ), it is important to find ways and means to help them more effectively: be it through therapeutic measures that are still not available , be it in the sense of symptomatic therapy and palliative medicine . Comprehensive and effective prevention is also required .

    The search for an ethically justifiable strategy to combat HIV / AIDS leads to partially contrary results: some emphasize the absolute necessity of an exclusively or primarily "technical" protection against the spread of the disease. Others see this answer as inadequate or reject it for reasons of religious ethics. They re-emphasize the value of permanent marital fidelity or, in specific cases, also demand temporary or complete abstinence . The propagation of condoms as protection against AIDS is questionable from a religious-Christian point of view. It has been argued that this promotes an irresponsible lifestyle associated with promiscuity and certain sexual practices, which puts you and others at risk. These demands are, however, to be seen in the context of the moral teaching that is widespread, particularly in the Catholic Church, which has negative connotations for promiscuity. Since the Catholic Church had considerable social influence during the spread of AIDS in Africa, numerous new infections have been accepted due to the years of hindrance to education and prevention (such as sex education in schools and the distribution of condoms). In the interview book Licht der Welt , published in 2010, the head of the Roman Catholic Church Pope Benedict XVI. that he sees the use of condoms "of course not as a real and moral solution". A justified individual case for an exception to this attitude could be that male prostitutes use a condom. This could then be “a first step towards a moralization” and help to develop an awareness that “everything is not permitted and you cannot do everything you want”. In principle, however, the Pope continued to reject the use of condoms in the fight against the global epidemic.

    HIV-positive and AIDS-infected people are often exposed to stigmatization and discrimination. A study by Deutsche AIDS-Hilfe 2012 came to the result that 77% of the more than 1,100 HIV-positive people questioned were discriminated against in the year before the survey - from gossip to insults to physical attacks. More positive people lost their jobs because of discrimination than for health reasons. Dismissals were related to discrimination in 84% of the cases. Around 20% of those questioned were refused medical treatment due to HIV in the year before the survey (for example at the dentist). Apart from open rejection, HIV patients repeatedly report delayed appointments, separate treatment times or discrimination e.g. B. with reference to labor-intensive hygiene guidelines. However, the German AIDS Society (DAIG e.V.) and the German Association of Resident Doctors in the Care of HIV-Infected Persons (DAGNÄ) emphasize that the dental treatment of HIV-infected persons does not require any hygienic requirements that go beyond the standard measures. are necessary to prevent transmission of HIV.

    In Austria in particular, the term “social AIDS” has been used to describe the discrimination against HIV-positive people. Even doctors who are principally obliged to treat refuse treatment in individual cases (“[…] I have no desire to expose myself to such a danger […]”). In Hanau and the Main-Kinzig district , a survey with telephone contact and questionnaire was started, but with little response. Practice employees didn't know what to do with the terms HIV and AIDS. The main reason for rejection was the alleged higher hygiene requirements in the treatment of people with HIV. In a practice, it is generally necessary to work so hygienically that there is no risk of transmission there. About 16% of HIV-positive people in Germany are not yet aware of their infection. The AIDS organizations and other organizations want to raise awareness of the issue throughout the year . Even the World AIDS Day on December 1, is used to and the now internationally acclaimed Life Ball in Vienna will not only raise funds but to fight on the media coverage with positive slogans against stigmatization.

    See also

    literature

    Guidelines

    magazine

    • The scientific journal AIDS Reviews appears quarterly and publishes reviews that deal with the various aspects of HIV and AIDS.

    miscellaneous

    chronologically

    Web links

    Wiktionary: Aids  - explanations of meanings, word origins, synonyms, translations
    Wiktionary: AIDS  - explanations of meanings, word origins, synonyms, translations
    Commons : AIDS  - collection of pictures, videos and audio files
    Wikiquote: AIDS  Quotes

    Individual evidence

    1. ^ "HIV", made available by the digital dictionary of the German language , <https://www.dwds.de/wb/HIV> , accessed on March 12, 2021.
    2. ^ A b J. L. Marx: New disease baffles medical community . In: Science . 217, No. 4560, 1982, pp. 618-621. PMID 7089584 .
    3. ↑ Fact Sheet - World Aids Day 2019. (PDF; 216 kB) In: unaids.org. 2019, accessed on May 22, 2020 .
    4. ↑ a b c UNAIDS : UNAIDS Report on the global AIDS epidemic 2013 . ( PDF; 1.4 MB [accessed January 30, 2014]).
    5. ↑ a b UNAIDS : 2008 Report on the global AIDS epidemic . ( PDF; 2.2 MB [accessed December 22, 2008]).
    6. ↑ a b Revised Surveillance Case Definitions for HIV Infection Among Adults, Adolescents, and Children Aged <18 Months and for HIV Infection and AIDS Among Children Aged 18 Months to <13 Years. CDC , December 5, 2008, accessed February 17, 2014 .
    7. ↑ 1993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults. In: cdc.gov . 1993, accessed January 14, 2020 .
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