HIV/Aids is often called the “silent epidemic” due to its very long incubation period - meaning that a person can be infected for many years without showing any symptoms. An HIV positive person may not even know that he or she is infected and unknowingly also infect other people through unprotected sexual intercourse.
Phases of infection:
Although HIV-infection can theoretically be divided into different phases, it is important to note that HIV-infection cannot in practice be precisely demarcated into separate and distinct phases with easily identifiable boundaries. The health of the HIV positive person will depend on the health of his or her immune system (on CD4 cell count and viral load in the blood, as well as on the exposure to infections and diseases in the environment).
HIV/Aids is seen as a chronic disease nowadays, because HIV positive people can live with the infection for many years if they look after their immune systems. Especially antiretroviral medication made it possible for many individuals who have been very sick with HIV/Aids, to become fully functioning again - with a low, or even undetectable viral load.
It is also not possible to say exactly what symptoms and diseases will be associated with HIV-infection in a specific person. Because of the unique way in which HIV attacks and disarms the immune system, all kinds of bacteria, fungi, protozoa, viruses and cancers are able to invade the body. That is the reason why we talk about Aids as a syndrome - a collection of many illnesses and infections.
HIV-infection can, however, theoretically be divided into the following phases or stages:
- The primary HIV infection phase (or acute sero-conversion illness). Graphic of HIV symptoms: Phase 1 (sero-conversion)
- The asymptomatic latent phase. Graphic of HIV symptoms: Phase 2
- The minor symptomatic phase. Graphic of HIV symptoms: Phase 3
- The major symptomatic phase and opportunistic diseases.Graphic of HIV symptoms: Phase 4, and How to recognise Phase 4.
- AIDS-defining conditions: the severe symptomatic phase. Graphic of HIV symptoms: Phase 5, and How to recognise Phase 5.
1. The primary HIV infection phase (or acute sero-conversion illness)Graphic, Phase 1.
The acute phase of HIV infection (also called acute sero-conversion illness) begins as soon as sero-conversion has taken place. Sero-conversion means the point in time when a person’s HIV status converts or changes from being HIV negative to HIV positive. This also usually coincides with the time when an HIV antibody test will show that a person is HIV positive.
Sero-conversion usually occurs four to eight weeks after an individual has been infected with the HI virus. About 30%-60% of people infected with HIV develop flu-like symptoms such as sore throat, headache, mild fever, fatigue, muscle and joint pains, swelling of the lymph nodes, rash, and (occasionally) oral ulcers. These symptoms usually last from between one and two weeks.
Because of the rapid replication of the virus, the HIV viral load is usually very high during the acute phase. Immediate and aggressive treatment with anti-retroviral therapy (ART) at this stage may be effective in reducing the viral load to undetectable levels, or even in eradicating the virus.
2. The asymptomatic latent phase
The second phase of HIV infection is the asymptomatic latent or silent phase. In this stage, an infected person displays no symptoms. Infected individuals are often not even aware that they are carrying the HI virus in this stage, and may therefore unwittingly infect new sex partners.
Even though the infected person may be ignorant of its presence, the virus nevertheless remains active in the body during this stage and it continues to damage and undermine its victim’s immune system. A positive HIV antibody test is often the only indication of HIV infection during this latent phase.
HIV-infected people can remain healthy for a long time, show no symptoms and carry on with their work in a normal way. Some people remain HIV positive for many years without any manifestation of clinical disease while others may deteriorate rapidly, develop Aids and die within months. In some cases the only symptom during this phase is swollen glands.
3. The minor symptomatic phase of HIV disease
In the third phase of infection, minor and early symptoms of HIV disease usually begin to manifest.
This phase usually starts when people with HIV antibodies begin to present with one or more of the following symptoms:
- Mild to moderate swelling of the lymph nodes in the neck, armpits and groin
- Occasional fevers
- Shingles (or Herpes zoster)
- Skin rashes and nail infections
- Sores in the mouth that come and go
- Recurrent upper respiratory tract infections
- Weight loss up to 10% of the person’s usual body weight
- General feelings of tiredness and non-feeling-well
What is shingles?
Shingles (or herpes zoster) is a viral infection that is caused by the same virus that causes chicken pox. In the days before the HIV/Aids pandemic, shingles used to be seen only in older people or in those who had weakened immune systems.
Nowadays shingles is very common in people with HIV infection and Aids, and it is even often seen in young people. Shingles is often one of the first symptoms of HIV infection. Shingles affects nerve cells, and it is characterised by an extremely painful skin rash or tiny blisters on the face, limbs or body. It can also affect the eyes, causing pain and blurred vision. Shingles can be very severe in people with depressed immune systems.
4. The major symptomatic phase of HIV infection and opportunistic diseases
Major symptoms and opportunistic diseases begin to appear as the immune system continues to deteriorate. At this point, the CD4 cell count becomes very low while the viral load becomes very high.
The following symptoms are usually an indication of advanced immune deficiency:
- Oral and vaginal thrush infections which are very persistent and recurrent (Candida)
- Recurrent herpes infections such as cold sores (herpes simplex)
- Recurrent herpes zoster (or shingles)
- Bacterial skin infections and skin rashes
- Fever for more than a month
- Night sweats
- Persistent diarrhoea for more than a month
- Weight loss (more than 10 percent of the usual body weight)
- Generalised lymphadenopathy (or, in some cases, the shrinking of previously enlarged lymph nodes)
- Abdominal discomfort, headaches
- Oral hairy leucoplakia (thickened white patches on the side of the tongue)
- Persistent cough and reactivation of tuberculosis
- Opportunistic diseases of various kinds
HIV and malaria
HIV-infected individuals are more prone to severe malaria than non-infected individuals. Malaria also causes a seven-fold increase in the HIV viral load of people with HIV infection. People with HIV infection should therefore take extra precautions when visiting malarial areas.
5. Aids-defining conditions: the severe symptomatic phase
Only when patients enter the last phase of HIV infection can they be said to have full-blown Aids. It usually takes about 18 months for the major symptomatic phase to develop into Aids.
In the final stage of Aids, the symptoms of HIV disease become more acute, patients become infected by relatively rare and unusual organisms that do not respond to antibiotics, the immune system deteriorates, and more persistent and untreatable opportunistic conditions and cancers begin to manifest.
While people with Aids (the last phase of HIV disease) usually die within two years, anti-retroviral therapy and the prevention and treatment of opportunistic infections may prolong this period.
The Aids patient in the final phase is usually plagued by many of the following problems:
- The Aids patient is usually very thin and emaciated due to continuous diarrhoea, nausea and vomiting (which may last for weeks or even for months).
- Conditions in the mouth (such as thrush and sores) may become so painful that the patient is no longer able to eat.
- Women suffer from persistent, recurrent vaginal infections and cervical cancer.
- Persistent generalised lymphadenopathy (PGL) is present - lymph nodes are larger than one centimetre in diameter, in two or more sites other than the groin area for a period of at least three months.
- Severe skin infections, warts and ringworm.
- Respiratory infections, persistent cough, chest pain and fever.
- Pneumonia, especially pneumocystis carinii pneumonia (PCP).
- Severe herpes zoster (or shingles).
- Nervous system problems - often complain of pains, numbness or “pins and needles” in the hands and feet.
- Neurological abnormalities with symptoms such as memory loss, poor concentration, tremor, headache, confusion, loss of vision and seizures. Aids patients may develop infections in the central nervous system or the brain.
- Kaposi’s sarcoma, or a rare form of skin cancer (painless reddish-brown or bluish-purple swelling on the skin and mucous membranes such as in the mouth). Kaposi’s sarcoma can also occur in the lungs and gastro-intestinal tract. It reacts well to chemotherapy or to alpha-interferon, but it can develop invasive open lesions and cause death if not promptly treated. Kaposi’s sarcoma is less common in black Africans.
- Lymphoma or cancer of the lymph nodes.
- Tuberculosis is a very serious opportunistic infection which affects people with Aids. According to a UNAIDS Report (2000, c), up to 50 percent of HIV-infected individuals in Africa have active tuberculosis.
- Other sexually transmitted diseases.
Revision date: June 18, 2011
Last revised: by Sebastian Scheller, MD, ScD