1st August 2023

AIDS and Other Complications of HIV

AIDS

Without treatment, HIV progresses to acquired immunodeficiency syndrome (AIDS). AIDS is defined as either an HIV positive patient with a CD4 count of less than 20 or developing an AIDS-defining illness in the context of HIV infection.

When a patient is diagnosed with AIDS, management of the underlying HIV infection with antiretroviral therapy (ART) should continue, alongside specific and supportive treatment of any associated complications. There is no cure for AIDS – treatment aims to slow the disease progression, minimise complications, and provide symptom relief. Palliative care input may be required, especially in the final stages of the illness.

ART is the single greatest intervention which prevents the progression of HIV into AIDS.

AIDS-defining illnesses

The following conditions, if they occur in the context of an HIV positive patient, are diagnostic of AIDS.

Table 2: AIDS-defining illnesses

Malignancies Associated with HIV

The three cancers most closely associated with HIV are Kaposi’s sarcoma, non-Hodgkin’s lymphoma, and cervical cancer –all of which are AIDS-defining illnesses. HIV patients are also at increased risk of liver and anal cancer and Hodgkin’s lymphoma.

Kaposi’s sarcoma

A type of skin tumour which originates from vascular and lymphatic endothelial skin layers. There is a strong aetiological association with herpesvirus type 8 (HHV-8).

It presents as characteristically purplish flat or nodular lesions. The form associated with HIV causes a severe presentation, with widespread lesions of the skin and oral cavity, as well as visceral disease in the bowel and lungs.

Skin and lymph node disease can be treated with localised radiotherapy, and systemic chemotherapy is given for disseminated disease. ART can also lead to the regression of lesions.

An example of limited Kaposi’s sarcoma, affecting the tip of a patient’s nose

Image Source: Wikimedia Commons (2018). Kaposi’sSarcoma, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Kaposi%27sSarcoma.jpg (Accessed: 12 July 2023).

Severe widespread cutaneous Kaposi’s sarcoma

Image Source: Wikimedia Commons (2008). Kaposi’s sarcoma before, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Kaposi%27s_sarcoma_before.jpg (Accessed: 12 July 2023).

Non-Hodgkin’s lymphoma

Large B-cell type lymphoma is the most common lymphoma in HIV patients. Epstein-Barr virus (EBV) is strongly implicated in aetiology in HIV patients.

Typically, lymphoma in HIV patients is very aggressive and frequently causes extranodal disease in the brain, lung, and gastrointestinal tract, with severe systemic ‘B’ symptoms (i.e. fatigue, weight loss, night sweats).

Treatment is with aggressive chemotherapy –there is a poor response rate, and the prognosis is poor for HIV-related lymphoma.

Cervical cancer

Women with HIV are at significantly increased risk of cervical cancer, especially caused by human papillomavirus (HPV). Colposcopy is offered to patients with a cervix at diagnosis, and annual smear tests are subsequently indicated.

Other Complications of HIV

Neurological complications

AIDS-dementia complex (ADC) is a type of dementia seen in HIV patients and commonly associated with cerebellar features. Clinical presentation can range from mild memory impairment to severe cognitive decline and personality change, and psychotic features may be seen. Diagnosis is supported by MRI head scans showing white matter lesions and encephalopathic features on EEG.

HIV is also associated with sensory neuropathies, which typically cause an intensely painful symmetrical sensory neuropathy of the feet, which may progress to the upper limbs. HIV is also associated with autonomic neuropathy, which mainly presents with postural hypotension and diarrhoea.

Haematological complications

Haematological complications are more frequent as HIV progresses and are associated with a falling CD4 count. Associated conditions include lymphopenia, anaemia (classically normocytic and normochromic), neutropenia, thrombocytopenia, and pancytopenia.

Metabolic and endocrine complications

Adrenal gland dysfunction and testosterone deficiency are associated with HIV.

Osteopenia, osteoporosis and avascular necrosis are all associated with HIV, with ART also implicated in the aetiology.

Cardiovascular complications

Lipid dysfunction is associated with ART, meaning HIV patients are more at risk of cardiovascular disease as a therapeutic side effect. Data also suggests that ischaemic heart disease is more common in untreated HIV patients, and there is a risk independent of treatment side effects.

Cardiomyopathy and myocarditis are also associated with HIV.

Renal complications

Renal disease in HIV is known as HIV-associated nephropathy (HIVAN). Nephrotic syndrome secondary to focal segmental glomerulosclerosis is the most common renal disease in HIV. It causes a severe, progressive illness, and dialysis is often indicated. HIVAN is most common in male patients and patients with African-American heritage.

Opportunistic Infections

The immunocompromised state of many HIV patients means they are vulnerable to various opportunistic infections. These are AIDS-defining illnesses, and many are listed in Table 2 above.

A useful way to consider these infections is the risk in relation to CD4 count, which is summarised in the following table.

Table 3: CD4 count with associated conditions

The key opportunistic infections are covered in greater detail in the Common Infections in Immunocompromised Hosts section.