How is HIV spread (transmitted)?

HIV is present to variable degrees in the blood and genital secretions of virtually all individuals infected with HIV, regardless of whether or not they have
symptoms. The spread of HIV can occur when these secretions come in contact with tissues such as those lining the vagina, anal area, mouth, or eyes (the mucus
membranes), or with a break in the skin, such as from a cut or puncture by a needle. The most common ways in which HIV is spreading throughout the world
include sexual contact, sharing needles, and by transmission from infected mothers to their newborns during pregnancy, labor (the delivery process), or
breastfeeding. (See the section below on treatment during pregnancy for a discussion on reducing the risk of transmission to the newborn.)

Sexual transmission of HIV has been described from men to men, men to women, women to men, and women to women through vaginal, anal, and oral sex. The
best way to avoid sexual transmission is abstinence from sex until it is certain that both partners in a monogamous relationship are not HIV-infected. Because the
HIV antibody test can take up to six months to turn positive after infection occurs, both partners would need to test negative six months after their last potential
exposure to HIV. If abstinence is out of the question, the next best method is the use of latex barriers. This involves placing a condom on the penis as soon as an
erection is achieved in order to avoid exposure to pre-ejaculatory and ejaculatory fluids that contain infectious HIV. For oral sex, condoms should be used for
fellatio (oral contact with the penis) and latex barriers (dental dams) for cunnilingus (oral contact with the vaginal area). A dental dam is any piece of latex that
prevents vaginal secretions from coming in direct contact with the mouth. Although such dams occasionally can be purchased, they are most often created by
cutting a square piece of latex from a condom.

The spread of HIV by exposure to infected blood usually results from sharing needles, as in those used for illicit drugs. HIV also can be spread by sharing needles
for anabolic steroids to increase muscle, tattooing, and body piercing. To prevent the spread of HIV, as well as other diseases including hepatitis, needles should
never be shared. At the beginning of the HIV epidemic, many individuals acquired HIV infection from blood transfusions or blood products, such as those used for
hemophiliacs. Currently, however, because blood is tested for both antibodies to HIV and the actual virus before transfusion, the risk of acquiring HIV from a blood
transfusion in the United States is extremely small and is considered insignificant.

There is little evidence that HIV can be transferred by casual exposure, as might occur in a household setting. For example, unless there are open sores or blood
in the mouth, kissing is generally considered not to be a risk factor for transmitting HIV. This is because saliva, in contrast to genital secretions, has been shown to
contain very little HIV. Still, theoretical risks are associated with the sharing of toothbrushes and shaving razors because they can cause bleeding, and blood can
contain large amounts of HIV. Consequently, these items should not be shared with infected people. Similarly, without sexual exposure or direct contact with
blood, there is little if any risk of HIV contagion in the workplace or classroom.

What happens after an exposure to the blood or genital secretions of an HIV-infected person? What are symptoms of
primary HIV infection?

The risk of HIV transmission occurring after any potential exposure to bodily fluids is poorly defined. The highest risk sexual activity, however, is thought to be anal
intercourse without a condom. In this case, the risk of infection may be as high as 3%-5% for each exposure. The risk is probably less for vaginal intercourse
without a condom and even less for oral sex without a latex barrier. Despite the fact that no single sexual exposure carries a high risk of contagion, HIV infection
can occur after even one sexual event. Thus, people must always be diligent in protecting themselves from potential infection.

Within two to six weeks of an exposure, the majority of infected people will have a positive HIV antibody test, with virtually all being positive by six months. The test
used most commonly for diagnosing infection with HIV is referred to as an ELISA. If the ELISA finds the HIV antibody, the presence of the antibody is confirmed by
a test called a Western blot. There are now several rapid antibody tests that can be performed on blood or saliva and provide preliminary results within 20 minutes.
These tests are fairly accurate but also need be confirmed with a Western blot. It is currently recognized that approximately 20% of HIV-infected individuals in the
United States are not aware that they are infected, largely as a result of not having been tested. In September 2007, the Centers for Disease Control and
Prevention recommended that HIV antibody testing be performed as part of routine care for individuals presenting to medical attention for any reason. The hope is
that this strategy will reduce the number of infected individuals who are not aware of their status in order to both get them into medical care earlier and to counsel
them as to how they can prevent spread to others. This strategy can be markedly enhanced with the rapid testing which can provide preliminary results before the
patient leaves the medical facility.

During this period of time shortly after infection, more than 50% of those infected will experience a "flu-like" or "infectious mono-like" illness for up to several
weeks. This illness is considered the stage of primary HIV infection. The most common symptoms of primary HIV infection are

• fever,

• aching muscles and joints,

• sore throat, and

• swollen glands (lymph nodes) in the neck.

It is not known, however, why only some HIV-infected people develop these symptoms. It also is unknown whether or not having the symptoms is related in any
way to the future course of HIV disease. Regardless, infected people will become symptom-free (asymptomatic) after this phase of primary infection. During the
first weeks of infection when a patient may have symptoms of primary HIV infection, antibody testing, if performed, may still be negative. If there is suspicion of
early infection based upon the types of symptoms present and a potential recent exposure, consideration should be given to having a test performed that
specifically looks for the virus circulating in the blood, such as a viral load test. Once the patient enters the asymptomatic phase, infected individuals will know
whether or not they are infected if a test for HIV antibodies is done. Therefore, anyone who might possibly have been exposed to HIV should seek testing even if
they are not experiencing symptoms.

During all stages of infection, literally billions of HIV particles (copies) are produced every day and circulate in the blood. This production of virus is associated with
a decline (at an inconsistent rate) in the number of CD4 cells in the blood over the ensuing years. Although the precise mechanism by which HIV infection results
in CD4 cell decline is not known; it probably results from a direct effect of the virus on the cell as well as the body's attempt to clear these infected cells from the
system. In addition to virus in the blood, there is also virus throughout the body, especially in the lymph nodes, brain, and genital secretions. The time from HIV
infection to the development of AIDS varies. Rarely, some individuals develop complications of HIV that define AIDS within one year, while others rema
completely asymptomatic after as many as 20 years from the time of infection. However, the time for progression from initial infection to AIDS is usually
approximately eight to10 years. The reason why people experience clinical progression of HIV at different rates remains an area of active research.