HIV/AIDS

Definition/Description

The Centers for Disease Control and Prevention (CDC) revised the definition of AIDS in 1992 to include those who have HIV-1 and a CD4 count below 200/mL (the normal CD4 lymphocyte count is 600 to 1200/mL) or 14% of the total lymphocyte count, even if the person has no other signs or symptoms of infection.

Three distinct points identify this continuum:

  1. asymptomatic HIV seropositive,
  2. early symptomatic HIV, and
  3. HIV advanced disease (AIDS).[1]

AIDS, acquired immunodeficiency syndrome, is a contagious, chronic and life-threatening condition caused by the human immunodeficiency virus (HIV). Acquired means the disease is not inherited or genetic in nature but develops as a result of a virus. Immuno refers to the immune system, and deficiency means the immune system is underperforming or hypoactive. By damaging your immune system, HIV interferes with your body's ability to fight off viruses, bacteria, and fungi that cause disease and other invasive pathologies. HIV makes you more susceptible to certain types of cancers and infections your body would normally resist. The cytopathogenic virus and the infection itself are known as HIV. "Acquired immunodeficiency syndrome (AIDS)" is the name given to the later and more serious stages of an HIV infection. [2]

According the AIDS.gov, 35.3 million people are currently living with HIV/AIDS worldwide. Though the spread of the virus has slowed in some countries, it has escalated or remained unchanged in others. The best hope for stemming the spread of HIV lies in prevention, treatment and education. [3]

For a visual illustration of how HIV and AIDs progresses, please visit the following: http://aids.gov/hiv-aids-basics/hiv-aids-101/what-is-hiv-aids/

Prevalence

Prevalence is defined as the number of people living with HIV infection at the end of a given year. According to the CDC, at the end of 2010, about 1.1 million people in the United States were living with HIV/AIDS. Of those people, about 16% do not know they are infected. The prevalence of HIV is increased in African American males, male to male sexual relations, and age 25-34. The prevalence is 5 times greater in incarcerated populations than the general population at large. The high HIV transmission rates among inmates maybe related to homosexual encounters and potentially tattooing. Ethnicity is not directly related to AIDS risk, but it is associated with other determinants of health status such as poverty, illegal drug use, access to health care, and living in communities with a high prevalence of AIDS. [4]

Incidence is the number of new HIV infections that occur during a given year. HIV infection is the 5th leading cause of death for people who are between the ages of 25-44 years old in the United States. In 2010, the CDC estimated that approximately 47,500 people were newly infected with HIV. There are four transmission categories of HIV: male to male sexual relations, heterosexual relations, injection drug users, and homosexual relations combined with injection drug users. Male to male sex accounted for 78% of new HIV infections among men and 63% of all new infections in 2010. Furthermore, black men represented 31% of all new HIV infections, in the United States, in 2010. Black/African American men and women were also strongly affected and were estimated to have an incidence rate that was 7 times as high as the incidence rate among whites. African-American's represent about 14% of the total United States population, but make up almost half of the people known that are suffering from AIDS. AIDS is the leading cause of death for African-American men between the ages of 35-44 years old in the United States. It is thought that approximately 5 million new HIV cases occur each year worldwide. [4]
For complete HIV/AIDS prevalence and incidence statistics, please visit http://www.cdc.gov/nchhstp/newsroom/docs/2012/HIV-Infections-2007-2010.pdf or visit the HIV/AIDS page on the CDC website at http://www.cdc.gov/hiv/default.html.

Clinical Presentation

The clinical presentation of HIV and AIDS vary depending on which stage of infection the person is in.

Early infection:

When a person first becomes infected with HIV, many people will experience flu-like symptoms often described as "the worst flu ever." These symptoms usually occur within 2-4 weeks of becoming infected with HIV. Early signs and symptoms may include: fever, headache, sore throat, swollen lymph vessels, fatigue, muscle and joint aches and pain, and rash. GI complaints include change in bowel and bladder function, especially diarrhea. Cutaneous complaints are common and include: dry skin, new skin rashes, and nail bed changes. Because these are very common and present in a number of other diseases, a combination of complaints is more suggestive of HIV infection than any one sign/symptom. In addition, many people with HIV present with back pain, but the underlying cause may differ from person to person. Back pain may be due to: muscle weakness and atrophy that occurs as a result of the disease process. Back muscle weakness and atrophy can alter the person's normal postural alignment and may cause subsequent back pain as well as a person's response to their medications may contribute to back pain as well. It has been reported that back pain is more likely to occur when the bodies T-cell count drops. Even though, the person may or may not exhibit symptoms they can still transmit the virus to others. Once, the virus enters the person's body, the person's immune system comes under attack. The virus then starts to multiply in the person's lymph nodes and slowly begins to eradicate the helper T- cells, the white blood cells that help the immune system. [3] [4] [2]

Later infection:

A person may remain symptom free for as long as 8-9 years, but as the virus continues to multiply and destroy immune cells, the person may begin to develop chronic symptoms and/or acquire mild infections. Chronic symptoms seen in this stage are but not limited to the following: swollen lymph nodes-which is often one of the first signs of HIV infection, diarrhea, weight loss, fever, cough and shortness of breath. [3]

Latest phase of infection:

Usually, after a person has been infected with HIV for 10 years or more the last phase of HIV commences. More serious symptoms of the virus start to appear and the infection may then meet the official definition of AIDS. Some of the signs/symptoms of later infection are: Kaposi's sarcoma, multiple purple blotches and bumps on skin, HTN (pulmonary and or cardiac), dyspnea, syncope, chest pain, non-productive cough, easy bruising, thrush, muscle atrophy and weakness, back pain, poor wound healing, HIV related dementia (memory loss, confusion, behavioral change, impaired gait), and distal symmetric polyneuropathy (pain, numbness, tingling, burning, weakness, and atrophy).    By the time AIDS develops, the person's immune system has been severely damaged, making the person susceptible to many opportunistic infections such as TB, Pneumocystsis carinii, pneumonia, lymphoma, thrush, herpes 1 and 2, toxoplasmosis and cansisiasis. They are called "opportunistic" infections or diseases because they take advantage of the compromised immune system to infect and destroy the person's body. Under normal conditions, a person would not be affected to the degree of severity they are under the presence of these infections with normal immune function.  The signs and symptoms of some of these infections may include but not limited to the following: soaking night sweats, shaking chills or fever higher than 100 degrees F (38 C) for several weeks, dry cough and shortness of breath, chronic diarrhea, persistent white spots or unusual lesions on the person's tongue or in their mouth, headaches, blurred and distorted vision, weight loss. [2]

In 1993, the CDC redefined AIDS to mean the presence of HIV infection as shown by a positive HIV antibody test with the presence of at least one of the following: [3]

1. If an individual has HIV and one or more of certain OIs defined by the CDC no matter what that person's CD4 count is. The CDC lists more than 20 OIs that are considered AIDS-defining conditions. These are:

  • Candidiasis of bronchi, trachea, esophagus, or lungs
  • Invasive cervical cancer
  • Coccidioidomycosis
  • Cryptococcosis
  • Cryptosporidiosis, chronic intestinal (greater than 1 month's duration)
  • Cytomegalovirus disease (particularly CMV retinitis)
  • Encephalopathy, HIV-related
  • Herpes simplex: chronic ulcer(s) (greater than 1 month's duration); or bronchitis, pneumonitis, or esophagitis
  • Histoplasmosis
  • Isosporiasis, chronic intestinal (greater than 1 month's duration)
  • Kaposi's sarcomav
  • Lymphoma, multiple forms
  • Mycobacterium avium complex
  • Tuberculosis
  • Pneumocystis carinii pneumonia
  • Pneumonia, recurrent
  • Progressive multifocal leukoencephalopathy
  • Salmonella septicemia, recurrent
  • Toxoplasmosis of brain
  • Wasting syndrome due to HIV

2. A CD4 lymphocyte, helper T cell count of 200 or less. According to AIDS.gov recent research has shown that it may be easier to mainatin higher CD4 counts if you start treatment before your count drops below 350. Normal count ranges from 500 to 1,000.

3. Certain Cancers such as: Lymphoma, CNS Lymphoma, Kaposi's Sarcoma, Anal Cancer, and Invasive Cervical Cancer.

 

Associated Co-morbidities

AIDS is an unique disease in that no other known infectious disease attacks the immune system directly in the same manner. Because the immune system is greatly affected many patient's suffering from AIDS may present with the folllowing co-morbidities among others:[5][6]

  • Cancer (especially with the appearance of the highly unusual Kaposi's Sarcoma)
  • Non-Hodgkin's Lymphoma
  • AIDS-related primary central nervous system lymphoma
  • Hepatocellular carcinoma
  • Tuberculosis (pulmonary and extrapulmonary TB)
  • HIV neurologic disease
  • AIDS dementia complex/HIV encephalopathy
  • Progressive multifocal leukoencephalopathy
  • Vacuolar myelopathy (most common in the Thoracic spine)
  • inflammatory polyneuropathies
  • sensory neuropathies
  • mononeuropathies
  • inflammatory demylinating polyneuropathy (similar to Guillain-Barre syndrome)
  • Cytomegalovirus
  • hypersensitivity disorders
  • A twofold increase in risk of MI[7]
  • Chronic Kidney Failure [7]
  • Osteoporosis [7]

Medications

When HIV was first identified there were few drugs to treat the virus and opportunistic infections associated with it. Since then, a number of medications have been developed to treat both HIV/AIDS and opportunistic infections. Anti-retroviral medications have provided HIV-positive Americans with an increased quality of life and extended life. No drug/treatment can cure HIV/AIDS, many of the drugs used have side effects that can be severe, and most drug therapies are expensive.

Anti-retroviral drugs inhibit the growth and replication of HIV at various stages of its life cycle. Seven classes of these drugs are available:

  • Nucleoside analogue reverse transcriptase/NRTIs
  • Protease inhibitors/PIs
  • Non-nucleoside reverse trabscriptase inhibitors/NNRTIs
  • Nucleotide reverse transcriptase inhibitors/NtRTIs
  • Fusion inhibitors
  • Integrase inhibitors
  • Chemokine co-receptor inhibitors

To learn more about how these anti-retroviral drugs prevent HIV from replicating in your body, visit http://aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/treatment-options/overview-of-hiv-treatments/index.html

A person's response to any of these medications is measured by viral load. Viral load is tested at the start of any treatment and then every three to four months while undergoing therapy.

Taking more than one drug protects the patient against HIV-drug resistance. Taking 3 different HIV meds does the best job of controlling the amount of virus in your body and protecting the immune system. Therefore, by following the 3-drug regimen, HIV will be less likely to reproduce and not respond to the medications. [3]

Side Effects of Medication:

Short Term:

  • rash
  • Anemia
  • diarrhea
  • nausea
  • headaches
  • dizziness
  • muscle pain
  • weakness
  • fatigue
  • insomnia

Long Term:

  • Lipodystrophy- a problem in the way the body produces, uses, and stores fat
  • Insulin Resistance
  • Lipid Abnormalities
  • Decrease in bone density
  • Lactic Acidosis

Hepatotoxicity is also a common complication which may manifest itself with the following signs/symptoms:

  • carpal tunnel syndrome
  • liver palms
  • asterixis
  • and other signs of liver impairment
  • If the patient notices any unusual or severe reactions after starting or changing a drug, report the side-effects to your health care provider immediately. Do not let these side-effects take over the patients treatment plan. [3]

For complete description of HIV drugs, including brand names, see AIDSmeds.com's Treatment for HIV and AIDS at http://www.aidsmeds.com/list.shtml. [8]

Diagnostic Tests

Early diagnosis is important so that early preventative therapies may be initiated, and sex partners can be notified of their risk of HIV. The U.S. Food and Drug Administration approved the first rapid HIV test in August 2013. This new test allows for simultaneous detection of HIV-1 p24 antigen as well as antibodies to HIV-1 and HIV-2 in human serum, plasma, and venous or fingerstick whole blood specimens. The Alere Determine HIV-1/2 Ag/Ab Combo test is the first FDA-approved test which independently distinguishes results for HIV-1 p24 antigen and HIV antibodies in a single test. Detection of HIV-1 antigen permits earlier detection of HIV-1 infection than is possible by testing for HIV-1 antibodies alone. The test can distinguish acute HIV-1 infection from established HIV-1 infection when the blood specimen is positive for HIV-1 p24 antigen but is negative for HIV-1 and HIV-2 antibodies

“This test helps diagnose HIV infection at an earlier time in outreach settings, allowing individuals to seek medical care sooner,” Karen Midthun, M.D., director of the FDA’s Center for Biologics Evaluation and Research. [3]

Other methods of screening for AIDS can be done by a finger stick blood test, the HIV-1 antibody enzyme immunoassay test. The blood test looks for the presence of antibodies to HIV-1. The test only indicates if person has been exposed to the virus. Antibody testing is not always reliable because the body takes varying amounts of time to produce a detectable level of antibodies. Consequently, a person who does have HIV could test negative for the for HIV antibodies. Antibody testing is also unreliable in neonates because transferred maternal antibodies are present for 6-10 months in the neonate. The Western blot test can be used when there is concern about false-positive results. HIV RNA viral loading is another test that can be done in the lab. It measures the plasma HIV RNA assay. OraQuick Rapid HIV Antibody Test is another test which individuals may use. This test is quick and results are available in 20 minutes. The test is a rapid, non-invasive test which uses saliva or a gum swab to detect the presence of HIV antibodies. The advantages to rapid testing is individuals with positive results can receive treatment quickly and education about how to prevent transmission of the illness to others and can partake in counseling services. The disadvantage of this quick test is it cannot detect the HIV infection in people who were exposed less than 3 months prior to taking the test. It has been estimated that one third of all individuals who do get tested for the presence of HIV do not return to get the results of their test.[4]

Causes

Around the late 1970's and 80's doctors began noticing that an increasing number of people were suffering from several unusual and rare illnesses. At first, little was known about what was happening to these initial victims of AIDS. Doctors were unsure as to what was causing the condition. Many of the first people diagnosed with this new condition were homosexual men.  Due to the infected population, the condition was labeled GRID, gay related immunodeficiency. However, the condition soon started showing up in women, intravenous drug users, and hemophiliacs. The first reported AIDS cases were in the United states in 1981. In 1983, the Institute Pasteur in France regonized the virus which was causing so much panic was the result of AIDS. The virus that resulted from AIDS was named HIV, human immunodeficiency virus. Researchers in France, now understood the virus passed from each person via the exchange of semen, blood, or vaginal secretions during sexual contact. Researchers also learned that AIDS weakens the immune system by destroying the body's white blood cells, specifically the helper T-cells. Helper T- cells help the body fight off viruses and bacteria that enter the body. In 1985 another breakthrough took place, a blood test which detected the presence of HIV antibodies in the person's blood stream. The first sample of HIV infected blood dates back to 1959, but computer analysis dates the emergence date back to the 1930's.  

There have been many theories and much speculation as to where the AIDS virus first originated. AIDS used to be a very rare and isolated virus which affected a few types of monkeys and chimpanzees in Africa. AIDS is related to another virus, Simian Immunodeficiency virus that affects monkeys and apes. It was thought that humans were first exposed to AIDS when they caught the monkeys for food, kept them as pets, or if they were scratched and bitten by an infected monkey/ape.

We now know that AIDS is caused by the spread of the HIV virus. The virus is spread though sexual contact; needles; a syringe that is shared by intravenous drug users; transfusion of infected blood or blood products; or perinatal transmission from infected birthing or breastfeeding a child from an infected mother. HIV is not transmitted through casual contact such as: the shared use of utensils, food, cups, towels, razors, toothbrushes or even kissing. Transmission always involves exposure to some body fluid from an infected client. The greatest concentrations of the virus have been found in blood, semen, cerebrospinal fluid, and cervical/vaginal secretions. HIV has been found to be in low concentrations in tears, saliva, and urine, but no cases of transmission have been reported via these routes. The primary cause of AIDS is the type 1 retrovirus, or HIV. Transmission of the HIV virus happens by individuals partaking in high risk behaviors. High risk behaviors are defined and include: unprotected vaginal, anal, or oral sex; having 6 or more sexual partners in the past year; sexual activity with someone known to carry HIV; exchanging sex for money or drugs; and  injecting drugs.   

Population groups at the greatest risk are: commercial sex workers (prostitutes) and their clients; homosexual men; injection drug users; blood recipients; dialysis recipients; organ transplant recipients; fetuses of HIV infected mothers; and people with other sexually transmitted diseases. People who already have a sexually transmitted disease are 3-5 times more likely to come in to contact with the HIV virus compared with people without STDs. [4][2]

Systemic Involvement

HIV is described mainly as a infection of the immune system resulting in progressive and profound immune suppression. The progression of the illness can have an effect on the following systems: musculoskeletal, neurologic/neuromuscular, cardiopulmonary, and the integumentary system. Some of the clinical manifestations of HIV on the musculoskeletal system is but not limited to: Myalgia/arthralgia, Rheumatologic manifestations, inflamed joints and associated disorders like: Reiter's syndrome, reactive arthritis, psoriatic arthritis, Myositis/pyomyositis, connective tissue diseases, Avascular necrosis, Musculoskeletal pain syndrome/HIV wasting syndrome, Myopathy, Pelvis pain, Extrapulmonary tuberculosis, delayed healing and Myositis ossificans.

HIV can hav the following implications on the neurologic/neuromuscular system: gait disturbances, intention tremor, delayed response of reflexes, HIV associated dementia, social withdraw, irritability, depression, apathy, lethargy, memory impairment, confusion, disorientation, ataxia, leg weakness with gait disturbances, loss of fine motor coordination, incontinence, paraplegia, Guillian-Barre syndrome, headaches, seizures, Radiculopathy, peripheral neuropathy, brachial neuropathy, and vacuolar spinal myelopathy.

The cardiopulmonary system can display the following clinical signs/symptoms: dyspnea, especially on exertion, nonproductive cough, hypoxia symptoms, pericardial effusion, cadriomyopathy, endocarditis and vasculitis. 

The integumentary system can display the following clinical manifestations: hair loss, basal cell carcinoma, Kaposi's sarcoma, mucocutaneous ulcers, rashes, Urticaria, delayed wound healing. [5][6]

Medical Management

It is important to note that there is currently no cure for AIDS. Recent medical advantages have been made that have allowed AIDS to become a chronic and manageable condition. Currently researchers are working on the development of a vaccine, but until a vaccine is developed the primary goal of intervention will be focused on stopping HIV from replicating, to increase the number of CD4 cells, and to slow the progression of the disease. Antiretroviral Therapy (ART) is the current best medical management for individuals with HIV/AIDS. These drugs do not completely eradicate the virus and lifelong treatment is required until a method for permanent eradication is developed. In a study done by The Strategies for Management of Antiretroviral Therapy (SMART) study group, it was concluded that episodic (meaning when the CD4+ count dropped to 250 or below) therapy significantly increased the risk of opportunistic disease or death, as compared with continuous (ART when CD4+ count is 350 or more). [9]

Non-pharmacological intervention include:

  • Physical Therapy
  • nutritional counseling
  • exercise
  • mental health support
  • alternative and complimentary interventions                                                                          

Physical Therapy Management

Physical Therapists play an important role in treating conditions that limit the patient’s movement and function. Goals will be set to improve quality of life and keep the patient active in both his/her life and in the community. Patients with HIV develop many of the functional limitations that any other patient may have, such as sports-related injuries or arthritis. In addition to managing impairments, these patients may have problems with the disease process, infections, and/or side effects of the medication. A physical therapist will develop a plan of care to help the patient improve his/her ability to do daily activities, improve heart health, improve balance, reduce pain, and maintain a healthy body weight. In addition this plan of care, a proper home exercise program will be prescribed to achieve goals set by the patient or physical therapist. [10]

In addition to improving the above mentioned positive benefits, the therapist must also address the following issues:

  • quality of life issues
  • work hardening
  • community management skills (how to access transportation, socialisation opportunities, shopping, banking, ability to access and negotiate health care and insurance systems)
  • integumentary care

What Does the Literature Say:

The current literature states aerobic exercise, progressive resistance exercise, or a combination may attribute to the following benefits:

  • Performing constant or interval training for at least 20 minutes at least 3 times per week for at least 5 weeks appears to be safe and may lead to significant improvements in cardiopulmonary fitness (maximum oxygen consumption) body composition (leg muscle area, percent body fat) and psychological status. [11]
  • Progressive resistance exercise appears to be safe and may be beneficial for medically-stable adults living with HIV. [11]
  • PRE or a combination of PRE and aerobic exercise may lead to statistically significant increases in weight and arm and thigh girth. [12]
  • Trends toward improvement in submaximum heart rate and exercise time were found. [12]
  • HIV patients have abnormally low functional capacities, expressed as lowered capacity to utilize and perform physical work. [13]
  • Low to moderate intensity exercise does not alter CD4 cell counts or viral load, nor does it increase the prevalence of opportunistic infections.[13]
  • Higher intensity aerobic exercise training has been effective at improving Functional Aerobic Capacity. [13]
  • All in all, fatigue remains the most frequent and debilitating complaint of HIV-infected people.[14]  With this said, patients who partake in aerobic exercise, PRE, or a combination will begin to achieve the above mentioned benefits to combat fatigue.

In addition to progressive resistance exercise and aerobic exercise, physical therapist may also perform the following interventions to treat any impairment the patient may present with:

  • Stretching
  • Soft Tissue and Joint Mobilization
  • Gait and Balance Training
  • Functional Electrical Stimulation/Neuromuscular Electrical Stimulation
  • Proprioceptive Neuromuscular Facilitation
  • Desensitisation Techniques

The Big Picture:

Exercise can provide the following benefits for patients suffering from HIV/AIDS:

  • Pain relief
  • Reduction of muscle atrophy
  • Regularity of bowels
  • Enhances immune function (by increasing T helper/ inducer CD4 cells and activating CD8 cells)
  • Improves cardiovascular function
  • Improves pulmonary function
  • Improves endurance
  • Helps prevent pneumonia and other respiratory infections
  • Reduces anxiety and improves mood

Standard AIDS/HIV precautions for therapists and other health care workers: [4]

  • Use protective barriers (gloves, glasses, gowns) when handling blood, body fluids, and infectious fluids.
  • Wash hands and mucous membranes
  • Prevent needle/scalpel sticks
  • Use ventilation devices for resuscitation
  • Don't treat a patient with HIV/AIDS if you have open wounds or skin lesions until lesions have healed.
  • If pregnant take extra precautions

Outcome Measure for Quality of Life

Functional Assessment of HIV Infection (FAHI)

Differential Diagnosis

Many individuals with HIV/AIDS may remain asymptomatic for years, with a mean time of 10 years between exposure and development. Virtually, all the findings in the initial onset of AIDS may be found/mimic other diseases such as:

  • Fever
  • Headaches
  • Night sweats
  • Fatigue
  • HTN
  • Back pain
  • Pulmonary complications ex. cough and SOA
  • GI complaints (change in bowel habits and function)
  • Cutaneous complaints (dry skin, new rashes, nail bed changes)
  • Poor wound healing
  • Thrush
  • Easy Bruising
  • Weight loss
  • Herpes Simplex virus
  • Cytomegalovirus
  • Lymphoma

 All of these signs/symptoms may be associated with other diseases, a combination of complaints is more suggestive of HIV infection than any one symptom alone. [5][6][15]

References

  1. Catherine C. Goodman, MBA, PT, CBP and Kenda S. Fuller, PT, NCS. Pathology, 3rd EditionfckLRImplications for the Physical Therapist. Chapter 7 Immune System. pg. 258
  2. 2.0 2.1 2.2 2.3 HIV/AIDS. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/hiv-aids/basics/symptoms/con-20013732. Accessed March 25, 2014.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 U.S. Department of Health and Human Services. HIV/AIDS Basics. AIDS.gov. http://aids.gov/hiv-aids-basics/. Accessed March 25, 2014.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 HIV/AIDS. Center for Disease Control and Prevention. http://www.cdc.gov/hiv/default.html. Updated March 20, 1014. Accessed March 25, 2014.
  5. 5.0 5.1 5.2 Goodman C, Snyder T. Screening for Immunologic Disease. Differential Diagnosis for Physical Therapists Screening for Referral. 5th Edition. St. Louis, MO: Elsevier Saunders; 2013: 454-457.
  6. 6.0 6.1 6.2 Goodman C, Fuller K. The Immune System. Pathology Implications for the Physical Therapist. 3rd Edition. St. Louis, MO: Elsevier Saunders; 2009: 257-274.
  7. 7.0 7.1 7.2 Gazzola L, Tincati C, Monforte AD. Noninfectious HIV-related Comorbidities and HAART Toxicities: Choosing Alternative Antiretroviral Strategies. HIV Therapy; 2010; 4(5): 553-565. Available from: Medscape.com. Accessed March 20, 2014.
  8. Treatment for HIV & AIDS. AIDS MEDS: Your Ultimate Guide to HIV Care. http://www.aidsmeds.com/list.shtml. Updated November 18, 2013. Accessed March 25, 2014.
  9. El-Sadr, WM; Lundgren, JD; Neaton, JD; Gordin, F; Abrams, D; Arduino, RC; Babiker, A; Burman, W; Clumeck, N; Cohen, CJ; Cohn, D; Cooper, D; Darbyshire, J; Emery, S; Fatkenheuer, G; Gazzard, B; Grund, B; Hoy, J; Klingman, K; Losso, M; Mejia, JMR; Markowitz, N; Neuhaus, J; Phillips, A; Rappoport, C; Strategies Management Antiretrovir,; CD4+count-guided interruption of antiretroviral treatment. NEW ENGL J MED, 2006; 355 (22): 2283 - 2296. http://eprints.ucl.ac.uk/6514/. Accessed March 25, 2014.
  10. Physical Therapist’s Guide to HIV Disease and AIDS. American Physical Therapy Association. http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=931ce05b-4b22-4952-9b18-34af9e201f8d#.UzGRfNnO_Tp. Accessed March 25, 2014.
  11. 11.0 11.1 O'Brien K, Nixon S, Tynan AM, Glazier R. Aerobic exercise interventions for adults living with HIV/AIDS. Cochrane Database Syst Rev. 2010;(8):CD001796. http://www.ncbi.nlm.nih.gov/pubmed/20687068. Accessed March 25, 2014.
  12. 12.0 12.1 O'Brien K, Tynan AM, Nixon S, Glazier RH. Effects of progressive resistive exercise in adults living with HIV/AIDS: systematic review and meta-analysis of randomized trials. AIDS Care. 2008; 20:631-653. http://www.ncbi.nlm.nih.gov/pubmed/18576165. Accessed March 25, 2014.
  13. 13.0 13.1 13.2 Hand G, Phillips K, Dudgeon W, Lyerly G, Durstine J, Burgess S. Moderate intensity exercise training reverses functional aerobic impairment in HIV-infected individuals. AIDS Care. 2008; 20 (9): 1066-1074. http://www.tandfonline.com/doi/abs/10.1080/09540120701796900#.UzGcZNnO_To. Accessed March 25, 2014.
  14. Barroso J, Voss J. Fatigue in HIV and AIDS: An Analysis of Evidence. Journal of the Assosciation of Nurses in AIDS Care. January/February 2013; 24: S5-S14. http://www.sciencedirect.com/science/article/pii/S1055329012002427. Accessed March 25, 2014.
  15. Bennett N, Bronze M. HIV Disease Differential Diagnoses. Medscape. http://emedicine.medscape.com/article/211316-differential. Updated March 20, 2014. Accessed March 25, 2014.