human immunodeficiency virus ( hiv ) causes progressive mutilation of the body 's cellular immune system , leading to augmented susceptibility to tumors and fatal conditions such as acquired immunodeficiency syndrome ( aids ) . the emergence and pandemic spread of aids constitute the greatest challenge to the public in modern times . from the onset of the hiv epidemic over 20 years ago ( since the appearance of the first cases of contamination by the hiv virus in the 1980s ) , more than 60 million people have become infected and more than 20 million people have died . more than 20 years into this hiv - aids pandemic , it has stuck almost all the countries and populations in many ways . aids , caused by hiv , is presently considered as one of the most dreadful diseases affecting human kind . an estimated 15,000 new infections occur each day , with more than 95% of these in developing countries . sub - saharan africa currently bears the greatest burden worldwide , with 28.5 million ( 70% ) individuals infected . in south africa , 5.2 million of the population was estimated to be infected with hiv / aids . hiv is transmitted by sexual means , through the exchange of body fluids ( especially infected semen during intercourse ) ; by non - sexual means , via the parenteral transfer of infected blood ; or through vertical transmission to infants born of infected mothers . the only fluids that have been demonstrated to be associated with transmission of the virus are blood , semen , breast milk , and vaginal secretions . casual contact ( shaking hands , hugging , casual kissing , etc . ) has not been shown to transmit hiv . the united nations programme on hiv / aids estimates that over 40 million people are living with hiv / aids globally . an estimated 15,000 new infections occur each day , with more than 95% of these in developing countries . sub - saharan africa currently bears the greatest burden worldwide , with 28.5 million ( 70% ) individuals infected . in south africa , 5.2 million of the population was estimated to be infected with hiv / aids . between 60% and 90% of the people with hiv infection will have at least one oral manifestation at some time during the course of their disease . oral lesions cause significant discomfort and have a major impact on the quality of life . recognition and management of these oral conditions is therefore important for the health and quality of life of the individual with hiv / aids . despite the increasing number of reports on the prevalence of oral manifestations in hiv - positive / aids patients , there is limited information about the impact of these lesions on the quality of life in these patients . the retrovirus family is composed of three subfamilies : oncoviruses , spumaviruses and lentiviruses . based on the structure , biologic properties , and protein and nucleic acid sequence homology , the nucleoid contains the hiv genome , which is diploid ( i.e. , composed of two identical single - stranded rnas ) . these genes code for the structural proteins that are used to assemble the virus particles and the regulatory proteins involved in the regulation of viral gene expression . the hiv rna genome is associated with a basic nucleic acid - binding protein p9 and the reverse transcriptase ( rt ) . the core or capsid antigen p24 encloses the nucleoid components , completing the nucleocapsid structure . the matrix antigen p17 encircles the viral core and lines the inner surface of the envelope of the virus . the surface of the hiv manifests external knob - like structures formed by the envelope glycoprotein gp120 . the transmembrane protein ( tmp ) gp41 spans the viral membrane and has both external and internal domains . the distinctive characteristic in the pathogenesis of hiv / aids is that the primary target cell for hiv is immune cells bearing the cd4 marker at their surface . with the infection of hiv , there will be gradual decrease of human immune cells bearing cd4 antigen receptor , the most important being t helper cells ( cd4 t cells ) , b lymphocytes , macrophages , and natural killer cells . the cd4 cells coordinate a number of immunological functions , and as these cells are decrease the risk and severity of opportunistic infections ( oi ) increasing the death of the patients . it is stated that the absolute number of cd4 lymphocytes fall from a normal level of 800900 cu / mm to 60100 per year . because the loss of immune containment is associated with declining cd4 counts , the centre for disease classification ( cdc ) stratifies patients with hiv infection into three categories on the basis of cd4 counts : cd4 counts 500 cells / mm , 200499 cells / mm and < 200 cells / mm . a cd4 count < 200 cells / mm is associated with severe immune suppression , and the cdc in 1993 included all hiv - infected persons with such a count as fulfilling an aids - defining diagnosis . the amount of cd4 lymphocyte cells per milliliter and/or the quantity of rna - hiv-1 copies per milliliter ( viral load ) are surrogate markers of hiv disease progression . it is known that hiv - positive patients with cd4 lymphocyte cells counts less than 200 per milliliter are severely immune depressed and hiv - positive patients with a viral load greater than 10,000 copies per milliliter show an active viremia . the cd4 cell count and viral load have been used lately as the most important laboratory parameters to evaluate the evolution of the disease . although there have been reports of delayed antibody response to hiv1 infection , 95% or more of the infected persons develop detectable antibodies to hiv1 within 36 months . the interval between infection and seroconversion or detection of antibodies has been called the window period . the standard screening test for hiv infection standard screening test for hiv infection symptoms of hiv disease can appear at any time during the course of hiv infection . the spectrum of illness changes as the cd4 + t cell count declines . the more severe and life - threatening complications of hiv infection occur in patients with a cd4 + t cell count < 200/l . a diagnosis of aids is made in anyone with hiv infection and a cd4 + t cell count < 200/l and in anyone with hiv infection who develops one of the hiv - associated diseases considered to be indicative of a severe defect in cell - mediated immunity . while the causative agents of the secondary infections are characteristically opportunistic organisms such as p. carinii , atypical mycobacteria , cytomegalo virus ( cmv ) , and other organisms that do not ordinarily cause disease in the absence of a compromised immune system , they also include common bacterial and mycobacterial pathogens . approximately 60% of the deaths among aids patients are as a direct result of an infection other than hiv , with p. carinii , viral hepatitis , and non - aids defining bacterial infections heading the list . following the widespread use of combination antiretroviral therapy and implementation of guidelines for the prevention of ois , overall , the clinical spectrum of hiv disease is constantly changing as patients live longer and new and better approaches to treatment and prophylaxis are developed . in general , it should be stressed that a key element of the treatment of symptomatic complications of hiv disease , whether they are primary or secondary , is achieving good control of hiv replication through the use of combination antiretroviral therapy and instituting primary and secondary prophylaxis as indicated . without treatment , hiv - infected patients will progress through the stages described in table 2 . stages of hiv progression oral lesions are common ( 3080% ) in patients infected by the hiv virus and may indicate an impairment in the patient 's general health status and , consequently , a poor prognosis . many of these hiv - positive patients present manifestations involving the maxillofacial region in all stages of the disease , and , in some cases , the oral lesions are the first signs of infection . with disease progression , the deleterious effect of hiv on the immune system results in an escalating incidence of widely recognized and extensively described ois and diseases , among which are the oral manifestations of hiv and , since the onset of the hiv pandemic , oral lesions have been well documented as early markers of hiv infection and as predictors of hiv disease progression . oral manifestations can suggest decreased cluster - differentiated 4 ( cd4 + ) t cell count and increased viral load , which might also aid in the diagnosis , progression , and prognosis of the disease.[1315 ] the risk of oral complication increases with immunologic deterioration . oral examination is therefore useful for the early diagnosis , which can prolong the asymptomatic period , delay disease progression , and prevent ois with proper education and counseling of the patient . however , the presence of one or more lesions requires that hiv infection be considered as a possible underlying cause . some oral lesions , such as oral candidiasis and oral hairy leukoplakia , are so strongly associated with hiv infection that they have been incorporated into the centers for disease control and prevention clinical classification of hiv disease . oral manifestations frequently observed in hiv patients may be classified according to etiologic factors : fungal , viral , bacterial , and neoplastic infections . these lesions are often the first clinical symptoms of hiv infection and their diagnosis is an auxiliary method to raise early suspicion of aids . clinical stages of oral lesions associated with hiv with respect to its occurrence are illustrated in table 4 . oral lesions associated with hiv clinical stages associated with hiv in the recent years , the management of hiv - positive individuals has been based on highly active antiretroviral therapy ( haart ) , comprising a combination of nucleoside analogue rt inhibitors and at least one protease inhibitor and/or one non - nucleoside analogue rt inhibitor . haart induces a marked reduction of viral replication and increases the cd4 + cell count . since the introduction of haart in the mid-1990s , it has been accompanied by a reduction in the frequency of many of the secondary events caused by hiv infection , including some oral lesions . since the advent of haart , studies had shown a decline in the prevalence of oral lesions associated with hiv / aids . these lesions include : oral candidiasis , hairy leukoplakia , kaposi 's sarcoma , herpes simplex labiali , and periodontal disease . human immunodeficiency virus ( hiv ) causes progressive mutilation of the body 's cellular immune system , leading to augmented susceptibility to tumors and fatal conditions such as acquired immunodeficiency syndrome ( aids ) . the emergence and pandemic spread of aids constitute the greatest challenge to the public in modern times . from the onset of the hiv epidemic over 20 years ago ( since the appearance of the first cases of contamination by the hiv virus in the 1980s ) , more than 60 million people have become infected and more than 20 million people have died . more than 20 years into this hiv - aids pandemic , it has stuck almost all the countries and populations in many ways . aids , caused by hiv , is presently considered as one of the most dreadful diseases affecting human kind . an estimated 15,000 new infections occur each day , with more than 95% of these in developing countries . sub - saharan africa currently bears the greatest burden worldwide , with 28.5 million ( 70% ) individuals infected . in south africa , 5.2 million of the population was estimated to be infected with hiv / aids . hiv is transmitted by sexual means , through the exchange of body fluids ( especially infected semen during intercourse ) ; by non - sexual means , via the parenteral transfer of infected blood ; or through vertical transmission to infants born of infected mothers . the only fluids that have been demonstrated to be associated with transmission of the virus are blood , semen , breast milk , and vaginal secretions . casual contact ( shaking hands , hugging , casual kissing , etc . ) has not been shown to transmit hiv . the united nations programme on hiv / aids estimates that over 40 million people are living with hiv / aids globally . an estimated 15,000 new infections occur each day , with more than 95% of these in developing countries . sub - saharan africa currently bears the greatest burden worldwide , with 28.5 million ( 70% ) individuals infected . in south africa , 5.2 million of the population was estimated to be infected with hiv / aids . between 60% and 90% of the people with hiv infection will have at least one oral manifestation at some time during the course of their disease . oral lesions cause significant discomfort and have a major impact on the quality of life . recognition and management of these oral conditions is therefore important for the health and quality of life of the individual with hiv / aids . despite the increasing number of reports on the prevalence of oral manifestations in hiv - positive / aids patients , there is limited information about the impact of these lesions on the quality of life in these patients . the retrovirus family is composed of three subfamilies : oncoviruses , spumaviruses and lentiviruses . based on the structure , biologic properties , and protein and nucleic acid sequence homology , the nucleoid contains the hiv genome , which is diploid ( i.e. , composed of two identical single - stranded rnas ) . these genes code for the structural proteins that are used to assemble the virus particles and the regulatory proteins involved in the regulation of viral gene expression . the hiv rna genome is associated with a basic nucleic acid - binding protein p9 and the reverse transcriptase ( rt ) . the core or capsid antigen p24 encloses the nucleoid components , completing the nucleocapsid structure . the matrix antigen p17 encircles the viral core and lines the inner surface of the envelope of the virus . the surface of the hiv manifests external knob - like structures formed by the envelope glycoprotein gp120 . the transmembrane protein ( tmp ) gp41 spans the viral membrane and has both external and internal domains . the distinctive characteristic in the pathogenesis of hiv / aids is that the primary target cell for hiv is immune cells bearing the cd4 marker at their surface . with the infection of hiv , there will be gradual decrease of human immune cells bearing cd4 antigen receptor , the most important being t helper cells ( cd4 t cells ) , b lymphocytes , macrophages , and natural killer cells . the cd4 cells coordinate a number of immunological functions , and as these cells are decrease the risk and severity of opportunistic infections ( oi ) increasing the death of the patients . it is stated that the absolute number of cd4 lymphocytes fall from a normal level of 800900 cu / mm to 60100 per year . because the loss of immune containment is associated with declining cd4 counts , the centre for disease classification ( cdc ) stratifies patients with hiv infection into three categories on the basis of cd4 counts : cd4 counts 500 cells / mm , 200499 cells / mm and < 200 cells / mm . a cd4 count < 200 cells / mm is associated with severe immune suppression , and the cdc in 1993 included all hiv - infected persons with such a count as fulfilling an aids - defining diagnosis . the amount of cd4 lymphocyte cells per milliliter and/or the quantity of rna - hiv-1 copies per milliliter ( viral load ) are surrogate markers of hiv disease progression . it is known that hiv - positive patients with cd4 lymphocyte cells counts less than 200 per milliliter are severely immune depressed and hiv - positive patients with a viral load greater than 10,000 copies per milliliter show an active viremia . the cd4 cell count and viral load have been used lately as the most important laboratory parameters to evaluate the evolution of the disease . although there have been reports of delayed antibody response to hiv1 infection , 95% or more of the infected persons develop detectable antibodies to hiv1 within 36 months . the interval between infection and seroconversion or detection of antibodies has been called the window period . symptoms of hiv disease can appear at any time during the course of hiv infection . the more severe and life - threatening complications of hiv infection occur in patients with a cd4 + t cell count < 200/l . a diagnosis of aids is made in anyone with hiv infection and a cd4 + t cell count < 200/l and in anyone with hiv infection who develops one of the hiv - associated diseases considered to be indicative of a severe defect in cell - mediated immunity . while the causative agents of the secondary infections are characteristically opportunistic organisms such as p. carinii , atypical mycobacteria , cytomegalo virus ( cmv ) , and other organisms that do not ordinarily cause disease in the absence of a compromised immune system , they also include common bacterial and mycobacterial pathogens . approximately 60% of the deaths among aids patients are as a direct result of an infection other than hiv , with p. carinii , viral hepatitis , and non - aids defining bacterial infections heading the list . following the widespread use of combination antiretroviral therapy and implementation of guidelines for the prevention of ois overall , the clinical spectrum of hiv disease is constantly changing as patients live longer and new and better approaches to treatment and prophylaxis are developed . in general , it should be stressed that a key element of the treatment of symptomatic complications of hiv disease , whether they are primary or secondary , is achieving good control of hiv replication through the use of combination antiretroviral therapy and instituting primary and secondary prophylaxis as indicated . without treatment oral lesions are common ( 3080% ) in patients infected by the hiv virus and may indicate an impairment in the patient 's general health status and , consequently , a poor prognosis . many of these hiv - positive patients present manifestations involving the maxillofacial region in all stages of the disease , and , in some cases , the oral lesions are the first signs of infection . with disease progression , the deleterious effect of hiv on the immune system results in an escalating incidence of widely recognized and extensively described ois and diseases , among which are the oral manifestations of hiv and , since the onset of the hiv pandemic , oral lesions have been well documented as early markers of hiv infection and as predictors of hiv disease progression . oral manifestations can suggest decreased cluster - differentiated 4 ( cd4 + ) t cell count and increased viral load , which might also aid in the diagnosis , progression , and prognosis of the disease.[1315 ] the risk of oral complication increases with immunologic deterioration . oral examination is therefore useful for the early diagnosis , which can prolong the asymptomatic period , delay disease progression , and prevent ois with proper education and counseling of the patient . however , the presence of one or more lesions requires that hiv infection be considered as a possible underlying cause . some oral lesions , such as oral candidiasis and oral hairy leukoplakia , are so strongly associated with hiv infection that they have been incorporated into the centers for disease control and prevention clinical classification of hiv disease . oral manifestations frequently observed in hiv patients may be classified according to etiologic factors : fungal , viral , bacterial , and neoplastic infections . these lesions are often the first clinical symptoms of hiv infection and their diagnosis is an auxiliary method to raise early suspicion of aids . clinical stages of oral lesions associated with hiv with respect to its occurrence are illustrated in table 4 . in the recent years , the management of hiv - positive individuals has been based on highly active antiretroviral therapy ( haart ) , comprising a combination of nucleoside analogue rt inhibitors and at least one protease inhibitor and/or one non - nucleoside analogue rt inhibitor . haart induces a marked reduction of viral replication and increases the cd4 + cell count . since the introduction of haart in the mid-1990s , it has been accompanied by a reduction in the frequency of many of the secondary events caused by hiv infection , including some oral lesions . since the advent of haart , studies had shown a decline in the prevalence of oral lesions associated with hiv / aids . these lesions include : oral candidiasis , hairy leukoplakia , kaposi 's sarcoma , herpes simplex labiali , and periodontal disease . the world health organization ( who ) global oral health program recently formulated policies for the prevention of oral manifestations in hiv / aids . prevention of hiv / aids - related oral disease is based on the involvement of primary healthcare workers as well as oral health professionals in the early detection and screening , on the integration of oral disease prevention and oral health promotion into community and national hiv / aids programmes , and on the who technical support to build capacity in countries . by using a systematic approach and giving the patient a complete oral examination , the dentist will be able to diagnose oral lesions in patients with hiv disease . rather than trying to guess the correct diagnosis , a good diagnostician should obtain the history of the lesion , should evaluate signs and symptoms , and should determine the possible etiology . important factors to be considered in the differential diagnosis are the history of the lesions , the clinical appearance , location , and symptoms like pain , burning sensation , and discomfort upon deglutition . it can be a localized process or part of a systemic disease . from the analysis of the data collected during clinical examination , the dentist can construct a list of differential diagnoses , listing the most probable disease that could cause that particular lesion . this procedure should lead to the final diagnosis of the disease and indicate the most appropriate treatment . not uncommonly , oral lesions in hiv patients can cause severe impairment of oral functions as well as pain and discomfort and , in addition , they are a manifestation of opportunistic diseases secondary to systemic immunosuppressant . therefore , from the oral cavity , they may disseminate systemically and cause a much more dangerous threat to the patient 's health . some of the lesions may be transmissible and patients must be counseled on the prevention of transmission ( e.g. , herpes , syphilis , tuberculosis ) . hiv - related oral abnormalities are present in 3080% of the hiv - infected individuals , and these abnormalities are often inaccurately described in medical care . dental expertise is necessary for the proper management of oral complications in hiv infection or aids . medical clinicians should be able to recognize hiv - associated oral disease and to provide appropriate care and referral . at the tertiary level of oral care , a dentist should be available to make definitive diagnoses of oral lesions and provide professional oral services such as prophylaxis , restorations , biopsies , and the prescription of appropriate medication . there is a need for dentists to be involved throughout the management of hiv patients and not only at the tertiary level of care . there is also a need for training and retraining of medical personnel in the diagnosis and management of hiv - associated oral lesions and appropriate patient referral .
from the onset of the human immunodeficiency virus ( hiv ) epidemic over 20 years ago ( since the appearance of the first cases of contamination by the hiv virus in the 1980s ) , more than 60 million people have become infected and more than 20 million people have died . 
 an estimated 15,000 new infections occur each day , with more than 95% of these in developing countries . 
 the distinctive characteristic in the pathogenesis of hiv / acquired immunodeficiency syndrome is that the primary target cell for hiv is immune cells bearing the cd4 marker at their surface , and the cd4 cell count and viral load have been used lately as the most important laboratory parameters to evaluate the evolution of the disease . 
 oral lesions are common ( 3080% ) in patients infected by the hiv virus and may indicate an impairment in the patient 's general health status and , consequently , a poor prognosis . 
 oral manifestations can suggest decreased cluster - differentiated ( cd4 + ) t cell count and increased viral load , which might also aid in diagnosis , progression , and prognosis of the disease . at the tertiary level of oral care , 
 a dentist should be available to make definitive diagnoses of oral lesions and provide professional oral services such as prophylaxis , restorations , biopsies , and the prescription of appropriate medication .