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Ian Holtby - libraries in the UK. Local researchers were contacted to provide additional grey literature. We made extensive use of Yolande Coombes' review on sexual and reproductive health behaviour in Malawi that was used as input for the national BCI strategy for paragraph 3.
The immune system is not able to eliminate the HIV virus, although it may control viral replication to some extent through humoral and cellular immune responses. Because it cannot remove the antigen, the immune system remains highly activated and in the process burns out and falls apart. This degeneration of the immune system over the years results in increased risk of opportunistic infections and malignancies and is the hallmark of Acquired Immune Deficiency Syndrome AIDS.
The rate at which the immune system is destroyed is directly related to the rate of viral replication. During acute HIV infection, viral load is high because replication occurs in the absence of an immune response. CD4 count drops and about half of recently infected individuals will experience a non-specific viral illness, characterized by fever, sweats, malaise, myalgia, pharyngitis, gastrointestinal disturbance, headache, generalised lymphadenopathy and hepatosplenomegaly.
Transmission risk is high during this period. After the immune response has developed, the viral load drops to a plateau and CD4 count increases but not to pre-HIV levels and then slowly declines over the years until it reaches such a low level that opportunistic infections and malignancies develop.
This is associated with high levels of viral replication and a steep decline in CD4 count. These long-term non-progressors, who sometimes have been infected for more than 20 years, have very low viral loads and competent immune systems. There is some evidence that poor socio-economic conditions, including malnutrition and limited access to health care, may contribute to a 1—2 year shorter latent period in developing countries. The final progression to AIDS is characterised by very low CD4 counts and rising viral load, thus leading to increased transmission risk in this period.