HIV:
A Normal Life with Treatment — Adherence, PrEP & U=U

1. What is HIV?

HIV stands for human immunodeficiency virus. It mainly infects CD4 helper cells, an important group of immune cells, and multiplies inside them. If left untreated, their number falls over the years until the immune system can no longer fight off pathogens adequately. This late stage is called AIDS (acquired immunodeficiency syndrome).^¹

The most important message first: with treatment started in good time, people with HIV today have a near-normal life expectancy. The infection cannot yet be cured, because the virus permanently stores its genetic material in resting immune cells. However, the medications suppress its replication so reliably that it can no longer be detected in the blood.^¹,²

According to an estimate by the Robert Koch Institute (RKI, Germany's public health institute), around 97,700 people were living with HIV in Germany at the end of 2024; about 2,300 new infections occurred in 2024. Almost everyone with a known diagnosis is being treated, and treatment works for the vast majority. The problem lies with the roughly 8,200 infections that people are unaware of — and with late diagnoses: around a third of the infections newly identified in 2024 were only detected once the immune deficiency was already advanced.^³

2. Course: from infection to AIDS

Without treatment, HIV infection typically progresses in three phases.^¹

Doctors also classify the course according to symptoms and the number of helper cells. If this falls below about 200 per microlitre of blood, the risk of AIDS-defining illnesses rises sharply. With treatment, the immune system usually recovers — the earlier treatment starts, the better.^²

3. Symptoms and warning signs

Acute HIV infection

Some people notice symptoms a few days to weeks after infection that are easily mistaken for flu or glandular fever:^¹

• Fever, exhaustion and aching limbs
• Swollen lymph nodes and a sore throat
• A rash on the upper body, often blotchy and not itchy
• Painful sores in the mouth, diarrhoea or headaches

The symptoms disappear on their own after one to two weeks — the infection remains. If you have such symptoms after a risk contact, ask specifically about an HIV test.

Signs of advanced infection

Certain illnesses are considered indicator conditions for which an HIV test should be offered: shingles at a younger age, recurrent pneumonia, oral thrush, hepatitis B or C, syphilis or persistent changes in the blood count. Unintentional weight loss, night sweats and long bouts of diarrhoea can also be signs.^²

4. Transmission and risks

HIV is transmitted through blood, semen, vaginal fluid, the fluid on the lining of the rectum and breast milk — provided the viral load is high enough and the virus reaches mucous membranes or the bloodstream.^¹

• Unprotected anal or vaginal sex with a person who has HIV and is not effectively treated — the most common route.
• Sharing needles, syringes and equipment when using drugs.
• From mother to child during pregnancy, birth or breastfeeding — very rare today with treatment.
• Increased risk with other sexually transmitted infections that damage the mucous membranes, such as syphilis or herpes.

Everyday contact carries no risk: shaking hands, hugging, kissing, sharing crockery, toilets, swimming pools, coughing or insect bites do not transmit HIV.

5. HIV testing and diagnosis

Only a test can give you certainty. It is important to have it at the right time — after infection, the immune system needs a few weeks before the test shows a result:^¹

• Laboratory test (combination test): detects antibodies and a component of the virus. A negative result reliably rules out infection six weeks after the risk.
• Rapid test and self-test: give a result within minutes; reliable from twelve weeks after the risk. Self-tests are available from pharmacies, chemists and online — look for the CE mark.
• Confirmatory test: a positive screening result is always confirmed in the laboratory before the diagnosis is made.
• Anonymous and free of charge: many local public health offices and the checkpoints run by AIDS service organisations (Aidshilfe) offer testing and counselling.
• After diagnosis: viral load, helper cell count, a resistance test of the virus, kidney and liver values, and tests for hepatitis and other infections form the basis for choosing treatment.^²

Laboratories report positive HIV results to the RKI without names — your name is not passed on. What the individual laboratory values mean is explained in the guide Understanding blood values.

6. HIV treatment today

The guideline recommends starting antiretroviral therapy (ART) in every person with HIV — as soon as possible after diagnosis, regardless of the helper cell count. The aim is a viral load below the limit of detection. This protects the immune system, lowers the risk of secondary illnesses and prevents transmission.^²

Treatment always uses a combination of active substances from different classes, so that the virus does not develop resistance. Many combinations are now available as one tablet once a day.

The medications are now usually well tolerated. At the start, nausea, headaches, sleep problems or diarrhoea can occur, and these often ease after a few weeks. Weight gain has been described with some combinations, especially those containing integrase inhibitors and tenofovir alafenamide. The HIV specialist practice decides which combination is right based on the resistance test, other conditions, other medications and your daily life.^²,⁴

7. Adherence and interactions

Why every dose counts

HIV treatment only works if drug levels in the blood remain high enough at all times. If doses are repeatedly missed, the virus can multiply and develop resistance — then not only the current medications work less well, but often related active substances too.^² How long you can still take a missed tablet varies by product and is stated in the package leaflet; if in doubt, ask your practice or pharmacy. General tips in the guide Missed a medication.

The most important interactions

HIV medications are broken down by the same liver enzymes as many other medicines. According to the product information, the following groups are particularly important:^⁴

Over-the-counter medicines, dietary supplements and herbal products are the ones most often overlooked. Show your complete medication list to every practice and pharmacy before anything new is added — background in the guide Understanding drug interactions.

8. U=U, PrEP and PEP

U=U: undetectable means untransmittable

Large studies of couples in which only one partner had HIV have shown: if the viral load on treatment has been below the limit of detection for at least six months and treatment continues to be taken reliably, HIV is not transmitted during sex — even without a condom.^¹,² This message, known in German as “n=n”, is one of the greatest advances against stigma. However, U=U does not protect against other sexually transmitted infections.

PrEP: protection against infection

Pre-exposure prophylaxis is a preventive treatment for HIV-negative people at increased risk. The standard is a tablet containing tenofovir disoproxil and emtricitabine, taken daily or — for men who have sex with men — also on demand according to a fixed schedule, as set out in the guideline. Taken correctly, it protects very reliably.^⁵

• Cost coverage: people with statutory health insurance aged 16 and over with a substantial HIV risk receive PrEP, including counselling and check-ups, at the insurance fund's expense.
• Check-ups: before starting and then regularly, usually every three months, tests for HIV, other sexually transmitted infections and kidney function.
• Long-acting injections: long-acting injections for PrEP are also approved in the EU — cabotegravir every two months and, since 2025, lenacapavir twice a year.^⁶ Whether and under what conditions they are offered and reimbursed in Germany can be clarified by your PrEP practice.

PEP: emergency treatment after a risk

After a risk contact, such as a split condom with a partner whose HIV status is unknown or untreated, post-exposure prophylaxis can prevent infection. It must start as quickly as possible — ideally within a few hours, at the latest after 48 to 72 hours — and is taken for four weeks.^⁷ Places to go are HIV specialist practices, hospitals with an infectious diseases outpatient clinic and, at night or at weekends, the emergency department.

9. Pregnancy, vaccinations and getting older

Wanting children and pregnancy

People with HIV can have children without infecting their partner or child. With effective treatment and an undetectable viral load, the risk of transmission to the child is very low; a vaginal birth is then usually possible, and the newborn receives preventive medication for a short time. Pregnant women are offered an HIV test as part of antenatal care. Whether breastfeeding is an option is now discussed individually with the practice if the viral load is permanently suppressed.^⁸ Which active substances are suitable during pregnancy is decided by the specialist practice — see also Medications during pregnancy.

Vaccinations

STIKO (Germany's Standing Committee on Vaccination) recommends that people with HIV receive vaccinations against pneumococci, flu and hepatitis B, among others, against hepatitis A and HPV if needed, and against shingles from as early as age 50. Live vaccines, such as those against measles or chickenpox, are only an option if the helper cell count is high enough.^⁹ The guide Vaccinations for adults gives an overview.

Getting older with HIV

Because treatment works so well, people with HIV now grow old — and develop the typical conditions of older age, sometimes somewhat earlier: cardiovascular disease, kidney impairment, osteoporosis, diabetes. Screening and checks of blood pressure and cholesterol therefore become more important, as does keeping an eye on interactions when taking many medications.^²

10. Living with HIV

• A fixed time for your dose — link it to a daily routine, such as brushing your teeth, and carry a small supply with you when you are out.
• Keep your check-up appointments — viral load and laboratory values are usually checked every three to six months, and on a fixed schedule with long-acting injections.
• Plan your travel — keep medications in your hand luggage and adjust the time you take them gradually when crossing time zones; tips in the guide Medications when travelling.
• Work and sport — HIV is no obstacle to the vast majority of jobs and sports. As a rule, you do not have to tell your employer.
• Mental health — the shock of diagnosis, stigma and worries about relationships take their toll. Counselling at AIDS service organisations and psychotherapy can help; if low mood persists, see depression.

All medications belong in an up-to-date plan — including those you buy for self-medication. The guide Creating a medication plan helps you put one together.

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