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People with advanced HIV infection are vulnerable to infections or malignancies that are called 'opportunistic infections' because they take advantage of the opportunity offered by a weakened immune system.

In industrialised countries, before the introduction of HAART, the prevention and treatment of opportunistic infections was long the basis of care for HIV positive people. Even now, the prevention and treatment of opportunistic infections plays an important part of management of HIV.

Prevention and treatment of opportunistic infections is an important part of HIV/AIDS care and support. Opportunistic infections result in significant morbidity and mortality for people living with HIV/AIDS. Taking care of the well-being of people is important on a practical as well as on a personal level. Interventions that prevent the occurrence of opportunistic infections can result in significant gains in life expectancy and quality of life among people living with HIV.

Providing prevention and treatment of opportunistic infections and HIV-associated diseases can:

• Reduce the suffering of people living with HIV/AIDS and improve their quality of life and the quality of life for their families.
• Allow people with HIV/AIDS to continue as contributing members of their families and communities for as long as possible.
• Prevent the further spread of TB and other transmittable opportunistic infections to other members of the family.

A partial list of the world's most common opportunistic diseases and infections includes:

• Bacterial diseases such as tuberculosis (TB), Mycobacterium avium complex disease (MAC), bacterial pneumonia and septicaemia ('blood poisoning').
• Protozoal diseases such as pneumocystis carinii pneumonia (PCP), toxoplasmosis, microsporidiosis, cryptosporidiosis, isopsoriasis and leishmaniasis
• Fungal diseases such as candidiasis, cryptococcosis (cryptococcal meningitis (CRM)) and penicilliosis
• Viral diseases such as those caused by cytomegalovirus (CMV), herpes simplex and herpes zoster virus
• HIV-associated malignancies such as Kaposi sarcoma, lymphoma and squamous cell carcinoma

In early HIV disease individuals can develop tuberculosis, malaria, pneumococcal pneumonia, shingles (herpes zoster), staphylococcal skin infections and septicaemia. These are diseases that people with normal immune systems can also get, but with HIV they occur at a much higher rate. It also takes longer for a person with HIV to get well than it takes for someone with a healthy immune system. With advanced HIV disease (equivalent to AIDS) infections such as pneumocystis, toxoplasma and cryptococcus develop.

Treatment of HIV-related opportunistic infections

Some of the opportunistic infections are easier to treat than others. Some opportunistic infections and symptoms such as candidiasis of the mouth and throat and vaginal candidiasis ('thrush'), herpes zoster and herpes simplex can be managed effectively through home-based care. In a home-based care setting diagnosis is made by symptoms.

Some opportunistic infections can be treated when there is minimum health infrastructure present. When minimum infrastructure is available, diagnosis can be made by symptoms or use of a simple microscope. Infections that can be diagnosed in minimum infrastructures are oral candidiasis, pulmonary TB, herpes, and cryptococcal meningitis.

In medium infrastructure setting, the facilities available are x-ray equipment or culture facilities. Using these, opportunistic infections as extra-pulmonary TB, cryptosporidiosis-isopsoriasis, PCP and Kaposi Sarcoma can be diagnosed and treated.

Opportunistic infections such as toxoplasmosis, Mycobacterium avium complex disease (MAC) and Cytomegalovirus infection (CMV) can be diagnosed and treated in places with advanced infrastructure. Treating these infections is often impossible in resource poor countries. Many developing countries lack the advanced equipment and infrastructure (such as CT scanning) needed to treat these more complex infections.

Prevention of HIV-related opportunistic infections

Several HIV-related infections can be prevented. Following successful treatment, prophylaxis can also prevent disease recurrence (TB, salmonella, cryptococcus). Although the variety of HIV-related illnesses, for example in Africa, differs from that in industrialised countries, several of the most common opportunistic infections are open to prevention through antibiotic prophylaxis.

Drugs for treatment of HIV-related opportunistic infections

HIV/AIDS care requires a range of essential medicines, in addition to antiretrovirals. If available, these effective and relatively inexpensive drugs can prevent or treat many of the common HIV-related diseases. These are the diseases that are responsible for the main burden of illness and death in high-prevalence countries.

Effective treatment depends on general health services being able to procure, store, select and administer the necessary drugs and to provide related treatment, care and diagnostic services to monitor health status and treatment response. Where health centres and district hospitals are available and accessible, diagnosis of the common infections and complications related to HIV/AIDS (e.g. TB, pneumonia, diarrhoea and candida infection of the mouth and throat) is usually possible, and these conditions can be treated with inexpensive, effective antibiotics and basic nursing procedures.

Individual opportunistic infections

Diagnosis and treatment of the following HIV related opportunistic infections requires minimum infrastructure.

Candidiasis

There are two main types of candidiasis (of the mouth and throat, and of the vagina) and systemic disease (of the oesophagus, and disseminated disease). The mouth and throat variant (oropharyngeal candidiasis or OCP) is believed to occur at least once in the lifetime of all HIV-infected patients. While OPC is not a cause of death, it causes oral pain and makes swallowing difficult. The symptom of oesophageal candidiasis is pain in the chest that increases with swallowing, and causes difficulty in swallowing. Disseminated candidiasis causes fever and symptoms in the organs affected by the disease. Localised disease is to treat first with relatively inexpensive drugs such as nystatin, miconazole or clotrimazole. Systemic candidiasis requires treatment with systemic antifungal agents such as ketoconazole, itraconazole or amphotericin.

Herpes simplex and Herpes zoster

Herpes simplex virus infection (HSV, which causes sores around the mouth and genitals) and herpes zoster virus infection ('zonal' herpes or shingles) are not life-threatening but can be extremely painful. Both can cause encephalitis, which can be life threatening. Treatment with aciclovir is only marginally effective in herpes zoster but it is sometimes dramatic in HIV-associated herpes simplex with extensive ulceration. Herpes can be treated with aciclovir. Aciclovir is only marginally effective in herpes zoster. This medicine makes the herpes outbreaks last for less time and less intensity, but it does not cure genital herpes.

Cryptococcal meningitis

Cryptococcal infection is a fungus that primarily infects the brain.Systemic mycoses such as cryptococcosis probably cause about 5% of all HIV-associated deaths worldwide. Cryptococcosis most often appears as meningitis and occasionally as pulmonary or disseminated disease. Cryptococcal meningitis (CRM) is the most frequent systemic fungal infection in HIV-infected persons. Without treatment, life expectancy is probably less than a month. Cryptococcosis is relatively easy to diagnose. However, its treatment (either amphotericin B with or without flucytosine or in mild cases with oral fluconazole) and secondary chemoprophylaxis are often impossible in developing countries because of high cost and limited availability of the drugs required.

Tuberculosis

Tuberculosis is a bacterial infection that primarily infects the lungs. Tuberculosis is the leading HIV-associated opportunistic disease in developing countries. For people who are dually infected with HIV and TB, the risk of developing active tuberculosis is 30-50 fold higher than for people infected with TB alone. And because Mycobacterium can spread through the air, the increase in active TB cases among dually infected people means:

• more transmission of the TB germ
• more TB and carries
• more TB in the whole population.

Tuberculosis is harder to diagnose in HIV-positive people than those who are uninfected. The diagnosis of TB is important because TB progresses faster in HIV-infected people. Also, TB in HIV-positive people is more likely to be fatal if undiagnosed or left untreated. TB occurs earlier in the course of HIV infection than other opportunistic infections.

A proper combination of anti-TB drugs achieves both prevention and cure:

• Effective treatment quickly makes the individual non-contagious. This prevents further spread of the TB germ.
• The DOTS (directly observed short course) treatment strategy recommended by WHO treats TB in HIV-infected persons as effectively as it treats those without the virus. A complete cure takes 6 to 8 months and uses a combination of antibiotics. In addition to curing the individual, it also prevents further spread of the disease to others. This is why treating infectious cases of TB has important benefits for society as whole. Isoniazid preventive therapy is recommended as a health-preserving measure for HIV-infected persons at risk of TB. TB prophylaxis has been shown to increase the survival of HIV-infected persons at risk of TB.

Diagnosis and treatment of the following HIV related opportunistic infections require medium infrastructure.

Cryptosporidiosis - isosporiasis

Cryptosporidiosis (crypto) and isosporiasis are both caused by a parasites. Crypto is easily spread by contaminated food or water, or direct contact with an infected person or animal. Crypto causes diarrhoea, nausea, vomiting and stomach cramps. In people with healthy immune systems, these symptoms do not last more than about a week. However, if the immune system is damaged crypto can continue for a long time. Diarrhoea can interfere with the absorption of nutrients and this can lead serious weight loss. To confirm diagnosis, the stool is normally checked for parasites and their eggs. There is no drug treatment that clears up or cures crypto. Isosporiasis symptoms include diarrhoea, cramps and weight loss. Diagnosis can be confirmed from the stool by microscope. TMP/SMX (trimethoprim-sulfamethoxazole) is the recommended drug of choice.

Kaposi Sarcoma

HIV -associated Kaposi Sarcoma causes dark blue lesions, which can occur in a variety of locations including the skin, mucous membranes, gastrointestinal tract, lungs or lymph nodes. The lesions usually appear early in the course of HIV infection. Treatment depends on the lesions' symptoms and location. For local lesions, injection therapy with vinblastine has been used with some success. Radiotherapy can also be used, especially in hard-to reach sites such as the inner mouth, eyes, face and soles of the feet. For severe widespread disease, systemic chemotherapy is the preferred treatment.

Leishmaniasis

Leishmaniasis is transmitted by sandflies. The most serious of its four forms is visceral leishmaniasis (VL)- also know as kala azar-, which is characterised by irregular bouts of fever, substantial weight loss, swelling of the spleen and liver and anaemia (occasionaly serious). Recently, there has been an increase in overlapping of VL and HIV infection. Treatment with pentavalent antimony is relatively expensive, partly because of the cost of drugs but also because hospital admission is recommended (in milder cases, trained health workers mat administer the injections or infusions at a patient's home). Even with optimal survival time with this co-infection, average survival time is only 12 months.

PCP

Pneumocystis carinii pneumonia is a parasite that infects the lungs.

PCP is the most frequent HIV associated opportunistic infection in industrialised countries but appears to be less frequent in for example in Africa. The symptoms are mainly pneumonia along with fever and respiratory symptoms such as dry cough, chest pain and dyspnoea. Definitive diagnosis requires microscopy of bodily tissues or fluids. Severe cases of PCP are initially treated with trimethoprim-sulfamethoxazole (TMP-SMZ) or clindamycin and oral primaquine. Mild cases can be treated with oral TMP-SMZ throughout. With both of these regimens, toxicity (notably allergic-type reactions) often requires changes in therapy. Prevention of PCP is strongly recommended for HIV-infected persons with significant immune compromise wherever PCP is a significant health problem for HIV-infected persons, and also after their first episode of PCP. Preventing and treating PCP need not be very expensive: use of non-brand generic products can reduce the cost of drugs for TMP-SMZ prophylaxis.

Last updated November 23, 2004

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