HIV AIDS opportunistic infections

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief:, Ujjwal Rastogi, MBBS [2]

Overview

Before the widespread use of potent combination antiretroviral therapy (ART), opportunistic infections (OIs), which have been defined as infections that are more frequent or more severe because of immunosuppression in HIV-infected persons, were the principal cause of morbidity and mortality in this population. In the early 1990s, the use of chemoprophylaxis, immunization, and better strategies for managing acute OIs contributed to improved quality of life and improved survival.[1] However, the widespread use of ART starting in the mid-1990s has had the most profound influence on reducing OI-related mortality in HIV-infected persons in those countries in which these therapies are accessible and affordable.

Etiology

Despite the availability of ART in the United States and other industrialized countries, OIs continue to cause considerable morbidity and mortality for three primary reasons:

  • Many patients are unaware of their HIV infection and seek medical care when an OI becomes the initial indicator of their disease.
  • Certain patients are aware of their HIV infection, but do not take ART because of psychosocial or economic factors.
  • Certain patients are prescribed ART, but fail to attain adequate virologic and immunologic response because of factors related to adherence, pharmacokinetics, or unexplained biologic factors.[2][3]

Thus, although hospitalizations and deaths have decreased since the implementation of ART, OIs remain a leading cause of morbidity and mortality in HIV-infected persons.[4][5][6]

Pathophysiology

Recognizing that the relation between OIs and HIV infection is bidirectional is important. HIV leads to immunosuppression that allows opportunistic pathogens to cause disease in HIV-infected persons. OIs and other coinfections that might be common in HIV-infected persons, such as sexually transmitted infections, can also have adverse effects on the natural history of HIV infection. Certain OIs are associated with reversible increases in circulating viral load and these increases could lead to accelerated HIV progression or increased transmission of HIV. Thus, although chemoprophylaxis and vaccination directly prevent pathogen-specific morbidity and mortality, they might also contribute to reduced rate of progression of HIV disease. For instance, randomized trials using trimethoprim-sulfamethoxazole (TMP-SMX) have documented that chemoprophylaxis can both decrease OI-related morbidity and improve survival.

Historical Perspective

The first guidelines for Prophylaxis against Pneumocystis carinii Pneumonia for persons infected with the human immunodeficiency virus became the first HIV-related treatment guideline published by the U.S. Public Health Service in 1989.

Related Chapters

Reference

  1. ↑ Walensky RP, Paltiel AD, Losina E, Mercincavage LM, Schackman BR, Sax PE, Weinstein MC, Freedberg KA (2006). "The survival benefits of AIDS treatment in the United States". J. Infect. Dis. 194 (1): 11–9. doi:10.1086/505147. PMID 16741877. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  2. ↑ Perbost I, Malafronte B, Pradier C, Santo LD, Dunais B, Counillon E, Vinti H, Enel P, Fuzibet JG, Cassuto JP, Dellamonica P (2005). "In the era of highly active antiretroviral therapy, why are HIV-infected patients still admitted to hospital for an inaugural opportunistic infection?". HIV Med. 6 (4): 232–9. doi:10.1111/j.1468-1293.2005.00282.x. PMID 16011527. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  3. ↑ Palacios R, Hidalgo A, Reina C, de la Torre M, Márquez M, Santos J (2006). "Effect of antiretroviral therapy on admissions of HIV-infected patients to an intensive care unit". HIV Med. 7 (3): 193–6. doi:10.1111/j.1468-1293.2006.00353.x. PMID 16494634. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  4. ↑ Gebo KA, Fleishman JA, Reilly ED, Moore RD (2005). "High rates of primary Mycobacterium avium complex and Pneumocystis jiroveci prophylaxis in the United States". Med Care. 43 (9 Suppl): III23–30. PMID 16116306. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  5. ↑ Bonnet F, Lewden C, May T, Heripret L, Jougla E, Bevilacqua S, Costagliola D, Salmon D, Chêne G, Morlat P (2005). "Opportunistic infections as causes of death in HIV-infected patients in the HAART era in France". Scand. J. Infect. Dis. 37 (6–7): 482–7. PMID 16089023. |access-date= requires |url= (help)
  6. ↑ Teshale EH, Hanson DL, Wolfe MI, Brooks JT, Kaplan JE, Bort Z, Sullivan PS (2007). "Reasons for lack of appropriate receipt of primary Pneumocystis jiroveci pneumonia prophylaxis among HIV-infected persons receiving treatment in the United States: 1994-2003". Clin. Infect. Dis. 44 (6): 879–83. doi:10.1086/511862. PMID 17304464. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
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