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Adult HIV_ HIV-associated infections
 

Adult HIV_ HIV-associated infections

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Adult HIV was developed by doctors and nurses with wide experience in the care of adults with HIV, under the auspices of the Desmond Tutu HIV Foundation at the University of Cape Town. It covers: ...

Adult HIV was developed by doctors and nurses with wide experience in the care of adults with HIV, under the auspices of the Desmond Tutu HIV Foundation at the University of Cape Town. It covers: introduction to HIV infection, management of HIV-infected adults at primary-care clinics, preparing patients for antiretroviral (ARV) treatment, ARV drugs, starting and maintaining patients on ARV treatment, opportunistic infections

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    Adult HIV_ HIV-associated infections Adult HIV_ HIV-associated infections Document Transcript

    • 6 HIV-associated infectionsBefore you begin this unit, please take the HIV-associated infections are common in patientscorresponding test at the end of the book to with a weakened immune system.assess your knowledge of the subject matter. Youshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned. 6-2 Which are the common HIV- associated infections? Objectives They are infections which are uncommon in HIV-negative people: When you have completed this unit you 1. Oral candidiasis (thrush) should be able to: 2. Tuberculosis (TB) • Define HIV-associated infections. 3. Recurrent bacterial pneumonia • List the common HIV-associated 4. Shingles (Herpes zoster) infections. 5. Severe, recurrent genital herpes • Diagnose and manage most HIV- 6. Severe, recurrent mouth ulcers associated infections. These infections are rare in HIV-negative • Explain why tuberculosis is an important people and are AIDS-defining: HIV-associated infection. • Describe how tuberculosis presents and 1. Oesophageal candidiasis is treated. 2. Pneumocystis pneumonia • Describe the problems of treating 3. Cryptococcal meningitis tuberculosis and HIV together. 4. Cerebral toxoplasmosis 5. Cytomegalovirus (CMV) retinitis NOTE Less common HIV-associated infectionsCOMMON HIV- include chronic diarrhoea due to isosporiasis orASSOCIATED INFECTIONS cryptosporidiosis, non-tuberculosis mycobacteria and disseminated fungal infections.6-1 What are HIV-associated infections? 6-3 Do HIV-associated infections always indicate that the patient has AIDS?HIV-associated infections (or opportunisticinfections) are infections which are common No, as many of the milder HIV-associatedin patients with HIV infection. They ‘take the infections such as pulmonary TB or shinglesopportunity’ of infecting and causing illness in may also be found in HIV-negative patientspatients with a weakened immune system. and patients with stage 1 to 3 HIV infections (i.e. not AIDS). These infections, however,
    • 90 ADULT HIVshould always alert one to the fact that the 6-6 Can HIV-associatedpatient may be HIV infected. HIV-associated infections be prevented?infections are therefore an important indicator The best way of preventing most severe HIV-for HIV counselling and screening. associated infections is to start antiretroviral treatment in HIV patients when their CD46-4 What are the ‘AIDS-defining illnesses’? count reaches 200 cells/μl. The risk of HIV-Clinical conditions that are so rare in people associated infections can also be reduced by:with a healthy immune system that they 1. Primary prophylaxis that prevents theusually indicate that the person has AIDS HIV-associated infection from occurring.(stage 4 HIV infection). AIDS-defining This is done for Pneumocystis and TB.illnesses include: 2. Secondary prophylaxis that prevents1. Infections such as oesophageal candidiasis, recurrences of HIV-associated infections extrapulmonary TB, cryptococcal which have already occurred. This is done meningitis and pneumocystis pneumonia. for cryptococcal meningitis.2. Illnesses, other than infections, such as HIV wasting syndrome, Kaposi’s sarcoma 6-7 How does oral candidiasis present? and non-Hodgkin’s lymphoma. Oral candidiasis (also called thrush or moniliasis) is common in HIV patients with Both infections and malignancies can be AIDS- a CD4 count above 200 cells/μl. Therefore it defining illnesses. occurs early in HIV infection and may be the first indication that the patient is infected with NOTE A number of malignancies associated HIV. The patient complains of a painful mouth with AIDS have a viral cause. and white patches are seen on the tongue, palate and inside the cheeks. White patches may6-5 Which patients are at high risk also be seen in the pharynx (oropharyngealfor HIV-associated infections? candidiasis). HIV-infected women often have severe or repeated vulvovaginal candidiasis.1. HIV-infected patients with moderately low CD4 counts (50 to 200 cells/μl) NOTE The diagnosis of oral Candida infection can commonly get infections which are be confirmed on microscopy when the fungal uncommon but not rare in people with spores and hyphae (threads) can be seen. a normal immune system, e.g. TB and pneumococcal pneumonia. However, Oral candidiasis in adults is often an early sign some of the milder HIV-associated that the patient has HIV infection. infections may occur in HIV patients with CD4 counts above 200 cells/μl.2. HIV-infected patients with very low CD4 6-8 How is oral candidiasis treated? counts (below 50 cells/μl) commonly Candidiasis of the mouth and pharynx can become infected with rare organisms such be treated with topical nystatin drops 1 ml as Pneumocystis and Toxoplasma. every six hours. A patient may also suck amphotericin B lozenges or nystatin vaginal The lower the CD4 count the higher the risk of an pessaries. Recurrences are common. Refer HIV-associated infection. patients to an HIV centre if treatment is not effective after five days.
    • HIV - ASSOCIATED INFECTIONS 916-9 What bacterial infections are Shingles is common in young adults with HIVcommon in HIV patients? infection as their damaged immune system no longer keeps the virus under control. PatientsMost HIV patients are at an increased risk of with shingles should be treated early with highserious or repeated bacterial infections such as: doses of oral acyclovir (800 mg four-hourly1. Meningitis for five days). The eye may become involved2. Pneumonia which can cause blindness. Patients with face3. Diarrhoea or eye involvement should be urgently referred to hospital for treatment.A wide range of bacteria may cause meningitisor pneumonia such as Pneumococcus,Haemophilis and Staphylococcus. These Shingles in a young adult suggests HIV infection.infections should be treated as for patientswho are not HIV positive. NOTE Early treatment with steroids and acyclovirProphylaxis with co-trimoxazole reduces the may prevent the development of painful post-risk of many bacterial infections. Therefore its shingles neuralgia. Only use after consultationuse should be considered. with an infectious disease specialist. 6-12 Why is recurrent herpes infection Common bacterial infections are often serious or common in HIV patients? recurrent in HIV patients. A painful, recurrent rash with many small vesicles in the genital or anal area is usually6-10 What organisms may cause due to a Herpes simplex infection. Thisdiarrhoea in HIV patients? sexually transmitted disease is often severe andA number of organisms that do not cause recurrent in patients with HIV infection dueproblems in healthy people may cause to their damaged immune system. The mouthchronic diarrhoea in HIV-infected patients. and lips may also be involved. Patients withExamples are non-typhoid Salmonella, severe infection should be treated with oralCryptosporidium and Isospora. Patients with acyclovir (400 mg eight-hourly for five days).severe or chronic diarrhoea should be referredto hospital if dehydrated. Recurrent, severe herpes is common in HIV NOTE Isosporiasis responds to co-trimoxazole. patients. Cryptosporidium infection often only resolves when the patient is given antiretroviral treatment. NOTE Genital and anal herpes are usually sexually transmitted and caused by6-11 What is shingles? Herpes simplex virus II (HSV-II) while oral herpes is usually due to recurrence of aThis is a very painful vesicular rash which childhood infection caused by HSV-I.usually only affects one part of the body.It is commonly seen in older people and is 6-13 What are common causes ofuncommon in young healthy adults. It is a sore mouth in HIV patients?caused by reactivation of the chickenpoxvirus (Varicella zoster) which has been 1. Oral candidiasis. This is the commonestsilent in nerve cells since a childhood mouth condition in HIV infection.infection. Shingles is infectious and can cause 2. Severe, recurrent aphthous ulcers. Thesechickenpox in children. Pain typically occurs are very painful ulcers that can occurfor a few days before the rash appears. anywhere in the mouth. They may be single or multiple, small or large. Manage with paracetamol (Panado) for pain,
    • 92 ADULT HIV and chlorhexidine mouthwashes to PNEUMOCYSTIS prevent secondary bacterial infection. Local (topical) steroids (e.g. Kenalog in PNEUMONIA Orabase) or spraying a beclomethasone inhaler directly onto the ulcer is helpful in severe cases. 6-16 What is pneumocystis pneumonia?3. Herpes infections. These multiple, shallow Pneumocystis pneumonia is a severe ulcers often are recurrent or become lung infection caused by a fungus called chronic. Topical gentian violet or 0.1% Pneumocystis. AIDS patients, especially povidone-iodine (Betadine mouth wash) children, are particularly likely to develop may be used while oral acyclovir is pneumocystis pneumonia if their CD4 count indicated for large ulcers. is below 100 cells/μl.4. Necrotising ulcerative gingivitis. This causes bleeding and ulceration along the NOTE Contrary to earlier teaching gum margins of the teeth. Mouth washes Pneumocystis jiroveci and not Pneumocystis with 0.2% chlorhexidine gluconate helps carinii infects humans. Pneumocystis has while oral metronidazole (Flagyl) is recently been identified as a fungus. indicated in severe cases. Severe cases should be referred to a dental hygienist. 6-17 How is pneumocystis pneumonia diagnosed?Oral hairy leucoplakia is not painful. The patient presents with:6-14 How does oesophageal 1. Fevercandidiasis present? 2. A dry coughOesophageal candidiasis is very common in 3. Shortness of breath, especially with exercisepatients with a CD4 count below 100 cells/μl. 4. Weight loss, fatigue and a feeling of beingPatients present with pain and difficulty on unwellswallowing. They usually have oral candidiasis 5. Cyanosis if severeas well which helps make the diagnosis. Early in the infection the chest X-ray mayOesophageal candidiasis may result in appear normal. Later the appearance is that ofdehydration due to poor fluid intake. ‘ground glass’, often involving both lungs. NOTE A definitive diagnosis is made by staining Oesophageal candidiasis presents with painful sputum, which can be obtained after saline swallowing and always indicates AIDS. nebulisation in a patient with a dry cough. Treatment may be initiated in patients with clinical symptoms after tuberculosis and6-15 How is oesophageal bacterial pneumonia have been excluded.candidiasis treated?Oesophageal candidiasis is treated with oral 6-18 How is a patient with pneumocystisfluconazole (200 mg daily for 14 days). Local pneumonia managed?treatment with topical drugs is not adequate. Oral co-trimoxazole, four tablets every sixThese patients must be referred to hospital if hours in patients of 60 kg or more and threethey need intravenous rehydration. tablets every six hours in patients under 60 kg, is the treatment of choice. Severe cases also require steroids. Oxygen will be needed by patients with severe pneumonia. These patients need to be hospitalised.
    • HIV - ASSOCIATED INFECTIONS 93 NOTE The full blood count and serum potassium 3. Cytomegalovirus (CMV) concentration should be monitored in these 4. Tuberculous meningitis patients on such high doses of co-trimoxazole. 6-23 What is cryptococcal meningitis?6-19 Can pneumocystispneumonia be prevented? This is a serious infection of the meninges covering the brain caused by a fungus calledYes. Prophylactic oral co-trimoxazole, two Cryptococcus neoformans. Cryptococcaltablets daily should be given to HIV-infected meningitis is rare in healthy people and is notpatients with a CD4 count below 200 cells/μl or infectious to others. It is usually seen in AIDSstage 3 or 4 disease. Prophylaxis can be stopped patients with a CD4 count below 100 cell/μl.when the CD4 count is above 200 cells/μl. NOTE Dapsone 100 mg daily can be used in Cryptococcus is an important cause of meningitis patients who do not tolerate co-trimoxazole. in AIDS patients.6-20 Can prophylactic co-trimoxazole NOTE Cryptococcus may also cause aprevent other HIV-associated infections? disseminated infection which involves other organs such as the lungs and skin.Prophylactic co-trimoxazole can lower the riskof the following HIV-associated infections: 6-24 How is cryptococcal1. Pneumocystis pneumonia meningitis diagnosed?2. Toxoplasmosis3. Bacterial infections It presents with the clinical signs of meningitis,4. Diarrhoea due to Isospora i.e. fever, headache, nausea and vomiting, neck stiffness, confusion and drowsiness. NOTE Dapsone only prevents The diagnosis is confirmed by examining the Pneumocystis infections. cerebrospinal fluid (CSF) obtained by lumbar puncture. The diagnostic tests on the CSF are:6-21 Does co-trimoxazole have side effects? 1. Indian ink stainYes. Especially in patients who are receiving 2. Cryptococcal antigenantiretroviral treatment. The commonest side 3. Cultureeffect is a rash. This can be severe and evenlife threatening. NOTE CSF chemistry may be normal or only mildly abnormal early in the infection. The Indian ink NOTE Co-trimoxazole may cause stain is not very sensitive while culture takes hypersensitivity reactions with bone weeks. The antigen test in both CSF and serum marrow suppression as well as hepatitis. is very sensitive for cryptococcal meningitis. 6-25 How is cryptococcalINFECTIONS OF meningitis treated?THE CENTRAL All patients with a clinical suspicion of meningitis must be urgently referred toNERVOUS SYSTEM hospital. Amphotericin B is given intravenously for two weeks followed by high oral doses of fluconazole for a further eight weeks.6-22 Which HIV-associatedinfections can affect the brain?1. Cryptococcal meningitis2. Toxoplasmosis
    • 94 ADULT HIV6-26 Can cryptococcal diagnosis and treatment with ganciclovir.meningitis be prevented? Visual impairment may be permanent.Patients who are treated and have recoveredfrom cryptococcal meningitis should be CMV retinitis may cause blindness in AIDS patients.placed on fluconazole prophylaxis to reducethe risk of a repeat infection. The dose ofdaily oral fluconazole is 200 mg. Prophylaxiscan be stopped when the CD4 count rises TUBERCULOSISabove 200 cells/μl. Fluconazole is not given asprophylaxis to HIV patients who have not had 6-29 What is tuberculosis?a previous episode of cryptococcal meningitis. Tuberculosis (TB) is a chronic infectious NOTEFluconazole is used for secondary disease which is caused by the bacteria prophylaxis (to prevent recurrence). Mycobacterium tuberculosis. TB usually affects the lungs (pulmonary TB).6-27 What is cerebral toxoplasmosis? NOTE Mycobacterium tuberculosis was firstToxoplasma gondii is a single-cell organism described by Robert Koch in 1882. Non-(parasite) that can cause serious illness tuberculous Mycobacterial infections suchwith brain infection (encephalitis) in AIDS as Mycobacterium avium complex (or MAC)patients with a CD4 count below 100 cells/μl. may occur in patients with advanced AIDS.Toxoplasmosis is not infectious to others.Patients with cerebral toxoplasmosis present 6-30 How is tuberculosis spreadwith fits, abnormal behaviour and/or from person to person?drowsiness. The diagnosis is confirmed on Tuberculosis is usually spread when an infectedCT scan. Patients with suspected cerebral person talks, coughs, spits, laughs, shouts, singstoxoplasmosis must be urgently referred to or sneezes. This sends a spray of very smallhospital for investigation and treatment with a droplets into the air. These small drops containprolonged course of co-trimoxazole. live TB bacteria (TB bacilli) from the patient’s lungs. They float in the air for up to one hour Cerebral toxoplasmosis is a serious complication and can be breathed in by other people. This of AIDS. may result in TB infection of the lung. Patients with many TB bacteria in their sputum (‘open TB’) are very infectious to others.6-28 What problems may be causedby cytomegalovirus (CMV)? NOTE Less commonly, TB bacteria inThis virus commonly causes mild illness in unpasteurised cows’ milk can be drunk and cause TB infection of the tonsil or gut.healthy children and adults. Most people areinfected as children. In AIDS patients with avery low CD4 count CMV may cause retinitis TB bacteria are spread from people with(infection of the eye), encephalitis (brain untreated pulmonary tuberculosis.infection), hepatitis, pneumonitis and bowelinfection. This may be a primary infection orrecurrence of a childhood infection. 6-31 Do all people who are infected with Mycobacterium tuberculosisCMV retinitis presents with sudden impaired develop tuberculosis?vision and is the commonest cause ofblindness in AIDS patients. Suspected cases No. Most people infected with TB bacteriamust be urgently referred to hospital for (i.e. Mycobacterium tuberculosis) do not develop tuberculosis because their healthy
    • HIV - ASSOCIATED INFECTIONS 95immune system is able to control the infection 6-34 Why is tuberculosis so commonand stop the TB bacteria from multiplying. in patients with HIV infection?However, the TB bacteria are often not Because their damaged immune system is notall killed but only controlled. The normal able to control the TB infection. Tuberculosisimmune response protects most people may be due to either:(90%) with TB infection from developingtuberculosis (TB disease) in their lifetime. 1. Reactivation of an old TB infection, which has been controlled for many years. Often the original TB infection was during Fortunately most people infected with TB childhood. With weakening of the immune bacteria do not develop tuberculosis. system by HIV infection the old TB infection flares up to result in tuberculosis.6-32 Is tuberculosis common in the 2. A new TB infection leading to tuberculosis.general population in South Africa? The weakened immune system is unable to kill the TB bacteria and keep the TBInfection with Mycobacterium tuberculosis infection under control.(TB infection) is very common, and it isestimated that almost 50% of South Africans Therefore, HIV infection increases the risk ofare infected, especially during childhood. reactivation of latent TB and also increasesHowever, only about 10% of healthy people the risk of new TB infections progressing towith TB infection progress to tuberculosis (TB tuberculosis.disease) during their lifetime. Therefore, TBinfection is far more common than tuberculosis NOTE In South Africa the steady fall in numbers of TB cases suddenly reversed in the 1990sdisease. Tuberculosis is common in most when the incidence of TB dramaticallydeveloping countries, such as South Africa. climbed as the HIV epidemic spread.6-33 Are patients with HIV infection 6-35 Is tuberculosis a commonat increased risk of tuberculosis? cause of death in AIDS patients?TB is very common in people who are HIV Tuberculosis is the most common cause ofpositive. Pulmonary TB indicates stage 3 and death in adults with HIV in South Africa.extrapulmonary TB stage 4 disease. TB isoften the first indication of HIV disease and isthe most common HIV-associated infection Tuberculosis is the commonest cause of death inin adults in South Africa. adults with HIV infection in South Africa. Tuberculosis is very common in HIV-positive people 6-36 What is the effect of tuberculosis and is the most common HIV-associated infection. on the progress of HIV infection? Patients with untreated HIV infection become NOTE In South Africa about 60% of patients worse much more rapidly if they also have TB. with TB are also HIV positive. In HIV-positive Tuberculosis therefore speeds up the progress people, primary TB infection progresses to TB of HIV infection as it further damages the disease in 30% of cases while an additional 10% per year will develop TB disease due immune system. to reactivation of latent TB infection. 6-37 What is the effect of HIV infection on the progress of tuberculosis? The course of tuberculosis is often very rapid in patients with HIV. Therefore, patients
    • 96 ADULT HIVwith both HIV infection and TB often need Sometimes the clinical diagnosis of TB is difficulthospitalisation. to confirm. NOTE HIV infection with a damaged immune system prevents the normal cellular response to TB. NOTE Lymph node biopsy is often helpful. Ideally all positive sputum samples should be cultured for resistance.6-38 What are the symptoms andsigns of pulmonary tuberculosis? 6-40 Are HIV patients withPatients with pulmonary TB present with: pulmonary tuberculosis a danger1. Chronic cough for more than two weeks. to the general public? Some patients may cough up blood Any patient with pulmonary tuberculosis may (haemoptysis). be infectious to the general public. As the2. Fever for more than two weeks. number of HIV patients with TB increases,3. Night sweats for more than two weeks. the risk of TB in HIV-negative people will also4. Weight loss. increase as they are being exposed to more5. They feel tired and weak. TB bacteria. It is therefore in the best publicSuspect TB in any HIV-positive person who interest to prevent and manage TB well.has a cough lasting more than two weeks. Anytwo of the above signs strongly suggests TB. The HIV epidemic is increasing the risk of tuberculosis to the general public. Pulmonary tuberculosis usually presents with chronic cough, fever, night sweats and weight loss. 6-41 Can tuberculosis affect organs other than the lungs?6-39 How is the clinical diagnosis of TB may affect most organs of the body suchpulmonary tuberculosis confirmed? as the meninges, brain, spine and bowel.1. Two early morning sputum examinations Tuberculous meningitis is common in HIV- for acid-fast bacilli (i.e. TB bacteria). infected patients. Smear-positive patients are infectious.2. Chest X-ray if two sputum stains are 6-42 How can tuberculosis be prevented negative but clinical finding suggest in patients with HIV infection? pulmonary tuberculosis. Typical adult TB 1. The risk of TB can be reduced in HIV- with cavities (holes) in the upper lobes positive people by controlling TB in the may be seen in patients with only mild general public and thereby reducing their depression of their CD4 count. However, exposure to TB bacteria. A high cure patients with advanced HIV infection may rate of TB by a well-functioning DOTS have widespread TB pneumonia, pleural programme is very important. effusions or enlarged TB lymph nodes. 2. Some protection can be obtained by giving3. Sputum culture if both sputum all children BCG immunisation at birth. examinations and chest X-ray are negative 3. TB prophylaxis can be given to patients at with clinical features of pulmonary high risk of tuberculosis. tuberculosis.In HIV-positive patients with tuberculosis the NOTE DOTS = Directly Observed Therapychest X-ray may appear normal and the sputum Shortcourse. A short, intensive course of anti- TB treatment where taking the medicationstain and culture may also be normal making is observed each day by a supporter.the clinical diagnosis difficult to confirm.
    • HIV - ASSOCIATED INFECTIONS 976-43 What is TB prophylaxis? 6-45 Do HIV patients on antiretroviral treatment have a lower risk of TB?HIV-infected patients at high risk of TB canbe protected by isoniazid (INH) at a dose The risk of TB is greatly reduced in the shortof 300 mg daily. Prophylaxis prevents the term in patients on antiretroviral treatment (inreactivation of an old TB infection as well as the first three years). However, as patients onnew TB infections. antiretroviral treatment now live longer, the lifetime risk of TB is still high. As a result theIt is suggested that TB prophylaxis should incidence of TB in the community may not fallbe given to HIV-positive patients who with the roll-out of antiretroviral treatment.have a positive tuberculin (Mantoux) skintest result of 5 mm or more or who are infrequent contact with a person with ‘open’ 6-46 Should HIV infection and tuberculosisTB. A positive TB skin test indicates that the be treated at the same time?person has previously had a TB infection. Yes. However, the TB treatment shouldProphylaxis is usually given for six months. be started before beginning antiretroviralThis offers protection for a further 18 treatment because:months. It is very important to exclude activetuberculosis before starting INH prophylaxis 1. The immune reconstitution inflammatoryas monotherapy with INH may lead to anti- syndrome may occur. This is particularlytuberculous drug resistance. common if TB treatment is given for less than two months before antiretroviral treatment is started, especially if the CD4 TB prophylaxis is important in HIV-infected count is less than 100 cells/μl. people at high risk of tuberculosis. 2. Drug interactions are common. 3. Drug side effects are more frequent and may NOTE Pyridoxine 25 mg per day is often be severe as anti-TB drugs and antiretroviral given with INH to reduce the risk of INH- drugs often have similar side effects. induced peripheral neuropathy. 4. A large number of different tablets have to be taken.6-44 How is tuberculosis treated? Therefore treatment of HIV is difficult if TBPatients with TB must be referred to a TB treatment is also being given at the same time.clinic. Usually rifampicin, isoniazid (INH),pyrazinamide and ethambutol are given Tuberculosis treatment should be started beforein a combination tablet. Daily dosage withcombination tablets is given according to starting antiretroviral treatment.weight: two tablets for patients weighing 30 to37 kg, three tablets if 38 to 54 kg, four tablets 6-47 Is it important to screenif 55 to 70 kg and five tablets if over 70 kg. TB patients for tuberculosis beforetreatment with DOTS lasts for a minimum of starting antiretroviral treatment?six months. Tuberculosis in patients with HIV Yes. If at all possible, tuberculosis shouldinfection usually responds well to treatment. be excluded before starting antiretroviral NOTE The commonly used combination tablet treatment. Any HIV patient with a chronic contains rifampicin 150 mg, isoniazid 75 mg, cough should be fully investigated. pyrazinamide 400 mg and ethambutol 275 mg. Tuberculosis is treated with a multiple drug regimen.
    • 98 ADULT HIV6-48 When should antiretroviral each dose of lopinavir/ritonavir, or thetreatment be started in patients dose of lopinavir/ritonavir should bewho have tuberculosis? doubled, as anti-TB treatment lowers the blood level of ritonavir.1. If the CD4 count is between 100 and 350 cells/μl and the patient is well, treat the As there are complex interactions between TB for one to two months before starting the drugs used to treat TB and the drugs used antiretroviral treatment. for antiretroviral treatment, the management2. Treat TB for two weeks before starting of these patients is best done by experts at an antiretroviral treatment: antiretroviral clinic. • If the CD4 count is below 100 cells/μl • If clinical stage 4 Drugs used in TB therapy and antiretroviral • If MDR or XDR TB • If the patient is ill treatment may interact with each other. The patient may die if antiretroviral treatment is delayed any longer. NOTE Rifampicin induces liver enzymes which break down some drugs used in antiretroviral treatment.6-49 Who should be responsible forthe anti-tuberculosis treatment? 6-52 What are the shared side effects of theThis must be arranged and managed together drugs used to treat tuberculosis and HIV?with the local TB clinic. Nausea, rash, hepatitis and peripheral neuropathy. As a result these side effects are6-50 What should be done if commoner and may be more serious if thepatients on antiretroviral treatment two drug regimens are used together. Thisdevelop tuberculosis? may result in a change in the choice of anti-The antiretroviral treatment must be retroviral drugs.continued and anti-TB treatment started. Drug side effects are more frequent and may be6-51 How do drugs used to more severe if anti-tuberculous and antiretroviraltreat tuberculosis and HIV treatments are given together.interact with each other?In patients who are already on antiretroviral 6-53 Can taking many tabletstreatment when tuberculosis is diagnosed, cause problems?some of the drugs being used in antiretroviraltreatment may have to be changed: Adherence may be poor when so many tablets need to be taken. There may also be1. Rifampicin is very important in the confusion between the many different types treatment of TB but it affects the drug of tablets. Patients should be told they will levels of many of the drugs used in have to take a large number of tablets and be antiretroviral treatment. As a result the counselled about these possible problems. choice of antiretroviral drugs and their A clearly written plan for both anti-TB and doses may need to be changed. antiretroviral treatment is helpful.2. If the first-line combination is to be used, nevirapine should be replaced with efavirenz as rifampicin may lower the 6-54 Is resistant tuberculosis a blood level of nevirapine. problem in HIV patients?3. If the second-line antiretroviral Tuberculosis resistant to many of the anti-TB combination is to be used, an extra three drugs is a growing problem in both HIV- capsules of ritonavir should be added to
    • HIV - ASSOCIATED INFECTIONS 99positive and negative people. A combination 3. What is the managementof HIV infection and drug-resistant TB is of oral candidiasis?often fatal. Good adherence is essential in Topical nystatin drops 1 ml every six hours.the treatment of both TB and HIV to prevent He could also suck amphotericin B lozengesdrug resistance. or nystatin vaginal pessaries. Refer if theMulti-drug-resistant (MDR) TB is resistant to candidiasis is not cleared after five days ofboth INH and rifampicin. This is becoming a treatment.worry in South Africa. 4. What is the management of NOTE Extensively drug-resistant (XDR) TB is oesophageal candidiasis? resistant to more than INH and rifampicin and often resistant to all the standard anti-TB drugs. Oral fluconazole. Make sure the patient is not dehydrated. If so, intravenous fluid may6-55 Are the public health strategies to be needed. Dehydrated patients should betreat tuberculosis and HIV similar? referred to hospital.There are important differences in the way that 5. What are the other causes of a soretreatment is managed: mouth in a patient with HIV infection?1. In TB programmes that use the DOTS Aphthous ulcers, herpes ulcers and gingivitis. approach, responsibility for ensuring adherence is largely placed on a supporter rather than on the patient. In contrast, with 6. Is oral candidiasis an HIV- antiretroviral treatment the responsibility associated infection? is on patients themselves. Yes. An HIV-associated infection occurs far2. A course of TB treatment is usually for six more commonly in HIV-positive people than to eight months only, while antiretroviral people who are HIV negative. These infections treatment is for life. are more common because HIV damages the immune system by reducing the CD4 count.CASE STUDY 1 Oral candidiasis indicates stage 3 disease.A 20-year-old man presents with a verypainful mouth for the past few days. On CASE STUDY 2examination he has white patches on histongue and palate. When questioned he A young woman complains of weight loss andadmits to difficulty swallowing. chronic diarrhoea. For the past few days she has had severe pain on one side of her chest. She has noticed a rash with small vesicles1. What is the likely diagnosis? (blisters) in the same area as the pain.Oral candidiasis. He probably also hasoesophageal candidiasis as he has difficulty 1. What is the cause of the pain and rash?swallowing. Shingles. This typically presents as localised pain followed by a vesicular rash.2. What is the likely underlying cause?HIV infection with suppression of his immune 2. Is this the same as chickenpox?function. Oral candidiasis is uncommon inhealthy adults with a normal immune system. No, but both rashes are due to the Varicella zoster virus. For many years the virus remains in nerve cells following chickenpox as a child.
    • 100 ADULT HIVWhen the immune system is weakened, the 2. What are the likely causes?virus is reactivated causing shingles. Shingles is Bacterial pneumonia, pneumocystisinfectious and can cause chickenpox in others. pneumonia or tuberculosis. The most likely cause is pneumocystis pneumonia.3. What is the concern when ayoung person gets shingles? 3. How can the diagnosis be confirmed?It suggests that the person has HIV infection. A chest X-ray will be helpful in mostShingles is uncommon in healthy HIV- cases. Exclude tuberculosis and bacterialnegative young people and is usually seen in pneumonia. Where laboratory supportan older person. is available request an examination for Pneumocystis in a sputum specimen.4. What is the management of shingles?Early treatment with oral acyclovir. If the pain 4. What is the treatment ofor rash involves the face or eye, the patient pneumocystis pneumonia?must be referred urgently to hospital. Oral co-trimoxazole, four tablets every six hours in patients of 60 kg or more and three5. What is the likely cause of tablets every six hours in patients under 60 kg.her chronic diarrhoea? Patients who are severely ill or cyanosed needThis is almost certainly caused by an infection oxygen and admission to hospital. Severeassociated with HIV. A number of organisms cases may need steroids.cause chronic diarrhoea in HIV patients, suchas non-typhoid Salmonella, Cryptosporidium 5. What is an ‘AIDS-defining illness’?and Isospora. She should be referred to hospital These are conditions which are very rare infor diagnosis and treatment. people who do not have AIDS (stage 4 HIV infection). Pneumocystis is an ‘AIDS-defining6. What prophylaxis will help illness’. Anyone presenting with pneumocystisprevent chronic diarrhoea? pneumonia almost certainly has AIDS.Prophylaxis with co-trimoxazole will help Certain malignancies such as Kaposi’s sarcomaprevent diarrhoea due to bacterial infections and non-lymphoid lymphoma are also ‘AIDS-as well as infections with Cryptosporidium defining illnesses’.and Isospora. 6. What other infections are ‘AIDS-defining illnesses’?CASE STUDY 3 Oesphageal candidiasis, cryptococcal meningitis, cerebral toxoplasmosis and CMVA known HIV patient develops a dry cough retinitis indicate stage 4 HIV infection.and fever. After a few days he feels worse andbecomes short of breath. CASE STUDY 41. What is the probable diagnosis?Pneumonia. Cough, fever and shortness of An HIV-positive patient presents with abreath suggest a lung infection. chronic cough, night sweats and fever. A chest X-ray suggests pulmonary tuberculosis.
    • HIV - ASSOCIATED INFECTIONS 1011. How common is tuberculosis 4. How is tuberculosis treated?in HIV-positive patients? With a course of multi-drug therapy. UsuallyVery common. It is the commonest HIV- rifampicin, isoniazid, pyrazinamide andassociated infection in adults in South Africa. ethambutol are used together. HIV-positive patients with TB usually respond well to anti-2. Is tuberculosis dangerous tuberculous treatment.in patients with HIV? 5. Should TB and HIV both beIt is the commonest cause of death in adults treated at the same time?with HIV in South Africa TB treatment should be started first before3. How can tuberculosis be prevented starting antiretroviral treatment. Thereforein HIV-positive people? all patients should be screened for TB before antiretroviral treatment is started.Controlling TB in the general populationand the routine use of BCG immunisation in 6. What are the problems if tuberculosisinfants. TB prophylaxis (primary prevention) and HIV are treated together?with isoniazid for six months in HIV patientswith a positive Mantoux skin test is effective Drugs used to treat TB and HIV often interactin reducing the incidence of TB in these high- with each other. The risk of side effects isrisk patients. increased and adherence is often poor due to the large number of tablets that have to be taken each day.
    • 6A Skills workshop: Screening tests for HIV B. The method of performing Objectives the HIV rapid test When you have completed this unit you 1. Clean a fingertip with an alcohol swab and should be able to: allow the finger to dry. • Screen a patient for HIV. 2. Remove a test strip from the foil cover. • Interpret the results of the screening test. 3. Prick the skin of the fingertip with a lancet. Wipe the first drop of blood away with aWhenever possible, patients should be offered sterile gauze swab.and encouraged to accept screening for HIV. 4. Collect the next drop of blood with theAn HIV rapid test can be used in any clinic, as EDTA tube. Either side of the tube can beno sophisticated equipment is required. Prior used to collect blood. Fill the tube fromto testing, patients need to be counselled and the tip to the first black circle (i.e. 50 μl ofconsent must be obtained. blood). Avoid collecting air bubbles. 5. Apply the 50 μl of blood from the EDTA tube onto the sample pad marked with anA. Equipment needed to arrow on the test strip.perform an HIV rapid test 6. Wait one minute until all the blood has1. The Abbott Determine HIV-1/2 Whole been absorbed into the sample pad and Blood Assay. Each kit contains 10 cards then apply one drop of Chase Buffer. It is with 10 tests. The Chase Buffer (2.5 ml important that the bottle is held vertically bottle) is supplied with the kit. (upside down) above the test strip when2. EDTA capillary tubes marked to indicate the drop of buffer is dropped onto the 50 μl, lancets, alcohol swabs and sterile sample pad. gauze swabs. These are not supplied with 7. Wait a minimum of 15 minutes and then the kit. read the results. The maximum waiting time for reading the test is 20 minutes.The kit needs to be stored at room temperature After 20 minutes the test becomes invalid.between 2 °C and 30 °C. Storage in a fridge isrequired during summer. The kit cannot beused after the expiry date. C. Reading the results of the HIV rapid test 1. Positive: A red bar will appear within both the Control window and the Patient window on the test strip. Any visible