1. Opportunistic Infections in
HIV+ Patients in Peru
Marin McCutcheon
Tulane School of Public Health and
Tropical Medicine
April 2015

2. Objectives
• Describe the epidemiology of opportunistic
infections (OI) in HIV+ patients in Peru
• Characterize programs and efforts to prevent
OIs in HIV+ patients in Peru
• Identify barriers to the prevention of OIs in
HIV+ patients in Peru
• Examine the impact of OIs in HIV+ patients in
Peru

3. Background
• Adult HIV prevalence in Peru is 0.6% overall
– MSM 11-18%
– Female sex workers 2%
– unlicensed female sex workers 10%
• Sex is primary mode of transmission
– MSM account for 42% of transmission
– MSW 40%
– IVDU 1%
• Lima and adjacent port of Callao has
– population of 8 million
– 75% of HIV/AIDS cases
• Free HAART since May 2004

4. Methods
• Key informant interviews
– 5 clinician researchers
– epidemiology, clinical knowledge, research,
knowledge and attitudes of general population and
medical professionals, ethical considerations
– in English and Spanish
• Literature review
– observational and experimental studies in South
America
– English and Spanish
• Clinical observation
– Clinical presentations
– Patient knowledge/attitudes of diagnoses

5. Results

6. Informant Interview:
HIV in Peru
• Affects populations with high rate of
malnutrition, poverty
• Weak health system →late presentation/early
death
• Patterns of OIs change with geography
– jungle, mountains, coast
• Research in Peru
– Few published studies of OIs

7. Informant Interview:
Clinical Considerations
• Knowledge and diagnosis of OIs
– Atypical presentations of infections
– Clinical experience
– Experienced lab technicians
• Most common OIs:
– 1) chronic diarrhea
– 2) TB
– →test for HIV
• Ethical considerations
– Patient privacy
– Diagnosis may not be known to family/person providing
financial support

8. Informant Interview:
Bacterial OIs in HIV
• TB
– Most common presentation: miliary
– More likely MDR due to patient
demographics→exposure to high risk popn
• Typhoid epidemic 1980s
• Cholera epidemic 1990s

9. Informant Interview:
Fungal OIs in HIV
• Histoplasmosis
– Infection, re-infection, re-activation
– Majority present with systemic disease
• Paracoccidiosis
– Infection, re-infection, re-activation
– Majority present with systemic disease:
lungs+skin+LNs+HSM
– More aggressive
– Most info from Brazil

10. Informant Interview:
Fungal OIs in HIV
• Cryptococcosis
– Acute disease (2 wks)
– 95% with systemic disease: CNS+lungs+blood+skin
• Sporotrichosis
– Case report
– systemic disease: cutaneous, subcutaneous, bone
marrow, multiple joint involvement

11. Informant Interview:
Parasitic OIs in HIV
• Malaria
– Higher parasitemia
– Stimulates inactive CD4→increases CD4
destruction
– More disease/fewer asymptomatic cases
– Lower response to antimalarial treatment
– Higher rate re-infection (failure to clear parasite)
– Transmission decreases with HAART

12. Informant Interview:
Parasitic OIs in HIV
• Leishmaniasis
– Reversal of Visceral Leishmania epidemiology:
normally in kids→in adults in HIV
– Reactivation of childhood infection
– CD4 not always avail and Leishmania not AIDS-
defining→appropriate diagnosis of AIDS
– Sxs difficult to distinguish from HIV/AIDS: fever,
weight loss, HSM, esoph pain, skin/mucosal
lesions

13. Informant Interview:
Parasitic OIs in HIV
• Coccidias
– Most important cause of chronic diarrhea
• Giardiasis
– Decreases effectiveness of HAART
• Entamoebiasis
– Increased rate of invasive form

14. Informant Interview:
Parasitic OIs in HIV
• Strongyloidiasis
– Hyperinfection in Peru, Brazil
– Controversial: no reports of different presentation in
HIV from Africa, Asia
• Schistosomiasis
– Prolonged transmission: weakened
immunity→uncontrolled egg production
• Free-living amoeba: Balamutia mandrilaris
– Acute, aggressive meningoencephalitis
– Granulomatous and disseminated skin and brain
lesions

15. Informant Interview:
Viral OIs in HIV
• HTLV-1 co-infection
– Faster progression to AIDS
– Decreased survival time
– Likely increased rate of TSP, leukemia/lymphoma
– Little data: small cohort, patients die
early→difficult to see progression, tumor
development
– Difficult to attain good immune reconstitution
with HAART→CD4 hovers at 200

16. Informant Interview:
Patient Knowledge/Perceptions of HIV
• Association of HIV with MSM, promiscuity,
IVDU→many patients believe they are not at
risk
• Gender roles/double-standards
– Social acceptance of male extramarital sex
– Financial dependence on husband

17. Informant Interview:
Patient Knowledge/Perceptions of HIV
• Stigma
– Homosexuality
– Concerns about job loss
– Who has knowledge of diagnosis
– Worry about death
• Poor understanding of chronic disease
– Preference for IM tx x 1→believe they are cured
• Concerns about AEs from HAART
– Kidney, liver damage

18. Literature Review: Eza 2006
• 16 HIV-related postmortems in Lima
• OIs in 14 patients
– CMV, histoplasmosis, cryptococcosis, toxoplasmosis,
PCP, aspergillosis, tuberculosis, varicella zoster,
cryptosporidiosis
– 2+ coexisting OIs in 7 patients
– Most common: CMV in 7 patients
• Primary COD determined in 12 patients→11 died
from infectious causes
– 3 pulmonary infections: miliary TB, aspergillus
– 7 disseminated infections: histoplasma, cryptococcus
– 2 CNS infections: cerebral toxoplasmosis
• 1 w dual pathology: CNS and disseminated

19. Literature Review: Shin 2008
• Cohort of HIV-TB infected patients to identify
risk factors for HAART nonadherence
– Majority of pts unemployed, in crowded
conditions, food scarcity, recent diagnosis HIV,
presented with advanced AIDS
• Factors associated with nonadherence to
HAART amongst TB-HIV pts in Lima
– low social support
– Depression
– substance abuse

20. Discussion: Barriers
• HAART available at no cost
• Patients have to pay for hospital tests
• Education
• Stigma
• Health care access
• No national programs to enhance adherence
to HAART

21. Discussion
• Many OIs also source of infection in
immunocompetent
– Prior infection
– Unusual presentations, systemic
– Often more severe, more difficult to treat
• Role of HAART in treatment
– Drug interactions
– IRIS

22. Discussion: Research
• Regional prevalence of OIs
– clinical management
– prevention
• Cost of hospital tests
– limits data available to researchers→not all tests are
performed
– viral load unavailable, sometimes CD4 unavailable
– CMV and PCP tests more expensive
– diagnosis more likely if based on PE or sputum
microscopy

23. Limitations
• Limited number of key informant interviews
– All conducted at one institution in Lima
– Not at primary hospital for HIV patients
• No patient interviews conducted
– IRB approval
• Literature review
– Few studies, many small
– Studies from Brazil

24. References
• Alarcon, J, et al. (2012). Opportunistic and Other Infections in HIV-infected Children in Latin America
Compared to a Similar Cohort in the United States. AIDS Research and Human Retroviruses. 2012;28(3),
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• Alave J, et al. Risk factors associated with virologic failure in HIV-infected patients receiving antiretroviral
therapy at a public hospital in Peru. Rev Chilena Infectol. 2013;30(1): 42–48.
• Bustamante, B, et al. Sporotrichosis in Human Immunodeficiency Virus Infected Peruvian Patients: Two
Case Reports and Literature Review. Infectious Diseases in Clinical Practice. 2009;17(2).
• Cama, V, et al. Differences in Clinical Manifestations among Cryptosporidium Species and Subtypes in HIV-
Infected Persons. The Journal of Infectious Diseases. 2007;196, 684-691.
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