Preventing opportunistic infections

Studies have shown that prophylaxis and antiretroviral therapy has increased survival among people with HIV. Today, people with HIV who develop AIDS tend to do so only when their CD4 count has fallen to a much lower level than in the past. This is presumably because antiviral treatment and the use of prophylaxis are delaying the opportunistic diseases that might otherwise occur earlier. Unfortunately prophylaxis is not always as effective once the CD4 count becomes very low, although it remains of value.

A small number of people who experience good immune recovery after previous advanced immune suppression nevertheless develop new opportunistic infections or recurrences of past infections at higher than expected CD4 cell counts.1 This most likely indicates the loss of CD4 memory T-cells that respond to a specific infectious agent. Thus, it seems that a small proportion of HIV-positive people do maintain persistent ‘gaps' in their immune function, despite overall immune recovery.

It is also important to consider viral load. If viral rebound occurs, indicating potential treatment failure, it may be prudent to recommence prophylaxis even if the CD4 cell count is still above the recommended cut-off.

The need for prophylaxis should also be a consideration for people thinking about stopping antiretroviral therapy, even temporarily, as studies have shown that intermittent interruption of HAART can increase the risk of opportunistic infections.2

In 2008, the British HIV Association issued guidelines for immunisation of HIV-infected adults.ref] These are available online at www.bhiva.org.

The US Department of Health and Human Services maintains recommendations on when to start, discontinue, and re-start prophylaxis for specific opportunistic infections in adult and paediatric patients.3 4 These guidelines can be accessed online at  www.aidsinfo.nih.gov/Guidelines/Default.aspx?MenuItem=Guidelines

For more detailed information on the prevention and treatment of opportunistic infections, please see specific entries in A to Z of illnesses.

References

  1. UK Collaborative HIV Cohort (CHIC) Study Steering Committee. Rate of AIDS diseases or death in HIV-infected antiretroviral therapy-naive individuals with high CD4 cell count. AIDS 21: 1717-1721, 2007
  2. Strategies for Management of Antiretroviral Therapy (SMART) Study Group. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med. 355: 2283-2296, 2006
  3. Centers for Disease Control and Prevention Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents MMWR 58 (No. RR-4) April 10: 1-216. Available at aidsinfo.nih.gov/contentfiles/Adult_OI_041009.pdf [accessed 21 October 2009], 2009
  4. Centers for Disease Control and Prevention Guidelines for prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. MMWR 58 (No. RR-11) Sept 4 2009:1-176. Available at: aidsinfo.nih.gov/contentfiles/Pediatric_OI.pdf [accessed 10 October 2009], 2009

Preventing opportunistic infections

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