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HIV-related opportunistic diseases

UNAIDS Technical update

October 1998

UNAIDS Best Practice Collection At a Glance UNAIDS Best Practice materials The Joint United Nations Programme on HIV/AIDS (UNAIDS) is preparing materials on subjects of relevance to HIV infection and AIDS, the causes and consequences of the epidemic, and best practices Opportunistic diseases in a person with HIV are the products of two in AIDS prevention, care and things: the person’s lack of immune defences caused by the virus, support. A Best Practice Collection and the presence of microbes and other in our everyday on any one subject typically environment. includes a short publication for journalists and community leaders A partial list of the world’s most common opportunistic diseases and diseases includes: (Point of View); atechnical summary of the issues, challenges and • bacterial diseases such as (TB, caused by Mycobacterium solutions (Technical Update); case tuberculosis), Mycobacterium avium complex disease (MAC), bacterial studies from around the world (Best pneumonia and septicaemia (“ poisoning”) Practice Case Studies); a set of • protozoal diseases such as Pneumocystis carinii pneumonia (PCP), presentation graphics; and a listing , microsporidiosis, , and of key materials (reports, articles, leishmaniasis books, audiovisuals, etc.) on the • fungal diseases such as candidiasis, cryptococcosis (cryptococcal subject. These documents are meningitis (CRM)) and penicilliosis updated as necessary. • viral diseases such as those caused by (CMV), Technical Updates and Points herpes simplex and herpes zoster virus ofView are being published in • HIV-associated malignancies such as Kaposi sarcoma, lymphoma English, French, Russian and and squamous cell carcinoma. Spanish. Single copies of Best Practice materials are available Effective intervention against opportunistic diseases requires not only the appropriate drug or other medications for a given medical condition, freefrom UNAIDS Information but also the infrastructure necessary to diagnose the condition, monitor Centres. To find the closest one, the intervention, and counsel patients. As well, use of drugs and tests visitUNAIDS on the Internet must be supported by proper storage, handling and administrative (http://www.unaids.org), contact procedures. UNAIDS by email ([email protected]) or telephone (+41 22 791 4651), The main challenge of choosing between interventions is to alleviate orwrite to the UNAIDS Information the morbidity and suffering of those in need while not exceeding the Centre, 20 Avenue Appia, financial and technical capabilities of the health system. Unfortunately, 1211Geneva 27, . these choices often need to be made without the help of formal cost-benefit and cost-effectiveness analyses. This is partly because the information needed to calculate costs is difficult to collect, but also because benefits other than short-term improvements in quality HIV-related opportunistic diseases: of life are not well understood or easily quantified. UNAIDS Technical Update. October 1998. In places where resources are very scarce, priority should be given to I. UNAIDS II. Series health needs shared by most or all of the population, including those who are HIV-infected. Examples are drugs to relieve pain in terminal 1. AIDS-related opportunistic patients—including those with AIDS—or for TB. Drugs to treat and infections—drug therapy prevent TB have a high overall value to society in many countries 2. AIDS-related opportunistic because they (a) benefit people affected by two epidemics (HIV/AIDS infections—diagnosis and TB), (b) are proven effective and (c) are relatively inexpensive 3. Prevalence given the number of people who can benefit. 4. Drug therapy—economics 5. Diagnosic services Only a few opportunistic diseases and symptoms such as oropharyngeal 6. Cost of illness and vaginal candidiasis (“thrush”) or herpes zoster and herpes simplex 7. Health priorities can be managed effectively through home-based care. Most other UNAIDS, Geneva opportunistic diseases require diagnosis and treatment which are WC 503.5 beyond the capabilities of most community-based groups and NGOs. For conditions that can be treated only at a very high cost, the public- health rationale for treatment is weaker, and humanitarian or equity considerations become more important. Examples of such conditions are CMV, MAC, cryptococcal meningitis (CRM), penicilliosis and rarer systemic mycoses.

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October 1998 HIV-related opportunistic diseases: UNAIDS Technical Update Background

People with advanced HIV infection are vulnerable to infections or malignancies that are called “opportunistic” because they take advantage of the opportunity offered by a weakened . Various treatments and prophylaxis—some simple and low-cost, others highly complex and expensive—exist to counter the most common opportunistic diseases, but delivery systems and funding are insufficient in many parts of the world to ensure their universal use.

The worldwide distribution of itraconazole, fluconazole or efficacy at a relatively high cost opportunistic diseases is highly amphotericin B. A two-week (which is increased by the need for varied. Table 1 shows data on their course of ketoconazole 200 mg close monitoring), and are not distribution in six countries from costs US$ 5.53. Other azole included in the WHO essential , the Americas, and South- antifungal agents are not available drugs list. East Asia. Like the following brief through generics suppliers, and are overview of the most common much more expensive. Herpes simplex diseases and the interventions and Herpes zoster available for their treatment Cryptococcosis Herpes simplex virus infection or prevention, the table is only Systemic mycoses such as crypto- (HSV, which causes sores around intended to give a sense of the coccosis probably cause about the mouth and genitals) and herpes wide differences from country 5% of all HIV-associated deaths zoster virus infection (“zonal” herpes) to country. worldwide. Cryptococcosis most are not life-threatening but can be Table 2 provides a comparison of often appears as meningitis, and extremely painful. Both occur costs of treatment and prophylaxis occasionally as pulmonary or frequently in HIV-infected persons, for the most common opportunistic disseminated disease. Cryptococcal but as they are not considered diseases. meningitis (CRM) is the most AIDS-defining conditions there are frequent systemic fungal infection few data about their incidence. Candidiasis in HIV-infected persons. Without Note, however, that both can treatment, life expectancy is cause , which can be The two main types of candidiasis probably less than a month. life-threatening. are localized disease (of the mouth and throat, and of the vagina), Cryptococcosis is relatively easy Treatment with aciclovir is only and systemic disease (of the to diagnose. However, its treat- marginally effective in herpes oesophagus, and disseminated ment (either amphotericin B with zoster but is sometimes dramatic disease). The mouth and throat or without flucytosine, or in mild in HIV-associated herpes simplex variant (oropharyngeal candidiasis cases with oral fluconazole) and with extensive ulceration. Aciclovir or OPC) is believed to occur at secondary chemoprophylaxis are is expensive, costing US$ 45.82 least once in the lifetime in all often impossible in developing and US$ 170.18 for 5-day herpes HIV-infected patients. countries because of the high simplex and 7-day herpes zoster cost and limited availability of regimens respectively. However, While OPC is not a cause of death, the drugs required. its cost is likely to decrease when it causes oral pain and makes it is no longer protected by patent, swallowing difficult. The symptom Cytomegalovirus infection (CMV) as is the case in the United Kingdom of oesophageal candidiasis is pain where generic aciclovir is available. in the chest that increases with Estimates of the incidence of CMV Aciclovir can also be used to treat swallowing, and difficulty in disease vary considerably between encephalitis at a cost of US$ 1282.76 swallowing. Disseminated geographical locations, but CMV for a ten-day intravenous regimen. candidiasis causes fever and causes significant suffering in HIV- symptoms in the organs affected by infected persons worldwide. Kaposi sarcoma the disease (for example, blind- Symptoms include fever and HIV-associated Kaposi sarcoma ness when it affects the eyes). diarrhoea from CMV colitis, dyspnoea causes dark blue lesions which Localized disease is treated first from CMV pneumonitis, and can occur in a variety of locations with relatively inexpensive topical blindness caused by CMV . including the skin, mucous membranes, gastrointestinal tract, drugs such as nystatin, miconazole, Treatment aims to alleviate lungs or lymph nodes. The lesions or clotrimazole. Systemic anti- symptoms, and to prevent blindness, usually appear early in the course fungals agents are usually given rather than provide a cure. The only when topical therapy fails. of HIV infection. drugs currently used are ganciclovir Systemic candidiasis requires and foscarnet, with cidofovir when Treatment depends on the lesions’ treatment with systemic antifungal the first two have failed. They symptoms and location. For local agents such as ketoconazole, have high toxicity and limited lesions, injection therapy with

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HIV-related opportunistic diseases: UNAIDS Technical Update October 1998 Background

vinblastine has been used with only sophisticated health-care significant health problem for HIV- some success. Radiotherapy can systems can handle them safely. infected persons, and also after also be used, especially in hard- their first episode of PCP. Preventing to-reach sites such as the inner Mycobacterium avium complex and treating PCP need not be very mouth, eyes, face and soles of disease (MAC) expensive: use of no-brand generic the feet. For severe widespread MAC disease appears to be products can reduce the cost of disease, systemic relatively rare in Africa, but drugs for TMP-SMZ prophylaxis to is the preferred treatment. elsewhere it occurs in around 5% under US$ 12.00 per year. of persons with AIDS. Symptoms Most drugs for the chemotherapy Toxoplasmosis of Kaposi sarcoma are included include fever, weight loss, night in the WHO essential drugs list. sweats, diarrhoea, and wasting. This disease is found in about 5% However, since international Recommended drugs for pro- of AIDS patients in the USA, but generic drug suppliers appear phylaxis include azithromycin, a greater proportion in Europe. to offer only vincristine and and rifabutin. Reliable data on its incidence in methotrexate, the availability For treatment, clarithromycin/ developing countries are lacking, of drugs to treat the disease is ethambutol/rifabutin combination but studies have demonstrated limited in developing countries. therapy is the only regimen that that the disease does occur in has been documented to increase a significant proportion of AIDS Leishmaniasis life expectancy; even so, in practice patients. In HIV-infected persons a two-drug regimen of a macrolide toxoplasmosis mainly appears as Leishmaniasis is transmitted by encephalitis or as disseminated sandflies and currently affects and ethambutol is often used as it reduces the potential for disease. Diagnosis of toxoplas- some 12 million people in 88 mosis is by CT scan or MRI scan. countries. The most serious of its both drug interactions and toxicity and it decreases cost. With the Brain are rarely carried four forms is visceral leishmaniasis out. If toxoplasmosis is strongly (VL)—also known as kala azar— exception of ethambutol, none of these drugs is included in the suspected, patients are more likely which is characterized by irregular to be given a trial of therapy, and bouts of fever, substantial weight WHO essential drugs list because of their high cost and the fact they only if they do not respond to this loss, swelling of the spleen and therapy is a brain considered. liver, and anaemia (occasionally do not cure MAC. serious). Recently, there has been Pneumocystis carinii The disease is treated with an increase in overlapping of VL pneumonia (PCP) plus . and HIV infection. Treatment with Primary chemoprophylaxis for PCP pentavalent antimony is relatively PCP is the most frequent HIV- with TMP-SMZ, or with expensive, partly because of the associated and pyrimethamine, offers protection cost of drugs but also because in industrialized countries, but against toxoplasmosis as well. hospital admission is recommended appears to be less frequent in Secondary chemoprophylaxis is (in milder cases, trained health Africa. The symptoms are mainly with pyrimethamine plus sulfadiazine workers may administer the pneumonia along with fever and and leucovorin. While pyrimethamine injections or infusions at a patient’s respiratory symptoms such as dry is widely available, the drug home). Even with optimal treatment, cough, chest pain and dyspnoea. combination is toxic to bone marrow mean survival time with this co- Definitive diagnosis requires micro- at the dosage recommended for infection is only 12 months. scopy of bodily tissues or fluids. prophylaxis. Prophylactic leucovorin Severe cases of PCP are initially (also called calcium folinate), which Lymphoma and squamous treated intravenously with is given to prevent the side effects cell carcinoma trimethoprim-sulfamethoxazole of pyrimethamine and as secondary (TMP-SMZ), or and prophylaxis, is very expensive. The treatment of lymphoma in HIV-infected persons is controver- oral . Mild cases can Tuberculosis sial. Survival is not greatly increased be treated with oral TMP-SMZ throughout. With both of these by expensive chemotherapy, Tuberculosis (TB) is the leading regimens, toxicity (notably and quality of life is poor during HIV-associated opportunistic treatment. Drugs used in these allergic-type reactions) often disease in developing countries. requires changes in therapy. regimens are included in the WHO The DOTS (directly observed, essential drugs list and ought to be Prevention of PCP is strongly short course) treatment strategy available, but this is often not the recommended for HIV-infected recommended by WHO treats TB case as they are not often stocked persons with significant immune in HIV-infected persons as effectively by generic drugs distributors. Also, compromise wherever PCP is a as it treats those without the virus.

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October 1998 HIV-related opportunistic diseases: UNAIDS Technical Update Background

A complete cure takes 6 to 8 months measure for HIV-infected persons incremental cost of isoniazid therapy— and uses a combination of anti- at risk of TB, such as those with US$ 5.15 for a year’s prevention biotics. In addition to curing the a positive TB skin test or who are according to the 1996 Drug and individual it also prevents further living in areas where the disease is Price Independent Guide—once a spread of the disease to others. endemic. TB prophylaxis has been person is identified as HIV-infected, This is why treating infectious cases shown to increase the survival of there is a strong case to provide of TB has important benefits for HIV-infected persons at risk of TB TB prophylaxis for HIV-infected society as a whole, and is the (see O’Brien and Perriëns in the persons whenever financially mainstay of the WHO’s TB control Selected Key Materials). The case feasible. (See WHO Policy Statement strategy. (See Tuberculosis and AIDS for public funding of TB prophylaxis on Preventive Therapy against in the UNAIDS Best Practice by developing countries awaits Tuberculosis in People Living with Collection for more information.) confirmation of its cost-effectiveness HIV in the Selected Key Materials.) Isoniazid preventive therapy is compared to treating infectious recommended as a health-preserving TB cases. However, given the low

Table 1. AIDS-defining opportunistic diseases: Prevalence in six countries1 Opportunistic disease Côte Brazil Mexico Thailand USA Zaire2 Infrastructure or malignancy d’Ivoire needed 3 Aspergillosis 3% 3–7% advanced Atypical mycobacteriosis 4% 5–6% 2% 4% advanced Bacteraemia 7% 4% advanced Candidiasis 24% 5% 30% 11% 13% minimal CMV 26% 5% 65–69% 4% 5% 13% advanced Cryptococcosis 5% 5% 7–11% 2% 7% 19% medium Cryptosporidiosis – Isosporiasis 4% 14% 8% 4% 6.2% <2% advanced Enteritis, non-specific 4 12% 13% minimal Herpes (systemic) 6% 5% 10% 4% minimal Histoplasmosis 3% 5–10% 8% <2% advanced Kaposi sarcoma 13% 5% 30–43% 21% 16% medium Lymphoma 4% 4% 10% 0.7% advanced Nocardiosis 5% <2% advanced Penicilliosis 4–25% advanced Progressive multifocal leukoencepha- lopathy (PML) or HIV encephalitis 6% 11% 7% 0.6% advanced Pneumocystis carinii pneumonia 4% 22% 24% 26% 64% <2% medium Pneumonia 5% 16% 34% advanced Toxoplasmosis 21% 14–34% 17% 2% 3% 11% advanced Tuberculosis 54% 41% 28% 20% 3% 41% medium Others 9% 9%

Source: Perriëns J, Clinical aspects of HIV-related opportunistic diseases in Africa: tuberculosis and candidiasis. University of Gent, 1994. 1 Data from autopsy studies, except Brazil (one autopsy and one clinical series), Thailand (two clinical series) and USA (one clinical series). 2 Democratic Republic of Congo. 3 Infrastructure needed to diagnose, treat 4 Clinical diagnosis for non-specific enteritis does not identify the cause. It permits treatment to be carried out, but not necessarily the most effective one.

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HIV-related opportunistic diseases: UNAIDS Technical Update October 1998 Background

Table 2. Comparative costs of treatment and prophylaxis for common opportunistic diseases in adults Opportunistic Drug and dose Duration Cost of treatment (in $) Source (b) disease course or per-year cost (a)

Candidiasis Ketoconazole 200 mg once a day 14 days 5.53 IDPIG Fluconazole 50 mg once a day 07 days 26.34 BNF Itraconazole liquid 100 mg twice a day 07 days 82.92 BNF Cryptococcosis Amphotericin B 1 mg/kg daily +/- 14 days 164 Acute treatment Flucytosine 100 mg/kg/day orally 14 days price not available BNF Fluconazole 800 mg orally for 2 days see dose 662 BNF followed by 600 mg daily Cryptococcosis Amphotericin 1 mg/kg/day 8 weeks 657 BNF Consolidation Fluconazole 400 mg/day 8 weeks 1685 BNF treatment Itraconazole 400 mg/day (liquid) 8 weeks 1238 BNF Cryptococcosis Fluconazole 200 mg once a day Long term 5493 p.a. BNF Secondary prophylaxis Amphotericin 50 mg twice a week Long term 610 p.a. BNF Cytomegalovirus Ganciclovir 1 g 3 times a day orally Long-term 21 968 BNF infection Ganciclovir 5 mg/kg once a day Long-term 12 358 BNF Prophylaxis Foscarnet 90 mg/kg once a day Long-term 18 148 BNF Cidofovir 5 mg/kg/14 days Long-term 29 071(c) Cytomegalovirus Ganciclovir 5 mg/kg twice a day 14 days 959 BNF infection Foscarnet 90 mg/kg twice a day 14 days 1160 BNF Treatment Cidofovir 5 mg/kg once a week 14 days 2236 (c) Herpes simplex Simplex: Aciclovir 200 mg 5 times a day 05 days 45.82(d) BNF and zoster Zoster: Aciclovir 800 mg 5 times a day 07 days 170(d) BNF Encephalitis: Aciclovir 10 mg/kg IV 3 times a day 10 days 1283(d) BNF Kaposi sarcoma Bleomycin 15 units and vincristine 2mg 1 cycle 25.84 BNF every three weeks. 33.58 BNF

Mycobacterium avium Azithromycin 1.25 g once a week (American dose 1.2 g) Long-term 923 p.a. BNF complex disease Clarithromycin 500 mg twice a day Long-term 1860 p.a. BNF Prophylaxis Rifabutin 300 mg once a day Long-term 3176 p.a. BNF Mycobacterium avium Clarithromycin 500 mg twice a day Long-term 1860 p.a. BNF complex disease + ethambutol 15 mg/kg once a day Long-term 34.68 p.a. IDPIG Treatment +/- rifabutin 450 mg once a day Long-term 4764 p.a. BNF Mycobacterium Isoniazid 300 mg daily 1 year 5.15 p.a. IDPIG tuberculosis Prophylaxis Mycobacterium Rifampicin 600 mg once a day 6 months Combined IDPIG tuberculosis Isoniazid 300 mg once a day 6 months 22.72 + Treatment Pyrazinamide 2 g once a day 2 months 11.11/course IDPIG Pneumocystis carinii Trimethoprim-sulfamethoxazole 960 mg once a day Long-term 11.39 p.a. IDPIG pneumonia Dapsone 100 mg a day Long-term 3.58 p.a. IDPIG Prophylaxis Dapsone 100 mg a day and pyrimethamine 25 mg Long-term 10.83 p.a. IDPIG three times a week Pneumocystis carinii Trimethoprim-sulfamethoxazole 90 mg/kg/day 21 days PO 3.93 IDPIG pneumonia IV: 611 BNF Treatment Clindamycin 600 mg four times a day 21 days PO 253 BNF and primaquine 15 mg once a day IV 1370 BNF PO 0.11 IDPIG

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October 1998 HIV-related opportunistic diseases: UNAIDS Technical Update Background

Table 2. (continued) Opportunistic Drug and dose Duration Cost of treatment (in $) Source (b) disease course or per-year cost (a)

Toxoplasmosis Sulfadiazine 2 g three times a day plus 6 weeks 217 BNF Treatment pyrimethamine 200 mg in divided 6 weeks 4.19 IDPIG doses then 50 mg daily and calcium 6 weeks 244 BNF folinate 15 mg daily (all oral) Clindamycin 600 mg orally four times 6 weeks 507+ BNF a day plus pyrimethamine and calcium 4.19 + folinate as above 244

Toxoplasmosis Sulfadiazine 1 g three times a day plus Long-term 944 p.a.+ BNF Secondary pyrimethamine 25 mg once a day and Long-term 16.97 p.a.+ IDPIG prophylaxis calcium folinate 15 mg once a day Long-term 2125 p.a. BNF Clindamycin 450 mg three times a day Long-term 4411 p.a.+ BNF and pyrimethamine and calcium 16.97 p.a.+ folinate as above 2125 p.a.

(a) PO—orally; IV—intravenously; p.a. per annum (b) Sources: IDPIG: International Drug Price Indicator Guide 1996, and BNF: British National Formulary Number 33 (March 1997) (c) Middlesex Hospital Price (recently released medication not yet in the BNF) (d) Aciclovir prices given are for branded products, reduced generic prices not in the BNF yet Doses calculated for an average 60 kg patient. If it is possible for intravenous vials to be used more than once or the reconstituted solution kept, doses have been calculated as the number of milligrams for the treatment course, and then converted into the number of vials (e.g. ganciclovir). When this is not possible, the number of vials for each dose has been calculated (e.g. amphotericin 60 mg would require 2 x 50 mg vials/day).

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HIV-related opportunistic diseases: UNAIDS Technical Update October 1998 The Challenges

Lack of advocacy and malignancies can be classified • Which regimens are available (somewhat arbitrarily) in three levels: to treat or prevent the conditions Because of the large variety of of interest, and at what cost? conditions related to HIV and the • Minimal: diagnosis can be made by number of care options, prophylaxis observation of symptoms or use of a • What are the non-drug costs of and management of opportunistic simple microscope; diagnostic, treat- dealing with opportunistic diseases diseases (including their diagnosis, ment and palliative procedures are (such as medical staff time, purchase treatment and palliation) is a difficult non-invasive; follow-up of patients and operation of diagnostic equip- issue to advocate for. Patients and does not require highly trained staff. ment, storage and transportation their families may enthusiastically Relatively little investment in equip- of drugs, etc.)? lobby for access to a particular ment is required. Successful diagnosis, The main challenge of choosing drug they have heard about. treatment and palliation (including for between interventions is to alleviate However, it is harder to for them terminal patients) chiefly require that the morbidity and suffering of to inform themselves sufficiently staff have sufficient knowledge and those in need while not exceeding to advocate in an effective way experience to recognize symptoms the financial and technical for a full “package” of equipment, and prescribe drugs that are easily capabilities of the health system. services, laboratory materials, stored, along with equipment for testing kits and staff training simple microscope work. Home-based Unfortunately, these choices often needed to deal with the full range care and community health initiatives need to be made without the help of opportunistic diseases. can be very effective in delivering of formal cost-benefit and cost- Representative organizations treatment and follow-up. Examples effectiveness analyses. This is partly may have the same problem of are oral candidiasis and pulmonary because, as described above, the insufficient knowledge, or they tuberculosis, herpes, and cryptococcal information needed to calculate may have too many other priority meningitis. costs is difficult to collect, but also because benefits other than short- issues to focus on this highly technical • Medium: diagnosis requires X-ray term improvements in quality one. Even medical personnel who, equipment or culture facilities, while of life are not well understood on a technical level, have a clear diagnostic and treatment procedures or easily quantified. For example, understanding of what is needed, require trained staff and well run it has been demonstrated that often do not have the means or laboratories. Significant investment prophylaxis of MAC with azithromycin motivation to turn this knowledge in equipment and ongoing operating can lengthen survival, but it is still into effective advocacy. costs are required. Examples not clear exactly how much life are extra-pulmonary tuberculosis, In some places, it is difficult or expectancy is lengthened with it. dangerous for people living with cryptosporidiosis-isosporiasis, PCP HIV to carry out their own advocacy and Kaposi sarcoma. The challenge of fairness openly, or for organizations to do • Advanced: diagnosis requirements Given the lack of complete epidemiol- it on their behalf. include endoscopy and CT scanning; ogical data in many regions and diagnosis and treatment require Lack of infrastructure the difficulties of formal cost-benefit highly trained and specialized staff; and cost-effectiveness analysis, Effective intervention against investment in equipment and operating the process of choosing which opportunistic diseases requires not costs is high; patient follow-up may interventions merit public funding only the appropriate drug or other be complex. Examples include toxo- is frequently forced into less medicament for a given medical plasmosis, MAC disease and CMV. methodologically solid—and more condition, but also the infrastructure political—calculations than most necessary to diagnose the condition, As one moves from level to level, health administrators would like. costs and training requirements monitor the intervention, and counsel This brings forward the additional patients. As well, use of drugs and increase dramatically. challenge of ensuring equity and tests must be supported by proper non-discrimination in the decision- Lack of information making process, and re-emphasizes storage, handling and administrative for decision-making procedures. (For a more detailed the need for informed advocacy. discussion of HIV-related drugs, To estimate which interventions and In places where resources are very see the Technical Update on Access what supporting infrastructure are scarce, priority should be given to to Drugs. Also relevant to this required to handle HIV-related health needs shared by most or all discussion is the Technical Update opportunistic infections and malignan- of the population, including those on HIV Testing Methods.) cies, decision makers need to know: who are HIV-infected. Examples are drugs to relieve pain in terminal As can be seen in Table 1, the infra- • What are the incidence rates of patients and to treat or prevent TB. structure required to prevent, diagnose the HIV-related conditions in the and manage opportunistic diseases area under their responsibility?

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October 1998 HIV-related opportunistic diseases: UNAIDS Technical Update The Responses

A complete response to the needs managed effectively through home- and coccidioidomycosis. All have created by HIV-related opportunistic based care. Most opportunistic very high treatment and prophylaxis diseases requires a variety of diseases require Toxoplasmosis costs. Governments should assess stakeholders to play their part. diagnosis and treatment of a which of these diseases are common On the one hand, people infected complexity beyond the capabilities in their population, and then decide with or affected by HIV must of most community-based groups whether subsidizing the available become aware of (and believe in) and NGOs. therapies is warranted. In many the possibilities for managing cases the only affordable approach opportunistic diseases if they are Priorities for public spending is to make available palliative to advocate for them. On the drugs that alleviate the suffering When faced with limited resources, other hand, health systems must caused by these conditions. as is the case for most health-care be prepared to make decisions systems, the best framework for about what interventions can and decision making is one that takes should be offered. In between, into account both the costs and the NGOs and community-based “spinoff” value of interventions for organizations can have a strong HIV-related opportunistic diseases. role to play both in advocacy and The term “spinoff” means that delivery of care. the framework must not only value Preventing the benefits of a given intervention opportunistic diseases for individual HIV-infected patients, but also the benefits for other Interventions that prevent the people—including those not occurrence of opportunistic infected with HIV. diseases can result in significant The clearest example of a high- gains in life expectancy and quality priority public intervention against of life among people living with opportunistic infection is probably HIV. Two useful sources for those the diagnosis, treatment and wishing more information on this prevention of tuberculosis. Even important subject are mentioned without exact information on HIV in the Selected Key Materials. In prevalence or the cost-benefit , the book Prise en charge ratios of these interventions in des personnes atteintes par le VIH a given setting, their overall value (Care for people with HIV) is to society can be accepted as high widely distributed to physicians on several counts: and presents a great deal of practical information on the subject. • they benefit people affected by In the , guidelines on or at risk from two epidemics: prevention of opportunistic diseases HIV/AIDS and TB; are jointly published and updated • they are proven effective; by the US Public Health Service • both the drug costs and (USPHS) and the Infectious Diseases associated costs are relatively Society of America (IDSA). These low given the number of people guidelines are also found on the reached by the intervention. Internet at http://www.thebody. com/cdcoiguide/guidelines1.html. Even in societies with “minimal” resources and facilities, a basic Mobilizing communities package of palliative care should be available for persons living with HIV/ In a variety of settings around the AIDS, including terminal patients. world, community-based groups and NGOs are working to provide For conditions that can be treated home-based care for people with but only at a very high cost, the HIV/AIDS. However, it should be decision to be made is more realized that only a few controversial. Examples are CMV, opportunistic diseases and MAC, fungal infections such as symptoms such as oropharyngeal cryptococcal meningitis (CRM), and vaginal candidiasis or herpes penicilliosis and rarer systemic zoster and herpes simplex can be mycoses such as histoplasmosis

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HIV-related opportunistic diseases: UNAIDS Technical Update October 1998 10

October 1998 HIV-related opportunistic diseases: UNAIDS Technical Update 11

HIV-related opportunistic diseases: UNAIDS Technical Update October 1998 Selected Key Materials

Dormont PJ (ed). Prise en charge des exposure. A version specific to Latin WHO Policy Statement on Preventive personnes atteintes par le VIH, 1996 America and the Caribbean has Therapy against Tuberculosis in edition. Paris: Flammarion, 1996. been published in Spanish. People Living with HIV. Geneva: This is a practical, compre-hensive WHO, August 1998. guide to management of HIV, Kaplan JE et al. Preventing Recommendations to governments published with the support of the opportunistic diseases in human based on a meeting of regional French Ministry of Labour and Social virus-infected experts, including discussion of cost- Services. It is widely distributed to persons: implications for the benefit and cost-efficacy. physicians in France. developing world. American Journal of Tropical Medicine and Hygiene Marco M et al. The OI Report: Steward GJ (ed). Managing HIV. 1996; 55(1):1–11. This discusses A Critical View of the Treatment and Sydney: The Australasian Medical how the USPHS/IDSA Guidelines Prophylaxis of HIV-related Publishing Company, 1996. can/should be adapted to fit Opportunistic Infections (version 2.0) Part 5 of this book provides a developing country needs. New York: The Treatment Action comprehensive overview of how HIV- Group (TAG), 1998. related opportunistic diseases should and HIV: in gridlock. This report discusses opportunistic be diagnosed and treated. Geneva: WHO/UNAIDS, 1998 infections since development (WHO/CTD/LEISH/98.9/UNAIDS). of protease inhibitors. Includes U.S. Public Health Service (USPHS), This document is aimed to help chapters on bacterial infections Infectious Diseases Society of decision-makers shape and prioritize and AIDS-related tuberculosis. America (IDSA). Guidelines for strategies to deal with the growing the Prevention of Opportunistic threat of leishmania/HIV co- Van der Horst CM et al. Treatment of Diseases in Persons Infected With infection. cryptococcal meningitis associated Human Immunodeficiency Virus: with the acquired immunodeficiency A Summary. Available on the Internet Management Sciences for Health. syndrome. New England Journal at http://www.thebody. com/cdc/ Managing Drug Supply: The Selection, of Medicine, 1997, 337:15–21. The oiguide/guidelines1.html. This Procurement, Distribution, and Use of authors report on a trial testing overview of prevention of HIV- Pharmaceuticals (2nd edition). Boston: treatment of AIDS-related crypto- related opportunistic infections Kumarian Press, 1998. coccal meningitis using amphotericin B includes therapeutic recommend- Comprehensive manual with plus flucytosine. The results include ations and guidance on practical case studies on all aspects increased rate of ownership, hygienic practices, of drug selection, procurement, sterilization and decreased mortality. and avoidance of environmental distribution and use.

© Joint United Nations Programme on HIV/AIDS 1998. All rights reserved. This publication may be freely reviewed, quoted, reproduced or translated, in part or in full, provided the source is acknowledged. It may not be sold or used in conjunction with commercial purposes without prior written approval from UNAIDS (contact: UNAIDS Information Centre, Geneva–see page 2.). The views expressed in documents by named authors are solely the responsibility of those authors. The designations employed and the presentation of the material in this work do not imply the expression of any opinion whatsoever on the part of UNAIDS concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers and boundaries. The mention of specific companies or of certain manufacturers' products do not imply that they are endorsed or recommended by UNAIDS in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. 12

October 1998 HIV-related opportunistic diseases: UNAIDS Technical Update