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 pathogens 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 tuberculosis (TB, caused by Mycobacterium solutions (Technical Update); case tuberculosis), Mycobacterium avium complex disease (MAC), bacterial studies from around the world (Best pneumonia and septicaemia (“blood poisoning”) Practice Case Studies); a set of • protozoal diseases such as Pneumocystis carinii pneumonia (PCP), presentation graphics; and a listing toxoplasmosis, microsporidiosis, cryptosporidiosis, isosporiasis 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 cytomegalovirus (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, Switzerland. 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. 2 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 immune system. 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 Africa, 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 encephalitis, 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 retinitis. 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 3 HIV-related opportunistic