- Cryptococcal Infection
- Mycobacterium avium complex
- Pneumocystis carinii pneumonia
This publication is intended as a general guide to managing opportunistic infections (OIs). It can't substitute for a detailed discussion of each infection. Anyone dealing with one or more of these infections should consult with their doctor.
Preventing and treating OIs is not an exact science. It often requires some complex trial-and-error to figure out the best regimen for a person. If standard drugs fail, it may be necessary to try different experimental drugs.
There's often a gap between the drugs prescribed by doctors with large HIV practices and those prescribed by doctors with less experience. At times, people may need to bring experimental drugs to the attention of their providers who haven't prescribed them before or do not know of their expanded access programs.
It can be challenging for some people to get the medications mentioned in this publication. Some are approved specifically for HIV disease; others are not approved for HIV but still may be prescribed for it. Most are available through clinical studies, expanded access or compassionate use programs.
However, not everyone has close or easy access to these programs or studies. Also, how individuals get prescription drugs may vary widely according to whether their healthcare is provided by private insurance or by government programs. Working closely with your doctor or finding an experienced treatment advocate may help some people access these drugs.
As more drugs become available for managing OIs, an ongoing concern is the possibility of more drug interactions. Many drugs are broken down in the liver by an enzyme called P450 cytochrome. Drugs that use this enzyme can greatly alter the blood levels of other drugs.
Drugs metabolized in the liver include clarithromycin, rifabutin, itraconazole, nevirapine, efavirenz, delavirdine, saquinavir, ritonavir, indinavir and nelfinavir. It is very important for people who take these drugs, especially those with chronic liver disease, to monitor drug side effects and efficacy. It's also important, if possible, to obtain specific drug levels in blood so that doses can be adjusted if necessary.
For a complete list of interactions with HIV drugs, read Project Inform's publication, "Drug Interactions."
Candidiasis is a fungal infection that can infect the whole body but often occurs in the mouth and vagina.
|Symptoms||White patches on gums, tongue or lining of mouth, pain, difficulty in swallowing and loss of appetite. Can also cause vaginal irritation, itching, burning and thick white discharge.|
|Diagnosis||Usually by visual exam, smear or culture from biopsy.|
|Preventative Therapy (Prophylaxis)||Not currently recommended because current drugs effectively treat the disease, resistant Candida may develop and drug interactions may occur. However, studies show that continuous fluconazole use lowers the risk of developing Candidiasis. Pregnant women should not use preventive therapies, particularly azole drugs due to the risk of birth defects. Some dietary changes may help decrease risk or recurrence.|
Mild oral and vaginal Candidiasis may be treated with topical therapy like nystatin and clotrimazole. Moderate oral, vaginal and esophageal Candidiasis should be treated with pill forms of therapy such as fluconazole, itraconazole or ketoconazole which treat through the body (systemically).
Alternatives: IV amphotericin B or amphotericin B oral solution usually reserved for fluconazole resistant Candida.
|Maintenance Therapy||Not currently recommended for oral or vaginal Candidiasis for the same reasons as prophylaxis. If Candida recurs frequently and/or severely, then fluconazole or itraconazole should be considered. People with frequent recurrences of esophageal Candidiasis should consider fluconazole (100-200mg a day). Pregnant women should avoid azole drugs due to risk of birth defects.|
|For more information, read Project Inform's publications, "Oral Candidiasis" or "Vaginal Candidiasis."|
Cryptococcal infection is a fungus that primarily infects the brain.
|Symptoms||Headaches, nausea, fever, fatigue, altered mental status and irritability. Can also cause seizures, coughing, sweats and difficulty in breathing.|
|Diagnosis||Usually by spinal tap to test for antigen in cerebral spinal fluid.|
|Preventative Therapy (Prophylaxis)||Not currently recommended because of the low incidence of the disease, lack of proven benefit, possible drug interactions and resistance to antifungal drugs. However, if a need for preventing other fungal infections exists, then people with CD4+ cell counts below 50 should consider fluconazole (100-200mg daily). Prevention with fluconazole or itraconazole should not be started by pregnant women because of the low incidence of the disease and possible birth defects. Also, women who become pregnant should stop using azole drugs.|
Preferred: IV amphotericin B (0.7mg/kg daily) + flucytosine (25mg/kg 4 times a day) for 2 weeks then fluconazole (400mg daily) for 8 weeks.
Alternatives: IV amphotericin B (0.7mg/kg daily) for 2 weeks then fluconazole (400mg daily) for 8 weeks.
Other alternatives: Amphotericin B Colloidal Dispersion (ABCD); or Amphotericin B Lipid Complex (ABLC) may also be useful.
Everyone who has had cryptococcal disease should be on maintenance therapy for life.
Preferred: Fluconazole (200mg daily).
Pregnant women should avoid azole drugs; amphotericin B is the preferred therapy.
|Stopping Maintenance Therapy||Not currently recommended because of the few people studied.|
|For more information, read Project Inform's publication, "Cryptococcal Meningitis."|
Cytomegalovirus is a virus that infects the entire body.
Retinitis (in eye, retina): blurry vision or loss of central vision that can lead to blindness.
Retinitis: eye doctor (ophthalmology) exam.
|Preventative Therapy (Prophylaxis)|
People whose CD4+ cell counts are consistently below 50 and who are CMV-positive are at highest risk for CMV disease and should consider oral ganciclovir (1g three times a day).
Pregnant women should not take oral ganciclovir because of possible birth defects. Also, women who become pregnant should stop using oral ganciclovir.
|Stopping Preventive Therapy||It may be reasonable to consider stopping CMV preventive therapy for people with sustained CD4+ cell counts above 100-150 for 6 months or longer as a result of potent anti-HIV therapy.|
Retinitis preferred treatment: Ganciclovir implants + oral ganciclovir (1,000mg three times a day); IV ganciclovir (5mg/kg every 12 hours for 14-21 days); IV foscarnet (90mg/kg every 12 hours for 14-21 days); or oral valganciclovir (900mg twice a day for 21 days then 900mg once a day for 7 days).
Alternatives: IV cidofovir (5mg/kg once a week for 2 weeks) + probenecid or combination IV ganciclovir + IV foscarnet (as dosed above).
Esophagitis and colitis: IV ganciclovir or IV foscarnet for 3-6 weeks.
Retinitis preferred treatment: IV ganciclovir (5mg/kg once a day); IV foscarnet (90-120mg/kg once a day); or ganciclovir implants + oral ganciclovir or oral valganciclovir (900mg once a day).
Alternatives: IV cidofovir (5mg/kg once every 2 weeks) or IV ganciclovir + IV foscarnet (as dosed above).
Esophagitis and colitis: Maintenance therapy is controversial although it might be considered if the initial symptoms were severe.
Pregnant women should take maintenance therapy, and the choice of therapy should be individualized.
|Stopping Maintenance Therapy|
It may be reasonable for people with sustained CD4+ cell counts above 100-150 (at least 3-6 months) and sustained suppression of viral load to consider stopping CMV retinitis maintenance therapy.
Maintenance therapy should be restarted if CD4+ cell counts return to 50-100.
|For more information, read Project Inform's publication, "Cytomegalovirus."|
|Mycobacterium avium complex (MAC)|
MAC is a bacterial infection found in water, dust, soil and bird droppings.
|Symptoms||Persistent fever, night sweats, fatigue, weight loss, anemia, abdominal pain, dizziness, diarrhea and weakness.|
|Diagnosis||Culture from a sterile site such as blood, bone marrow or cerebral spinal fluid.|
|Preventative Therapy (Prophylaxis)|
People whose CD4+ cell counts stay consistently below 50 should start preventive therapy.
Preferred: Clarithromycin (500mg twice a day); or azithromycin (1,200mg once a week).
Alternative: Rifabutin (300mg once a day).
|Stopping Preventive Therapy||People with sustained CD4+ cells above 100 for 3-6 months and sustained viral load suppression may consider stopping preventive therapy.|
Preferred: Azithromycin (500-600mg once a day); or clarithromycin (500mg twice a day) + ethambutol (15mg/kg/day) + rifabutin (300mg once a day).
Alternative: Azithromycin or clarithromycin + ethambutol + rifabutin +/- ciprofloxacin (500-750mg twice a day) +/- IV amikacin (10-15mg/kg/day).
IV amikacin can be added for severe disease.
Higher doses of clarithromycin (1,000mg twice a day) may be linked with increased risk of death. Clofazimine may be associated with increased side effects and risk of death and it should not be used.
|Maintenance Therapy||Everyone who has had MAC should be on maintenance therapy with either clarithromycin (500mg twice a day) or azithromycin (500mg once a day) if it has been proven there is no resistance to either drug + ethambutol (15mg/kg once a day) +/- rifabutin (300mg once a day).|
|Stopping Maintenance Therapy||People with sustained CD4+ cells above 100 for 6-12 months as a result of potent anti-HIV therapy may consider stopping maintenance therapy.|
|For more information, read Project Inform's publication, "MAI/MAC."|
|Pneumocystis carinii pneumonia (PCP)|
Pneumocystis carinii pneumonia is a parasite that infects the lungs.
|Symptoms||Usually fever, cough and difficulty in breathing. Occasionally weight loss, night sweats and fatigue.|
|Diagnosis||X-ray, induced sputum or bronchoscopy.|
|Preventative Therapy (Prophylaxis)|
Indicated when CD4+ cell counts equal or are below 200 (some say <250), when lowest ever (nadir) CD4+ cell count is below 200, and/or if history of Candidiasis in the throat and/or unexplained persistent fever for over 2 weeks regardless of CD4+ cell counts.
Preferred: TMP/SMX (also called Bactrim or Septra; one single-strength tablet daily or one double-strength tablet daily or three times a week). A gradual increase in TMP/SMX dose may help reduce side effects.
Preferred alternative: If unable to tolerate TMP/SMX, then dapsone (100mg once a day); or dapsone (50mg once a day) + pyrimethamine (50mg once a week) + leucovorin (25mg once a week).
Other alternatives: Aerosol pentamidine (300mg once a month); atovaquone (1,500mg once a day); or IV pentamidine (300mg once a month).
|Stopping Preventive Therapy||May be able to stop if CD4+ cell counts remain above 200 for more than 12 weeks from using potent anti-HIV therapy.|
Preferred: TMP/SMX (2 double-strength tablets every 8 hours); or 5mg/kg TMP and 25mg/kg SMX intravenously every 8 hours.
Alternatives: Trimethoprim (320mg every 8 hours) + dapsone (100mg once a day); atovaquone (750mg twice a day); clindamycin (300-450mg every 6 hours) + primaquine (15-30mg once a day); or IV pentamidine (300mg once a day).
Other alternative: Trimetrexate (45mg/m2 once a day intravenously) + leucovorin (20mg/m2 every 6 hours) may also be useful.
Prednisone should be considered for people with acute illness (40mg every 12 hours for 5 days, then 40mg once a day for 5 days, then 20mg once a day for 11 days).
|Maintenance Therapy||Everyone who has had PCP should be on maintenance therapy. The choice is the same as those for primary preventive therapy.|
|Stopping Maintenance Therapy||Although it may be possible to stop maintenance therapy if CD4+ cell counts stay above 200, there are insufficient data to make a current recommendation.|
|For more information, read Project Inform's publications, "PCP Prevention" or "PCP Treatment."|