Post on 31-Mar-2015
Dr Steve WelchBirmingham Heartlands Hospital
3rd Annual Conference of the Children’s HIV Association‘Young People and HIV: Back to the Future’
Friday 15 May, The Bridgewater Hall, Manchester
Other opportunistic infections
Steve WelchHeartlands Hospital, Birmingham
3rd Annual CHIVA ConferenceManchester, 15th May 2009
Other opportunistic infections
• Cases
• When to start ART in OI?
• Effect of OI on HIV – CMV
• Areas not covered - guidance
Case
• 15 yo
• Recurrent pneumonia and then PcP
• Started kivexa, efavirenz
• Good VL, CD4 response
• VL undetectable for more than 1 year
• CD4 400
Why?
• Not adherent to medication?
• On wrong medication?
• Should still be on septrin?
• Has developed resistance to penicillin?
• Susceptible because of rheumatic fever?
• That’s what happens
• Blame National Express
Effect of HAART on bacterial infections in children with HIV
0
2
4
6
8
10
12
Pneumonia Bacteraemia
Ep
iso
des
/ 1
00 c
hil
d y
ears
HIV pre-HAART
HIV on HAART
Effect of HAART on bacterial infections in children with HIV
0
2
4
6
8
10
12
Pneumonia Bacteraemia
Ep
iso
des
/ 1
00 c
hil
d y
ears
HIV pre-HAART
HIV on HAART
HIV uninfected
Effect of HAART on bacterial infections in children with HIV
1
10
100
1000
10000
100000
Pneumonia Bacteraemia
Ep
iso
des
/ 1
00,0
00 c
hil
d y
ears
HIV pre-HAART
HIV on HAART
HIV uninfected
Prevention of bacterial disease
• HAART
• Antibiotic prophylaxis
• Immunisation
• Immunoglobulins
Why?
• Not adherent to medication?
• On wrong medication?
• Should still be on septrin?
• Has developed resistance to penicillin?
• Susceptible because of rheumatic fever?
• That’s what happens
• Blame National Express
• 15yr old Zimbabwean girl
• In UK 2005
• Unusual rash 2yrs• Nodular, pruritic• Biopsy : nodular prurigo• Hiv 1positive (mar 2006)
• Further work up– Low CD4 4%(19)– Lymphadenopathy– Viral load : 276000c/ml
• Drug • Kivexa/efavirenz/septrin (April 2006)• Kaletra /lamivudine/abacavir(Nov 2006)• Lamivudine (dec 2006)• Kaletra/Truvada (from January 2007)
• Adherence issues• Poor drug compliance / DNA• PEG inserted Oct 2007• Poor response to treatment/ viral resistance• Counselling
0.00E+00
1.00E+05
2.00E+05
3.00E+05
4.00E+05
5.00E+05
6.00E+05
04/04/06 04/04/07 04/04/08
vira
l lo
ad
0
20
40
60
80
100
120
140
cd4 vl
CD4
Should she be on MAI prophylaxis?
MAI prophylaxis
• Evidence that it works:
• 90-95% reduction in incidence in adults by prophylaxis or HAART
MAI prophylaxis
• Recommended by US guidelines
• What are suitable agents?
• In what circumstances?
MAI prophylaxis
• What are suitable agents?– Azithromycin– Clarithromycin– Rifabutin– Rifampicin– Clofazamine
MAI prophylaxis
• In what circumstances?
• CD4 < 50
• At new diagnosis
• After starting treatment until immune reconstitution
• If not on treatment
• If not adherent to treatment
Case
• 13 yo from Zambia• Weight loss, chronic cough• Bronchiectasis• Hi influenzae, pneumococcus• VL 10 million• CD4 2 (<1%)• HLA B*5701 negative• No significant resistance mutations• Now has secondary fevers• ALT 250
When should he start HAART?
• Now
• When fever abates and LFT’s back down
• When fever abates
• When LFT’s back down
• When completely stable
• Should have started before having RT and HLA result back
CROI 2008 Abstract142Immediate vs Deferred ART in the Setting of Acute AIDS-related Opportunistic
Infection: Final Results of a Randomized Strategy Trial, ACTG A5164Andrew Zolopa*1, J Andersen2, L Komarow2, A Sanchez3, C Suckow4, I Sanne5, E
Hogg6, W Powderly7, and ACTG A5164 Study Team
• 282 patients randomised to immediate (<14 days) or deferred (>4 weeks) ART• PcP 63%• Cryptococcal meningitis 13%• Pneumonia 10%
• No progression and VL<50 48 v 45%
• BUT 14 v 24% progression to AIDS or death, faster time to undetectable VL and VD4 >50, >100
CROI 2009: 36cLBEarly vs Delayed ART in the Treatment of Cryptococcal Meningitis in Africa
Azure Makadzange*1,2, C Ndhlovu2, K Takarinda2, M Reid2, M Kurangwa2,Vhikwasha2,
and J Hakim2 • 54 patients randomised to early (<72 hours) v late (10 weeks) ART in
cryptococcal meningitis:
• Mortality 82% v 37%
Case
• 7 yo from Zimbabwe
• VL 2 million
• CD4 10 (1%)
• Presents with allergic reaction to septrin
• Ongoing fevers and symptoms
34
35
36
37
38
39
40
41
What is the likely diagnosis?
• Septrin allergy• Bacterial infection• Common respiratory virus• TB• Atypical Mycobacteria• PcP• Candida• Cryptococcus• Other
What are alternatives to septrin?
What are alternatives to septrin?
• Dapsone
• Atovaquone
• Pentamidine
• Fansidar (Pyrimethamine-sulfadoxine)
• 4-month old girl
• Birthweight 4.1 kg (75th centile)
• Now 5.2 kg (2nd centile)
• Respiratory distress, diagnosed PcP
• Good response to ART. CD4 2300 (35%)
• When can she stop septrin?
AIDS 2005
Stopping PcP prophylaxis
• Cd4>15%, 200 for 6 months
• Cd4> 15%, 500 below age 5
• Not in first 12-18 months of life?
What not covered?
• Immunisation
• Guideline
• Other OIs - cryptosporidia
• Varicella