The problem today with opportunistic infections (OIs) is that so many people, especially people of color, are unaware of their HIV infection until they are hit with a serious disease. The U.S. Centers for Disease Control and Prevention (CDC) estimates that one out of four people with HIV in this country are unaware of their infection. The good news is that many OIs can be averted with prevention medicines, also called "prophylaxis."
Transmission: None. Exposure to someone with PCP will not trigger PCP in you.
Symptoms: Persistent dry cough (more than two weeks), shortness of breath or difficulty breathing on exertion, fevers, chills, sweats, and increasing fatigue. Cough may produce thin, clear mucus.
Prevention: Everyone with less than 200 T-cells should take prophylaxis (preventative medicine), as well as people with a prior history of PCP and those with thrush and persistent fevers. Fortunately, prevention medications are very inexpensive. Taken at night, prophylaxis can help with the sun sensitivity often caused by TMP-SMX (brand names Bactrim, Septra). The daily double-strength medication also protects against toxoplasmosis and some common respiratory bacterial infections. People with severe reactions can discontinue until they get better, then go back on at lower doses until their tolerance builds up. People who once had less than 200 T-cells may discontinue prophylaxis when they have more than 200 T-cells for three to six months with HIV therapy.
Transmission: None, although very rare cases of person-to-person transmission have been documented.
Symptoms: Causes fuzzy white or pinkish-red patches in the mouth and esophagus (feeding tube down the throat). Burning, altered taste sensation (especially when eating spicy or sweet food), and difficulty swallowing and eating. Also, because food can get stuck in the esophagus, people with candida esophagitis have chest discomfort when eating. Thick white discharge in the vagina, plus itchiness, rash, and burning sensation.
Prevention: Not recommended due to the low mortality rate of the disease, the cost of prophylaxis and the potential for developing resistance to it. Also, treatment is usually effective if thrush does develop. Interventions include smoking cessation, good oral hygiene, and avoiding both unnecessary antibiotics and use of corticosteroids. Additionally, diabetics tend to have thrush because of its tendency to live off sugar, so if you're diabetic, watch your sugar intake and keep blood glucose (sugar) levels under control. Vaginal thrush is associated with high-estrogen oral contraceptives, pregnancy, diabetes, tight-fitting pants, deodorant tampons and deodorant sprays, douches, intestinal parasites, sexually transmitted diseases, and antibiotics (ironically, some of which are used to treat other vaginal conditions).
Transmission: Blood-to-blood contact, including the sharing of straws for snorting cocaine, and sexual contact. Injection drug users should avoid sharing equipment, including water and cookers, or sterilize the equipment that they can clean. Estimated to be present in 85% of current or former injection drug users. Can be transmitted at birth from an infected mother. May possibly be transmitted through unprotected sex, infected instruments during tattooing or body piercing, and by using the razor or toothbrush of an infected person.
Symptoms: May cause no symptoms until liver damage occurs. Then causes flu-like symptoms such as nausea, fatigue, and headache.
Prevention: Infusion during labor. Bleaching syringes. Syringe exchange programs. Use of either new needles or of an autoclave for sterilizing needles by tattoo artists and body piercers. People with HCV should be vaccinated against hepatitis A. They should also avoid "excessive amounts of alcohol" to prevent serious liver damage, although it is unclear if even 12 ounces of beer a week can increase the risk of cirrhosis (scarring of the liver).
Transmission: Through the air by coughing and sneezing.
Symptoms: Productive coughing (producing phlegm), chest pain, fever, fatigue, night sweats, weight loss and the spitting of blood.
Prevention: Upon HIV diagnosis, undergo a tuberculin skin test (TST). If positive, or if you have symptoms, undergo a chest radiography and doctor's evaluation to look for active TB. If no TB is found but the TST is positive, take preventative medicine for either two months or nine months. (See the OI guidelines for TB drugs that cannot be taken with HIV antivirals.) Also avoid places thought to be high-risk, such as volunteer work or employment in prisons, homeless shelters and health clinics (believe it or not), but always consult your healthcare provider.
Transmission: Seems to be sexually transmitted, including during deep kissing. Research has found greater amounts of the virus in saliva than in semen.
Prevention: HAART that successfully lowers viral load has been shown to reduce progression of KS, including development of new lesions. People who've used either Cytovene (ganciclovir) or Famvir (famciclovir) to treat CMV (cytomegalovirus) also have fewer cases of KS, but these drugs are not recommended for prevention and treatment at this time.
Transmission: Contaminated water. Oral/anal contact. Raw oysters. Failure to wash hands (after gardening, playing with pets, changing diapers, using the bathroom, etc.).
Symptoms: Severe persistent diarrhea. Also, nausea, vomiting, and stomach cramps.
Prevention: Bringing tap water to a rolling boil for three minutes kills the parasite. Water filters should be those that use distillation or reverse osmosis, those labeled as absolute (not "nominal") 1-µm filters, and those labeled as meeting NSF #53 for cyst removal. Not all bottled waters meet these standards; call the toll-free number on the bottle to check. Don't forget to use safe water for ice cubes and be careful with drinks made with tap water when you go out.
Transmission: Sexually transmitted. Found in saliva, semen, respiratory excretions and urine. Presence is higher among positive men who have sex with men than in other groups. Also, CMV can remain dormant in the body (latent) and in immunocompromised people, CMV can be reactivated, producing disease in various organs, such as the eye.
Symptoms: Look out for floaters (spots in your vision), especially if increasing over time. Also watch for blurring when reading.
Prevention: A new drug has become FDA-approved. It is a version of ganciclovir (Cytovene) and is called valganciclovir (Valcyte). It should be considered for people with less than 50 T-cells who are CMV positive. Weigh the possibility of neutropenia (decreased white blood cells), anemia (especially if already taking Retrovir or hydroxyurea), conflicting reports of efficacy, lack of proven survival benefit, and risk of developing resistance to ganciclovir. Also, the drug is expensive and dose is an inconvenient 12 capsules a day (although the oral form of ganciclovir is a vast improvement over the old days of daily intravenous infusions). Do not use acyclovir (Zovirax) or valacyclovir (Valtrex). People whose T-cells have increased to more than 100 for three to six months with therapy, plus have a drop in their viral load, can stop taking CMV prophylaxis, but those with CMV disease should first check with their eye doctor.
Transmission: Extremely contagious, through direct contact with skin lesions or through airborne droplets from the lesions getting into mucosal surfaces (nasal sinuses, lining of the mouth, etc.). VZV also seems to enter through the skin surfaces of sensory nerves and then travel down into the nerve fibers. Infectivity usually begins a couple of days before outbreak and continues until all sores are crusted over. For people with HIV, this can take several weeks.
Prevention: No recommendations as yet.
Transmission: Not spread person to person.
Symptoms: Recurring fevers, fatigue, swollen glands, night sweats, diarrhea, and severe weight loss.
Prevention: Should be taken by people with less than 50 T-cells. Various medications are available. While it seems that people whose T-cells have increased to more than 100 for three to six months under therapy, with decreased viral loads, can stop prophylaxis without getting MAC, stopping prophylaxis is not yet recommended due to the insufficient number of people having been evaluated.
Transmission: None. Development of NHL is associated with Epstein-Barr virus, long-term HIV infection, and genetic factors.
Symptoms: Swollen lymph nodes, fever, night sweats, and weight loss.
Prevention: As with herpes, condoms do not offer complete protection. To watch out for cancer, women should obtain two Pap smears during the first year after infection and if results are normal, a yearly Pap after that. HIV-positive men who have sex with men are at increased risk of anal cancer, but routine screening with an anal Pap smear is not yet recommended by the guidelines. Wouldn't hurt -- it's a little cotton swab that can pick up trouble. It's also been found to be cost-effective (medical jargon for "benefits are worth the price"). People with HIV, whether male or female, whether they have anal sex or not, are at greater risk for anal cancer.
Always confer with your healthcare provider before initiating or discontinuing any medication.
Take Home PointContinue to monitor your T-cells, even if you're not on therapy. You're more at risk for certain infections when your T-cells are at certain levels. If you can't, or don't want to take HIV meds, you can still take OI prevention medications (prophylaxis) to keep you healthier and out of the hospital.
What's HAART Got to Do with It?Opportunistic infections have gone down as much as 85% in developed countries following the introduction of HAART (highly active antiretroviral therapy, the so-called "drug regimen"). According to the OI guidelines, "HAART is the most effective approach to preventing OIs and should be considered for all HIV-infected person who qualify for such therapy. . . . In addition, [prevention] against specific OIs continues to provide survival benefits even among person who are receiving HAART." [See "Adherence 101" and "To Start or not to Start?"]