The Stalker Awaits—Opportunistic
Infections 101
by Enid Vázquez
An opportunist: someone
who takes advantage of you. Well, that’s what an opportunistic
infection is—one that waits until your immune system is weak
so it can prey on you. Specific microorganisms that normally
live in a peaceful co-existence can potentially overcome the
body when the immune system is failing. In fact, getting some
of these illnesses gives you an AIDS diagnosis.
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.”
PCP (Pneumocystis carinii
pneumonia)
Formally thought to be caused
by a parasite, but Pneumocystis carinii is now recognized
as a fungus. It’s present in almost all people since childhood.
PCP generally occurs when T-cells fall below 200.
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 if they now have more
than 200 T-cells for three to six months with HIV therapy.
Candidasis (thrush)
Usually the first OI to appear,
and certainly the most common. Although there’s a very low
mortality rate for thrush, its often painful oral presence
can lead to a decrease in eating and therefore, nutritional
intake, with the potential for escalating complications such
as wasting, which is life-threatening. Lots of sugar, alcohol,
caffeine and carbohydrates (like bread and pasta) promote
thrush. Stress and lack of rest encourages fungus growth.
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 with 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. Vagina 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).
Hepatitis C Virus (HCV)
A virus that infects the
liver. Now considered an OI because people with HIV are seven
times more likely to die from it than people who are HIV-negative.
[See “HCV/HIV co-infection”.]
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).
Tuberculosis (TB)
A disease of the lungs that
can spread to other organs. Risk of TB increases 100 times
with HIV infection. It generally occurs in HIV-positive people
when they have between 200 and 300 T-cells. Also, heavy drinkers,
injection drug users and people who are very underweight are
at higher risk.
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 was 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.
Human herpesvirus 8 (HHV-8)
The virus associated with
Kaposi’s sarcoma (KS). Kaposi’s sarcoma is a rare cancer that
is generally benign but sometimes disfiguring. It can cause
purplish or brownish marks on the skin and sometimes spreads
to cause disease in the organs. Most commonly occurs in men.
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 show less cases of KS,
but these drugs are not be recommended for prevention and
treatment at this time.
Cryptosporidiosis
Caused by the parasite cryptosporidium.
Difficult to control. May lead to rapid weight loss and severe
weakness. There is no standard treatment. Drugs being tested
for treatment include paromomycin (Humatin), azithromycin
(Zithromax), latrazuril and atovaquone (Mepron). Research
with the promising drug nitazoxanide was stopped after the
drug failed to win FDA approval. Also, bovine colostrum concentrate
(Sporidin-G) is being tested for controlling diarrhea caused
by crypto.
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 tollfree
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.
Cytomegalovirus (CMV)
Cytomegalovirus infection
can be acquired throughout life by direct contact with bodily
fluids. It is spread throughout childhood and later in adults
through sexual activity. Approximately 40 to 100% of the U.S.
adult population has been exposed to CMV. It primarily damages
eyesight (CMV retinitis) and can lead to blindness. May affect
other organs. CMV is a herpes virus, and thus lingers in your
body forever.
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.
Shingles
Caused by the varicella-zoster
virus (VZV, varicella means chickenpox and zoster means shingles).
Varicella-zoster is a herpes virus, so it’s with you forever.
Shingles is a painful condition of blisters and sores that
run along nerve paths, usually on one side of the body or
as a band around your middle. It may occur early in HIV disease.
Pain may persist after healing of skin lesions and may be
difficult to control. People with HIV experience many more
lesions. They are at greater risk of getting bacterial infections
on their sores (try to keep them clean and dry as much as
possible) and of a life-threatening spread to internal organs.
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.
Mycobacterium avium complex
(MAC)
Bacterial infection. Organisms
of the M. avium complex are common in food, water, and soil.
Almost everyone has the bacteria in their body.
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.
Lymphoma
Cancers involving white blood
cells. AIDS-related lymphoma is also called non-Hodgkin’s
Lymphoma (NHL).
Transmission: None.
Development of NHL is associated with Epstein-Barr virus,
longterm HIV infection, and genetic factors.
Symptoms: Swollen
lymph nodes, fever, night sweats, and weight loss.
Prevention: None.
Human Papilloma Virus
(HPV)
A very common sexually transmitted
virus that causes genital warts. Tends to be much more aggressive
in people with HIV. Can lead to cancer of the cervix (the
lower part of the uterus, leading into the vagina), especially
the virus strains HVP-16 and HPV-18. May also cause infertility.
Prevention: As
with herpes, condoms do not offer complete protection. To
stave off 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.
For more information
There’s more useful
information in the OI guidelines, published by the U.S. Public
Health Service and the Infectious Diseases Society of America,
including additional OIs, as well as information regarding
pets, travel, children and pregnancy. Call 1-800-448-0440
for a free copy or visit www.hivatis.org.
Always confer with your healthcare
provider before initiating or discontinuing any medication.
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