1. Connie van Marrewijk IDA Foundation Product Selection for Opportunistic Infections

2. Opportunistic Infections People with advanced HIV infection are vulnerable to infections or malignancies that are called 'opportunistic infections' because they take advantage of the opportunity offered by a weakened immune system. “HIV does not kill, opportunistic infections do!”

3. Sequential loss of CD4 cells accounts for progressive immunosuppression

5. Probable pathogens based on CD4 count CD4 count > 200/mm3Pulmonary Tuberculosis Streptococcus pneumonia Herpes Zoster Vaginal candidiasis 100 – 200 mm3Oral candidiasis (thrush) Progressive multifocal leukoencephalopathy Pneumocystis jiroveci (carinii)

6. Probable pathogens based on CD4 count CD4 count 50 – 100 mm3Disseminated herpes simplex Toxoplasmosis encephalitis Cryptococcal meningitis Extrapulmonary tuberculosis Cryptosporidiosis Candida esophagitis Penicilliosis < 50 mm3Disemminated cytomegalovirus Disseminated mycobacterium avium

7. Frequency of OI (US) Male(%)Female(%) Pneumocystis carinii pneumonia35.733.7 Kaposi sarcoma12.51.3 Esophageal candidiasis11.919.9 Wasting syndrome7.89.0 Mycobacterium avium complex6.46.8 Pulmonary tuberculosis4.86.6 Extrapulmonary cryptococcosis4.33.1 HIV encephalopathy4.23.2 Cytomegalovirus retinitis3.83.4 Cytomegalovirus disease3.42.1 Toxoplasmosis of brain2.93.8 Chronic cryptosporidiosis2.91.5 Recurrent pneumonia2.37.1 Extrapulmonary tuberculosis2.03.0 Chronic herpes simplex2.04.1

8. Fungal Infections Candidiasis (oral, vaginal or esophageal) Coccidiodomycosis (lung problems) Cryptococcal Meningitis (yeast like fungus) Histoplasmosis (lung and other organs)

9. Thrush in an HIV patient

10. Antifungal agents Amphotericin-B (only parenteral) Fluconazole (oral) Itraconazole (oral) Ketoconazole (oral) Clotrimazole (cream, vaginal tabs) Miconazole (oral bucal tabs)

11. Protozoal Infections Pneumocystis Carinii Pneumonia (PCP) most frequently identified serious OI most common; profylaxis with co-trimoxazole) Cryptosporidiosis (GI tract) Isosporiasis (GI tract) Micosporidiosis (GI tract) Toxoplasmosis (brain)

12. Cerebral toxoplasmosis - Toxoplasma Gondii Seizures, hemiparesis, visual problems Headache: severe, localized Fever, confusion Treatment: acute phase -Pyrimethamine 100-200 mg loading dose then 50-100 mg+ folinic acid + sulfadiazine OR: Co-trimoxazole for 4 weeks

13. Bacterial Infections Bacterial pneumonia Streptococcus pneumonia Salmonella septicaemia (spread from GI tract) Pulmonary tuberculosis HIV changes presentation more extra-pulmonary, more smear Mycobacterium Avium Complex

14. Type of TB in function of CD4 count

15. Antibacterial and antiprotozoal agents Azithromycine, Clarithromycine, Erythromycin Ceftriaxone, Cefixime Amoxicillin Ciprofloxacin, Ofloxacin, Levofloxacin Co-trimoxazole ( TMP-SMX) Clindamycine Gentamicine Tinidazole, Metronidazole Pentamidine

16. Viral Infections Cytomegalovirus (CMV) herpes type CMV retinitis in eye can lead to blindnes Hepatitis (hepatitis B) Herpes Simplex (eye, lips) Genital Herpes Herpes Zoster Human Pappilloma Virus (HPV-related anogenital abnormalities)

17. Cytomegalovirus in eye - blindness

18. Antiviral agents Aciclovir Oral IV Ganciclovir, IV Valganciclovir Foscarnet

19. Malignancies Kaposi's sarcoma Kaposi's sarcoma, is a type of cancer. Lesions appear as red or purple maculae or nodules CNS lymphoma Central nervous system (CNS) lymphoma is found in the brain and/or spine Non-Hodgkin's lymphoma Burkitt's / Small non-cleaved cell lymphoma is one of the most common types seen in HIV patients Cervical cancer

20. Extensive cutaneous Kaposi’s

21. Anti cancer agents (all injections) Vincristine, Vinblastine Etoposide Doxorubicine Bleomycine