.
Introduction
Infection with the Human
Immunodeficiency Virus (HIV) has a wide
range of clinical manifestations. Some are
due to a direct effect of the virus on certain
body cells, such as those of the central
nervous system and gastrointestinal tract.
But many clinical manifestations are the
result of damage to the immune system,
which leaves the body open to infection by
a variety of opportunistic pathogens
(disease-causing organisms). Infections
that are latent in the body re-activate when
immunity decreases. Patients with AIDS
typically have multiple opportunistic
infections which can be difficult to
diagnose. The pattern of opportunistic
infections depends on which organisms are
prevalent in the environment.
There are two human retroviruses which
cause AIDS: HIV-1 and HIV-2. In this
commentary we refer to HIV-1 as “HIV”,
for clarity. HIV-2 was discovered in 1986
in West Africa. It is less common than
HIV-1 but has been found in many parts of
the world. The course of disease following
infection with HIV-2 appears to be more
slowly progressive and less severe than
that with HIV-1. Infection with both
viruses at the same time usually causes
more severe disease.
It is not possible to illustrate all the clinical
manifestations of HIV related disease in 24
slides. So in this set we draw attention to
the parts of the body which most
commonly show signs of HIV related
disease. These are the mouth, the skin, the
lungs, the gastrointestinal tract, the genitals
and the central nervous system. Clinical
manifestations that are not illustrated are
discussed in Appendix 1.
At present, there is no cure for AIDS.
However there are treatments that relieve
symptoms, and drugs to treat and prevent
opportunistic infections. These are
mentioned in the commentary for the
slides. More detailed guidelines for the
management of HIV related illness are
available from WHO (see Appendix 4).
There is now an increasing range of
antiretroviral (ARV) drugs that attack HIV
itself (see slide 23). In the past the cost of
ARV drugs and monitoring made
treatment too expensive in resource poor
settings. But national and international
advocacy has achieved impressive
decreases in prices of ARV drugs, and
scientists are developing lower cost tests
for monitoring the patient’s response.
Several countries now have pilot programs
for delivering ARV treatment to HIV
positive people. However, the drugs must
be taken for life, and even with lower
prices, treatment remains costly,
especially where HIV prevalence is high.
Unless the drugs are taken regularly the
virus can rapidly become resistant.
Decisions on management policy involve
ethical and social as well as medical issues.
It is important for health planners to
allocate available resources in a rational
way. We present discussion points on
these difficult issues in Slide 23.
People living with HIV/AIDS may need
counselling and social support as well as
clinical care. A ‘continuum of care’
between hospital, clinic and community
needs to be established and maintained.
The HIV epidemic presents many
challenges for health care services. We do
not attempt to cover these in detail in this
set, but some of the important issues are
discussed in Appendix 3. We suggest that,
after showing the slides, you allow time for
a discussion of these management issues.
Teacher’s Note
This slide set assumes that the audience is
familiar
with the accompanying set “HIV Infection -
Virology
and Transmission”. We recommend that you
study
or revise the material contained in that set
before
you study this one. The first slide is the same
as
slide 7 in the Virology and Transmission set – it
may
be a useful opportunity to remind the audience
of
some of the facts learned in the earlier set.
HIVCM-F
5.Slide 1 Natural history of
HIV infection
This diagram shows what happens after
infection with HIV.
Q. What does seroconversion mean?
A. In the few weeks after HIV enters the
body the virus replicates rapidly until
the person develops antibodies to the
1
virus. This is called ‘seroconversion.’
Q. Is the person able to infect
someone else during the time
between infection with HIV and
seroconversion?
A. Yes, the person has high levels of
virus in their blood and can infect
someone else through unprotected
sexual activity, through donating
blood, or through sharing a needle
and syringe.
Q. Is the HIV antibody test positive
during this time?
A. No. The HIV antibody test only
becomes positive after
seroconversion.
Q. What is the time between infection
and seroconversion called, and how
long does it usually last?
A. This interval when the person is
infectious but the HIV antibody test
is negative is called the ‘window
period’. It is usually between two
and six weeks, but it may be up to
three months before antibodies
develop.
Most people develop a glandular-fever like
illness at the time of seroconversion. This
‘primary HIV infection’ lasts about 14
days, and clinical manifestations include:
• generalised enlargement of the lymph
•••
Nausea/vomiting, diarrhoea, mouth /
anogenital ulcers
Maculopapular rash (often itchy)
Meningitis, encephalitis, neuropathy,
Guillain-Barre syndrome
Patients usually recover rapidly, but
fatigue may last for several weeks.
Management includes treatment of
symptoms, counselling and education to
prevent further spread of the virus.
Q. What happens after
seroconversion?
A. Most people infected with HIV
remain well for several years, with
low levels of virus in the blood.
Although the person has developed
antibodies they are unable to clear HIV
from the body completely. By 5 years
after infection most people develop signs
and symptoms due to immune deficiency.
Some develop manifestations that are a
result of direct infection of the gut cells or
brain cells by HIV.
At the final stage of infection with HIV is
the Acquired Immune Deficiency
Syndrome, or AIDS. AIDS is
characterised by opportunistic infections,
and malignancies, that only occur in
patients with very low immunity. We call
an infection opportunistic when the
organism does not normally cause disease,
but takes the opportunity to infect a patient
who has low immunity.
10 - 30% of adults infected with HIV
develop AIDS within five years; about
60% within 12 years of infection. Studies
show that adults of different race, sex and
geographical area have similar rates of
progression to AIDS, in the absence of
specific treatments.
Q. With which disease do you think
that HIV related illness is
commonly confused?
Fever, malaise, arthralgia, sore throat,
headaches, enlarged lymph nodes
A. With tuberculosis
HIVCM-F
6.Q. Why are tuberculosis and HIV
infection confused?
A. Tuberculosis has many clinical
features similar to HIV infection,
particularly: weight loss, chronic
fever, persistent cough and
nodes. Also TB and HIV infection
are often found together.
Psychiatric illness, especially depression,
can also be confused with HIV related
illness. Features in common are multiple
somatic symptoms, loss of weight,
weakness and mood changes.
The division of symptomatic HIV infection
into “AIDS” and other categories of HIV
related illness occurred because AIDS was
described before the discovery of HIV.
The division is not useful in the
management or counselling of patients.
However it is helpful for epidemiological
reporting and is a guide to prognosis.
Once a person develops AIDS they usually
die within a year, unless they have access
to prophylaxis for opportunistic infections
and treatment with antiretroviral drugs.
In 1990, the World Health Organisation
(WHO) categorised clinical status of HIV
infection in four stages which indicate the
level of immune suppression and the
prognosis of people living with HIV (see
2
also appendix 2)1 .
Stage 1: asymptomatic infection
Stage 2: early (mild) disease
Stage 3: intermediate (moderate) disease
Stage 4: late (severe) disease.
Manifestations of HIV disease are rare at
CD4 counts above 500 × 10 6 cells/l, and
severe illness and death are rare in patients
with counts above 200 × 10 6 /l.
Further Information:
Definition of AIDS and HIV related
disease
A consistent definition of AIDS is needed for
surveillance purposes, so that the number of
cases can be compared in different years and in
different regions.
AIDS was first defined by the US Centres for
Disease Control (CDC) in 1982, before the
discovery of HIV. That definition was based
on a list of diseases which indicated immune
deficiency. When HIV was discovered the
definition was modified to include laboratory
evidence of HIV infection.
In industrialised countries people infected with
HIV began to live longer, and prophylaxis and
treatment for opportunistic infections led to a
decrease in incidence of AIDS-defining
illnesses. Many people with late disease and
low CD4 (T4) cell counts had few symptoms
and did not meet the CDC criteria for a
diagnosis of AIDS. (The ‘CD4 count’ refers to
the number of CD4 lymphocytes in the blood.
CD4 are a subset of T lymphocytes that are
most affected by HIV and which control the
immune system.) In 1993, therefore, the CDC
definition of AIDS was changed to include a
CD4 lymphocyte white cell count of less than
200 × 10 6 /l 2 . Additional diseases which
indicate a diagnosis of AIDS in HIV infected
individuals were also included: pulmonary
tuberculosis, recurrent pneumonia, and
invasive cervical carcinoma. These changes
enabled inclusion of diseases more commonly
seen in women and non-homosexual males,
and allowed more HIV infected people in the
USA to qualify for government subsidies for
care.
Many areas with a high prevalence of HIV
infection do not yet have laboratory facilities
1 World Health Organization. Acquired
Immunodeficiency Syndrome(AIDS): interim
proposal for a WHO staging system for HIV
infection and disease. Weekly Epidemiol Rec
1990;65:221-228
2 1993 Revised Classification System for HIV
Infection and Expanded Surveillance Case
Definition for AIDS Among Adolescents and
Adults. MMWR Weekly December 25, 1992 /
41(51);961-962. http://www.cdc.gov/mmwr
HIVCM-F
7.for HIV testing or for diagnosis of indicator
diseases. Because of this WHO developed a
clinical case definition of AIDS at a workshop
in the central African Republic in 1985.
Clinical case definition of AIDS in adults
AIDS can be diagnosed if a patient has at least
two of the following major signs and at least
one of the minor signs. The patient must not
have any other known cause of immune
suppression. The presence of generalised
Kaposi’s sarcoma or cryptococcal meningitis
by themselves indicate the diagnosis of AIDS.
Major signs
•••••••••
weight loss > 10% body weight
chronic diarrhoea > one month
fever > one month (intermittent or
constant)
Minor signs
chronic cough > one month
generalised pruritic dermatitis
recurrent herpes zoster
oro-pharyngeal candidiasis
chronic progressive and disseminated
herpes simplex infection
generalised lymphadenopathy
Most of the manifestations of AIDS are non-specific,
so it is difficult to develop an accurate
clinical definition. Researchers have evaluated
this WHO clinical definition in several African
countries. They found that it does not reliably
predict which patients have a positive HIV
antibody test. Many countries use this
definition, but some use their own modified
version. The Expanded WHO Case Definition
for AIDS surveillance uses a similar case
definition but includes a positive HIV antibody
test.
HIVCM-F
8.Slide 2 Gastrointestinal
manifestations
Malabsorption can occur early in HIV
infection. Severe nutritional deficiencies
are common so good nutrition with
adequate intake of vitamins, and minerals
is important for people infected with HIV 3 .
Q. Why is there a black bar over
Mary’s eyes? Q. What do you notice about the
young woman in this picture?
A. We have put a black bar over the
3
eyes of the patients in this slide set so
that they cannot be identified.
A. She is very thin: we can see the
outline of her bones.
Q. What are the likely causes of such
severe weight loss? We have also changed the names and
some
details of the stories of patients for the
same reason. It is important to maintain
confidentiality when looking after people
with HIV related disease. This important
issue is discussed in Appendix 3.
A. This weight loss might be caused by
malnutrition, or by a severe
debilitating condition such as a
malignancy, or tuberculosis, or by
AIDS.
This young woman, Mary, presented with
loss of weight, tiredness, diarrhoea, and
intermittent fever. She also had oral thrush
and an itchy rash. Two years previously
she had suffered a brief illness similar to
glandular fever. She did not gain weight
despite adequate food and treatment for
infections. The HIV antibody test was
positive.
Further Information
Treatment:
During episodes of diarrhoea, fluid
replacement may be necessary. Symptomatic
treatment with anti-motility agents such as
codeine or loperamide can make the patient
more comfortable.
Other gastrointestinal manifestations:
Severe weight loss with chronic diarrhoea
is a common manifestation of HIV
infection. The cause is not certain. Where
gastrointestinal pathogens such as Giardia
lamblia and Entamoeba histolytica are
common, they will be found in the stools.
But they may not be the cause of the
chronic diarrhoea, which may continue
after treatment. HIV can infect
gastrointestinal epithelial cells, and may be
the direct cause of diarrhoea.
Although HIV may be the cause of the
diarrhoea, it is important to look for and treat
secondary infections.
Cytomegalovirus and herpes simplex virus can
both cause focal or diffuse ulceration from the
mouth to the anus. Herpes simplex usually
causes mucocutaneous lesions at the upper and
lower ends of the intestinal tract. CMV is
associated with abdominal pain, fever and
diarrhoea. Toxic dilatation, perforation and
haemorrhage may occur. The diagnosis is not
easy as it requires biopsy and culture.
Ulceration of the oesophagus causes
retrosternal chest pain and dysphagia. The Centres for
Disease Control in the US
have defined the HIV wasting syndrome
as: “Weight loss of more than 10%, plus
either unexplained chronic diarrhoea (more
than 1 month), or chronic weakness and
unexplained prolonged fever (more than 1
month)”. Patients with HIV wasting
syndrome are classified as having WHO
Stage 4 HIV infection (see Appendix 2).
Cryptosporidium, isospora belli and
microsporidia are protozoal causes of
3 Piwoz E, Preble E. HIV/AIDS and Nutrition: A
review of the literature and recommendations for
nutritional care and support in sub-Saharan Africa.
Nov 2000. SARA project, USAID. Available at:
http//63.107.122.20/documents/3360_aed_HIVand
Nutrition.pdf
HIVCM-F
9.diarrhoea in HIV infected patients. In HIV
infected hosts cryptosporidium may cause
intermittent or persistent diarrhoea. The stools
may be loose or watery with colic and severe
fluid and electrolyte loss. Where facilities are
available the diagnosis is made by finding the
cysts in the stools by a direct, modified acid
fast stain. There is no effective treatment for
this parasite at present.
Disseminated infection with Mycobacterium
tuberculosis and atypical mycobacteria occurs
in AIDS. Gastrointestinal infection may be
associated with fever, weight loss, diarrhoea
and malabsorption. Diagnosis is by acid fast
staining of the stool or biopsy. Kaposi’s
sarcoma may affect the GI tract.
Complications are unusual but include
ulceration, haemorrhage and diarrhoea. A
protein losing enteropathy may also occur.
HIVCM-F
10.Slide 3 Persistent
generalised lymphadenopathy
Q. What do you notice about this
man’s neck?
A. He has enlarged cervical lymph
nodes. You can see the enlarged
gland behind his ear most easily. He
also has enlarged occipital,
submental, submandibular, anterior
and posterior cervical glands.
One of the common ways in which HIV
infection presents is with widespread
lymph node enlargement. The syndrome is
4
called persistent generalised
lymphadenopathy, or PGL.
The cervical, axillary and inguinal glands,
and the epitrochlear glands inside the
elbow, are often palpable. The
enlargement is usually symmetrical, and
the glands are typically firm, discrete and
not tender. They are not usually very large
and may be difficult to see. Sometimes the
spleen is also enlarged.
The definition of PGL states that:
• the enlarged lymph nodes should
be at least 1 cm in diameter;
• they should be found in two or
more sites (not including the
inguinal region);
• they should persist for at least three
months;
• Further Information
there should be no current illness or
medication known to produce
enlarged nodes.
Generalised enlargement of the lymph
nodes is a common feature in primary HIV
infection (seroconversion illness). Even in
those who do not experience this, PGL
may develop early in the course of HIV
infection. The patient may not be aware of
the lymph gland enlargement so it is
important to examine the axillae of every
patient. If a patient has generalised
lymphadenopathy without an obvious
cause look for other symptoms and signs
suggestive of HIV infection.
Q. What are some other causes of
enlarged lymph nodes?
A. Tuberculosis
Syphilis
Infectious mononucleosis (EB virus)
Cytomegalovirus infection
Lymphomas and leukaemia
Kaposi’s sarcoma
Toxoplasmosis
When the lymph node enlargement is
typical of PGL and the patient is HIV
antibody positive, it is not necessary to
biopsy the glands. This is because the
biopsy findings are non-specific and the
prognosis is not affected. It is important to
biopsy if there is:
• asymmetrical or painful
enlargement of nodes;
• sudden increase in size;
• constitutional symptoms such as
fever, night sweats or weight loss;
or hilar lymphadenopathy.
Further information
Histology
Lymph node biopsy in HIV related PGL shows
non-specific reactive hyperplasia. Many causes
of lymph node enlargement result in these
histological changes.
HIVCM-F
11.Because Candida albicans can cause a
decrease in T cells, candidiasis itself may
make immune deficiency worse.
Slide 4 Oral candidiasis
It is an important part of the routine of any
clinical examination to look in the patient’s
mouth. Patients with HIV infection often
have abnormalities in their mouths. This
patient complained of a sore mouth and
difficulty in swallowing.
Treatment
Oral candidiasis: Topical anti-fungal drugs
such as nystatin suspension, miconazole or
clotrimazole are usually effective, but oral
fluconazole or ketaconazole are sometimes
necessary. In many parts of the world Gentian
Violet paint (crystal violet 0.5% in water) may
be all that is available. It is effective, but
messy. Warn the patients that Gentian Violet
stains clothes and skin.
Q. What do you notice that is
abnormal?
A. The hard palate has a white exudate
on a red background. The buccal
mucosa also has a white coating.
Q. What do you think is the
diagnosis? Oesophageal and disseminated candidiasis:
Systemic anti-fungal agents are necessary such
as ketoconazole, fluconazole, nystatin or
amphotericin B. Ketoconazole 200mgs is
available through generic suppliers and costs
about US $5.50 for a two-week course 4 .
Fluconazole has less risk of side-effects but it
much more expensive.
A. Oral candidiasis, or thrush. The
tongue and buccal mucosa may be
coated with white plaques, or they
may be beefy red.
Oral candidiasis is a very common feature
of HIV infection, especially when the CD4
cell count falls below 500 × 10 6 /l.
In prospective studies of patients with HIV
related illness, oral candidiasis indicates a
poor prognosis.
Patients who experience the acute
seroconversion HIV illness often have oral
5
candidiasis, which improves rapidly when
they recover.
In the absence of another specific cause,
such as diabetes, oral candidiasis in adults
is highly predictive of HIV infection.
Oral candidiasis can also cause angular
stomatitis. It may be associated with
pharyngeal and oesophageal candidiasis.
This causes pain in the chest that worsens
when swallowing. In patients with AIDS,
oral candidiasis is a marker for
oesophageal candidiasis.
Disseminated candidiasis causes fever and
symptoms in affected organs, eg blindness.
4 HIV-related opportunistic diseases: UNAIDS
Technical Update October 1998. www.unaids.org
HIVCM-F
12.Slide 5 Oral hairy
leukoplakia
Q. What abnormality do you notice on
the side of this man’s tongue?
A. There are white projections, or
corrugations, on the side of the
tongue which give it a ribbed
appearance.
This is a condition called hairy
leukoplakia. The white warty-like
projections occur on the lateral aspects of
the tongue and sometimes on the mucosa
of the cheeks. It is found only in patients
with HIV infection, so it is a diagnostic
sign. It is usually painless, so does not
require treatment.
The cause of oral hairy leukoplakia is
Epstein Barr Virus (EBV). It tends to
occur late in the course of HIV disease.
Oral hairy leukoplakia differs from
ordinary leukoplakia in which flat white
patches may occur on any part of the
mucosa inside the mouth. Ordinary
leukoplakia is a result of chronic irritation
and may become malignant.
HIVCM-F
13.Slide 6
1. Viral warts
HIVCM-F
14
Q. What do you see on the patient’s
lower lip in picture 1?
A. There are small raised lesions on the
mucosa of the lower lip.
They are warts, caused by a virus. This is
a minor opportunistic infection that may
occur early or late in HIV disease.
2. Early lesion of Kaposi’s
sarcoma
Q. What do you see on this patient’s
hard palate?
A. There is a purple, plaque-like lesion
on one side.
This is an early lesion of HIV related
Kaposi’s sarcoma (KS). These lesions
often appear just above the second molar
teeth.
KS is a tumour that arises from the
endothelium of blood vessels. In tropical
Africa the tumour has been endemic for
many decades. In the endemic, classical
form the tumour presented usually on the
hands or feet. It tended to grow slowly
without causing general symptoms.
A new form of KS was seen in American
patients in 1981 and in African countries
from 1983. It is much more severe and
aggressive than the endemic form. The
lesions are more widespread; constitutional
symptoms are worse; and there is often
associated oedema. This is called
aggressive or fulminating KS. It occurs
only in people with immune deficiency and
it is one of the ‘indicator diseases’ for the
definition of AIDS.
The lesions of HIV-related KS may present
in many different sites.
Q. What are some other common sites
to see early KS?
A. The penis, the groin, the medial third
of the lower eyelid and the tip of the
nose.
Further Information
Cause
In recent years researchers have discovered
that a person develops KS after they have
become infected with human herpes virus 8
(HHV-8). This virus is now also called KS
associated herpes virus (KSHV). It is a
sexually transmitted infection.
Summary – Oral manifestations
Oral manifestations of HIV infection are
common, so always look in a patient’s mouth.
You may find
opportunistic infections, including:
• oral candidiasis
• ulcers, which may be herpetic, aphthous or
bacterial
• viral warts
You may find specific manifestations, such as
KS or oral hairy leukoplakia. There may also be
a
number of non-specific conditions, such as:
6
• severe dental caries
• dental abscesses
• gingivitis
• lip depigmentation
• coated tongue
Encourage patients who are HIV positive to
keep their mouths clean and to brush their
teeth after
meals..Slide 7. Fulminant Kaposi’s
sarcoma
Q. What abnormalities do you notice
in the skin of this young woman?
A. She has hyperpigmented nodular
lesions all over her face and body.
She looks extremely ill. You may be
able to see from her face that she is
oedematous.
Q. What do you think the diagnosis
might be?
A. She has fulminating or aggressive
Kaposi’s sarcoma which is related to
AIDS.
KS is rarely the cause of death in people
with AIDS, who usually die of multiple
opportunistic infections. However, severe
weight loss, oedema of head or trunk,
pulmonary infiltration and encephalopathy
are poor prognostic signs.
This malignancy is now seen commonly in
countries in Sub-Saharan Africa,
associated with AIDS, as well as in AIDS
patients in Europe and America.
Further Information
Treatment
Treatment for KS is expensive and often not
available. Patients may benefit
psychologically from treatment of unsightly
lesions. Excision is the most simple method.
One dose of irradiation may treat localised
nodules.
Doctors may use cytotoxic therapy in patients
with rapidly progressive systemic KS.
Bleomycin and Vincristine give a response in
50-60% of patients. Liposomal doxyrubicin is
now the treatment of choice but it is very
expensive. These drugs reduce the patient’s
immunity further. Remissions on treatment are
temporary and incomplete. KS usually
improves if a patient starts antiretroviral drugs
(see slide 23).
If there is no specific treatment available for
this woman it is very important that she
receives good palliative care (see Appendix 3),
and that her family receives support.
Histology
The histology of a typical nodule shows
collections of spindle cells in the dermis which
trap red blood cells. There is an associated
deposition of haemosiderin.
HIVCM-F
15.Researchers believe that Epstein Barr virus
is the cause of HIV associated lymphoma. Slide 8
Lymphoma
Further information Q. What do you see in this man’s
neck? Lymphoma most commonly occurs late in HIV
disease with low CD4 count. In Europe and the
USA, lymphomas affect homosexuals more
commonly than other risk groups such as
haemophiliacs and drug abusers. In developing
countries lymphoma is rare, perhaps because
people do not live long enough to develop
lymphoma or because of lack of diagnosis.
A. He has a large swelling on both sides
of his neck.
The swelling is asymmetrical.
These are enlarged lymph glands, which
were painful.
Q. What features suggest that this is
not PGL? Figure 2: Lymphoma in the
neck
Teacher’s Note
Encourage the audience to recall the features
of the
cervical glands in slide 3 and to compare them
with
the features visible here.
A. •
The lymph nodes are very much
enlarged;
•
the enlargement is asymmetrical;
• the gland is painful.
These three features suggest that the gland
enlargement is not PGL, and they are
indications for biopsy. Biopsy in this case
showed a malignant lymphoma. Histology:
The histology of this lesion showed a
poorly differentiated, diffuse non-Hodgkin’s
malignant lymphoma. Most
HIV-related lymphomas are extranodal
high-grade B cell lymphomas.
After KS, malignant lymphoma is the
commonest malignant tumour that affects
people with AIDS. Patients often present
with infiltration in other sites rather than
with signs of lymph node involvement.
These sites include the central nervous
system, the bone marrow, the
gastrointestinal tract and mucocutaneous
sites. Patients may present at a late stage,
7
with constitutional symptoms such as fever
and weight loss.
Treatment
Treatment is controversial because it is very
expensive, not often effective, and patients
have poor quality of life. Intravenous multiple
agent chemotherapy can give initial remission,
but there is a high relapse rate with poor
response to second line chemotherapy.
Treatment includes CNS irradiation or
intrathecal chemotherapy. Survival of these
patients is poor. ARV therapy, although it
reduces the frequency of other AIDS related
malignancies, has had little effect on
lymphoma.
The prognosis of HIV related lymphoma is
poor; mean survival is less than one year.
Lymphoma of the CNS can be difficult to
distinguish from both HIV neurological
disease and other space occupying CNS
lesions such as toxoplasmosis.
HIVCM-F
16.Slide 9 Further Information
Diagnosis
1. Pneumocystis carinii
pneumonia Fiberoptic bronchoscopy with alveolar
lavage
to provide cells for cytology, or transbronchial
biopsy, is necessary for diagnosis of PCP. Q. What
abnormalities do you see in
chest X-ray 1? Treatment
High dose cotrimoxazole is an effective
treatment. It is well absorbed orally. The dose
is 4 tablets, 3 times a day (15-20 mgs of the
trimethoprim component per kg body weight
per day). One tablet of cotrimoxazole contains
400 mgs sulphamethoxazole and 80 mgs
trimethoprim). Adverse reactions to
cotrimoxazole are common in AIDS patients.
They include rashes, nausea, febrile reactions
and cytopenia. Give prochlorperazine for
nausea and folic acid to prevent cytopenia.
A. There is diffuse symmetrical
interstitial shadowing.
This patient has Pneumocystis carinii
pneumonia (PCP). PCP is one of the
major opportunistic infections found in
patients with HIV infection. It can occur
as an early or late complication of AIDS.
Pneumocystis carinii has characteristics of
both protozoa and fungi. It does not
usually cause lung infection in people who
have normal immunity. It may infect the
lungs in patients with immune deficiency
due to any cause. 85% of lung infections
in AIDS patients in Europe are due to PCP.
It is less common in developing countries,
where tuberculosis and fungal infections
are more common opportunistic infections.
Prophylaxis
Studies show that co-trimoxazole can prevent
many bacterial and parasitic opportunistic
infections in adults and children living with
HIV, including PCP, toxoplasmosis,
salmonellosis, bacteremia, and pneumococcal
pneumonia. This is a cost-effective
intervention for people living with HIV and
governments because it reduces hospital
admissions and deaths. The cost is under
US$12 per person per year.
Q. What are the symptoms and signs
of PCP?
A. The symptoms include a history of
several weeks of breathlessness, and
dry, non-productive cough. Patients
often complain that they cannot take
a deep breath. Headache is common;
pleuritic pain is unusual.
WHO recommend a daily double-strength dose
of co-trimoxazole (trimethoprim 160 mg;
sulfamethoxazole 800 mg) for :
• anyone with symptomatic HIV disease
• asymptomatic individuals with a CD4
count of less than 500
On examination, signs include fever and
tachypnoea at rest. On auscultation the
chest often sounds clear.
• HIV positive pregnant women after the
first trimester 5 .
This prophylaxis should continue indefinitely
unless there are side-effects. If severe skin
rashes occur the co-trimoxazole should be
stopped. Patients will need to be followed up
every month initially and then every 3 months.
Early in the course of the infection the
chest X-ray may be normal. Later the
typical, though non-specific, changes that
you see here may develop.
Accurate confirmation of the diagnosis
requires facilities for bronchoscopy. So it is
often necessary to treat the patient when
you suspect the diagnosis from the history
and examination.
5 UNAIDS. Provisional WHO / UNAIDS
secretariat recommendations on the use of co-trimoxazole
prophylaxis in adults and children
living with HIV/AIDS in Africa. Sept 2000.
http://www.unaids.org/publications/
HIVCM-F
17.2. Bacterial pneumonia
8
Q. What abnormalities do you see in
chest X-ray 2?
Teacher’s Note
Ask one of the audience to point to the
features
of the chest X-ray as they are mentioned.
A. There is a dense shadow in the right
middle and lower zones which
suggests consolidation. The right
diaphragm is raised and the trachea is
deviated to the right which suggest
collapse of a lobe on the right.
Q. What do you think is the
diagnosis?
A. Pneumonia - most likely bacterial.
Lobar pneumonia caused by Streptococcus
pneumoniae and Haemophilus influenzae
occurs more commonly in people with
HIV than the general population. Other
bacteria that cause pneumonia include
Staphylococcus aureus, Klebsiella
pneumoniae and E. Coli. The presentation
is the same as in uninfected patients, with
fever, cough and sometimes pleuritic pain.
Further information
Treatment
Treat with benzylpenicillin six-hourly, or, if
the patient is not severely ill, procaine
penicillin daily.
HIVCM-F
18.Slide 10. Tuberculosis
This is the chest X-ray of a young man
who presented with a history of loss of
weight, productive cough and fever for one
month.
Q. What abnormalities do you see in
his chest X-ray?
A. There are diffuse, soft-looking
opacities in both lung fields, more on
the right than on the left. There are
cavities in the right lower lobe. There
is enlargement of the hilar nodes on
the left.
Q. What condition does this
appearance suggest?
A. It suggests pulmonary tuberculosis.
The soft looking opacities suggest
that the tuberculosis is of recent
onset. The cavities imply that there is
active disease.
AIDS can present with florid pulmonary
tuberculosis. The X-ray appearances are
often atypical. As in this slide, the middle
or lower lobes are commonly affected, and
the upper lobes are often clear. (Usually in
tuberculosis, the upper lobes are more
severely affected.) Enlargement of hilar
lymph nodes, and effusions, are common.
This man had a positive HIV antibody test,
and acid fast tubercle bacilli were found in
his sputum. He has AIDS and
tuberculosis. His tuberculin test was
negative.
Q. Why do you think that his
tuberculin test was negative?
A. The tuberculin test depends on a
cutaneous delayed hypersensitivity
reaction. In patients with HIV
infection the skin reaction may be
suppressed (anergy).
Tuberculosis infects people with normal
immunity; but it behaves as an
opportunistic infection in people living
with HIV/AIDS. It is the commonest
opportunistic infection in sub-Saharan
African countries. Both primary infection
with tuberculosis and reactivation of latent
tuberculosis infection are common in HIV
infected people. An increase in
tuberculosis in the general population
follows in the wake of the HIV epidemic.
HIVCM-F
19.Fungal pulmonary infections are not
common. Treatment is with Amphotericin B. Slide 11.
Tuberculosis
Kaposi’s sarcoma often affects the lungs but
rarely causes symptoms. Q. What diagnosis does this
chest X-ray
appearance suggest?
A. Miliary tuberculosis.
The presentation of tuberculosis in HIV
infected patients is often atypical.
Mycobacteria may disseminate through the
body, causing miliary tuberculosis or
meningitis. Tuberculous lymphadenopathy
is common. It is clinically similar to HIV
related lymphadenopathy. Involvement of
the genito-urinary tract, bone marrow and
central nervous system is also common.
Standard treatment regimens are usually
effective in HIV positive patients with
pulmonary TB. Relapse may be common
when treatment is stopped.
Figure 3. This is a view of the fundus of the
eye through an ophthalmoscope. The pupil
has been dilated with 0.25% atropine
ointment. The small round spots on the
retina are choroidal (retinal) tubercles.
Their presence makes the diagnosis of
miliary tuberculosis certain.
9
Further information
Tuberculous lymphadenopathy may
resemble HIV-related lymphadenopathy.
Indications for biopsy are listed in slide 3.
Doctors in Zambia studied the appearance of
the cut surface of biopsied lymph nodes to the
naked eye (that is, without using a
microscope). They found that they could see
tuberculous caseation in 42.5% and
tuberculomata in 34.5%. So a microscope is
not essential for diagnosis.
Atypical mycobacteria
HIV positive patients may become infected
with atypical mycobacteria, such as M.
Xenope, M. Kansasii, or M. Avium-intracellulare.
These infections produce minor
symptoms and they are difficult to treat. They
often resolve if the patient is started on
treatment with antiretroviral drugs.
Other causes of pulmonary manifestations
of HIV infection:
Cytomegalovirus is another common
pulmonary pathogen in HIV positive patients.
Infection with CMV usually occurs with
Pneumocystis carinii infection. Patients with
these mixed infections usually recover with co-
trimoxazole.
The chest radiograph is similar to
that of PCP.
HIVCM-F
20.Challenge doses for detecting hypersensitivity:
Slide 12. Drug reaction
Drug Day 1 Day 2
Isoniazid 50 mg 300 mg
Rifampicin 75 mg 300 mg
Pyrazinamide 50 mg 1.0 gm
Ethambutol 100 mg 500 mg
Thiacetazone 25 mg 50 mg
Streptomycin 125 mg 500 mg
Joseph, age 22, has HIV infection and
tuberculosis. He has been treated with
anti-tuberculous drugs for two weeks.
Q. What do you notice about Joseph’s
face?
A. His face is swollen. There are many
vesicles.
Q. What do you think is the cause of
this appearance?
A. Stevens-Johnson syndrome. This is a
reaction to one of the anti-
tuberculous drugs. The reaction is usually a slight skin rash
or
fever which starts within 2 – 3 hours. If
possible, give a different anti-tuberculous drug
instead of the one that you find caused the
reaction. If you do not have alternative drugs,
it is possible to slowly desensitise the patient
to the drug that they are sensitive to. To do
this begin with a tenth of the normal dose and
slowly increase the dose each day. If a mild
reaction occurs continue the same dose for
another day. If a severe reaction occurs make
every effort to obtain an alternative drug.
Q. Which drugs are most likely to
cause this reaction?
A. Thiacetazone and streptomycin
Drug reactions are more common in HIV
positive patients, and are most commonly
due to thiacetazone or streptomycin.
However patients may react badly to any
anti-tuberculous drugs. Reactions may
vary from a mild itchy rash to a severe
Stevens-Johnson syndrome, such as this.
Joseph also has a fever and enlarged lymph
nodes, liver and spleen. He has ulcers on
the mucous membranes of his mouth, eyes
and genitals.
Further Information
Management of reactions:
If a severe reaction occurs, stop all drugs. If
the patient cannot swallow well they will need
intravenous fluids. Give prednisolone 15 mgs
three times daily. Reduce the dose gradually
as the patient improves. When the reaction has
disappeared start to give anti-tuberculous drugs
again, one at a time. Try thiacetazone and
streptomycin last. Start giving test doses as
shown in the table.
HIVCM-F
21.The HIV epidemic causes increased spread
of tuberculosis Discussion points on tuberculosis
HIVCM-F
22
Teacher’s Note
The problem of an increase in tuberculosis in
the
wake of the HIV epidemic is so serious that
you
may feel you want to encourage a discussion
about
the implications. The following questions and
notes
may stimulate comments.
Spread of tuberculosis will occur to non-HIV
infected people in the population.
WHO estimates that without treatment,
each person with active TB will infect on
average between 10 and 15 people every
year.
Clinical presentation
10
Clinical presentation varies depending on
the stage of HIV disease. Early on in HIV
infection, patients most often develop
pulmonary TB. Later, in advanced HIV
infection, once cell- mediated immunity
has been damaged TB is more likely to
present with non-specific symptoms and
signs including fever, weight loss and
fatigue. Patients with low CD4 counts less
than 150 x 10 6 /l might also have extra-pulmonary
disease. This can affect the
bone marrow, lymph nodes, central
nervous system and liver.
• How common is tuberculosis in your
area?
• infected people they have reduced
What control measures are in place?
• Could detection and treatment of cases
be improved?
• Do health professionals in the area
need further training about
tuberculosis, especially about the more
unusual presentations?
• What is the potential for the
development of resistant organisms in
your area? Is treatment often
intermittent or inadequate? A recent study in Thailand and
Malawi
found that a large proportion of hospital
patients with fever have unrecognised
tuberculosis in their blood 6 . Where
resources for clinical microbiology testing
are scarce remember that HIV positive
patients with oral thrush, chronic fever,
cough or weight loss may have M.
tuberculosis bacteraemia. Trial of anti-tuberculous
therapy may be worthwhile.
Tuberculosis remains common
Every year about 8 million people
worldwide become ill with tuberculosis
and 2-3 million die of the disease. One in
three of the population of poor countries is
infected with the tubercle bacilli.
Tuberculosis most common HIV-related
opportunistic infection Tuberculosis may suppress
lymphocyte
numbers, and so worsen HIV-related
immunosuppression. Treatment seems to
prevent this effect so early diagnosis of
tuberculosis is important.
TB is the most common opportunistic
infection for people living with HIV/AIDS
in poor countries throughout the world.
WHO estimate that 15 million people have
dual infection with TB and HIV. Clinical
tuberculosis may be expected to develop in
about 30% of HIV antibody positive
subjects with past tuberculous infection.
There will also be cases of primary
infection in HIV infected patients.
6 McDonald L.C., Archibald L.K.,
Rheanpumikankit S., et al. Unrecognized
Mycobacterium tuberculosis bacteraemia among
hospital inpatients in less developed countries.
Lancet 1999;354: 1159-1163..Prognosis • A secure system
of supplies, and
• Proper recording and reporting of cases HIV positive
people with tuberculosis
usually respond well to standard TB
treatment. But when compared to non-HIV
survival. Low CD4 count at diagnosis is
associated with a poor prognosis.
After the establishment of a national
programme success depends on the
introduction of short-course therapy.
DOTS
The Directly Observed Treatment Short
Course (DOTS) strategy provides correct
combination of TB drugs for 6 or 8
months, and observes patients swallowing
their medicines. This is especially
important during the first two months of
treatment.
Anti-tuberculous chemotherapy and BCG
vaccination of children are among the most
cost-effective health interventions
available in countries with high risks of
infection. Prophylaxis
Prophylaxis means taking a medicine to
prevent rather than treat an infection.
WHO and UNAIDS recommend 12
months of isoniazid prophylaxis for people
living with HIV at risk of tuberculosis,
such as those with a positive TB skin test
or who are living in areas where the
disease is endemic. Isoniazid has been
shown to increase the survival of HIV-infected
persons at risk of tuberculosis.
The short course should consist of, for new
infectious cases, four drugs, (which will
always include isoniazid, rifampicin and
pyrazinamide) for two months of the initial
intensive phase, followed by isoniazid and
thiacetazone (or ethambutol) for six
months in the continuation phase. Staff
need to be trained well before this regimen
is introduced.
Rifampicin interacts with some
antiretroviral drugs (particularly protease
11
inhibitors and non-nucleoside reverse
transcriptase inhibitors). For example
rifampicin will reduce nevirapine blood
levels by 30%. Some specialists
recommend treating TB before starting
ARV therapy.
An analysis of studies in Haiti, Kenya,
USA and Uganda showed that giving
isoniazid prophylaxis reduces TB
incidence by 43% among people infected
with HIV, when compared with placebo.
Public health management of the
tuberculosis epidemic
The International Union Against
Tuberculosis and Lung Disease have
identified essential factors to manage the
epidemic of tuberculosis that follows the
spread of HIV:
• The establishment of a national TB
programme
• Q. How do we know that this is herpes
Government commitment to provide a
central unit to guide that programme
• The integration of diagnosis and
treatment into the general health
structure throughout the country
• Diagnosis by a network of microscopy
centres with quality control
HIVCM-F
23.Q. What do you notice about the
rash? Slide 13.
1. Bacterial skin infection A. There are many small
vesicles
(blisters). The skin is red and the
eyelid is swollen. Picture 1 shows the leg of a patient with
HIV infection. Q. What do you think this is?
Q. What abnormalities do you see? A. Herpes simplex.
A. The lower leg is swollen and red.
There is an ulcerated area with an
exudate of pus and blood. Some of
the skin near the ulcers looks recently
healed.
The lips and the genitals are the most
common sites for the lesions of herpes
simplex but herpes simplex may affect any
part of the skin surface. It may be
recurrent at one site. In patients with HIV
infection, herpes simplex lesions are more
severe, more persistent, and they recur
more frequently than normal. Herpes
simplex infection may lead to encephalitis.
This patient has had a chronic bacterial
skin infection which improved with
treatment but soon relapsed.
Bacterial infections of all sorts are more
common in patients who have reduced
immunity due to HIV. For example, they
are more likely to suffer from pyomyositis,
abscesses, osteomyelitis and acute arthritis.
Q. What other diagnosis might you
think of?
A. Shingles (Herpes zoster).
The rash of shingles has a similar
appearance. After chicken-pox, the herpes
zoster virus remains latent in the sensory
ganglia. Years later the virus may
reactivate to cause shingles. Shingles
causes pain followed by a vesicular rash
over the skin supplied by that nerve.
Post-operative wound infections are also
more common in these patients. Consider
antibiotic prophylaxis, and observe closely
after operation. Ensure that wound
dressings are carried out under sterile
conditions.
simplex and not herpes zoster of
the ophthalmic division of the
trigeminal nerve?
Septicaemia is also common. Consider
bacteria such as Salmonella and
Staphylococcus aureus.
Skin infections like this are also common
in those without HIV infection. As with
most other manifestations of HIV infection
this is a non-specific condition. Because
of this non-specific nature of many
presentations of HIV related illness it is
important always to take a good history
and to examine the patient carefully.
A. The rash in this picture does not
affect the skin supplied by the
ophthalmic nerve. The rash extends
below the eye but does not affect the
skin above the eyebrow.
Q. What do you see on the palate in
picture 3?
2 and 3. Herpes simplex
The young woman in picture 2 presented
with a painful rash around her eye.
HIVCM-F
24.A. There are some small ulcers
surrounded by an area of
inflammation.
There ulcers are also caused by herpes
simplex virus. Herpes simplex virus also
commonly presents on the upper lip, and
on the genitals.
Further Information
Treatment
12
To prevent secondary bacterial infection apply
an antiseptic such as chlorhexidine. Analgesics
may be needed. Topical acyclovir is expensive
but effective. If the infection is severe, oral
acyclovir 3 times a day for 5 days is helpful,
but expensive, although generic preparations
are now available.
HIVCM-F
25.A. He has two types of lesion. The most
obvious is the large area of affected
skin on one side of his trunk. It is
made up of a number of vesicles and
pustules with some ulceration and
crusting. This is typical of shingles.
The patient has some talcum powder
on the lesions, to help to keep them
dry.
Slide 14 Shingles
The health worker in a rural health centre
asked the visiting doctor to see the patient
in picture 1. The health worker had made
a diagnosis of impetigo and had dressed
the lesion with antiseptic cream and gauze.
Q. What do you notice about the skin
lesion? There are also smaller, but similar, lesions
all over his back. These are chicken pox
spots.
A. There are raw areas with exudate and
dark crusts on the left side of her
forehead. The left eye is also
affected. Both of these conditions are caused by the
same virus, herpes zoster. This virus most
commonly causes chicken pox in children.
When a child recovers from chicken pox
the virus stays in the body. If the virus is
reactivated, it can cause shingles. In
patients with shingles who have normal
immunity antibodies to the virus prevent
spread of the virus to other parts of the
body.
Q. What is the correct diagnosis?
A. The diagnosis is shingles
Shingles is due to the virus herpes zoster
invading one or more nerve root ganglia.
It causes pain followed by a vesicular rash
over the skin supplied by that nerve. The
rash usually heals in about 2 weeks, and
often leaves hypo- or hyperpigmented
scars. Sometimes raised keloid scarring
remains after the shingles rash heals. Q. Why do you
think that this man
has shingles and chicken pox at the
same time? Q. What is the feature which most
strongly suggests the diagnosis? A. HIV infection has
damaged his
immunity, and he is unable to
produce effective antibodies to fight
the virus. So the virus has spread to
produce the chicken pox rash in
addition to the shingles.
A. The lesion is very clearly defined. It
is confined to the area of skin
supplied by a particular nerve
(dermatome). In this case it is the
ophthalmic division of the trigeminal
nerve. Even in HIV infected patients, this
disseminated form of herpes zoster is not
common. It is more usual to find the
typical shingles rash, confined to the skin
supplied by one nerve root. The most
common site is one side of the trunk.
Picture 2 shows the back of a man with
HIV infection.
Q. What abnormalities do you see?
Teacher’s Note
HIVCM-F
26
Give the audience plenty of time to study this
slide.
There are two types of skin lesion that they
need to
see – shingles and chicken pox. If they
concentrate
on the shingles encourage them to look further
at
the rest of the patient’s skin, to see the other
rash,
and then help them to make the connection
between them.
Shingles occurs most commonly in older
people. Now, however it is a common
early manifestation in younger people
infected with HIV.
In a young adult, a history of shingles
within the last 5 years strongly predicts
HIV infection. Patients may not at first
give a clear history of the rash, even if it is.recent. Always
examine for scars, and ask
specific questions.
Further Information
Treatment of shingles
It is best to leave the rash exposed. Analgesic
preparations containing paracetamol and
codeine are useful. Shingles is a very painful
condition. Apply an antiseptic solution to
prevent secondary bacterial infection, which
may be severe in immune deficient patients.
Severe shingles can also be treated with oral
acyclovir but this must be given 5 times per
day, and is expensive.
13
HIVCM-F
27.Further information Slide 15
Diagnosis
1. Fungal nail infections Cut small pieces of nail with
scissors or
scalpel. Soften the keratin on a glass slide
with potassium hydroxide solution. You can
then see the characteristic segmented hyphae
under the microscope.
Q. Describe the abnormalities of the
nails in picture 1.
A. The nails are thickened and ridged.
The nail fold is swollen or bossed.
Treatment Q. What is the cause of this
appearance? Because the nail does not absorb drugs it is
necessary to treat dermatophyte infection with
oral griseofulvin for several months. If severe
it may be easier to remove the nail under
general anaesthetic and treat the interdigital
skin with local application of an anti-fungal
cream (eg an imidazole such as clotrimazole)
or Gentian Violet paint.
A. Chronic fungal infection.
Fungal infections of the nails are called
onychomycoses. Fungal nail infections
may be due to tinea (dermatophyte) or the
yeast Candida albicans.
Dermatophyte nail infections commonly
follow chronic tinea pedis (athlete’s foot).
The nail eventually becomes friable and
crumbles away.
Nystatin solution or clotrimazole is an
effective treatment for candidal nail infections.
Gentian violet is a useful alternative.
In HIV infected patients there may be little
response to treatment. Candidal nail infections are more
common
in HIV positive women. They begin with
tenderness of the nail fold. Secondary
bacterial infection is common. The nails
become thickened with transverse ridges,
and the curve of the nail may increase. In
immune deficient patients the infection
may spread to involve the soft tissues of
the finger.
Question and examine the patient for signs
of fungal infection in other areas.
People infected with HIV are vulnerable to
a variety of fungal infections. Tinea
capitis, tinea pedis and candidiasis in skin
folds all occur.
The condition of fungal mycetoma of the
foot (Madura foot) may be worse when the
patient is infected with HIV. Clotrimazole
and ketaconazole combined with surgery
can provide a cure.
Fungi, and most other organisms
associated with opportunistic infection,
themselves have an immunosuppressive
effect on the host.
HIVCM-F
28.3. Folliculitis 2. Seborrhoeic dermatitis
The woman in picture 2 presented with an
itchy rash on her face.
Picture 3 shows a close up of the upper
part of the chest of a patient with severe
HIV disease. Q. What do you notice about her
skin? Q. What abnormality do you notice on
the skin? A. She has a rash of papules, pustules,
scaly areas and hyper pigmentation. A. There is a fine
papular rash.
The rash is itchy, and it affects her face,
neck, groin and axillae. It is called
“seborrhoeic”, although the term refers
more to the appearance and distribution of
the rash than to the cause. Seborrhoeic
dermatitis can be difficult to distinguish
from psoriasis.
A fine papular rash is often found in
patients with HIV infection. The
commonest sites are the chest, the upper
arms, the neck, the face, the scalp, the
axilla and the thighs. It is itchy.
Q. What does the close-up picture of
the skin tell you about the nature
of the rash? Seborrhoeic dermatitis is common in
patients with HIV infection. It is also
common in the general population. The
dermatitis tends to become more severe,
with thick scales, as immune deficiency
worsens.
A. You can see that the hair follicles are
inflamed, so the rash is a folliculitis.
But there is little redness around the
follicles, and the inflammation is not
severe.
On examination this woman also had
generalised lymphadenopathy and scars
from recent herpes zoster. The woman and
her husband were counselled and agreed to
be tested for HIV. They were found to be
positive and a community health worker
provided support and advice.
This kind of folliculitis is not usually
caused by bacteria. It is caused by
organisms such as the yeast Pytyrosporum
orbiculare.
Penicillium marneffei is a yeast which can
cause folliculitis but may also disseminate
through the body when immunity is low.
14
Penicillosis is common in the north of
Thailand. Studies show that prophylaxis
with itraconazole is effective, but very
expensive.
Further information
Cause
Researchers believe that seborrhoeic dermatitis
is related to overgrowth of a yeast that
normally lives on the skin, Pityrosporum ovale
(also known as Malassezia furfur).
Treatment
Seborrheic dermatitis usually responds well to
steroid creams such as hydrocortisone 1%. An
anti-fungal imidazole cream may be helpful for
seborrhoeic dermatitis in addition to the steroid
cream.
HIVCM-F
29.Slide 16 Florid rash of
secondary syphilis
Farai had had a rash for one month. It was
not itchy or painful. She complained of
genital sores, and said that she had had
“chickenpox” 5 weeks ago.
Q. What lesions can you see?
A. There are some hyperpigmented
lesions on her forearms and on the
palm of her right hand.
She had dark plaques like this all over her
face and body. The lesions developed from
a pustular rash, similar to chicken pox. On
her vulva, she had florid condylomata lata.
Q. What do you think the diagnosis
could be?
A. Clinically Farai appears to have
secondary syphilis.
Serological testing showed that her VDRL
test for syphilis antibodies was negative.
Her ELISA test for HIV antibodies was
positive.
Q. Can you explain these findings?
A. She has HIV infection, which is
associated with a history of genital
ulceration and sexually transmitted
diseases. She also has syphilis, but
her immune response is impaired
because of the HIV infection, so she
has not made antibodies to syphilis.
However people with HIV infection do not
always have negative syphilis serology.
Secondary syphilis has a wide variety of
manifestations. In patients with HIV
infection, lesions such as skin rashes and
condylomata lata may be more florid than
usual, as in this woman. There is some
evidence that progression to neurosyphilis
may be more common in HIV infection.
Further information
Diagnosis
There is no simple culture system for
Treponema pallidum. The organisms may be
identified from early lesions with dark field
microscopy. But often serological tests are
necessary for diagnosis. HIV infected patients
may have false negative non-treponemal tests,
such as VDRL, despite active syphilis.
Specific syphilis tests such as the fluorescent
treponemal antibody absorption test (FIA-
ABS) may become negative in 10% of AIDS
patients. RPRs may be extremely high in HIV
infected patients compared to uninfected
patients with syphilis.
Neurosyphilis
Consider neurosyphilis in any HIV infected
patient who develops acute meningitis,
neuroretinitis, deafness, blindness, other
cranial nerve abnormalities or stroke.
Treatment
Procaine penicillin 1.5g im daily for 10 – 14
days with probenecid 500mgs qds orally
or
Benzathine penicillin 2.4 million units weekly
for three weeks.
Neurosyphilis: Penicillin G 2-4 million units 4
hourly, iv, for 15 days. Remember to treat the
sexual partner(s).
HIVCM-F
30.Summary – Skin manifestations
Skin rashes are an important feature of HIV
related illness.
A maculopapular roseola-like eruption may
occur with the seroconversion illness. It usually
disappears
within 2 weeks.
Skin manifestations may be due to neoplastic
disease, especially Kaposi’s sarcoma, or they
may be of
an inflammatory nature, such as drug
reactions, and dermatoses such as seborrhoeic
dermatitis and
psoriasis. People with HIV infection may
develop psoriasis rapidly. It is a disorder in
which there is loss
of control of normal epidermal cell turnover.
There may be typical large ‘discoid’ lesions,
often on the
elbows and lower arms, with clear margins and
thick white scales, or acute pustular psoriasis.
Psoriasis
15
is not itchy. Associated arthritis may occur,
especially of the joints of the fingers and toes.
The
fingernails may show ‘thimble’ pitting.
Interestingly, spontaneous remission of
psoriasis may occur in
the terminal stage of AIDS. Steroid creams are
helpful, but methotrexate should not be used
to treat
psoriasis in people with HIV because it
suppresses immunity.
Viral, bacterial or fungal skin infections are
also common, and are more likely to be florid
and to recur
when there is immune deficiency. Viral skin
infections include herpes simplex, herpes
zoster, and
molluscum contagiosum. Molluscum
contagiosum has shiny umbilicated papules
about 2 to 3
millimetres in diameter. They tend to occur in
groups, especially around body flexures. In
people with
HIV it often appears on the face. The lesions
can be treated with local application of phenol.
Systemic infections may cause unusually florid
skin manifestations, such as the rash of
secondary
syphilis.
Generalised dry skin is a common problem in
HIV infection. It is often very itchy. Acquired
ichthyosis is
common, especially on the legs. Regular
massage with an emollient cream such as
aqueous cream is
helpful and soothing.
HIVCM-F
31.Slide 17 Genital warts
This slide shows the genitals of a woman
and a man, who both have decreased
immunity due to HIV and the same genital
infection.
Q. What causes these lesions?
A. These lesions are genital warts
caused by the Human Papilloma
Virus (HPV).
HPV infection is very common. When
immunity decreases due to HIV, warts tend
to grow rapidly and become florid.
Q. What condition might HPV warts
be confused with?
A. With condylomata lata of secondary
syphilis.
Even in a busy outpatient clinic it is
important to conduct a quick general
examination when a patient presents with
local signs.
Further Information
Treatment
If cryotherapy using liquid nitrogen is
available then this is an effective treatment.
If not, the health worker can apply
podophyllum (an antimitotic agent) in a
concentration of 10 to 25% in Tinct.Benz. Co.
carefully to the warts only. Wash off after 4
hours. Apply twice a week. This is best in
early or extensive infection. Do not use
podophyllin in pregnancy.
Other options are trichloracetic acid (safe in
pregnancy) or electrocautery for persistent
lesions.
Warts that have a ‘stalk’ can be snipped off
with scissors.
HIVCM-F
32.2. Vaginal candidiasis Slide 18
1. Genital herpes simplex Picture 2 shows the cervix
of an HIV
infected woman, seen with the aid of a
speculum. Picture 1 shows the vulva of a woman with
HIV related disease.
Q. What abnormalities do you notice? Q. What
abnormalities do you notice? A. There is a thick white
exudate on the
cervix and right vaginal wall. The
cervix is inflamed.
A. There are many superficial ulcers and
some blisters. The mucosa and
surrounding skin is red and inflamed.
There is a moist exudate from the
ulcers.
Q. What is the diagnosis?
A. Vaginal candidiasis (thrush) and
cervicitis. Q. What is the likely cause of these
ulcers? This woman’s cervix was friable – that is it
bled when gently wiped with a swab. A. Herpes simplex
virus.
Women with immunodeficiency due to
HIV infection may present with severe,
chronic or recurrent genital herpes
simplex. Because herpes simplex can be
fatal to newborn babies, Caesarean section
is indicated when a pregnant woman has
active genital herpes at term.
Q. What do you notice about her
perineal area?
A. She also has warts around her anus.
Vaginal candidiasis is an early feature of
symptomatic HIV infection in women. Of
course, vaginal candidiasis is also a
common condition in otherwise healthy
16
women. Predisposing factors include
antibiotic therapy, pregnancy, the
contraceptive pill and diabetes.
Further information
Treatment
Oral acyclovir is effective treatment, but
very expensive, and not widely available.
Genital herpes is a very painful condition
so analgesia is important. Cleanliness and
a local antiseptic such as chlorhexidine
cream help to prevent secondary bacterial
infection.
Further information
Treatment
If possible, treat both partners, because
candida can be spread by sexual intercourse.
There are several effective topical applications:
clotrimazole, econazole, miconazole and
nystatin. One effective regime is one nystatin
pessary (100,000 units) or nystatin cream
(100,000 units/4g) inserted high into the
vagina once daily for 7 days. If these pessaries
or creams are not available, the vagina can be
painted with Gentian violet daily. Warn
patients that Gentian violet stains clothes. If
topical treatment fails it may be necessary to
prescribe oral nystatin 500,000 units 3 times
daily for 10 days.
HIVCM-F
33.Slide 19 Cervical neoplasia
This picture shows the cervix of an HIV
infected woman magnified at colposcopy.
It has been painted with dilute acetic acid.
Q. What do you notice about the
appearance of the cervix?
A. There is a pale area around the os.
This lesion is an area of abnormal cells
which contains some cells which are
malignant. These abnormal cells show up
more clearly when painted with acetic
acid. A biopsy of this area later showed
early invasive carcinoma.
Q. What virus is associated with the
development of carcinoma of the
cervix?
A. Human Papilloma virus (HPV).
There is a high prevalence of HPV
infection in HIV infected women. In
countries where cervical cytology
screening is performed gynaecologists
have found that HIV infected women have
a much higher incidence of abnormal and
malignant cells.
Women with more advanced HIV related
disease are more likely to have cervical
abnormalities. HIV infection seems to
make it more likely that HPV infection of
the cervix will lead to malignancy.
If possible, HIV infected women should be
offered a smear for cervical cytology every
6 months.
HIVCM-F
34.Summary – Gynaecological
manifestations
Many studies show that HIV infected women
have a high risk of treatable gynaecological
conditions 7 .
Urinary tract infections are also more common.
Always ask HIV seropositive women about
gynaecological and urinary symptoms and
examine them carefully.
Women are sometimes treated for vaginal
candidiasis when they complain of vulval
itchiness and
irritation, without examination. It is important
to examine thoroughly women who complain
of a
discharge. Proper exposure, usually in the
dorsal position, with a good light to view the
vulva, introitus,
urethra, vagina and cervix is essential.
Discharges due to Neisseria gonorrhoea,
Trichomonas vaginitis,
and Gardnerella vaginalis have all been found
to be more common in HIV infected women.
Pelvic inflammatory disease is also more
common and more severe in HIV infected
women. PID
presents with a history of lower abdominal
pain, backache, fever and sometimes vaginal
discharge.
Examination findings include tenderness of the
lower abdomen, tenderness in the vaginal
fornices and
pain when the cervix is gently tipped with the
examiner’s finger. Gonorrhoea and chlamydia
are the
most common causes, but other organisms
may be involved, including anaerobes. Early
treatment is
important to prevent complications and
chronic infection. Treatment needs to cover a
broad range of
organisms. Several regimes are suitable. An
acceptable regime is ampicillin 500 mgs orally
8 hourly or
erythromycin 500 mgs orally 6 hourly,
together with metronidazole 400 mgs orally,
12 hourly with food,
17
all for 14 days. Analgesics, fluids and rest are
also important. If the patient is very ill give
intravenous
antibiotics in hospital. If you suspect
septicaemia, add gentamicin to the regime.
Amenorrhoea may occur in HIV infection, as in
any debilitating illness. Stress associated with
the
diagnosis may lead to menstrual irregularities,
but most studies have not found menstrual
abnormalities
to be a feature of HIV infection.
In some parts of Africa women may douche
regularly, or put substances in their vagina to
clean the
vagina or to make the vagina dry and ‘tight’
because of beliefs that friction increases the
pleasure of
sex. Regular douching, or putting substances
or objects in the vagina, can increase the risk
of
infections and inflammation of the vagina and
cervix. In turn this increases the risk of
transmission of
HIV. Explain this to your patients. Teach them
that vulval hygiene is important but that the
vagina itself
is self- cleaning. Cloths or cotton wool put in
the vagina at menstruation should be very
clean.
7 Hankins CA, Handley MA.HIV disease and
AIDS in women: current knowledge and a
research agenda. J
Acquir Immune Defic Syndr. 1992
Oct;5(10):957-71.
HIVCM-F
35.Slide 20. Cytomegalovirus
chorioretinitis
This slide shows the retina of a patient
with AIDS seen through a fundoscope. He
complained of blurred vision, and that he
saw dots floating in front of his left eye.
His eye was not painful. On examination
the doctor found blind spots in his visual
fields.
Q. What is the appearance on
fundoscopy?
A. There are creamy white granular
areas with exudates and perivascular
haemorrhages.
This appearance is sometimes called
“cottage cheese (curd) and tomato sauce”.
The right eye was normal. Unfortunately
the retinitis progressed with necrosis of the
retina and the patient lost the sight of the
left eye.
Chorioretinitis due to cytomegalovirus is
the most common severe ocular
complication of HIV infection. It is
usually a late complication when the CD4
cell count is very low.
Without treatment CMV retinitis causes
blindness in a few weeks. Toxoplasma and
Candida albicans retinitis may look like
CMV retinitis.
HIV infected patients suffer a variety of
eye problems which include dry eyes,
conjunctivitis and early presbyopia. They
may have eye disease that does not cause
symptoms so examination of the eyes is
important.
Further information
Treatment
The antiviral drug ganciclovir is effective but it
is very expensive and not widely available.
The initial dose of ganciclovir is 5 mgs / Kg iv
12 hourly for 10-14 days, followed by
maintenance therapy of 30 mgs / kg / week in
3 or 5 divided doses. The relapse rate is very
high without maintenance therapy.
HIVCM-F
36.Slide 21. HIV neurological
disease
Picture 1 is a photograph of a sculpture
from the national gallery of Zimbabwe.
Teacher’s Note
Ask the audience to describe the sculpture and
what they think it represents. They might talk
about sadness, anxiety or depression.
Figure 5. The first symptoms of HIV
dementia are loss of concentration and
poor memory. We are using this photograph to illustrate
the problem of HIV related dementia,
which occurs when HIV infects the nerve
cells.
The first symptoms someone with HIV
may notice are forgetfulness, loss of
concentration and slowness of thought.
The person may feel depressed. They may
develop poor balance, and weakness of the
legs. Their gait becomes wide-based and
ataxic, and they may develop a tremor.
On examination there will be brisk reflexes
and leg weakness. The condition may
progress slowly or rapidly to severe
dementia. The patient eventually becomes
bedridden and incontinent.
Q. What abnormalities can you see in
the CT scan of the brain of
someone with HIV dementia in
18
picture 2?
A. This CT scan shows cortical cerebral
atrophy. The ventricles are enlarged.
The EEG showed diffuse bilateral slowing.
HIVCM-F
37.Further Information Slide 22
Cause
1. Facial palsy Recent research provides strong evidence
that
herpes simplex is the cause of Bell’s palsy 8 . This woman
presented to the clinic
because her friends said that her face
looked strange. She complained that she
had had pain behind the ear for a day and a
fever.
The herpes simplex virus remains dormant in
the geniculate ganglion cells. It then
reactivates and replicates to induce
inflammation in the geniculate ganglion and
the labyrinthine region of the facial nerve.
Animal experiments show that HSV can
induce facial paralysis. Polymerase chain
reaction assays have detected HSV DNA in
geniculate ganglia in the facial nerves of Bell's
palsy patients.
Q. What is wrong with her face?
A. Her face is asymmetrical. She cannot
raise her right eyebrow and the right
side of her mouth turns down when
she tries to smile. Treatment
Acyclovir combined with prednisone may be
effective in improving facial function. It is also
important to protect the eye from drying at
night. Paracetamol can be used to treat pain 9 .
On examination the voluntary and
involuntary movements of the muscles of
the right side of his face were impaired,
and she was drooling a little from the right
side of her mouth. Ramsey Hunt Syndrome
Ramsey Hunt syndrome is similar to Bell's
palsy and is also more common in people with
HIV infection. It is a form of shingles
("herpes-zoster oticus"), caused by reactivation
of the varicella zoster virus (VZV, the virus
that causes chicken pox). Like HSV, VZV is a
highly neurotropic virus that travels along the
sensory nerves to establish latency at the
sensory ganglia.
Q. What is the diagnosis?
A. She has a facial palsy, sometimes
called “Bell’s palsy”.
Q. What nerve has been damaged?
A. The seventh cranial nerve, also
known as the facial nerve.
The first symptom is usually severe pain felt
inside the ear. There may also be a fever,
headache, localized tenderness and enlarged
lymph nodes. Blisters usually appear in the ear
a day or so later. They may last 2 - 5 weeks,
and can be quite painful. Pain and dizziness
associated with Ramsey Hunt syndrome may
last for several weeks or months. The auditory
nerve may also be affected resulting in hearing
loss.
She also had generalised lymphadenopathy
and an itchy papular rash. These three
“clues” alerted the doctor to the possibility
of HIV infection. He counselled the
woman, and with her consent, tested her
blood for HIV antibodies. The result was
positive.
Bell’s palsy occurs early in the course of
HIV infection. The paralysis usually starts
to recover within 2 weeks, and about 80%
recover completely within 3 months. In
some cases, however, the symptoms
persist.
8 Schirm J, Mulkens PS. Bell's palsy and herpes
simplex virus. APMIS. 1997;105(11):815-23.
Coker NJ.Bell palsy: a herpes simplex
mononeuritis? Arch Otolaryngol Head Neck Surg.
1998;124(7):823-4.
9 Grogan PM, Gronseth GS. Practice parameter:
Steroids, acyclovir, and surgery for Bell's palsy (an
evidence-based review): report of the Quality
Standards Subcommittee of the American Academy
of Neurology. Neurology. 2001;56(7):830-6.
HIVCM-F
38.2. Opportunistic infections Further information
Diagnosis of cryptococcal meningitis This computerised
tomography (CT) scan
of the brain belongs to a different patient.
This patient had received an injection of
contrast media before the scan.
India Ink staining of the CSF to show
encapsulated yeasts has been found to be both
a sensitive and specific diagnostic test. The
cryptococcal antigen titre test has superior
sensitivity. The organism may also be cultured
from CSF. The CSF may be normal or may
show mild pleocytosis, lowered glucose and
raised protein.
Q. What abnormality do you notice?
A. There is a focal lesion with contrast
enhancement which suggests a
walled cyst. Treatment Q. What might cause a focal
cerebral
lesion like this? Toxoplasmosis:
Pyrimethamine 50 – 100 mg loading dose, then
25 – 50 mgs orally daily + Sulphadiazine 1
19
gram 6 hourly orally or intravenously.
A. This is toxoplasmosis. It might also
be a tuberculoma or a cerebral
abscess.
Cryptococcus: Cerebral toxoplasmosis is usually a
reactivation of a previous infection, so
most patients are already seropositive and
do not develop rising titres of antibodies.
The clinical features are headache, fever,
seizures and focal neurological signs.
Diagnosis is on clinical grounds.
The outcome of cryptococcal meningitis is
improved if a combination of Amphotericin
and Flucytosine is used as initial therapy and
Fluconazole is reserved for maintenance.
Initial therapy:
1. Amphotericin B 0.7 mgs/Kg/day iv for
one week, after a 1 mg test dose. Cryptococcal meningitis
may also present
with headache. Cryptococcus neoformans
is the commonest opportunistic pathogen
to infect the brain. Cryptococcal
meningitis occurs late in the course of HIV
disease.
2. Amphotericin B 0.7 mgs/Kg iv three
times a week after the first week, for a
further 4 – 6 weeks depending on
response.
3. Flucytosine 100 mgs/Kg/day or iv in 3 –
4 divided doses for the duration of
Amphotericin B therapy. Headache and decreased
conscious level
are common but focal signs and neck
stiffness are uncommon so it is important
to think of the diagnosis. The organism
may also disseminate to the lungs, kidneys,
skin, fundi and other organs.
Maintenance therapy:
Fluconazole 400 mgs/day orally for 4 – 6
weeks, until 10 weeks from the start of
therapy.
Knowledge of the CD4 white cell count
may help to indicate the cause of infectious
neurological presentations of HIV
infection. Toxoplasmosis and
Cryptococcus can occur at counts less than
200 x 10 6 /l. CMV neurological disease
usually occurs at CD4 counts less than 50
x 10 6 /l.
HIVCM-F
39.Summary - Neurological manifestations
HIV can infect the glial cells in the central
nervous system and cause neurological
problems. The CNS
may also be affected by opportunistic
infections and tumours.
Acute neurological manifestations may
occur at the time of seroconversion. These
include acute
neuropathies with motor and sensory
impairment of arms and legs; acute
meningitis; and acute
encephalopathy - fever, malaise, changes of
mood and fits, with recovery after one week.
Neurological manifestations often occur late in
the course of HIV infection. Dementia (HIV
associated
dementia complex or HIV dementia) is the
commonest problem, but almost any
neurological symptoms
may occur. If a patient presents with any
unexplained neurological signs or symptoms,
suspect HIV
infection, examine the patient for other signs
of infection, and test for HIV antibodies.
Psychiatric disorders are an important
differential diagnosis in neurological disease.
Organic and
psychiatric diseases often occur together.
HIV may directly infect the spinal cord so
myelopathy is often associated with HIV
dementia.
Symptoms are paraesthesia and leg weakness.
Signs include paraparesis with or without
spasticity and
ataxia.
Peripheral neuropathy is a common
neurological disorder in AIDS. The most
common pattern is a
symmetrical, distal, sensory neuropathy which
is often painful. Mononeuritis and the Guillain-
Barre
syndrome may occur.
The combination of peripheral neuropathy and
myelopathy can lead to an extensor plantar
response
with absent ankle jerks. This used to indicate
Vitamin B12 deficiency, but it is now important
to think of
HIV disease.
Patients with atypical aseptic meningitis
present with headache, fever and meningeal
signs. They
may also have involvement of cranial nerves,
most commonly the fifth, seventh and eighth
cranial
nerves. The meningitis may recur or be
chronic.
20
The autonomic nervous system is often
damaged in people with HIV related illness.
An AIDS related neurological condition called
progressive multifocal leuco-
encephalopathy is
thought to be due to reactivation of Japanese
Encephalitis virus in immunosuppressed
individuals.
Primary cerebral lymphoma occurs late in
HIV infected patients. It causes about 15% of
AIDS related
lymphoma. It is related to Epstein Barr virus
infection. It can be difficult to know whether
the patient
has cerebral lymphoma or cerebral
toxoplasmosis because the symptoms and
signs may be the same.
HIVCM-F
40.Review of history and examination Review of
history and examination
You have seen that many of the signs and symptoms
of HIV infection are non-specific.
It is important to be alert to the possibility of HIV
infection in anyone who
presents with any of the signs or symptoms
mentioned.
You have seen that many of the signs and symptoms
of HIV infection are non-specific.
It is important to be alert to the possibility of HIV
infection in anyone who
presents with any of the signs or symptoms
mentioned.
Always take a careful history from the patient. Always
take a careful history from the patient.
Q. What specific questions will you ask? Q. What
specific questions will you ask?
A. Do you have a cough? fever? diarrhoea? A. Do
you have a cough? fever? diarrhoea?
• How long have you had these symptoms for? •
How long have you had these symptoms for?
• Do you have night sweats? • Do you have night
sweats?
• Have you been losing weight? • Have you been
losing weight?
• Have you been feeling weak? • Have you been
feeling weak?
• Have you had any rashes or itchiness? • Have you
had any rashes or itchiness?
• Have you had sores on the genitals in the previous
six months? • Have you had sores on the genitals in
the previous six months?
• How is your spouse/partner? • How is your
spouse/partner?
• How is your baby? • How is your baby?
You must also examine the patient carefully,
particularly You must also examine the patient
carefully, particularly
• the skin • the skin
• the neck, axillae and elbows for enlarged nodes •
the neck, axillae and elbows for enlarged nodes
• the eyes • the eyes
• the mouth • the mouth
• the chest • the chest
• abdomen, • abdomen,
• genitals, and • genitals, and
• neurological system. • neurological system.
If you suspect HIV infection on clinical grounds it is
essential to discuss this carefully
with the patient, counsel them, and test for HIV
antibodies only with the patient’s
consent.
If you suspect HIV infection on clinical grounds it is
essential to discuss this carefully
with the patient, counsel them, and test for HIV
antibodies only with the patient’s
consent.
HIVCM-F
41
HIVCM-F
41.Chronology of HIV related disease
Immune deficiency:
Early Intermediate Advanced
CD4 > 500 500 > CD4 > 200 CD4<200
HIVCM-F
42.Slide 23 Treatment for HIV
infection
Although there is no cure for HIV
infection, there are treatments for the relief
of HIV related symptoms and treatment for
opportunistic infections, which we have
mentioned in this slide set.
Antiretroviral (ARV) drugs that prevent
the replication of HIV began to be
introduced in 1986. In richer countries
people with HIV are now living much
longer because they take combinations of
ARV drugs.
ARV drugs lower the viral load – so
people taking them are less likely to infect
others. When people know that treatment
is a possibility they are more willing to
come forward for counselling and testing
for HIV – so there is an important link
between treatment and prevention.
Q. What has happened to the cost of
ARV drugs in recent years?
A. Advocacy efforts by activists, such as
ACT UP (AIDS Coalition to Unleash
Power) have led to great reductions
21
in the prices of ARV drugs 10 . This is
both because some pharmaceutical
companies in developing countries
have begun to produce generic ARV
drugs at low cost, and because
international pharmaceutical
companies have lowered their prices
for developing countries.
This raises hopes that poor people in
developing countries will be able to have
access to these life-saving drugs.
Q. In addition to the drugs, what are
some of the other costs of
providing ARV treatment?
10 www.globaltreatmentaccess.org
A. Training of doctors and nurses,
infrastructure such as laboratories,
monitoring tests, and follow up visits.
Experiences in Brazil and Thailand have
shown that it is possible to deliver HAART
in a middle-income country. However cost
is not the only barrier to providing
effective treatment.
Q. Why do you think the tablets in the
picture are called ‘Triomune’?
A. Because they contain a combination
of 3 drugs: lamivudine, nevirapine
and stavudine.
Q. Why is it necessary to give a
combination of ARVdrugs?
Teacher’s note
You might ask the audience what other
infection requires a combination of drugs and
why. Tuberculosis is treated with a
combination of drugs because if a single drug
is
used resistance develops.
A. Because HIV mutates frequently it
rapidly develops resistance to ARV
drugs. This is less likely to happen if
3 drugs are taken at the same time.
A combination of ARV drugs is called
‘Highly active anti-retroviral therapy’ or
HAART.
Resistance
The drugs remain in the blood for different
lengths of time, that is, they have different
half-lives. So it is important that the
person remembers to take their tablets
every day, and has a steady supply. If they
do not the level of some of the drugs in the
combination will fall to a low level so that
only one drug remains in the bloodstream.
The virus then becomes resistant to this
drug and treatment may fail. The person
taking HAART needs to take at least 95%
of their doses at the correct time to prevent
treatment failure.
HIVCM-F
43.If a person on HAART plans to stop taking
the drugs they need to continue to take the
drug with the shortest half-life (in the case
of Triomune this is stavudine) alone for
three days. Otherwise resistant virus will
limit drug choices in future.
People who have previously taken a single
or double drug regimen are likely to have
resistant virus and treatment failure may
result. Combinations with only two ARV
drugs are no longer recommended.
It is possible for someone to transmit
resistant virus to another person.
When to start treatment
HIV specialists have disagreed about the
best time to start treatment with ARVs.
WHO/UNAIDS currently recommend
HAART for all those who have WHO
stage IV disease, and those with WHO
stage I, II, or III with CD4 cell counts <
200/mm 3
If CD4 testing is not available those with
stage II or III disease with a total
lymphocyte count of 1200/mm 3 or less
should be treated, as well as those with
stage IV disease 11 .
HAART is not recommended for PLWH/A
without symptoms who have a CD4 white
cell count >350/ mm 3 . Recommendation
for therapy for those with CD4 counts
between 200 and 350/ mm 3 , depends on
the wishes of the patient, the affordability
of the drugs, and the rate of decline of the
CD4 count.
WHO / UNAIDS have produced useful
guidelines with advice on drug regimens,
monitoring, adherence and drug
interactions 10 .
11 WHO. Scaling up antiretroviral therapy in
resource-limited settings: Guidelines for a public
health approach. WHO/HIV/2002.02
Where treatment programs for tuberculosis
are in place these offer an opportunity to
integrate treatment of HIV with ARV
drugs.
Q. What services need to be in place
before starting to offer HAART?
A. UNAIDS recommend that the
following services be in place:
• Access to VCT for HIV and follow up
counselling
22
• affect the central nervous system.
Identification and treatment of
common HIV related illnesses and
opportunistic infections (OIs)
• Reliable laboratory services for
monitoring of side-effects and the
effect of therapy
• Reliable and affordable supply of
quality ARVs and drugs for the
treatment and prevention of OIs
• Careful clinical evaluation and
confirmation of HIV infection, and
baseline laboratory investigations
Further Information
Types of antiretroviral drugs
The WHO Model List of Essential
Medicines now includes 12 ARV drugs:
Nucleoside reverse transcriptase inhibitors
Abacavir (ABC)
Didanosine (ddI)
Lamivudine (3TC )
Stavudine (D4T)
Zidovudine (ZDV or AZT)
Non-nucleoside reverse transcriptase
inhibitors
Nevirapine (NVP),
Efavirenz (EFV)
Protease inhibitors
Indinavir (IDV)
Lopinavir + ritonavir (LPV/r)
Nelfinavir (NFV)
Saquinavir (SQV)
HIVCM-F
44.Side effects
Nucleoside reverse transcriptase inhibitors
Nausea, vomiting, abdominal pain and
distension, and generalised weakness may
occur due to lactic acidosis. This may lead to
breathing difficulties and respiratory failure.
The drug should be stopped if lactic acidosis is
suspected. Abacavir may cause a fatal
hypersensitivity reaction in 3 – 5% of patients.
If a reaction is suspected the drug should be
stopped and never given again.
Non-nucleoside reverse transcriptase
inhibitors
Skin rashes are common. They may be mild or
progress to Stevens-Johnson syndrome. Liver
function tests may become abnormal and there
have been rare fatal cases of hepatitis.
Nevirapine must be given 200 mgs once daily
for 2 weeks and then increased to 200 mgs
twice daily to reduce the incidence of
hepatotoxicity. Efavirenz is teratogenic and
should be avoided in pregnancy; it may also
Protease inhibitors
Side–effects include insulin resistance,
diabetes mellitus, hyperlipidaemia,
lipodystrophy, hepatitis, and bone disorders.
It is important to monitor patients on HAART
for side-effects with regular complete blood
count, serum alanine or aspartate
aminotransferase, serum glucose and serum
creatinine and/or blood urea, every 3 to 6
months.
Interrupted dosing regimens
Studies are underway to see whether
interrupted courses of HAART will be
effective. When someone stops taking
medication the level of HIV in their blood
starts to increase. At first the virus may be
resistant to the antiretroviral drugs that the
person has taken. But after a time the new
mutations of the virus are no longer resistant to
the drugs. When the person begins to take the
drug combination again the new HIV
mutations are susceptible to the drugs and
replication is rapidly controlled. An
interrupted regimen would be less expensive
and allow the person a break from the side-
effects of the drugs and from the discipline of
taking the drugs.
Possibilities for low cost monitoring
HIV antibody tests, viral load assays, CD4
and lymphocyte counts, full blood counts,
liver and renal function tests are useful for
monitoring HIV disease, treatment response
and side-effects to ARV drugs.
Researchers are developing lower cost tests for
monitoring in resource poor settings. The gold
standard for CD4 testing is flow cytometry,
which is expensive and the equipment difficult
to maintain. Enzyme Linked Immunosorbent
Assay (ELISA) or Dynabeads can be used to
calculate the number of CD4 cells more
cheaply. The Dynabeads method is less
expensive and needs less equipment. In this
test, the Dynabeads attract CD4 cells, other
cells are removed and the CD4 cells are
stained and counted.
Researchers have developed an ultrasensitive
ELISA assay for p24 antigen, a core antigen of
HIV. The assay includes an immune-complex
dissociation step, so free p24 and p24 bound to
host antibody are both detected. The assay can
detect p24 down to a level of 1500 fg/ml. This
assay can be used as a much cheaper
alternative to the PCR to detect HIV and
determine the viral load 12 .
23
Discussion point
Teacher’s Note
Antiretroviral drugs are also used in a short
course
as prophylaxis to lower the risk of transmission
of
HIV from a pregnant woman to her baby (see
slide
set “Parent to child transmission of HIV”).
Some
have suggested that programs to prevent
mother to
child transmission of HIV (PMTCT) are a good
place
to introduce HAART 13 . In many settings the
ante-
12 Shupbach J, Varnier OE. HIV-1 p24 antigen - a
sensitive and precise, yet inexpensive alternative to
PCR for viral DNA or RNA. Newsletter.
International AIDS Society 15:9-11, 2000.
http://hivinsite.ucsf.edu/InSite.jsp?page=kb-02-02-02-
02
13 Rosenfield A, Yanda K. AIDS treatment and
maternal mortality in resource-poor countries. J
Am Med Womens Assoc. 2002;57(3):167-8.
HIVCM-F
45.natal clinic is the only place that VCT for HIV
is
available, and there is a natural desire to
prolong
the life of infected mothers with the additional
beneficial effects on the survival, health and
well-being
of their children. If you have time ask your
audience what issues need to be considered in
order to minimise unintended harms from this
approach. The following notes may help to
facilitate
the discussion.
Resistance: Where VCT with ARV
prophylaxis has been available for two years or
more there will be increasing numbers of
women attending ante-natal care who are not
naïve to ARV drugs. Careful thought needs to
be given to how to avoid the rapid production
and dissemination of drug-resistant virus if
95% adherence cannot be achieved.
Impact on ante-natal care services: If the ante-natal
clinic is to be the setting for delivery of
HAART there will be a need for greatly
increased resources if other maternal health
services are not to suffer.
Sustainability: Unless her husband /
partner is also provided with HAART a
woman may want, or be pressured, to give
her drugs to her husband, and to her other
children, if they are infected. It may also
be difficult for a women to receive ART if
other extended family members also need
treatment. In each setting budget
calculations need to be made on the basis
of a life-long commitment to treatment for
not only the woman but for her family.
Where HAART is to be introduced it should be
available to all infected with HIV who meet
the clinical / laboratory criteria. VCT for HIV
should be available both outside and within the
ante-natal clinic setting. Men need to be
encouraged to attend for one visit to the
antenatal clinic with their wives so that they
can be counselled, and if willing, tested
together, and so that men can receive
information about the need to protect
themselves, their wife and their baby from
HIV by avoiding unprotected sex during
pregnancy and the period of breastfeeding.
Selective access: In a situation where those
infected with HIV can only access free or
subsidized HAART through the ante-natal
clinic there might be a risk that a woman may
become pregnant, or be pressured to become
pregnant, in order to access HAART for
herself and her family.
In most poor countries that have introduced
VCT during pregnancy with ARV prophylaxis
for those who test positive the service is
generally only available in the larger centres.
If access to ART begins through ante-natal
clinic VCT programs this will reinforce
existing inequities in access to health care
services.
HIVCM-F
46.Q. What can be done to address these
fears and concerns? Slide 24 Caring for the
carers A. It is important that health
professionals and volunteers receive
in-service training in the basic facts
about the virus and it’s transmission,
in the clinical presentations and
management of HIV disease, and in
counselling skills so that they feel
confident to look after their patients.
When HIV incidence rises the workload in
clinics and hospitals starts to increase.
HIV infection is a chronic condition that
often requires frequent clinic visits or
admissions. Health care workers often
become familiar with these patients.
It is also important to provide opportunities
for peer support, and for health care
24
workers to be able to talk together.
Q. What are some possible causes of
concern and stress for health care
professionals and home-based care
volunteers in relation to the HIV
epidemic?
Good personnel management is important,
so that workers know who they can talk to
if they feel stressed, and rosters well
organised so that the workload is shared. Teacher’s
Note
If your audience are health professionals who
are
already looking after patients with HIV
infection ask
them if they have stories from their experience
that
they would like to tell. If the prevalence of HIV
is
very low ask your audience to imagine what
difficulties they might face in the future if HIV
becomes more common.
All health care institutions should have
guidelines for universal precautions to
protect patients and workers from exposure
to blood borne viruses, including HIV 14 .
They should also have a clear protocol to
follow when health care workers are
exposed accidentally to HIV infected
blood. Workers need accurate information
that will reassure them that the risks of
occupational exposure are very low and
access to post-exposure prophylaxis if this
becomes necessary (see text for slide 16 of
the Virology and Transmission set)
A. Worry about lack of knowledge
about how to recognise and manage
this new illness
• Fear that they may become infected
with HIV through occupational
exposure
Home-based care volunteers should be
treated with the same respect as health
professionals. We need to recognize that
the burden of home-based care generally
falls disproportionately on women. Child
care, and preparing for the future care of
orphaned children, are important
components of home-based care programs.
• Sadness at the deaths of young patients
• A sense of powerlessness and
frustration that they cannot cure
patients with HIV
• Tiredness and stress from overwork
• Fear that they may become stigmatised
because they are known to work with
patients with HIV
• Worry about the impact of the
epidemic on their own family and
community, including fear that
members of their family and friends
may become infected.
14 CDC Public Health Service guidelines for the
management of health care worker exposures to
HIV and recommendations for post-exposure:
http://epi-center.ucsf.edu/PEP/pepnet.html • If the carer is
HIV positive it may be
confronting for them to care for others
who are dying of AIDS.
HIVCM-F
47.Appendix 1:
Other manifestations
Haematological problems
Haematological problems, especially anaemia,
are common in HIV infection. Lymphocytes,
neutrophils, and thrombocytes often decrease
in numbers.
Thrombocytopenia is a common early problem
in HIV infection. It is due to a variety of
autoimmune mechanisms. The decrease in
number of platelets is usually moderate and
often temporary. However a few patients drop
their platelet counts very low which results in
severe spontaneous bleeds. In these patients
splenectomy may be helpful. Treatment with
steroids is dangerous because they further
depress the immune system. HIV associated
thrombocytopenia may involve not only
peripheral destruction of platelets but also
primary suppression of megakaryocytes.
Serum electrolytes may be disturbed.
Hyponatraemia in AIDS patients is common. It
is usually a result of inappropriate antidiuretic
hormone secretion associated with pulmonary
and CNS disease. The adrenal glands may be
directly affected by HIV. CMV and
mycobacteria can also infect the adrenals.
Some HIV infected patients have impaired
responsiveness of the pituitary - renal axis.
Musculoskeletal manifestations
Polyarthralgia – General joint pains may
occur at the time of seroconversion and are
common in established HIV infection. The
knees, shoulders and elbows are usually
affected. The pain is not severe.
HIV associated arthritis usually involves the
knees and ankles, and is asymmetrical. There
is pain and inflammation which responds to
intra-articular injections of corticosteroids. It
is important to exclude septic arthritis before
25
treatment. People with HIV infection may
develop joint infections due to a number of
organisms including bacteria, fungi or
mycobacteria.
Sometimes an HIV infected patient may
present with sudden onset of very severe pain
in a joint without any signs of inflammation.
The painful attack may last for a few hours or
a few days. It is called “lightning pain”
syndrome.
Reiter’s syndrome – arthropathy
urethritis/cervicitis, conjunctivitis and mouth
ulcers - may occur early or late in HIV
infection.
Polymyositis – Sometimes HIV infected
patients present with proximal muscle
weakness and muscle pain, with raised serum
creatine kinase.
Cardiac manifestations
Myocarditis is often found at post mortem
examination. Early lesions (deposits) in the
coronary arteries have been reported.
Cardiomyopathy and exercise dysfunction may
occur.
Psychiatric problems
Psychological distress and psychiatric disorder
are common in people with HIV infection. An
individual’s emotional reaction to the
diagnosis of HIV infection will depend on
many factors. These include the extent of his
or her knowledge about the virus, and cultural
and religious attitudes towards disease
causation.
Appropriate counselling before and after the
HIV antibody test are essential and help to
prevent psychiatric complications. Distress at
the diagnosis may cause major depression,
persistent agitation, sleep disturbance, suicidal
ideas, and excessive guilt and remorse. Mood
change may indicate the onset of a major
depressive syndrome, or it may be a
manifestation of CNS complications of HIV.
Repeated episodes of anxiety, grief and
traumatic stress reactions may occur as
physical health deteriorates. Anxieties about
death may be present even in the early stages
of infection. These need to be sensitively
discussed with the patient.
If an HIV infected person receives treatment
for depression with tricyclic anti-depressants,
give a lower dose than normal because these
patients may have more severe anticholinergic
effects than expected.
HIVCM-F
48.HIV infection and ‘tropical’ diseases
It is now clear that HIV and parasitic
infections interact with each other 15 . Parasitic
diseases worsen the natural history of HIV
infection and may make people more
susceptible to infection with HIV. HIV
infection increases the frequency and severity
of infection with parasitic diseases. HIV
infection may also make it more difficult to
diagnose parasitic diseases and reduce the
efficacy of their treatment. Parasitic diseases
activate cell-mediated immunity with specific
activation of the T helper (Th)2 type, thus
increasing replication of HIV. Control of
parasitic diseases should be a component of
HIV prevention strategies.
Malaria
Recent evidence demonstrates interactions
between malaria and HIV infection. PLWH/A
are more likely to experience clinical malaria
with increased frequency and severity,
especially during pregnancy 16 . Acute malaria
increases the replication of HIV, leading to
higher plasma viral loads. This is most serious
in pregnant women, where HIV infection
increases the risk of placental malaria, leading
to increased infant morbidity and mortality.
The higher maternal viral load increases the
risk that HIV will pass to the baby.
Those who inject drugs may become infected
with both malaria and HIV through sharing
contaminated needles and syringes 17 .
As with tuberculosis, the HIV epidemic has the
potential to increase the spread of malaria
across communities. Public health
surveillance and control programs need to be
strengthened 18 .
Leishmaniasis
Leishmaniasis is caused by a protozoa. There
are about 15 million cases of leishmaniasis in
the world and about 2 million new cases of
leishmaniasis develop each year.
Leishmaniasis and HIV infection overlap in
many parts of the world, including East Africa,
India, Brazil and Europe. The main clinical
condition in co-infections with HIV and
leishmaniasis is visceral leishmaniasis (kala
azar). Leishmania amastigotes multiply in
macrophages, which are also HIV target cells
in the early stages of viral infection.
A strong cell-mediated immune response is
needed to control leishmaniasis. In HIV
infection this is destroyed and the leishmania
parasites increase and travel throughout the
body.
Visceral leishmaniasis may appear as an
26
opportunistic infection with CD4 cell counts
less than 200 × 10 6 /l. People with
leishmaniasis and HIV have a worse outcome
for both diseases than those with only one
infection.
Clinical diagnosis of leishmaniasis is difficult
in people with HIV. The characteristic pattern
of fever, splenomegaly and hepatomegaly is
present in only about 50% of cases. As HIV
infection progresses leishmania parasites can
multiple in many places including gastro-intestinal
tract, larynx, lung and peritoneum.
Treatment is with pentavalent antimonials.
Other treatments include amphotericin B.
Side–effects are often greater in HIV
infected patients. The mean survival is
shorter in patients with HIV infection.
15 Harms G, Feldmeier H.HIV infection and
tropical parasitic diseases – deleterious interactions
in both directions? Trop Med Int Health.
2002;7(6):479-88.
Trypanosomiasis
There has been no association reported
between HIV infection and Trypanosoma
brucei. In one study HIV positive patients 16 Rowland-
Jones SL, Lohman B.Interactions
between malaria and HIV infection-an emerging
public health problem? Microbes Infect.
2002;4(12):1265-70.
18 Corbett EL, Steketee RW, ter Kuile FO, et al.
HIV-1/AIDS and the control of other infectious
diseases in Africa. Lancet. 2002;359(9324):2177-87.
17 Chau TT, Mai NT, Phu NH et al. Malaria in
injection drug abusers in Vietnam. Clin Infect Dis.
2002;34(10):1317-22.
HIVCM-F
49.were more likely to relapse after treatment
with DFMO.
Yaws, bejel and pinta
Yaws is a disfiguring and disabling non-
venereal endemic treponematosis. It is caused
by a spirochaete of the same family as the
organism that causes syphilis. It used to be
one of the most common skin diseases in
tropical countries until mass treatment
campaigns in the 1950s and 60s dramatically
reduced its incidence. However some endemic
foci of yaws, and the other treponematoses,
bejel and pinta, remain. Recently there has
been a resurgence in several parts of the world,
including South East Asia and the western
Pacific. Yaws is found in rural areas among
people who live in poor hygienic conditions,
with little or no access to health services.
Dutch authors who describe an outbreak of
yaws in Indonesia are worried that the rapid
spread of HIV infection may increase the
spread and severity of yaws. They fear that
immunodeficiency would reactivate latent
treponemal infections in the same way as
tuberculosis.
Typhoid
In endemic areas the incidence of Salmonella
typhi and Salmonella paratyphi infection in
patients with HIV is higher than in the general
population. These organisms commonly cause
fulminant diarrhoea, colitis, collapse and death
in patients with HIV infection.
Intestinal helminths
Infection with intestinal helminths increases
activation of T cells and other cells that have
HIV receptors. This activation can increase
viral replication and damage to the immune
system in HIV positive people.
In a study in Ethiopia HIV viral load was
found to be higher in people who had helminth
infections compared to those who did not. The
higher the parasite load, the higher the HIV
viral load. The viral load was shown to
decrease after antiparasitic treatment.
Schistosomiasis
This is the second most common tropical
disease after malaria. It affects 200 million
people in Africa, Asia, South America and the
Caribbean. It is not yet clear whether
schistosomiasis has a negative effect on the
course of HIV infection. Recent evidence has
suggested that genital schistosomiasis, which
causes thinning and ulceration of the genital
area, might be a risk factor for transmission of
HIV.
Onchocerciasis and lymphatic filariasis
There is little evidence for an interaction
between these diseases and HIV.
Leprosy
A large study in Malawi has not found leprosy
to be more common in people infected with
HIV than in others. However leprosy has a
long incubation period (2-5 years for
paucibacillary disease and 8-12 years for
multibacillary disease). So it is possible that
the patient will die of HIV related illness
before there are clinical effects from
Mycobacteria leprae.
Cell-mediated immunity is decreased in
patients with lepromatous leprosy. Evidence
from India shows that in a co-infection with
HIV, the lesions may be florid, progressive and
highly resistant to antileprotic therapy.
Tuberculoid leprosy patients have strong
27
immune resistance. This is shown by positive 11. Oral hairy leukoplakia
skin tests and in vitro lymphocyte 12. Pulmonary tuberculosis, within the past
transformation to Mycobacteria leprae. year
Because HIV damages this cell-mediated 13. Severe bacterial infections (i.e.
immune resistance it may act as a trigger to pneumonia, pyomyositis)
convert patients with tuberculoid to *
lepromatous leprosy. Weight loss of > 10%, plus either unexplained
HIVCM-F chronic diarrhoea (> 1 month), or chronic weakness
50.Clinical stage IV Appendix 2. 14. HIV wasting and unexplained prolonged fever (> 1 month).
syndrome, as defined by .
CDC Clinical findings of disabling cognitive and/or
* motor dysfunction interfering with activities of
WHO staging system for HIV daily living, progressing over weeks to months, in
infection and disease in adults the absence of a concurrent illness or condition
and adolescents (interim other than HIV infection that could explain the
proposal) findings.
15. Pneumocystis carinii pneumonia HIVCM-F
16. Toxoplasmosis of the brain 51.Appendix 3:
17. Cryptosporidiosis with diarrhoea > 1 Issues in management of
month people living with HIV/AIDS
18. Cryptococcosis, extrapulmonary Clinical stage 1: *
1. Asymptomatic 19. Cytomegalovirus disease of an organ Management of patients with HIV
other than the liver, spleen or lymph infection presents many difficulties.
nodes 2. Persistent generalised Although there is no cure for the disease,
lymphadenopathy people living with HIV/AIDS (PLWH/A)
20. Herpes simplex virus infection, can be helped a great deal with
mucocutaneous > 1 month, or visceral symptomatic treatment, support and skilled
any duration Clinical stage II: counselling. It is necessary to develop
3. Weight loss, < 10% of body weight 21. Progressive management policies so that the best use
multifocal can be made of the resources available.
leukoencephalopathy 4. Minor mucocutaneous Patients with AIDS will require frequent
manifestations admission to hospital. Many more patients
(seborrhoeic dermatitis, prurigo, fungal will present as out-patients with HIV
nail infections, recurrent oral related signs and symptoms. It is
ulcerations, angular cheilitis). necessary for health service planners to
22. Any disseminated endemic mycosis prepare policies for different
(i.e. histoplasmosis, contingencies 19 . Encourage discussion of
coccidioidomycosis) the following issues:
5. Herpes zoster, within the last 5 years 23. Candidiasis of Counselling
the oesophagus, trachea, This is an extremely important part of
bronchi or lungs 6. Recurrent upper respiratory tract management of patients with HIV
infections (i.e. bacterial sinusitis) 24. Atypical infection, and their families. Some useful
mycobacteriosis, resources on the subject of counselling are
disseminated shown in Appendix 4.
25. Non-typhoid Salmonella septicaemia Clinical stage III The availability of well-informed and
26. Extrapulmonary tuberculosis 7. Weight loss, > 10% objective supportive counselling without
body weight judgement can improve well-being and
27. Lymphoma 8. Unexplained chronic diarrhoea, > 1 assist PLWH/A to live productive lives.
month 28. Kaposi’s sarcoma Health care consultations provide an
9. Unexplained prolonged fever opportunity to give information, and to talk
(intermittent or constant), > 1 month 29. HIV about prevention. PLWH/A may also need
encephalopathy, as defined by good advice and access to methods of
CDC contraception. Those who inject drugs
. need advice and support. They may need
10. Oral candidiasis (thrush) referral to drug substitution and

28
rehabilitation services if these are
available. If they continue to inject it is
essential to provide supplies of needles and
syringes in order to protect others, and to
counsel them about the need for safe sex.
The ‘continuum of care’
When available, voluntary counselling and
testing for HIV infection should be an
entry point to a continuum of care.
Sometimes people will be well for years
after they learn their HIV status. Others
may only learn that they have HIV when
they present with a serious opportunistic
infection or malignancy. Ideally people
with HIV related illness should be cared
for in their own home, with support from
their family, friends and community. Their
symptoms and signs should be able to be
assessed by health workers at the local
clinic or by outreach health workers. If
PLWH/A need to be hospitalised, trained
nurses and doctors, appropriate standard
treatment protocols, and essential drugs
should be available to treat the most
common opportunistic infections.
The idea of a continuum of care is that
there will be links between hospital,
clinics, community and home-based care.
This is so that people are not discharged
from hospital without any support, and are
able to be referred to specialist services
from a primary health care clinic.
The ideal of a continuum of care can only
be achieved with much consultation,
communication and coordination between
a range of stakeholders who provide care
in these different settings. It is important
to develop links between the levels of care
that may be available.
Model projects for comprehensive care
across the continuum from hospital to
community to home have been successful
in northern Thailand, which has
experienced a severe HIV epidemic.
Buddhist monks have played an important
role 10 .
* best place to care for sick PLWH/A. Most
Much of this appendix is adapted from Holmes
W, International Rescue Committee. Protecting the
Future. Kumarian Press. 2003
19 Narain JP, Chela C, van Praag E. Planning and
implementing HIV/AIDS care programmes: A step-by-
step approach. WHO Regional Office for
South-East Asia, New Delhi, India. December 1998
HIVCM-F
52.Hospital care
The opportunistic infections suffered by
PLWH/A generally respond well to
treatment, but tend to recur frequently.
This means that adults and children with
HIV may require frequent admission to
hospital. It is helpful to keep their notes on
the ward and to try to make their
admissions as short and as comfortable as
possible. Studies have found that lack of
information about the patient’s condition
and progress adds to the stress of family
members.
HIVCM-F
53
Patients with HIV do not need to be
isolated unless there are patients in the
ward with infections that PLWH/A may be
susceptible to, such as chickenpox or
hepatitis.
Arrange to see patients at regular intervals
as outpatients. Ask about medical, social
and psychological problems. Try to keep
admissions short so that the patient has as
much time as possible at home, and so that
beds remain available for other patients.
Primary health care
The skills, knowledge and supplies to
support home and community based care
need to be available at primary health care
(PHC) level. The PHC clinic should be the
contact point for referral to hospital care
and other relevant services. It is important
that staff at PHC level know when and
how to refer patients for further
investigation or treatment. Standard
treatment protocols for common problems
in PLWH/A need to include indications for
referral. Problems with communications
and transport are often obstacles to
effective referral. Inter-sectoral and
community consultation are necessary to
identify solutions to these problems.
Home-based care
Experience from many countries has
shown that home-based care is often the
patients prefer to be looked after at home.
Where HIV is common, home-based care
may be the only way to care for the large
numbers of patients when hospital services
are overwhelmed.
Home-based care requires training,
support, supervision and equipment. A
hospital may send an outreach team to
29
make home visits. More commonly a team
of volunteers are trained to provide care
and support. It is important that carers
know that they can refer patients to the
clinic or hospital when necessary.
Discharge policies need to be in place to
ensure that arrangements are co-ordinated
for home-based care before the patient is
discharged from hospital.
When a PLWH/A receives care visits, the
family and neighbours know that the
patient has AIDS. The visits raise
awareness of AIDS in the community.
This leads to useful community discussion
about the need for behaviour change.
Experience has shown that there is a strong
link between home care and community
action to prevent spread of HIV.
Discussion Point
The success of a home-based care policy
will depend on local factors which include
religious and cultural attitudes, resources
in the community and availability of
support services. Discuss the possibility of
home-based care in your local area. What
would be the obstacles? What factors
would help?
Nursing care and treatment for
symptoms
Weight loss, fever, night sweats, diarrhoea
and itchy skin disorders are common early
symptoms and signs of HIV infection.
Good nursing care such as washing,
frequent mouth washes and massage can
be a great help to patients. Nursing care
needs to include sympathetic psychological
support for patients who may often feel
frightened..Some useful treatments to lessen
discomfort from HIV related symptoms
include: •
Chlorpheniramine for itching and drug
reactions
• positive” and “ counselled about HIV
Calamine lotion for itchy rashes
• Prochlorperazine for vomiting
• Oral rehydration fluids for diarrhoea
• Analgesics, such as aspirin or
acetaminophen (paracetamol) for pain
• Aspirin or acetaminophen
(paracetamol) for fever
• Loperamide for diarrhoea
Traditional remedies may also relieve
symptoms.
Discussion point
Drugs may be in short supply. Standard
treatment policies, based on the principles
of rational, economic prescribing, need to
be worked out. Choose some of the
conditions illustrated in the slides and
work out standard treatment plans for
them, according to drug availability in
your setting.
Confidentiality
Unfortunately HIV infection carries a
stigma. We must make efforts through
education, and through our own behaviour,
to reduce this stigma. It is also important
to ensure that the patient’s diagnosis
remains confidential. You may find it
helpful to arrange staff meetings to discuss
how you can improve confidentiality at
your hospital or clinic. Involve all the staff
- porters and clerks may have access to
confidential information. Discuss with
them the importance of confidentiality.
Ensure that patients’ notes are secure. Do
not leave notes out on patients’ beds in the
ward because visitors or other patients may
read them. Explain to patients that their
records are private, including those that
they keep themselves, such as outpatient
records. They are not obliged to show them
to employers or anyone else.
Discussion Point
What information should be recorded on
outpatient cards? These cards are essential
for communication between health care
workers who may see a patient on different
occasions. It is necessary to communicate
the fact that the patient has been tested for
HIV, and whether or not they have been
counselled. However if information on
HIV status is recorded on patient held
records the patient is at risk of exposure of
his or her HIV status. Could symbols or
codes be used to record: “blood taken for
HIV antibody test”, “HIV antibody
infection”? Could a separate card be used
for information about HIV? Would any of
these methods succeed for long, or would
the public soon learn about them?
Whatever the health worker writes on the
card it is important that the patient knows
what has been written.
Nutritional support
Communication materials about nutrition
should be prepared in consultation with
PLWH/A and their carers to ensure that the
advice given is feasible, with appropriate
30
foods and methods of preparation. People
with HIV who are asymptomatic should try
to eat a variety of foods with sufficient
calories and micronutrients.
PLWH often have a poor appetite, and may
feel better if they can eat small frequent
meals. Soft foods, such as soups and
mashed bananas, are easier to eat for those
who have an inflamed throat. Many
societies have fermented foods or drinks,
either dairy-based (such as yoghurt) or
cereal-based. Fermentation increases the
digestibility of foods, increases the
absorption of micronutrients, and
decreases bacterial contamination. If a
person is too ill to eat they may need to be
fed via a naso-gastric tube.
HIVCM-F
54.Relaxation and exercise
There is evidence that stress is harmful to
the immune system, and may make HIV
disease progress more quickly. Massage
and progressive muscle relaxation can help
PLWH/A to cope and lessen feelings of
anxiety and depression. Exercise,
including walking and running, can also be
beneficial.
Palliative care
Palliative care is the care of someone who
cannot be cured and who is too sick for
carers to be able to prolong their life.
Palliative care enables people to die with
dignity. It aims to provide relief from pain
and distressing symptoms and provides
spiritual and psychological support to the
patient and their family as they prepare for
death.
Even in cultures where it is not traditional
to talk about death, people who are dying
are usually grateful for the opportunity to
talk about it.
It is important to help PLWH/A to arrange
for the care of their children after their
death, and to prepare their children for
their death. Often stigma associated with
AIDS prevents parents from telling their
children what is going on and this
contributes to the confusion and grief that
children feel when their parents die.
PLWH/A may also need help to prepare a
will, or legal advice to prevent problems
when their assets are distributed after their
death.
Common physical symptoms in the final
stages of AIDS are cough, diarrhoea, loss
of appetite and wasting, itching, weakness
and fatigue, fever, difficulty swallowing,
psychiatric symptoms – anxiety,
depression, agitation pain.
Effective management of pain is one of the
most important components of palliative
care. Pain may result from local tissue
damage to skin or organs, or may result
from pressure on or destruction of nerves.
Pain also has an emotional component. –
The person feeling the pain needs to make
the decisions about pain relief. A sense of
control is very important at this stage of an
illness.
The first step is simple analgesics such as
aspirin and acetaminophen (paracetamol),
and good nursing care to ensure that the
patient is as comfortable as possible. For
example a simple soothing cream may be
applied to inflamed rashes or the anal area.
When these measures become ineffective,
weak opioid drugs such as acetaminophen
(paracetamol) or aspirin combined with
codeine will be required. These tablets
may cause constipation.
The third step requires stronger painkillers
in the form of strong opioid drugs.
Morphine, taken by mouth as a syrup or
tablets, is the most effective drug for
palliative care. It needs to be given every
four hours, and regularly, in order to
prevent the pain returning, rather than
waiting until pain returns. Injections of
morphine (under the skin) should only be
used when the patient cannot swallow.
Intra-muscular injections are painful,
especially when the patient has reduced
muscle mass. The side-effects of morphine
are: constipation (which may be useful
when the patient has diarrhoea), nausea
and vomiting (anti-nausea treatment can be
given), drowsiness, which wears off over
time, and dry mouth (the patient will need
frequent sips of water). There is no need
to worry that the patient may become
addicted to the drug, the important aim is
pain relief. However it is not always legal
to give morphine to these patients, even
when it is available. We should advocate
strongly for morphine to be available to
patients dying from AIDS-related illnesses.
An alternative is pentazocine.
Other medicines that may be helpful
include tricyclic antidepressants for nerve
pain, steroids, anti-convulsants and anti-spasmodics.
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Restlessness that sometimes
HIVCM-F
55.The role of traditional healers accompanies dying
may be relieved by
diazepam given via the rectum. Check
first for possible treatable causes of the
restlessness such as urinary retention or
pain.
In many countries in sub-Saharan Africa
people often attend traditional healers
when ill and respect their knowledge and
power to heal. There are many examples
of traditional or spiritual healers and
modern health practitioners working
together in HIV prevention and care.
Respite care
Respite care is temporary care that enables
the usual carer to have a rest from the
stress and work of caring for an ill person.
It might be provided through a day-care
centre, a residential centre, a drop-in centre
– or as respite for carers in their own
home. When respite care is available
family and friends are more willing to care
for PLWH/A and are able to have a better
relationship with the person. Provision of
regular and reliable respite care should be
a priority for home-based care programs.
Traditional healers have been trained to
recognise and counsel HIV infected patients.
When the traditional healer gives the same
prevention advice as hospital or clinic staff,
the message is likely to be very effective.
Traditional healers may also be able to
provide important relief for HIV related
symptoms.
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