1. Dr Steve Welch Birmingham Heartlands Hospital
3rd Annual Conference of the Children’s HIV Association
‘Young People and HIV: Back to the Future’
Dr Steve Welch
Birmingham Heartlands Hospital
Friday 15 May, The Bridgewater Hall, Manchester

2. Other opportunistic infections
Steve Welch
Heartlands Hospital, Birmingham
3rd Annual CHIVA Conference
Manchester, 15th May 2009

3. Other opportunistic infections
Cases
When to start ART in OI?
Effect of OI on HIV – CMV
Areas not covered - guidance

4. Case 15 yo Recurrent pneumonia and then PcP Started kivexa, efavirenz
Good VL, CD4 response
VL undetectable for more than 1 year
CD4 400

6. 1st cxr 5/11/08

7. Why? Not adherent to medication? On wrong medication?
Should still be on septrin?
Has developed resistance to penicillin?
Susceptible because of rheumatic fever?
That’s what happens
Blame National Express

8. Effect of HAART on bacterial infections in children with HIV

9. Effect of HAART on bacterial infections in children with HIV

10. Effect of HAART on bacterial infections in children with HIV

11. Prevention of bacterial disease
HAART
Antibiotic prophylaxis
Immunisation
Immunoglobulins

12. Why? Not adherent to medication? On wrong medication?
Should still be on septrin?
Has developed resistance to penicillin?
Susceptible because of rheumatic fever?
That’s what happens
Blame National Express

13. 15yr old Zimbabwean girl In UK 2005 Unusual rash 2yrs Further work up
Nodular, pruritic
Biopsy : nodular prurigo
Hiv 1positive (mar 2006)
Further work up
Low CD4 4%(19)
Lymphadenopathy
Viral load : c/ml

14. Drug Adherence issues Kivexa/efavirenz/septrin (April 2006)
Kaletra /lamivudine/abacavir(Nov 2006)
Lamivudine (dec 2006)
Kaletra/Truvada (from January 2007)
Adherence issues
Poor drug compliance / DNA
PEG inserted Oct 2007
Poor response to treatment/ viral resistance
Counselling

16. Should she be on MAI prophylaxis?

17. MAI prophylaxis Evidence that it works:
90-95% reduction in incidence in adults by prophylaxis or HAART

18. MAI prophylaxis Recommended by US guidelines What are suitable agents?
In what circumstances?

19. MAI prophylaxis What are suitable agents? Azithromycin Clarithromycin
Rifabutin
Rifampicin
Clofazamine

20. MAI prophylaxis In what circumstances? CD4 < 50 At new diagnosis
After starting treatment until immune reconstitution
If not on treatment
If not adherent to treatment

21. Case 13 yo from Zambia Weight loss, chronic cough Bronchiectasis
Hi influenzae, pneumococcus
VL 10 million
CD4 2 (<1%)
HLA B*5701 negative
No significant resistance mutations
Now has secondary fevers
ALT 250

22. When should he start HAART?
Now
When fever abates and LFT’s back down
When fever abates
When LFT’s back down
When completely stable
Should have started before having RT and HLA result back

23. CROI 2008 Abstract142 Immediate vs Deferred ART in the Setting of Acute AIDS-related Opportunistic Infection: Final Results of a Randomized Strategy Trial, ACTG A5164 Andrew Zolopa*1, J Andersen2, L Komarow2, A Sanchez3, C Suckow4, I Sanne5, E Hogg6, W Powderly7, and ACTG A5164 Study Team
282 patients randomised to immediate (<14 days) or deferred (>4 weeks) ART
PcP 63%
Cryptococcal meningitis 13%
Pneumonia 10%
No progression and VL<50 48 v 45%
BUT 14 v 24% progression to AIDS or death, faster time to undetectable VL and VD4 >50, >100

24. CROI 2009: 36cLB Early vs Delayed ART in the Treatment of Cryptococcal Meningitis in Africa Azure Makadzange*1,2, C Ndhlovu2, K Takarinda2, M Reid2, M Kurangwa2,Vhikwasha2, and J Hakim2
54 patients randomised to early (<72 hours) v late (10 weeks) ART in cryptococcal meningitis:
Mortality 82% v 37%

25. Case 7 yo from Zimbabwe VL 2 million CD4 10 (1%)
Presents with allergic reaction to septrin
Ongoing fevers and symptoms

27. What is the likely diagnosis?
Septrin allergy
Bacterial infection
Common respiratory virus TB
Atypical Mycobacteria
PcP
Candida
Cryptococcus
Other

28. What are alternatives to septrin?

29. What are alternatives to septrin?
Dapsone
Atovaquone
Pentamidine
Fansidar (Pyrimethamine-sulfadoxine)

30. 4-month old girl
Birthweight 4.1 kg (75th centile)
Now 5.2 kg (2nd centile)
Respiratory distress, diagnosed PcP
Good response to ART. CD (35%)
When can she stop septrin?

31. AIDS 2005

32. Stopping PcP prophylaxis
Cd4>15%, 200 for 6 months
Cd4> 15%, 500 below age 5
Not in first months of life?

33. What not covered? Immunisation Guideline Other OIs - cryptosporidia
Varicella