World AIDS Day is held on 1 December each year, and strives to increase awareness of HIV/AIDS, dispel myths and misconceptions about the disease, and eradicate prejudice and stigma towards people living with HIV/AIDS. Of the estimated 33.4 million HIV-infected people worldwide, only 5.25 million have access to antiretroviral therapy in low- and middle-income countries. Each year, 2 million people die of HIV/AIDS and its complications, and 2.7 million new people become infected.
Owing to their weakened immune state, people living with HIV/AIDS are more vulnerable to infections. These so-called 'opportunistic infections' may not be fatal in a person without HIV infection; however, they are a major cause of morbidity and death among patients with low CD4 counts or who are in the advanced stages of AIDS. Opportunistic infections are caused by bacteria (e.g. tuberculosis, bacterial pneumonia), fungus (e.g. candidiasis, cryptococcosis, Pneumocystis jiroveci pneumonia), protozoan parasites (e.g. toxoplasmosis, cryptosporidiosis) and viruses (e.g. herpes simplex, herpes zoster).
In addition to opportunistic infections, people living with HIV/AIDS are susceptible to a number of HIV/AIDS-associated malignancies (cancers) such as Kaposi’s sarcoma, lymphoma, and squamous cell carcinoma. These, too, can have a devastating impact on the health status of people with HIV/AIDS, even those being treated with antiretroviral therapy.
This special collection brings together a selection of Cochrane Reviews from the Cochrane HIV/AIDS Group on the prevention and management of opportunistic infections and HIV/AIDS-associated malignancies in people with HIV/AIDS.
Children with HIV are at an increased risk of acquiring tuberculosis. Tuberculosis is a common cause of acute and chronic respiratory disease and death in HIV-infected children living in areas of high tuberculosis prevalence. Even with treatment, HIV-infected children with tuberculosis have a worse outcome than HIV-uninfected children. Hence preventing tuberculosis infection and disease in HIV-infected children is desirable and potentially an important public health intervention. Isoniazid, an anti-tuberculosis medication, has been used to effectively prevent tuberculosis in HIV-uninfected children, but there are currently no guidelines on the use of tuberculosis-preventive therapy in HIV-infected children. This review evaluates the impact of tuberculosis-preventive therapy on tuberculosis incidence and death in HIV-infected children.
Individuals with HIV infection are at an increased risk of developing active tuberculosis. It is known that treatment of latent tuberculosis infection (also referred to as 'tuberculosis-preventive therapy' or 'chemoprophylaxis') helps prevent progression to active tuberculosis in HIV-negative populations. However, the extent and magnitude of protection (if any) associated with preventive therapy in those infected with HIV are unknown. This review assesses the effectiveness of tuberculosis-preventive therapy in reducing the risk of active tuberculosis and death in HIV-infected persons.
Pneumocystis jiroveci pneumonia remains the most common opportunistic infection in patients infected with HIV, and mortality rate among co-infected people is 10% to 20% during the initial infection of Pneumocystis jiroveci pneumonia and increases substantially with the need for mechanical ventilation. In these patients corticosteroids adjunctive to standard treatment for Pneumocystis jiroveci pneumonia may prevent the need for mechanical ventilation and decrease mortality. This review assesses the effects of adjunctive corticosteroids on overall mortality and the need for mechanical ventilation in HIV-infected patients with Pneumocystis jiroveci pneumonia and substantial hypoxemia.
Oral candidiasis associated with HIV infection occurs commonly and recurs frequently, often presenting as an initial manifestation of the disease. Left untreated, these lesions contribute considerably to the morbidity associated with HIV infection. Interventions aimed at preventing and treating HIV-associated oral candidal lesions form an integral component of maintaining the quality of life for affected individuals. This review evaluates the effects of interventions in preventing or treating oral candidiasis in children and adults with HIV infection.
Vulvovaginal candidiasis is one of the most common fungal infections that recur frequently in HIV-infected women. Symptoms of vulvovaginal candidiasis are pruritis, discomfort, dyspareunia, and dysuria. Vulval infection presents as a morbiliform rash that may extend to the thighs. Vaginal infection is associated with white discharge, and plaques are seen on erythematous vaginal walls. Even though rarely or never resulting in systemic fungal infection or mortality, left untreated these lesions contribute considerably to the morbidity associated with HIV infection. Prevention and treatment of this condition is an essential part of maintaining the quality of life for these individuals. This review compares the efficacy of various antifungals given vaginally or orally for the treatment and prophylaxis of vulvovaginal candidiasis in HIV-infected women.
Cryptococcal disease is an opportunistic infection that causes significant morbidity and mortality in adults with HIV. Primary prophylaxis with antifungal interventions may decrease cryptococcal disease incidence and associated mortality. This review assesses the efficacy of antifungal interventions for the primary prevention of cryptococcal disease in adults with HIV.
Despite the advent and increasingly wide availability of antiretroviral therapy, cryptococcal meningitis remains a significant cause of mortality and morbidity among individuals with HIV infection in resource-limited settings. However, the ideal management of cryptococcal meningitis remains unclear. This review assesses the evidence for deciding which antifungal regimen to use, as well as other modalities of management, with the aim of enabling individuals with cryptococcal meningitis to survive their acute illness and benefit from antiretroviral therapy.
Cryptosporidiosis is a disease that causes diarrhoea lasting about one to two weeks, sometimes extending up to two and a half months among the immunocompetent, and becoming a more severe life-threatening illness among immunocompromised individuals. Cryptosporidiosis is common in HIV-infected individuals. This review assesses the efficacy of interventions for the treatment and prevention of cryptosporidiosis among immunocompromised individuals.
Cerebral toxoplasmosis or toxoplasmic meningoencephalitis was one of the first opportunistic infections to be described in HIV-infected patients. Treatment of toxoplasmic meningoencephalitis has been relatively successful in comparison to other opportunistic infections, but the optimal management of toxoplasmic meningoencephalitis is important if the benefits of subsequently initiating highly active antiretroviral therapy are to be seen. This review assesses the most effective therapy for toxoplasmic meningoencephalitis in HIV-infected adults. Different treatment regimens have been compared with regard to clinical and radiological response, mortality, morbidity, and serious adverse events.
The prevention and early treatment of infections are the mainstay of the medical management of the majority of people with HIV infection who live in low-income countries without access to antiretroviral drugs. Cotrimoxazole is cheap and effective against a wide range of organisms. However, routine prophylactic treatment is difficult to deliver in low-resource settings, and could also lead to increased resistance to the drug. This review assesses the effects of routinely administered cotrimoxazole on episodes of illness, and death, in HIV-infected adults.
The majority of children with HIV infection live in low-income countries without access to antiretroviral drugs. The prevention and early treatment of opportunistic infections are the mainstay of their medical management. Cotrimoxazole is cheap and effective against a wide range of organisms, including Pneumocystis jiroveci pneumonia, which is an important cause of death and illness in the first year of life, and it is safe with relatively few side-effects. Diagnosis of HIV in children is complicated by the presence of maternal antibodies in early life. Providing prophylaxis based initially on maternal status is one possible solution. However, routine prophylactic treatment is difficult to deliver in low-resource settings, and could also lead to increased resistance to the drug. This review assesses the effects of routinely administered cotrimoxazole on episodes of illness, and death, in children with HIV infection, and in infants of HIV-infected mothers.
Opportunistic infections continue to cause a significant amount of morbidity and mortality worldwide in patients infected with HIV. Cotrimoxazole is used in the treatment and prophylaxis of several opportunistic infections. In patients with HIV/AIDS, cotrimoxazole use can cause a higher rate of adverse drug reactions than in the general population. Given the cost-effectiveness of cotrimoxazole, the management of these adverse reactions has included continuing the drug (treating-through) and reintroducing the drug at a later date, either using dose-escalation (desensitization), or rechallenge at full dose. This review compares the rate of discontinuation of cotrimoxazole and adverse reactions among the three strategies of treating-through, desensitization, and rechallenge in patients living with HIV who previously had an adverse reaction to cotrimoxazole.
Smooth muscle tumour composed of leiomyoma and leiomyosarcoma recently has been described in many HIV-infected children. Leiomyosarcoma has become the second most frequent malignancy in children with HIV infection or other immunodeficiency diseases in the United States. Although leiomyosarcoma accounts for only 2% to 4% of childhood soft tissue sarcomas, the prognosis is poor in HIV-infected patients compared with non-infected people. The development of Epstein–Barr virus-associated smooth muscle tumour in children with AIDS decreases health, reduces quality of life, and often results in death. Some researchers, therefore, ascribe cause of death to smooth muscle tumour in the majority of these cases, not to AIDS. Currently, the optimal therapeutic strategy is controversial, and there is a need to identify the efficacy and safety of different interventions for AIDS-associated smooth muscle tumour on overall survival and disease-free survival in children. This review assesses the effectiveness of current therapeutic interventions for previously untreated children with AIDS-associated leiomyoma and leiomyosarcoma.
HIV infection is known to be associated with an increased risk of non-Hodgkin's lymphoma, but the treatment of non-Hodgkin's lymphoma is not standardized. The majority of lymphomas (>80%) occurring during immunosuppression are aggressive B-cell in origin and have a high-to-intermediate histology grade. This review assesses the clinical effectiveness and safety of single-agent or combination chemotherapy with or without immunochemotherapy (rituximab) and with or without highly active antiretroviral therapy on overall survival and disease-free survival for previously untreated patients with AIDS-related non-Hodgkin's lymphoma.
Hodgkin's disease is the most common non-AIDS-defining malignancy in HIV-infected patients. Its unusually aggressive tumour behaviour includes a higher frequency of unfavourable histologic subtypes, high-stage and extranodal involvement by the time of presentation (anal canal, stomach), and poor therapeutic outcome, in comparison with Hodgkin's disease outside the HIV setting. The optimal therapeutic strategy is still controversial, and median overall survival is short, ranging from 12 to 18 months. This review assesses the effects of different interventions for treating AIDS-associated Hodgkin's disease, including chemotherapy, bone marrow transplantation, and gene therapy on overall survival and disease-free survival in treatment-naive adults with AIDS.
Squamous cell carcinoma of the conjunctiva is a rare, slow-growing tumour of the eye, normally affecting elderly men around 70 years of age. In Africa, however, the disease is different. The incidence is rising rapidly, affecting young persons (around 35 years of age), and usually affecting women. It is more aggressive, with a mean history of three months at presentation. This pattern is related to the co-existence of the HIV/AIDS pandemic, high human papillomavirus exposure, and solar radiation in the region. Various interventions exist, but despite therapy, there is a high recurrence rate (up to 43%) and poor cosmetic results in late disease. This review evaluates the effect of interventions for treating squamous cell carcinoma of the conjunctiva in HIV-infected individuals on local control, recurrence, death, time to recurrence, and adverse events.
In many countries, Kaposi's sarcoma is the most common malignancy among individuals infected with HIV-1 and is a cause of substantial morbidity and mortality. This review assesses the effectiveness of current therapeutic regimens for the treatment of HIV-associated Kaposi's sarcoma, with a focus on options that may be available in resource-poor settings.
Acknowledgements: Hana Azman (Editorial Assistant Cochrane HIV/AIDS Group) for drafting the introduction text, and Tara Horvath (Co-Managing Editor Cochrane HIV/AIDS Group) for supplying the list of reviews.
Image credit: Sinclair Stammers/Science Photo Library, P910/078
Date published: 30 November 2010; updated 1 December 2011 with one new Cochrane Review
Contact: Cochrane Editorial Unit (email@example.com)