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Dr Steve Welch

3 rd 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. Other opportunistic infections. Steve Welch Heartlands Hospital, Birmingham

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Dr Steve Welch

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  1. 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

  5. 1st cxr 5/11/08

  6. 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

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

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

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

  10. Prevention of bacterial disease • HAART • Antibiotic prophylaxis • Immunisation • Immunoglobulins

  11. 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

  12. 15yr old Zimbabwean girl • In UK 2005 • Unusual rash 2yrs • Nodular, pruritic • Biopsy : nodular prurigo • Hiv 1positive (mar 2006) • Further work up • Low CD4 4%(19) • Lymphadenopathy • Viral load : 276000c/ml

  13. Drug • 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

  14. Should she be on MAI prophylaxis?

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

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

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

  18. 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

  19. 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

  20. 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

  21. CROI 2008 Abstract142Immediate vs Deferred ART in the Setting of Acute AIDS-related Opportunistic Infection: Final Results of a Randomized Strategy Trial, ACTG A5164Andrew 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

  22. CROI 2009: 36cLBEarly vs Delayed ART in the Treatment of Cryptococcal Meningitis in AfricaAzure 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%

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

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

  25. What are alternatives to septrin?

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

  27. 4-month old girl • Birthweight 4.1 kg (75th centile) • Now 5.2 kg (2nd centile) • Respiratory distress, diagnosed PcP • Good response to ART. CD4 2300 (35%) • When can she stop septrin?

  28. AIDS 2005

  29. Stopping PcP prophylaxis • Cd4>15%, 200 for 6 months • Cd4> 15%, 500 below age 5 • Not in first 12-18 months of life?

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

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