OPPORTUNISTIC INFECTIONS. Institute of Infectious Diseases, Pune India
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1 OPPORTUNISTIC INFECTIONS Institute of Infectious Diseases, Pune India
2 DISCLOSURES Nothing to declare
3 Outline The problem Bacterial Fungal Protozoal Viral
4 Decline in OI prevalence in HAART era: USA CROI 2017, abstr 737
5 Declining OI s in NA-ACCORD J Infect Dis Sep 15;214(6):
6 ART: Impact on OI incidence in LMICs Clin Infect Dis ;62(12):
7 Why do OI s still occur? Late HIV diagnosis, missed presentations (HIV Med Aug 1 (epub), BMC Infect Dis. 2012;12:72-72) Sub-optimal adherence ARV (Curr Opin HIV AIDS Jul;10(4):219-25) ART failure Prophylaxis Delayed identification of ARV failure Immunologic disconnect (J Int AIDS Soc Mar 3;17:18651) Functional immune reconstitution (Clin Infect Dis 2009;48:609 11)
8 Advanced disease at ART initiation WHO guidelines for management of advanced HIV disease, 2017
9 Causes of hospital admissions in adult PLHIV Lancet HIV 2015;2(10):e438-e444.
10 Causes of hospital admissions in adult PLHIV Lancet HIV 2015;2(10):e438-e444.
11 Causes of in-hospital mortality Lancet HIV 2015;2(10):e438-e444.
12 Outline The problem Bacterial Fungal Protozoal Viral
13 HIV prevalence: New/relapsed TB: 2015 WHO global TB report 2016
14 Global TB incidence and deaths WHO global TB report 2016
15 HIV/AIDS and TB deaths in 2015 WHO global TB report 2016
16 VL is independent risk factor for TB in SA J Int AIDS Soc Jun 23;20(1):1-7
17 VL independent risk factor for TB in SA J Int AIDS Soc Jun 23;20(1):1-7
18 Point of care CRP for TB screening for PLHIV initiating ART Sensitivity Specificity Lancet Infect Dis Aug 25 (epub)
19 Sputum quality and diagnostic accuracy of Xpert PLoS One Jul 7;12(7):e
20 Early morning urinary sample for TB-LAM BMC Infect Dis May 12;17(1):339
21 REMEMBER:EMPIRICAL ATT vs IPT with ART Lancet. 2016;387(10024):
22 PredART: Prednisolone to prevent paradoxical TB IRIS Pred Placebo IRIS need Pres gr 3 evets CROI 2017; abstr 81 LB
23 Syphilis incidence amongst HIV + MSM in Swiss HIV cohort study in ART era Medicine (Baltimore) (2):e5849.
24 Single dose BPG effective to treat early syphilis amongst PLHIV Clin Infect Dis. 2017;64(6):
25 Early ART reduces incidence of severe bacterial infections: START study Lancet HIV. 2017;4(3):e105-e112
26 REALITY: Enhanced prophylaxis amongst African PLHIV with CD4<100 at ART initiation HIV + Adults Children>5 yrs CD4<100 Initiating ART Enhanced prophylaxis TMP-SMX Albendazole single dose Azithromycin x 5 days INH X 12 wks Fluconazole x 12 weeks Standard prophylaxis TMP-SMX N Engl J Med. 2017;377(3): Primary outcome Death (any cause) up to 24 wks
27 Overall mortality at 48 weeks N Engl J Med. 2017;377(3):
28 Main causes of death at 48 weeks N Engl J Med. 2017;377(3):
29 Secondary or other outcomes at 48 wks N Engl J Med. 2017;377(3):
30 Good virologic and immunologic success N Engl J Med. 2017;377(3):
31 Outline The problem Bacterial Fungal Protozoal Viral
32 Annual incidence of cryptococcal infection: 2014 Lancet Infect Dis Aug;17(8):
33 Acridine orange vs India Ink for CM PLoS One Jul 27;12(7):e
34 Acridine orange vs India Ink for CM PLoS One Jul 27;12(7):e
35 ACTA: Treatment of CM Regimen 1: Fluconazole 1200 mg/d + 5-FC 100 mg/kg/d 14 days HIV + CM Regimen 2: AmB 1 mg/kg/day + Fluconazole 1200 mg/d OR 5-FC 100 mg/kg/d D1-7, FLU 1200 mg/d D7-14 FOLLOW UP TREATMENT Fluconazole 800 mg/d until ART (D28 +/- 3d), then 400 mg/d to 10 weeks, then 200 mg/d IAS 2017; Abstr 5573 Regimen 3: AmB 1 mg/kg/day + Fluconazole 1200 mg/d OR 5-FC 100 mg/kg/d 14 days
36 ACTA: Mortality risk difference Better than 2wk AmB Worse than 2wk AmB IAS 2017; Abstr 5573
37 ACTA: Mortality risk difference Hazard Ratio (95% CI) Secondary Outcomes Oral vs 2 weeks AmB 1 week AmB vs 2 weeks AmB p-value (log-rank test) 2 week mortality 0.82 (0.54 to 1.25) 1.01 (0.68 to 1.51) week mortality 0.83 (0.61 to 1.13) 0.89 (0.66 to 1.21) 0.47 IAS 2017; Abstr 5573
38 ACTA: FLU vs 5FC Hazard Ratio (95% CI) AmB+FLU vs AmB vs 5FC p-value (log-rank test) 10 week mortality 1.62 (1.19 to 2.20) week mortality: FLU: 45% (101/225) 5FC: 31% (71/228) IAS 2017; Abstr 5573
39 ACTA: Cumulative incidence of all cause mortality IAS 2017; Abstr 5573
40 Cryptococcosis: role of steroids N Engl J Med. 2016; 11;374(6):
41 Higher mortality in CrAG +ve in spite of preemptive fluconazole treatment Clin Infect Dis 2016; 62:
42 Talaromyces marneffei N Engl J Med 2017;376:
43 AmpB vs itraconazole for talaromyces N Engl J Med 2017;376:
44 AmpB vs itraconazole for talaromyces N Engl J Med 2017;376:
45 Outline The problem Bacterial Fungal Protozoal Viral
46 Toxoplasma infection amongst PLHIV Lancet HIV Apr;4(4):e177-e188.
47 Higher prevalance of Toxo infection amongst PLHIV ns gen population Acta Trop Aug 4;176:
48 Discontinuing TMP-SMX when CD CROI 2017 Abstr 646
49 PI based regimens reduce malaria incidence AIDS. 2017;31(4):
50 Stopping TMP-SMX increases malaria amongst PLHIV in kenya J Infect Dis. 2017;215(1):88-94
51 Stopping TMP-SMX increases malaria amongst PLHIV in kenya J Infect Dis. 2017;215(1):88-94
52 Outline The problem Bacterial Fungal Protozoal Viral
53 Recurrence of PML despite immune recovery J Neurovirol Aug;22(4):541-5
54 Recurrence of PML despite immune recovery J Neurovirol Aug;22(4):541-5
55 Increasing HPV DNA prevalence with severity of cervical disease amongst WLHIV: Geographic distribution Clin Infect Dis. 2017;64(9):
56 HPV type prevalence: Africa vs NA/Europe Africa NA/Europe Clin Infect Dis. 2017;64(9):
57 CMV serostatus and normalization of CD4:CD8 ratio on ART All patients Amongst CD4>500/mm3 PLoS One. 2016;11(11):e
58 HSV-2 shedding increases in 6 mo s following ART initiation J Infect Dis. Sep ;208(5):
59 Summary OI s: Going, Going, but not gone Widespread testing for HIV, linkage to care and ART initiation key to reduce burden of OI s Preventive strategies e.g. enhanced prophylaxis, vaccination, screening for cancers need to be implemented Clinicians must remain knowledgeable about optimal management and prevention of OI s to provide high quality care
60
61 Late presenters in Netherlands BMJ Open. 2016;6(1):e009688
62 Late presenters in Asia AIDS Res Hum Retroviruses Mar 1;32(3):
63 Predicting AKI on AmpB: Urinary NGAL Open Forum Infect Dis Jun 20;4(3):ofx127
64 AKI on AmB: 12 mo mortality by Urinary protein quartiles Open Forum Infect Dis Jun 20;4(3):ofx127
65 AKI on AmpB: AKI by quartiles of Urinary protein Open Forum Infect Dis Jun 20;4(3):ofx127
66 Approach to toxoplasmosis treatment Trop Parasitol Jul-Dec;6(2):
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