Diagnosis, Treatment, and Prevention of Selected Common HIV-Related Opportunistic Infections in the Caribbean Region
And practice for taking daily antiretroviral therapy regimens. Diagnosis, prevention, and treatment of TB was discussed more fully in the …
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The Caribbean region, like other resource-limited areas, lacks many of the diagnostic and treatment modalities taken for granted in richer areas of the world. The Caribbean Guidelines for the Treatment of Opportunistic Infections in Adults and Adolescents Infected With the Human Immunodeficiency Virus provides guidelines for the region for preventing and treating more than 20 opportunistic diseases reflecting the variable availability of diagnostic and treatment resources. Elements of diagnosis and prevention of tuberculosis, Pneumocystis jiroveci pneumonia, and other common opportunistic conditions in this resource-limited setting were discussed by Jonathan E. Kaplan, MD, at the first CHART Caribbean Conference on the Clinical Management of HIV/AIDS in Montego Bay, Jamaica, in June 2004.
The Caribbean region, like other resource-limited areas, lacks many of the diagnostic and treatment modalities taken for granted in richer areas of the world. Polling of the attendees at the first CHART Caribbean Conference on the Clinical Management of HIV/AIDS (almost 350 HIV clinicians from 29 countries in the Caribbean region) indicated that approximately one third had access to both computed tomography (CT) and magnetic resonance imaging (MRI), whereas approximately one third had neither; only 10% had access to cryptococcal antigen testing; approximately one fifth reported having the ability to diagnose Pneumocystis jiroveci (formerly carinii) pneumonia (PCP), which requires induced sputum collection or bronchoscopy to obtain bronchioalveolar lavage specimens, as well as appropriate laboratory staining techniques; and approximately one half did not have access to CD4+ cell count testing. The Caribbean Guidelines for the Treatment of Opportunistic Infections in Adults and Adolescents Infected with the Human Immunodeficiency Virus, presented at the conference, represents a prodigious effort on the part of the Caribbean HIV-care community and offers invalu-
able regional guidelines for preventing and treating more than 20 opportunistic infections (OIs). The guidelines are oriented toward diagnosis and treatment of specific OIs. However, a syndromic approach to diagnosis and treatment of OIs is critical in assessing HIV-infected patients in settings in which laboratory diagnostics are lacking. Many of the OIs occurring in HIV-infected individuals are signaled by symptoms or signs that should prompt suspicion for specific conditions. The syndromic approach is represented in the acute care module of the World Health Organization (WHO)
Stages of HIV Disease: Acute HIV Infection Asymptomatic
Integrated Management of Adolescent and Adult Illness modules. (The 4 modules of this program–acute care, chronic HIV care with antiretroviral treatment, general principles of good chronic care, and palliative care–are available at www.who.int/3by5/publications/documents/imai/en/.) The acute care module covers all common illnesses, but gives particular attention to those associated with HIV infection. It was specifically prepared to be used in peripheral health centers with limited or no laboratory diagnostics and where care may be provided by nurses and physician assistants.
Diagnosis of Opportunistic Infections
Tuberculosis The natural history of HIV disease is such that most OIs occur after the CD4+ cell count has decreased to below 200/L (Figure 1). Tuberculosis (TB) can occur at any CD4+ cell count. The presSymptomatic
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