Transcript Treating Opportunistic Infections Among HIV

Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults
and Adolescents
Human Herpesvirus-8 Slide Set
Prepared by the AETC National Resource Center
based on recommendations from the CDC,
National Institutes of Health, and HIV Medicine
Association/Infectious Diseases Society of America
About This Presentation
These slides were developed using recommendations
published in May 2013. The intended audience is
clinicians involved in the care of patients with HIV.
Users are cautioned that, because of the rapidly
changing field of HIV care, this information could
become out of date quickly. Finally, it is intended that
these slides be used as prepared, without changes in
either content or attribution. Users are asked to honor
this intent.
– AETC National Resource Center
http://www.aidsetc.org
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HHV-8 Disease: Epidemiology
 Associated with Kaposi sarcoma (KS) (all
forms) and certain neoplastic and
lymphoproliferative disorders (primary effusion
lymphoma [PEL]), multicentric Castleman
disease)
 HHV-8 seroprevalence in United States: 1-5%
 Higher in MSM regardless of HIV serostatus (2077%)
 Higher in some Mediterranean countries (10-20%)
and parts of sub-Saharan Africa (30-80%)
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HHV-8 Disease: Epidemiology (2)
 Pathogenesis of HHV-8 disease is unclear
 KS and PEL usually seen in advanced
immunosuppression (CD4 count <200 cells/µL),
but can occur at any CD4 count
 KS incidence up to 30% among AIDS patients in
United States before use of effective ART
 Dramatically lower incidence in recent years
 ART prevents and may regress KS lesions
 Ganciclovir, foscarnet, and cidofovir given for CMV
treatment may prevent or suppress KS
 Castleman disease and PEL remain rare
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HHV-8 Disease: Clinical Manifestations
 Most with chronic HHV-8 infection are
asymptomatic
 Acute infection may cause fever, rash,
lymphadenopathy, bone marrow failure,
occasional rapid progression to KS
 Castleman disease: generalized adenopathy,
fever; may progress to multiorgan failure
 PEL: pleural, pericardial, or abdominal effusions;
mass lesions are less common
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HHV-8 Disease: Clinical Manifestations (2)
 KS presentation varies
widely
 Most have nontender,
purplish, indurated skin
lesions
 Intraoral lesions are
common
 Visceral dissemination
may occur
Credit: P. Volberding, MD;
UCSF Center for HIV
Information Image Library
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HHV-8 Disease: Diagnosis
 Routine screening for HHV-8 is not
indicated
 Quantitation of HHV-8 by PCR has no
established role in diagnosis
 KS: biopsy
 Consult with specialist for diagnosis of
other suspected HHV-8 disease
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HHV-8 Disease: Prevention
 Preventing Exposure
 HHV-8 shedding in saliva and genital secretions
may transmit HHV-8 to uninfected partners
 Interventions to prevent exposure to HHV-8 not
likely to be highly effective, have not been
validated; are not recommended
 Preventing Disease
 Toxicity of anti-HHV-8 therapy outweighs
potential benefits
 Early initiation of ART likely to be most
effective prevention measure
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HHV-8 Disease: Treatment
 ART for all: initiate or optimize
 Limited studies of HHV-8-specific agents
 KS:
 Ganciclovir, foscarnet may regress lesions; cidofovir ineffective
in 1 study
 Chemotherapy if visceral KS; consider if widely disseminated
cutaneous KS
 Castleman disease:
 Preferred: valganciclovir 900 mg PO BID for 3 weeks or
ganciclovir 5 mg/kg IV Q12H for 3 weeks or valganciclovir 900
mg PO BID + zidovudine 600 mg PO Q6H for 7-12 days
 Alternative: rituximab for 4-8 weeks (effective as alternative or
adjunctive therapy; associated with subsequent exacerbation or
emergence of KS)
 PEL:
 Chemotherapy
 IV ganciclovir or PO valganciclovir may be useful adjunct
 Consult with specialist
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HHV-8 Disease: Starting ART
 Early ART initiation is likely to prevent KS and
PEL
 ART should be given to all with KS, muticentric
Castleman disease, or PEL
 Insufficient evidence to support specific ARV
regimens
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HHV-8 Disease: Monitoring and
Adverse Events
 IRIS reported in HHV-8-infected patients
who initiate ART
 KS: new onset KS or exacerbations of
previously stable disease
 Castleman disease: clinical decompensation
 PEL: no data
 ART is key component of therapy and
should not be delayed
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HHV-8 Disease: Preventing Recurrence
 ART recommended for all with HHV-8
disease
 May prevent KS progression or recurrence
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HHV-8 Disease: Considerations in
Pregnancy
 HHV-8 seropositivity does not appear to affect
pregnancy outcome; screening for HHV-8 not
indicated
 Antiviral therapy for HHV-8 infection during
pregnancy is not recommended
 Diagnosis as in nonpregnant women
 For treatment, consult with specialist
 Perinatal transmission occurs infrequently,
higher risk with higher maternal antibody titer;
may be associated with increased infant
mortality
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Websites to Access the Guidelines
 http://www.aidsetc.org
 http://aidsinfo.nih.gov
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About This Slide Set
 This presentation was prepared by Susa Coffey,
MD, for the AETC National Resource Center in
May 2013
 See the AETC NRC website for the most current
version of this presentation:
http://www.aidsetc.org
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