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Preventive therapies delay the onset of some opportunistic
diseases in HIV patients
Opportunistic diseases are common complications of HIV infection,
but the incidence rates of secondary Pneumocystis carinii pneumonia (PCP), cryptococcal meningitis, and herpes zoster have
declined in the past 5 years, and they are being diagnosed at a
later stage of HIV disease (lower median CD4 cell count). In
addition, the incidence rates of primary PCP and Kaposi sarcoma
also appear to be declining compared with historical
These improvements are due to the effective use of antiretroviral
therapy, targeted preventive therapy, and more comprehensive
clinical management of the disease, according to a study
supported by the Agency for Health Care Policy and Research
through its pharmaceutical outcomes research program (HS07809).
The study was led by Johns Hopkins University School of Medicine
researchers, Richard D. Moore, M.D., M.H.Sc., and Richard E.
They estimated the probability of developing opportunistic
infection and cancer, measured the number of CD4 cells at the
time opportunistic disease developed and survival after its
onset, and examined the association between preventive drug
therapies and occurrence of opportunistic infection among 1,246
HIV-infected patients with CD4 counts of 300 or less (normal
count is about 1,000) at an urban university HIV clinic from 1989
to 1995. Between the earlier period (1989-1992) and the later
period (1993-1995), the incidence of several opportunistic
infections decreased: cryptococcal meningitis declined from 3 to
1.4 events per 100 person-years; second-time PCP declined from
6.2 to 3.7; and herpes zoster declined from 4.2 to 2.4.
In the late 1980s, opportunistic infections typically began to
appear when an HIV-infected person's CD4 lymphocyte count dropped
to about 200. In this study, only infections with herpes simplex
virus, tuberculosis, and herpes zoster occurred at CD4 counts
greater than 100. Toxoplasmosis, progressive multifocal
leukoencephalopathy, the wasting syndrome, second-time PCP,
cytomegalovirus infection, and Mycobacterium avium complex
bacteremia occurred at a mean CD4 count of less than 50. After
adjustment for CD4 count, the use of fluconazole was associated
with a decreased rate of cryptococcal meningitis and candidiasis,
rifabutin use with a decreased rate of M. avium complex bacteremia, and
trimethoprim-sulfamethoxazole use with a decreased rate of secondary PCP.
For more information, see "Natural history of opportunistic
disease in an HIV-infected urban clinical cohort," by Drs. Moore
and Chaisson, in the April 1, 1996, Annals of Internal
Medicine 124(7), pp. 633-642.
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