What is PCP?

How is PCP Treated?

Can PCP be Prevented?

Which Drug is best?

What Is PCP?

Pneumocystis pneumonia (PCP or pneumocystis) is the most common opportunistic infection in people with HIV. Without treatment, over 85% of people with HIV would eventually develop PCP. It has been the major killer of people with HIV. However, PCP is now almost entirely preventable and treatable.

PCP is caused by a fungus. It used to be called pneumocystis carinii, but scientists now call it pneumocystis jiroveci. A healthy immune system can control the fungus. However, PCP causes illness in children and in adults with a weakened immune system.

Pneumocystis almost always affects the lungs, causing a form of pneumonia. People with CD4 cell counts under 200 have the highest risk of developing PCP. People with counts under 300 who have already had another opportunistic infection are also at risk. Most people who get PCP become much weaker, lose a lot of weight, and are likely to get PCP again.

The first signs of PCP are difficulty breathing, fever, and a dry cough. Anyone with these symptoms should see a doctor immediately. However, everyone with CD4 counts below 300 should discuss PCP prevention with their doctor, before they experience any symptoms. 

How Is PCP Treated?

For many years, antibiotics were used to prevent PCP in cancer patients with weakened immune systems. It was not until 1985 that a small study showed that these drugs would also prevent PCP in people with AIDS.

Unfortunately, many people still develop PCP and some die from it because they have not been tested and treated for their HIV infection.

A new anti-PCP drug, DB289, is being studied. The drugs now used to treat PCP include TMP/SMX, dapsone, pentamidine, and atovaquone.

TMP/SMX (Bactrim? or Septra?) is the most effective anti-PCP drug. It's a combination of two antibiotics: trimethoprim (TMP) and sulfamethoxazole (SMX).
Dapsone is similar to TMP/SMX. Dapsone seems to be almost as effective as TMP/SMX against PCP. 
Pentamidine (NebuPent?, Pentam?, Pentacarinat?) is a drug that is inhaled in an aerosol form to prevent PCP. Pentamidine is also used intravenously (IV) to treat active PCP. 
Atovaquone (Mepron?) is a drug used in people with mild or moderate cases of PCP who can not take TMP/SMX or pentamidine.


Can Pcp Be Prevented?

The best way to prevent PCP is to use strong antiviral therapy. People who have less than 200 T-cells can prevent PCP by taking the same medications used for PCP treatment

Combination antiviral therapy can make your T-cell count go up. If it goes over 200 and stays there for 3 months, it may be safe to stop taking PCP medications. However, because PCP medications are inexpensive and have mild side effects, some researchers think they should be continued until your T-cell count reaches 300. Be sure to talk with your doctor before you stop taking any of your prescribed medications.


Which Drug Is Best?

Bactrim or Septra (TMP/SMX) is the most effective drug against PCP. It is also inexpensive, costing only about $10 per month. It is taken in pill form, not more than one pill daily.

However, the "SMX" part is a sulfa drug and almost half of the people who take it have an allergic reaction. This usually is a skin rash, sometimes a fever. Allergic reactions can be overcome using a desensitization procedure. Patients start with a very small amount of the drug and take increasing amounts until they can tolerate the full dose.

Dapsone causes fewer allergic reactions than TMP/SMX. It is also fairly inexpensive - about $30 per month. It also is taken as a pill and, like Bactrim or Septra, not more than one pill daily.

Pentamidine involves a monthly visit to a clinic with a nebulizer, the machine that produces a very fine mist of the drug. The mist is inhaled directly into the lungs. The procedure takes about 30 to 45 minutes. You pay for the drug plus the clinic costs, between $120 and $250 per month. Patients using aerosol pentamidine get PCP more often than people taking the antibiotic pills.

New research has looked at taking even fewer pills to prevent PCP. Cutting back from one pill a day to three pills a week reduces the allergy problems of Bactrim and Septra, and seems to work just as well. 


Treating OIs

For each OI, there are specific drugs, or combinations of drugs, that seem to work best. 

Strong antiviral drugs can allow a damaged immune system to recover and do a better job of fighting OIs. 



Kaposi's Sarcoma (KS)

What Is KS?

Kaposi's sarcoma (KS) is a cancer-like disease. It usually shows up in the skin, or in the linings of the mouth, nose, or eye. KS can also spread to the lungs, liver, stomach and intestines, and lymph nodes. KS involves the development of many new, tiny blood vessels. This process is called angiogenesis. KS is caused by a herpes virus called Human Herpes Virus 8 (HHV-8). In a recent study, men with HHV-8 were nearly 12 times more likely to be diagnosed with KS than men who did not have HHV-8.

KS affects about 20% of people with AIDS who aren't taking anti-HIV drugs. In the US, the rate of KS dropped by more than two thirds after the introduction of strong antiviral medications.

KS is mostly a disease of men: there are at least 8 men with KS for each woman. It is one of the most visible signs of AIDS, because it usually shows up as spots on the skin (lesions) that look red or purple on white skin, and bluish, brownish or black on dark skin. Lesions often occur on the face, arms and legs.

KS on the skin is not life threatening. However, KS lesions on the feet and legs can make it difficult to walk. If KS spreads to other parts of the body, it can cause serious problems. In the mouth lining, it can cause trouble eating and swallowing. In the stomach or gut, it can cause internal bleeding and blockages. If KS blocks lymph nodes, it can cause severe swelling of the arms, legs, face, or scrotum. The most serious form of KS is in the lungs, where it can cause a serious cough, shortness of breath, or an accumulation of fluid that can be fatal.

KS can often be diagnosed by looking at the skin lesions. They are usually flat, painless, and do not itch or drain. They can look like a bruise, but a bruise will lose its purple color if you push on it; a KS lesion won't. KS lesions can grow into raised bumps or patches and grow together. Your doctor might take a small sample (a biopsy) from skin spots to examine under a microscope and confirm a diagnosis of KS.


How Is Ks Treated?

Highly active antiretroviral therapy (HAART) is the best treatment for active KS. In many people, HAART can stop the growth or even clear up skin lesions. In addition to HAART, there are different treatments for KS in the skin or in other parts of the body.

In the skin, KS may not have to be treated if there are only a few lesions. Skin lesions can be:

Frozen with liquid nitrogen,
Treated with radiation,
Cut out surgically,
Injected with anti-cancer drugs or interferon alpha.
Treated with Panretin gel (retinoic acid)

These treatments only deal with the skin lesions, not with KS overall. Skin lesions may come back after treatment.

If KS has spread into internal organs, into internal organs, systemic (whole-body) drug treatment is used. If HAART treatment is not enough, the drugs doxorubicin (Doxil?,) daunorubicin (DaunoXome?) or paclitaxel (Taxol?) may be added.

Doxil and DaunoXome are anti-cancer drugs in "liposomal" form. "Liposomal" means that tiny amounts of drug are encased in small fat bubbles (liposomes). The drugs last longer in this form and seem to move to the areas where they're needed. Some side effects are reduced with liposomal forms of drugs.


Can Ks Be Prevented?

It is not clear how HHV-8 spreads. It might be spread through sexual activity and deep kissing. As with other opportunistic infections, a healthy immune system can control HHV-8 infection. The best way to prevent KS is by using strong anti-HIV medications to keep your immune system strong.

Cytomegalovirus (CMV)

What Is Cmv?

Cytomegalovirus (CMV) is an opportunistic infection. The virus is very common. A healthy immune system keeps this virus in check. 

When the immune defenses are weak, CMV can attack several parts of the body. This can be caused by various diseases including HIV. Combination antiviral therapy has reduced the rate of CMV in people with HIV by 75%. However, about 5% of people with HIV still develop CMV disease. 

The most common illness caused by CMV is retinitis. This is the death of cells in the retinas, the back of the eye. It can quickly cause blindness unless treated. CMV can spread throughout the body and infect several organs at once. The risk of CMV is highest when CD4 cell counts are below 50. It is rare in people with more than 100 T-cells.

The first signs of CMV retinitis are vision problems such as moving black spots. These are called "floaters." They may indicate an inflammation of the retina. Patients may also notice light flashes, decreased or distorted vision, or blind spots. Some doctors recommend eye exams to catch CMV retinitis. The exams are done by an ophthalmologist (an eye specialist.) If your CD4 count is below 100 and you experience any vision problems, tell your doctor immediately.

Some patients who have recently started using anti-HIV medications can get inflammation in their eyes, causing loss of vision. This is called immune restoration syndrome.


How Is Cmv Treated?

The first treatments for CMV required daily intravenous infusions. Most people had a permanent medication port inserted into their chest or arm. People had to keep taking anti-CMV drugs for life. 

Strong HIV medications can improve the immune system. Patients can stop taking CMV drugs if their CD4 cell count goes over 100 to 150 and stays there for at least three months. However, there are two special cases: 

1. Immune restoration syndrome can cause severe inflammation in the eyes of people with HIV even if they didn’t have CMV before. The usual treatment is to add anti-CMV drugs to the patient's anti-HIV drugs. 

2. If the CD4 count drops below 50, there is an increased risk of developing CMV disease.


Can Cmv Be Prevented?

Ganciclovir was approved for prevention (prophylaxis) of CMV. However, many physicians don't prescribe it. They don't want to add up to 12 capsules a day for their patients. Also, it's not clear that it does any good. Two large studies came to different conclusions. Finally, strong antiviral medications keep most people's CD4 counts high enough so that they won't get CMV.

Candidiasis (Thrush)

What Is Thrush?

Candidiasis is an infection caused by a common type of yeast. This yeast (fungus) is found in most people's bodies. A healthy immune system keeps it under control. Candidiasis is a common opportunistic infection in people with HIV. It usually infects the mouth, throat, or vagina. Candidiasis can occur months or years before other, more serious opportunistic infections.

In the mouth, the infection is called thrush. It looks like white patches similar to cottage cheese, or red spots. It can cause a sore throat, pain when swallowing, nausea, and loss of appetite. The infection can spread deeper into the throat. This is called esophagitis.

Candidiasis is a common vaginal infection. Symptoms of vaginitis include itching, burning, and a thick whitish discharge.


Can It Be Prevented?

There is no way to prevent exposure to candida. Medications are not normally used to prevent candidiasis. There are several reasons for this:

It is not very dangerous
There are effective drugs to treat it
The yeast could develop resistance to the medications.

Strengthening your immune system by taking combination antiviral therapy is the best way to prevent an outbreak of candidiasis.


How Is It Treated?

Treating candidiasis will not get rid of the yeast. Treatment will keep it under control.

A healthy immune system keeps it in balance. Bacteria normally found in the body also help control it. Some antibiotics kill these helpful bacteria and cause an outbreak of candida.

Treatments can be local or systemic. Local treatments are applied where the infection is found. Systemic treatments affect the whole body. Many doctors prefer to use local treatment first. It puts the medication directly where it is needed. It has fewer side effects than a systemic treatment. Also, there is less risk of candida becoming resistant to the medications. The medications used to fight candida are antifungal drugs. Their names almost all end in "-azole."

Local treatments include:

creams
suppositories to treat vaginitis
liquids
"troches" or "lozenges" that dissolve in the mouth

Local treatments may cause some stinging or irritation.

Systemic treatment is needed if local treatments don't work, or if the infection has spread into the throat (esophagitis). Some systemic drugs are taken in pill form. The most common side effects are nausea, vomiting, and abdominal pain. Less than 20% of people have these side effects.

Candidiasis can come back repeatedly. Some doctors prescribe anti-fungal drugs on a long-term basis. This can cause resistance. The yeast can mutate so that a drug no longer works.

Some serious cases do not respond to other medications. Amphotericin B might be used. It is a very potent and toxic drug, given intravenously. The major side effects are kidney problems and anemia. Other reactions include fever, chills, nausea, vomiting, and headache. These usually get better after the first few doses.


Natural Therapies

Several non-drug therapies seem to help. They have not been carefully studied to prove that they work.

Reduce the amount of sugar you eat
Drink Pau d'Arco tea. It is made from the bark of a South American tree. 
Take garlic supplements or eat raw garlic. Garlic has anti-fungal and anti-bacterial properties. However, it can interfere with protease inhibitor drugs. 
Gargle with tea tree oil diluted in water.
Take lactobacillus (acidophilus) capsules or eat yogurt with this bacteria. It may help to take it after taking antibiotics.
Take supplements of gamma-linoleic acid (GLA) and Biotin. They both seem to slow the spread of candida. GLA is found in several cold-pressed oils. Biotin is a B vitamin.