Opportunistic Infections and Mortality: Still Room for Improvement

Abstract

Among the accomplishments having the greatest impact during the first decade of the AIDS epidemic was the rapid development of effective tools and strategies to diagnose, treat, and prevent opportunistic infections. Prior to 1981, clinicians had little experience with managing infections such as pneumocystis pneumonia, Toxoplasma cerebritis, cytomegalovirus (CMV) retinitis, disseminated Mycobacterium avium complex infection, and chronic diarrhea due to cryptosporidia or microsporidia. Highly effective drugs to treat CMV and M. avium complex infection had not been developed for clinical practice, and many physicians used intravenous pentamidine, a relatively toxic drug, to treat pneumocystis pneumonia. Aided by randomized prospective clinical trials and the development of national guidelines to rapidly disseminate new information [1], clinicians quickly learned how to recognize and treat these syndromes and diseases. In the eras when no antiretroviral therapy (ART) was available or when ART was limited to single or dual nucleoside agents, median survival times after the diagnosis of the first AIDS-associated opportunistic infection were very limited, ranging from 2 to 22 months, depending on the infection [2]. Human immunodeficiency virus (HIV) testing was not widely available, and most patients presented to healthcare providers with an opportunistic infection. Accordingly, most patients had profoundly depressed CD4 + T-cell counts at the time of presentation. There were limited programs to support retention in care for HIV-infected patients and no effective treatments for restoring immunologic function. In the late 1990s, with the development and availability of more-effective ART, immunity could be more effectively and durably restored, and health outcomes improved dramatically. To supplement the Ryan White Act of 1990 [3],more federal and local programs were developed to support retention in care. The management of opportunistic infections was improved by developing new molecular diagnostic tests, by developing new drugs, and by completing well-designed prospective studies. Medical support improved, especially in critical care departments where ventilator management, treatment for septic shock, and management of intracranial pressure, for in