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OIs and Co-Infections and STIs -- Oh, My!

Staying Healthy With HIV

September/October 2009

Now that powerful HIV medications can slow down the progression of HIV-related disease and even AIDS, more common illnesses (such as heart disease and cancer) have become a greater concern for people living with the virus.

Still, some of the same old AIDS-related bugaboos continue to be a problem. A little knowledge about these other illnesses can help prevent them, and thus assist in maintaining a healthy life with HIV. First, some background information.

What's That?

In the beginning of the epidemic, and for a long time afterwards, opportunistic infections (OIs) were a major (if not the major) cause of death in people with AIDS. Opportunistic infections are those that can get stronger and cause illness as the immune system gets weaker (as can happen with untreated HIV).

OIs are a type of co-infection. For someone with a chronic (long-term) condition like HIV, having another infectious illness on top of it is called a "co-infection." For example, "He is co-infected with HIV and hepatitis C."

In HIV, other sexually transmitted infections (STIs) are also co-infections. STIs continue to be a major concern in HIV.

U.S. Guidelines

The U.S. National Institutes of Health (NIH) publishes OI guidelines for people with HIV. (Electronic copies only are available; visit

While vaccinations, prevention drugs (called "prophylaxis"), and better strategies for dealing with OIs helped save lives in the early 1990s, it was really the very effective HIV medications of the mid-90s that helped squash these infections. For this reason, the guidelines emphasize the use of HIV drugs for the prevention, as well as treatment, of OIs.


Ironically, there's an undesirable condition that's sometimes seen as a result of starting HIV therapy. It's called "IRIS," which stands for "immune reconstitution inflammatory syndrome." This syndrome is not yet well understood. It has generally been seen in people who have advanced immune damage (low T-cell count or high viral load) at the time they begin taking HIV medicine, or sometimes when they go back on it.

The "immune reconstitution" is a good thing. It means that the immune system is recovering, or getting stronger. The "inflammatory" part is not so good. Inflammation occurs when the body is fighting disease or injury. People who experience IRIS can become very sick as their body battles an OI.

At this point, according to the OI guidelines, it seems that IRIS can occur four to eight weeks after starting therapy, and is most commonly seen with tuberculosis (TB) or disseminated MAC (mycobacterium avium complex). It can be seen with any of the OIs, however. Each OI listed in the guidelines has a section on the influence of IRIS that is known so far.

Opportunistic Infections

Pneumocystis jirovecii pneumonia (PCP) is probably the most common or well-known OI. It used to be known as pneumocystis carinii pneumonia until the fungus jirovecii was found to be the actual cause, and the initials PCP were kept because they were so well known.

The major symptom of PCP (as with all pneumonias) is difficulty breathing. Anyone having a hard time breathing should go immediately to the emergency room. Unfortunately, it is still common for people to find out they are HIV-positive at the time they are diagnosed with PCP (and other OIs, as well). Getting tested for HIV earlier, and treated for it, helps avoid PCP and other illnesses.

Hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV) are viral diseases that cause inflammation of the liver. Prevention, or early diagnosis, is important because treatment can be very difficult, as well as expensive. Hep A can be picked up through unsanitary food preparation (as in using the restroom and not washing hands before handling food). Hep B can be acquired through blood contact (as sometimes occurs with anal sex, for example). Hep C can also be transmitted through blood-to-blood contact, as well as during sex. Hepatitis C is very common among injection drug users. Symptoms of a recent viral hepatitis infection include nausea and vomiting, but hep C may not cause symptoms.

Creamy white spots on the tongue are a sign of thrush (a yeast infection also known as "candidiasis," since it's from the Candida albicans fungus). The infection can travel down the throat to the esophagus (the tube that helps take food to the stomach), causing pain or burning sensations and making eating difficult. Diflucan (fluconazole) is the treatment of choice, but other drugs might be necessary, depending on the individual's infection.

Tuberculosis (TB) is more common in poorer countries, but is not that uncommon in the U.S. in people with HIV. TB, which is usually an infection of the lungs (although the pathogen can affect other parts of the body), causes coughing. TB diagnosis in a person with AIDS can be difficult. Time spent in places like correctional facilities, homeless shelters, and nursing homes might increase the risk of infection. TB medications must be taken for six months, sometimes longer.

CMV -- cytomegalovirus -- usually affects the eyes. It can lead to partial or full blindness. CMV is very common in the U.S., but because it is an "opportunistic" infection, it does not cause illness in most people who have it. Treatment consists of pills or IV (intravenous) medications, but the immune recovery seen with HIV therapy can bring CMV under control.

Sex, Sex, Sex

A little knowledge about OIs can help prevent them, and thus assist in maintaining a healthy life with HIV.
Syphilis remains a tremendous problem in gay communities throughout the country. That's why free testing and treatment is widely available. Check with the health department for a referral. An inexpensive penicillin shot treats syphilis. Sometimes, however, treatment is more complicated. The first sign of syphilis is a sore (called a "chancre"), or several of them. They are usually firm, round, small, and painless, and appear at the site of infection (mouth, vulva, penis, etc.). Contact with a chancre is what causes infection. Left untreated, the infection can then cause rash, especially on the palms of the hands and the bottoms of the feet. The rash, which usually does not cause itching, looks like rough red or brownish-red spots. Sometimes, the rash can be very light and hard to notice. There may also be fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. Left untreated, syphilis can spread to the internal organs (heart, brain, liver, etc.). Again, free testing, and even free treatment, can be found.

People have been surprised to be diagnosed with gonorrhea in the throat, which they picked up during oral sex. Gonorrhea is easily treated with inexpensive pills. Symptoms include a painful or burning sensation when urinating, and a discharge from the penis or vagina. The discharge may be white, yellow, or green. Gonorrhea may cause pain or swelling of the testicles. In women, it may be confused with more common vaginal infections. Symptoms may be very mild or take a long time to appear. Antibiotics treat gonorrhea, but special ones may be necessary in some cases. That's because antibiotic-resistant gonorrhea has been around for a while. Therapy is usually combined with treatment for another STI, chlamydia.

Like gonorrhea, symptoms of chlamydia are frequently unseen, but are similar to the symptoms for gonorrhea. Some women may experience bleeding after sex or between periods and lower abdominal pain.

Herpes has been found to increase the risk of HIV infection. Flare-ups may be more common and more severe in people with HIV. One herpes drug, Valtrex (valacyclovir), is not recommended for people with suppressed immune systems.

HPV -- human papillomavirus -- causes genital warts. It can later cause abnormal cells (called "dysplasia"), and then may progress to cancer. These problems are more common and more severe in HIV-positive people. Regular Pap smears are recommended. In the future, anal Pap smears may become readily available. At this point, health care providers are rarely trained to do them. For now, a digital (finger) examination is recommended to feel for tumors. Anal cancer is more common in both men and women with HIV. If abnormal cells are found during a Pap smear, a teeny, tiny microscope can be used to examine the cervix, anus, or rectum. The cells can then be removed, but if the infection has spread, cancer chemotherapy (either in pills or intravenously) and/or radiation may be required. In women with HIV, a cone biopsy of the cervix (a cone-shaped removal of abnormal cells) is common.


Left untreated, any of the above conditions can cause illness. The following is a list of tips for staying healthy.

  • People with HIV should get tested for a variety of co-infections, including hepatitis A, B, and C.
  • Get vaccinated to avoid infections. People with HIV should get an annual flu shot (FluMist nasal spray is not recommended). They should get vaccinated against pneumococcal pneumonia, meningococcal meningitis, hepatitis A and B (there's a combination vaccine available), and measles, mumps, and rubella (MMR), if they were born after 1957 and did not get the shot in childhood. The MMR shot is not recommended for people with less than 200 T-cells. They should also get a combination vaccine against tetanus (relatively common among injection drug users) and diphtheria (often found in homeless people), but not more than once every 10 years. People under age 65 should get the triple TDAP shot -- tetanus, diphtheria, and pertussis (whooping cough), followed by TD booster shots.
  • People with less than 200 CD4+ T-cells should take a medication to prevent PCP (Bactrim, TMP-SMX, Septra, Sulfatrim, or co-trimoxazole). This medication is inexpensive, and there are other medications available for people with sulfa allergies.
  • Seeing a medical provider on a regular basis -- even if not taking HIV treatment -- can help catch an infection earlier rather than later, before it causes more damage or becomes more difficult to treat. Symptoms, even minor ones, should be brought up with the provider.
  • Remember, strong HIV therapy (called "HAART" -- pronounced like "heart" -- for highly active antiretroviral therapy) is currently the best bet for preventing OIs and the damage and death they can cause.

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See Also
Strategies for Managing Opportunistic Infections
More on Opportunistic Infections & Complications


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