Opportunistic infections (OIs) are infections affecting HIV patients with weakened immunity, indicated by a white blood cell count below 200 cells/cm³ (14%).

  • Advanced HIV infection makes individuals vulnerable to opportunistic infections or malignancies. These infections exploit the weakened immune system.
  • Childhood acquisition of OIs and HIV often occurs from infected mothers.
  • Women living with HIV are more prone to co-infections with opportunistic pathogens, increasing the risk of transmission to their infants.
  • Adolescents with HIV, including long-time survivors of perinatal infection, are increasingly common. Treatment guidelines also apply to youth living with HIV who have not yet completed pubertal development.

Examples of Opportunistic Infections




Bacterial OIs

Pneumococcal pneumonia

A bacterial infection causing severe respiratory illness, commonly affecting HIV patients due to weakened immunity.

Pulmonary tuberculosis

A serious infectious disease that primarily affects the lungs, prevalent in HIV patients due to compromised immune defenses.


An infection caused by Salmonella bacteria, leading to severe gastrointestinal symptoms, more common in immunocompromised individuals.

Extra-pulmonary tuberculosis

Tuberculosis infection occurring outside the lungs, such as in the lymph nodes or bones, often seen in advanced HIV cases.

Viral OIs

Herpes zoster

Also known as shingles, caused by the reactivation of the chickenpox virus, leading to painful skin rashes in HIV patients.

Recurrent/disseminated viral herpes simplex

Chronic or widespread herpes simplex virus infections, more severe and frequent in individuals with HIV.

Parasitic OIs

Pneumocystis carinii pneumonia

A fungal infection (previously classified as parasitic) causing severe lung disease, a common and life-threatening infection in HIV patients.


An infection caused by the Toxoplasma gondii parasite, leading to severe neurological issues in immunocompromised individuals like those with HIV.

Fungal OIs


A parasitic infection causing severe diarrhea, often found in HIV patients due to their weakened immune systems.

Oro-pharyngeal candida

A fungal infection in the mouth and throat, also known as thrush, common in HIV patients.

Candida Esophagitis

A severe fungal infection of the esophagus, causing difficulty in swallowing and chest pain, prevalent in advanced HIV cases.


A fungal infection caused by inhaling Histoplasma spores, leading to lung disease, more severe in immunocompromised patients.


A fungal disease also known as Valley fever, causing respiratory issues, especially severe in those with weakened immune systems.

Cryptococcal meningitis

A life-threatening fungal infection of the brain and spinal cord, common in advanced HIV/AIDS patients.

Opportunistic Cancers

Invasive cervical cancer

Cancer caused by the human papillomavirus (HPV), more prevalent and aggressive in women with HIV.

Kaposi sarcoma

A cancer caused by human herpesvirus 8 (HHV-8), leading to lesions on the skin and other organs, commonly seen in HIV patients.

Non-Hodgkin lymphoma

A type of cancer affecting the lymphatic system, more common and aggressive in individuals with HIV.

Other OIs

Oral hairy leukoplakia

A condition characterized by white patches on the tongue, caused by Epstein-Barr virus, indicating immunosuppression in HIV patients.


A rare, progressive viral disease affecting the white matter of the brain, often seen in severe immunocompromised states like advanced HIV.

Progressive multifocal leukoencephalopathy

A demyelinating disease of the central nervous system caused by the JC virus, highly fatal in HIV patients.

Causes of Opportunistic Infections:

  • Poor adherence to treatment
  • Presence of other diseases (e.g., juvenile diabetes mellitus)
  • Delay in identification of the infection
  • High viral load
  • Poor nutrition
  • Exposure to opportunistic infectious agents
  • Ingestion of substances contaminated with opportunistic infectious agents
  • Missing out on immunization programs
  • Poor hygiene
  • Poor sanitation
  • Poor ventilation

Prevention of Opportunistic Infections:

  • Avoidance of contact with the disease agents
  • Proper treatment of other underlying diseases
  • Adherence to HIV drug treatment
  • Immunization of children against killer diseases
  • Ensuring that children consume well-cooked food and boiled water
  • Early identification and treatment of opportunistic diseases
  • Health education of the family and infected child about opportunistic infections


Hepatitis B is a chronic liver infection characterized by inflammation of hepatocytes caused by the hepatitis B virus.


  • High: Blood
  • Moderate: Semen, Urine, Serum, Wound exudate, Vaginal fluid
  • Low/Not Detectable: Saliva, Feces, Sweat, Tears, Breast milk

Stages of Hepatitis B:

  1. Immune Tolerance: Represents the incubation period, lasting approximately 2-4 weeks in healthy adults, and often decades in newborns.
  2. Immune Active/Immune Clearance: Inflammatory reaction occurs with active viral replication. Duration varies; for acute infection, approximately 3-4 weeks; for chronic infection, up to 10 years.
  3. Inactive Chronic Infection: Host targets infected hepatocytes and HBV, with low or no measurable viral replication in serum. Anti-HBe can be detected.
  4. Chronic Disease: Chronic HBeAg-negative disease may emerge.
  5. Recovery: Virus undetectable in blood, antibodies to viral antigens produced.

Clinical Features:

Symptoms can be symptomatic or asymptomatic:

  • Weakness, malaise, low-grade fever
  • Nausea, loss of appetite, vomiting
  • Pain or tenderness over right upper abdomen
  • Jaundice, dark urine, severe pruritus
  • Enlarged liver
  • Complications: liver cirrhosis, hepatocarcinoma


  • Hepatitis B surface antigen positive for >6 months
  • Hepatitis B core antibody: Negative IgM and Positive IgG to exclude acute hepatitis B infection
  • Liver tests, repeated at 6 months
  • HBeAg (can be positive or negative)
  • HBV DNA if available
  • HIV serology
  • APRI (AST to Platelets Ratio Index): a marker for fibrosis
  • Alpha fetoprotein at 6 months
  • Abdominal ultrasound at 4-6 months


General Principles:

  • Screen for HIV and refer if positive.
  • Refer to a regional hospital for specialist management if HIV is negative.
  • Antiviral treatment is given to prevent complications and usually for life.
  • Patients with chronic hepatitis B need periodic monitoring and follow-up for life.
  • Periodic screening for hepatocarcinoma with alfa fetoprotein and abdominal ultrasound once a year.

Treatment with Antivirals:

  • Treat with antivirals based on specific criteria.

First-line antivirals:

  • Adults and children >12 years or >35 kg: tenofovir 300 mg once a day
  • Child 2-11 years (>10 kg): Entecavir 0.02 mg/kg

Health Education:

  • Management is lifelong.
  • Bed rest is recommended.
  • Avoid alcohol as it worsens the disease.
  • Immunization of household contacts.
  • Do not share items that the patient puts in the mouth (e.g. toothbrushes, cutlery, razor blades).
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