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IMPAACT4HIV

Opportunistic Infections

On this page, explore how research drives progress in AHD care — with access to key studies, clinical trial results, guidelines, and insights shaping policy and practice across sub-Saharan Africa.

This page offers clinical resources, training tools, patient support, policy content, multimedia, and accessibility features — all designed to support comprehensive care and education.

Viral Infections

People with AHD are prone to several viral infections that can cause significant disease due to the weakened immune surveillance. Common viral infections in advanced HIV include cytomegalovirus (CMV), herpes viruses, and human papillomavirus (HPV), among others.

Home > Viral Infections

How Viruses Replicate

This diagram shows the basic steps of how viruses infect a cell and reproduce. In people with advanced HIV disease, the immune system is too weak to stop this process, allowing viruses like CMV, HSV, and HPV to cause serious complications. ART helps restore immune function and slow or stop this cycle.

Viral Infections in People with AHD

Infection Signs & Symptoms Screening / Diagnosis Treatment When to Start or Continue ART

Cytomegalovirus (CMV) 

Vision problems (blurry vision or blindness), diarrhea, inflammation of the food pipe, brain infection (encephalitis)
Eye exam, blood test (PCR), or biopsy if available
Ganciclovir or Valganciclovir (antiviral

Delay ART by 2 weeks if brain disease is present, to

Herpes Simplex Virus (HSV) 

Painful cold sores or genital ulcers that don’t heal; may spread throughout the body
Clinical exam; swab or blood test
Acyclovir or Valacyclovir; Foscarnet if resistant

Continue or start ART promptly; suppressive therapy helps healing

Human Papillomavirus (HPV) 

Warts on genitals, cervix, anus, or throat; linked to several types of cancer
Visual exam; Pap smear; HPV DNA test
Warts removal, surgery, or cancer treatment if needed
Start/continue ART; regular screening is essential
Mpox (Monkeypox)
Fever; body rash that turns into painful blisters; may be severe in people with AHD
Clinical exam; PCR test from lesion
Supportive care (pain relief, fluids); Tecovirimat (where available); Cidofovir in severe cases
Start/continue ART; vaccinate if at risk (JYNNEOS vaccine)
  • CMV eye disease is preventable with early ART and regular eye exams in people with CD4 <50.
  • Herpes and HPV are common in PLHIV; suppressive therapy and safe sex practices are important.
  • Mpox is not on WHO's core AHD list but is now prioritized for PLHIV in outbreak settings (per CDC and WHO).

Overview 

CMV is a herpesvirus that remains latent in the body and can reactivate in immunocompromised individuals, particularly those with CD4 counts below 50 cells/mm³. Reactivation can lead to end-organ diseases such as retinitis, colitis, esophagitis, and encephalitis.  

Symptoms  

  • Retinitis: Floaters, blurred vision, blind spots, and potential progression to blindness.  
  • Colitis: Chronic diarrhea and abdominal pain.  
  • Esophagitis: Painful swallowing.  
  • Encephalitis: Confusion, fever, and neurological deficits.  

 

Diagnosis  

  • Clinical examination, particularly ophthalmologic assessment for retinitis.  
  • PCR testing for CMV DNA in blood.  
  • Biopsy of affected tissues for histopathological confirmation.  

 

Treatment  

  • First-line: Intravenous ganciclovir or oral valganciclovir.  
  • Alternative: Foscarnet or cidofovir for resistant cases or when ganciclovir is contraindicated.  
  • Treatment is typically continued until immune recovery (CD4 count >100 cells/mm³ for at least 6 months).  

 

Prevention  

  • Regular ophthalmologic screening for early detection of retinitis.  
  • Maintenance of effective antiretroviral therapy (ART) to preserve immune function.  
  • Routine prophylaxis is not generally recommended due to potential drug toxicity. 

Overview 

HSV types 1 and 2 cause oral and genital herpes infections. In individuals with HIV, HSV infections can be more severe, frequent, and prolonged. Chronic HSV ulcers lasting more than one month are considered an AIDS-defining condition.  

Symptoms  

  • Painful ulcers on the mouth, lips, genitals, or anus.  
  • Chronic non-healing ulcers.  
  • Disseminated infections leading to pneumonitis or hepatitis in severe immunosuppression.  

 

Diagnosis  

  • Clinical evaluation of lesions.  
  • PCR or culture of lesion samples to confirm HSV and determine the type. 

 

Treatment  

  • First-line: Acyclovir, valacyclovir, or famciclovir.  
  • Higher doses or longer treatment durations may be necessary for HIV-positive individuals.  
  • For acyclovir-resistant HSV, intravenous foscarnet is used.  

 

Prevention  

  • Consistent use of condoms to reduce transmission.  
  • Daily suppressive antiviral therapy for individuals with frequent outbreaks.  
  • No vaccine is currently available for HSV.  
  • Effective ART can reduce the frequency and severity of HSV outbreaks.  

Overview  

HPV is a common sexually transmitted infection with multiple strains, some of which are associated with cancers such as cervical, anal, penile, and oropharyngeal cancers. Individuals with HIV are at increased risk for persistent HPV infections and related complications.  

Symptoms  

  • Anogenital warts: Flesh-colored or whitish bumps in the genital area.  
  • Cervical dysplasia: Often asymptomatic in early stages; may progress to cervical cancer.  
  • Anal dysplasia: May present with bleeding, discharge, or pain.  

 

Diagnosis  

  • Visual examination for warts.  
  • Pap smear and HPV testing for cervical changes.  
  • High-resolution anoscopy for anal dysplasia.  

 

Treatment  

  • Removal of warts via cryotherapy, laser therapy, or topical agents.  
  • Treatment of high-grade lesions with surgical excision, ablation, or topical therapies.  
  • Management of invasive cancers with standard oncology approaches.  

 

Prevention  

  • HPV vaccination recommended for individuals up to age 26, and up to age 45 in some guidelines.  
  • Regular cervical and anal cancer screening for early detection.  
  • Consistent condom use to reduce transmission risk.  
  • Smoking cessation to lower cancer risk.  

Overview  

Mpox, formerly known as monkeypox, is an emerging viral infection caused by the monkeypox virus, an orthopoxvirus related to smallpox. While it can affect anyone, individuals with advanced HIV are at increased risk of severe disease and complications.  

Symptoms  

  • Fever, headache, muscle aches, and swollen lymph nodes.  
  • A characteristic rash that progresses through macules, papules, vesicles, pustules, and scabs.  
  • In advanced HIV, lesions may be more numerous, confluent, and take longer to heal.  
  • Severe cases can involve complications like sepsis, encephalitis, and ocular infections.  

 

Diagnosis  

  • Clinical evaluation of symptoms and rash progression.  
  • Confirmation via PCR testing of lesion samples.  

 

Treatment  

  • Supportive care for mild cases.  
  • Antiviral therapy with tecovirimat (Tpoxx) is recommended for severe cases or those at high risk, including individuals with advanced HIV.  
  • Other antivirals like cidofovir may be considered in specific scenarios.  

 

Prevention  

  • Vaccination with the JYNNEOS vaccine is advised for high-risk populations, including people with HIV.  
  • Reducing exposure through safe practices and avoiding contact with infected individuals.  
  • Maintaining effective ART to support immune function.  

Sources

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