‘Almost 70% – 80% of adults that are being hospitalised for pneumonia are adults that are HIV-infected. Even though in South Africa HIV-infected adults only make up about 10% to 15% of the population, they are responsible for 70% – 80% of all of the hospitalisations for pneumonia’, says Professor Shabir Madhi, Director of the National Institutes for Communicable Diseases (NICD).
According to Professor Madhi, pneumonia has become a serious opportunistic infection in people living with HIV in South Africa. It’s also one of the leading causes of deaths in HIV-infected individuals. In saying so, Professor Madhi speaks of a very intricate relationship between pneumonia and tuberculosis, another rife opportunistic chest infection.
‘It’s a leading cause of deaths together with tuberculosis. What we see in HIV-infected adults, especially if you go to rural hospitals as an example, is that almost 60% of HIV-infected adults are dying because of tuberculosis. What we’ve been able to show in South Africa, both in adults as well as in children, is that what happens in HIV-infected individuals especially, is that the underlying tuberculosis predisposes those individuals from developing super-imposed bacterial infections. So, what’s happening in HIV-infected individuals is that the pneumonia death is becoming very complex in terms of what is actually causing the death. It’s both a combination of the TB itself as well as possibly a consequence of the TB predisposing that individual to developing additional bacterial infections such as infections from pneumococcus’, he says.
But why are HIV-positive people at more risk of pneumonia?
‘Because of the problems they experience with their immune systems which become weak, they are much more vulnerable to getting infections from common bacteria as well as unusual bacteria and unusual pathogens. Specifically, what we’ve seen in HIV-infected individuals, is that there is one single bacteria and that bacteria is known as ‘pneumococcus’, which is also the most common cause of pneumonia in HIV-uninfected adults. That one particular bacteria seems to be especially a big problem in HIV-infected adults – so much so that a chance of an HIV-infected adult being hospitalised for pneumonia due to the pneumococcus is about 40 ‘ 100 times greater than an HIV-uninfected adult’, Professor Madhi explains.
He says this occurs despite the increased availability of antiretroviral therapy.
‘Even though antiretroviral treatment has been available to HIV-infected adults since 2004 in the public sector in South Africa, we still find that the amount of pneumonia occurring in HIV-infected adults is still about 40 ‘ 50 times greater than what’s occurring in HIV-uninfected adults. What that tells us is that, firstly, we’re not getting enough HIV-infected adults onto antiretroviral treatment, and it indicates to us that we need to be looking at other strategies in addition to antiretroviral treatment of HIV-infected adults in controlling this huge problem of pneumonia in HIV-infected individuals’.
If HIV-infected adults that are not on treatment are at an increased risk of contracting pneumonia, then what is the risk of those HIV-infected adults on treatment?
‘That risk is reduced significantly’, says Professor Madhi.
‘But it’s still greater than for HIV-uninfected adults. That risk is decreased from around a hundred-fold increase to round about a twenty-fold increase. So, even with antiretroviral treatment’¦ unfortunately antiretroviral treatment is unable to get the immune system to function as well as in someone that’s not HIV-infected. Those individuals unfortunately will still occasionally develop some sort of illnesses, including illnesses because of pneumococcal pneumonia’, he adds.
He says access to antiretroviral therapy must be scaled up to reach more people who should be getting treatment. But he adds that there are other interventions to prevent pneumonia.
‘One of the simple strategies that have been found to work is another antibiotic, which is meant to be taken regularly, especially in HIV-infected individuals with very low CD 4 counts, known as Cotrimoxazole or Bactrim. Now, Bactrim, when used as prophylaxis is to prevent the infection rather than to actually treat the infection. It’s taken almost daily. And what it’s been shown to do is reduce the risk of the HIV-infected adult, even if the adult is not on antiretroviral treatment, from being hospitalised or developing pneumonia’.
Cotrimoxazole prophylaxis is freely available at public health facilities and if patients do not get it, they should ask for it. HIV-infected individuals should also consider vaccination for the flu every year.
‘What we’ve showed in studies in Johannesburg is that when HIV-infected adults receive the influenza vaccine the chance of them getting an influenza illness is reduced by up to 75% and that reduction of influenza illness of up to 75% will also translate into a reduction of hospitalisation for pneumonia in those HIV-infected adults’, says Professor Madhi.