Opportunistic Infection in HIV: Challenges in Management

Abstract

Managing opportunistic infections (OIs) in people living with HIV (PLHIV) remains a critical challenge, as illustrated by 1,759 PLHIV at the Infectious Disease Hospital, Dhaka (2001–2025), where mortality was 9.5% versus 18.6% nationally. The spectrum includes disseminated tuberculosis (splenic abscess, recurrent abscesses, Tuberculosis verrucosa cutis), histoplasmosis, ocular/cerebral toxoplasmosis, post-kala-azar dermal leishmaniasis, and molluscum contagiosum. Key challenges are atypical OI presentations unresponsive to standard antimicrobials, limited diagnostics (CD4, viral load, mycobacterial/fungal cultures, biopsy), and stigma causing delayed linkage to care—patients refused surgical drainage or transferred without CSF studies. Management complexity increases with coinfections requiring nuanced ART timing: for TB meningitis, ART should start once meningitis is under control (2–4 weeks after TB treatment and steroids), not immediately; for cryptococcal meningitis, ART is recommended 2–4 weeks after antifungal induction, provided intracranial pressure is controlled and CSF cultures negative. Drug-drug interactions further complicate care—rifampin reduces dolutegravir (DTG) levels, requiring DTG twice daily during active TB treatment or once daily with 3HP for latent TB, while bictegravir/FTC/TAF twice daily with rifampin shows high efficacy. Alternatives like boosted protease inhibitors require rifabutin substitution. Antimicrobial resistance in concurrent STIs (e.g., reduced ceftriaxone susceptibility in Neisseria gonorrhoeae) adds another layer. Without integrated, stigma-free diagnostic algorithms, expanded laboratory capacity, knowledge of ART-OI timing, and management of drug interactions, preventable OI mortality will persist. Treating HIV as an immunocompromised state like any other, with timely biopsy, culture, and adherence support, is essential.

Bangladesh J Medicine 2026; Vol. 37, No. 2(1): pp. 194