Prevention and treatment of the immune reconstitution inflammatory syndrome

The immune reconstitution inflammatory syndrome occurs in a proportion of HIV-infected patients initiated on combination antiretroviral therapy and results from dysregulated inflammatory responses driven by the recovering immune system. Infective forms may manifest as the unmasking of preexisting untreated opportunistic infections or the paradoxical clinical deterioration of appropriately treated opportunistic infections. The prevention and treatment of this condition is the focus of much research attention, which is the scope of this review.

Approaches to prevention are informed by studies that have reported on risk factors, particularly those that are modifiable. Two key ongoing research issues are optimal screening for opportunistic infections prior to combination antiretroviral therapy in order to prevent unmasking forms and the optimal timing of combination antiretroviral therapy in patients on treatment for an opportunistic infection, balancing the risk of paradoxical immune reconstitution inflammatory syndrome that is associated with early initiation with the risk of advancing immunosuppression associated with delaying. In most cases of immune reconstitution inflammatory syndrome combination antiretroviral therapy has been continued. A variety of additional management strategies have been used including corticosteroids, nonsteroidal anti-inflammatory drugs, drainage procedures and surgery. The advantages and disadvantages of different management strategies are discussed.

No controlled clinical trials regarding the prevention or treatment of immune reconstitution inflammatory syndrome have been completed. There is a need for such studies in order to guide clinicians in their approach to this condition.