Prophylaxis for HIV-associated infections in the developing world

Prophylaxis for specific HIV-associated infections has made a major difference in the industrialized world to patient survival and the quality of life. However, the HIV epidemic is spreading most rapidly in the poor developing world, where prophylaxis is neither currently used nor recommended. Streptococcus pneumoniae. Mycobacterium tuberculosis and non-typhi salmonellae are the pathogens responsible for much of the morbidity and mortality associated with HIV infection in the tropics. Because these problems often present relatively early in the course of the HIV disease, prophylaxis may be cost-effective and increase the years of productive life. Prevention of pneumococcal disease has not been considered a priority in the developing world. Penicillin chemoprophylaxis may be efficacious; immunization which is recommended for all HIV seropositive adults in the USA, has not been used. The importance of studies to test both efficacy and cost compared to benefit is discussed. The problem of HIV-associated tuberculosis is of major importance and several intervention studies are now in progress. The efficacy of chemoprophylaxis may be limited if the problem is largely acute infection rather than reactivated disease and if shown to be effective compliance will present a major operational difficulty. Systemic salmonellosis is greatly underdiagnosed but may be the leading cause of death. Recurrent infection can be prevented by chemoprophylaxis but this will be costly. The use of novel or currently unlicensed vaccines may eventually prove to be the most effective means of controlling the burden of disease and death caused by salmonellosis.