Fungal infections in AIDS

Fungi are major contributors to the opportunistic infections that threaten patients with AIDS. Pneumocystis jirovecii is the commonest respiratory infection and Cryptococcus neoformans the commonest central nervous system infection in AIDS patients across large parts of the world. Histoplasma capsulatum and Talaromyces (Penicillium) marneffei are thermally dimorphic fungi that cause disseminated infections, the former being especially common in parts of the Americas, and the latter endemic in SE Asia. With widespread availability of ART and earlier testing for HIV, the incidence of systemic fungal infections has decreased in HIV-infected persons in the developed world. But, importantly, in many areas of high HIV prevalence, many patients continue to present late with a low CD4 cell count or re-present with persistent low CD4 cell counts due to problems of adherence and or ART resistance. For pneumocystosis, talaromycosis, and in particular histoplasmosis, affordable, rapid point-of-care diagnostic tests, as have been developed for cryptococcosis, are urgently needed. In addition, antifungal drugs, including amphotericin B, liposomal amphotericin B, and flucytosine, need to be made much more widely available. Such measures, together with continued international efforts in education and training in the management of fungal disease, have the potential to significantly improve patient outcomes.