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J Res Med Sci 2017,  22:93

The aware, alert, avert strategy for immune reconstitution inflammatory syndrome in HIV/AIDS

Department of Microbiology, Government Medical College and Rajindra Hospital, Patiala, Punjab, India

Date of Web Publication16-Aug-2017

Correspondence Address:
Udhayvir Singh Grewal
Government Medical College and Rajindra Hospital, Patiala, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrms.JRMS_206_16

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How to cite this article:
Grewal US. The aware, alert, avert strategy for immune reconstitution inflammatory syndrome in HIV/AIDS. J Res Med Sci 2017;22:93

How to cite this URL:
Grewal US. The aware, alert, avert strategy for immune reconstitution inflammatory syndrome in HIV/AIDS. J Res Med Sci [serial online] 2017 [cited 2020 Dec 1];22:93. Available from: https://www.jmsjournal.net/text.asp?2017/22/1/93/213058


HIV immune reconstitution inflammatory syndrome (IRIS) is one of the most significant challenges of highly active antiretroviral treatment (ART) faced by physicians across the world. Through this letter, I wish to draw the attention of readers to a simple aware, alert, avert strategy that can be used to deal with IRIS, especially in areas with a high load of HIV/AIDS patients.

Aware: Awareness about IRIS among physicians of all disciplines is necessary for prompt identification in clinical settings.

IRIS occurs because of the enhancement in the immune system of the body that renews its ability to mount a strong inflammatory response. This manifests clinically as worsening of symptoms of the patient initiated on ART.[1] IRIS can be classified as:

  1. Paradoxical IRIS: Paradoxical worsening of an existing infection/disease process
  2. Unmasking IRIS: Appearance of a new infection/disease process soon after initiation of therapy.[2]

Alert: Crucial to the prevention of IRIS is identification and understanding of the risk factors and staying alert to suspect them. [Table 1] enlists the major risk factors of the two broad categories of IRIS, modeled on tuberculosis-IRIS.
Table 1: Risk factors for development of unmasking tuberculosis-immune reconstitution inflammatory syndrome versus paradoxical tuberculosis-immune reconstitution inflammatory syndrome in HIV infected patients

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Avert: Based on the risk factors, some basic preventive strategies have been devised through research and clinical experience that can be used to avert IRIS.

Prevention of unmasking IRIS can be achieved through:

  1. Systematic screening for opportunistic infections (OIs) before initiation of ART
  2. Screening of all patients, irrespective of the presence of symptoms in endemic areas
  3. Screening of patients for subclinical cryptococcal infection at the time of entry into ART programs.[1]

Preventive strategies for paradoxical IRIS include:

  1. Prompt diagnosis and intensive treatment of the OI
  2. Deferral of ART initiation based on CD4 count of the patient.[6] Deferral may prove to be beneficial for OIs such as cryptococcal or tubercular meningitis but may reduce survival in Pneumocystis jirovecii infection.

The knowledge about IRIS, its risk factors and preventive strategies are much needed among physicians of all disciplines, especially in regions of high endemicity. This simple strategy, proposed through this letter, can greatly help in curbing the rise in this challenge in the management of HIV/AIDS and will go a long way in reducing the overall morbidity and mortality associated with it.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Shahani L, Hamill RJ. Therapeutics targeting inflammation in the immune reconstitution inflammatory syndrome. Transl Res 2016;167:88-103.  Back to cited text no. 1
Sharma SK, Soneja M. HIV & immune reconstitution inflammatory syndrome (IRIS). Indian J Med Res 2011;134:866-77.  Back to cited text no. 2
[PUBMED]  [Full text]  
Valin N, Pacanowski J, Denoeud L, Lacombe K, Lalande V, Fonquernie L, et al. Risk factors for 'unmasking immune reconstitution inflammatory syndrome' presentation of tuberculosis following combination antiretroviral therapy initiation in HIV-infected patients. AIDS 2010;24:1519-25.  Back to cited text no. 3
Haddow LJ, Moosa MY, Mosam A, Moodley P, Parboosing R, Easterbrook PJ. Incidence, clinical spectrum, risk factors and impact of HIV-associated immune reconstitution inflammatory syndrome in South Africa. PLoS One 2012;7:e40623.  Back to cited text no. 4
Bonnet M, Baudin E, Jani IV, Nunes E, Verhoustraten F, Calmy A, et al. Incidence of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome and impact on patient outcome. PLoS One 2013;8:e84585.  Back to cited text no. 5
National Institutes of Health, AIDSinfo. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents; 2013. http://www.aidsinfo.nih.gov. [Last accessed on 2017 May 02].  Back to cited text no. 6


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