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Changing disease pattern in adults - AIDS
In different parts of the world, AIDS tends to have its own characteristics. This may be due to the pattern of other illnesses present in different communities, which explains why TB is the commonest cause of death from AIDS in Africa and Asia. Different patterns may be related to different co-factors (compared to drug injectors, for example), viral differences or possibly genetic differences.
However, patterns are changing. For example, the incidence of Kaposi's sarcoma is falling among with HIV in a number of countries, while it is rising among drug users. Some of these changed patterns are because of altered treatments; others are due to other factors.
As survival times have increased, other problems have emerged which are far more difficult to treat. These include blindness due to cytomegalovirus, progressive multifocal leucoencephalopathy (weakness, muscle wasting, difficulty thinking), cryptosporidiosis (causes various infections), mycobacterium infections and cryptococcal meningitis.
In addition, as we have seen, advanced Kaposi's sarcoma can bring its own problems, with lung involvement causing shortness of breath and triggering chest infections, gut involvement causing obstruction or sudden bleeding, and with blockage of lymphatic drainage causing swollen limbs or face, skin ulceration and infection.
In a quarter of those dying with AIDS, the exact cause of death may be difficult to establish, with profound weakness, loss of weight and multi-system failure. Many infections can be chronic, low grade and difficult to diagnose, and when diagnosed can be hard to treat. Indeed, post-mortem examinations show that half of all HIV-related diseases found at autopsy have not been diagnosed during life.
In the early days in many countries, those with AIDS often spent a long time in hospital as doctors battled to get to grips with the complex spectrum of illnesses. Now people with AIDS are usually able to spend more time at home, with many treatments given in clinics or in the home. However, many have multiple problems and need practical help, backed by nursing care and symptom control, to stay at home in comfort and in control of their own lives. Later on in this book we will look at the practicalities of setting up community care programmes.
Many people who are ill are now opting not to have every symptom investigated, when the price is valuable time spent in hospital, unpleasant tests, and treatments that may have side effects.