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 Zambia HIV National Guidelines


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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS



Diagnosis>Organ System>
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Cholangiopathy, HIV

Andrea Cox, M.D., Ph.D. and Christopher J. Hoffmann, M.D., M.P.H.

  • Almost no data on epidemiology of HIV cholangiopathy in Zambia or sub-Saharan Africa
  • Given association between HIV cholangiopathy and organisms prevalent in HIV+ patients in Zambia, (e.g. Cryptosporidium, microsporidia, Cyclospora, and CMV), this disease likely underdiagnosed in Zambia.
  • ERCP not readily available in Zambia. Ultrasound and lab findings in appropriate clinical scenario may lead to presumptive diagnosis.
  • Treatment options, besides ART, are limited in Zambia.
Zambia Information Author: Larry William Chang, MD, MPH



  • Syndrome of biliary obstruction resulting from infection-associated strictures of the biliary tract. Typically occurs in pts with advanced HIV disease(CD4 <50). 4 sub-classifications:
  •  - Papillary strictures/stenosis (10%)
  •  - Sclerosing cholangitis-like (20%)
  •  - Papillary stenosis with sclerosing cholangitis (50-60%)
  •  - Extra-hepatic strictures (rare)
  • Sx: RUQ pain (90%) often sharp & radiating to back (especially if strictures present). Fever (50%), low grade if present. Diarrhea common due to small bowel involvement with infectious agent.
  • Signs: LFTs suggest cholestasis: mild increase in ALT/AST (2-3x ULN), total bili usually <2x ULN (jaundice rare but can be present), alk phos 5-10x ULN. LFTs normal in 20%.
  • Large intrahepatic ducts most commonly involved; Cryptosporidium and CMV are usual pathogens in such cases.
  • Idiopathic in ~20% of cases.


  • Established with ERCP. Sensitivity of ultrasound (US) is 75-97%.
  • If US positive, ERCP indicated to confirm Dx and treat. If US negative, ERCP if abd. pain is severe or w/ known CMV or Cryptosporidium infection.
  • OIs (usually CMV, Cryptosporidium, or microsporidium) involved in >50% of cases.


Papillary stenosis

  • ERCP with sphincterotomy provides relief of Sx, but alk phos often remains high.
Isolated bile duct stricture

  • Endoscopic stenting considered for pain management
Cholangiopathy without papillary stenosis

  • Ursodeoxycholic acid (ursodiol 300 mg PO three times a day chronically) used experimentally in HIV cholangiopathy.

  • Role of ART in managing cholangiopathy is unclear, but overall survival improved by ART. 
Pathogen-specific therapy

Differential Diagnosis

  • Viral hepatitis (HAV, HBV, HCV, HDV) 
  • CMV, HSV, EBV infection
  • Heptobiliary cryptococcosis
  • Mycobacterial infection of the liver (TB, MAC)
  • Fatty infiltration of liver
  • Drug reaction (TMP-SMX, INH, rifampin, ketoconazole, pentamidine, pyrimethamine, dapsone)
  • Lymphoma 
  • Vanishing bile duct syndrome (associated with high bilirubin)



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