Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

Varicella-Zoster Virus Disease

Last Updated: September 5, 2019; Last Reviewed: September 5, 2019

Recommendations for Preventing and Treating Varicella Zoster Virus (VZV) Infections
Pre-Exposure Prevention of VZV Primary Infection

Indications:
  • Adults and adolescents with HIV who have CD4 counts ≥200 cells/mm3 and who do not have documentation of varicella vaccination, a history or diagnosis of varicella or herpes zoster confirmed by a health care provider, or laboratory confirmation of VZV disease; and anyone with HIV who is VZV seronegative should avoid exposure to persons with varicella or herpes zoster (CIII).
Vaccination:
  • VZV-susceptible household contacts of VZV-susceptible persons with HIV should be vaccinated to prevent potential transmission of VZV to their contacts with HIV (BIII).
  • In VZV-seronegative persons with CD4 counts ≥200 cells/mm3, primary varicella vaccination (Varivax™), 2 doses (0.5 mL SQ) administered 3 months apart (CIII).
  • If vaccination results in disease due to live-attenuated vaccine virus, treatment with acyclovir is recommended (AIII).
  • If post-exposure VariZIG has been administered, wait ≥5 months before varicella vaccination (CIII).
  • If post-exposure acyclovir has been administered, wait ≥3 days before varicella vaccination (CIII).
  • Administration of varicella vaccine to severely immunocompromised patients with HIV (CD4 counts <200 cells/mm3) is contraindicated (AIII).
Post-Exposure Prophylaxis of VZV Primary Infection

Indication (AIII):
  • Close contact with a person who has active varicella or herpes zoster, and
  • Susceptible to VZV (i.e., no history of varicella vaccination, no history of varicella or herpes zoster, or known to be VZV seronegative)
Preferred Prophylaxis:
  • VariZIG™ 125 IU/10 kg (maximum of 625 IU) IM, administered as soon as possible and within 10 days after exposure to a person with active varicella or herpes zoster (AIII)
  • VariZIG can be obtained by contacting FFF Enterprises (Temecula, California) at (800) 843-7477 or ASD Healthcare (Frisco, Texas) at (800) 746-6273. If post-exposure VariZIG has been administered, wait ≥5 months before varicella vaccination (CIII).
Note: Patients receiving monthly high dose IVIG (i.e., >400 mg/kg) are likely protected against VZV and probably do not require VariZIG if the last dose of IVIG they received was administered <3 weeks before VZV exposure.

Alternative Prophylaxis (Begin 7–10 Days After Exposure)
  • Acyclovir 800 mg PO 5 times a day for 5–7 days (BIII), or
  • Valacyclovir 1 g PO three times a day for 5–7 days (BIII)
Note: Neither these pre-emptive interventions nor post-exposure varicella vaccination have been studied in adults and adolescents with HIV. If acyclovir or valacyclovir is used, varicella vaccines should not be given <72 hours after the last dose of the antiviral drug.
Preventing Herpes Zoster (Shingles)

Vaccination:
  • RZV (Shingrix) is preferred over attenuated ZVL (Zostavax) for prevention of herpes zoster (AIII).
RZV:
  • Recommended in adults with HIV aged ≥50 years, regardless of CD4 count
  • RZV 0.5 mL IM injection (2 dose series) at 0 and then at 2 to 6 months (AIII).
  • RZV should not be given during an acute episode of herpes zoster (AIII).
  • Following initiation of ART, some experts would delay RZV vaccination until patients are virologically suppressed on ART (CIII) or until CD4 count recovery (CIII) to maximize immunologic response to the vaccine.
Attenuated ZVL:
  • If RZV is not available or cannot be given because of allergy or intolerance, ZVL can be administered (0.65 mL SQ for 1 dose) (BIII).
  • ZVL is contraindicated for persons with CD4 count<200 cells/mm3 (AIII).
Treating Varicella Infections

Primary Varicella Infection (Chickenpox)
Uncomplicated Cases
Preferred Therapy:
  • Valacyclovir 1 g PO three times a day (AII), or
  • Famciclovir 500 mg PO three times a day (AII)
Alternative Therapy:
  • Acyclovir 800 mg PO 5 times daily (BII)
Duration:
  • 5–7 days
Severe or Complicated Cases:
  • Acyclovir 10 mg/kg IV every 8 hours for 7–10 days (AIII)
  • May switch to oral famciclovir, valacyclovir, or acyclovir after defervescence if there is no evidence of visceral involvement (BIII)
Herpes Zoster (Shingles)
Acute Localized Dermatomal
Preferred Therapy:
  • Valacyclovir 1,000 mg PO three times a day (AII), or
  • Famciclovir 500 mg PO three times a day (AII)
Alternative Therapy:
  • Acyclovir 800 mg PO 5 times a day (BII)
Duration:
  • 7–10 days; longer duration should be considered if lesions resolve slowly
HZO:
  • Late dendriform lesions of the corneal epithelium should be treated with systemic or topical anti-herpetic medications (AIII).
Extensive Cutaneous Lesion or Visceral Involvement
  • Acyclovir 10 mg/kg IV every 8 hours until clinical improvement is evident (AII).
  • Switch to oral therapy (valacyclovir 1 g three times a day, famciclovir 500 mg three times a day, or acyclovir 800 mg PO five times a day to complete a 10-day to 14-day course) when formation of new lesions has ceased and signs and symptoms of visceral VZV infection are improving (BIII).
ARN:
  • Acyclovir 10 mg/kg IV every 8 hours for 10–14 days, followed by valacyclovir 1 g PO three times a day for ≥14 weeks (AIII) plus ganciclovir 2 mg/0.05 mL intravitreal twice weekly for 1–2 doses (BIII).
  • Involvement of an experienced ophthalmologist is strongly recommended (AIII).
  • Use of oral valaciclovir instead of IV acyclovir for initial treatment has been reported, but this approach should be used with caution, as serum drug levels with oral treatment will not be as high as those achieved with IV administration (CIII).
PORN:
  • Involvement of an experienced ophthalmologist is strongly recommended (AIII).
  • Acyclovir 10 mg/kg IV every 8 hours or ganciclovir 5 mg/kg every 12 hours plus ganciclovir 2 mg/0.05 mL and/or foscarnet 1.2 mg/0.05 mL intravitreal twice weekly (AIII)
  • Optimize ART regimen (AIII)
  • Duration of therapy is not well defined and should be determined based on clinical, virologic, and immunologic responses in consultation with an ophthalmologist.
Note: Ganciclovir ocular implants are no longer commercially available.

Key: ARN = acute retinal necrosis; ART = antiretroviral therapy; CD4 = CD4 T lymphocyte cell; HZO = herpes zoster ophthalmicus; IM = intramuscular; IU = international unit; IV = intravenous; IVIG = intravenous immunoglobulin; PO = orally; PORN = progressive outer retinal necrosis; RZV = recombinant zoster vaccine; SQ = subcutaneous; VariZIG = varicella zoster immune globulin; VZV = varicella zoster virus; ZVL = zoster vaccine live

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