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

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.

Herpes

Varicella-Zoster Virus Disease

Last Updated: July 8, 2013; Last Reviewed: July 25, 2017

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

Indications:
  • Adult and adolescent patients with CD4 count ≥200 cells/mm3 without documentation of vaccination, health-care provider diagnosis or verification of a history of varicella or herpes zoster, laboratory confirmation of disease, or persons who are seronegative for VZV (CIII)
Note: Routine VZV serologic testing in HIV-infected adults and adolescents is not recommended.

Vaccination:
  • Primary varicella vaccination (Varivax™), 2 doses (0.5 mL SQ) administered 3 months apart (CIII)
  • If vaccination results in disease because of vaccine virus, treatment with acyclovir is recommended (AIII).
  • VZV-susceptible household contacts of susceptible HIV-infected persons should be vaccinated to prevent potential transmission of VZV to their HIV-infected contacts (BIII).
  • If post-exposure VariZIG has been administered, wait at least 5 months before varicella vaccination (CIII).
  • If post-exposure acyclovir has been administered, wait at least 3 days before varicella vaccine (CIII).
Post-Exposure Prophylaxis:

Indication (AIII):
  • Close contact with a person who has active varicella or herpes zoster, and
  • Is susceptible to VZV (i.e., has no history of vaccination or of either condition, or is known to be VZV seronegative)
Preferred Prophylaxis:
  • VariZIG 125 international units per 10 kg (maximum of 625 international units) 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 only through an expanded access program under a treatment IND by contacting FFF Enterprise at (800) 843-7477.
  • If post-exposure VariZIG has been administered, wait at least 5 months before varicella vaccination (CIII).
Note: Patients receiving monthly high dose IVIG (i.e., >400 mg/kg) are likely to be protected against VZV and probably do not require VariZIG if the last dose of IVIG was administered <3 weeks before VZV exposure.

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

Primary Varicella Infection (Chickenpox)
Uncomplicated Cases
Preferred Therapy:
  • Valacyclovir 1 g PO TID (AII), or
  • Famciclovir 500 mg PO TID (AII)
Alternative Therapy:
  • Acyclovir 800 mg PO 5 times daily (BII)
Duration:
  • 5–7 days
Severe or Complicated Cases:
  • Acyclovir 10–15 mg/kg IV q8h for 7–10 days (AIII)
  • May switch to oral famciclovir, valacyclovir, or acyclovir after defervescence if no evidence of visceral involvement is evident (BIII)
Herpes Zoster (Shingles)
Acute Localized Dermatomal
Preferred Therapy:
  • Valacyclovir 1000 mg PO TID (AII), or
  • Famciclovir 500 mg PO TID (AII)
Alternative Therapy:
  • Acyclovir 800 mg PO 5 times daily (BII)
Duration:
  • 7–10 days, longer duration should be considered if lesions resolve slowly
Extensive Cutaneous Lesion or Visceral Involvement
  • Acyclovir 10–15 mg/kg IV q8h until clinical improvement is evident (AII)
  • Switch to oral therapy (valacyclovir 1 g TID, famciclovir 500 mg TID, or acyclovir 800 mg PO 5 times daily)—to complete a 10–14 day course, when formation of new lesions has ceased and signs and symptoms of visceral VZV infection are improving (BIII)
PORN
  • Involvement of an experienced ophthalmologist is strongly recommended (AIII)
  • Ganciclovir 5 mg/kg and/or foscarnet 90 mg/kg IV q12h plus ganciclovir 2 mg/0.05mL and/or foscarnet 1.2 mg/0.05mL 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 response in consultation with ophthalmologist.
Note: ganciclovir ocular implants are no longer commercially available

ARN
  • Acyclovir 10-15 mg/kg IV q8h for 10–14 days, followed by valacyclovir 1 g PO TID for 6 weeks PLUS ganciclovir 2 mg/0.05mL intravitreal twice weekly X 1-2 doses (AIII)
  • Involvement of an experienced ophthalmologist is strongly recommended (AIII)
  • Duration of therapy is not well defined and should be determined based on clinical, virologic, and immunologic response in consultation with ophthalmologist.
Key to Acronyms: ARN = acute retinal necrosis; CD4 = CD4 T lymphocyte cell; IND = investigational new drug application; IV = intraveneously; IVIG = intraveneous immunoglobulin; PO = orally; PORN = progressive outer retinal necrosis; q(n)h = every “n” hours; SQ = subcutaneously; TID = three times a day; VariZIG = varicella zoster immune globulin; VZV = varicella zoster virus 

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