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

Human Herpesvirus-8 Disease

Last Updated: May 29, 2018; Last Reviewed: February 21, 2018

Recommendations for Treating HHV-8 Diseases—Kaposi Sarcoma (KS), Primary Effusion Lymphoma (PEL), Multicentric Castleman’s Disease (MCD)
Preventing Development of KS
  • Since low CD4 cell count and uncontrolled HIV viremia are strong risk factors of KS, early initiation of ART is likely to be the most effective measure for the prevention of KS (AII)
Mild-to-Moderate KS (localized involvement of skin and/or lymph nodes)1
  • Initiation or optimization of ART (AII)
Advanced KS (visceral and/or disseminated cutaneous disease):1
  • Chemotherapy (in consultation with specialist) + ART [visceral KS (AI) or widely-disseminated cutaneous KS (BIII)].
  • Liposomal doxorubicin is preferred first-line chemotherapy (AI)
  • Avoid use of corticosteroids in patients with KS, including those with KS-IRIS, given the potential for exacerbation of life-threatening disease (AIII)
  • Antiviral agents with activity against HHV-8 are not recommended for KS treatment (AIII).
PEL:
  • Chemotherapy (in consultation with a specialist) (AIII) + ART (AIII)
  • Oral valganciclovir or IV ganciclovir can be used as adjunctive therapy (CIII)

MCD:

All patients with MCD should receive ART (AIII) in conjunction with one of the therapies listed below.

Therapy Options (in consultation with a specialist, and depending on HIV/HHV-8 status, presence of organ failure, and refractory nature of disease):

  • IV ganciclovir (or oral valganciclovir) +/- high dose zidovudine (CII)
  • Rituximab +/- prednisone (CII)
  • For patients with concurrent KS and MCD: rituximab + liposomal doxorubicin (BII)
  • Monoclonal antibody targeting IL-6 or IL-6 receptor (BII)
  • Corticosteroids are potentially effective as adjunctive therapy, but should be used with caution or avoided, especially in patients with concurrent KS. (AIII)
Other Considerations:
  • Patients who receive rituximab or corticosteroids for treatment of MCD may experience subsequent exacerbation or emergence of KS
Key to Acronyms: ART = antiretroviral therapy; BID = twice daily; IV = intraveneously; KS = Kaposi sarcoma; MCD = multicentric Castleman’s disease; PEL = primary effusion lymphoma; PO = orally; q(n)h = every ”n” hours

1 The commonly used AIDS Clinical Trials Group (ACTG) KS Staging Classification uses T(Tumor), Immune(I), and Systemic illness (S) criteria to classify patients into ”Good Risk” and ”Poor Risk” categories (ref Krown, JCO, 1989). ”Good Risk” tumor stage criteria are used by some specialists to correspond with mild-to-moderate KS.

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