Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children
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.
Last Updated: November 6, 2013; Last Reviewed: November 6, 2013
should receive VZV immunoglobulin prophylaxis as soon as possible (ideally within 96 hours but potentially beneficial up to 10 days) after the close contact (AII). Many experts limit this recommendation to varicella- or zoster-exposed HIV-infected children who are considered to be severely immunocompromised (i.e., CDC Immunologic Category 3) especially if they have high HIV viral loads and would be classified in CDC Clinical Category C (BIII). When passive immunization is impossible, some experts recommend prophylaxis with acyclovir beginning 7 to 10 days after exposure, while others consider it prudent to wait until the first appearance of rash to start acyclovir therapy in VZV-susceptible and VZV-exposed, HIV-infected children (CIII).
|Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials in children† with clinical outcomes and/or validated endpoints; I* = One or more randomized trials in adults with clinical outcomes and/or validated laboratory endpoints with accompanying data in children† from one or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; II = One or more well-designed, nonrandomized trials or observational cohort studies in children† with long-term outcomes; II* = One or more well-designed, nonrandomized trials or observational studies in adults with long-term clinical outcomes with accompanying data in children† from one or more similar nonrandomized trials or cohort studies with clinical outcome data; III = Expert opinion
†Studies that include children or children/adolescents, but not studies limited to post-pubertal adolescents
|Indication||First Choice||Alternative||Comments/Special Issues|
||See Figures 1 and 2 for detailed vaccine recommendations.
|Primary (Post-Exposure) Prophylaxis
||VariZIG 125 IU/10 kg body weight IM (maximum 625 IU), administered ideally within 96 hours (potentially beneficial up to 10 days) after exposure
||Primary Post-Exposure Prophylaxis Indicated for:
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a CDC. Revised classification system for human immunodeficiency virus infection in children less than 13 years of age. Official authorized addenda: human immunodeficiency virus infection codes and official guidelines for coding and reporting ICD-9-CM. MMWR Morb Mortal Wkly Rep. 1994;43:1-19. Available at http://www.cdc.gov/mmwr/PDF/rr/rr4312.pdf.
||N/A||N/A||There is no indication for secondary prophylaxis|
Children with No or Moderate Immune Suppression (CDC Immunologic Categories 1 and 2) and Mild Varicella Disease:
Children with Uncomplicated Zoster:
Children with Severe Immunosuppression (CDC Immunologic Category 3), Trigeminal or Sacral Nerve Involvement, Extensive Multidermatomal, or Disseminated Zoster:
Children with Progressive Outer Retinal Necrosis:
Children with ARN:
Oral valacyclovir 1 g/dose TID for 4–6 weeks (for children old enough to receive adult dose). Alternative oral acyclovir dose: 20 mg/kg body weight/dose QID for 4–6 weeks
|Patients Unresponsive to Acyclovir:
In children ≥1 year of age, some experts base IV acyclovir dosing on body surface area (500 mg/m2 body surface area/dose IV every 8 hours) instead of body weight.
Involvement of an ophthalmologist with experience in managing herpes zoster ophthalmicus and its complications in children is strongly recommended when ocular involvement is evident.
Optimal management of PORN has not been defined.
|Key to Acronyms: ARN = acute retinal necrosis; CDC = Centers for Diseases Control and Prevention; IM = intramuscular; IU = international units; IV = intravenous; IVIG = intravenous immunoglobulin; PORN = progressive outer retinal necrosis; QID = four times a day; TID = three times daily; VariZIG = varicella zoster immune globulin; VZV = varicella zoster virus