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: December 9, 2019; Last Reviewed: December 9, 2019
I. Should children with HIV without evidence of immunity to varicella receive the varicella vaccine, compared to not receiving the vaccine?
Strength of Recommendation: Strong; Weak
Quality of Evidence: High; Moderate; Low; or Very Low
I. Should children with HIV without evidence of immunity to varicella receive the varicella vaccine, compared to not receiving the varicella vaccine?
III. Should children with HIV with varicella be treated with acyclovir, compared to not being treated with acyclovir?
|Indication||First Choice||Alternative||Comments/Special Issues|
|Pre-Exposure Prophylaxis||Varicella vaccine||N/A||See Figure 1 for detailed vaccine recommendations.|
|Primary (Post-Exposure) Prophylaxis||VariZIG 125 IU/10 kg body weight (maximum 625 IU) IM, administered ideally within 96 hours (potentially beneficial up to 10 days) after exposure||If VariZIG is not available, IVIG 400 mg/kg body weight, administered once should be considered. IVIG should ideally be administered within 96 hours of exposure.
When passive immunization is not possible, some experts recommend prophylaxis with acyclovir 20 mg/kg body weight/dose (maximum dose acyclovir 800 mg) by mouth, administered four times a day for 7 days, beginning 7–10 days after exposure.
|Primary Post-Exposure Prophylaxis Indicated for:
a Centers for Disease Control and Prevention. Revised classification system for human immunodeficiency virus infection in children aged <13 years. 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.
|Secondary Prophylaxis||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 and No or Moderate Immune Suppression:
|Patients Unresponsive to Acyclovir:
||In children aged ≥1 year, 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.
Valacyclovir is approved for use in adults and adolescents with zoster at 1 g/dose by mouth three times a day for 7 days; the same dose has been used for varicella infections. Valacyclovir can be used in children at a dose of 20 to 25 mg/kg body weight administered 2 to 3 times a day. Doses lower than this may be insufficient for children weighing <20 kg. There is no pediatric preparation, although 500-mg capsules can be extemporaneously compounded to make a suspension to administer valacyclovir 20 mg/kg body weight/dose (maximum dose 1 g) given three times a day (see prescribing information).
Famciclovir is approved for use in adults and adolescents with zoster at 500 mg/dose by mouth three times a day for 7 days; the same dose has been used for varicella infections. A sprinkle formulation of famciclovir is available for children who are unable to swallow the available pill formulation. A schedule for weight-adjusted dosing is available to inform dosing of small children.
Involvement of an ophthalmologist with experience in managing HZ ophthalmicus and its complications in children is strongly recommended when ocular involvement is evident.
Optimal management of progressive outer retinal necrosis has not been defined.
|Key: CDC = Centers for Disease Control and Prevention; HZ = herpes zoster; IM = intramuscular; IU = international units; IV = intravenous; IVIG = intravenous immunoglobulin; VariZIG = varicella zoster immune globulin; VZV = varicella zoster virus|