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

What's New in the Guidelines

(Last updated: December 17, 2015; last reviewed: December 17, 2015)

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

The Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV Infected Adults and Adolescents document was published in an electronic format that could be easily updated as relevant changes in prevention and treatment recommendations occur.

The editors and subject matter experts are committed to timely changes in this document because so many health care providers, patients, and policy experts rely on this source for vital clinical information.

All changes are developed by the subject matter groups listed in the document (changes in group composition are also promptly posted). These changes are reviewed by the editors and by relevant outside reviewers before the document is altered.

Major revisions within the last 6 months are as follows:

December 17, 2015

  1. Syphilis: This section has been updated. New information is summarized about current testing algorithms for syphilis. Discussion of management of patients with sexual risk history is expanded in terms of diagnostic and therapeutic approaches. Recommendations for the diagnosis and management of neurosyphilis and ocular syphilis have been more extensively delineated. Updated recommendations for treatment and retreatment options for syphilis in non-pregnant and pregnant persons are also provided.

December 8, 2015

  1. CandidaThe section has been updated to provide clinicians with guidance on the use of topical and systemic antifungal agents to treat oropharyngeal candidiasis.

November 4, 2015

  1. Cytomegalovirus: This revision provides guidance for the management of Cytomegalovirus (CMV) retinitis which develops or worsens in the setting of ART initiation. Data supporting the treatment of CMV retinitis with systemic anti-CMV therapy for prevention of contralateral eye and visceral disease are discussed. The term “Secondary Prophylaxis” is replaced by “Maintenance Therapy”.

October 19, 2015:

  1. Toxoplasmosis: The Toxoplasmosis section has been updated to provide clinicians with guidance on the use of trimethoprim-sulfamethoxazole for treatment of acute infection and chronic maintenance therapy for suspected or documented toxoplasmosis if pyrimethamine is not readily available.

September 24, 2015:

  1. HPV: This update provides new recommendations regarding the cervical cancer screening interval for HIV-positive women after 3 consecutive normal Pap tests, and the use of HPV co-testing among HIV-positive women >30 years of age. It additionally includes recommendations regarding the use of 9-valent HPV vaccine among HIV-positive females and males ages 9-26 to prevent HPV infection.
  2. Chagas: This update provides new information regarding management of treatment failure. Results of a randomized clinical trial have shown that posaconazole was not efficacious for treatment of chronic Chagas disease when compared to benznidazole.

September 17, 2015: 

  1. Herpes Simplex Virus: This update provides new information regarding the use of suppressive acyclovir to reduce the risk of genital ulcer disease in persons who are initiating cART with a CD4 count <250 cells/mm3.  Data which do not support the use of suppressive acyclovir for prevention of HSV-2 transmission in persons not on cART, or for prevention of HIV disease progression in persons on cART are also included.
  2. Cryptococcosis: In this update, it is recommended to withhold initiating potent antiretroviral therapy for at least two weeks and up to 10 weeks after starting antifungal therapy for cryptococcosis. While the deoxycholate formulation of amphotericin B remains recommended for treatment, liposomal amphotericin B is also an appropriate choice. For those patients newly diagnosed with HIV infection with CD4 counts <50 cells/µL, testing for cryptococcosis prior to starting antiretroviral therapy should be considered.

September 10, 2015: 

  1. Notice of Availability of Pyrimethamine: Pyrimethamine is recommended for treatment and/or prophylaxis of Toxoplasma encephalitis, Pneumocystis pneumonia, and Isospora infection. As of June 2015, pyrimethamine is no longer available in retail pharmacies in the United States. It is only available through a special pharmacy program ( If there is a delay in procuring pyrimethamine for a patient in whom it is needed for one of the above indications, please refer to the specific pathogen section for alternative drug regimens for treatment or prophylaxis. For patients with suspected or documented toxoplasmosis who do not have a history of sulfa allergy, trimethoprim-sulfamethoxazole should be used to substitute for (pyrimethamine with sulfadiazine or clindamycin) until pyrimethamine is available.

August 18, 2015: 

  1. Bacterial Enteric Infections:This update provides new data on ciprofloxacin resistance in Shigella sonnei and improved clinical success when Clostridium difficile infection (CDI) is treated with vancomycin. Limited data suggest fecal microbiota therapy for recurrent CDI may be safe and successful in HIV-infected patients.

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