Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents
Table 1. Prophylaxis to Prevent First Episode of Opportunistic Disease
Last Updated: March 7, 2018; Last Reviewed: March 7, 2018
|Pneumocystis pneumonia (PCP)
|Toxoplasma gondii encephalitis||
||TMP-SMXa 1 DS PO daily (AII)||
|Mycobacterium tuberculosis infection (TB) (i.e., treatment of latent TB infection [LTBI])
For persons exposed to drug-resistant TB, select anti-TB drugs after consultation with experts or public health authorities (AII).
|Disseminated Mycobacterium avium complex (MAC) disease
||CD4 count <50 cells/µL—after ruling out active disseminated MAC disease based on clinical assessment (AI).
||Rifabutin (dose adjusted based on concomitant ART)e (BI); rule out active TB before starting rifabutin.
|Streptococcus pneumoniae infection
||For individuals who have not received any pneumococcal vaccine, regardless of CD4 count, followed by:
PCV13 0.5 mL IM x 1 (AI).
PPV23 0.5 mL IM at least 8 weeks after the PCV13 vaccine (AII).
PPV23 can be offered at least 8 weeks after receiving PCV13 (CIII) or can wait until CD4 count increased to ≥200 cells/µL (BIII).
|PPV23 0.5 mL IM x 1 (BII)
|For individuals who have previously received PPV23
||One dose of PCV13 should be given at least 1 year after the last receipt of PPV23 (AII).
|Influenza A and B virus infection
||All HIV-infected patients (AIII)
||Inactivated influenza vaccine annually (per recommendation for the season) (AIII)
Live-attenuated influenza vaccine is contraindicated in HIV-infected patients (AIII).
||Benzathine penicillin G 2.4 million units IM for 1 dose (AII)
||For penicillin-allergic patients:
|Histoplasma capsulatum infection
||CD4 count ≤150 cells/µL and at high risk because of occupational exposure or live in a community with a hyperendemic rate of histoplasmosis (>10 cases/100 patient-years) (BI)
||Itraconazole 200 mg PO daily (BI)
||A new positive IgM or IgG serologic test in patients who live in a disease-endemic area and with CD4 count <250 cells/µL (BIII)
||Fluconazole 400 mg PO daily (BIII)
|Varicella-zoster virus (VZV) infection
Patients with CD4 counts ≥200 cells/µL who have not been vaccinated, have no history of varicella or herpes zoster, or who are seronegative for VZV (CIII)
Note: Routine VZV serologic testing in HIV-infected adults and adolescents is not recommended.
Post-exposure prevention: (AIII)
Close contact with a person with chickenpox or herpes zoster; and is susceptible (i.e., no history of vaccination or of either condition, or known to be VZV seronegative)
Primary varicella vaccination (Varivax™), 2 doses (0.5 mL SQ each) administered 3 months apart (CIII).
If vaccination results in disease because of vaccine virus, treatment with acyclovir is recommended (AIII).
Varicella-zoster immune globulin (VariZIG™) 125 international units per 10 kg (maximum 625 international units) IM, administered as soon as possible and within 10 days after exposure (AIII)
Note: VariZIG is exclusively distributed by FFF Enterprises at 800-843-7477.
Individuals receiving monthly high-dose IVIG (>400 mg/kg) are likely to be protected if the last dose of IVIG was administered <3 weeks before exposure.
VZV-susceptible household contacts of susceptible HIV-infected persons should be vaccinated to prevent potential transmission of VZV to their HIV-infected contacts (BIII).
Alternative post-exposure prevention:
If antiviral therapy is used, varicella vaccines should not be given until at least 72 hours after the last dose of the antiviral drug.
|Human Papillomavirus (HPV) infection
||Females and males aged 13–26 years (BIII)
||For patients who have completed a vaccination series with the recombinant bivalent or quadrivalent vaccine, providers may consider additional vaccination with recombinant 9-valent vaccine, but there are no data to define who might benefit or how cost effective this approach might be (CIII).|
|Hepatitis A virus (HAV) infection
||HAV-susceptible patients with chronic liver disease, or who are injection-drug users, or MSM (AII).
||Hepatitis A vaccine 1 mL IM x 2 doses at 0 and 6–12 months (AII).
IgG antibody response should be assessed 1 month after vaccination; non-responders should be revaccinated when CD4 count >200 cells/µL (BIII).
|For patients susceptible to both HAV and hepatitis B virus (HBV) infection (see below):
Combined HAV and HBV vaccine (Twinrix®), 1 mL IM as a 3-dose (0, 1, and 6 months) or 4-dose series (days 0, 7, 21 to 30, and 12 months) (AII)
|Hepatitis B virus (HBV) infection
Anti-HBs should be obtained 1-2 months after completion of the vaccine series. Patients with anti-HBs <10 IU/mL are considered non-responders, and should be revaccinated with another 3-dose series (BIII).
|Some experts recommend vaccinating with 4-doses of double dose of either HBV vaccine (BI).
||Re-vaccinate with a second vaccine series (BIII)
|Malaria||Travel to disease-endemic area
||Recommendations are the same for HIV-infected and HIV-uninfected patients. Recommendations are based on region of travel, malaria risks, and drug susceptibility in the region. Refer to the following website for the most recent recommendations based on region and drug susceptibility:
||Patients with CD4 cell counts <100 cells/µL who live or stay for a long period in rural areas in northern Thailand, Vietnam, or Southern China (BI)
||Itraconazole 200 mg once daily (BI)
||Fluconazole 400 mg PO once weekly (BII)
Key to Acronyms: anti-HBc = hepatitis B core antibody; anti-HBs = hepatitis B surface antibody; ART = antiretroviral therapy; BID = twice daily; BIW = twice a week; CD4 = CD4 T lymphocyte cell; DOT = directly observed therapy; DS = double strength; HAV = hepatitis A virus; HBV = hepatitis B virus; HPV = human papillomavirus; IgG = immunoglobulin G; IgM = immunoglobulin M; IM = intramuscular; INH = isoniazid; IV= intravenously; IVIG = intravenous immunoglobulin; LTBI = latent tuberculosis infection; MAC = Mycobacterium avium complex; PCP = Pneumocystis pneumonia; PCV13 = 13-valent pneumococcal conjugate vaccine; PO = orally; PPV23 = 23-valent pneumococcal polysaccharides vaccine; SQ = subcutaneous; SS = single strength; TB = tuberculosis; TMP-SMX = Trimethoprim-sulfamethoxazole; VZV = varicella zoster virus
a TMP-SMX DS once daily also confers protection against toxoplasmosis and many respiratory bacterial infections; lower dose also likely confers protection
b Patients should be tested for glucose-6-phosphate dehydrogenase (G6PD) before administration of dapsone or primaquine. Alternative agent should be used in patients found to have G6PD deficiency
c Screening tests for LTBI include tuberculin skin test (TST) or interferon-gamma release assays (IGRA)
d Refer to Drug Interactions section in the Adult and Adolescent ARV Guidelines for dosing recommendation
Strength of Recommendation:
A: Strong recommendation for the statement
B: Moderate recommendation for the statement
C: Optional recommendation for the statement
Quality of Evidence for the Recommendation:
I: One or more randomized trials with clinical outcomes and/or validated laboratory endpoints
II: One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes
III: Expert opinion
In cases where there are no data for the prevention or treatment of an OI based on studies conducted in HIV-infected populations, but data derived from HIV-uninfected patients exist that can plausibly guide management decisions for patients with HIV/AIDS, the data will be rated as III but will be assigned recommendations of A, B, C depending on the strength of recommendation.
- CDC | 2015 STD Treatment Guidelines
- HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C
- AIDSinfo Patient Materials: What is an Opportunistic Infection?
- AIDSource | HIV-Related Conditions
- AETC National HIV Curriculum
- How to Cite These Guidelines
- Adult and Adolescent OI Guidelines Archive