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Guidelines for Prevention and Treatment of Opportunistic Morbidity and Mortality Weekly Report www.cdc.gov/mmwr Recommendations and Reports April 10, 2009 / Vol. 58 / No. RR-4 Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America INSIDE: Continuing Education Examination department of health and human services Centers for Disease Control and Prevention MMWR CONTENTS The MMWR series of publications is published by the Coordinating Center for Health Information and Service, Centers for Disease Summary ...............................................................................................1 Control and Prevention (CDC), U.S. Department of Health and Introduction ...........................................................................................2 Human Services, Atlanta, GA 30333. History of the Guidelines .........................................................................2 Suggested Citation: Centers for Disease Control and Prevention. Guidelines Process .................................................................................2 [Title]. MMWR 2009;58(No. RR-#):[inclusive page numbers]. Major Changes in Guidelines Since Last Publication ..................................3 How to Use the Information in this Report .................................................3 Centers for Disease Control and Prevention Effect of ART on the Management of OIs ..................................................4 Richard E. Besser, MD Initiation of ART in the Setting of an Acute OI (Acting)Director (Treatment-Naïve Patients) .....................................................................4 Tanja Popovic, MD, PhD Management of Acute OIs in Patients Receiving ART .................................5 Chief Science Officer Special Considerations During Pregnancy ................................................5 Disease Specific Recommendations ..........................................................6 James W. Stephens, PhD Associate Director for Science Pneumocystis Pneumonia .....................................................................6 Toxoplasma gondii Encephalitis ..........................................................10 Steven L. Solomon, MD Cryptosporidiosis ..............................................................................14 Director, Coordinating Center for Health Information and Service Microsporidiosis ................................................................................17 Jay M. Bernhardt, PhD, MPH Mycobacterium tuberculosis Infection and Disease ...............................19 Director, National Center for Health Marketing Disseminated Mycobacterium avium Complex Disease .........................28 Katherine L. Daniel, PhD Bacterial Respiratory Disease .............................................................31 Deputy Director, National Center for Health Marketing Bacterial Enteric Infections ..................................................................36 Bartonellosis .....................................................................................39 Editorial and Production Staff Syphilis ............................................................................................41 Frederic E. Shaw, MD, JD Mucocutaneous Candidiasis ...............................................................45 Editor, MMWR Series Cryptococcosis ..................................................................................48 Susan F. Davis, MD Histoplasmosis ..................................................................................50 (Acting) Assistant Editor, MMWR Series Coccidioidomycosis ...........................................................................52 Teresa F. Rutledge Aspergillosis .....................................................................................54 Managing Editor, MMWR Series Cytomegalovirus Disease ...................................................................55 David C. Johnson Herpes Simplex Virus Disease ............................................................61 (Acting) Lead Technical Writer-Editor HHV-6 and HHV-7 Disease ................................................................63 Varicella-Zoster Virus Diseases ...........................................................64 Suzanne M. Hewitt, MPA Human Herpesvirus-8 Disease ............................................................66 Project Editor Human Papillomavirus Disease ...........................................................68 Martha F. Boyd Hepatitis B Virus Infection ..................................................................75 Lead Visual Information Specialist Hepatitis C Virus Infection ..................................................................84 Malbea A. LaPete Progressive Multifocal Leukoencephalopathy/JC Virus Infection .................91 Stephen R. Spriggs Geographic OIs of Specific Consideration ..............................................94 Visual Information Specialists Malaria ............................................................................................94 Kim L. Bright, MBA Penicilliosis marneffei ........................................................................98 Quang M. Doan, MBA Leishmaniasis ....................................................................................99 Phyllis H. King Chagas Disease .............................................................................103 Information Technology Specialists Isosporiasis .....................................................................................105 Editorial Board References .........................................................................................107 Tables ................................................................................................145 William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Figures ..............................................................................................197 Virginia A. Caine, MD, Indianapolis, IN Appendix ..........................................................................................199 David W. Fleming, MD, Seattle, WA List of Abbreviations Used in this Report ...............................................204 William E. Halperin, MD, DrPH, MPH, Newark, NJ Contributors .......................................................................................206 Margaret A. Hamburg, MD, Washington, DC King K. Holmes, MD, PhD, Seattle, WA Continuing Education Activity .............................................................CE-1 Deborah Holtzman, PhD, Atlanta, GA Disclosure of Relationship John K. Iglehart, Bethesda, MD Dennis G. Maki, MD, Madison, WI CDC, our planners, and our content specialists wish to disclose they have no finan- Sue Mallonee, MPH, Oklahoma City, OK cial interests or other relationships with the manufacturers of commercial products, Patricia Quinlisk, MD, MPH, Des Moines, IA suppliers of commercial services, or commercial supporters, with the exception of Constance Benson and King K. Holmes. Dr. Benson discloses being on the Advisory Patrick L. Remington, MD, MPH, Madison, WI Board for Merck, GlaxoSmithKline, and Boehringer Ingelheim; being a grant Barbara K. Rimer, DrPH, Chapel Hill, NC recipient for Gilead; and being a Data Safety Monitoring Board (DSMB) member John V. Rullan, MD, MPH, San Juan, PR for Achillion and JJR Australia. Her spouse also is a consultant for Merck, Gilead, William Schaffner, MD, Nashville, TN Achillion, Monogram, and Vertex. Dr. Holmes discloses being a DSMB member of Anne Schuchat, MD, Atlanta, GA Merck, receiving an honorarium at the 2005 Infectious Diseases Society of America Dixie E. Snider, MD, MPH, Atlanta, GA Conference, and serving on the Mycology Research Laboratories scientific advisory John W. Ward, MD, Atlanta, GA board. Presentations will not include any discussion of the unlabeled use of a product or a product under investigational use. Vol. 58 / RR-4 Recommendations and Reports 1 Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America Prepared by Jonathan E. Kaplan, MD1 Constance Benson, MD2 King K. Holmes, MD, PhD3 John T. Brooks, MD1 Alice Pau, PharmD4 Henry Masur, MD4 1CDC, Atlanta, Georgia 2 University of California San Diego, San Diego, California 3University of Washington, Seattle, Washington 4National Institutes of Health, Bethesda, Maryland Summary This report updates and combines earlier versions of guidelines for the prevention and treatment of opportunistic infections (OIs) in HIV-infected adults (i.e., persons aged >18 years) and adolescents (i.e., persons aged 13–17 years), last published in 2002 and 2004, respectively. It has been prepared by the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by clinicians and other health-care providers, HIV-infected patients, and policy makers in the United States. These guidelines address several OIs that occur in the United States and five OIs that might be acquired during international travel. Topic areas covered for each OI include epidemiology, clinical manifestations, diagnosis, prevention of exposure; prevention
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