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Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents Tables Only

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Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents Tables Only Table 1. Prophylaxis to Prevent First Episode of Opportunistic Disease (Last updated August 18, 2021; last reviewed April 14, 2021) Opportunistic Indication Preferred Alternative Infections Coccidioidomycosis A new positive IgM or IgG serologic Fluconazole 400 mg PO daily (BIII) test in patients who live in a disease-endemic area and with CD4 count <250 cells/µL (BIII) Hepatitis A virus (HAV) HAV-susceptible patients with Hepatitis A vaccine 1 mL IM x 2 doses For patients susceptible to infection chronic liver disease, or who are at 0 and 6–12 months (AII). both HAV and hepatitis B injection-drug users, or MSM (AII). virus (HBV) infection (see IgG antibody response should be below): assessed 1 month after vaccination; non-responders should be revaccinated Combined HAV and HBV when CD4 count >200 cells/µL (BIII). 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) • Patients without chronic HBV or • HBV vaccine IM (Engerix-B 20 µg/mL Some experts recommend infection without immunity to HBV (i.e., anti- or Recombivax HB 10 µg/mL), 0, 1, vaccinating with 40-µg doses HBs <10 international units/mL) and 6 months (AII), or of either HBV vaccine (CIII). (AII) • HBV vaccine IM (Engerix-B 40 µg/mL • Patients with isolated anti-HBc and or Recombivax HB 20 µg/mL), 0, 1, 2 negative HBV DNA (BII) and 6 months (BI), • Early vaccination is recommended • Combined HAV and HBV vaccine before CD4 count falls below 350 (Twinrix®), 1 mL IM as a 3-dose (0, 1, cells/µL (AII). and 6 months) or 4-dose series (days 0, 7, 21 to 30, and 12 months) (AII) • However, in patients with low CD4 cell counts, vaccination should not Anti-HBs should be obtained 1 month be deferred until CD4 count after completion of the vaccine series. reaches >350 cells/µL, because Patients with anti-HBs <10 IU/mL at 1 some patients with CD4 counts month are considered non-responders. <200 cells/µL do respond to (BIII). vaccination (AII). Vaccine Non-Responders: Re-vaccinate with a second vaccine • HBV vaccine IM (Engerix-B series (BIII) 40 µg/mL or Recombivax • Anti-HBs <10 international units/mL 1 month after vaccination HB 20 µg/mL), 0, 1, 2 and 6 series months (BI), For patients with low CD4 counts at time of first vaccine series, some experts might delay revaccination until after a sustained increase in CD4 count with ART (CIII). Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV CC-1 Opportunistic Indication Preferred Alternative Infections Histoplasma capsulatum CD4 count ≤150 cells/µL and at Itraconazole 200 mg PO daily (BI) infection high risk because of occupational exposure or live in a community with a hyperendemic rate of histoplasmosis (>10 cases/100 patient-years) (BI) Human Papillomavirus Target age for vaccination is 11-12 HPV recombinant vaccine 9 valent For patients who have (HPV) infection years (AIII) (Types 6, 11, 16, 18, 31, 33, 45, 52, 58) completed a vaccination 0.5 mL IM at 0, 1–2, and 6 months (BIII) series with the recombinant Vaccination through age 26 is bivalent or quadrivalent recommended, but vaccine vaccine, some experts would effectiveness is lower if vaccination give an additional full series occurs after onset of sexual activity of recombinant 9-valent (BII) vaccine, but there are no data Vaccination is not recommended to define who might benefit or for PWH ages 27 to 45 years of age how cost effective this or older (BI). In some situations, approach might be (CIII) there might be vaccine benefit (e.g., PWH with minimal HPV exposure). In these situations, shared clinical decision-making between the provider and patient is recommended. The public health benefit for HPV vaccination in this age range is minimal. Influenza A and B Virus All persons with HIV (AIII) Inactivated influenza vaccine annually N/A Infection (per recommendation for the season) (AIII) High-dose inactivated influenza vaccine may be given to individuals aged ≥65 years (CIII). Live-attenuated influenza vaccine is contraindicated in patients with HIV (AIII). 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: http://www.cdc.gov/malaria/. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV CC-2 Opportunistic Indication Preferred Alternative Infections Mycobacterium avium CD4 Count <50 cells/mm3 Azithromycin 1,200 mg PO once weekly Rifabutin (dose adjusted complex (MAC) disease (AI), based on concomitant ART)a Not recommended for those who (BI); rule out active TB before immediately initiate ART (AII). or starting rifabutin. Recommended for those who are Clarithromycin 500 mg PO BID (AI), not on fully suppressive ART, after ruling out active disseminated MAC or disease (AI). Azithromycin 600 mg PO twice weekly (BIII) Mycobacterium Positive screening test for LTBI,b (INH 300 mg plus pyridoxine 25-50 mg) Rifapentine (see dose below) tuberculosis infection (TB) with no evidence of active TB, and PO daily for 9 months (AII) PO plus INH 900 mg PO plus (i.e., treatment of latent TB no prior treatment for active TB or pyridoxine 50 mg PO once or infection [LTBI]) LTBI (AI) weekly for 12 weeks (AII) LTBI treatment and ART act or Note: Rifapentine only independently to decrease the risk of TB recommended for persons Close contact with a person with disease. Thus, ART is recommended for receiving RAL or EFV-based infectious TB, with no evidence of all persons with HIV and LTBI (AI). ART regimen active TB, regardless of screening test results (AI). Rifapentine Weekly Dose Weighing 32.1 to 49.9 kg: • 750 mg Weighing >50 kg: • 900 mg or Rifampin 600 mg PO daily for 4 months (BI) or For persons exposed to drug- resistant TB, select anti-TB drugs after consultation with experts or public health authorities (AII). Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV CC-3 Opportunistic Indication Preferred Alternative Infections Pneumocystis Pneumonia • CD4 count <200 cells/mm3 (AI), or • TMP-SMXc 1 DS tablet PO daily (AI), • TMP-SMXc 1 DS PO three (PCP) or times weekly (BI), or • CD4 <14% (BII), or • TMP-SMXc 1 SS tablet daily (AI) • Dapsoned 100 mg PO daily • If ART initiation must be delayed, or 50 mg PO BID (BI), or CD4 count ≥200, but <250 cells/mm3 and if monitoring of CD4 • Dapsoned 50 mg PO daily cell count every 3 months is not with (pyrimethaminee 50 mg possible (BII) plus leucovorin 25 mg) PO weekly (BI), or Note: Patients who are receiving pyrimethamine/sulfadiazine for • (Dapsoned 200 mg plus treatment or suppression of pyrimethaminee 75 mg plus toxoplasmosis do not require leucovorin 25 mg) PO additional PCP prophylaxis (AII). weekly (BI); or • Aerosolized pentamidine 300 mg via Respigard II™ nebulizer every month (BI), or • Atovaquone 1500 mg PO daily (BI), or • (Atovaquone 1500 mg plus pyrimethaminee 25 mg plus leucovorin 10 mg) PO daily (CIII) Streptococcus pneumoniae For individuals who have never PCV13 0.5 mL IM one time (AI) followed PPV23 0.5 mL IM one time Infection received any pneumococcal by: (BII) vaccine, regardless of CD4 count If CD4 Count ≥200 cells/mm3 • PPV23 0.5 mL IM at least 8 weeks after the PCV13 vaccine (AI). If CD4 Count <200 cells/mm3 • PPV23 can be offered at least 8 weeks after receiving PCV13 (CIII), or • Can wait until CD4 count increased to >200 cells/mm3 on ART (BIII). For individuals who have previously One dose of PCV13 should be given at N/A received PPV23 least 1 year after the last receipt of PPV23 (AII). Adults (aged ≥19 years) should wait at least 1 year, and adolescents (aged <19 years) should wait at least 8 weeks after last receipt of PPV23 (BIII). Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV CC-4 Opportunistic Indication Preferred Alternative Infections Re-Vaccination: PPV23 0.5 mL IM one time (BII) N/A • If aged 19–64 years and ≥5 years since the first PPV23 dose • Final dose to be given at age ≥65 years, and if ≥5 years since the previous PPV23 dose • Typically, no more than 3 doses of PPV23 in a lifetime Syphilis • For individuals exposed to a sex Benzathine penicillin G 2.4 million units For penicillin-allergic patients: partner with a diagnosis of IM for 1 dose (AII) • Doxycycline 100 mg PO BID primary, secondary, or early latent for 14 days (BII), or syphilis within past 90 days (AII), or • Ceftriaxone 1 g IM or IV daily for 8–10 days (BII), or • For individuals exposed to a sex partner >90 days before syphilis • Azithromycin 2 g PO for 1 diagnosis in the partner, if dose (BII) – not serologic test results are not recommended for MSM or available immediately and the pregnant women (AII) opportunity for follow-up is uncertain (AIII) Talaromycosis Persons with HIV and CD4 cell For persons who reside in endemic For persons who reside in (Penicilliosis) counts <100 cells/mm3, who are areas, itraconazole 200 mg PO once endemic areas, fluconazole unable to have ART, or have daily (BI). 400 mg PO once weekly treatment failure without access to (BII). For those traveling to the highly endemic effective ART options, and regions, begin itraconazole 200 mg PO For those traveling to the 1) Who reside in the highly endemic once daily 3 days before travel, and highly endemic regions, take regions* in northern Thailand, continue for 1 week after leaving the the first dose of fluconazole northern or southern Vietnam, or endemic area (BIII).
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