Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America How to Cite the Adult and Adolescent Opportunistic Infection Guidelines: Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed (insert date) [include page numbers, table number, etc. if applicable] It is emphasized that concepts relevant to HIV management evolve rapidly. The Panel has a mechanism to update recommendations on a regular basis, and the most recent information is Access AIDSinfo available on the AIDSinfo website (http://aidsinfo.nih.gov). mobile site What’s New in the Guidelines Updates to the Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV The Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV document is published in an electronic format that can 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: May 26, 2020 1. Candidiasis (Mucocutaneous): The Panel updated the text, treatment, pregnancy considerations, references, and treatment table and made the following key changes: • Added important new information on spontaneous abortion in pregnant women after any exposure to fluconazole (low—even single-dose—or high exposure). • Added a brief discussion on the gentian violet topical application randomized clinical trial for oral candidiasis and updated the treatment table. • Added a statement indicating that azole resistance can be seen in vulvovaginal candidiasis caused by non-C. albicans species. • Added details for the use of boric acid in azole-refractory C. glabrata vaginitis in the treatment table. 2. Herpes Simplex Virus: The Panel updated references throughout the section and improved the readability of the text. In addition, the Panel made the following key changes: • Updated information about the seroprevalence of HSV-1 and HSV-2 in the United States.. • Addressed HSV-1 as a cause of genital herpes. • Provided additional information about the interpretation of type-specific HSV serologic assays. • Updated information about prevention methods for HSV-2 infection. • Updated information about treatment of acyclovir-resistant HSV infection. February 11, 2020 1. Table 8. Summary of Pre-Clinical and Human Data on, and Indications for, Opportunistic Infection Drugs During Pregnancy: The Panel updated this table to include the following key changes: • Information on several new drug combinations for hepatitis C treatment have been added, including dasabuvir/ombitasvir/paritaprevir/ritonavir, elbasvir/grazoprevir, glecaprevir/pibrentasvir, ombitasvir/ paritaprevir/ritonavir, sofosbuvir/velpatasvir, and sofosbuvir/velpatasvir/voxilaprevir. Data on the use of these new drugs in pregnancy are limited but they can be used if the benefit is felt to outweigh the potential risks. However, ribavirin is contraindicated during pregnancy so regimens including ribavirin should not be used in pregnant women. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV i • Information on isavuconazole, a new oral antifungal, has been added. Use in pregnancy is not recommended. • Information on rifapentine has been added. Given malformations and fetal loss noted in animal studies, use of alternate drugs for tuberculosis treatment and prophylaxis in pregnancy are recommended. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV ii Table of Contents What’s New in the Guidelines ..........................................................................................................................i Introduction ..................................................................................................................................................A-1 Bacterial Enteric Infections ........................................................................................................................ B-1 Bartonellosis ................................................................................................................................................. C-1 Candidiasis (Mucocutaneous) .....................................................................................................................D-1 Chagas Disease ............................................................................................................................................. E-1 Coccidioidomycosis .......................................................................................................................................F-1 Community-Acquired Pneumonia .............................................................................................................G-1 Cryptococcosis ..............................................................................................................................................H-1 Cryptosporidiosis .......................................................................................................................................... I-1 Cystoisosporiasis ........................................................................................................................................... J-1 Cytomegalovirus Disease .............................................................................................................................K-1 Hepatitis B Virus Infection ......................................................................................................................... L-1 Hepatitis C Virus Infection ........................................................................................................................ M-1 Herpes Simplex Virus Disease .....................................................................................................................N-1 Histoplasmosis ..............................................................................................................................................O-1 Human Herpesvirus-8 Disease .....................................................................................................................P-1 Human Papillomavirus Disease ..................................................................................................................Q-1 Leishmaniasis ............................................................................................................................................... R-1 Malaria ...........................................................................................................................................................S-1 Microsporidiosis ............................................................................................................................................T-1 Mycobacterium avium Complex Disease .....................................................................................................U-1 Mycobacterium tuberculosis Infection and Disease ................................................................................... V-1 Pneumocystis Pneumonia............................................................................................................................ W-1 Progressive Multifocal Leukoencephalopathy/JC Virus Infection .........................................................X-1 Syphilis .......................................................................................................................................................... Y-1 Talaromycosis (Penicilliosis) ....................................................................................................................... Z-1 Toxoplasma gondii Encephalitis ...............................................................................................................AA-1 Varicella-Zoster Virus Diseases ............................................................................................................... BB-1 Tables Table 1. Prophylaxis to Prevent First Episode of Opportunistic Disease ..................................... CC-1 Table 2. Treatment of AIDS-Associated Opportunistic Infections (Includes Recommendations Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV iv for Acute Treatment and Chronic Suppressive/Maintenance Therapy) ......................................... CC-7 Table 3. Recommended Doses of First-Line Drugs for Treatment of Tuberculosis