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: PanelHow to onCite Opportunistic the Adult and Adolescent Infections Opportunistic in Adults and Infection Adolescents Guidelines: with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the preventionthe Centers and for treatment Disease of opportunisticControl and infections Prevention, in adults the andNational adolescents Institutes with HIV of : Health, and the HIV Medicine recommendationsAssociation of the from Infectious the Centers Diseases for Disease Society Control ofand America. Prevention, Available the National at https://clinicalinfo.hiv.gov/sites/Institutes ofdefault/files/guidelines/documents/Adult_OI.pdf Health, and the HIV Medicine Association of the Infectious. Accessed Diseases (insertSociety ofdate)[include America. page numbers, table Availablenumber, at etc. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf if applicable] . 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 It is emphasized that concepts relevant to HIV management evolve rapidly. The Panel has a mechanismupdate recommendations to update recommendations on a regular on a regularbasis, basis,and theand mostthe most recent recent information information is is available onAccess the Clinical AIDSinfo availableInfo website on the ( Ahttps://clinicalinfo.hiv.govIDSinfo website (http://aidsinfo.nih.gov). ). mobile site 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 updated easily 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 also are posted promptly). 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: What’s New August 18, 2021 Human Papillomavirus Disease. Key updates to the guidelines include the following: • New recommendation for cervical cancer screening to start at age 21 based on the HIV/AIDS Cancer Match Study with no reported cases of cervical cancer below the age of 25. July 21, 2021 Varicella-Zoster Virus. Key updates to the guidelines include the following: • Updated to reflect that recombinant zoster vaccine (RZV, Shingrix) is the only available vaccine for prevention of shingles in the United States. As of November 18, 2020, attenuated zoster vaccine live (ZVL, Zostavax) is no longer available for use in the United States. July 1, 2021 Cytomegalovirus. Key updates to the guidelines include the following: • Updated to improve readability and to update references. • The toxicities of alternative antiviral medications used to treat cytomegalovirus are highlighted. • The document was updated for person-first language. Cryptococcosis. Key updates to the guidelines include the following: Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV i • Recommended an increase in the dose of fluconazole from 400 mg to 800 mg daily for consolidation therapy. For clinically stable patients who have been started on ART and whose CSF culture results return with no growth, the dose can be decreased to 400 mg daily. • Included results of a trial in a resource-limited setting that used only one week of amphotericin B induction therapy but did NOT recommend this approach for high-resource settings. • Clarified that the treatment of non-CNS extrapulmonary cryptococcosis and diffuse pulmonary disease should be the same as that for meningitis and that treatment of mild- moderate focal pulmonary infection should be with fluconazole, 400-800 mg daily. • Clarified treatment for patients who have been found to have asymptomatic antigenemia. • Revised the Pregnancy text for consistency with other sections of the guidelines. • Revised the table of recommendations to clarify recommended treatment of the various forms of cryptococcosis in persons with HIV. June 11, 2021 Coccidioidomycosis. Key updates to the guidelines include the following: • Revised the section on serology for the diagnosis of coccidioidomycosis. • Added polymerase chain reaction (PCR) as a commercially available diagnostic test. • Revised the section on patients who are asymptomatic and have a positive serological test. Bartonellosis. Key updates to the guidelines include the following: • Updated the section on diagnostics, including the role of PCR-based testing. • Updated the section on treatment for endocarditis. Immunizations for Preventable Diseases in Adults and Adolescents Living with HIV. Key updates to the guidelines include the following: • Revised the figure summarizing immunizations in people with HIV. • Added a table comparing Advisory Committee on Immunization Practices (ACIP) recommendations with Panel recommendations. • Added narrative sections with evidence summaries. • Updated the recommendation for zoster vaccine. 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 ..................................................................................