15. Primary and Secondary Prophylaxis Against Opportunistic Infections in HIV AIDS

OI

Indication

(CD4 cells/mm3)

Recommended

Alternative

Pneumocystis jiroveci (PCP)

CD4 count <200

OR

CD4 % <14%

TMP-SMX SS or DS daily (DS daily is most common regimen)

TMP-SMX DS 3x weekly;

Dapsone 100mg daily or 50mg BID*;

Atovaquone 1500mg daily;

Aerosolized pentamidine 300 mg/month

Toxoplasma gondii

Toxo IgG + and CD4 <100**

TMP-SMX DS daily

TMP-SMX SS daily or DS 3x weekly;

Dapsone 50mg daily (or 200 mg qweek)* + pyrimethamine 75mg qweek + leucovorin 25mg qweek;

Atovaquone 1500mg  daily +/- pyrimethamine 25mg daily +/- leucovorin 10mg daily

Mycobacterium avium complex

<50 (rule out active MAC infection)

  • Not recommended for those who immediately start ART
  • Recommended for those not on fully suppressive ART after ruling out active infection

Azithromycin 1200mg q week

Clarithromycin 500mg BID;

Azithromycin 600mg 2x weekly

*Rule out G6PD deficiency prior to initiating dapsone therapy

** If on PCP prophylaxis not active against toxo (e.g. pentamidine or dapsone), retest toxo serology if CD4 falls <100 for initiation of appropriate prophylaxis

Discontinuing Primary Prophylaxis

  • PCP and toxoplasmosis: can be stopped if CD4 count > 200 for ≥ 3 months on ART. Reinitiate if CD4 falls < 200.
  • MAC: if the patient is on fully suppressive ART, MAC prophylaxis should be stopped, regardless of CD4 count.

Secondary Prophylaxis

Prevention of recurrence in someone who has already had a primary infection.

  • PCP: TMP-SMX DS or SS daily until CD4 > 200 for ≥ 3 months on ART (consider lifelong suppressive therapy if PCP occurred in setting of CD4 > 200).
  • Toxoplasmosis: pyrimethamine 25-50mg daily + sulfadiazine 2000-4000mg (in 2-4 divided doses) + leucovorin 10-25mg daily until CD4 > 200 for ≥ 3 months on ART without symptoms after having completed full treatment course.
  • MAC: if patient is asymptomatic, CD4 ≥ 100 for 6 months after initiating ART, and completed > 12 months of treatment for MAC, then risk of recurrence is low. Secondary prophylaxis is not recommended.
  • Cryptococcal meningitis: fluconazole 200mg daily for at least one year. Then can discontinue if patient remains asymptomatic from cryptococcus and CD4 count ≥100 cells/µL for ≥3 months and has suppressed HIV RNA in response to effective ART.

Latent TB Infection

  • Treat patients with LTBI (PPD > 5 mm induration or positive IGRA) with no evidence of active disease with:
    • INH 300 mg daily plus pyridoxine 50 mg daily for 9 months (preferred)
    • Rifapentine plus INH weekly x 12 weeks (alternative)
    • Rifampin 600mg PO daily x 4 months (alternative)
  • Also treat patients with close contact with a person with infectious TB, without evidence of active TB, even if screening test is negative.

Other Considerations

  • Consider primary prophylaxis for Coccidioidomycosis, Histoplasmosis, and Talaromycosis for patients with low CD4 counts who live in endemic areas.
  • Vaccinate patients against: HAV, HBV, HPV, seasonal influenza, and Streptococcus pneumoniae.

See IDSA or DHHS OI guidelines for preventions and treatment of opportunistic infections for further recommendations:

https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/0

Key words: prophylaxis-AIDS; opportunistic infection; vaccination-HIV; pneumocystis-prophylaxis, toxoplasmosis-prophylaxis, MAC-prophylaxis, VZV