Table of Contents What’s New in the Guidelines..........................................................................................................................i Introduction ..................................................................................................................................................A1 Pneumocystis Pneumonia .............................................................................................................................B1 Toxoplasma gondii Encephalitis...................................................................................................................C1 Cryptosporidiosis .........................................................................................................................................D1 Microsporidiosis............................................................................................................................................E1 Mycobacterium tuberculosis Infection and Disease ....................................................................................F1 Disseminated Mycobacterium avium Complex Disease .............................................................................G1 Bacterial Respiratory Disease .....................................................................................................................H1 Bacterial Enteric Infections ..........................................................................................................................I1 Bartonellosis...................................................................................................................................................J1 Syphilis ..........................................................................................................................................................K1 Mucocutaneous Candidiasis ........................................................................................................................L1 Invasive Mycoses..........................................................................................................................................M1 Introduction.......................................................................................................................................M1 Cryptococcosis ..................................................................................................................................M1 Histoplasmosis ................................................................................................................................M12 Coccidioidomycosis........................................................................................................................M19 Cytomegalovirus Disease .............................................................................................................................N1 NonCMV Herpes.........................................................................................................................................O1 Herpes Simplex Virus Disease...........................................................................................................O1 VaricellaZoster Virus Diseases .........................................................................................................O7 Human Herpesvirus8 Disease ........................................................................................................O15 Human Papillomavirus Disease ...................................................................................................................P1 Hepatitis B Virus Infection..........................................................................................................................Q1 Hepatitis C Virus Infection..........................................................................................................................R1 Progressive Multifocal LeukoencephalopathyJC Virus Infection...........................................................S1 Geographic Opportunistic Infections of Specific Consideration..............................................................T1 Malaria................................................................................................................................................T1 Penicilliosis marneffei........................................................................................................................T9 Leishmaniasis ...................................................................................................................................T15 Chagas Disease.................................................................................................................................T26 Isosporiasis (Cystoisosporiasis)........................................................................................................T34 Downloaded from https:aidsinfo.nih.govguidelines on 8172017 Guidelines for the Prevention and Treatment of Opportunistic Infections in HIVInfected Adults and Adolescents iii Tables Table 1. Prophylaxis to Prevent First Episode of Opportunistic Disease .........................................U1 Table 2. Treatment of AIDSAssociated Opportunistic Infections (Includes Recommendations for Acute Treatment and Chronic SuppressiveMaintenance Therapy)...................................................U6 Table 3. Recommended Doses of FirstLine Drugs for Treatment of Tuberculosis in Adults and Adolescents....................................................................................................................U29 Table 4. Indications for Discontinuing and Restarting Opportunistic Infection Prophylaxis in HIVInfected Adults and Adolescents...............................................................................................U30 Table 5. Significant Pharmacokinetic Interactions for Drugs Used to Treat or Prevent Opportunistic Infections ..................................................................................................................U33 Table 6. Common or Serious Adverse Reactions Associated With Drugs Used for Preventing or Treating Opportunistic Infections....................................................................................................U47 Table 7. Dosing Recommendations for Drugs Used in Treating or Preventing Opportunistic Infections Where Dosage Adjustment is Needed in Patients with Renal Insufficiency....................U52 Table 8. Summary of PreClinical and Human Data on, and Indications for, Opportunistic Infection Drugs During Pregnancy .................................................................................................U59 Figure: Immunization Schedule for Human Immunodeficiency Virus (HIV)Infected Adults.............V1 Appendix A. Recommendations to Help HIVInfected Patients Avoid Exposure to, or Infection from, Opportunistic Pathogens..................................................................................................W1 Appendix B. List of Abbreviations..............................................................................................................X1 Appendix C. Panel Roster and Financial Disclosures ...............................................................................Y1 Appendix D. Contributors............................................................................................................................Z1 Downloaded from https:aidsinfo.nih.govguidelines on 8172017 Guidelines for the Prevention and Treatment of Opportunistic Infections in HIVInfected Adults and Adolescents A1 Introduction (Last updated June 17, 2013; last reviewed July 25, 2017) NOTE: Update in Progress Prior to the widespread use of potent combination antiretroviral therapy (ART), opportunistic infections (OIs), which have been defined as infections that are more frequent or more severe because of immunosuppression in HIVinfected persons,1,2 were the principal cause of morbidity and mortality in this population. In the early 1990s, the use of chemoprophylaxis, immunization, and better strategies for managing acute OIs contributed to improved quality of life and improved survival.3 Subsequently, the widespread use of potent ART has had the most profound influence on reducing OIrelated mortality in HIVinfected persons.310 Despite the availability of ART, OIs continue to cause considerable morbidity and mortality in the United States for three main reasons: 1. Approximately 20% of HIVinfected persons in the United States are unaware of their HIV infection,11,12 and many present with an OI as the initial indicator of their disease;13 2. Some individuals are aware of their HIV infection, but do not take ART due to psychosocial or economic factors; and 3. Some patients are enrolled in HIV care and prescribed ART, but do not attain an adequate virologic and immunologic response due to inconsistent retention in care, poor adherence, unfavorable pharmacokinetics, or unexplained biologic factors.6,14,15 Recent analyses suggest that while 77% of HIVinfected persons who are retained in care and prescribed ART are virologically suppressed, only 20% to 28% of the total estimated HIVinfected population in the United States are virologically suppressed,11,16 with as few as 10% in some jurisdictions.17 Thus, while hospitalizations and deaths have decreased dramatically due to ART, OIs continue to cause substantial morbidity and mortality in HIVinfected persons.1828 Clinicians must be knowledgeable about optimal strategies for diagnosis, prevention, and treatment of OIs to provide comprehensive, high quality care for these patients. It is important to recognize that the relationship between OIs and HIV infection is bidirectional. HIV causes the immunosuppression that allows opportunistic pathogens to cause disease in HIVinfected persons. OIs, as well as other coinfections that may be common in HIVinfected persons, such as sexually transmitted infections (STIs), can adversely affect the natural history of HIV infection by causing reversible increases in circulating viral load2934 that could accelerate HIV progression and increase transmission of HIV.35 Thus, while chemoprophylaxis and vaccination directly prevent pathogenspecific morbidity and mortality, they may also contribute to reduced rate of progression of HIV disease. For instance, randomized trials have shown that chemoprophylaxis with trimethoprimsulfamethoxazole can both decrease OIrelated morbidity and improve survival. The survival benefit is likely to result, in part, from reduced progression of HIV infection.3640 In turn, the reduced progression of HIV infection would reduce the risk of subsequent OIs.
Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Downloaded from https://aidsinfo.nih.gov/guidelines on 8/17/2017 Visit the AIDSinfo website to access the most up-to-date guideline Register for e-mail notification of guideline updates at https://aidsinfo.nih.gov/e-news Downloaded from https://aidsinfo.nih.gov/guidelines on 8/17/2017 Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents 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 HIV-Infected Adults and Adolescents Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: 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 available on the AIDSinfo website (http://aidsinfo.nih.gov) Downloaded from https://aidsinfo.nih.gov/guidelines on 8/17/2017 Access AIDSinfo mobile site What’s New in the Guidelines Updates to the Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents The Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV Infected Adults and Adolescents document was published in an electronic format that could 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 months are as follows: August 10, 2017 Bacterial Enterics: This revision highlights new data from the CDC Health Advisory Network (April, 2017) indicating growing concern over fluoroquinolone resistant in Shigella isolates Fluoroquinolones should only be used to treated Shigella isolates when the MIC