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 and updated as relevant changes in prevention and treatment recommendations occur.

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 relevant outside reviewers before the document is altered. Major revisions within the last 6 months are as follows:

December 16, 2024

Hepatitis B Virus

• Recommended Heplisav-B as the preferred vaccine for all people with HIV, including those who are vaccine naive or prior vaccine nonresponders.
• Included a new section on considerations of nucleos(t)ide-sparing regimens in people with past hepatitis B virus (HBV), chronic HBV, and isolated hepatitis B core antibody positivity.
• Changed the consideration for pegylated interferon to an alternative treatment used only in rare cases.
• Removed PreHevbrio since it no longer will be available in the United States.

November 12, 2024

Immunizations

• Updated COVID-19 and influenza recommendations with new information on current vaccine formulations and data supporting their use.
• Provided new recommendations for the use of respiratory syncytial virus (RSV) vaccines including data supporting their use.
• Updated HepBCpG (Heplisav-B) to the preferred hepatitis B vaccine for people with HIV.
• Added pentavalent meningococcal conjugate vaccine (MenABCWY) recommendations as an alternative to separate administration of quadrivalent meningococcal vaccine and meningococcal group B vaccine.

October 29, 2024

Coccidioidomycosis

• Added isavuconazole sulfate as an alternative treatment for mild-to-moderate pulmonary infections.
• Updated the recommended fluconazole dosing for treatment of coccidioidal meningitis.
• Updated information and recommendations on the use of azole antifungals during pregnancy.

Cryptococcosis

• Updated alternative regimens for induction, consolidation, and maintenance therapy and recommendations on the timing and frequency of lumbar punctures for central nervous system and/or disseminated disease.
• Updated the recommended fluconazole dosing for the treatment of focal pulmonary infiltrates and isolated cryptococcal antigenemia.
• Provided more detailed recommendations for treatment during pregnancy.

Histoplasmosis

• Added alternative maintenance therapy regimens for treatment of severe disseminated disease.
• Updated information on the importance of monitoring serum concentration levels for itraconazole and voriconazole.

October 8, 2024

Bacterial Enteric Infections

• Updated information on antimicrobial resistance among bacterial enteric pathogens.
• Updated recommended regimens for empiric therapy pending susceptibility results, including a recommendation to consider empiric carbapenem therapy in people with advanced HIV and severe diarrhea where campylobacter bacteremia is suspected.
• Updated information on the use of antibiotics for bacterial enteric infections during pregnancy.

September 16, 2024

Candidiasis

• Added information on the role of ibrexafungerp in the treatment of vulvovaginal candidiasis and recurrent vulvovaginal candidiasis and the approval of ibrexafungerp by the U.S. Food and Drug Administration (FDA).
• Added information on the role of oteseconazole for the treatment of recurrent vulvovaginal candidiasis and the approval of oteseconazole by the FDA.

Pneumocystis Pneumonia

• Simplified indications for starting primary prophylaxis.
• Added intermittent intravenous pentamidine as an alternative regimen for primary or secondary prophylaxis.
• Provided more detailed recommendations for management during pregnancy.

Toxoplasmosis

• Recommended primarily limiting baseline serologic screening and measures to prevent exposure to individuals with CD4 T lymphocyte cell counts <200 cells/mm³.
• Added trimethoprim-sulfamethoxazole as a preferred regimen for acute infection.
• Provided more detailed recommendations for management during pregnancy.

August 15, 2024

Disseminated Mycobacterium avium Complex Disease

• Updated information to prioritize the initiation of effective antiretroviral therapy and to refrain from primary prophylaxis for Mycobacterium avium Complex (MAC) except for people with HIV who are not receiving antiretroviral therapy (ART), remain viremic on ART, or have no options for a fully suppressive ART regimen.
• Added new information indicating that drugs demonstrating substantive in vitro activity against MAC might be considered for the treatment of refractory MAC disease (e.g., bedaquiline, tedizolid, linezolid, omadacycline), acknowledging that there is insufficient observational or clinical trial data to support formal recommendations in this setting.
• Updated information on drug–drug interactions between anti-MAC therapies, particularly rifabutin, and antiretroviral drugs and provided a link to the Adult and Adolescent Antiretroviral Guidelines on drug–drug interactions.

July 29, 2024

Leishmaniasis

• Updated information on prevalence, including transmission in the United States.
• Updated information on the use of polymerase chain reaction, or PCR, and serological tests for the diagnosis of leishmanial diseases.
• Updated treatment regimens for each of the leishmanial diseases, including regimens that reduce the likelihood of recurrence.
• Added new information about special considerations in pregnancy.

July 9, 2024

Human Papillomavirus Disease

• A brief summary of this update is available here from the NIH Office of AIDS Research.
• Based on the ANCHOR study results, provided new screening and treatment recommendations for anal cancer prevention.
• Provided new anal cancer screening algorithms.