Updated
Reviewed
Feb. 09, 2021
Tables
Table 4. Indications for Discontinuing and Restarting Opportunistic Infection Prophylaxis in HIV-Infected Adults and Adolescents
Opportunistic Infection | Indication for Discontinuing Primary Prophylaxis | Indication for Restarting Primary Prophylaxis | Indication for Discontinuing Secondary Prophylaxis/Chronic Maintenance Therapy | Indication for Restarting Secondary Prophylaxis/Chronic Maintenance |
---|---|---|---|---|
Bacterial Enteric Infections: Salmonellosis | Not applicable | Not applicable | Resolution of Salmonella infection and after response to ART with sustained viral suppression and CD4 counts >200 cells/µL (CII) | No recommendation |
Bartonellosis | Not applicable | Not applicable |
|
No recommendation |
Candidiasis (Mucocutaneous) | Not applicable | Not applicable | If used, reasonable to discontinue when CD4 count >200 cells/µL (AIII). | No recommendation |
Coccidioidomycosis | CD4 count ≥250 cells/µL with viral suppression on ART (BIII) | Restart at CD4 count <250 cells/µL (BIII) | Only for patients with mild to moderate pneumonia (AII):
Suppressive therapy should be continued indefinitely. |
No recommendation |
Cryptococcal Meningitis | Not applicable | Not applicable | If the following criteria are fulfilled (BII):
|
CD4 count <100 cells/µL (AIII) |
Cystoisosporiasis (Formerly Isosporiasis) | Not applicable | Not applicable | Sustained increase in CD4 count to >200 cells/µL for >6 months in response to ART and without evidence of I. belli infection (BIII) | No recommendation |
Cytomegalovirus Retinitis | Not applicable | Not applicable |
|
CD4 count <100 cells/µL (AIII) |
Histoplasmosis | On ART, with CD4 count >150 cells/mm3 and undetectable HIV-1 viral load for 6 months (BIII) | For patients at high risk of acquiring histoplasmosis, restart if CD4 count falls to <150 cells/mm3 (CIII) | If the Following Criteria (AI) are Fulfilled:
|
CD4 count <150 cells/mm3 (BIII) |
Leishmaniasis: Visceral (and possibly cutaneous leishmaniasis in immunocompromised patients with multiple relapses) | Not applicable | Not applicable | There is no consensus regarding when to stop secondary prophylaxis. Some investigators suggest that therapy can be stopped if CD4 count increases to >200 to 350 cells/µL for 3–6 months in response to ART, but others suggest that therapy should be continued indefinitely. | No recommendation |
Microsporidiosis | Not applicable | Not applicable | No signs and symptoms of non-ocular (BIII) or ocular (CIII) microsporidiosis and CD4 count >200 cells/µL for >6 months in response to ART. | No recommendation |
Mycobacterium avium Complex Disease | Initiation of effective ART (AI) | CD4 count <50 cells/mm3: only if not on fully suppressive ART (AIII) | If the following criteria are fulfilled (AI):
|
CD4 count <100 cells/mm3 (AIII) |
Pneumocystis Pneumonia | CD4 count increased from <200 to >200 cells/mm3 for >3 months in response to ART (AI) Can consider when CD4 count is 100–200 cells/mm3 if HIV RNA remains below limits of detection for ≥3 months–6 months (BII). |
CD4 count <100 cells/mm3 (AIII) CD4 count 100–200 cells/mm3 and HIV RNA above detection limit of the assay (AIII). |
CD4 count increased from <200 cells/mm3 to >200 cells/mm3 for >3 months in response to ART (BII) Can consider when CD4 count is 100–200 cells/mm3 if HIV RNA remains below limits of detection for ≥3 months–6 months (BII). If PCP occurs at a CD4 count >200 cells/mm3 while not on ART, discontinuation of prophylaxis can be considered once HIV RNA levels are suppressed to below limits of detection for ≥3 months–6 months (CIII). If PCP occurs at a CD4 count >200 cells/mm3 while on ART, continue PCP prophylaxis for life, regardless of how high the CD4 cell count rises as a consequence of ART (BIII). |
CD4 count <100 cells/mm3 (AIII) CD4 count 100–200 cells/mm3 and with HIV RNA above detection limit of the assay (AIII). |
Talaromycosis (Penicilliosis) | CD4 count >100 cells/mm3 for >6 months in response to ART (BII) or If achieved sustained HIV viral suppression for >6 months (BIII) |
CD4 count <100 cells/mm3 (BIII)—if patient is unable to have ART, or has treatment failure without access to effective ART options, and still resides in or travels to the endemic area | CD4 count >100 cells/mm3 for ≥6 months in response to ART (BII) or If achieved sustained HIV viral suppression for >6 months (BIII) |
CD4 count <100 cells/mm3 (BIII) |
Toxoplasma gondii Encephalitis | CD4 count increased to >200 cells/µL for >3 months in response to ART (AI) Can consider when CD4 count 100-200 cells/µL if HIV RNA remain below limits of detection for at least 3-6 months (BII) |
CD4 count <100 cells/µL (AIII). CD4 count 100-200 cells/ µL and with HIV RNA above detection limit of the assay (AIII). |
Successfully completed initial therapy, receiving maintenance therapy and remain free of signs and symptoms of TE, and CD4 count >200 cells/µL for >6 months in response to ART (BI). | CD4 count <200 cells/ µL (AIII) |
Key to Acronyms: ART = antiretroviral therapy; CD4 = CD4 T lymphocyte cell; CMV = cytomegalovirus; MAC = Mycobacterium avium complex; PCP = Pneumocystis pneumonia; TE = Toxoplasma encephalitis Evidence Rating: Strength of Recommendation: A: Strong recommendation for the statement B: Moderate recommendation for the statement C: Optional recommendation for the statement Quality of Evidence for the Recommendation: I: One or more randomized trials with clinical outcomes and/or validated laboratory endpoints II: One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes III: Expert opinion In cases where there are no data for the prevention or treatment of an OI based on studies conducted in HIV-infected populations, but data derived from HIV-uninfected patients exist that can plausibly guide management decisions for patients with HIV/AIDS, the data will be rated as III but will be assigned recommendations of A, B, C depending on the strength of recommendation. |
Tables
Table 4. Indications for Discontinuing and Restarting Opportunistic Infection Prophylaxis in HIV-Infected Adults and Adolescents
Opportunistic Infection | Indication for Discontinuing Primary Prophylaxis | Indication for Restarting Primary Prophylaxis | Indication for Discontinuing Secondary Prophylaxis/Chronic Maintenance Therapy | Indication for Restarting Secondary Prophylaxis/Chronic Maintenance |
---|---|---|---|---|
Bacterial Enteric Infections: Salmonellosis | Not applicable | Not applicable | Resolution of Salmonella infection and after response to ART with sustained viral suppression and CD4 counts >200 cells/µL (CII) | No recommendation |
Bartonellosis | Not applicable | Not applicable |
|
No recommendation |
Candidiasis (Mucocutaneous) | Not applicable | Not applicable | If used, reasonable to discontinue when CD4 count >200 cells/µL (AIII). | No recommendation |
Coccidioidomycosis | CD4 count ≥250 cells/µL and with viral suppression while on ART (CIII) | Restart at CD4 count <250 cells/µL (BIII) | Only for patients with focal coccidioidal pneumonia (AII):
Suppressive therapy should be continued indefinitely, even with increase in CD4 count on ART. |
No recommendation |
Cryptococcal Meningitis | Not applicable | Not applicable | If the following criteria are fulfilled (BII):
|
CD4 count <100 cells/µL (AIII) |
Cystoisosporiasis (Formerly Isosporiasis) | Not applicable | Not applicable | Sustained increase in CD4 count to >200 cells/µL for >6 months in response to ART and without evidence of I. belli infection (BIII) | No recommendation |
Cytomegalovirus Retinitis | Not applicable | Not applicable |
|
CD4 count <100 cells/µL (AIII) |
Histoplasmosis | On ART, with CD4 count >150 cells/mm3 and undetectable HIV-1 viral load for 6 months (BIII) | For patients at high risk of acquiring histoplasmosis, restart if CD4 count falls to <150 cells/mm3 (CIII) | If the Following Criteria (AI) are Fulfilled:
|
CD4 count <150 cells/mm3 (BIII) |
Leishmaniasis: Visceral (and possibly cutaneous leishmaniasis in immunocompromised patients with multiple relapses) | Not applicable | Not applicable | There is no consensus regarding when to stop secondary prophylaxis. Some investigators suggest that therapy can be stopped if CD4 count increases to >200 to 350 cells/µL for 3–6 months in response to ART, but others suggest that therapy should be continued indefinitely. | No recommendation |
Microsporidiosis | Not applicable | Not applicable | No signs and symptoms of non-ocular (BIII) or ocular (CIII) microsporidiosis and CD4 count >200 cells/µL for >6 months in response to ART. | No recommendation |
Mycobacterium avium Complex Disease | Initiation of effective ART (AI) | CD4 count <50 cells/mm3: only if not on fully suppressive ART (AIII) | If the following criteria are fulfilled (AI):
|
CD4 count <100 cells/mm3 (AIII) |
Pneumocystis Pneumonia | CD4 count increased from <200 to >200 cells/mm3 for >3 months in response to ART (AI) Can consider when CD4 count is 100–200 cells/mm3 if HIV RNA remains below limits of detection for ≥3 months–6 months (BII). |
CD4 count <100 cells/mm3 (AIII) CD4 count 100–200 cells/mm3 and HIV RNA above detection limit of the assay (AIII). |
CD4 count increased from <200 cells/mm3 to >200 cells/mm3 for >3 months in response to ART (BII) Can consider when CD4 count is 100–200 cells/mm3 if HIV RNA remains below limits of detection for ≥3 months–6 months (BII). If PCP occurs at a CD4 count >200 cells/mm3 while not on ART, discontinuation of prophylaxis can be considered once HIV RNA levels are suppressed to below limits of detection for ≥3 months–6 months (CIII). If PCP occurs at a CD4 count >200 cells/mm3 while on ART, continue PCP prophylaxis for life, regardless of how high the CD4 cell count rises as a consequence of ART (BIII). |
CD4 count <100 cells/mm3 (AIII) CD4 count 100–200 cells/mm3 and with HIV RNA above detection limit of the assay (AIII). |
Talaromycosis (Penicilliosis) | CD4 count >100 cells/mm3 for >6 months in response to ART (BII) or If achieved sustained HIV viral suppression for >6 months (BIII) |
CD4 count <100 cells/mm3 (BIII)—if patient is unable to have ART, or has treatment failure without access to effective ART options, and still resides in or travels to the endemic area | CD4 count >100 cells/mm3 for ≥6 months in response to ART (BII) or If achieved sustained HIV viral suppression for >6 months (BIII) |
CD4 count <100 cells/mm3 (BIII) |
Toxoplasma gondii Encephalitis | CD4 count increased to >200 cells/µL for >3 months in response to ART (AI) Can consider when CD4 count 100-200 cells/µL if HIV RNA remain below limits of detection for at least 3-6 months (BII) |
CD4 count <100 cells/µL (AIII). CD4 count 100-200 cells/ µL and with HIV RNA above detection limit of the assay (AIII). |
Successfully completed initial therapy, receiving maintenance therapy and remain free of signs and symptoms of TE, and CD4 count >200 cells/µL for >6 months in response to ART (BI). | CD4 count <200 cells/ µL (AIII) |
Key to Acronyms: ART = antiretroviral therapy; CD4 = CD4 T lymphocyte cell; CMV = cytomegalovirus; MAC = Mycobacterium avium complex; PCP = Pneumocystis pneumonia; TE = Toxoplasma encephalitis Evidence Rating: Strength of Recommendation: A: Strong recommendation for the statement B: Moderate recommendation for the statement C: Optional recommendation for the statement Quality of Evidence for the Recommendation: I: One or more randomized trials with clinical outcomes and/or validated laboratory endpoints II: One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes III: Expert opinion In cases where there are no data for the prevention or treatment of an OI based on studies conducted in HIV-infected populations, but data derived from HIV-uninfected patients exist that can plausibly guide management decisions for patients with HIV/AIDS, the data will be rated as III but will be assigned recommendations of A, B, C depending on the strength of recommendation. |
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