What's New in the Guidelines

Updated
Reviewed
Apr. 14, 2021

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 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 6 months are as follows:

What’s New

July 22, 2021

Varicella-Zoster Virus Disease: 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.
  • Highlighted the toxicities of alternative antiviral medications used to treat CMV.

Cryptococcosis: Key updates to the guidelines include the following:

  • 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. For patients whose serum titer is <1:320 using a lateral flow assay, treatment can be with fluconazole 400-800 mg daily. For patients whose serum titer is >1:640, the likelihood that meningitis is present or will develop is high, and treatment should be the same as that for cryptococcal meningitis.
  • 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

  1. Coccidioidomycosis: Key updates to the guidelines include the following:
    • Revised section on serology for the diagnosis of coccidioidomycosis
    • Added PCR as a commercially available diagnostic test
    • Revised the section on patients who are asymptomatic with a positive serological test
  2. Bartonellosis: Key updates to the guidelines include the following:
    • Updated section on diagnostics, including role of PCR-based testing
    • Updated the section on treatment for endocarditis
  3. Immunizations for Preventable Diseases in Adults and Adolescents Living with HIV: Key updates to the guidelines include the following:
    • Revised figure summarizing immunizations in PLWH
    • Added table comparing ACIP recommendations with Panel recommendations
    • Added narrative sections with evidence summaries
    • Updated recommendation for zoster vaccine

May 26, 2020

  1. Candidiasis (Mucocutaneous): The Panel updated the text, treatment, pregnancy considerations, references, and treatment table and made the following key changes:
    • Added important new information on spontaneous abortion in pregnant women after any exposure to fluconazole (low—even single-dose—or high exposure).
    • Added a brief discussion on the gentian violet topical application randomized clinical trial for oral candidiasis and updated the treatment table.
    • Added a statement indicating that azole resistance can be seen in vulvovaginal candidiasis caused by non-C. albicans species.
    • Added details for the use of boric acid in azole-refractory C. glabrata vaginitis in the treatment table.
  2. Herpes Simplex Virus: The Panel updated references throughout the section and improved the readability of the text. In addition, the Panel made the following key changes:
    • Updated information about the seroprevalence of HSV-1 and HSV-2 in the United States.
    • Addressed HSV-1 as a cause of genital herpes.
    • Provided additional information about the interpretation of type-specific HSV serologic assays.
    • Updated information about prevention methods for HSV-2 infection.
    • Updated information about treatment of acyclovir-resistant HSV infection.

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 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 6 months are as follows:

What’s New

July 22, 2021

Varicella-Zoster Virus Disease: 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.
  • Highlighted the toxicities of alternative antiviral medications used to treat CMV.

Cryptococcosis: Key updates to the guidelines include the following:

  • 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. For patients whose serum titer is <1:320 using a lateral flow assay, treatment can be with fluconazole 400-800 mg daily. For patients whose serum titer is >1:640, the likelihood that meningitis is present or will develop is high, and treatment should be the same as that for cryptococcal meningitis.
  • 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

  1. Coccidioidomycosis: Key updates to the guidelines include the following:
    • Revised section on serology for the diagnosis of coccidioidomycosis
    • Added PCR as a commercially available diagnostic test
    • Revised the section on patients who are asymptomatic with a positive serological test
  2. Bartonellosis: Key updates to the guidelines include the following:
    • Updated section on diagnostics, including role of PCR-based testing
    • Updated the section on treatment for endocarditis
  3. Immunizations for Preventable Diseases in Adults and Adolescents Living with HIV: Key updates to the guidelines include the following:
    • Revised figure summarizing immunizations in PLWH
    • Added table comparing ACIP recommendations with Panel recommendations
    • Added narrative sections with evidence summaries
    • Updated recommendation for zoster vaccine

May 26, 2020

  1. Candidiasis (Mucocutaneous): The Panel updated the text, treatment, pregnancy considerations, references, and treatment table and made the following key changes:
    • Added important new information on spontaneous abortion in pregnant women after any exposure to fluconazole (low—even single-dose—or high exposure).
    • Added a brief discussion on the gentian violet topical application randomized clinical trial for oral candidiasis and updated the treatment table.
    • Added a statement indicating that azole resistance can be seen in vulvovaginal candidiasis caused by non-C. albicans species.
    • Added details for the use of boric acid in azole-refractory C. glabrata vaginitis in the treatment table.
  2. Herpes Simplex Virus: The Panel updated references throughout the section and improved the readability of the text. In addition, the Panel made the following key changes:
    • Updated information about the seroprevalence of HSV-1 and HSV-2 in the United States.
    • Addressed HSV-1 as a cause of genital herpes.
    • Provided additional information about the interpretation of type-specific HSV serologic assays.
    • Updated information about prevention methods for HSV-2 infection.
    • Updated information about treatment of acyclovir-resistant HSV infection.

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