Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents With HIV

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

Updated October 29, 2024 Reviewed October 29, 2024

Tables

Table 3. Indications for Discontinuing and Restarting Opportunistic Infection Secondary Prophylaxis or Chronic Maintenance in Adults and Adolescents with HIV

Table 3. Indications for Discontinuing and Restarting Opportunistic Infection Secondary Prophylaxis or Chronic Maintenance in Adults and Adolescents with HIV
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/mm³ (CII)	No recommendation
Bartonellosis	Not applicable	Not applicable	Received at least 3–4 months of treatment, and CD4 count >200 cells/mm³ for ≥6 months (CIII) Some specialists would only discontinue therapy if Bartonella titers have also decreased by four-fold (CIII).	No recommendation
Candidiasis (Mucocutaneous)	Not applicable	Not applicable	If used, reasonable to discontinue when CD4 count >200 cells/mm³(AIII).	No recommendation
Coccidioidomycosis	CD4 count ≥250 cells/mm³ with virologic suppression on ART (BIII)	No recommendation	Focal Coccidioidal Pneumonia (AII) Clinically responded to 3–‍6 months of antifungal therapy, with CD4 count ≥250 cells/mm³, and achieved viral suppression on ART Continue monitoring for recurrence after treatment discontinuation by using serial chest radiographs and coccidioidal serology. Diffuse Pulmonary or Disseminated Non-Meningeal Disease (BIII) Clinical and serological response to ≥12 months of therapy, and Consultation with experts For diffuse pulmonary disease, continue monitoring for recurrence after treatment discontinuation by using serial chest radiographs and coccidioidal serology. Coccidioidal Meningitis (AII) Suppressive therapy should be continued indefinitely, even with an increase in CD4 count on ART.	No recommendation
Cryptococcal Meningitis	Not applicable	Not applicable	If the following criteria are fulfilled (BII): Completed initial (induction and consolidation) therapy, and Received at least 1 year of antifungal therapy, and Remain asymptomatic of cryptococcal infection, and CD4 count ≥100 cells/mm³ and with suppressed plasma HIV RNA in response to ART	CD4 count <100 cells/mm³ (AIII)
Cytomegalovirus Retinitis	Not applicable	Not applicable	CMV treatment for at least 3‍ to 6 months and with CD4 count >100 cells/mm³for >3 to 6 months in response to ART (AII) Therapy should be discontinued only after consultation with an ophthalmologist, taking into account anatomic location of lesions, vision in the contralateral eye, and feasibility of regular ophthalmologic monitoring. Routine (i.e., every 3 months) ophthalmologic follow-up is recommended after stopping therapy for early detection of relapse or immune restoration uveitis, and then periodically after sustained immune reconstitution (AIII).	CD4 count <100 cells/mm³ (AIII)
Histoplasma capsulatum Infection	On ART with CD4 count ≥150 cells/mm³ for 6 months and with viral suppression on ART (BIII)	For patients at high risk of acquiring histoplasmosis (as noted in Table 1), restart if CD4 count decreases to <150 cells/mm³ (BIII).	If the following criteria (AI) are fulfilled: Received azole therapy for >1 year, and Negative fungal blood cultures, and Serum or urine Histoplasma antigen below the level of quantification, and Viral suppression on ART, and CD4 count ≥150 cells/mm³ for ≥6 months in response to ART	CD4 count <150 cells/mm³ (BIII)
Isospora belli Infection	Not applicable	Not applicable	Sustained increase in CD4 count to >200 cells/mm³ for >6 months in response to ART and without evidence of I. belli infection (BIII)	No recommendation
Leishmaniasis: Visceral (and possibly cutaneous leishmaniasis in immunocompromised patients with multiple relapses)	Not applicable	Not applicable	If CD4 count increases to >350 cells/mm³ and HIV viral load is suppressed for 6 months in response to ART and there is no evidence of clinical relapse of visceral leishmaniasis (CIII)	No recommendation
Microsporidiosis	Not applicable	Not applicable	If there are no signs or symptoms of non-ocular (BIII) or ocular (CIII) microsporidiosis and CD4 count is >200 cells/mm³ for >6 months in response to ART.	No recommendation
Mycobacterium avium Complex Disease	Continuing a fully suppressive ART regimen (AI)	CD4 count <50 cells/mm³ and not on fully suppressive ART (AIII)	If the following criteria are fulfilled (AI): Completed ≥12 months of therapy, and No signs and symptoms of MAC disease, and Have sustained (>6 months) CD4 count >100 cells/mm³ in response to ART.	If a fully suppressive ART regimen is not possible and CD4 count is consistently <100 cells/mm ³ (BIII)
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 to 6 months (BII).	CD4 count <100 cells/mm³ regardless of HIV RNA level (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 (AII). Can consider when CD4 count is 100–200 cells/mm³ if HIV RNA remains below limits of detection for 3–6 months (BII). 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). If PCP occurs at a CD4 count >200 cells/mm³ while not on ART, discontinuation of prophylaxis can be considered when HIV RNA levels are suppressed to below limits of detection for ≥3 to 6 months (CIII).	CD4 count <100 cells/mm³ regardless of HIV RNA level (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/mm³ for >3 months and sustained HIV RNA below limits of detection in response to ART (AI) Can consider when CD4 count is 100‍–‍200 cells/mm³ if HIV RNA remains below limits of detection for at least 3–6 months (BII)	CD4 count <100 cells/mm³ (AIII) CD4 count 100‍–‍200 cells/mm³ and with HIV RNA above detection limit of the assay (AIII)	If the following criteria are fulfilled (BI): Successfully completed initial therapy, Receiving maintenance therapy and remaining free of signs and symptoms of TE, and CD4 count >200 cells/mm³ for >6 months in response to ART	CD4 count <200 cells/mm³ (AIII)
For information regarding the evidence ratings, refer to the Rating System for Prevention and Treatment Recommendations in the Introduction section of the Adult and Adolescent Antiretroviral Guidelines. Key: ART = antiretroviral therapy; CD4 = CD4 T lymphocyte; CMV = cytomegalovirus; MAC = Mycobacterium avium complex; PCP = Pneumocystis pneumonia; TE = Toxoplasma encephalitis

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