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

• 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).

Only for patients with focal coccidioidal pneumonia (AII):

• Clinically responded to ≥12 months antifungal therapy, with CD4 count >250 cells/mm³, and receiving effective ART
• Should continue monitoring for recurrence with serial chest radiographs and coccidioidal serology

For patients with diffuse pulmonary (BIII), disseminated non-meningeal (BIII), or meningeal diseases (AII):

• Suppressive therapy should be continued indefinitely, even with increase in CD4 count on ART.

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

• CMV treatment for at least 3‍ to 6 months and with CD4 count >100 cells/mm³ for >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).

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
• Undetectable HIV viral load, and
• CD4 count ≥150 cells/mm³ for ≥6 months in response to ART

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.

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 to 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 to 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)

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 for ≥6 months in response to ART (BII)

or

If achieved sustained HIV viral suppression for >6 months (BIII)

CD4 count increased 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 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)