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

CD4 count <50 cells/mm³ AND not receiving ART or remains viremic on ART or has no options for a fully suppressive ART regimen (AI)

Not recommended for those who immediately initiate ART after HIV diagnosis (AII)

Disseminated MAC disease should be ruled out before starting primary prophylaxis. See the MAC section for more information.

Azithromycin 1,200 mg PO once weekly (AI), or

Clarithromycin 500 mg PO twice daily (AI), or

Azithromycin 600 mg PO twice weekly (BIII)

Positive screening test for LTBI,^b no evidence of active TB, and no prior treatment for active TB or LTBI (AI), or

Close contact with a person with infectious TB (with no evidence of active TB), regardless of screening test results and CD4 count (AII)

For recommendations on management of drug interactions with ARVs, see the Dosing Recommendations for Use of ARV and Anti-TB Drugs When Treating Latent TB Infection table in the Mycobacterium tuberculosis Infection and Disease section and the Drug-Drug Interactions in the Adult and Adolescent Antiretroviral Guidelines.

3HP:

Rifapentine (see weight-based dosing below) plus INH 15 mg/kg (900 mg maximum) plus pyridoxine 50 mg PO once weekly for 12 weeks (AI)

Weight-Based Rifapentine Dose

• Weighing 25.1–32 kg: 600 mg PO once weekly
• Weighing 32.1–49.9 kg: 750 mg PO once weekly
• Weighing >50 kg: 900 mg PO once weekly

Note: 3HP is recommended only for virally-suppressed persons receiving EFV, RAL, or once daily DTG-based ARV regimen (AII).

or

3HR:

INH 300 mg plus rifampin 600 mg plus pyridoxine 25–50 mg PO daily for 3 months (AI)

INH 300 mg plus pyridoxine 25–50 mg PO daily for 6–9 months (AII), or

4R: Rifampin 600 mg PO daily for 4 months (BI), or

1HP: Rifapentine (see weight-based dosing below) plus INH 300 mg plus pyridoxine 25–50 mg) PO once daily for 4 weeks (BI)

Weight-Based Rifapentine Dose

• Weighing <35 kg: 300 mg PO once daily
• Weighing 35–45 kg: 450 mg PO once daily
• Weighing >45 kg: 600 mg PO once daily

Note: 1HP is recommended only for patients receiving an efavirenz-based ARV regimen (AI).

For persons exposed to drug-resistant TB, select anti-TB drugs after consultation with experts and public health authorities (AIII).

CD4 count 100–‍200 cells/mm³, if plasma HIV RNA level is above detection limits (AI), or

CD4 count <100 cells/mm³, regardless of plasma HIV RNA level (AIII)

Note: Patients who are receiving pyrimethamine/ sulfadiazine for treatment or suppression of toxoplasmosis do not require additional PCP prophylaxis (AII).

TMP-SMX 1 DS tablet PO daily (AI), or

TMP-SMX 1 SS tablet PO daily (AI)

Note: TMP-SMX also confers protection against toxoplasmosis and some protection against many respiratory bacterial infections.

The following regimens can be used for people who are seropositive or seronegative for Toxoplasma gondii:

• TMP-SMX 1 DS PO three times weekly (BI), or
• Dapsone^c 50 mg PO daily with pyrimethamine^d 50 mg plus leucovorin 25 mg PO weekly (BI), or
• Dapsone^c 200 mg plus pyrimethamine^d 75 mg plus leucovorin 25 mg PO weekly (BI), or
• Atovaquone 1,500 mg PO daily with food (BI)

The following regimens should only be used if the person is seronegative for Toxoplasma gondii:

• Dapsone^c 100 mg PO daily or 50 mg PO twice daily (BI), or
• Aerosolized pentamidine 300 mg via Respigard II nebulizer every month (BI), or
• Intravenous pentamidine 300 mg every 28 days (CIII)

Individuals exposed sexually within ≤90 days of the diagnosis of primary, secondary, or early latent syphilis in a sex partner, regardless of serologic status (AII), or

Individuals exposed >90 days before syphilis diagnosis in a sex partner, if serologic test results are not available immediately and the opportunity for follow-up is uncertain (AIII)

For penicillin-allergic patients:

• Doxycycline 100 mg PO twice daily for 14 days (BII), or
• Ceftriaxone 1 g IM or IV daily for 10–14 days (BII)

Persons with HIV and CD4 cell counts <100 cells/mm³, who are unable to have ART, or have treatment failure without access to effective ART options, and—

• Who reside in the highly endemic regions* in northern Thailand, northern or southern Vietnam, or southern China (BI), or
• Who are from countries outside of the endemic region, and must travel to the region (BIII)

* Particularly in highland regions during the rainy and humid months

For persons who reside in endemic areas, itraconazole 200 mg PO once daily (BI)

For those traveling to the highly endemic regions, begin itraconazole 200 mg PO once daily 3 days before travel, and continue for 1 week after leaving the endemic area (BIII).

For persons who reside in endemic areas, fluconazole 400 mg PO once weekly (BII)

For those traveling to the highly endemic regions, take the first dose of fluconazole 400 mg 3 days before travel, continue 400 mg once weekly, and take the final dose after leaving the endemic area (BIII).

Toxoplasma IgG-positive patients with CD4 count <100 cells/mm³ (AII)

Note: All regimens recommended for primary prophylaxis against toxoplasmosis also are effective as PCP prophylaxis.

TMP-SMX 1 DS PO three times weekly (BII), or

TMP-SMX 1 SS PO daily (BIII), or

Dapsone^c 50 mg PO daily plus (pyrimethamine^d 50 mg plus leucovorin 25 mg) PO weekly (BI), or

(Dapsone^c 200 mg plus pyrimethamine^d 75 mg plus leucovorin 25 mg) PO weekly (CI), or

Atovaquone 1,500 mg PO daily (CIII), or

(Atovaquone 1,500 mg plus pyrimethamine^d 25 mg plus leucovorin 10 mg) PO daily (CIII)