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Tables

Table 1. Chemoprophylaxis to Prevent First Episode of Opportunistic Disease

This table provides recommendations for the use of chemoprophylaxis to prevent the first episode of opportunistic disease. For the use of immunizations to prevent hepatitis A virus, hepatitis B virus, human papillomavirus, influenza A and B viruses, Streptococcus pneumoniae, and varicella-zoster virus infections, please refer to the Immunizations for Preventable Diseases in Adults and Adolescents with HIV section.

Opportunistic InfectionsIndicationPreferredAlternative
CoccidioidomycosisA new positive IgM or IgG serologic test in patients who live in a disease-endemic area and with CD4 count <250 cells/µL (BIII)Fluconazole 400 mg PO daily (BIII) 
Histoplasma capsulatum infectionCD4 count ≤150 cells/µL and at high risk because of occupational exposure or living in a community with a hyperendemic rate of histoplasmosis (>10 cases/100 patient-years) (BI)Itraconazole 200 mg PO daily (BI) 
MalariaTravel to disease-endemic areaRecommendations are the same for HIV-infected and HIV-uninfected patients. Recommendations are based on the region of travel, malaria risks, and drug susceptibility in the region. Refer to the Centers for Disease Control and Prevention webpage for the most recent recommendations based on region and drug susceptibility: Malaria. 
Mycobacterium avium complex (MAC) disease

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)

Rifabutin (dose adjustment may be necessary with some ARV drugs, and rifabutin is not recommended if used with certain ARV drugs)a (BI); rule out active TB before starting rifabutin to avoid monotherapy in the setting of TB.
Mycobacterium tuberculosis infection (TB) (i.e., treatment of latent TB infection [LTBI])

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).

Pneumocystis Pneumonia (PCP)

CD4 count <200 cells/mm3(AI), or

CD4 <14% (BII), or

If ART initiation must be delayed, CD4 count ≥200 cells/mm3 but <250 cells/mm3 and if monitoring of CD4 cell count every 3 months is not possible (BII)

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

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

TMP-SMXc 1 SS tablet daily (AI)

  • TMP-SMXc 1 DS PO three times weekly (BI), or
  • Dapsoned 100 mg PO daily or 50 mg PO BID (BI), or
  • Dapsoned 50 mg PO daily with (pyrimethaminee 50 mg plus leucovorin 25 mg) PO weekly (BI), or
  • (Dapsoned 200 mg plus pyrimethaminee 75 mg plus leucovorin 25 mg) PO weekly (BI); or
  • Aerosolized pentamidine 300 mg via Respigard II™ nebulizer every month (BI), or
  • Atovaquone 1,500 mg PO daily (BI), or
  • (Atovaquone 1,500 mg plus pyrimethaminee 25 mg plus leucovorin 10 mg) PO daily (CIII)
Syphilis

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)

Benzathine penicillin G 2.4 million units IM for one dose (AII)

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)
Talaromycosis (Penicilliosis)

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 gondii encephalitis

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

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

TMP-SMXa 1 DS PO daily (AII)
  • TMP-SMXc 1 DS PO three times weekly (BIII), or
  • TMP-SMXc 1 SS PO daily (BIII), or
  • Dapsoned 50 mg PO daily plus (pyrimethaminee 50 mg plus leucovorin 25 mg) PO weekly (BI), or
  • (Dapsoned 200 mg plus pyrimethaminee 75 mg plus leucovorin 25 mg) PO weekly (BI), or
  • Atovaquone 1500 mg PO daily (CIII), or
  • (Atovaquone 1500 mg plus pyrimethaminee 25 mg plus leucovorin 10 mg) PO daily (CIII)
a Refer to the Dosing Recommendations for Use of ARV and Anti-TB Drugs for Treatment of Active Drug Sensitive TB table in the Mycobacterium tuberculosis section for dosing recommendations.

b Screening tests for LTBI include tuberculin skin test or interferon-gamma release assays.

c TMP-SMX DS once daily also confers protection against toxoplasmosis and many respiratory bacterial infections; lower dose also likely confers protection.

d Patients should be tested for glucose-6-phosphate dehydrogenase (G6PD) before administration of dapsone or primaquine. An alternative agent should be used in patients found to have G6PD deficiency.

e Refer to Daraprim Direct for information regarding how to access pyrimethamine.

For information regarding the evidence ratings, refer to the Rating System for Prevention and Treatment Recommendations in the Introduction section of the Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV.

Key: ART = antiretroviral therapy; ARV = antiretroviral; BID = twice daily; CD4 = CD4 T lymphocyte cell; DS = double strength; DTG = dolutegravir; EFV = efavirenz; IgG = immunoglobulin G; IgM = immunoglobulin M; IM = intramuscular; INH = isoniazid; IV = intravenously; LTBI = latent tuberculosis infection; MAC = Mycobacterium avium complex; PCP = Pneumocystis pneumonia; PO = orally; RAL= raltegravir; SS = single strength; TB = tuberculosis; TMP-SMX = trimethoprim-sulfamethoxazole

Tables

Table 1. Chemoprophylaxis to Prevent First Episode of Opportunistic Disease

Opportunistic InfectionsIndicationPreferredAlternative
CoccidioidomycosisA new positive IgM or IgG serologic test in patients who live in a disease-endemic area and with CD4 count <250 cells/µL (BIII)Fluconazole 400 mg PO daily (BIII) 
Histoplasma capsulatum infectionCD4 count ≤150 cells/µL and at high risk because of occupational exposure or living in a community with a hyperendemic rate of histoplasmosis (>10 cases/100 patient-years) (BI)Itraconazole 200 mg PO daily (BI) 
MalariaTravel to disease-endemic areaRecommendations are the same for HIV-infected and HIV-uninfected patients. Recommendations are based on the region of travel, malaria risks, and drug susceptibility in the region. Refer to the Centers for Disease Control and Prevention webpage for the most recent recommendations based on region and drug susceptibility: Malaria. 
Mycobacterium avium complex (MAC) disease

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)

Rifabutin (dose adjustment may be necessary with some ARV drugs, and rifabutin is not recommended if used with certain ARV drugs)a (BI); rule out active TB before starting rifabutin to avoid monotherapy in the setting of TB.
Mycobacterium tuberculosis infection (TB) (i.e., treatment of latent TB infection [LTBI])

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).

Pneumocystis Pneumonia (PCP)

CD4 count <200 cells/mm3(AI), or

CD4 <14% (BII), or

If ART initiation must be delayed, CD4 count ≥200 cells/mm3 but <250 cells/mm3 and if monitoring of CD4 cell count every 3 months is not possible (BII)

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

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

TMP-SMXc 1 SS tablet daily (AI)

  • TMP-SMXc 1 DS PO three times weekly (BI), or
  • Dapsoned 100 mg PO daily or 50 mg PO BID (BI), or
  • Dapsoned 50 mg PO daily with (pyrimethaminee 50 mg plus leucovorin 25 mg) PO weekly (BI), or
  • (Dapsoned 200 mg plus pyrimethaminee 75 mg plus leucovorin 25 mg) PO weekly (BI); or
  • Aerosolized pentamidine 300 mg via Respigard II™ nebulizer every month (BI), or
  • Atovaquone 1,500 mg PO daily (BI), or
  • (Atovaquone 1,500 mg plus pyrimethaminee 25 mg plus leucovorin 10 mg) PO daily (CIII)
Syphilis

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)

Benzathine penicillin G 2.4 million units IM for one dose (AII)

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)
Talaromycosis (Penicilliosis)

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 gondii encephalitis

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

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

TMP-SMXa 1 DS PO daily (AII)
  • TMP-SMXc 1 DS PO three times weekly (BIII), or
  • TMP-SMXc 1 SS PO daily (BIII), or
  • Dapsoned 50 mg PO daily plus (pyrimethaminee 50 mg plus leucovorin 25 mg) PO weekly (BI), or
  • (Dapsoned 200 mg plus pyrimethaminee 75 mg plus leucovorin 25 mg) PO weekly (BI), or
  • Atovaquone 1500 mg PO daily (CIII), or
  • (Atovaquone 1500 mg plus pyrimethaminee 25 mg plus leucovorin 10 mg) PO daily (CIII)
a Refer to the Dosing Recommendations for Use of ARV and Anti-TB Drugs for Treatment of Active Drug Sensitive TB table in the Mycobacterium tuberculosis section for dosing recommendations.

b Screening tests for LTBI include tuberculin skin test or interferon-gamma release assays.

c TMP-SMX DS once daily also confers protection against toxoplasmosis and many respiratory bacterial infections; lower dose also likely confers protection.

d Patients should be tested for glucose-6-phosphate dehydrogenase (G6PD) before administration of dapsone or primaquine. An alternative agent should be used in patients found to have G6PD deficiency.

e Refer to Daraprim Direct for information regarding how to access pyrimethamine.

For information regarding the evidence ratings, refer to the Rating System for Prevention and Treatment Recommendations in the Introduction section of the Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV.

Key: ART = antiretroviral therapy; ARV = antiretroviral; BID = twice daily; CD4 = CD4 T lymphocyte cell; DS = double strength; DTG = dolutegravir; EFV = efavirenz; IgG = immunoglobulin G; IgM = immunoglobulin M; IM = intramuscular; INH = isoniazid; IV = intravenously; LTBI = latent tuberculosis infection; MAC = Mycobacterium avium complex; PCP = Pneumocystis pneumonia; PO = orally; RAL= raltegravir; SS = single strength; TB = tuberculosis; TMP-SMX = trimethoprim-sulfamethoxazole

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