Table 1. Primary Prophylaxis of Opportunistic Infections in Children with and Exposed to HIV— Summary of Recommendations

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Table 1. Primary Prophylaxis of Opportunistic Infections in Children with and Exposed to HIV— Summary of Recommendations
Indication First choice Alternative Comments/Special Issues Last Reviewed
Bacterial Infections
(S. pneumoniae and other invasive bacteria)
  • Pneumococcal, Meningococcal and Hib vaccines
  • Intravenous immune globulin (400 mg/kg body weight every 2 to 4 weeks)
  • TMP-SMX, 75/375 mg/m2 body surface area per dose by mouth twice daily
See Figures 1 and 2 for detailed vaccines recommendations.

Vaccines Routinely Recommended for Primary Prophylaxis. Additional Primary Prophylaxis Indicated for— 
  • Hypogammaglobulinemia (that is, IgG <400 mg/dL)
Criteria for Discontinuing Primary Prophylaxis
  • Resolution of hypogammaglobulinemia
Criteria for Restarting Primary Prophylaxis
  • Relapse of hypogammaglobulinemia
November 6, 2013
Candidiasis Not routinely recommended N/A N/A January 31, 2019
Coccidioidomycosis N/A N/A Primary prophylaxis not routinely indicated in children. November 6, 2013
Cryptococcosis

Not recommended

Not recommended

N/A November 6, 2013
Cryptosporidiosis

ARV therapy to avoid advanced immune deficiency

N/A N/A August 29, 2019
Cytomegalovirus (CMV)

 

  • For older children who can receive adult dose (based on their BSA), valganciclovir tablets 900 mg orally once daily with food
  • For children aged 4 months to 16 years, valganciclovir oral solution 50 mg/mL at dose in milligrams = 7 x BSA x CrCl (up to maximum CrCl of 150 mL/min/1.73 m2) orally once daily with food (maximum dose 900 mg/day)
  Primary Prophylaxis Can Be Considered for— 
  • CMV antibody positivity and severe immunosuppression (i.e., CD4 count <50 cells/mm3 in children age ≥6 years; CD4 percentage <5% in children age <6 years).
Criteria for Discontinuing Primary Prophylaxis
  • Age ≥6 years with CD4 count >100 cells/mm3 
  • Age <6 years with CD4 percentage >10% 
Criteria for Considering Restarting Primary Prophylaxis
  • Age ≥6 years with CD4 count <50 cells/mm3 
  • Age <6 years with CD4 percentage <5%
August 3, 2023
Giardiasis ART to avoid advanced immunodeficiency N/A N/A August 22, 2019
Hepatitis B Virus (HBV)
  • Hepatitis B vaccine
  • Combination of hepatitis B immunoglobulin and hepatitis B vaccine to infants born to mothers with hepatitis B infection

Hepatitis B immunoglobulin following exposure

See Figures 1 and 2 for detailed vaccines recommendations.

Primary Prophylaxis indicated for—  

  • All individuals who are not HBV infected


Criteria for discontinuing primary prophylaxis

  • N/A


Criteria for restarting primary prophylaxis

  • N/A
November 6, 2013
Hepatitis C Virus (HCV)

None

N/A N/A November 6, 2013
Herpes Simplex Virus Infections (HSV) N/A N/A Primary prophylaxis not indicated November 6, 2013
Histoplasmosis N/A N/A

Primary Prophylaxis Indicated for—

  • Selected HIV-infected adults but not children.

Criteria for Discontinuing Primary Prophylaxis

  • N/A


Criteria for restarting primary prophylaxis

  • N/A
November 6, 2013
Human Papillomavirus (HPV) HPV vaccine N/A See Figures 1 and 2 for detailed vaccine recommendations. November 6, 2013
Influenza A and B Oseltamivir
Aged <3 Months:
  • Not recommendeda
Aged 3 Months to <1 Year:
  • 3 mg/kg body weight/dose once dailya
Aged ≥1 Year to 12 Years; Weight-Band Dosing:a
  • Weighing ≤15 kg: 30 mg once daily
  • Weighing >15 kg to 23 kg: 45 mg once daily
  • Weighing >23 kg to 40 kg: 60 mg once daily
  • Weighing >40 kg: 75 mg once daily
Aged ≥13 Years:
  • 75 mg once daily
Zanamivir (Aged ≥5 Years):
  • 10 mg (2 inhalations) once dailyb
None Post-exposure Chemoprophylaxis
Indications
  • After careful consideration of risks and benefits, pre-exposure antiviral chemoprophylaxis may be considered for children with HIV with severe immunosuppression while influenza virus is circulating in the community.
Duration:
  • When employed, pre-exposure antiviral chemoprophylaxis should continue for the duration of influenza virus circulation in the community.

Post-exposure Chemoprophylaxis

Indications Recommended for— 

  • Children with HIV with severe immunosuppression regardless of influenza vaccination status.
  • Children with HIV with moderate to no immunosuppression if: 
    • Influenza vaccination is contraindicated or unavailable, or
    • Low influenza vaccine effectiveness is documented in the current influenza season, and
    • Antiviral chemoprophylaxis can be started within 48 hours of exposure to an ill person with confirmed or suspected influenza.
Duration:
Note: Duration of chemoprophylaxis depends on the type of exposure, whether influenza vaccination was provided after the exposure, and whether influenza vaccine is anticipated to be effective based on the child’s degree of immunosuppression and the degree of match with circulating influenza viruses.
  • If influenza vaccination is provided after contact, chemoprophylaxis duration should be 2 weeks after vaccination.
  • If exposure is to a household contact, chemoprophylaxis duration should be 7 days.
  • If chemoprophylaxis is provided in setting of an institutional outbreak, the duration is either 14 days or 7 days after onset of symptoms in the last person infected, whichever is longer.c
Oseltamivir Dosing Adjustments
Premature Infants:
  • Current weight-based dosing recommendations for oseltamivir are not appropriate for premature infants (i.e., gestational age at delivery <38 weeks).d
Renal Insufficiency:
  • A reduction in dose of oseltamivir is recommended for patients with CrCl <30 mL/min. For patients with CrCl 10–30 mL/min, a reduction in chemoprophylaxis dosing frequency to every other day is recommended. PK data are limited for dosing recommendations for patients with severe renal insufficiency on dialysis.
a Oseltamivir is FDA-approved for prophylaxis of influenza in children aged ≥1 year. It is not approved for prophylaxis in children aged <1 year. However, CDC recommends that health care providers who treat children aged ≥3 months to <1 year administer a chemoprophylaxis dose of oseltamivir 3 mg/kg body weight/dose once daily. Chemoprophylaxis for infants aged <3 months is not recommended unless the exposure situation is judged to be critical.

b Zanamivir is not recommended for chemoprophylaxis in children aged <5 years or for children with underlying respiratory disease.

c See Fiore 2011 and Influenza Antiviral Medications: Summary for Clinicians for further details.

d See Acosta et al. J Infect Dis 2010; 202:563-566 for dosing recommendations in premature infants.
July 17, 2018
Isosporiasis (Cystoisosporiasis) There are no U.S. recommendations for primary prophylaxis of isosporiasis. N/A Initiation of ART to avoid severe immunodeficiency may reduce incidence; TMP-SMX prophylaxis may reduce incidence. February 8, 2019
Malaria For Travel to Chloroquine-Sensitive Areas— 
  • Chloroquine base 5 mg/kg body weight base by mouth, up to 300 mg once weekly (equivalent to 7.5 mg/kg body weight chloroquine phosphate). Start 1–2 weeks before leaving, take weekly while away, and then take once weekly for 4 weeks after returning home
  • Atovaquone/proguanil once daily started 1–2 days before travel, for duration of stay, and then for 1 week after returning home
  • 11–20 kg; One pediatric tablet (62.5 mg/25 mg)
  • 21–30 kg, Two pediatric tablets (125 mg/50 mg)
  • 31–40 kg; Three pediatric tablets (187.5 mg/75 mg)
  • >40 kg; One adult tablet (250 mg/100 mg)
  • Doxycycline 2.2 mg/kg body weight (maximum 100 mg) by mouth once daily for children aged ≥8 years. Must be taken 1-2 days before travel, daily while away, and then up to 4 weeks after returning
  • Mefloquine 5 mg/kg body weight orally given once weekly (maximum 250 mg)
For Areas with Mainly P. Vivax—
  • Primaquine phosphate 0.6 mg/kg body weight base once daily by mouth, up to a maximum of 30 mg base/day. Starting 1 day before leaving, taken daily, and for 3–7 days after return
For Travel to Chloroquine-Resistant Areas—
  • Atovaquone/proguanil once daily started 1–2 days before travel, for duration of stay, and then for 1 week after returning home
    • 11–20 kg; One pediatric tablet (62.5 mg/25 mg)
    • 21–30 kg; Two pediatric tablets (125 mg/50 mg)
    • 31–40 kg; Three pediatric tablets (187.5 mg/75 mg)
    • >40 kg; One adult tablet (250 mg/100 mg)
  • Doxycycline 2.2 mg/kg body weight (maximum 100 mg) by mouth once daily for children aged ≥8 years. Must be taken 1–2 days before travel, daily while away, and then up to 4 weeks after returning
  • Mefloquine 5 mg/kg body weight orally given once weekly (maximum 250 mg)
N/A Recommendations are the same for HIV-infected and HIV-uninfected children. Please refer to the following website for the most recent recommendations based on region and drug susceptibility: https://www.cdc.gov/malaria/

For travel to chloroquine-sensitive areas. Equally recommended options include chloroquine, atovaquone/proguanil, doxycycline (for children aged ≥8 years), and mefloquine; primaquine is recommended for areas with mainly P. vivax.

G6PD screening must be performed prior to primaquine use.

Chloroquine phosphate is the only formulation of chloroquine available in the United States; 10 mg of chloroquine phosphate = 6 mg of chloroquine base.

For travel to chloroquine-resistant areas, preferred drugs are atovaquone/proguanil, doxycycline (for children aged ≥8 years) or mefloquine.
November 6, 2013
Microsporidiosis N/A N/A Not recommended December 14, 2016
Mycobacterium avium Complex (MAC)
  • Clarithromycin 7.5 mg/kg body weight (maximum 500 mg) orally twice daily, or
  • Azithromycin 20 mg/kg body weight (maximum 1,200 mg) orally once weekly
  • Azithromycin 5 mg/kg body weight (maximum 250 mg) orally once daily
  • Children aged >5 years: rifabutin 300 mg orally once daily with food
Primary Prophylaxis Indicated for Children
  • Age <1 year: CD4 count <750 cells/mm3
  • Age 1 to <2 years: CD4 count <500 cells/mm3
  • Age 2 to <6 years: CD4 count <75 cells/mm3
  • Age ≥6 years: CD4 count <50 cells/mm3
Criteria for Discontinuing Primary Prophylaxis
  • Do not discontinue in children age <2 years.
  • After ≥6 months of ART, and:
    • Age 2 to <6 years: CD4 count >200 cells/mm3 for >3 consecutive months
    • Age ≥6 years: CD4 count >100 cells/mm3 for >3 consecutive months

Criteria for Restarting Primary Prophylaxis

  • Age 2 to <6 years: CD4 count <200 cells/mm3
  • Age ≥6 years: CD4 count <100 cells/mm3
January 8, 2019

Mycobacterium tuberculosis

Treatment of LTBI, Also Known as TB Preventive Therapy

Source Case Drug Susceptible
  • Age 2 to <12 years
    • 12 weekly doses of isoniazid (25 mg/kg for children aged 2–‍12 years) and rifapentine (10–‍14.0 kg: 300 mg; 14.1–‍25.0 kg: 450 mg; 25.1–‍32.0 kg: 600 mg; 32.1–‍49.9 kg: 750 mg; ≥50.0‍ kg: 900 mg maximum) 
  • Age ≥12 years
    • 12 doses of weekly isoniazid (15 mg/kg rounded up to the nearest 50 or 100 mg; 900 mg maximum) and rifapentine (10–14.0 kg: 300 mg; 14.1–‍25.0 kg: 450 mg; 25.1–‍32.0 kg: 600 mg; 32.1–‍49.9 kg: 750 mg; ≥50.0 kg: 900 mg maximum) 
Source Case Drug Resistant
  • For isoniazid-resistant source cases, daily rifampin 10–‍20 mg/kg (maximum 300 mg/day) for 4 months is recommended.
  • For isoniazid- and rifampin-resistant (i.e., MDR-TB) source cases, consult a TB expert and local public health authorities.

 

Rifampin 15–20 mg/kg (max 600 mg) daily for 4 months duration
or
isoniazid 10–15 mg/kg (max 300 mg) daily and rifampin 10–‍20 mg/kg (maximum 300 mg/day) for 3 months duration
or
isoniazid 10–15 mg/kg (max 300 mg) daily for 6–‍9 months


Indications
  • Positive TST (TST ≥5 mm in children with HIV) or IGRA without previous TB treatment
  • Close contact with any infectious TB case (repeated exposures warrant repeated post-exposure prophylaxis)
Considerations
  • TB disease must be excluded before starting treatment for latent TB infection. 
  • Drug–drug interactions with ART should be considered for all rifamycin-containing alternatives.
Criteria for Discontinuing Prophylaxis
  • Only with documented severe adverse event, such as hepatotoxicity, hypersensitivity, or other adverse drug reactions, which are rare in children and adolescents.

Adjunctive Treatment

  • Pyridoxine 1–2 mg/kg body weight once daily (maximum 25–‍50 mg/day) with isoniazid; pyridoxine supplementation is recommended for exclusively breastfed infants and for children and adolescents on meat- and milk-deficient diets; children with nutritional deficiencies, including all children with HIV; and pregnant adolescents and adults.
September 14, 2023
Pneumocystis jirovecii Pneumonia
  • TMP–SMX (Cotrimoxazole): Trimethoprim (2.5–5 mg/kg body weight/dose) with sulfamethoxazole (12.5–25 mg/kg body weight/dose twice per day) .Dosing based on TMP component
  • The total daily dose should not exceed 320 mg trimethoprim and 1,600 mg sulfamethoxazole. Several dosing schemes have been used successfully:
    • Given 3 days per week on consecutive days or on alternate days
    • Given 2 days per week on consecutive days or on alternate days
    • Given every day (total daily dose of TMP 5–10 mg/kg body weight given as a single dose each day)
Dapsone
Children aged ≥1 months:
  • 2 mg/kg body weight (maximum 100 mg) by mouth once daily or 4 mg/kg body weight (maximum 200 mg) by mouth once weekly
Atovaquone
Children Aged 1–3 Months and >24 Months–12 Years:
  • 30-40 mg/kg body weight/dose by mouth once daily with food
Children Aged 4–24 Months:
  • 45 mg/kg body weight/dose by mouth once daily with food
Children Aged ≥13 Years:
  • 1,500 mg (10 cc oral yellow suspension) per dose by mouth once daily
Aerosolized Pentamidine
Children Aged ≥5 Years:
  • 300 mg every month via Respirgard II™ nebulizer (manufactured by Marquest; Englewood, Colorado)
Primary Prophylaxis Indicated for—
  • All HIV-infected or HIV-indeterminate infants from aged 4–6 weeks to 12 months regardless of CD4 cell count/percentage
  • HIV-infected children aged 1 to <6 years with CD4 count <500 cells/mm3 or CD4 percentage <15%; HIV-infected children aged 6–12 years with CD4 count <200 cells/mm3 or CD4 percentage <15%
Criteria for Discontinuing Primary Prophylaxis:
Note: Do not discontinue in HIV-infected children aged <1 year
After ≥6 Months of cART
  • Aged 1 to <6 years; CD4 percentage ≥15% or CD4 count is ≥500 cells/mm3 for >3 consecutive months, or
  • Aged ≥6 years, CD4 percentage ≥15% or CD4 count is ≥200 cells/mm3 for >3 consecutive months
Criteria for Restarting Primary Prophylaxis:
  • Aged 1 to < 6 years with CD4 percentage <15 or CD4 count <500 cells/mm3
  • Aged ≥6 years with CD4 percentage <15% or CD4 count <200 cells/mm3
November 6, 2013
Syphilis N/A N/A

Primary prophylaxis indicated for— 

  • N/A


Criteria for Discontinuing Primary Prophylaxis

  • N/A


Criteria for Restarting Primary Prophylaxis

  • N/A
November 6, 2013
Toxoplasmosis TMP-SMX, 150/750 mg/m2 body surface area once daily by mouth Children Aged ≥1 Month:
  • Dapsone 2 mg/kg body weight or 15 mg/m2 body surface area (maximum 25 mg) by mouth once daily, plus
  • Pyrimethamine 1 mg/kg body weight (maximum 25 mg) by mouth once daily, plus
  • Leucovorin 5 mg by mouth every 3 days
Children Aged 1–3 Months and >24 Months:
  • Atovaquone 30 mg/kg body weight by mouth once daily
Children Aged 4–24 Months:
  • Atovaquone 45 mg/kg body weight by mouth once daily, with or without pyrimethamine 1 mg/kg body weight or 15 mg/m2 body surface area (maximum 25 mg) by mouth once daily, plus
  • Leucovorin 5 mg by mouth every 3 days
Acceptable Alternative Dosage Schedules for TMP-SMX:
  • TMP-SMX 150/750 mg/m2 body surface area per dose once daily by mouth three times weekly on 3 consecutive days per week
  • TMP-SMX 75/375 mg/m2 body surface area per dose twice daily by mouth every day
  • TMP-SMX 75/375 mg/m2 body surface area per dose twice daily by mouth three times weekly on alternate days
Primary Prophylaxis Indicated for—
IgG Antibody to Toxoplasma and Severe Immunosuppression:
  • HIV-infected children aged <6 years with CD4 percentage <15%; HIV-infected children aged ≥6 years with CD4 count <100 cells/mm3.
Criteria for Discontinuing Primary Prophylaxis
Note: Do not discontinue in children aged <1 year
  • After ≥6 months of cART, and
  • Aged 1 to <6 years: CD4 percentage is ≥15% for >3 consecutive months
  • Aged ≥6 years: CD4 count >200 cells/mm3 for >3 consecutive months
Criteria for Restarting Primary Prophylaxis
  • Aged 1 to <6 years with CD4 percentage <15%
  • Aged ≥6 years with CD4 count <100 to 200 cells/mm3
November 6, 2013
Varicella-Zoster Virus (VZV)

Pre-exposure Prophylaxis
Varicella vaccine N/A See Figure 1 for detailed vaccine recommendations. December 9, 2019
Varicella-Zoster Virus (VZV)

Primary (Post-exposure) Prophylaxis
VariZIG 125 IU/10 kg body weight (maximum 625 IU) IM, administered ideally within 96 hours (potentially beneficial up to 10 days) after exposure If VariZIG is not available, IVIG 400 mg/kg body weight, administered once should be considered. IVIG should ideally be administered within 96 hours of exposure.

When passive immunization is not possible, some experts recommend prophylaxis with acyclovir 20 mg/kg body weight/dose (maximum dose acyclovir 800 mg) by mouth, administered four times a day for 7 days, beginning 7–10 days after exposure

Primary Post-exposure Prophylaxis Indicated for—

  • Patients with substantial exposure to varicella or zoster who have no verified history of varicella or zoster, or who are seronegative for VZV on a sensitive, specific antibody assay, or who lack evidence of vaccination.
  • Many experts limit the recommendation for passive immunization to varicella- or zoster-exposed children with HIV considered severely immunocompromised, (i.e., in CDC Immunologic Category 3), especially if severely symptomatic (i.e., CDC Clinical Category Ca) and experiencing a high HIV RNA plasma viral load.
  • Some experts start acyclovir at first appearance of rash in children with HIV, rather than providing acyclovir as prophylaxis.
Note: VariZIG is commercially available in the United States from a broad network of specialty distributers.

a Centers for Disease Control and Prevention. Revised classification system for human immunodeficiency virus infection in children aged <13 years. Official authorized addenda: human immunodeficiency virus infection codes and official guidelines for coding and reporting ICD-9-CM. MMWR Morb Mortal Wkly Rep. 1994;43:1-19. Available at https://www.cdc.gov/mmwr/PDF/rr/rr4312.pdf
December 9, 2019
Key to Acronyms: ART = antiretroviral therapy; BSA = body surface area; cART = combination antiretroviral therapy; CD4 = CD4 T lymphocyte; CDC = Centers for Disease Control and Prevention; CMV = cytomegalovirus; CrCl = creatinine clearance; FDA = Food and Drug Administration; HBV = hepatitis B virus; HCV = hepatitis C virus; HPV = human papillomavirus; HSV = herpes simplex virus; IgG = immunoglobulin G; IGRA = interferon-gamma release assay; IVIG = intravenous immunoglobulin; LTBI = latent TB infection; MDR-TB = multidrug-resistant TB; QID = four times a day; TB = tuberculosis; TMP-SMX = trimethoprim-sulfamethoxazole; TST = tuberculin skin test; VZV = varicella-zoster virus

 

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