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

• 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

Pemivibart (Pemgarda)

Aged ≥12 Years and ≥40 kg

• Pemivibart injection solution: 4,500 mg administered as a single IV infusion

COVID-19 Vaccination Indicated for—

• All children with HIV aged ≥6 months regardless of CD4 cell count or viral load
• Household members and close contacts of children with HIV aged ≥6 months

For up-to-date vaccine guidance, see CDC’s Use of COVID-19 Vaccines in the United States webpage. Children with HIV may qualify for additional doses of COVID-19 vaccines if they have stage 3 HIV infection, history of an AIDS-defining illness without immune reconstitution, clinical manifestations of symptomatic HIV, or untreated HIV infection.

Pemivibart Indicated for—

• Adults and adolescents aged ≥12 years and who weigh ≥40 kg with moderate-to-severe immunocompromise (including those with advanced or untreated HIV infection) who are unlikely to have an adequate response to COVID-19 vaccination.

• 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%

• Hepatitis B vaccine
• Combination of hepatitis B immunoglobulin and hepatitis B vaccine to infants born to mothers with hepatitis B infection

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

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

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)

• 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

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 15–‍20 mg/kg (maximum 600 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 15–‍20 mg/kg (maximum 600 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.

• 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

Primary prophylaxis indicated for— 

• N/A

Criteria for Discontinuing Primary Prophylaxis

• N/A

Criteria for Restarting Primary Prophylaxis

• N/A

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

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 C^a) 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