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
IndicationFirst choiceAlternativeComments/Special Issues
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
CandidiasisNot routinely recommendedN/AN/A
CoccidioidomycosisN/AN/APrimary prophylaxis not routinely indicated in children.
COVID-19COVID-19 vaccines and updated vaccines

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.
CryptococcosisNot recommendedNot recommendedN/A
CryptosporidiosisARV therapy to avoid advanced immune deficiencyN/AN/A
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%
GiardiasisART to avoid advanced immunodeficiencyN/AN/A
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
Hepatitis C Virus (HCV)NoneN/AN/A
Herpes Simplex Virus Infections (HSV)N/AN/APrimary prophylaxis not indicated
HistoplasmosisN/AN/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
Human Papillomavirus (HPV)HPV vaccineN/ASee Figures 1 and 2 for detailed vaccine recommendations.
Isosporiasis (Cystoisosporiasis)There are no U.S. recommendations for primary prophylaxis of isosporiasis.N/AInitiation of ART to avoid severe immunodeficiency may reduce incidence; TMP-SMX prophylaxis may reduce incidence.
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/ARecommendations 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.
MicrosporidiosisN/AN/ANot recommended
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

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.
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
SyphilisN/AN/A

Primary prophylaxis indicated for— 

  • N/A


Criteria for Discontinuing Primary Prophylaxis

  • N/A


Criteria for Restarting Primary Prophylaxis

  • N/A
ToxoplasmosisTMP-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
Varicella-Zoster Virus (VZV) 

Pre-exposure Prophylaxis
Varicella vaccineN/ASee Figure 1 for detailed vaccine recommendations.
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 exposureIf 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

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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