Tables
Table 3. Indications for Discontinuing and Restarting Opportunistic Infection Secondary Prophylaxis or Chronic Maintenance in Adults and Adolescents with HIV
Opportunistic Infection | Indication for Discontinuing Primary Prophylaxis | Indication for Restarting Primary Prophylaxis | Indication for Discontinuing Secondary Prophylaxis/Chronic Maintenance Therapy | Indication for Restarting Secondary Prophylaxis/Chronic Maintenance |
---|---|---|---|---|
Bacterial Enteric Infections: Salmonellosis | Not applicable | Not applicable | Resolution of Salmonella infection and after response to ART with sustained viral suppression and CD4 counts >200 cells/mm3 (CII) | No recommendation |
Bartonellosis | Not applicable | Not applicable |
Some specialists would only discontinue therapy if Bartonella titers have also decreased by four-fold (CIII). | No recommendation |
Candidiasis (Mucocutaneous) | Not applicable | Not applicable | If used, reasonable to discontinue when CD4 count >200 cells/mm3 (AIII). | No recommendation |
Coccidioidomycosis | CD4 count ≥250 cells/mm3 with virologic suppression on ART (BIII) | No recommendation | Focal Coccidioidal Pneumonia (AII)
Diffuse Pulmonary or Disseminated Non-Meningeal Disease (BIII)
Coccidioidal Meningitis (AII)
| No recommendation |
Cryptococcal Meningitis | Not applicable | Not applicable | If the following criteria are fulfilled (BII):
| CD4 count <100 cells/mm3 (AIII) |
Cytomegalovirus Retinitis | Not applicable | Not applicable |
| CD4 count <100 cells/mm3 (AIII) |
Histoplasma capsulatum Infection | On ART with CD4 count ≥150 cells/mm3 for 6 months and with viral suppression on ART (BIII) | For patients at high risk of acquiring histoplasmosis (as noted in Table 1), restart if CD4 count decreases to <150 cells/mm3 (BIII). | If the following criteria (AI) are fulfilled:
| CD4 count <150 cells/mm3 (BIII) |
Isospora belli Infection | Not applicable | Not applicable | Sustained increase in CD4 count to >200 cells/mm3 for >6 months in response to ART and without evidence of I. belli infection (BIII) | No recommendation |
Leishmaniasis: Visceral (and possibly cutaneous leishmaniasis in immunocompromised patients with multiple relapses) | Not applicable | Not applicable | If CD4 count increases to >350 cells/mm3 and HIV viral load is suppressed for 6 months in response to ART and there is no evidence of clinical relapse of visceral leishmaniasis (CIII) | No recommendation |
Microsporidiosis | Not applicable | Not applicable | If there are no signs or symptoms of non-ocular (BIII) or ocular (CIII) microsporidiosis and CD4 count is >200 cells/mm3 for >6 months in response to ART. | No recommendation |
Mycobacterium avium Complex Disease | Continuing a fully suppressive ART regimen (AI) | CD4 count <50 cells/mm3 and not on fully suppressive ART (AIII) | If the following criteria are fulfilled (AI):
| If a fully suppressive ART regimen is not possible and CD4 count is consistently <100 cells/mm 3 (BIII) |
Pneumocystis Pneumonia | CD4 count increased from <200 to ≥200 cells/mm3 for ≥3 months in response to ART (AI). Can consider when CD4 count is 100–200 cells/mm3 if HIV RNA remains below limits of detection for ≥3 to 6 months (BII). | CD4 count <100 cells/mm3 regardless of HIV RNA level (AIII) CD4 count 100–200 cells/mm3 and HIV RNA above detection limit of the assay (AIII) | CD4 count increased from <200 cells/mm3 to ≥200 cells/mm3 for ≥3 months in response to ART (AII). Can consider when CD4 count is 100–200 cells/mm3 if HIV RNA remains below limits of detection for 3–6 months (BII). If PCP occurs at a CD4 count >200 cells/mm3 while on ART, continue PCP prophylaxis for life, regardless of how high the CD4 cell count rises as a consequence of ART (BIII). If PCP occurs at a CD4 count >200 cells/mm3 while not on ART, discontinuation of prophylaxis can be considered when HIV RNA levels are suppressed to below limits of detection for ≥3 to 6 months (CIII). | CD4 count <100 cells/mm3 regardless of HIV RNA level (AIII) CD4 count 100–200 cells/mm3 and with HIV RNA above detection limit of the assay (AIII) |
Talaromycosis (Penicilliosis) | CD4 count >100 cells/mm3 for >6 months in response to ART (BII) or If achieved sustained HIV viral suppression for >6 months (BIII) | CD4 count <100 cells/mm3 (BIII)—if patient is unable to have ART, or has treatment failure without access to effective ART options, and still resides in or travels to the endemic area | CD4 count >100 cells/mm3 for ≥6 months in response to ART (BII) or If achieved sustained HIV viral suppression for >6 months (BIII) | CD4 count <100 cells/mm3 (BIII) |
Toxoplasma gondii Encephalitis | CD4 count increased to >200 cells/mm3 for >3 months and sustained HIV RNA below limits of detection in response to ART (AI) Can consider when CD4 count is 100–200 cells/mm3 if HIV RNA remains below limits of detection for at least 3–6 months (BII) | CD4 count <100 cells/mm3 (AIII) CD4 count 100–200 cells/mm3 and with HIV RNA above detection limit of the assay (AIII) | If the following criteria are fulfilled (BI):
| CD4 count <200 cells/mm3 (AIII) |
For information regarding the evidence ratings, refer to the Rating System for Prevention and Treatment Recommendations in the Introduction section of the Adult and Adolescent Antiretroviral Guidelines. Key: ART = antiretroviral therapy; CD4 = CD4 T lymphocyte; CMV = cytomegalovirus; MAC = Mycobacterium avium complex; PCP = Pneumocystis pneumonia; TE = Toxoplasma encephalitis |
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