Opportunistic infections in HIV

CD4	Infections	Action
Any	Tuberculosis	Screen for latent tuberculosis Vaccinate for pneumococcus, influenza, varicella, HPV (if appropriate), hepatitis A, and hepatitis B
<500	Kaposi sarcoma (HHV-8) Herpes simplex Varicella-zoster
<300	Candida Molluscum contagiosum Diarrhea from microsporidia and cryptosporidia
<200	Pneumocystis jirovecii pneumonia	Start PJP prophylaxis (TMP-SMX SS or DS)
<150	Dimorphic fungi	Start histoplasmosis prophylaxis if high risk (occupation or hyperendemic) (itraconazole)
<100	Toxoplasmosis Cryptococcus	Start toxoplasmosis prophylaxis if IgG positive (TMP-SMX DS)
<50	Mycobacterium avium complex Cytomegalovirus, including retinitis Progressive multifocal leukoencephalopathy (PML) from JC virus	Start MAC prophylaxis (azithromycin)

Prophylaxis regimens

Infection	Preferred	Alternative
Pneumocystis jirovecii (CD4 <200 or <14%)	TMP-SMX 1 DS or SS PO daily	TMP-SMX 1 DS PO three times weekly
		Dapsone 100 mg PO daily or 50 mg PO BID
		Pentamidine nebs 300 mg every month
		Atovaquone 1500 mg PO daily
Toxoplasma gondii (CD4 <100 and IgG positive)	TMP-SMX 1 DS PO daily	TMP-SMX 1 DS PO three times weekly
		TMP-SMX 1 SS PO daily
		Dapsone 50 mg PO daily + pyrimethamine/leucovorin PO weekly
		Atovaquone 1500 mg PO daily
Mycobacterium avium complex (CD4 <50 and not on HIV therapy)	Azithromycin 1200 mg PO once weekly	Clarithromycin 500 mg PO BID
		Azithromycin 600 mg PO twice weekly
		Rifabutin, dose-adjusted to HIV meds
Histoplasma capsulatum (CD4 <150 and high risk)	Itraconazole 200 mg PO once daily
Coccidioides immitis (new IgM or IgG positivity in an endemic area and with CD4 <250)	Fluconazole 400 mg PO daily

• "High risk" for Histoplasma includes occupational exposure or residence in a community with a hyperendemic rate of histoplasmosis (>10 cases/100 patient-years)

Further Reading

• AIDSinfo Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents