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 (Septra SS or DS)
< 150	Dimorphic fungi	Start histoplasmosis prophylaxis if high risk (occupation or hyperendemic) (itra)
<100	Toxoplasmosis Cryptococcus	Start toxo prophylaxis if IgG positive (Septra DS)
<50	Mycobacterium avium complex Cytomegalovirus, including retinitis Progressive multifocal leukoencephalopathy (PML) from JC virus	Start MAC prophylaxis (azithromycin)

Prophylaxis regimens

• Pneumocystis jirovecii (CD4 <200)
  • Preferred: TMP-SMX 1 DS or SS PO daily
  • Alternate
    • 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)
  • Preferred: TMP-SMX 1 DS PO daily
  • Alternate
    • 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)
  • Preferred: Azithromycin 1200 mg PO once weekly
  • Alternate
    • Clarithromycin 500 mg PO BID
    • Azithromycin 600 mg PO twice weekly
    • Rifabutin, dose-adjusted to HIV meds
• Histoplasma capsulatum (CD4 <150 and high risk)
  • "High risk" includes occupational exposure or residence in a community with a hyperendemic rate of histoplasmosis (>10 cases/100 patient-years)
  • Preferred: Itraconazole 200 mg PO once daily

Further Reading

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