Primary Prophylaxis of OIs

According to Stage of Immunodeficiency

CD4 count threshold / indication

CD4 count < 200 cells/µL, CD4 percentage < 14%, recurrent oral thrush, or relevant concomitant immunosuppression*
*Prophylaxis against Pneumocystis* jirovecii Pneumonia (PcP) & Toxoplasma gondii infection Stop*: if CD4 count > 100 cells/µL and HIV-VL undetectable over 3 months e.g. use of corticosteroids > 20 mg prednisone equivalent per day for > 2 weeks, cancer chemotherapy, biological agents such as rituximab and others. Decisions on initiation and discontinuation in these situations have to be taken individually
Preferred regimen	Drug / Dose	Comments
Positive or negative serology for toxoplasmosis	trimethoprim sulfamethoxazole (TMP-SMX) 80/400 mg qd po or 160/800 mg qd po or 160/800 mg x 3/week po	In case of non-severe TMP-SMX allergy and if other therapeutic options are not available/not clinically appropriated, desensitization can be attempted**
Alternative regimens	Drug / Dose	Comments
Negative serology for toxoplasmosis	dapsone 100 mg qd po	Check for G6PD-deficiency
	atovaquone suspension 1500 mg qd (with food)
	pentamidine 300 mg in 6 mL sterile water x 1 inhalation/month	Does not prevent the rare extrapulmonary manifestations of P. jirovecii
Positive serology for toxoplasmosis	dapsone 200 mg/week po + pyrimethamine 75 mg/week po + folinic acid 25-30 mg/week po	Check for G6PD-deficiency
	atovaquone suspension 1500 mg qd po (with food) +/- pyrimethamine 75 mg/week po +/- folinic acid 25-30 mg/week po
CD4 count < 100 cells/µL
Pre-emptive therapy against cryptococcal disease in individuals with: positive cryptococcal serum antigen AND CD4 count <100/µL AND No evidence of cryptococcal meningitis or other manifestations of cryptococcal disease after thorough investigation
Preferred regimen	Dose	Comments
Fluconazole	800 mg qd po for 2 weeks followed by 400 mg qd po for 8 weeks	Asymptomatic individual and cryptococcal meningitis, pulmonary or other site infection ruled out. See also Cryptococcal meningitis
CD4 count < 50 cells/µL
Prophylaxis against Non-Tuberculous Mycobacteria (NTM) (M. avium complex, M. genavense, M. kansasii) Prophylaxis is not recommended if ART is started Prophylaxis may be considered for persons with CD4 counts < 50 cells/µL who remain viremic on ART (drug resistant HIV with no option to achieve virologic control); exclude disseminated MAC disease before starting
Regimens listed are alternatives	azithromycin 1200-1250 mg/week po	Check for interactions with ARVs, see Anti-infective and ART interactions table
Regimens listed are alternatives	or clarithromycin 500 mg bid po
	or rifabutin 300 mg qd po	Check for interactions with ARVs, see Anti-infective and ART interactions table Active TB should be ruled out before starting rifabutin

** for protocols see: J. Allerg. Clin. Immunol 1994; 93:1001-1005; J Infect Dis 2001 Oct 15;184(8):992-7