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 installation and discontinuation in these situations have to be taken individually

  Drug / Dose Comments
Positive or negative serology for

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* 
Negative serology for toxoplasmosis pentamidine
300 mg in 6 mL sterile water x 1
Does not prevent the rare extrapulmonary
manifestations of P. jirovecii
Negative serology for toxoplasmosis dapsone
100 mg qd po
Check for G6PD-deficiency
Negative serology for toxoplasmosis atovaquone suspension
1500 mg qd (with food)
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
Positive serology for toxoplasmosis atovaquone suspension
1500 mg qd po (with food)
+/- pyrimethamine 
75 mg/week po
+ folinic acid
25-30 mg/week po
Positive cryptococcal serum antigen
and CD4 count < 100 cells/μL

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
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
500 mg bid po
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