Primary Prophylaxis of OIs
CD4 count threshold / indication
CD4 count < 200 cells/µL, CD4 percentage < 14%, recurrent oral thrush, or relevant concomitant immunosuppression* | ||
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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. |
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Drug / Dose | Comments | |
Positive or negative serology for toxoplasmosis |
trimethoprim sulfamethoxazole (TMP-SMX) |
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 inhalation/month |
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) |
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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 |
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Positive cryptococcal serum antigen and CD4 count < 100 cells/μL |
fluconazole |
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 |
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Regimens listed are alternatives | azithromycin 1200-1250 mg/week po |
Check for interactions with ARVs, see Anti-infective and ART interactions table |
or clarithromycin 500 mg bid po |
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or rifabutin 300 mg qd po |
Check for interactions with ARVs, 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