Prepared by Henry Masur, MD; Jonathan E. Kaplan, MD; King K. Holmes, MD, PhD
The material in this report was prepared for publication by the National Center for HIV, STD, and TB Prevention, Harold W. Jaffe, MD, Acting Director, the Division of HIV/AIDS Prevention—Surveillance and Epidemiology, Robert S. Janssen, MD, Director; and the National Center for Infectious Diseases, James M. Hughes, MD, Director.
This document was originally published in MMWR on 14 June 2002 (RR81).
Masur PBH, Kaplan JE, Holmes KK. Guidelines for Preventing Opportunistic Infections among HIV-Infected Persons—2002: Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America*. Ann Intern Med. 2002;137:435-478. doi: 10.7326/0003-4819-137-5_Part_2-200209031-00002
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Published: Ann Intern Med. 2002;137(5_Part_2):435-478.
In 1995, the U.S. Public Health Service (USPHS) and the Infectious Diseases Society of America (IDSA) developed guidelines for preventing opportunistic infections (OIs) among persons infected with human immunodeficiency virus (HIV); these guidelines were updated in 1997 and 1999. This fourth edition of the guidelines, made available on the Internet in 2001, is intended for clinicians and other health-care providers who care for HIV-infected persons. The goal of these guidelines is to provide evidence-based guidelines for preventing OIs among HIV-infected adults and adolescents, including pregnant women, and HIV-exposed or infected children. Nineteen OIs, or groups of OIs, are addressed, and recommendations are included for preventing exposure to opportunistic pathogens, preventing first episodes of disease by chemoprophylaxis or vaccination (primary prophylaxis), and preventing disease recurrence [secondary prophylaxis]. Major changes since the last edition of the guidelines include 1) updated recommendations for discontinuing primary and secondary OI prophylaxis among persons whose CD4+ T lymphocyte counts have increased in response to antiretroviral therapy; 2) emphasis on screening all HIV-infected persons for infection with hepatitis C virus; 3) new information regarding transmission of human herpesvirus 8 infection; 4) new information regarding drug interactions, chiefly related to rifamycins and antiretroviral drugs; and 5) revised recommendations for immunizing HIV-infected adults and adolescents and HIV-exposed or infected children.
Table. System Used to Rate the Strength of Recommendations and Quality of Supporting Evidence
Higher level ratings have been provided for discontinuing primary prophylaxis for PCP and Mycobacterium avium complex (MAC) when CD4+ T lymphocytes have increased to >200 cells/µL and >100 cells/µL, respectively, for ≥ 3 months in response to HAART (AI), and a new recommendation to discontinue primary toxoplasmosis prophylaxis has been provided when the CD4+ T lymphocyte count has increased to >200 cells/µL for ≥ 3 months (AI).
Secondary PCP prophylaxis should be discontinued among patients whose CD4+ T lymphocyte counts have increased to >200 cells/µL for ≥ 3 months as a consequence of HAART (BII).
Secondary prophylaxis for disseminated MAC can be discontinued among patients with a sustained (e.g., ≥ 6-month) increase in CD4+ count to >100 cells/µL in response to HAART, if they have completed 12 months of MAC therapy and have no symptoms or signs attributable to MAC (CIII).
Secondary prophylaxis for toxoplasmosis and cryptococcosis can be discontinued among patients with a sustained increase in CD4+ counts (e.g. ≥ 6 months) to >200 cells/µL and >100–200 cells/µL, respectively, in response to HAART, if they have completed their initial therapy and have no symptoms or signs attributable to these pathogens (CIII).
The importance of screening all HIV-infected persons for hepatitis C virus (HCV) is emphasized (BIII).
Additional information concerning transmission of human herpesvirus 8 infection (HHV-8) is provided.
New information regarding drug interactions is provided, chiefly related to rifamycins and antiretroviral drugs.
Revised recommendations for vaccinating HIV-infected adults and HIV-exposed or infected children are provided.
Table 1. Prophylaxis to Prevent First Episode of Opportunistic Disease among Adults and Adolescents Infected with Human Immunodeficiency Virus (HIV)
Table 2. Prophylaxis to Prevent Recurrence of Opportunistic Disease, after Chemotherapy for Acute Disease, among Adults and Adolescents Infected with Human Immunodeficiency Virus (HIV)
Table 3. Effects of Food on Drugs Used to Prevent Opportunistic Infections
Table 4. Effects of Medications on Drugs Used to Prevent Opportunistic Infections
Table 5. Effects of Opportunistic Infection Medications on Antiretroviral Drugs Commonly Administered to Persons Infected with Human Immunodeficiency Virus (HIV)
Table 6. Adverse Effects of Drugs Used in Preventing Opportunistic Infections
Table 7. Dosing of Drugs for Primary Prevention of or Maintenance Therapy for Opportunistic Infections Related to Renal Insufficiency
Table 8. Wholesale Acquisition Costs of Agents Recommended for Preventing Opportunistic Infections among Adults Infected with Human Immunodeficiency Virus
Table 9. Immunologic Categories for Human Immunodeficiency Virus-Infected Children, Based on Age-Specific CD4+ T Lymphocyte Counts and Percentage of Total Lymphocytes
Table 10. Recommended Immunization Schedule for Human Immunodeficiency Virus (HIV)-Infected Children
Table 11. Prophylaxis to Prevent First Episode of Opportunistic Disease among Infants and Children Infected with Human Immunodeficiency Virus
Table 12. Prophylaxis to Prevent Recurrence of Opportunistic Disease, after Chemotherapy for Acute Disease, among HIV-Infected Infants and Children
Table 13. Criteria for Starting, Discontinuing, and Restarting Opportunistic Infection Prophylaxis for Adults with Human Immunodeficiency Virus Infection
aerosolized pentamidine administered by other nebulization devices,
intermittently administered parenteral pentamidine,
oral pyrimethamine plus sulfadoxine,
oral clindamycin plus primaquine, and
children aged ≥ 6 years, <50 cells/µL;
children aged 2–6 years, <75 cells/µL;
children aged 1–2 years, <500 cells/µL; and
children aged <12 months, <750 cells/µL (AII).
stop using injection drugs (AIII); and
enter and complete a substance-abuse treatment program, including a relapse prevention program (AIII).
never reuse or share syringes, needles, rinse water, or drug-preparation equipment; if, nonetheless, injection equipment that has been used by other persons is shared, the equipment should be cleaned before reuse with bleach and water as is recommended for HIV prevention;
use only sterile syringes obtained from a reliable source (e.g., pharmacies or syringe-exchange programs);
use sterile (e.g., boiled) water to prepare drugs, and if this is not possible, to use clean water from a reliable source (e.g., fresh tap water);
use a new or disinfected container (i.e., cooker) and a new filter (i.e., cotton) to prepare drugs;
clean the injection site with a new alcohol swab before injection; and
safely dispose of syringes after one use.
never reuse or share syringes, needles, water, or drug preparation equipment; if, nonetheless, injection equipment that has been used by other persons is shared, they should first clean the equipment with bleach and water (A-1);
use sterile (e.g., boiled) water to prepare drugs, and if this is not feasible, to use clean water from a reliable source (e.g., fresh tap water); to use a new or disinfected container (i.e., cooker) and a new filter (i.e., cotton) to prepare drugs;
clean the injection site with a new alcohol swab before injection;
avoid soft cheeses (e.g., feta, Brie, Camembert, blue-veined, and Mexican queso fresco cheese). Hard cheeses, processed cheeses, cream cheese, including slices and spreads, cottage cheese, or yogurt need not be avoided;
cook leftover foods or ready-to-eat foods (e.g., hot dogs) until steaming hot before eating;
avoid foods from delicatessen counters (e.g., prepared salads, meats, cheeses) or heat/reheat these foods until steaming before eating;
avoid refrigerated pâtés and other meat spreads, or heat/reheat these foods until steaming if eaten; canned or shelf-stable pâté and meat spreads need not be avoided;
avoid raw or unpasteurized milk, including goat's milk, or milk products, or foods that contain unpasteurized milk or milk products (CIII).
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