BC Centre in HIV/AIDS Primary Care Guidelines

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2.4 Primary Prophylaxis of Opportunistic Infection in Advanced HIV

PathogenIndicationFirst choiceAlternativeCriteria for discontinuing primary prophylaxisCriteria for restarting primary prophylaxis
PCP (Pneumocystis pneumonia)
  • CD4 <200 cells/mm³
  • thrush
  • CD4 <14% or history of AIDS-defining illness
  • CD4 >200 but <250 cells/mm³ if monitoring CD4 every 1–3 months is not possible
  • TMP-SMX, 1 DS PO daily or
  • TMP-SMX, 1 SS PO daily

Screen for G6PD deficiency in patients with a racial or ethnic predisposition to prevent hemolysis with TMP-SMX or dapsone.

  • TMP-SMX 1 DS PO 3 times a week
  • Dapsone 100 mg PO daily or 50 mg PO bid
  • Dapsone 50 mg PO daily + (pyrimethamine 50 mg + leucovorin 25 mg) PO weekly
  • Atovaquone 1500 mg PO daily
  • Aerosolized pentamidine 300 mg via Respigard 11™ nebulizer every month

Screen for G6PD deficiency in patients with a racial or ethnic predisposition to prevent hemolysis with TMP-SMX or dapsone.

  • CD4 >200 cells/mm³ for >3 months in response to ARV therapy
  • CD4 100–200 cells/mm³ for >3 months in response to ARV therapy, and pVL <40 copies/mL
  • CD4 <200 cells/mm³ if pVL >40 copies/mL
  • CD4 <100 cells/mm³ if pVL <40 copies/mL
  • if PCP recurred at CD4 >200 cells/mm³
Toxoplasma encephalitis
  • Toxoplasma IgG+ patients with CD4 <100 cells/mm³
  • Toxoplasma IgG patients receiving PCP prophylaxis not active against toxoplasmosis should have Toxoplasma IgG repeated if CD4 declines to <100 cells/mm³.
  • Prophylaxis should be initiated if seroconversion occurred
  • TMP-SMX, 1 DS PO daily

Screen for G6PD deficiency in patients with a racial or ethnic predisposition to prevent hemolysis with TMP-SMX or dapsone.

  • TMP-SMX 1 DS PO 3 times a week
  • TMP-SMX 1 SS PO daily
  • Dapsone 50 mg PO daily + pyrimethamine 50 mg PO weekly + leucovorin 25 mg PO weekly

Screen for G6PD deficiency in patients with a racial or ethnic predisposition to prevent hemolysis with TMP-SMX or dapsone.

  • CD4 >200 cells/mm³ for >3 months in response to ARV therapy
  • CD4 <100–200 cells/mm³
Tuberculosis
  • + diagnostic test for LTBI, no evidence of active TB, and no prior history of treatment for active or latent TB
  • diagnostic test for LTBI, but close contact with a person with infectious pulmonary TB and no evidence of active TB
  • A history of untreated or inadequately treated healed TB (i.e. old fibrotic lesions) regardless of diagnostic tests for LTBI and no evidence of active TB
  • See also: 1.4 Co-Infection Screening
  • INH 300 mg PO daily + pyridoxine 50 mg PO daily
  • INH 900 mg PO twice a week for 9 months + pyridoxine 50 mg PO daily
  • for persons exposed to drug-resistant TB, selection of drugs after consultation with public health authorities
  • Rifampin 600 mg PO daily × 4 months
  • Rifabutin (dose adjusted based on concomitant ARVs — see Drug Interactions Table) × 4 months
Not applicable Not applicable
MAC
  • CD4 <50 cells/mm³ after ruling out active MAC infection

For asymptomatic patients, MAC prophylaxis can be started after drawing a mycobacterial blood culture. Symptomatic patients should wait for the results of blood culture before starting MAC prophylaxis.

  • Azithromycin 1200 mg PO once weekly
  • Clarithromycin 500 mg PO bid
  • Azithromycin 600 mg PO twice weekly
  • Rifabutin 300 mg PO daily (dosage adjustment based on drug–drug interactions with ARV therapy — see Drug Interactions Table)
  • rule out active TB before starting rifabutin
  • CD4 >100 cells/mm³ for ≥3 months in response to ARV therapy
  • CD4 <50 cells/mm³

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