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Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents

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Table 4. Indications for Discontinuing and Restarting Opportunistic Infection Prophylaxis in HIV-Infected Adults and Adolescents

(Last updated:July 08, 2013; last reviewed:July 08, 2013)

 

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Table 4. Indications for Discontinuing and Restarting Opportunistic Infection Prophylaxis in HIV-Infected Adults and Adolescents
Opportunistic Infection
Indication for Discontinuing Primary Prophylaxis
Indication for Restarting Primary Prophylaxis
Indication for Discontinuing Secondary Prophylaxis/Chronic Maintenance Therapy  Indication for Restarting Secondary Prophylaxis/Chronic Maintenance 
Pneumocystis Pneumonia
CD4 count increased from <200 to >200 cells/µL for >3 months in response to ART (AI)
CD4 count <200 cells/mm3 (AIII)
CD4 count increased from <200 cells/µL to >200 cells/µL for >3 months in response to ART (BII)

If PCP was diagnosed when CD4 count was >200 cells/µL, continue prophylaxis for life regardless of CD4 count rise in response to ART (BIII).
  • CD4 count <200 cells/µL (AIII), or 
  • If PCP recurred at CD4 count >200 cells/µL, prophylaxis should be continued for life (CIII).
Toxoplasma gondii Encephalitis
CD4 count increased to >200 cells/µL for >3 months in response to ART (AI)
CD4 count <100 to 200 cells/µL (AIII)
Successfully completed initial therapy, remain free of signs and symptoms of TE, and CD4 count >200 cells/µL for >6 months in response to ART (BI).
CD4 count <200 cells/ µL (AIII)
Microsporidiosis
Not applicable
Not applicable
No signs and symptoms of non-ocular (BIII) or ocular (CIII) microsporidiosis and CD4 count >200 cells/µL for >6 months in response to ART. 
No recommendation
Disseminated Mycobacterium avium Complex Disease
CD4 count >100 cells/µL for ≥3 months in response to ART (AI)
CD4 count <50 cells/µL (AIII)
If the following criteria are fulfilled (AI):
  • Completed ≥12 months of therapy, and 
  • No signs and symptoms of MAC disease, and
  • Have sustained (>6 months) CD4 count >100 cells/µL in response to ART. 
CD4 count <100 cells/µL (AIII)
Salmonellosis
Not applicable
Not applicable
Resolution of Salmonella infection and after response to ART with sustained viral suppression and CD4 counts >200 cells/µL (CII)
No recommendation
Bartonellosis
Not applicable
Not applicable
  • Received at least 3–4 months of treatment, and
  • CD4 count >200 cells/µL for ≥6 months (CIII)
  • Some specialists would only discontinue therapy if Bartonella titers have also decreased by four-fold (CIII). 
No recommendation
Mucosal Candidiasis
Not applicable
Not applicable
If used, reasonable to discontinue when CD4 count >200 cells/µL (AIII).
No recommendation
Cryptococcal Meningitis
Not applicable
Not applicable
If the following criteria are fulfilled (BII):
  • Completed initial (induction and consolidation) therapy, and 
  • Received at least 1 year of maintenance therapy, and
  • Remain asymptomatic of cryptococcal infection, and
  • CD4 count ≥100 cells/µL for >3 months, and with suppressed plasma HIV RNA in response to ART 
CD4 count <100 cells/µL (AIII)
Histoplasma capsulatum Infection
CD4 count >150  cells/µL for 6 months while on ART (BIII)
For patients at high risk of acquiring histoplasmosis, restart at CD4 count <150 cells/µL (CIII)
If the following criteria (AI) are fulfilled:
  • Received itraconazole for >1 year, and 
  • Negative fungal blood cultures, and
  • CD4 count ≥150 cells/µL for ≥6 months in response to ART, and
  • Serum Histoplasma antigen <2 ng/mL
CD4 count <150 cells/mm3 (BIII)
Coccidioidomycosis
CD4 count ≥250 cells/µL for ≥6 months (CIII)
Restart at CD4 count <250 cells/µL (BIII)
Only for patients with focal coccidioidal pneumonia (AII):
  • Clinically responded to ≥12 months antifungal therapy, with CD4 count >250 cells/mm3, and receiving effective ART. 
  • Should continue monitoring for recurrence with serial chest radiographs and coccidioidal serology.
For patients with diffuse pulmonary (BIII), disseminated non-meningeal (BIII), or meningeal diseases (AII): 
  • Suppressive therapy should be continued indefinitely, even with increase in CD4 count on ART.
No recommendation
Cytomegalovirus Retinitis
Not applicable
Not applicable
  • CMV treatment for >3 to 6 months; and with CD4 count >100 cells/µL for >3 to 6 months in response to ART (AII)
  • Therapy should be discontinued only after consultation with an ophthalmologist, taking into account anatomic location of lesions, vision in the contralateral eye, and feasibility of regular ophthalmologic monitoring.
  • Routine (i.e., every 3 months) ophthalmologic follow-up is recommended for early detection of relapse or immune restoration uveitis, and then annually after immune reconstitution (AIII).
CD4 count <100 cells/µL (AIII)
Penicillium marneffei Infection
CD4 count >100 cells/µL for >6 months in response to ART (BII)
CD4 count <100 cells/µL (BIII)
CD4 count >100 cells/µL for ≥6 months in response to ART (BII)
  • CD4 count <100 cells/µL (AIII), or 
  • If penicilliosis recurs at CD4 count >100 cells/µL (CIII)
Visceral Leishmaniasis (and possibly cutaneous leishmaniasis in immunocompromised patients with multiple relapses)
Not applicable
Not applicable
There is no consensus regarding when to stop secondary prophylaxis. Some investigators suggest that therapy can be stopped if CD4 count increases to >200 to 350 cells/µL for 3–6 months in response to ART, but others suggest that therapy should be continued indefinitely.
No recommendation
Isospora belli Infection
Not applicable
Not applicable
Sustained increase in CD4 count to >200 cells/µL for >6 months in response to ART and without evidence of I. belli infection (BIII)
No recommendation
Key to Acronyms: ART = antiretroviral therapy; CD4 = CD4 T lymphocyte cell; CMV = cytomegalovirus; MAC = Mycobacterium avium complex; PCP = Pneumocystis pneumonia; TE = Toxoplasma encephalitis
Evidence Rating:
Strength of Recommendation: 
A: Strong recommendation for the statement
B: Moderate recommendation for the statement
C: Optional recommendation for the statement 

Quality of Evidence for the Recommendation:
I: One or more randomized trials with clinical outcomes and/or validated laboratory endpoints
II: One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes
III: Expert opinion

In cases where there are no data for the prevention or treatment of an OI based on studies conducted in HIV-infected populations, but data derived from HIV-uninfected patients exist that can plausibly guide management decisions for patients with HIV/AIDS, the data will be rated as III but will be assigned recommendations of A, B, C depending on the strength of recommendation.

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