When is antimicrobial prophylaxis indicated for the prevention of opportunistic infections in patients with HIV infection?

Updated: Mar 09, 2021
  • Author: Justin R Hofmann, MD; Chief Editor: John Bartlett, MD  more...
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Answer

Despite increasingly widespread and targeted HIV screening, many HIV infections continue to be diagnosed late and after OI have already developed. [15]  Favorably for these patients, initiating ART in patients with CD4 counts below 350 cells/uL results in a significant decline in the risk for AIDS-related morbidity and mortality. [16, 17, 18, 19, 20, 21]  

For most patients, ART should be initiated shortly after diagnosis, regardless of CD4 count or viral load [22, 23, 24, 25] ; however, ART should be initiated within 2 weeks for patients presenting with OI. [1, 22, 23]  When compared with a deferred (median, 45 days) ART initiation strategy, an early (mean, 12 days) ART initiation strategy for patients presenting with AIDS (median CD4, 29) plus an OI was associated with less AIDS progression and death without increased adverse events or loss of virologic response. [16]  

Early ART is indicated for patients presenting with PCP, toxoplasmosis encephalitis, and pulmonary TB; however, early ART initiation is controversial in cases of a new HIV diagnosis with comorbid cryptococcal meningitis or tuberculous meningitis (TB meningitis). [26, 27, 28, 29]  A 5-week deferral of ART initiation in cases of cryptococcal meningitis was associated with improved 6-month survival (hazard ratio, 1.73 [1.06 - 2.82]). [29]  A small study in a resource-limited area of Zimbabwe found that early ART initiation (within 72 hours of diagnosis) was associated with a 3 times higher risk for mortality compared with a 10-week deferral (hazard ratio, 2.85 [1.1 - 7.23]). [28]  Patients with CD4 counts of fewer than 50 cells/μL at presentation should be considered for serum cryptococcal antigen testing, and, if diagnosed with cryptococcal meningitis, it may be prudent to delay ART for at least 2 weeks and possibly up to 10 weeks into cryptococcal therapy. [1, 26]


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