Guidelines: Opportunistic infections and HIV patients
By Dean L. Winslow, MD, FACP, FIDSA, Chief, Division of AIDS Medicine, Santa Clara Valley Medical Center; Clinical Professor, Stanford University, School of Medicine
Synopsis: The U.S. Department of Health and Human Services (HHS) has updated their guidelines for the prevention and treatment of opportunistic infections (OIs) in HIV-infected adults and adolescents, effective March 24, 2009.
Source: http://www.cdc.gov/mmwr/pdf/rr/rr58e324.pdf
These guidelines were last updated for adults in 2002 and for adolescents in 2004. The document (available in pdf format through the link above) is a 209-page file containing 1,391 references which update current recommendations for the prophylaxis and treatment of HIV-related OIs. As with most guidelines published in recent years by professional societies, a well-qualified expert panel has thoroughly reviewed both new and old data and has developed a relatively comprehensive document which will be of use to physicians who treat complicated HIV patients. An attempt has been made to qualify recommendations with both the strength and quality of evidence supporting each recommendation. Obviously, it is not possible to summarize the entire document, but six major changes from previous iterations of the OI guidelines stand out in the March 24, 2009 guidelines:
Emphasis is placed on the importance of antiretrovirals for the prevention and treatment of OIs, especially for those diseases in which specific antimicrobial treatment is minimally effective.1
Guidance on the diagnosis and management of immune reconstitution/inflammatory syndrome (IRIS) complicating specific OIs is given.
Recommendations on the use of interferon gamma release assays (IGRAs) for the diagnosis of latent tuberculosis infection (LTBI) are made.2 (At this point IGRAs are considered to be more specific than tuberculin skin testing for the diagnosis of LTBI, especially in HIV patients who may have received BCG or have been exposed to other mycobacteria. However, they are no more sensitive than tuberculin skin testing, especially in HIV patients with more severe immunosuppression.)
More specific recommendations are made concerning drug/drug interactions, particularly surrounding the use of rifamycins concomitantly with antiretroviral therapy.
Detailed recommendations are made regarding the treatment of hepatitis B virus/HIV co-infected patients, including the recommendation to avoid HBV antiviral monotherapy with agents such as entecavir due to the risk of selecting M184V HIV reverse transcriptase substitutions.3
A section on the bi-directional effects of malaria and HIV co-infection has been added, which is of great significance in the developing world where both of these infections are endemic.
Lastly, it was interesting to note that these latest guidelines contain a well-reasoned discussion regarding the controversies surrounding routine screening for HPV-related anal intraepithelial neoplasia in men who have sex with men.4,5
This latest update to the OI guidelines is an important document which will be of value to all physicians who treat HIV-infected patients.
References
- Zolopa A, et al. Immediate versus deferred ART in the setting of acute AIDS-related OI: final results of a randomized strategy trial, ACTG A5164. 15th CROI;2008; Boston, MA. Abstract 142.
- Menzies D, et al. Meta-analysis: New tests for the diagnosis of latent tuberculosis infection: Areas of uncertainty and recommendations for research. Ann Intern Med. 2007;146:340-354.
- Matthews GV, Dore GJ. Combination of tenofovir and lamivudine versus tenofovir after lamivudine failure for therapy of hepatitis B in HIV-coinfection. AIDS. 2007;21:777-778.
- CDC. Workowski KA, Berman SM: Sexually transmitted diseases treatment guidelines. MMWR. 2006;55:(No. RR-11).
- Chin-Hong PV, Palefsky JM. Human papillomavirus anogenital disease in HIV-infected individuals. Dermatol Ther. 2005;18:67.
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