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U.S. Agencies Release Updated Opportunistic Infection and Pediatric Antiretroviral Therapy Guidelines

In recent weeks, U.S. agencies have released updated version of 2 sets of guidelines for treatment of people with HIV/AIDS.

Opportunistic Infections

While the widespread use of effective combination antiretroviral therapy (ART) has dramatically reduced the incidence of opportunistic infections (OIs) among HIV positive people in industrialized countries, they remain a concern for individuals who do not receive ART in a timely manner.

In the March 24, 2009 online early release of Morbidity and Mortality Weekly Report, authors with the Opportunistic Infections Working Group published a new version of Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents.

Prepared under the auspices of the Office of AIDS Research Advisory Council of the National Institutes of Health (NIH), the guidelines reflect the recommendations of the NIH, the Centers for Disease Control and Prevention (CDC), and the HIV Medicine Association of the Infectious Diseases Society of America (IDSA).

This latest edition updates and combines earlier versions of guidelines for the prevention and treatment of OIs in HIV-infected adults (age 18 and older) and adolescents (ages 13-17), last published in 2002 and 2004, respectively.

Intended for use by clinicians and other healthcare providers, patients, and policymakers in the U.S., the guidelines address several OIs that occur in the U.S. and 5 that may be acquired during international travel.

In addition to classic AIDS-defining OIs such as Pneumocystis pneumonia and cytomegalovirus, the guidelines also include infections that regularly affect the general HIV negative population, but occur more often or cause more severe disease in HIV positive individuals, including herpes, syphilis, human papillomavirus, hepatitis B, hepatitis C, malaria, and tuberculosis.

The included OIs are:

• Pneumocystis pneumonia (PCP)
• Toxoplasma gondii encephalitis
• Cryptosporidiosis
• Microsporidiosis
• Mycobacterium tuberculosis (TB)
• Disseminated Mycobacterium avium complex
• Bacterial respiratory disease (e.g., Pseudomonas aeruginosa, Staphylococcus aureus)
• Bacterial enteric (gastrointestinal) infections (e.g, Campylobacter, Salmonella, Shigella)
• Bartonellosis
• Syphilis
• Mucocutaneous candidiasis (oropharyngeal, esophageal, vulvovaginal)
• Cryptococcosis
• Histoplasmosis
• Coccidioidomycosis
• Aspergillosis
• Cytomegalovirus disease
• Herpes simplex virus (HSV)
• Human herpesvirus 6 (HHV-6) and HHV-7
• HHV-8 (cause of Kaposi's sarcoma, lymphoproliferative disorders)
• Varicella-zoster virus (cause of chickenpox, shingles)
• Human papillomavirus (HPV) (cause of genital warts, cervical and anal cancer)
• Hepatitis B virus (HBV) infection
• Hepatitis C virus (HCV) infection
• JC virus infection and progressive multifocal leukoencephalopathy (PML)
• Malaria
• Penicilliosis marneffei
• Leishmaniasis
• Chagas disease (Trypanosoma cruzi)
• Isosporiasis

For each OI, the guidelines include information on preventing exposure, preventing disease, primary prophylaxis, discontinuing primary prophylaxis after immune reconstitution, adverse effects including immune reconstitution inflammatory syndrome (IRIS), managing treatment failure, preventing disease recurrence (secondary prophylaxis or maintenance therapy), and special considerations during pregnancy.

Major changes in the latest revision include a greater emphasis on the importance of ART for the prevention and treatment of OIs (especially those for which there is no specific therapy), more information regarding diagnosis and management IRIS, information about interferon-gamma release assays for the diagnosis of latent tuberculosis, and updated information concerning drug interactions that affect rifamycin anti-TB drugs.

The full text of the updated OI guidelines is available online.

Pediatric Treatment

On February 23, the U.S. government's AIDSinfo service announced the availability of updated Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection.

Prepared by the Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children, the new guidelines reflect the latest scientific research related to treatment of infants and children with HIV/AIDS.

Changes in the latest version -- which are summarized in the "What's New in the Document?" section at the front of the guidelines and are highlighted in yellow throughout the text and tables -- include the following:

• Addition of information on darunavir (Prezista) in "What Drugs to Start."
• Revision of section on management of treatment failure in children, entitled "Antiretroviral Treatment Failure in Infants, Children, and Adolescents."
• Addition of a detailed discussion of discordance among virological, immunological, and clinical responses.
• New table on "Assessment of Antiretroviral Treatment Failure."
• Revised sections on "Approach to the Management of Treatment Failure" and "Choice of Next Antiretroviral Regimen for Treatment Failure with Evidence of Drug Resistance."
• New section on use of antiretroviral agents that have been approved for adults but not children.
• Updated "Antiretroviral Drug Resistance Testing" section including information on tropism assays.
• Updated "Appendix B: Characteristics of Available Antiretroviral Drugs" and "Supplement I: Pediatric Antiretroviral Drug Information," adding new information about several drugs learned since the last revision.

The updated pediatric treatment guidelines are available online.

3/31/09

References

JE Kaplan, C Benson, KK Holmes, and others. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Morbidity and Mortality Weekly Report 58 (early release): 1-98. March 24, 2009

Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. February 23, 2009.