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Content Update

April 4, 2019

New guideline recommendations regarding prophylaxis in Pneumocystis pneumonia (PCP) and Mycobacterium avium complex (MAC) disease: The U.S. Department of Health and Human Services (DHHS) Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV were updated in early 2019. Among the updates included in this guideline issue were recommendations for when to discontinue prophylaxis (both primary and secondary) for PCP and the decision to initiate primary prophylaxis for MAC. Guidelines now support the discontinuation of PCP prophylaxis (primary or secondary) in patients with an undetectable viral load and a CD4 count between 100 – 200 cells/mm3 for 3-6 months (BII rating). Additionally, the panel no longer recommends primary prophylaxis for MAC in patients able to initiate antiretroviral therapy (ART) immediately regardless of CD4 cell count (AII rating). Healthcare providers should carefully interpret updated guidelines and integrate into clinical practice.



Upon completion of the chapter, the reader will be able to:

  1. Explain the routes of transmission for human immunodeficiency virus (HIV) and its natural disease progression.

  2. Identify typical and atypical signs and symptoms of acute and chronic HIV infection.

  3. Identify the desired therapeutic outcomes for patients living with HIV.

  4. Recommend appropriate first-line pharmacotherapy interventions for patients with HIV infection.

  5. Recommend appropriate second-line pharmacotherapy interventions for patients with HIV infection.

  6. Describe the components of a monitoring plan to assess effectiveness and adverse effects of pharmacotherapy for HIV infection.

  7. Educate patients about the disease state, appropriate lifestyle modifications, and drug therapy required for effective treatment.


Human immunodeficiency virus (HIV) is the cause of acquired immunodeficiency syndrome (AIDS). HIV primarily targets CD4+ T-lymphocytes, which are critical to proper immune system function. If left untreated, patients experience a prolonged asymptomatic period followed by rapid, progressive immunodeficiency. Therefore, most complications experienced by patients with AIDS involve opportunistic infections and cancers. AIDS occurs when a patient with HIV has a CD4+ cell count below 200 cells/mm3 (200 × 106/L), a CD4+ cell percentage of total T-lymphocytes less than 14% (0.14), or one of the Centers for Disease Control and Prevention (CDC) AIDS defining conditions.1


Although the global incidence of HIV has fallen 39% since 2000, HIV prevalence has increased, largely due to life-extending antiretroviral therapy. Combination antiretroviral therapy (cART) has increased both the length and quality of life for HIV-infected patients; however, to date, there are no treatments that eradicate HIV from the body.2

As of 2016, approximately 36.7 million people are infected with HIV worldwide. Approximately 70% of these cases are in Sub-Saharan Africa, with a prevalence of approximately 4%. In 2016 alone, approximately 1 million people worldwide died from HIV-related illnesses and 1.8 million people were newly infected ...

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