1999 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus

In 1995, the US Public Health Service (USPHS) and the Infectious Diseases Society of America (IDSA) developed guidelines for preventing opportunistic infections (OIs) in persons infected with human immunodeficiency virus (HIV) [1–3]. These guidelines, written for health-care providers and patients, were revised in 1997 and published in Morbidity and Mortality Weekly Report [4, Clinical Infectious Diseases [5], Annals of Internal Medicine [6], American Family Physician [7], and Pediatrics [8]; an accompanying editorial appeared in Journal of the American Medical Association [9]. Response to these guidelines (e.g., the many requests for reprints and observations from health-care providers) suggests they have served as a valuable reference for HIV care providers. Because the 1995 and 1997 guidelines included ratings that indicated the strength of each recommendation and the quality of supporting evidence, readers were able to assess the relative importance of each recommendation. Since AIDS was first recognized ∼20 years ago, remarkable progress has been made in improving the quality and duration of life of HIV-infected persons. During the first decade of the epidemic, this improvement occurred because of better recognition of opportunistic disease processes; better therapy for acute and chronic complications; and the introduction of chemoprophylaxis against Pneumocystis carinii pneumonia (PCP), toxoplasmosis, Mycobacterium avium complex disease, and bacterial infections. Trimethoprim-sulfamethoxazole was shown to reduce the incidence not only of PCP but also of toxoplasmosis and bacterial infections. The second decade of the epidemic has witnessed extraordinary progress in developing highly active antiretroviral therapies (HAART), as well as continuing progress in preventing and treating individual OIs. HAART has reduced the incidence of OIs and extended life substantially [10]. HAART is the most effective approach to preventing OIs and should be considered for all HIV-infected persons who qualify for such therapy. However, some patients are not ready or able to take HAART, and others have tried HAART regimens, but therapy has failed. Such patients will benefit from prophylaxis against OIs. In addition, prophylaxis against specific OIs continues to provide survival benefits, even among persons who are receiving HAART [11. Because important new data concerning the prevention of opportunistic diseases have emerged since 1997, the USPHS and the IDSA reconvened the Prevention of Opportunistic Infections Working Group on 4–5 March 1999, to determine which recommendations warranted revision. Participants included representatives from federal agencies, universities, and professional societies, as well as community health-care providers and patient advocates. Much attention was focused on recent data related to the advisability of discontinuing OI prophylaxis (primary prophylaxis and prophylaxis against recurrence) among persons whose CD4+ T lymphocyte counts have increased to above prophylaxis thresholds because of HAART. The OI Working Group also addressed 2 pathogens not previously considered—human herpesvirus type 8 and hepatitis C virus. In addition, working group members reviewed data concerning the prevention of all common HIV-associated OIs. In revising these current guidelines, as in earlier editions of the guidelines, the group considered factors such as incidence of disease; severity of disease in terms of morbidity and mortality; level of immunosuppression at which disease is most likely to occur; feasibility, efficacy, and cost of preventive measures; impact of intervention on quality of life; and drug toxicities, drug interactions, and the potential for drug resistance to develop. During the development of these revised guidelines, working group members reviewed published manuscripts, as well as abstracts and material presented at professional meetings, if complete manuscripts providing data were available for review. A review of the data that served as the basis for the revisions and additional information discussed at the meeting but not deemed sufficient to justify a revision of the recommendations will be published separately in Clinical Infectious Diseases. Primary changes in the disease-specific recommendations include the following: The addition of statements concerning discontinuation of prophylaxis against specific OIs when the CD4+ T lymphocyte count increases in response to HAART. New recommendations regarding human herpesvirus type 8 and hepatitis C virus. New recommendations concerning injection drug users. New recommendations about short-course chemoprophylaxis against tuberculosis in HIV-infected persons with positive tuberculin skin tests. Changes in secondary prophylaxis (chronic to the of Mycobacterium avium complex and against concerning the of and among HIV-infected These guidelines developed the OI Working Group were made available for in the and The is the USPHS and as well as the Infectious Diseases Society of and and the for Infectious Diseases. each of the diseases in this specific recommendations are that prevention of to the opportunistic prevention of the first of disease, and prevention of disease are a revised of the IDSA and In this the the strength of the recommendation for or against a preventive and the quality of supporting the recommendation. for HIV-infected from the for for the on the American of and the American of Family also to to HIV-infected whose HIV has not been a is not to be the for the for of are available and be of all of the is should the for are the the of for the for at years of hepatitis should be to not previously to should of or of The second should be the first to should of hepatitis of and of or of at a The second is at of and the at of to whose is should of or of of The second of is at of and the at of should be at the of to determine the if is the should as as of The and of should be the and who have not been against hepatitis in the who have not previously of hepatitis should or complete the the to The second should be at the first and the should be at the first and at 2 the second and and is the for all in the of the in who have of The of be as as of have since the and if the is considered to at of and for is at years of if at years have since the of or are type are for in is at 2 and of a at of is not the has been be as a is the only for HIV-infected persons an the of is at of the of been to be as as of should not be to HIV-infected persons of should be to HIV-infected immunosuppression should first of as as first should be to the second of as as a of the first virus should be to all HIV-infected of each years who are receiving virus for the first should 2 of virus at In a of virus for persons years of who or virus for persons years of should be each The of for is the for years is should be to HIV-infected at of should be to HIV-infected years earlier or years earlier virus is as a and years of a second should be The should be only to to the strength of recommendations for prevention of opportunistic infections in persons infected with a of that are as for prophylaxis to first of opportunistic disease in HIV-infected and for prophylaxis to of opportunistic disease in HIV-infected and of on to OIs of on to OIs of OI on to HIV-infected persons of to HIV of for prevention of OIs for persons with of for the prevention of OIs in with HIV for HIV-infected for HIV-infected for prophylaxis to first of opportunistic disease in HIV-infected and for prophylaxis to of opportunistic disease in HIV-infected and and for discontinuing and OI prophylaxis for patients with HIV for patients to to opportunistic pathogens in the at the of this to 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and of data that of bacterial HIV and in a of HIV-infected persons. 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