From the Guidelines
For patients with HIV-associated neurotoxoplasmosis, initiation of antiretroviral therapy (ART) is recommended as soon as possible after diagnosis, ideally within 7 days, if the individual is ready and there is no suspicion for a concomitant opportunistic infection that would require a delay in ART initiation. However, in the context of HIV-associated neurotoxoplasmosis, the approach may need to be tailored to balance the treatment of the opportunistic infection and the initiation of ART. According to the 2024 recommendations of the international antiviral society-USA panel 1, the general guideline is to start ART as soon as possible, but the presence of an opportunistic infection like neurotoxoplasmosis may necessitate a careful consideration of the timing. Key considerations include:
- The treatment of neurotoxoplasmosis typically involves a regimen of pyrimethamine, sulfadiazine, and leucovorin for at least 6 weeks.
- The introduction of ART should be done cautiously to minimize the risk of immune reconstitution inflammatory syndrome (IRIS).
- Close monitoring for drug interactions between antiretrovirals and toxoplasmosis medications is crucial.
- The choice of ART regimen, such as two nucleoside reverse transcriptase inhibitors (NRTIs) plus an integrase strand transfer inhibitor (INSTI), should be made with consideration of potential drug interactions and the patient's overall clinical status. Given the most recent and highest quality evidence from the international antiviral society-USA panel 1, the initiation of ART in patients with HIV-associated neurotoxoplasmosis should be guided by the principle of starting as soon as possible while managing the opportunistic infection, with careful consideration of the potential risks and benefits.
From the Research
EACS HIV Neurotoxoplasmosis and Initiation of ART
- The European AIDS Clinical Society (EACS) guidelines recommend initiating antiretroviral therapy (ART) in patients with HIV-associated neurotoxoplasmosis as soon as possible, ideally within 2 weeks after starting antitoxoplasma therapy 2.
- Early initiation of ART is crucial in reducing the risk of immune reconstitution inflammatory syndrome (IRIS), a condition that can occur in HIV-infected patients after starting ART 3, 4, 5.
- The risk of IRIS is higher in patients with low CD4 counts and preexisting opportunistic infections, such as cerebral toxoplasmosis 3, 5.
- The management of IRIS involves pathogen-specific therapy, anti-inflammatory therapies, and other novel approaches, but discontinuation of ART is not generally recommended 6, 5.
- The initiation of ART can be performed within 2 weeks after initiation of antitoxoplasma therapy, and pyrimethamine-based regimens and trimethoprim-sulfamethoxazole (TMP-SMX) seem to present similar efficacy in treating cerebral toxoplasmosis 2.
Key Considerations
- The immune reconstitution inflammatory syndrome is uncommon in cerebral toxoplasmosis, and the initiation of combined antiretroviral therapy (cART) can be performed within 2 weeks after initiation of antitoxoplasma therapy 2.
- The overall incidence of IRIS is unknown, but it is dependent on the population studied and the burden of underlying opportunistic infections 3.
- Biomarkers, including interferon-γ (INF-γ), tumour necrosis factor-α (TNF-α), C-reactive protein (CRP), and inter leukin (IL)-2,6, and 7, are being investigated to better understand the pathophysiology of IRIS 3.