What are the prophylaxis and treatment regimens for opportunistic diseases in HIV/AIDS patients in India, according to the national guidelines?

HIV Opportunistic Infections: Prophylaxis and Treatment in India

Critical Note on Available Evidence

The provided evidence does not contain specific guidelines from Indian national organizations (NACO - National AIDS Control Organization). The recommendations below are based on international guidelines (CDC, IDSA) that form the foundation for most national HIV programs, supplemented by Indian epidemiological data where available.

Primary Prophylaxis Regimens

Pneumocystis Pneumonia (PCP)

• Initiate prophylaxis when CD4 count <200 cells/μL 1
• First-line regimen: Trimethoprim-sulfamethoxazole (TMP-SMX) 800mg/160mg (double-strength) one tablet orally three times weekly 2
• Alternative: Dapsone 100 mg orally daily 2
• Continue prophylaxis until CD4 count recovers to ≥200 cells/μL for ≥3 months duration after ART initiation 2

Toxoplasmosis

• Initiate prophylaxis when CD4 count <100 cells/μL in patients with positive Toxoplasma IgG antibodies 1
• TMP-SMX double-strength three times weekly provides dual coverage for both PCP and toxoplasmosis 1
• Continue until CD4 count >200 cells/μL for ≥3 months 1

Mycobacterium avium Complex (MAC)

• Initiate prophylaxis when CD4 count <50 cells/μL 1
• Azithromycin 1200 mg orally once weekly 2
• Continue until CD4 count recovers to ≥100 cells/μL for ≥3 months duration post-ART 2

Tuberculosis Prophylaxis

• Critical for India given the dual HIV-TB epidemic burden 3
• For HIV-infected persons with positive tuberculin skin test (≥5 mm induration): Isoniazid 300 mg daily for minimum 12 months 4
• For recent converters or close TB contacts, isoniazid prophylaxis is strongly indicated regardless of age 4
• TB can occur at any CD4 level, though risk increases significantly with CD4 <300 cells/μL 1

Cryptococcosis and Other Fungal Infections

• Typically occur with CD4 counts <100 cells/μL 1
• Primary prophylaxis not routinely recommended; focus on early ART initiation 2

Treatment Considerations for Active Opportunistic Infections

Tuberculosis in HIV Co-infection

• Tuberculosis is the most common opportunistic infection in India, affecting 56-62% of AIDS cases 3
• For CD4 <50 cells/μL: Start ART within 2 weeks of TB treatment initiation to reduce mortality, accepting increased IRIS risk 5
• For CD4 ≥50 cells/μL: Initiate ART at 8-12 weeks after starting TB treatment 5
• Use rifampin-based TB regimens with careful attention to drug-drug interactions with antiretrovirals 6

Candidiasis

• Second most common opportunistic infection in India (57-61% of AIDS cases) 3
• Nystatin for mild oral/esophageal candidiasis 2
• Fluconazole for moderate-severe disease, but avoid during pregnancy 2

Cryptosporidiosis

• Significant burden in India (47% in one study) 7
• No specific antimicrobial therapy; ART is the primary treatment 2
• Emphasize safe drinking water and hygiene measures 7

Pneumocystis Pneumonia Treatment

• TMP-SMX 15-20 mg/kg/day (based on TMP component) divided three times daily for 21 days 2
• Add corticosteroids for moderate-severe disease (PaO2 <70 mmHg) 2

Immune Reconstitution Inflammatory Syndrome (IRIS)

Recognition and Risk Factors

• IRIS typically occurs within 3-6 months after ART initiation 5
• Major risk factors: CD4 <50 cells/μL at ART start, early ART initiation (<2 weeks after OI treatment), disseminated disease 5
• TB-IRIS and cryptococcal IRIS are most common in resource-limited settings 5

Management Principles

• For mild-moderate IRIS: Continue both ART and antimicrobial therapy 5
• NSAIDs (ibuprofen) for symptomatic relief 5
• For severe IRIS: Prednisone 0.5-1.0 mg/kg/day for 2-6 weeks with gradual taper 5
• Only discontinue ART if life-threatening complications develop 5

Antiretroviral Therapy as Primary Prevention

Core Principle

• HAART is the most effective approach to preventing opportunistic infections and should be considered for all HIV-infected persons 2
• ART reduces OI incidence by suppressing HIV replication and increasing CD4 counts 2
• Even with effective ART, some OI risk persists, particularly for TB, herpes zoster, and pneumococcal disease 2

Discontinuation of Prophylaxis

Safe Discontinuation Criteria

• PCP/Toxoplasmosis prophylaxis: Discontinue when CD4 >200 cells/μL for ≥3 months on ART 2
• MAC prophylaxis: Discontinue when CD4 >100 cells/μL for ≥3 months on ART 2
• Requires sustained virologic suppression and immune reconstitution 2

Special Populations

Pregnant Women

• Avoid fluconazole during pregnancy 2
• Adjust TB treatment regimens appropriately 4
• Continue essential prophylaxis with careful drug selection 4

Children

• PCP prophylaxis: TMP-SMX dosing based on weight 2
• TB prophylaxis: Isoniazid 10-15 mg/kg daily (max 300 mg) 4
• All infants and children <4 years with tuberculin skin test ≥10 mm require prophylaxis 4

Critical Pitfalls to Avoid

• Never use single-drug therapy for active tuberculosis; always use multiple agents to prevent resistance 4
• Do not delay ART in patients with CD4 <50 cells/μL and non-CNS TB 5
• Screen for and treat latent TB before initiating ART when feasible 5
• Monitor for IRIS in first 3-6 months after ART initiation, especially in patients starting with low CD4 counts 5
• Do not discontinue prophylaxis prematurely; ensure sustained CD4 recovery for specified duration 2

India-Specific Considerations

• Dual HIV-TB epidemic requires aggressive TB screening and prophylaxis 3
• Cryptosporidium burden necessitates emphasis on water safety 7
• Heterosexual transmission predominates; target prevention accordingly 7
• Lower socioeconomic populations disproportionately affected; address access barriers 7