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Prophylaxis of Opportunistic Infections

Prophylaxis of Opportunistic Infections. HAIVN Harvard Medical School AIDS Initiative in Vietnam. Learning Objectives. By the end of this session, participants should be able to: Differentiate between primary and secondary prophylaxis

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Prophylaxis of Opportunistic Infections

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  1. Prophylaxis of Opportunistic Infections HAIVN Harvard Medical School AIDS Initiative in Vietnam

  2. Learning Objectives By the end of this session, participants should be able to: • Differentiate between primary and secondary prophylaxis • Explain the benefits and indications of cotrimoxazole prophylaxis • Describe the process of cotrimoxazole desensitization • Describe how to provide isoniazid (INH) prophylaxis

  3. Relationship Between CD4 Count and Opportunistic Infections • The lower a person’s CD4 count is, the more vulnerable he/she is to opportunistic infections (OIs) • Different infections can occur based on how weak a person’s immune system is • The level of the CD4 count determines the OIs a person is at risk for

  4. Sample OIs per CD4 Count

  5. Two Types of OI Prophylaxis Primary prophylaxis: • Giving medication to prevent an OI from occurring in the first place Secondary prophylaxis: • Giving medication after an OI is treated to prevent it from recurring • Also known as maintenance therapy

  6. Cotrimoxazole Prophylaxis (CTP)

  7. Cotrimoxazole (1) Can prevent: • PCP • Cerebral toxoplasmosis • Malaria • Parasitic diarrheas • Non-typhoid salmonelloses • Streptococcus pneumoniae pneumonia

  8. Cotrimoxazole (2) Benefits • Decreases morbidity and mortality • Inexpensive • Well tolerated • Prepares patient for daily medication taking (adherence) Concerns • Hypersensitivity (allergic) rash • Anemia The benefits greatly outweigh the risks

  9. Cotrimoxazole Allergy (1) • Clinically: • Maculopapular rash • Can have fever • Usually within first few weeks of treatment • Epidemiology • No studies in Asia • In Africa, about 2% had allergy to CTX* • Resolves when drug is stopped * Lancet. 2004 Oct 16-22;364(9443):1428-34.

  10. CotrimoxazoleAllergy (2) – How to Manage? Vietnam MOH guidelines on treatment of HIV/AIDS, 2009

  11. Cotrimoxazole Desensitization • Desensitization is a rechallengefollowing an adverse reaction starting with low doses and gradually escalating • Review patient daily or give instructions on how to respond to any reaction:

  12. When to Start CTP in Vietnam? • Indications: • CD4 ≤ 350 (any clinical stage) • WHO Stage 3 or 4 regardless of CD4 count • If CD4 testing is not available: clinical stage 2, 3, 4 • Pregnant women can use CTX for entire pregnancy • Dose: • Adult: 960 mg/day or 960mg 3x /week • Pediatric: 5 mg/kg/day

  13. When to Stop CTP in Vietnam? • No ARV: continue lifelong • With ARV: stop cotrimoxazole when CD4 > 350

  14. What Should You Do When You Cannot Use Cotrimoxazole?

  15. Dapsone • Indications: • Prophylaxis of PCP in patients with allergy or adverse reaction to cotrimoxazole • Dose: • Adults: 100 mg daily • Pediatrics: 2 mg/kg once a day • Note: not effective against other OIs • Side effects (uncommon): rash, haemolytic anemia, hepatitis

  16. TB Prophylaxis Therapy

  17. Isoniazid Preventive Therapy (IPT) • Indication: • PLHIV with negative TB screening • Dose: Isoniazid 300 mg (5 mg/kg) once daily for 9 months • Must exclude active TB

  18. Case Study: Duong • Duong, a 23-year-old man is newly diagnosed with HIV • He is clinical stage 1 • His initial CD4 count returns at 89 cells/mm3 • You perform a TB symptom screen: • He denies fever, cough, sweats, and weight loss • What OIs is he at risk for? • What prophylaxis would you start?

  19. Primary Prophylaxis for Select OIs

  20. Secondary Prophylaxis

  21. Secondary Prophylaxis of OIs (1) • Also called “Maintenance Therapy” • OI medication is continued to prevent relapse • Continued for life or until the patient: • starts ART • has an increase in CD4 count which persists over a specified period of time

  22. Secondary Prophylaxis of OIs (2) • OIs which require secondary prophylaxis include: • PCP • Cerebral toxoplasmosis • Systemic fungal infections • Disseminated MAC infection • CMV disease

  23. Secondary Prophylaxis for Select OIs

  24. Case Study: Nga • Nga, a 25-year-old woman, presents to your clinic for follow-up of penicillium infection • She is about to complete 10 weeks of intensive phase treatment (Itraconazole 400 mg/day) • She has recently been started on ART • She is feeling well and wants to know whether she can stop the Itraconazole at the end of the 10 week course • What should you recommend regarding the Itraconazole? • When can she safely stop it?

  25. Key Points • Many OIs can be prevented with the use of primary or secondary • CTP is inexpensive, effective against many OIs, and reduces overall morbidity and mortality • IPT can prevent latent TB from becoming active TB

  26. Thank you! Questions?

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