40

CHAPTER
Human Immunodeficiency
Virus Infection

Tables 40–1 40–2

human immunodeficiency virus

ETIOLOGY AND PATHOGENESIS

Chlamydia,

CLINICAL PRESENTATION AND DIAGNOSIS

Table 40–3

Table 40–2

368
 TABLE 40–1 Surveillance Case Definition for HIV Infection Among Adults and Adolescents (≥13 years) – United States, 2008
Stage Laboratory evidence (laboratory-confirmed HIV infec- Clinical evidence
tion plus)
Stage 1 CD4+ cell count ≥500 cells/mm3 (500 × 106/L) or CD4+ percent- None required (but no AIDS-defining condition)
age ≥29
Stage 2 CD4+ cell count 200–499 cells/mm3 (200–499 × 106/L) or CD4+ None required (but no AIDS-defining condition)
percentage 14–28
Stage 3 (AIDS) CD4+ cell count <200 cells/mm3 (<200 × 106/L) or CD4+ Or documentation of an AIDS-defining condition
percentage <14 (with laboratory-confirmed HIV infection)

Human Immunodeficiency Virus Infection

Stage unknown No information on CD4 counts
+
And no information on presence of AIDS-defining
conditions
AIDS indicator conditions
Candidiasis of bronchi, trachea, or lungs Lymphoma, Burkitt
Candidiasis, esophageal Lymphoma, immunoblastic
Cervical cancer, invasive Lymphoma, primary, for brain
Coccidioidomycosis, disseminated or Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary
extrapulmonary
Cryptococcosis, extrapulmonary Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary)
Cryptosporidiosis, chronic intestinal (duration >1 Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
month)
Cytomegalovirus disease (other than liver, spleen, Pneumocystis jirovecii pneumonia

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or nodes)

CHAPTER 40
Cytomegalovirus retinitis (with loss of vision) Pneumonia, recurrent
(continued)
369
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SECTION 8 | Infectious Diseases

TABLE 40–1 Surveillance Case Definition for HIV Infection Among Adults and Adolescents (≥13 years) – United States, 2008 (Continued)
Stage Laboratory evidence (laboratory-confirmed HIV infec- Clinical evidence
tion plus)
Encephalopathy, HIV related Progressive multifocal leukoencephalopathy
Herpes simplex: chronic ulcer(s) (duration >1 Salmonella septicemia, recurrent
month); or bronchitis, pneumonitis, or esopha-
gitis
Histoplasmosis, disseminated or extrapulmonary Toxoplasmosis of brain
Isosporiasis, chronic intestinal (duration >1 month) Wasting syndrome due to HIV
Kaposi sarcoma

Data from Schneider E, Whitmore S, Glynn KM, Dominguez K, et al. Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged <18 months and for HIV infection and AIDS among
children aged 18 months to <13 years–United States, 2008. MMWR Recomm Rep 2008;57(RR-10):1–12.
 Human Immunodeficiency Virus Infection | CHAPTER 40

TABLE 40–2 Centers for Disease Control and Prevention 1994 Revised Classification System
for HIV Infection in Children Younger Than 13 Years
12 Months 1–5 Years 6–12 Years
cells/µL or cells/µL or cells/µL or
Immunologic Categories 10 6/L (%)a 10 6/L (%)a 10 6/L (%)a
1. No evidence of suppression ≥1500 ≥1000 (≥25%) ≥500 (≥25%)
(≥25%)
2. Evidence of moderate sup- 750–1499 500–999 200–499
pression (15–24%) (15–24%) (15–24%)
3. Severe suppression <750 (<15%) <500 (<15%) <200 (<15%)
N: No A: Mild B: Moderate C: Severe
Signs/ Signs/ Signs/ Signs/
Immunologic Categories Symptoms Symptoms Symptoms Symptoms
1. No evidence of suppression N1 A1 B1 C1
2. Evidence of moderate N2 A2 B2 C2
suppression
3. Severe suppression N3 A3 B3 C3

HIV, human immunodeficiency virus.

a
Percentage of total lymphocytes.

TABLE 40–3 Clinical Presentation of Primary HIV Infection in Adults

Symptoms
Fever, sore throat, fatigue, weight loss, and myalgia
40%–80% of patients will also exhibit a morbilliform or maculopapular rash usually involving
the trunk
Diarrhea, nausea, and vomiting
Lymphadenopathy, night sweats
Aseptic meningitis (fever, headache, photophobia, and stiff neck) may be present in one
fourth of presenting case
Other
High viral load (may exceed 1 million copies/mL)
Persistent decrease in CD4 lymphocytes

HIV, human immunodeficiency virus.

371
SECTION 8 | Infectious Diseases

TREATMENT

GENERAL APPROACH

http://
aidsinfo.nih.gov/

Table 40–4

PHARMACOLOGIC THERAPY
Antiretroviral Agents

Table 40–5

tenofovir disoproxil fumarate emtricitabine

darunavir atazanavir efavirenz
372
 TABLE 40–4 Treatment of Human Immunodeficiency Virus Infection: Antiretroviral Regimens Recommended in Antiretroviral-Naïve Persons
Preferred Regimens Limitation
NNRTI-based Efavirenz + tenofovir+ emtricitabine (AI) Not recommended in the first trimester of pregnancy or in women with-
out adequate contraception
HIV PI-based Darunavir + ritonavir + tenofovir + emtricitabine (AI) Rash (darunavir has sulfonamide moiety)
Atazanavir + ritonavir + tenofovir + emtricitabine (AI) Not with high doses of proton-pump inhibitors, unconjugated hyperbili-
rubinemia
InSTI-based Raltegravir + tenofovir + emtricitabine (AI) Twice daily (not once daily)

Human Immunodeficiency Virus Infection

Alternative Regimens (Some Potential Disadvantages vs. Preferred Regimens)
NNRTI-based Efavirenz + abacavir + lamivudine (BI) Possible reduced efficacy for high viral loads (abacavir)
Rilpivirine + tenofovir + emtricitabine (BI) Possible reduced efficacy for high viral loads; no proton-pump inhibitors
(rilpivirine)
Rilpivirine + abacavir + lamivudine (BIII) See above
HIV PI-based Atazanavir + ritonavir + abacavir + lamivudine (BI) See above
Darunavir + ritonavir + abacavir + lamivudine (BII) See above
Lopinavir–ritonavir (once or twice daily) either with GI intolerance, lipids
abacavir + lamivudine or tenofovir + emtricitabine (BI)
Fosamprenavir/ritonavir (once or twice daily) either with Rash
abacavir + lamivudine or tenofovir + emtricitabine (BI)
InSTI-based Raltegravir + abacavir + lamivudine (BIII) See above
Elvitegravir + cobicistat + tenofovir + emtricitabine (BI) Should not be used when creatinine clearance <70 mL/min (<1.17 mL/s)

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(continued )
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SECTION 8 | Infectious Diseases

TABLE 40–4 Treatment of Human Immunodeficiency Virus Infection: Antiretroviral Regimens Recommended in Antiretroviral-Naïve Persons (Continued )
Preferred Regimens Limitation
Acceptable Regimens (Potential Additional Disadvantages or Pending Additional Data)
NNRTI-based Efavirenz + zidovudine + lamivudine (CI) Nausea, anemia, lipoatrophy (zidovudine)
Nevirapine + zidovudine + lamivudine or tenofovir + emtricitabine (CI) Not in moderate/severe hepatic impairment; not in women with pre-ART
CD4 count >250 cells/mm3 (> 250 × 106/L) and men with pre-ART
CD4 count >400 cells/mm3 (> 400 × 106/L)
Nevirapine + abacavir + lamivudine (CIII) See above
Rilpivirine + zidovudine + lamivudine (CIII) See above
HIV PI-based Atazanavir + (abacavir or zidovudine) + lamivudine (CI) Lower atazanavir concentrations compared with atazanavir–ritonavir
(Fosamprenavir + ritonavir or atazanavir + ritonavir) + zidovudine + See above
lamivudine (CI)
(Darunavir + ritonavir or lopinavir + ritonavir) + zidovudine + lamivudine See above
(CIII)
CCR5-inhibitor-based Maraviroc + zidovudine + lamivudine (CI) Lower virologic activity versus efavirenz, need tropism test
Maraviroc + (tenofovir + emtricitabine or abacavir + lamivudine) (CIII) See above
InSTI-based Raltegravir + zidovudine + lamivudine (CIII) See above
Regimens or Components that should not be used as Initial Therapy
Regimen or Component Comment
Any all NRTI regimen (DI) Inferior virologic efficacy
Lamivudine (or emtricitabine) + didanosine (DIII) Inferior virologic efficacy
Didanosine + tenofovir (DII) Inferior virologic efficacy, CD4 declines
Stavudine (DI) Toxicity including subcutaneous fat loss, peripheral neuropathy, and lactic
acidosis
 Darunavir, fosamprenavir, saquinavir, or Insufficient plasma concentrations and efficacy
tipranavir without ritonavir (DI-DIII) or not studied
Delavirdine (DIII) Inferior virologic efficacy and inconvenient dosing
Enfuvirtide (DIII) Not studied in naїve patients, inconvenient injections
Etravirine (DIII) Insufficient data in naїve patients
Indinavir with or without ritonavir (DIII) Nephrolithiasis, fluid requirements and inconvenient
Nelfinavir (without ritonavir) (DI) Inferior virologic efficacy

Human Immunodeficiency Virus Infection

Ritonavir at virologic doses (DIII) GI intolerance
Tipranavir–ritonavir (DI) Inferior virologic efficacy
Tenofovir, tenofovir disoproxil fumarate.
Evidence-based rating definition.
Rating strength of recommendation:
A: Both strong evidence for efficacy and substantial clinical benefit support recommendation for use; should always be offered.
B: Moderate evidence for efficacy or strong evidence for efficacy but only limited clinical benefit, supports recommendation for use; should usually be offered.
C: Evidence for efficacy is insufficient to support a recommendation for or against use, or evidence for efficacy might not outweigh adverse consequences (e.g., drug toxicity, drug interac-
tions) or cost of treatment under consideration; use is optional.
D: Moderate evidence for lack of efficacy or for adverse outcome supports recommendation against use; should usually not be offered.
E: Good evidence for lack of efficacy or for adverse outcome supports a recommendation against use; should never be offered.
Rating Quality of Evidence Supporting the Recommendation:
I: Evidence from at least one correctly randomized, controlled trial with clinical outcomes and/or validated laboratory endpoints.
II: Evidence from at least one well-designed clinical trial without randomization or observational cohorts with long-term clinical outcomes.
III: Evidence from opinions of respected authorities based on clinical experience, descriptive studies, or reports of consulting committees.
Lamivudine and emtricitabine are considered interchangeable.

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Adapted from Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Updated

CHAPTER 40
March 27, 2012. http://AIDSinfo.NIH.gov. From reference 30.
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SECTION 8 | Infectious Diseases

TABLE 40–5 Selected Pharmacologic Characteristics of Antiretroviral Compounds
Adult Doseb Plasma
Drug F (%) t1/2 (h)a (doses/day) Cmax/Cmin (μM) Distinguishing Adverse Effect
Integrase Inhibitors (InSTI)
Elvitegravir (coformulated with cobicistat) ? 13 150 mg (1) 3.8/1 Diarrhea, nausea, headache
Raltegravir ? 9 400 mg (2) 1.74/0.22 Increased creatine phosphokinase
Nucleoside (Nucleotide) Reverse Transcriptase Inhibitors (NtRTIs)
Abacavir 83 1.5/20 300 mg (2) 5.2/0.03 Hypersensitivity
or
600 mg (1) 7.4c
Didanosine 42 1.4/24 200 mg (2) 2.8/0.03 Peripheral neuropathy, pancreatitis
or
400 mg (1) 5.6c
Emtricitabine 93 10/39 200 mg (1) 7.3/0.04 Pigmentation on soles and palms in non-whites
Lamivudine 86 5/22 150 mg (2) 6.3/1.6 Headache, pancreatitis (children)
or
300 mg (1) 10.5/0.5
Stavudine 86 1.4/7 40 mg (2) 2.4/0.04 Lipoatrophy, peripheral neuropathy
Tenofovir disoproxil fumarate 40 17/150 300 mg (1) 1.04/0.4 Renal toxicity (proximal tubulopathy)
Zidovudine 85 2/7 200 mg (3) 0.2 Anemia, neutropenia, myopathy
or
300 mg (2) 3c
Nonnucleoside Reverse Transcriptase Inhibitors (NNRTIs)
Delavirdine 85 5.8 400 mg (3) 35/14 Rash, elevated liver function tests
or
600 mg (2)
 Efavirenz 43 48 600 mg (1) 12.9/5.6 CNS disturbances and potential teratogenicity
Etravirine ? 41 200 mg (2) 1.69/0.86 Rash, nausea
Nevirapine 93 25 200 mg (2)d 22/14 Potentially serious rash and hepatotoxicity
Rilpivirine ? 50 25 mg (1) 0.7/0.3 Possibly depression
Protease Inhibitors (PIs)
Fosamprenavire 1400 mg (1)e,f 14.3/2.9 Rash
Atazanavir 68 7 400 mg (1) 3.3/0.23 Unconjugated hyperbilirubinemia
or
300 mg (1)f 6.2/0.9

Human Immunodeficiency Virus Infection

Darunavir 82 15 800 mg (1)f 11.9/6.5 Hepatitis, rash
or
600 mg (2)f
Indinavir 60 1.5 800 mg (3) 13/0.25 Nephrolithiasis
or
400–800 mg (2)f
Lopinavirg ? 5.5 800 mg (1) 13.6/7.5 Hyperlipidemia/GI intolerance
or
400 mg (2)
Nelfinavir ? 2.6 750 mg (3) 5.3/1.76 Diarrhea
or
1250 mg (2) 7/1.2
(continued )

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377
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SECTION 8 | Infectious Diseases

TABLE 40–5 Selected Pharmacologic Characteristics of Antiretroviral Compounds (Continued )
Adult Doseb Plasma
Drug F (%) t1/2 (h)a (doses/day) Cmax/Cmin (μM) Distinguishing Adverse Effect
Ritonavir 60 3–5 600 mg (2)d 16/5 GI intolerance
or
“Boosting doses”
Saquinavir 4 3 1,000 mg (2)f 3.9/0.55 QT prolongation
Tipranavir ? 6 500 mg (2)f 77.6/35.6 Hepatotoxicity, intracranial hemorrhage
Entry Inhibitors—Fusion Inhibitor
Enfuvirtide 84 3.8 90 mg (2) 1.1/0.73 Injection-site reactions
Coreceptor Inhibitor
Maraviroc 33 15 300 mg (2) 1.2/0.066 Hepatitis, allergic reaction
Cmax, maximum plasma concentration; Cmin, minimum plasma concentration; F, bioavailability; t1/2, elimination half-life.
a
NtRTIs: Plasma NtRTI t1/2/intracellular (peripheral blood mononuclear cells) NtRTI-triphosphate t1/2; plasma t1/2 only for other classes.
b
Dose adjustment may be required for weight, renal or hepatic disease, and drug interactions.
c
C min
concentration typically below the limit of quantification.
d
Initial dose escalation recommended to minimize side effects.
e
Fosamprenavir is a tablet phosphate prodrug of amprenavir. Amprenavir is no longer available.
f
Must be boosted with low doses of ritonavir (100 to 200 mg).
g
Available as coformulation 4:1 lopinavir to ritonavir.
Adapted from Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Updated
March 27, 2012. http://AIDSinfo.NIH.gov and product information for agents.
 Human Immunodeficiency Virus Infection | CHAPTER 40

raltegravir

✓ Ritonavir
Rifampin -

maraviroc
TREATMENT DURING PREGNANCY

abacavir -
lamivudine zidovudine.
-

-
nevirapine

POSTEXPOSURE PROPHYLAXIS

EVALUATION OF THERAPEUTIC OUTCOMES

✓
✓

THERAPEUTIC FAILURE

379
SECTION 8 | Infectious Diseases

INFECTIOUS COMPLICATIONS OF HUMAN IMMUNODEFICIENCY VIRUS

✓
✓
✓

✓
✓
✓
-
Table 40–6 .

Pneumocystis carinii (Pneumocystis jiroveci)

P. jiroveci

CLINICAL PRESENTATION

P. carinii
-

TREATMENT
trimethoprim–sulfamethoxazole

380
 TABLE 40–6 Therapies for Common Opportunistic Pathogens in HIV-Infected Individuals
Preferred Initial Therapies for Acute Infection in Adults Common Drug- or Dose-Limiting
Clinical Disease (Strength of Recommendation in Parentheses) Adverse Reactions
Fungi
Candidiasis, oral Fluconazole 100 mg orally for 7–14 days (AI) Elevated liver function tests, hepatotoxicity, nau-
sea, and vomiting
or
Nystatin 500,000 units oral swish (~5 mL) four times daily for 7–14 days (BII) Taste, patient acceptance

Human Immunodeficiency Virus Infection

Candidiasis, esophageal
Pneumocystis jirovecii
pneumonia
Cryptococcal meningitis
Fluconazole 100–400 mg orally or IV daily for 14–21 days (AI) Same as above
or
Itraconazole 200 mg/day orally for 14–21 days (AI) Elevated liver function tests, hepatotoxicity, nau-
sea, and vomiting
Trimethoprim–sulfamethoxazole IV or orally 15–20 mg/kg/day as trimethoprim Skin rash, fever, leucopenia Thrombocytopenia
component in three to four divided doses for 21 daysa (AI)
Moderate or severe therapy should be started IV
or
Pentamidine IV 4 mg/kg/day for 21 daysa (AI) Azotemia, hypoglycemia, hyperglycemia,
arrhythmias
Mild episodes
Atovaquone suspension 750 mg (5 mL) orally twice daily with meals for 21 daysa (BI) Rash, elevated liver enzymes, diarrhea
Amphotericin B 0.7 mg/kg/day IV for a minimum of 2 weeks with flucytosine 100 mg/ Nephrotoxicity, hypokalemia, anemia, fever, chills
kg/day orally in four divided doses (AI) followed by

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Bone marrow suppression

CHAPTER 40
Elevated liver enzymes
(continued )
381
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SECTION 8 | Infectious Diseases

TABLE 40–6 Therapies for Common Opportunistic Pathogens in HIV-Infected Individuals (Continued )
Preferred Initial Therapies for Acute Infection in Adults Common Drug- or Dose-Limiting
Clinical Disease (Strength of Recommendation in Parentheses) Adverse Reactions
Fluconazole 400 mg/day, orally for 8 weeks or until CSF cultures are negative (AI)a Same as above
Histoplasmosis Liposomal amphotericin B 3 mg/kg/day IV for 2 weeks (AI) followed by Itraconazole 200 Same as above
mg orally thrice daily for 3 days then twice daily, for 12 months (AII)a
Coccidioidomycosis Amphotericin B 0.7–1 mg/kg/day IV until clinical improvement (usually after 500–1,000 Same as above
mg) then switch to azole (AII)a
or
Fluconazole 400–800 mg once daily (meningeal disease) (AII)a Same as above
Protozoa
Toxoplasmic encephalitis Pyrimethamine 200 mg orally once, then 50–75 mg/day Bone marrow suppression
plus
Sulfadiazine 1–1.5 g orally four times daily Allergy, rash, drug fever
and
Leucovorin 10–25 mg orally daily for 6 weeks (AI)a
Isosporiasis Trimethoprim and sulfamethoxazole: 160 mg trimethoprim and 800 mg Same as above
sulfamethoxazole orally or IV four times daily for 10 days (AII)a
Bacteria
Mycobacterium avium complex Clarithromycin 500 mg orally twice daily GI intolerance, optic neuritis, peripheral neuritis
plus
ethambutol 15 mg/kg/day orally (AI) Rash, GI intolerance
and
For advanced disease, rifabutin 300 mg/day (dose may need adjustment with ART) (AI)a Neutropenia, discolored urine, uveitis
 Salmonella enterocolitis or Ciprofloxacin 500–750 mg orally (or 400 mg IV) twice daily for 14 days GI intolerance
bacteremia (longer duration for bacteremia or advanced HIV) (AIII)
Campylobacter Ciprofloxacin 500 mg orally twice daily Same as above
enterocolitis or
Azithromycin 500 mg orally daily for 7 days (or 14 days with bacteremia) (BIII)
Shigella enterocolitis Ciprofloxacin 500 mg orally twice daily for 5 days Same as above
(or 14 days for bacteremia) (AIII)

Human Immunodeficiency Virus Infection

Viruses
Mucocutaneous herpes
simplex
Primary varicella-zoster
Cytomegalovirus (retinitis)
Cytomegalovirus esophagitis
or colitis
ART, antiretroviral therapy; CSF, cerebrospinal fluid; HIV, human immunodefi ciency virus.
Acyclovir 5 mg/kg IV every 8 hours until lesions regress, then acyclovir 400 mg orally GI intolerance, crystalluria
three times daily until complete healing (famciclovir or valacyclovir is alternative) (AII)
Acyclovir 10–15 mg/kg every 8 hours IV for 7–10 days, then switch to oral acyclovir Obstructive nephropathy, CNS symptoms
800 mg five times daily after defervescence (famciclovir or valacyclovir is alternative)
(AIII)
Ganciclovir intraocular implant Neutropenia, thrombocytopenia
plus
valganciclovir 900 mg twice daily for 14–21 days then once daily until immune recovery
from ART (AI)a
Ganciclovir 5 mg/kg IV every 12 hours for 21 to 28 days (BII) Same as above

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CHAPTER 40
a
Maintenance therapy is recommended.
See Table 103-4 for levels of evidence-based recommendations. .
383
384
TABLE 40–7 Therapies for Prophylaxis of First-Episode Opportunistic Diseases in Adults and Adolescents
Pathogen
I. Standard of care
Pneumocystis jirovecii
Mycobacterium tuberculosis
Isoniazid-sensitive
For exposure to
drug-resistant TB
Toxoplasma gondii
Mycobacterium avium
complex
Varicella zoster virus (VZV)
Indication
CD4+ count <200/mm3 (<200 × 106/L) or oropharyngeal candidiasis
(Active TB should be ruled out):
+ test for latent TB infection with no prior TB treatment history
or – test for latent TB infection, but close contact with case of active or
tuberculosis
or history of untreated or inadequately treated healed TB regardless of
latent TB infection test results
Consult public health authorities
Immunoglobulin G antibody to Toxoplasma and CD4+ count <100/
mm3 (<100 × 106/L)
CD4+ count <50/mm3 (<50 × 106/L)
Preexposure: CD4 ≥200/mm3 (≥200 × 106/L), no history of varicella
infection, or, if available, negative antibody to VZV
Postexposure: Significant exposure to chicken pox or shingles for
patients who have no history of either condition or, if available,
negative antibody to VZV
SECTION 8 | Infectious Diseases
First Choice (Strength of Recommendation in Parentheses)
Trimethoprim–sulfamethoxazole, one double-strength tablet orally
once daily (AI) or one single-strength tablet orally once daily (AI)
Isoniazid 300 mg orally plus pyridoxine, 50 mg orally once daily for 9
months (AII)
Isoniazid 900 mg orally twice weekly (BII) plus pyridoxine 50 mg orally
daily for 9 months (BIII)
Trimethoprim–sulfamethoxazole one double-strength tablet orally
once daily (AII)
Azithromycin 1,200 mg orally once weekly (AI) or 600 mg orally twice
weekly (BIII) or clarithromycin 500 mg orally twice daily (AI)
Varicella vaccination; two doses, 3 months apart (CIII)
Varicella-zoster immune globulin, 125 IU per 10 kg (maximum of 625
IU) IM, within 96 hours after exposure to a person with active vari-
cella or herpes zoster (AIII)
 Streptococcus pneumoniae
Hepatitis B virus
Influenza virus
CD4 count ≥200 cells/mm3 (≥200 × 106/L) or no receipt of vaccination 23-valent polysaccharide vaccine, 0.5 mL intramuscularly (BII) revac-
in past 5 years. Consider for those with CD4 <200/mm3 (<200 × cination every 5 years may be considered (CIII)
106/L) and those with an CD4 increase to > 200/mm3 (>200 × 106/L)
on ART (CIII)
All susceptible patients Hepatitis B vaccine, three doses (AII)
Anti-HBs should be obtained 1 month after the vaccine series
completion (BIII)
All patients (annually, before influenza season) Inactivated trivalent influenza virus vaccine (annual): 0.5 mL
intramuscularly (AIII)

Human Immunodeficiency Virus Infection

Hepatitis A virus All susceptible (anti-hepatitis A virus–negative) patients at increased Hepatitis A vaccine: two doses (AII) antibody response should be
risk for hepatitis A infection (e.g., chronic liver disease, illegal drug assessed 1 month after vaccination; with revaccination as needed
users, men who have sex with men) (BIII)
Human papillomavirus (HPV) 15–26 year old women HPV quadravalent vaccine months 0, 2, and 6 (CIII)
infection
Histoplasma capsulatum CD4+ count <150/mm3 (<150 × 106/L) endemic geographic area and Fluconazole 100–200 mg orally once daily (CI)
high risk for exposures
See Table 103–4 for levels of evidence-based recommendations.

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SECTION 8 | Infectious Diseases

PROPHYLAXIS

See Chapter 103, Human Immunodeficiency Virus Infection, authored by Peter L.

Anderson, Thomas N. Kakuda, and Courtney V. Fletcher, for a more detailed discussion
of this topic.
386