Tables-Adult-Adolescent-oi Hiv DGN Infeksi 2023

Guidelines for the Prevention and Treatment of
Opportunistic Infections in
Adults and Adolescents with HIV
Developed by the National Institutes of Health, the Centers for Disease Control
and Prevention, and the HIV Medicine Association of the Infectious Diseases
Society of America Panel on Guidelines for the Prevention and Treatment of
Opportunistic Infections in Adults and Adolescents with HIV—A Working Group of
the NIH Office of AIDS Research Advisory Council (OARAC)
How to Cite the Adult and Adolescent Opportunistic Infection Guidelines:
Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents
with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents
with HIV. National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association,
and Infectious Diseases Society of America. Available at https://clinicalinfo.hiv.gov/en/guidelines/adult-and-
adolescent-opportunistic-infection. Accessed (insert date) [include page numbers, table number, etc., if
applicable].
It is emphasized that concepts relevant to HIV management evolve rapidly. The Panels have a mechanism to
update recommendations on a regular basis, and the most recent information is available on the Clinicalinfo
website (https://clinicalinfo.hiv.gov/).
Table of Contents
Table 1. Chemoprophylaxis to Prevent First Episode of Opportunistic Disease ................................................... A-1
Table 2. Treatment of HIV-Associated Opportunistic Infections (Includes Recommendations for
Acute Treatment and Secondary Prophylaxis/Chronic Suppressive/Maintenance Therapy) ............................... B-1
Table 3. Indications for Discontinuing and Restarting Opportunistic Infection Secondary Prophylaxis
or Chronic Maintenance in Adults and Adolescents with HIV ................................................................................. C-1
Table 4. Significant Pharmacokinetic Interactions Between Drugs Used to Treat or Prevent
Opportunistic Infections ............................................................................................................................................. D-1
Rifamycin-Related Induction Interactions ...................................................................................................................... D-1
Pharmacodynamic Interactions...................................................................................................................................... D-2
Therapeutic Drug Monitoring ......................................................................................................................................... D-2
Table 5. Serious and/or Common Adverse Reactions Associated with Systemically Administered
Drugs Used to Treat or Prevent Opportunistic Infections........................................................................................ E-1
Table 6. Dosing Recommendations for Drugs Used to Treat or Prevent Opportunistic Infections
that Require Dosage Adjustment in Patients with Renal Insufficiency................................................................... F-1
Table 7. Summary of Pre-Clinical and Human Data on, and Indications for, Opportunistic Infection
Drugs During Pregnancy ............................................................................................................................................ G-1
Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV i
Table 1. Chemoprophylaxis to Prevent First Episode of Opportunistic Disease
This table provides recommendations for the use of chemoprophylaxis to prevent the first episode of opportunistic
disease. For the use of immunizations to prevent hepatitis A virus, hepatitis B virus, human papillomavirus,
influenza A and B viruses, Streptococcus pneumoniae, and varicella-zoster virus infections, please refer to the
Immunizations for Preventable Diseases in Adults and Adolescents with HIV section.
Updated: February 17, 2022

Reviewed: January 11, 2023
Opportunistic
Indication Preferred Alternative
Infections
Coccidioidomycosis A new positive IgM or IgG Fluconazole 400 mg PO daily (BIII)

serologic test in patients who
live in a disease-endemic
area and with CD4 count
<250 cells/µL (BIII)
Histoplasma CD4 count ≤150 cells/µL Itraconazole 200 mg PO daily (BI)

capsulatum infection and at high risk because of
occupational exposure or
living in a community with a
hyperendemic rate of
histoplasmosis
(>10 cases/100 patient-
years) (BI)
Malaria Travel to disease-endemic Recommendations are the same for

area HIV-infected and HIV-uninfected
patients. Recommendations are
based on the region of travel,
malaria risks, and drug susceptibility
in the region. Refer to the Centers
for Disease Control and Prevention
webpage for the most recent
recommendations based on region
and drug susceptibility: Malaria.
Mycobacterium CD4 count <50 cells/mm3 Azithromycin 1,200 mg PO once Rifabutin (dose adjusted based on concomitant
avium complex (MAC) weekly (AI), or ART)a (BI); rule out active TB before starting
Not recommended for those
disease rifabutin.
who immediately initiate ART Clarithromycin 500 mg PO BID (AI),
(AII). or
Recommended for those Azithromycin 600 mg PO twice
who are not on fully weekly (BIII)
suppressive ART, after ruling
out active disseminated MAC
disease (AI).
Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV A-1
Opportunistic
Infections
Mycobacterium Positive screening test for (Rifapentine [see dose below] plus (INH 300 mg plus pyridoxine 25–50 mg) PO
tuberculosis infection LTBI,b with no evidence of INH 900 mg plus pyridoxine 50 mg) daily for 9 months (AII), or
(TB) (i.e., treatment of active TB, and no prior PO once weekly for 12 weeks (AII)
Rifampin 600 mg PO daily for 4 months (BI), or
latent TB infection treatment for active TB or
Note: Rifapentine is recommended
[LTBI]) LTBI (AI), or (Rifapentine [see dose below] plus INH 300 mg
only for persons receiving EFV,
plus pyridoxine 25–50 mg) PO once daily for
Close contact with a person RAL, or once daily DTG -based
4 weeks (AII)
with infectious TB, with no ARV regimen.
evidence of active TB, Weight-Based Rifapentine Dose
Weight-Based Rifapentine Dose
regardless of screening test
results (AII) • Weighing <35 kg: 300 mg PO once daily
• Weighing 32.1–49.9 kg: 750 mg
LTBI treatment and ART act PO once weekly • Weighing 35–45 kg: 450 mg PO once daily
independently to decrease • Weighing >50 kg: 900 mg PO • Weighing >45 kg: 600 mg PO once daily
the risk of TB disease. Thus, once weekly
ART is recommended for all See the Dosing Recommendations for Anti-TB
persons with HIV and LTBI or Drugs table in the Mycobacterium tuberculosis
(AI). (INH 300 mg plus rifampin 600mg Infection and Disease section for the list of ARV
plus pyridoxine 25–50 mg) PO daily drugs not recommended to be used with
for 3 months (AI) rifampin and those which require dosage
adjustment.
See the Dosing Recommendations
for Anti-TB Drugs table in the For persons exposed to drug-resistant TB,
Mycobacterium tuberculosis select anti-TB drugs after consultation with
Infection and Disease section for the experts or public health authorities (AII).
list of ARV drugs not recommended
to be used with rifampin and those
which require dosage adjustment.
Opportunistic
Infections
Pneumocystis CD4 count <200 cells/mm3 TMP-SMXc 1 DS tablet PO daily • TMP-SMXc 1 DS PO three times weekly (BI),
Pneumonia (PCP) (AI), or (AI), or or
CD4 <14% (BII), or TMP-SMXc 1 SS tablet daily (AI) • Dapsoned 100 mg PO daily or 50 mg PO BID
If ART initiation must be (BI), or
delayed, CD4 count • Dapsoned 50 mg PO daily with
≥200 cells/mm3 but (pyrimethaminee 50 mg plus leucovorin
<250 cells/mm3 and if 25 mg) PO weekly (BI), or
monitoring of CD4 cell count
every 3 months is not • (Dapsoned 200 mg plus pyrimethaminee
possible (BII) 75 mg plus leucovorin 25 mg) PO weekly
(BI); or
Note: Patients who are
receiving pyrimethamine/ • Aerosolized pentamidine 300 mg via
sulfadiazine for treatment or Respigard II™ nebulizer every month (BI), or
suppression of • Atovaquone 1,500 mg PO daily (BI), or
toxoplasmosis do not require
additional PCP prophylaxis • (Atovaquone 1,500 mg plus pyrimethaminee
(AII). 25 mg plus leucovorin 10 mg) PO daily (CIII)
Syphilis For individuals exposed to a Benzathine penicillin G 2.4 million For penicillin-allergic patients:
sex partner with a diagnosis units IM for 1 dose (AII)
of primary, secondary, or • Doxycycline 100 mg PO BID for 14 days
early latent syphilis within the (BII), or
past 90 days (AII), or • Ceftriaxone 1 g IM or IV daily for 8–10 days
For individuals exposed to a (BII), or
sex partner >90 days before • Azithromycin 2 g PO for 1 dose (BII)—not
syphilis diagnosis in the recommended for men who have sex with
partner, if serologic test men or pregnant people (AII)
results are not available
immediately and the
opportunity for follow-up is
uncertain (AIII)
Opportunistic
Infections
Talaromycosis Persons with HIV and CD4 For persons who reside in endemic For persons who reside in endemic areas,
(Penicilliosis) cell counts <100 cells/mm3, areas, itraconazole 200 mg PO fluconazole 400 mg PO once weekly (BII)
who are unable to have once daily (BI)
For those traveling to the highly endemic
ART, or have treatment
For those traveling to the highly regions, take the first dose of fluconazole
failure without access to
endemic regions, begin itraconazole 400 mg 3 days before travel, continue 400 mg
effective ART options, and—
200 mg PO once daily 3 days once weekly, and take the final dose after
• Who reside in the highly before travel, and continue for leaving the endemic area (BIII).
endemic regions* in 1 week after leaving the endemic
northern Thailand, area (BIII).
northern or southern
Vietnam, or southern
China (BI), or
• Who are from countries
outside of the endemic
region, and must travel to
the region (BIII)
* Particularly in highland
regions during the rainy and
humid months
Toxoplasma gondii Toxoplasma IgG-positive TMP-SMXa 1 DS PO daily (AII) • TMP-SMXc 1 DS PO three times weekly
encephalitis patients with CD4 count (BIII), or
<100 cells/µL (AII)
• TMP-SMXc 1 SS PO daily (BIII), or
Note: All regimens
recommended for primary • Dapsoned 50 mg PO daily plus
prophylaxis against (pyrimethaminee 50 mg plus leucovorin
toxoplasmosis also are 25 mg) PO weekly (BI), or
effective as PCP • (Dapsoned 200 mg plus pyrimethaminee
prophylaxis. 75 mg plus leucovorin 25 mg) PO weekly
(BI), or
• Atovaquone 1500 mg PO daily (CIII), or
• (Atovaquone 1500 mg plus pyrimethaminee
25 mg plus leucovorin 10 mg) PO daily (CIII)
a Refer to the Drug–Drug Interactions section of the Adult and Adolescent Antiretroviral Guidelines for dosing recommendations.
b Screening tests for LTBI include tuberculin skin test or interferon-gamma release assays.
c TMP-SMX DS once daily also confers protection against toxoplasmosis and many respiratory bacterial infections; lower dose also likely confers
protection.
d Patients
should be tested for glucose-6-phosphate dehydrogenase (G6PD) before administration of dapsone or primaquine. An alternative agent
should be used in patients found to have G6PD deficiency.
e Refer to Daraprim Direct for information regarding how to access pyrimethamine.
For information regarding the evidence ratings, refer to the Rating System for Prevention and Treatment Recommendations in the Introduction
section of the Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV.
Key: ART = antiretroviral therapy; ARV = antiretroviral; BID = twice daily; CD4 = CD4 T lymphocyte cell; DS = double strength; DTG = dolutegravir;
EFV = efavirenz; IgG = immunoglobulin G; IgM = immunoglobulin M; IM = intramuscular; INH = isoniazid; IV = intravenously; LTBI = latent
tuberculosis infection; MAC = Mycobacterium avium complex; PCP = Pneumocystis pneumonia; PO = orally; RAL= raltegravir; SS = single
strength; TB = tuberculosis; TMP-SMX = trimethoprim-sulfamethoxazole
Table 2. Treatment of HIV-Associated Opportunistic Infections (Includes Recommendations for Acute
Treatment and Secondary Prophylaxis/Chronic Suppressive/Maintenance Therapy)
Updated: June 14, 2023

Reviewed: June 14, 2023
Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Bacterial Empiric therapy Diagnostic fecal specimens should be Empiric Therapy Oral or IV rehydration (if
Enteric pending definitive obtained before the initiation of empiric indicated) should be given
In Patients with Marked
Infections diagnosis antimicrobial therapy. If a pathogen is to patients with diarrhea
Nausea, Vomiting,
identified, antibiotic susceptibilities should (AIII).
Diarrhea, Electrolyte
be performed to confirm and inform
Abnormalities, Acidosis, Anti-motility agents should
antibiotic choices given increased reports
Blood Pressure Instability, be avoided if there is
of antibiotic resistance. Reflex culture for
and/or When concern about inflammatory
antibiotic susceptibilities should also be
Hospitalization Is Needed diarrhea, including CDI
done if diagnosis is made using PCR-
based methods. • Ceftriaxone 1 g IV (BIII).
every 24 hours (BIII), or
Empiric antibiotic therapy may be If no clinical response is
indicated for patients with CD4 count • Cefotaxime 1 g IV observed after 3–4 days,
200–500 cells/mm3 when diarrhea is every 8 hours (BIII) consider a follow-up stool
severe enough to compromise quality of culture with antibiotic
life or the ability to work (CIII) and is susceptibility testing or
indicated in patients with CD4 count alternative diagnostic tests
<200 cells/mm3 or concomitant AIDS- (e.g., toxin assays,
defining illness and with clinically severe molecular testing) to
diarrhea (≥6 stools per day or bloody evaluate alternative
stool) and/or accompanying fever or chills diagnoses, antibiotic
(AIII). resistance, or drug–drug
interactions.
Empiric Therapy
• Ciprofloxacin 500–750 mg PO (or 400
mg IV) every 12 hours for 5 days (AIII)
(particularly if diarrhea is not associated
with international travel)
Therapy should be adjusted based on the

results of a diagnostic work-up.
For patients with chronic diarrhea

(>14 days) without severe clinical signs,
empiric antibiotics therapy is not
necessary. Treatment can be withheld
until a diagnosis is made.
Campylobacteriosis For Mild Disease and if CD4 Count For Mild-to-Moderate Oral or IV rehydration if
>200 Cells/mm3 Disease (if Susceptible) indicated (AIII)
• No therapy unless symptoms persist for • Levofloxacin 750 mg Anti-motility agents should
more than several days (CIII). (PO or IV) every 24 be avoided (BIII).
hours (BIII), or
For Mild to Moderate Disease (if If no clinical response is
Susceptible) • Moxifloxacin 400 mg
(PO or IV) every 24 observed after 5–7 days,
hours (BIII) consider a follow-up stool
culture, alternative
diagnosis, or antibiotic
Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV B-1
• Ciprofloxacin 500–750 mg PO (or 400 • Add an aminoglycoside resistance.

mg IV) every 12 hours for 7–10 days to fluoroquinolone in
(BIII), or bacteremic patients In the United States in
(BIII). 2018, 29% of C. jejuni
• Azithromycin 500 mg PO daily for isolates were resistant to
5 days (BIII) (Note: Not for patients with ciprofloxacin and 2% were
bacteremia [AIII]) resistant to azithromycin;
among C. coli isolates,
For Campylobacter Bacteremia 40.5% were resistant to
• Ciprofloxacin 500–750 mg PO (or 400 fluoroquinolone and 13.3%
mg IV) every 12 hours for ≥14 days if were resistant to
the isolate is sensitive (BIII) plus an azithromycin.
aminoglycoside (BIII)
The rationale for addition of
For Recurrent Infections an aminoglycoside to a
fluoroquinolone in
• Duration of therapy may be extended to bacteremic patients is to
2–6 weeks (BIII). prevent emergence of
quinolone resistance.
Effective ART may reduce

the frequency, severity, and
recurrence of
Campylobacter infections.
Clostridium difficile Fidaxomicin 200 mg PO two times daily For Nonsevere CDI Recurrent CDI
infection (CDI) for 10 days (AI)
If Fidaxomicin or Treatment is the same as in
Vancomycin 125 mg PO four times daily Vancomycin Access Is patients without HIV
for 10 days (AI) Limited infection.
• Metronidazole 500 mg Bezlotoximab (CIII) or fecal
For severe, life-threatening CDI, see text (PO) three times daily
and references for additional information. microbiota therapy may be
for 10 days (CII) successful and safe to treat
recurrent CDI (CIII). See
text and references for
additional information.
Salmonellosis All people with HIV and salmonellosis should receive antimicrobial Oral or IV rehydration if
treatment due to an increase of bacteremia (by 20-fold to 100-fold) and indicated (AIII)
mortality (by up to 7-fold) compared to individuals without HIV (AIII).
Anti-motility agents should
• Ciprofloxacin 500–750 mg PO (or 400 • Levofloxacin 750 mg be avoided (BIII).
mg IV) every 12 hours, if susceptible (PO or IV) every 24
(AIII) hours (BIII), or The role of long-term
secondary prophylaxis in
Duration of Therapy • Moxifloxacin 400 mg patients with recurrent
(PO or IV) every 24 Salmonella bacteremia is
For Gastroenteritis Without Bacteremia hours (BIII), or not well established. Must
• If CD4 count ≥200 cells/mm3: • TMP 160 mg-SMX 800 weigh benefit against risks
7–14 days (BIII) mg (PO or IV) every 12 of long-term antibiotic
hours (BIII), or exposure (BIII).
• If CD4 count <200 cells/mm3:
2–6 weeks (BIII) • Ceftriaxone 1 g IV Effective ART may reduce
every 24 hours (BIII), or the frequency, severity, and

For Gastroenteritis with Bacteremia • Cefotaxime 1 g IV recurrence of salmonella
every 8 hours (BIII) infections.
• If CD4 count ≥200/mm3: 14 days or
longer duration if bacteremia persists or
if the infection is complicated (e.g., if
metastatic foci of infection are present)
(BIII)
• If CD4 count <200 cells/mm3:
2–6 weeks (BIII)
Secondary Prophylaxis Should Be

Considered
• For patients with recurrent Salmonella
bacteremia (BIII), or
• For patients with recurrent
gastroenteritis (with or without
bacteremia) with CD4 count
<200 cells/mm3 with severe diarrhea
(BIII)
Shigellosis • Ciprofloxacin 500–750 mg PO (or 400 • Levofloxacin 750 mg Therapy may slightly
mg IV) every 12 hours (if MIC (PO or IV) every 24 shorten duration of illness
<0.12 µg/mL (AIII) hours (BIII), or and/or prevent spread of
infection (AIII).
Duration of Therapy • Moxifloxacin 400 mg
(PO or IV) every 24 Given increasing
• Gastroenteritis: 7–10 days (AIII)
hours (BIII), or antimicrobial resistance and
• Bacteremia: ≥14 days (BIII) limited data showing that
• TMP 160 mg-SMX 800
mg (PO or IV) every 12 antibiotic therapy limits
• Recurrent infections: Up to 6 weeks
hours (BIII) (Note: transmission, antibiotic
(BIII)
Shigella infections treatment may be withheld
Note: Increased resistance of Shigella to acquired outside of the in patients with CD4 count
fluoroquinolones is occurring in the United United States have >500 cells/mm3 whose
States. Avoid fluoroquinolones if high rates of TMP-SMX diarrhea resolves prior to
ciprofloxacin MIC is ≥0.12 µg/mL, even if resistance), or culture confirmation of
the laboratory identifies the isolate as Shigella infection (CIII).
sensitive. Many Shigella strains resistant • Azithromycin 500 mg
PO daily for 5 days Oral or IV rehydration if
to fluoroquinolones exhibit resistance to
(BIII) (Note: not indicated (AIII).
other commonly used antibiotics. Thus,
antibiotic sensitivity testing of Shigella recommended for
patients with Anti-motility agents should
isolates from individuals with HIV should be avoided (BIII).
be performed routinely. bacteremia [AIII].)
Note: Azithromycin- If no clinical response after

resistant Shigella spp. 5–7 days, consider a follow-
has been reported in up stool culture, alternative
MSM with HIV. diagnosis, or antibiotic
resistance.
Effective ART may

decrease the risk of
recurrence of Shigella
infections.

Bartonellosis For Bacillary Angiomatosis, Peliosis For Bacillary When RIF is used, take into
Hepatis, Bacteremia, and Angiomatosis, Peliosis consideration the potential
Osteomyelitis Hepatis, Bacteremia, for significant interaction
and Osteomyelitis with ARV drugs and other
• Doxycycline 100 mg PO or IV every 12 medications (see Table 4
hours (AII), or • Azithromycin 500 mg for dosing
PO daily (BIII) recommendations).
• Erythromycin 500 mg PO or IV every 6
hours (AII) • Clarithromycin 500 mg
PO twice a day (BIII) If relapse occurs after initial
CNS Infections (>3 month) course of
Confirmed Bartonella therapy, long-term
• (Doxycycline 100 mg +/- RIF 300 mg) Endocarditis, but with suppression with
PO or IV every 12 hours (AIII) Renal Insufficiency doxycycline or a macrolide
is recommended as long as
Confirmed Bartonella Endocarditis • (Doxycycline 100 mg IV the CD4 count is <200
plus RIF 300 mg PO or cells/mm3 (AIII).
• (Doxycycline 100 mg IV every 12 hours
IV) every 12 hours for 2
plus gentamicin 1 mg/kg IV every 8
weeks, then continue
hours) for 2 weeks, then continue with
with doxycycline 100
doxycycline 100 mg IV or PO every 12
mg IV or PI every
hours (BII)
12 hours (BII)
Other Severe Infections
• (Doxycycline 100 mg PO or IV +/- RIF
300 mg PO or IV) every 12 hours (BIII),
or
• (Erythromycin 500 mg PO or IV every 6
hours) +/- RIF 300 mg PO or IV every
12 hours (BIII)
Duration of Therapy
• At least 3 months (AII)
Candidiasis (Mucocutaneous) For Oropharyngeal Candidiasis; Initial For Oropharyngeal Chronic or prolonged use of
Episodes (for 7–14 Days) Candidiasis; Initial azoles may promote
Episodes (for 7–14 development of resistance.
Oral Therapy
Days)
• Fluconazole 100 mg PO daily (AI) Higher relapse rate for
Oral Therapy esophageal candidiasis is
For Esophageal Candidiasis (for 14–21 • Itraconazole oral seen with echinocandins
Days) solution 200 mg PO than with fluconazole use.
daily (BI), or
• Fluconazole 100 mg (up to 400 mg) PO Suppressive therapy is
or IV daily (AI), or • Posaconazole oral usually not recommended
suspension 400 mg PO (BIII) unless patients have
• Itraconazole oral solution 200 mg PO
twice a day for 1 day, frequent or severe
daily (AI)
then 400 mg daily (BI) recurrences.
For Uncomplicated Vulvo-Vaginal If Decision Is to Use
Topical Therapy
Candidiasis Suppressive Therapy
• Clotrimazole troches,
• Oral fluconazole 150 mg for one dose Oropharyngeal Candidiasis
10 mg PO five times
(AII), or
daily (BI), or
• Topical azoles (clotrimazole, • Miconazole • Fluconazole 100 mg PO

butoconazole, miconazole, tioconazole, mucoadhesive buccal daily or three times
or terconazole) for 3–7 days (AII) 50-mg tablet; apply to weekly (BI), or
mucosal surface over
For Severe or Recurrent Vulvo-Vaginal the canine fossa once • Itraconazole oral solution
Candidiasis daily (do not swallow, 200 mg PO daily (CI)
chew, or crush tablet)
• Fluconazole 100–200 mg PO daily for Esophageal Candidiasis
(BI), or
≥7 days (AII), or
• Fluconazole 100–200 mg
• Nystatin suspension
• Topical antifungal ≥7 days (AII) PO daily (BI); or
4–6 mL four times a
day or one to two • Posaconazole 400 mg
flavored pastilles four PO twice a day (BII)
to five times daily (BII)
Vulvo-Vaginal Candidiasis
• Gentian violet
(0.00165%) topical • Fluconazole 150 mg PO
application twice daily once weekly (CII)
(BI)
For Esophageal
Candidiasis (for 14–21
Days)
• Voriconazole 200 mg
PO or IV twice a day
(BI), or
• Isavuconazole 200 mg
PO as a loading dose,
followed by 50 mg PO
daily (BI), or
PO as a loading dose,
followed by 100 mg PO
daily (BI), or
PO once weekly (BI),
or
• Anidulafungin 100 mg
IV one time, then 50
mg IV daily (BI), or
• Caspofungin 50 mg IV
daily (BI), or
• Micafungin 150 mg IV
daily (BI), or
• Amphotericin B
deoxycholate
0.6 mg/kg IV daily (BI),
or
• Lipid formulation of
amphotericin B 3–4
mg/kg IV daily (BIII)
For Uncomplicated
Vulvo-Vaginal
Candidiasis
• Itraconazole oral
solution 200 mg PO
daily for 3–7 days (BII)
For Azole-Refractory
Candida glabrata
Vaginitis
• Boric acid vaginal
suppository 600 mg
once daily for 14 days
Chagas Disease (American For Acute or Reactivated Disease None Treatment is effective in
Trypanosomiasis) reducing parasitemia and
• Benznidazole 5–8 mg/kg/day PO in two preventing clinical
divided doses for 60 days (BIII) symptoms or slowing
(commercially available at disease progression. These
http://www.benznidazoletablets.com/en; drugs have limited efficacy,
most experts recommend a daily however, in achieving
maximum of 300 mg), or parasitological cure.
• Nifurtimox (Lampit®) 8–10 mg/kg/day
PO in three divided doses for 60 days Treatment is not
(BIII) (commercially available through recommended for patients
retail sources) with advanced chagasic
cardiomyopathy.
Duration of therapy has not

been studied in patients
with HIV.
Initiation or optimization of
ART is recommended for all
people with HIV with
concomitant
Trypanosoma cruzi (AIII).
Coccidioidomycosis Mild to Moderate Pulmonary Infection Mild to Moderate Some patients with
Pulmonary Infection meningitis may develop
• Fluconazole 400 mg PO daily (AII), or hydrocephalus and require
For Patients Who Failed to
• Itraconazole 200 mg three times a day CSF shunting.
Respond to Fluconazole
for 3 days, then 200 mg PO twice a day or Itraconazole
(AII) Therapy should be lifelong
• Posaconazole delayed in patients with meningeal
• Duration of therapy: clinical response to release tablet 300 mg infections because relapse
3-6 months of therapy, and CD4 count PO twice a day for first occurs in 80% of patients
≥250 cells/mm3, and viral suppression day, then 300 mg PO with HIV after
on ARV (AII) once daily (BIII), or discontinuation of triazole

Severe Pulmonary or Extrapulmonary • Voriconazole 400 mg therapy (AII).
Infection (except meningitis) PO twice daily for first
day, then 200 mg PO See Table 4 for antifungal
• Lipid formulation amphotericin B 3–5 drug-drug interactions.
twice a day (BIII)
mg/kg IV daily (AIII); or
• Amphotericin B deoxycholate 0.7–1.0 Severe Pulmonary or Itraconazole, posaconazole,
mg/kg IV daily (AII) Extrapulmonary and voriconazole may have
Infection (except significant interactions with
• Continue until clinical improvement, meningitis) certain ARV agents. These
then switch to an azole (BIII). Therapy interactions are complex
should be continued for at least 12 • Some specialists will and can be bi-directional.
months and usually much longer, and add a triazole Refer to Drug–Drug
should be continued in patients with (fluconazole or Interactions in the Adult and
HIV viremia or with CD4 count <250 itraconazole, with Adolescent Antiretroviral
cells/mm3 (BIII) itraconazole preferred Guidelines for dosage
for bone disease) recommendations.
Meningeal Infections 400 mg per day to Therapeutic drug
• Fluconazole 400–800 mg IV or PO amphotericin B therapy monitoring and dosage
daily (AII) and continue triazole adjustment may be
once amphotericin B is necessary to ensure
• Duration of therapy: lifelong (AII) stopped (CIII). triazole antifungal and
antiretroviral efficacy and
Meningeal Infections reduce concentration-
• Itraconazole 200 mg related toxicities.
PO two or three times
daily (BII), or Intrathecal amphotericin B
should only be given in
• Voriconazole 200–400 consultation with a
mg PO twice a day specialist and administered
(BIII), or by an individual with
experience with the
• Posaconazole delayed
technique.
release tablet 300 mg
PO twice on first day,
then 300 mg PO daily
(CIII), or
• Isavuconazole sulfate
372 mg PO every 8 hrs
for 6 doses, then 372
mg daily (CIII)
• Intrathecal
amphotericin B
deoxycholate, when
triazole antifungals are
ineffective (AIII)
Community-Acquired Pneumonia Empiric antibiotic therapy should be Empiric antibiotic therapy Duration
(CAP) initiated promptly for patients presenting should be initiated
For most patients, 5–7 days
with clinical and radiographic evidence promptly for patients
consistent with bacterial pneumonia. The presenting with clinical Patients should be afebrile
recommendations listed are suggested and radiographic for 48–72 hours and
empiric therapy. The regimen should be evidence consistent with clinically stable before
modified as needed once microbiologic bacterial pneumonia. The
results are available (BIII). Providers must recommendations listed

also consider the risk of opportunistic lung are suggested empiric stopping antibiotics.
infections (e.g., PCP, TB), which may therapy. The regimen
alter the empiric therapy. should be modified as Longer duration is often
needed once required if severe CAP or
Empiric Outpatient Therapy microbiologic results are bacteremia is present, and
available (BIII). Providers particularly if due to
• A PO beta-lactam plus a PO macrolide S. pneumoniae or
must also consider the
(azithromycin or clarithromycin) (AII) complicated S. aureus
risk of opportunistic lung
infections (e.g., PCP, TB), pneumonia.
Preferred Beta-Lactams Fluoroquinolones should be
which may alter the
• High-dose amoxicillin or empiric therapy. used with caution in
amoxicillin/clavulanate patients in whom TB is
Empiric Outpatient suspected but is not being
Alternative Beta-Lactams Therapy treated.
• Cefpodoxime or cefuroxime, or • A PO beta-lactam plus Empiric therapy with a
PO doxycycline (CIII) macrolide alone is not
• Levofloxacin 750 mg PO once daily
(AII), or moxifloxacin 400 mg PO once routinely recommended,
Preferred Beta-Lactams because of increasing
daily (AII), especially for patients with
penicillin allergies • High-dose amoxicillin pneumococcal resistance
or (up to 30%) (BIII).
Empiric Therapy for Hospitalized amoxicillin/clavulanate
Patients with Non-Severe CAP Patients receiving a
Alternative Beta-Lactams macrolide for MAC
• An IV beta-lactam plus a macrolide prophylaxis may have
(azithromycin or clarithromycin) (AI) • Cefpodoxime or bacterial resistance to
cefuroxime macrolide due to chronic
Preferred Beta-Lactams exposure.
Empiric Therapy for
• Ceftriaxone, cefotaxime, or ampicillin- Hospitalized Patients For patients begun on IV
sulbactam with Non-Severe CAP antibiotic therapy, switching
• Levofloxacin 750 mg IV once daily (AI), to PO should be considered
• An IV beta-lactam plus
or moxifloxacin, 400 mg IV once daily when they are clinically
doxycycline (CIII)
(AI), especially for patients with improved and able to
penicillin allergies. Empiric Therapy for tolerate oral medications.
Hospitalized Patients
Empiric Therapy for Hospitalized Antibiotic chemoprophylaxis
with Severe CAP
Patients with Severe CAP is generally not
For Penicillin-Allergic recommended because of
• An IV beta-lactam plus IV azithromycin Patients the potential for developing
(AI), or drug resistance and drug
• Aztreonam IV plus toxicities (AI).
• An IV beta-lactam plus (levofloxacin (levofloxacin 750 mg IV
750 mg IV once daily or moxifloxacin once daily or
400 mg IV once daily) (AI) moxifloxacin 400 mg IV
once daily) (BIII)
Preferred Beta-Lactams
• Ceftriaxone, cefotaxime, or ampicillin- Empiric Therapy for
sulbactam Patients at Risk of
Pseudomonas
Pneumonia
• An IV
antipneumococcal,
antipseudomonal
beta-lactam plus an IV

Empiric Therapy for Patients at Risk of aminoglycoside plus
Pseudomonas Pneumonia azithromycin (BII), or
• An IV antipneumococcal, • An IV
antipseudomonal beta-lactam plus antipneumococcal,
(ciprofloxacin 400 mg IV every 8–12 antipseudomonal
hours or levofloxacin 750 mg IV once beta-lactam plus an
daily) (AI) aminoglycoside plus
(levofloxacin 750 mg IV
Preferred Beta-Lactams once daily or
moxifloxacin 400 mg IV
• Piperacillin-tazobactam, cefepime,
once daily) (BIII)
imipenem, or meropenem
For Penicillin-Allergic
Empiric Therapy for Patients at Risk
Patients
for Methicillin-Resistant
Staphylococcus aureus Pneumonia • Replace the beta-
lactam with aztreonam
• Add vancomycin IV or linezolid (IV or
(BIII).
PO) to the baseline regimen (AII).
• Addition of clindamycin to vancomycin
(but not to linezolid) can be considered
for severe necrotizing pneumonia to
minimize bacterial toxin production
(CII).
Cryptococcosis Cryptococcal Meningitis Cryptococcal Meningitis Addition of flucytosine to

amphotericin B has been
Induction Therapy (2 weeks, followed by Induction Therapy (for at
associated with more rapid
consolidation therapy) least 2 weeks, followed by
sterilization of CSF and
consolidation therapy)
• Liposomal amphotericin B 3–4 mg/kg decreased risk for
IV daily plus flucytosine 25 mg/kg PO • Amphotericin B lipid subsequent relapse.
four times a day (AI) (Note: Flucytosine complex 5 mg/kg IV
dose should be adjusted in patients daily plus flucytosine Patients receiving
with renal dysfunction.) 25 mg/kg PO four times flucytosine should have
a day (BII), or either blood levels
• Amphotericin B deoxycholate 0.7–1.0 monitored (peak level
mg/kg IV daily plus flucytosine • Liposomal 2 hours after dose should
25 mg/kg PO four times a day (AI) (if amphotericin B be 25–100 mcg/mL) or at
cost is an issue and the risk of renal 3–4 mg/kg IV daily plus least twice weekly
dysfunction is low), or fluconazole 800–1,200 monitoring of complete
mg PO or IV daily blood counts for cytopenia.
• If not improved clinically or remain (BIII), or
clinically unstable, continue induction Dosage should be adjusted
therapy until the CSF culture is • Fluconazole 1,200 mg in patients with renal
confirmed to be negative (BIII). PO or IV daily plus insufficiency (BII).
flucytosine 25 mg/kg
Consolidation Therapy (for at least In resource-limited settings,
PO four times a day
8 weeks (AI), followed by maintenance induction of 1 week of
(BII), or
therapy) amphotericin B
• Fluconazole 800 mg deoxycholate with
• Fluconazole 800 mg PO (or IV) daily PO or IV daily plus flucytosine followed by high
(AI) flucytosine 25 mg/kg dose fluconazole is
PO four times a day preferred (BIII).
(BIII), or
Opening pressure should
• For clinically stable patients with • Amphotericin B always be measured when

negative CSF cultures, dose can be deoxycholate an LP is performed.
reduced to 400 mg PO once daily (AII) 0.7–1.0 mg/kg IV daily Repeated LPs or CSF
plus fluconazole 800– shunting are essential to
• If CSF remains positive (but clinically 1,200 mg PO or IV effectively managing
stable) after 2 weeks of induction daily (BI), or increased intracranial
therapy, increase fluconazole dose to pressure.
1,200 mg and perform LP 2 weeks later • Liposomal
(BIII); duration of consolidation therapy amphotericin B Corticosteroids and
should be 8 weeks from the time of 3–4 mg/kg IV daily (BI), mannitol are ineffective in
negative CSF culture (AI). or reducing ICP and are not
• Amphotericin B recommended (AIII).
Maintenance Therapy
deoxycholate
• Fluconazole 200 mg PO daily for ≥1 Some specialists
0.7–1.0 mg/kg IV once
year from initiation of antifungal therapy recommend a brief course
daily alone (BI), or
(AI) of tapering dose of
• Liposomal corticosteroid for
For Non-CNS, Extrapulmonary amphotericin B management of severe IRIS
Cryptococcosis and Diffuse Pulmonary 3–4 mg/kg IV once symptoms (BIII).
Disease or Patients with Isolated daily plus flucytosine
Asymptomatic Antigenemia Without 25 mg/kg PO four times
Meningitis and Serum CrAg. ≥1:640 by a day for 1 week
LFA followed by fluconazole
1,200 mg PO once
• Treatment same as for cryptococcal daily (BIII), or
meningitis (BIII)
• Fluconazole 1,200 mg
Non-CNS Cryptococcosis with Mild to PO or IV daily (CI)
Moderate Symptoms and Focal
Pulmonary Infiltrates, or Patients with Consolidation Therapy (for
Isolated Asymptomatic Antigenemia at least 8 weeks (AI),
Without Meningitis and Serum CrAg followed by maintenance
≤1:320 by LFA) therapy)
• Fluconazole, 400 to 800 mg PO daily • If patient’s CSF culture
for 10 weeks, followed by 200 mg daily remains positive at the
for a total of 6 months (BIII) end of 2 weeks, but the
patient is not ill enough
to be hospitalized,
continue flucytosine for
an additional 2 weeks
with fluconazole
1,200 mg daily, before
starting a single-drug
consolidation regimen.
• Itraconazole 200 mg
PO twice a day for 8
weeks—less effective
than fluconazole (CI)
Maintenance Therapy
• No alternative therapy
recommendation

Cryptosporidiosis • Aggressive oral and/or IV rehydration No therapy has been Tincture of opium may be
and replacement of electrolyte loss shown to be effective more effective than
(AIII), and without ART. Consider loperamide in management
trial of these agents in of diarrhea (CIII).
• Symptomatic treatment of diarrhea with conjunction with ART,
anti-motility agents (AIII), and Because diarrhea can
rehydration, and
cause lactase deficiency,
• Initiate ART to achieve immune symptomatic treatment:
patients should avoid milk
restoration to CD4 count • Nitazoxanide 500– products (CIII).
>100 cells/mm3 (AII). 1,000 mg PO twice a
day with food for at
least 14 days (CIII), or
• Paromomycin 500 mg
PO four times daily for
14–21 days (CIII)
Cytomegalovirus (CMV) Disease CMV Retinitis Induction Therapy CMV Retinitis The choice of therapy for
(followed by chronic maintenance CMV retinitis should be
For Immediate Sight-
therapy) individualized, based on
Threatening Lesions
tolerance of systemic
For Immediate Sight-Threatening Lesions (within 1,500 microns of
medications, prior exposure
(within 1,500 microns of the fovea) the fovea): Intravitreal
to anti-CMV drugs, and
therapy as listed in the
• Ganciclovir 5 mg/kg every 12 hours IV location of the lesion (AIII).
Preferred section, plus
or valganciclovir 900 mg PO twice a one of the following:
day or for 14–21 days (AI) (some prefer Initial therapy in patients
IV ganciclovir initially and transition to Alternative Systemic with CMV retinitis,
PO valganciclovir when there is Induction Therapy esophagitis, colitis, and
evidence of clinical response) with or (followed by chronic pneumonitis should include
without maintenance therapy) initiation or optimization of
ART (BIII).
• Intravitreal injections of ganciclovir (2 • Foscarnet 90 mg/kg IV
mg) or foscarnet (2.4 mg) to rapidly every 12 hours or 60 Given the evident benefits
achieve high intraocular concentration, mg/kg every 8 hours for of systemic therapy in
continue weekly until lesion inactivity is 14–21 days (BI), or preventing contralateral eye
achieved (AIII); plus involvement, reduce CMV
• Cidofovir 5 mg/kg/week
visceral disease and
For Peripheral Lesions IV for 2 weeks; saline
improve survival. Whenever
hydration before and
• Valganciclovir 900 mg PO twice a day feasible, treatment should
after therapy and
for 14–21 days, then 900 mg once daily include systemic therapy.
probenecid, 2 g PO 3
(AI) hours before dose, The ganciclovir ocular
followed by 1 g PO implant, which is effective
Maintenance Therapy 2 hours and 8 hours for treatment of CMV
• Valganciclovir 900 mg PO daily (AI) for after the dose (total of retinitis, is no longer
3–6 months until ART induced immune 4 g) (CI) (Note: This available.
recovery regimen should be
avoided in patients with Routine (i.e., every
CMV Esophagitis or Colitis sulfa allergy because of 3 months) ophthalmologic
cross hypersensitivity follow-up is recommended
• Ganciclovir 5 mg/kg IV every 12 hours; with probenecid.) after stopping chronic
may switch to valganciclovir 900 mg
maintenance therapy for
PO every 12 hours once the patient can
early detection of relapse or
tolerate oral therapy (BI)
IRU, and then periodically
after sustained immune
• Valganciclovir 900 mg PO every Chronic Maintenance reconstitution (AIII).

12 hours may be considered as initial (for 3–6 months until
therapy in mild diseases (CIII). ART-induced immune IRU may develop in the
recovery) setting of immune
• Duration: 21–42 days or until symptoms reconstitution.
have resolved (CII) • Foscarnet 90–120
mg/kg IV once daily Treatment of IRU
• Maintenance therapy is usually not (AI), or
necessary but should be considered Periocular, intravitreal, or
after relapses (BII). • Cidofovir 5 mg/kg IV short courses of systemic
every other week with steroid (BIII)
Well-Documented, Histologically saline hydration and
Confirmed CMV Pneumonia probenecid as above
(BI)
• Experience for treating CMV
pneumonitis in HIV patients is limited. CMV Esophagitis or
Use of IV ganciclovir or IV foscarnet is Colitis
reasonable (doses same as for CMV
retinitis) (CIII). • Foscarnet 90 mg/kg IV
every 12 hours or
• The optimal duration of therapy and the 60 mg/kg every 8 hours
role of oral valganciclovir have not been (BI) for patients with
established. treatment-limiting
toxicities to ganciclovir
CMV Neurological Disease
or with ganciclovir
Note: Treatment should be initiated resistance, or
promptly.
• Valganciclovir 900 mg
• Ganciclovir 5 mg/kg IV every 12 hours PO every 12 hours in
plus (foscarnet 90 mg/kg IV every 12 milder disease and if
hours or 60 mg/kg IV every 8 hours) to able to tolerate PO
stabilize disease and maximize therapy (BII), or
response, continue until symptomatic
• Duration: 21–42 days
improvement and resolution of
or until symptoms have
neurologic symptoms (CIII)
resolved (CII)
• The optimal duration of therapy and the
• For mild disease, if
role of oral valganciclovir have not been
ART can be initiated
established.
without delay, consider
withholding CMV
therapy (CIII).
Hepatitis B Virus (HBV) Disease ART is recommended for all patients with For Persons Not on ART Directly acting HBV drugs—
HIV/HBV coinfection regardless of CD4 such as adefovir,
cell count (AIII). • Anti-HBV therapy is emtricitabine, entecavir,
indicated for those who lamivudine, telbivudine, or
The ART regimen must include two drugs meet criteria for tenofovir—must not be
that are active against both HBV and HIV treatment according to given in the absence of a
(AIII). the AASLD Hepatitis B fully suppressive ART
Guidance. regimen to avoid selection
If CrCl ≥60 mL/min: • Peginterferon alfa-2a of drug-resistant HIV (AII).
• (TDF 300 mg plus [FTC 200 mg or 3TC 180 mcg SQ once
weekly for 48 weeks Cross-resistance to
300 mg]) or (TAF [10 or 25 mg]a plus
(CIII), or emtricitabine or telbivudine
FTC 200 mg) PO once daily (AII)
should be assumed in
patients with suspected or

Note: TAF 10 mg is in the STR tablets of • Peginterferon alfa-2b proven lamivudine
EVG/COBI/TAF/FTC and 1.5 mcg/kg SQ once resistance.
DRV/COBI/TAF/FTC; when TAF is used weekly for 48 weeks
with other ARVs, the dose is 25 mg. (CIII) When changing ART
regimens, continue agents
If CrCl 30–59 mL/min: with anti-HBV activity (AIII).
• TAF (10 or 25 mg)a plus FTC 200 mg If anti-HBV therapy is
PO once daily (AII) discontinued and a flare
If CrCl <30 mL/min, not on HD: occurs, therapy should be
re-instituted because it can
• Renally dosed entecavir (in place of be potentially lifesaving
TDF or TAF), or (AIII).
• ART with renally dose-adjusted TDF Because HBV reactivation
and FTC can be used (BIII) if recovery can occur during treatment
of renal function is unlikely. for HCV with direct-acting
antivirals in the absence of
If on HD: anti-HBV therapy, all people
• (TDF or TAF) plus (FTC or 3TC) can be with HIV/HBV coinfection
used. Refer to Table 6 for dosing who will be treated for HCV
infection should be on HBV-
recommendation.
active ART at the time of
Duration HCV treatment initiation
(AIII).
• Continue treatment indefinitely (BIII).
If immunosuppressive
therapy is given, HBV
reactivation can occur. For
people who are HBsAg-
positive, treatment for HBV
infection should be
administered (AII).
Hepatitis C Virus (HCV) Disease For Treatment-Naive Patients Without For Treatment-Naive Simplified approach to HCV
Cirrhosis (Any Genotype or No Pre- Patients with treatment can be used in
Treatment Genotype) Compensated Cirrhosis treatment-naive patients
(Recommendations with any genotype and
• Glecaprevir/pibrentasvir FDC (100 Based on Genotypes) without cirrhosis. This
mg/40 mg per tablet), three tablets daily approach includes
for 8 weeks (AI), or Genotypes 1, 2, 4–6
standardized treatment,
• Sofosbuvir/velpatasvir FDC (400 • Glecaprevir/pibrentasvir with no on-treatment testing
mg/100 mg per tablet), one tablet daily FDC (100 mg/40 mg or in-person follow-up and
for 12 weeks (AI) per tablet), three limited follow-up to confirm
tablets daily for 12 SVR.
Characteristics that exclude patients from weeks (CI)
receiving simplified approach to therapy See Hepatitis C Virus
are outlined in Box 1 of the Hepatitis C Genotype 3 section to review a
Virus section. summary of drug–drug
• Glecaprevir/pibrentasvir interactions between HCV
FDC (100 mg/40 mg therapy and ARV drugs.
For Treatment-Naive Patients with
per tablet), three
Compensated Cirrhosis
tablets daily for 12 HCV treatment should not
(Recommendations Based on
weeks (CI) or be withheld solely due to
Genotypes)
perceived lack of

Genotypes 1, 2, 4–6 • Sofosbuvir/velpatasvir adherence to ART or
FDC (400 mg/100 mg untreated HIV (BIII).
• Glecaprevir/pibrentasvir FDC (100
per tablet), one tablet
mg/40 mg per tablet), three tablets daily Effort should be made to
daily with or without
for 8 weeks (AIII), or document SVR (HCV RNA
ribavirin for 12 weeks
• Sofosbuvir/velpatasvir FDC (400 pending results of less than lower limits of
mg/100 mg per tablet), one tablet daily NS5A RAS testing (CI) quantification) at least
for 12 weeks (AI) 12 weeks after completion of
therapy (AI). Patients
Genotype 3 without cirrhosis who
achieve SVR do not require
• Glecaprevir/pibrentasvir FDC (100 continued liver disease
mg/40 mg per tablet), three tablets daily monitoring.
for 8 weeks (AIII)
Recommendations for
For Treatment of Acute HCV Infection treatment after DAA failure
• Glecaprevir/pibrentasvir FDC (100 are not provided. The
mg/40 mg per tablet), three tablets daily reader is referred to the
for 8 weeks (AII) or corresponding section in
the AASLD/IDSA HCV
• Sofosbuvir/velpatasvir FDC (400 treatment guidance.
mg/100 mg per tablet), one tablet daily
for 12 weeks (AII)
Herpes Simplex Virus (HSV) Disease Orolabial Lesions (for 5–10 Days) For Acyclovir-Resistant Patients with HSV infection
HSV can be treated with episodic
• Valacyclovir 1 g PO twice a day (AIII), therapy when symptomatic
or Preferred Therapy
lesions occur, or with daily
• Famciclovir 500 mg PO twice a day • Foscarnet 80– suppressive therapy to
(AIII), or 120 mg/kg/day IV in prevent recurrences.
two to three divided
• Acyclovir 400 mg PO three times a day doses until clinical Extemporaneous
(AIII) response (AI) compounding of topical
products can be prepared
Initial or Recurrent Genital HSV (for 5– Alternative Therapy (CIII) using trifluridine ophthalmic
14 days) solution and the IV
• IV cidofovir (dosage as formulation of cidofovir and
• Valacyclovir 1 g PO twice a day (AI), or in CMV retinitis), or foscarnet.
• Famciclovir 500 mg PO twice a day • Topical trifluridine 1%
(AI), or three times a day, or An expanded access
program of oral pritelivir is
• Acyclovir 400 mg PO three times a day • Topical cidofovir 1% now available for
(AI) once daily, or immunocompromised
patients with acyclovir-
Severe Mucocutaneous HSV • Topical imiquimod 5%
resistant HSV infection. For
three times weekly, or
• Initial therapy acyclovir 5 mg/kg IV more information, see the
every 8 hours (AIII) • Topical foscarnet 1% AiCuris Pritelivir website.
five times daily
• After lesions begin to regress, change
to PO therapy as above. Continue until Duration of Therapy
lesions are completely healed.
• 21–28 days or longer
Chronic Suppressive Therapy
For Patients with Severe Recurrences of

Genital Herpes (AI) or Patients Who Want
to Minimize Frequency of Recurrences
(AI)
• Valacyclovir 500 mg PO twice a day
(AI), or
• Famciclovir 500 mg PO twice a day
(AI), or
• Acyclovir 400 mg PO twice a day (AI)
• Continue indefinitely, regardless of CD4
count.
Histoplasmosis Moderately Severe to Severe Moderately Severe to Itraconazole, posaconazole,

Disseminated Disease Severe Disseminated and voriconazole may have
Disease significant interactions with
Induction Therapy
certain ARV agents. These
Induction Therapy (for at
• For at least 2 weeks or until clinically least 2 weeks or until interactions are complex
improved and can be bi-directional.
clinically improved)
Refer to Drug–Drug
• Liposomal amphotericin B 3 mg/kg IV • Amphotericin B lipid Interactions in the Adult and
daily (AI) complex 5 mg/kg IV Adolescent Antiretroviral
daily (AIII), or Guidelines for dosage
recommendations.
Maintenance Therapy Alternatives to
Itraconazole for Therapeutic drug
• Itraconazole 200 mg PO three times a
Maintenance Therapy or monitoring and dosage
day for 3 days, then 200 mg PO twice a
Treatment of Less adjustment may be
day (AII)
Severe Disease necessary to ensure
Less Severe Disseminated Disease triazole antifungal and ARV
• Posaconazole
efficacy and reduce
Induction and Maintenance Therapy extended release 300
concentration-related
mg PO twice a day for
• Itraconazole 200 mg PO three times a toxicities.
1 day, then 300 mg PO
day for 3 days, then 200 mg PO twice a once daily (BIII) Random serum
day (AII)
• Voriconazole 400 mg concentration of
Duration of Therapy PO twice a day for 1 itraconazole between
day, then 200 mg twice 1–2 mcg/mL is
• At least 12 months recommended. Frequency
a day (BIII), or
and severity of toxicities
Meningitis • Fluconazole 800 mg increase when
Induction Therapy (4–6 weeks) PO daily (CII) concentration is >4
Meningitis (These mcg/mL.
• Liposomal amphotericin B 5 mg/kg/day
(AIII) Recommendations Are
Acute pulmonary
Based on Limited
Maintenance Therapy histoplasmosis in patients
Clinical Data for Patients
with HIV with CD4 counts
• Itraconazole 200 mg PO twice a day to with Intolerance to
>300 cells/mm3 should be
three times a day for ≥12 months and Itraconazole)
managed as non-
until resolution of abnormal CSF • Posaconazole immunocompromised host
findings (AII) extended release 300 (AIII).
mg PO twice a day for
Long-Term Suppression Therapy
For patients with severe disseminated or

CNS infection (AIII) after completion of at 1 day, then 300 mg PO
least 12 months of therapy and who once daily (BIII)
relapse despite appropriate therapy (BIII)
• Itraconazole 200 mg PO daily (AIII) PO twice a day for 1
day, then 200 mg twice
a day (BIII), or
• Fluconazole 800 mg
PO daily (CII)
Long-Term Suppression
Therapy
• Posaconazole 300 mg
extended release tablet
PO once daily (BIII)
PO twice daily (BIII)
• Fluconazole 400 mg
PO once daily (CII)
Human Herpesvirus-8 Diseases Mild to Moderate KS (Localized MCD Corticosteroids should be

Involvement of Skin and/or Lymph avoided in patients with KS,
(Kaposi Sarcoma [KS], Primary Effusion • Rituximab (375 mg/m2
Nodes) including those with KS-
Lymphoma [PEL], Multicentric given weekly for IRIS (AIII).
Castleman’s Disease [MCD]) • Initiate or optimize ART (AII). 4–8 weeks) may be an
alternative to or used Corticosteroids are
Advanced KS (Visceral [AI] or adjunctively with potentially effective as
Disseminated Cutaneous KS [BIII)] antiviral therapy (CII). adjunctive therapy for MCD,
• Chemotherapy (per oncology consult) but should be used with
plus ART caution, especially in
patients with concurrent KS.
• Liposomal doxorubicin first-line
chemotherapy (AI) Patients who received
rituximab for MCD may
Primary Effusion Lymphoma experience subsequent
• Chemotherapy (per oncology consult) exacerbation or emergence
plus ART (AIII) of KS.
• PO valganciclovir or IV ganciclovir can

be used as adjunctive therapy (CIII)
MCD Therapy Options (in Consultation

with Specialist, Depending on
HIV/HHV-8 Status, Presence of Organ
Failure, and Refractory Nature of
Disease)
ART (AIII) along with one of the following:
• Valganciclovir 900 mg PO twice a day
for 3 weeks (CII), or
• Ganciclovir 5 mg/kg IV every 12 hours
for 3 weeks (CII), or
• Valganciclovir PO or Ganciclovir IV plus

zidovudine 600 mg PO every 6 hours
for 7–21 days (CII)
• Rituximab +/- Prednisone (CII)
• Monoclonal antibody targeting IL-6 or
IL-6 receptor (BII)
Concurrent KS and MCD

• Rituximab plus liposomal doxorubicin
(BII)
Human Papillomavirus (HPV) Disease Treatment of Condyloma Acuminata (Genital Warts) Patients with HIV may have
larger or more numerous
Patient-Applied Therapy for Provider-Applied warts and may not respond
Uncomplicated External Warts That Therapy for Complex or as well to therapy for genital
Can Be Easily Identified by Patients Multicentric Lesions, or warts when compared to
Lesions Inaccessible to individuals without HIV.
• Podophyllotoxin (e.g., podofilox 0.5% Patient
solution or 0.5% gel): Apply to all Topical cidofovir has activity
lesions twice a day for 3 consecutive Applied Therapy against genital warts, but
days, followed by 4 days of no therapy, the product is not
• Cryotherapy (liquid
repeat weekly for up to 4 cycles, until commercially available
nitrogen or cryoprobe):
lesions are no longer visible (BIII), or (CIII).
Apply until each lesion
• Imiquimod 5% cream: Apply to lesion at is thoroughly frozen.
bedtime and remove in the morning on Repeat every Intralesional interferon-
3 nonconsecutive nights weekly for up 1–2 weeks for up to alpha is usually not
to 16 weeks, until lesions are no longer 4 weeks, until lesions recommended because of
visible. Each treatment should be are no longer visible high cost, difficult
washed with soap and water 6–10 (BIII). Some providers administration, and
hours after application (BII), or allow the lesion to potential for systemic side
thaw, then freeze a effects (CIII).
• Sinecatechins 15% ointment: Apply to second time in each
affected areas three times a day for up session (BIII), or The rate of recurrence of
to 16 weeks, until warts are completely genital warts is high despite
cleared and not visible (BIII). • Trichloroacetic acid or treatment in patients with
bichloroacetic acid HIV.
cauterization: 80%–
90% aqueous solution, There is no consensus on
apply to wart only, the treatment of oral warts.
allow to dry until a Many treatments for
white frost develops. anogenital warts cannot be
Repeat weekly for up to used in the oral mucosa.
6 weeks, until lesions Surgery is the most
are no longer visible common treatment for oral
(BIII), or warts that interfere with
function or for aesthetic
• Surgical excision (BIII) reasons.
or laser surgery (CIII) to
external or anal warts,
or
• Podophyllin resin 10%–

25% in tincture of
benzoin: Apply to all
lesions (up to 10 cm2),
then wash off a few
hours later, repeat
weekly for up to 6
weeks until lesions are
no longer visible (CIII).
Isosporiasis For Acute Infection For Acute Infection Fluid and electrolyte
(Cystoisosporiasis) management in patients
• TMP-SMX (160 mg/800 mg) PO (or IV) • Pyrimethamineb 50–75 with dehydration (AIII).
four times a day for 10 days (AII), or mg PO daily plus
leucovorin 10–25 mg Nutritional supplementation
• TMP-SMX (160 mg/800 mg) PO (or IV) PO daily (BIII), or
twice a day for 7–10 days (BI) for malnourished patients
• Ciprofloxacin 500 mg (AIII).
• Can start with twice a day dosing first PO twice a day for 7
and increase daily dose and/or duration days (CI) as a second Immune reconstitution with
(up to 3–4 weeks) if symptoms worsen line alternative ART may result in fewer
or persist (BIII) relapses (AIII).
• IV therapy may be used for patients Chronic Maintenance
with potential or documented Therapy (Secondary
malabsorption. Prophylaxis)
• TMP-SMX (160 mg/
Chronic Maintenance Therapy 800 mg) PO daily or
(Secondary Prophylaxis) (320 mg/1,600 mg)
• In patients with CD4 count <200/mm3, three times weekly
TMP-SMX (160 mg/800 mg) PO three (BIII)
times weekly (AI) • Pyrimethaminea 25 mg
PO daily plus
leucovorin 5–10 mg PO
daily (BIII)
• Ciprofloxacin 500 mg
three times weekly (CI)
as a second-line
alternative
Leishmaniasis Visceral For Initial Infection For Initial Infection ART should be initiated or
optimized (AIII).
• Liposomal amphotericin B 2–4 mg/kg • Other lipid formulation
IV daily (AII), or of amphotericin B, dose For sodium stibogluconate,
and schedule as in contact the CDC Drug
• Liposomal amphotericin B interrupted Preferred Therapy, or
schedule (e.g., 4 mg/kg on days 1–5, Service at 404-639-3670 or
10, 17, 24, 31, 38) (AII) • Amphotericin B drugservice@cdc.gov.
deoxycholate 0.5–
• To achieve total dose of 20–60 mg/kg 1.0 mg/kg IV daily for For miltefosine, visit
(AII) total dose of 1.5–2.0 g https://www.impavido.com.
(BII), or
Chronic Maintenance Therapy
(Secondary Prophylaxis); Especially in • Sodium stibogluconate
Patients with CD4 Count <200 (pentavalent antimony)

cells/mm3 (BII) 20 mg/kg IV or IM
daily for 28 days.
• Liposomal amphotericin B 4 mg/kg
every 2–4 weeks (AII), or • Miltefosine—if 30–44
kg: 50 mg two times
• Amphotericin B lipid complex (AII) daily; if ≥45 kg, 50 mg
3 mg/kg every 21 days (AII) three times a day—for
28 days (CIII)
Chronic Maintenance
Therapy (Secondary
Prophylaxis)
• Sodium stibogluconate
20 mg/kg IV or IM
every 4 weeks (BII)
Cutaneous For Initial Infection Possible Options None

• Liposomal amphotericin B 2–4 mg/kg • Oral miltefosine (can
IV daily for 10 days (BIII), or be obtained via a
treatment IND), or
• Liposomal amphotericin B interrupted
schedule (e.g., 4 mg/kg on days 1–5, • Topical paromomycin,
10, 17, 24, 31, 38) to achieve total dose or
of 20–60 mg/kg (BIII), or
• Intralesional sodium
• Sodium stibogluconate 20 mg/kg IV or stibogluconate, or
IM daily for 3–4 weeks (BIII)
• Local heat therapy
No data exist for any of
May be indicated in immunocompromised these agents in patients
patients with multiple relapses (CIII) with HIV; choice and
efficacy are dependent on
species of Leishmania.
Malaria Because Plasmodium falciparum malaria When suspicion for For treatment
can progress within hours from mild malaria is low, antimalarial recommendations for
symptoms or low-grade fever to severe treatment should not be specific regions, clinicians
disease or death, all patients with HIV initiated until the diagnosis should refer to
with confirmed or suspected P. falciparum is confirmed. http://www.cdc.gov/malaria
infection should be hospitalized for or call the CDC Malaria
evaluation, initiation of treatment, and Hotline: 770-488-7788,
observation (AIII). Monday–Friday, 8 a.m.–
4:30 p.m. ET; or
Treatment recommendations for patients 7704887100 after hours.
with HIV are the same as for patients
without HIV (AIII).
Choice of therapy is guided by the degree

of parasitemia, the species of
Plasmodium, the patient’s clinical status,
region of infection, and the likely drug
susceptibility of the infected species, and
can be found at
https://www.cdc.gov/malaria.

Microsporidiosis For GI Infections Caused by For GI Infections Caused Anti-motility agents can be
Enterocytozoon bienuesi by E. bienuesi used for diarrhea control if
required (BIII).
• Initiate or optimize ART with immune • Fumagillin 60 mg/day
restoration to CD4 count >100 (BII) and TNP-470 (a
cells/mm3 (AII); plus synthetic analog of
fumagillin) (BIII) may
• Manage dehydration and diarrhea with be effective, but neither
fluid support (AII) and malnutrition and is available in the
wasting with nutritional supplement United States.
(AIII).
• Nitazoxanide (1,000
For Intestinal and Disseminated (Not mg twice daily) may
Ocular) Infections Caused by have some effect, but
Microsporidia Other Than E. bienuesi response may be
and Vittaforma corneae minimal in patients with
low CD4 counts (CIII).
• Albendazole 400 mg PO twice daily
(AII), continue until CD4 count
>200 cells/mm3 for >6 months after
initiation of ART (BIII)
For Disseminated Disease Caused by

Trachipleistophora or Anncaliia
• Itraconazole 400 mg PO daily plus
albendazole 400 mg PO twice daily
(CIII)
For Ocular Infection

• Topical fumagillin
bicylohexylammonium (Fumidil B)
eyedrops 3 mg/mL in saline (fumagillin
70 µg/mL): two eyedrops every 2 hours
for 4 days, then two eyedrops four
times daily (investigational use only in
United States) (BII) plus albendazole
400 mg PO twice daily, for
management of systemic infection (BIII)
If CD4 Count >200 Cells/mm3
• Continue until symptoms resolved
(CIII).
If CD4 Count ≤200 Cells/mm3
• Continue until resolution of ocular
symptoms and CD4 count increases to
>200 cells/mm3 for >6 months in
response to ART (BIII).
Mycobacterium avium At Least Two Drugs as Initial Therapy Some experts Testing of susceptibility to
Complex (MAC) Disease to Prevent or Delay Emergence of recommend addition of a clarithromycin and
Resistance third or fourth drug for azithromycin is
patients with high recommended (BIII).
mycobacterial loads
• Clarithromycin 500 mg PO two times (>2 log CFU/mL of blood), NSAIDs can be used for
daily (AI) plus ethambutol 15 mg/kg PO or in the absence of moderate to severe
daily (AI), or effective ART (CIII). symptoms attributed to IRIS
(CIII).
• If drug interaction or intolerance Third or Fourth Drug
precludes the use of clarithromycin, Options May Include If IRIS symptoms persist, a
azithromycin 500–600 mg plus short course (i.e.,
ethambutol 15 mg/kg PO daily (AII) • Rifabutin 300 mg PO 4 weeks–8 weeks) of a
daily (dose adjustment systemic corticosteroid
Duration may be necessary (equivalent to 20–40 mg
based on drug prednisone) can be used
• At least 12 months of therapy; can interactions) (CI), or
discontinue if no signs and symptoms (CII).
of MAC disease and sustained (>6 • A fluoroquinolone, such
months) CD4 count >100 cells/mm3 in as moxifloxacin 400 mg
response to ART. PO daily (CIII) or
levofloxacin 500 mg
PO daily (CIII), or
• An injectable
aminoglycoside such
as amikacin 10–15
mg/kg IV daily (CIII) or
streptomycin 1 g IV or
IM daily (CIII)
Mycobacterium tuberculosis (TB) After collecting a specimen for culture and Treatment for Drug- DOT is recommended for
Disease molecular diagnostic tests, empiric TB Resistant TB all patients (AII).
treatment should be started in individuals
Empiric therapy for All rifamycins may have
with clinical and radiographic presentation
resistance to rifamycin +/- significant pharmacokinetic
suggestive of TB (AIII).
other drugs interactions with ARV
Refer to the Dosing Recommendations for • INH plus PZA plus drugs; please refer to the
Anti-TB Drugs Recommendations table in EMB plus (moxifloxacin Dosing Recommendations
the Mycobacterium tuberculosis section or levofloxacin) plus for Anti-TB Drugs table in
for dosing recommendations. (linezolid or amikacin) the Mycobacterium
(BII) tuberculosis section and the
Initial Phase (8 weeks or 2 months, Drug–Drug Interactions
Given Daily by DOT) (AI) • Therapy should be section in the Adult and
modified once rifamycin Adolescent Antiretroviral
• INH (plus pyridoxine) plus (RIF or RFB) resistance is confirmed Guidelines for dosing
plus PZA plus EMB (AI) and based on drug recommendations.
• If drug susceptibility report shows susceptibility results to
sensitivity to INH and RFP, then EMB provide ≥5 drugs (BII). Therapeutic drug
can be discontinued before the end of monitoring should be
2 months (AI). Resistant to INH considered in patients
• (Moxifloxacin or receiving rifamycin and
Continuation Phase (Duration depends interacting ART.
levofloxacin) plus (RIF
on site and severity of infection [as
or RFB) plus EMB plus
noted below].) Adjunctive corticosteroids
PZA for 6 months (BII)
for TB meningitis (AII):
• INH (plus pyridoxine) plus (RIF or RFB) Dexamethasone
daily (AI) Resistance to Rifamycin
+/- Other Drugs 0.3–0.4mg/kg/day for
2–4 weeks, then taper by
• Therapy should be 0.1 mg/kg per week until
individualized based on 0.1 mg/kg, then 4 mg per

Total Duration of Therapy (for Drug- drug susceptibility day, and taper by
Susceptible TB) results and clinical and 1 mg/week for total of 12
microbiologic weeks.
• Pulmonary, Drug-Susceptible,
responses, to include
Uncomplicated TB Adjunctive corticosteroid is
≥5 active drugs, and
• 6 months (AI) with close consultation not recommended for
with experienced patients with TB
Pulmonary TB with Positive Culture After specialists (AIII). pericarditis.
2 Months of TB Treatment, or Severe
Cavitary or Disseminated Extrapulmonary Paradoxical IRIS that is not
TB severe can be treated with
NSAIDs without a change in
• 9 months (BII) TB or HIV therapy (BIII).
TB Meningitis See text for prednisone
• 9–12 months (BII) dosing recommendations
for preemptive treatment or
Extra-Pulmonary TB in Other Sites management of IRIS.
• 6 months (BII)
Pneumocystis Pneumonia (PCP) Patients who develop PCP despite TMP- For Moderate to Severe Indications for Adjunctive
SMX prophylaxis can usually be treated PCP Corticosteroids (AI)
with standard doses of TMP-SMX (BIII).
• Pentamidine 4 mg/kg • PaO2 <70 mmHg at room
Duration of PCP treatment: 21 days (AII) IV daily infused over air, or
≥60 minutes (AI); can
reduce dose to 3 mg/kg • Alveolar-arterial DO2
For Moderate to Severe PCP gradient >35 mmHg
IV daily in the event of
• TMP-SMX: (TMP 15–20 mg and SMX toxicities (BI), or
75–100 mg)/kg/day IV given every Prednisone Doses
6 hours or every 8 hours (AI); may • Primaquine 30 mg (Beginning as Early as
switch to PO formulations after clinical (base) PO daily plus Possible and Within
improvement (AI). (clindamycin 600 mg IV 72 Hours of PCP Therapy)
every 6 hours or 900 (AI)
For Mild to Moderate PCP mg IV every 8 hours) or
• Days 1–5: 40 mg PO
(clindamycin 450 mg
• TMP-SMX: (TMP 15–20 mg and SMX twice daily
PO every 6 hours or
75–100 mg)/kg/day, given PO in three 600 mg PO every 8 • Days 6–10: 40 mg PO
divided doses (AI), or hours) (AI) daily
• TMP-SMX: (160 mg/800 mg or DS) two • Days 11–21: 20 mg PO
tablets PO three times daily (AI) For Mild-to-Moderate
PCP daily
Secondary Prophylaxis, After • Dapsone 100 mg PO IV methylprednisolone can
Completion of PCP Treatment daily plus TMP 5 mg/kg be administered as 75% of
• TMP-SMX DS: One tablet PO daily PO three times a day prednisone dose.
(AI), or (BI), or
Benefit of corticosteroid if
• TMP-SMX (80 mg/400 mg or SS): One • Primaquine 30 mg started after 72 hours of
tablet PO daily (AI) (base) PO daily plus treatment is unknown, but
(clindamycin 450 mg some clinicians will use it
PO every 6 hours or for moderate to severe PCP
600 mg PO every 8 (BIII).
hours) (BI), or
• Atovaquone 750 mg Whenever possible,

PO twice daily with patients should be tested
food (BI) for G6PD before use of
dapsone or primaquine.
Secondary Prophylaxis, Alternative therapy should
After Completion of PCP be used in patients found to
Treatment have G6PD deficiency.
• TMP-SMX DS: One Patients who are receiving
tablet PO three times pyrimethaminea/sulfadiazine
weekly (BI), or for treatment or
• Dapsone 100 mg PO suppression of
daily (BI), or toxoplasmosis do not
require additional PCP
• Dapsone 50 mg PO prophylaxis (AII).
daily with
(pyrimethaminea 50 mg If TMP-SMX is discontinued
plus leucovorin 25 mg) because of a mild adverse
PO weekly (BI), or reaction, re-institution
should be considered after
• Dapsone 200 mg plus
the reaction resolves (AII).
pyrimethaminea 75 mg
The dose can be increased
plus leucovorin 25 mg
gradually (desensitization)
PO weekly (BI), or
(BI), reduced, or the
• Aerosolized frequency modified (CIII).
pentamidine 300 mg
monthly via Respirgard TMP-SMX should be
II™ nebulizer (BI), or permanently discontinued in
patients with possible or
• Atovaquone 1,500 mg definite Stevens-Johnson
PO daily (BI), or Syndrome or toxic
• Atovaquone 1,500 mg epidermal necrosis (AII).
plus pyrimethaminea 25
mg plus leucovorin 10
mg PO daily (CIII)
Progressive Multifocal There is no specific antiviral therapy for None Corticosteroids may be
Leukoencephalopathy (PML)/JC Virus JC virus infection. The main treatment used for PML-IRIS (BIII).
Infections approach is to reverse the The optimal corticosteroid
immunosuppression caused by HIV. regimen has not been
established but should be
Initiate ART immediately in ART-naive tailored to individual
patients (AII). patients.
Optimize ART to achieve viral ART should not be
suppression in patients who develop PML discontinued during PML-
and receive ART but remain viremic (AIII). IRIS (AIII).
Syphilis (Treponema pallidum Early-Stage (Primary, Secondary, and Early-Stage (Primary, The efficacy of non-
Infection) Early-Latent Syphilis) Secondary, and Early- penicillin alternatives has
Latent Syphilis) not been evaluated in
• Benzathine penicillin G 2.4 million units patients with HIV and they
IM for one dose (AII) For penicillin-allergic
should be used only with
patients
close clinical and serologic
Late-Latent Disease (>1 year or of

Unknown Duration and No Signs of • Doxycycline 100 mg monitoring.
Neurosyphilis) PO twice a day for 14
days (BII), or Combination of procaine
• Benzathine penicillin G 2.4 million units penicillin and probenecid is
IM weekly for three doses (AII) • Ceftriaxone 1 g IM or not recommended for
IV daily for 10–14 days patients who are allergic to
Late-Stage (Tertiary–Cardiovascular or (BII), or sulfa-containing
Gummatous Disease) medications (AIII).
• Azithromycin 2 g PO
• Benzathine penicillin G 2.4 million units for 1 dose (BII) (Note:
IM weekly for three doses (AII) (Note: The Jarisch-Herxheimer
Azithromycin is not
Rule out neurosyphilis before initiation reaction is an acute febrile
recommended for men
of benzathine penicillin and obtain reaction accompanied by
who have sex with men
infectious diseases consultation to headache and myalgia that
or for pregnant women
guide management.) can occur within the first
[AII].)
24 hours after therapy for
Neurosyphilis (Including Otic or Ocular Late-Latent Disease (>1 syphilis. This reaction
Disease) year or of Unknown occurs most frequently in
Duration, and No Signs patients with early syphilis,
• Aqueous crystalline penicillin G 18–24 high non-treponemal titers,
million units per day (administered as of Neurosyphilis)
and prior penicillin
3–4 million units IV q4h or by For penicillin-allergic treatment.
continuous IV infusion) for 10–14 days patients
(AII) +/- benzathine penicillin G
2.4 million units IM weekly for • Doxycycline 100 mg
three doses after completion of IV PO twice a day for 28
therapy (CIII) days (BIII)
Neurosyphilis
• Procaine penicillin
2.4 million units IM
daily plus probenecid
500 mg PO four times
a day for 10–14 days
(BII) +/- benzathine
penicillin G 2.4 million
units IM weekly for
three doses after
completion of above
(CIII), or
• For penicillin-allergic
patients,
desensitization to
penicillin is the
preferred approach
(BIII); if not feasible,
ceftriaxone, 2 g IV daily
for 10–14 days (BII).
Talaromycosis (Penicilliosis) Induction Therapy Induction Therapy Itraconazole is not

recommended as induction
• Liposomal amphotericin B • Amphotericin B therapy for talaromycosis
3–5 mg/kg/day IV (AI) deoxycholate (AI).
0.7 mg/kg/day IV for
Duration
2 weeks (if liposomal ART can be initiated as
• 2 weeks (AI), followed by consolidation amphotericin B is not early as 1 week after

therapy available) (AI) initiation of treatment for
talaromycosis (BIII).
Consolidation Therapy If Amphotericin B is Not
Available Itraconazole and
• Itraconazole 200 mg PO twice daily for voriconazole may have
10 weeks (AI), followed by chronic • Voriconazole 6 mg/kg
IV every 12 hours for 1 significant interactions with
maintenance therapy certain ARV agents. These
day (loading dose),
then 4 mg/kg IV every interactions are complex
12 hours (BII), or and can be bi-directional.
• Itraconazole 200 mg PO once daily, Refer to Drug–Drug
until CD4 count >100 cells/mm3 for • Voriconazole 600 mg Interactions in the Adult and
≥6 months (AII) PO twice daily for 1 day Adolescent Antiretroviral
(loading dose), then Guidelines for dosage
400 mg PO twice daily recommendations.
(BII)
TDM and dosage
Duration
adjustment may be
• 2 weeks (BII), followed necessary to ensure
by consolidation triazole antifungal and ARV
therapy with efficacy and reduce
itraconazole (preferred) concentration-related
or voriconazole toxicities. The goals of
itraconazole and
Consolidation Therapy voriconazole trough
concentrations are
>0.5 mcg/mL and
PO twice daily for 10
>1.0 mcg/mL, respectively.
weeks (BII), followed
by chronic
maintenance therapy
Chronic Maintenance
Therapy
• Itraconazole should be
used (AII). Chronic
maintenance therapy
with voriconazole has
not been studied.
Toxoplasma gondii Encephalitis Treatment of Acute Infection (AI) Treatment of Acute If pyrimethamine is
Infection unavailable or there is a
• Pyrimethaminea 200 mg PO one time, delay in obtaining it, TMP-
followed by weight-based therapy: • Pyrimethaminea SMX should be utilized in
(leucovorin)* plus place of pyrimethamine-
o If <60 kg: pyrimethaminea 50 mg PO
clindamycin 600 mg IV sulfadiazine (BI).
once daily plus sulfadiazine 1,000
or PO every 6 hours
mg PO every 6 hours plus
(AI), or For patients with a history
leucovorin 10–25 mg PO once daily
• TMP-SMX (TMP 5 of sulfa allergy, sulfa
o If ≥60 kg: pyrimethaminea 75 mg PO desensitization should be
mg/kg and SMX 25
once daily plus sulfadiazine 1,500 attempted using one of
mg/kg) IV or PO twice a
mg PO every 6 hours plus several published strategies
day (BI), or
leucovorin 10–25 mg PO once daily (BI).
• Leucovorin dose can be increased to • Atovaquone 1,500 mg Atovaquone should be

50 mg daily or twice a day. PO twice a day with administered until
food plus therapeutic doses of TMP-
Duration for Acute Therapy pyrimethaminea SMX are achieved (CIII).
(leucovorin)* (BII), or
• At least 6 weeks (BII); longer duration if Adjunctive corticosteroids
clinical or radiologic disease is • Atovaquone 1,500 mg (e.g., dexamethasone)
extensive or response is incomplete at PO twice a day with should only be administered
6 weeks food plus sulfadiazine when clinically indicated to
1,000–1,500 mg PO treat mass effect associated
• After completion of acute therapy, all
every 6 hours (weight- with focal lesions or
patients should be initiated on chronic
based dosing, as in associated edema (BIII);
maintenance therapy.
preferred therapy) (BII), discontinue as soon as
Chronic Maintenance Therapy or clinically feasible.
• Pyrimethaminea 25–50 mg PO daily • Atovaquone 1,500 mg
Anticonvulsants should be
plus sulfadiazine 2,000–4,000 mg PO PO twice a day with
administered to patients
daily (in 2–4 divided doses) plus food (BII)
with a history of seizures
leucovorin 10–25 mg PO daily (AI) (AIII) and continued through
Chronic Maintenance
Therapy acute treatment but should
not be used as seizure
• Clindamycin 600 mg prophylaxis (AIII).
PO every 8 hours plus
(pyrimethaminea 25–50 If clindamycin is used in
mg plus leucovorin place of sulfadiazine,
10–25 mg) PO daily additional therapy must be
(BI), or added to prevent PCP (AII).
• TMP-SMX DS one
tablet twice a day (BII),
or
• TMP-SMX DS one
tablet once daily (BII);
or
• Atovaquone 750–1,500
mg PO twice a day plus
(pyrimethaminea 25 mg
plus leucovorin 10 mg)
PO daily (BII), or
mg PO twice a day plus
sulfadiazine 2,000–
4,000 mg PO daily (in
2–4 divided doses
(BII), or
mg PO twice a day with
food (BII)
* Pyrimethaminea and
leucovorin doses are the
same as for preferred

therapy.
Varicella Zoster Virus (VZV) Disease Primary Varicella Infection Primary Varicella In managing VZV of the
(Chickenpox) Infection (Chickenpox) eyes, consultation with an
ophthalmologist
Uncomplicated Cases Uncomplicated Cases (for
experienced in
5–7 Days)
• Initiate as soon as possible after management of VZV
symptom onset and continue for 5–7 • Acyclovir 800 mg PO retinitis is strongly
days: five times a day (BII) recommended (AIII).
o Valacyclovir 1 g PO three times a Herpes Zoster Duration of therapy for VZV
day (AII), or (Shingles) retinitis is not well defined
o Famciclovir 500 mg PO three times and should be determined
Acute Localized based on clinical, virologic,
a day (AII) Dermatomal and immunologic responses
Severe or Complicated Cases • For 7–10 days; and ophthalmologic
• Acyclovir 10 mg/kg IV every 8 hours for consider longer responses.
7–10 days (AIII) duration if lesions are
slow to resolve Optimization of ART is
• May switch to oral valacyclovir, recommended for serious
famciclovir, or acyclovir after • Acyclovir 800 mg PO and difficult-to-treat VZV
defervescence if no evidence of five times a day (BII) infections (e.g., retinitis,
visceral involvement (BIII). encephalitis) (AIII).
Herpes Zoster (Shingles) In patients with herpes

zoster ophthalmicus who
Acute Localized Dermatomal have stromal keratitis and
• For 7–10 days; consider longer anterior uveitis, topical
duration if lesions are slow to resolve. corticosteroids to reduce
inflammation may be
• Valacyclovir 1 g PO three times a day necessary. The role of ART
(AII), or has not been established in
• Famciclovir 500 mg three times a day these cases.
(AII)
Extensive Cutaneous Lesion or

Visceral Involvement
• Acyclovir 10 mg/kg IV every 8 hours
until clinical improvement is evident
(AII)
• May switch to PO therapy (valacyclovir,
famciclovir, or acyclovir) after clinical
improvement (i.e., when no new vesicle
formation or improvement of signs and
symptoms of visceral VZV), to complete
a 10- to 14-day course (BIII).
ARN
• Acyclovir 10 mg/kg IV every 8 hours for
10–14 days, followed by valacyclovir 1
g PO three times a day for >14 weeks
(AIII), plus
• Intravitreal ganciclovir 2 mg/0.05 mL

twice weekly for 1–2 doses (BIII)
PORN
• Acyclovir 10 mg/kg IV every 8 hours or
ganciclovir 5 mg/kg IV every 12 hours
(AIII), plus
• ≥1 intravitreal antiviral injection:
ganciclovir 2 mg/0.05 mL or foscarnet
1.2 mg/0.05 mL twice weekly (AIII)
• Initiate or optimize ART (AIII).
a TAF 10 mg dose is in the fixed-dose combination tablets of elvitegravir/cobicistat/TAF/FTC and darunavir/cobicistat/TAF/FTC; when TAF is used
with other antiretrovirals, the dose is 25 mg.
b Refer to Daraprim Direct for information on accessing pyrimethamine.
For information regarding the evidence ratings, refer to the Rating System for Prevention and Treatment Recommendations in
the Introduction section of the Adult and Adolescent Opportunistic Infection Guidelines.
Key: 3TC = lamivudine; ARN = acute retinal necrosis; ART = antiretroviral therapy; ARV = antiretroviral; CD4 = CD4 T lymphocyte cell;
CDC = Centers for Disease Control and Prevention; CDI = Clostridium difficile infection; CFU = colony-forming unit; CNS = central nervous system;
COBI = cobicistat; CrCl = creatinine clearance; CSF = cerebrospinal fluid; CYP3A4 = Cytochrome P450 3A4; DOT = directly observed therapy;
DRV = darunavir; DS = double strength; EMB = ethambutol; EVG = elvitegravir; FDC = fixed dose combination; FTC = emtricitabine; g = gram;
G6PD = Glucose-6-phosphate dehydrogenase; GI = gastrointestinal; HD = hemodialysis; ICP = intracranial pressure; IM = intramuscular;
IND = investigational new drug; INH = isoniazid; IRIS = immune reconstitution inflammatory syndrome; IRU = immune reconstitution uveitis;
IV = intravenous; LP = lumbar puncture; MIC = minimum inhibitory concentrations; mg = milligram; mmHg = millimeters of mercury; MSM = men
who have sex with men; NSAID = non-steroidal anti-inflammatory drugs; PCR = polymerase chain reaction; PI = protease inhibitor; PO = oral;
PORN = progressive outer retinal necrosis; PZA = pyrazinamide; RFB = rifabutin; RIF = rifampin; SQ = subcutaneous; STR = single-tablet regimen;
SVR – sustained virologic response; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumerate; TMPSMX = trimethoprim-sulfamethoxazole;
TVR = telaprevir
Table 3. Indications for Discontinuing and Restarting Opportunistic Infection Secondary Prophylaxis or
Chronic Maintenance in Adults and Adolescents with HIV
Updated: July 1, 2021

Indication for
Indication for Indication for Discontinuing
Indication for Restarting
Opportunistic Discontinuing Secondary
Restarting Primary Secondary
Infection Primary Prophylaxis/Chronic
Prophylaxis Prophylaxis/Chronic
Prophylaxis Maintenance Therapy
Maintenance
Bacterial Enteric Not applicable Not applicable Resolution of Salmonella infection No recommendation
Infections: and after response to ART with
Salmonellosis sustained viral suppression and
CD4 counts >200 cells/mm3 (CII)
Bartonellosis Not applicable Not applicable • Received at least 3–4 months of No recommendation
treatment, and
• CD4 count >200 cells/µL for
≥6 months (CIII)
Some specialists would only

discontinue therapy if Bartonella
titers have also decreased by four-
fold (CIII).
Candidiasis Not applicable Not applicable If used, reasonable to discontinue No recommendation

(Mucocutaneous) when CD4 count >200 cells/mm3
(AIII).
Coccidioidomycosis CD4 count Restart at CD4 count Only for patients with focal No recommendation
≥250 cells/µL for ≥6 <250 cells/µL (BIII) coccidioidal pneumonia (AII):
months (CIII)
• Clinically responded to
≥12 months antifungal therapy,
with CD4 count >250 cells/mm3,
and receiving effective ART.
• Should continue monitoring for
recurrence with serial chest
radiographs and coccidioidal
serology.
For patients with diffuse
pulmonary (BIII), disseminated
non-meningeal (BIII), or meningeal
diseases (AII):
• Suppressive therapy should be
continued indefinitely, even with
increase in CD4 count on ART.
Cryptococcal Meningitis Not applicable Not applicable If the following criteria are fulfilled CD4 count <100 cells/
(BII): mm3 (AIII)
Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV C-1
Indication for
Maintenance
• Completed initial (induction and

consolidation) therapy, and
• Received at least 1 year of
antifungal therapy, and
• Remain asymptomatic of
cryptococcal infection, and
• CD4 count ≥100 cells/mm3 and
with suppressed plasma HIV
RNA in response to ART
Cytomegalovirus Not applicable Not applicable • CMV treatment for at least 3 to CD4 count
Retinitis 6 months; and with CD4 count <100 cells/mm3 (AIII)
>100 cells/mm3 for >3 to 6
months in response to ART
(AII).
• Therapy should be discontinued
only after consultation with an
ophthalmologist, taking into
account anatomic location of
lesions, vision in the
contralateral eye, and feasibility
of regular ophthalmologic
monitoring.
• Routine (i.e., every 3 months)
ophthalmologic follow-up is
recommended after stopping
therapy for early detection of
relapse or immune restoration
uveitis, and then periodically
after sustained immune
reconstitution (AIII).
Histoplasma capsulatum On ART, with CD4 For patients at high risk If the following criteria (AI) are CD4 count
Infection count >150 cells/mm3 of acquiring fulfilled: <150 cells/mm3 (BIII)
and undetectable HIV- histoplasmosis, restart
1 viral load for if CD4 count falls to • Received azole therapy for
6 months (BIII) <150 cells/mm3 (CIII) >1 year, and
• Negative fungal blood cultures,
and
• Serum or urine Histoplasma
antigen below the level of
quantification, and
• Undetectable HIV viral load, and
Indication for
Maintenance
• CD4 count ≥150 cells/mm3 for

≥6 months in response to ART
Isospora belli Infection Not applicable Not applicable Sustained increase in CD4 count No recommendation
to >200 cells/mm3 for >6 months in
response to ART and without
evidence of I. belli infection (BIII)
Leishmaniasis: Visceral Not applicable Not applicable There is no consensus regarding No recommendation
(and possibly cutaneous when to stop secondary
leishmaniasis in prophylaxis. Some investigators
immunocompromised suggest that therapy can be
patients with multiple stopped if CD4 count increases to
relapses) >200 to 350 cells/mm3 for 3 to
6 months in response to ART, but
others suggest that therapy should
be continued indefinitely.
Microsporidiosis Not applicable Not applicable No signs and symptoms of non- No recommendation
ocular (BIII) or ocular (CIII)
microsporidiosis and CD4 count
>200 cells/mm3 for >6 months in
response to ART.
Mycobacterium avium Initiation of effective CD4 count If the following criteria are fulfilled CD4 count
Complex Disease ART (AI) <50 cells/mm3: only if (AI): <100 cells/mm3 (AIII)
not on fully
suppressive ART (AIII) • Completed ≥12 months of
therapy, and
• No signs and symptoms of MAC
disease, and
• Have sustained (>6 months)
CD4 count >100 cells/mm3 in
response to ART.
Pneumocystis CD4 count increased CD4 count CD4 count increased from CD4 count
Pneumonia from <200 to <100 cells/mm3 (AIII) <200 cells/mm3 to >200 cells/mm3 <100 cells/mm3 (AIII)
>200 cells/mm3 for for >3 months in response to ART
CD4 count CD4 count
>3 months in response (BII).
100–200 cells/mm3 and 100–200 cells/mm3 and
to ART (AI)
HIV RNA above with HIV RNA above
Can consider when CD4 count is
detection limit of the detection limit of the
Can consider when 100–200 cells/mm3 if HIV RNA
assay (AIII). assay (AIII).
CD4 count is remains below limits of detection
100–200 cells/mm3 if for ≥3 months–6 months (BII).
HIV RNA remains
below limits of If PCP occurs at a CD4 count
detection for >200 cells/mm3 while not on ART,
≥3 months to discontinuation of prophylaxis can
6 months (BII). be considered once HIV RNA
levels are suppressed to below
Indication for
Maintenance
limits of detection for ≥3 months to
6 months (CIII).
If PCP occurs at a CD4 count

>200 cells/mm3 while on ART,
continue PCP prophylaxis for life,
regardless of how high the CD4
cell count rises as a consequence
of ART (BIII).
Talaromycosis CD4 count CD4 count CD4 count >100 cells/mm3 for CD4 count
(Penicilliosis) >100 cells/mm3 for <100 cells/mm3 (BIII)— ≥6 months in response to ART <100 cells/mm3 (BIII)
>6 months in response if patient is unable to (BII)
to ART (BII) have ART, or has
treatment failure or
or without access to
effective ART options, If achieved sustained HIV viral
If achieved sustained
and still resides in or suppression for >6 months (BIII)
HIV viral suppression
travels to the endemic
for >6 months (BIII)
area
Toxoplasma gondii CD4 count increased CD4 count Successfully completed initial CD4 count
Encephalitis to >200 cells/mm3 for <100 cells/mm3, (AIII) therapy, receiving maintenance <200 cells/mm3 (AIII)
>3 months in response therapy and remain free of signs
to ART (AI) CD4 count and symptoms of TE, and CD4
100–200 cells/µL and count >200 cells/mm3 for >6
Can consider when with HIV RNA above months in response to ART (BI).
CD4 count detection limit of the
100–200 cells/mm3 if assay (AIII).
HIV RNA remain

below limits of
detection for at least
3-6 months (BII)
For information regarding the evidence ratings, refer to the Rating System for Prevention and Treatment Recommendations in the Introduction
section of the Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV.
Key: ART = antiretroviral therapy; CD4 = CD4 T lymphocyte cell; CMV = cytomegalovirus; MAC = Mycobacterium avium complex;
PCP = Pneumocystis pneumonia; TE = Toxoplasma encephalitis
Opportunistic Infections
Updated: March 8, 2023

Reviewed: March 8, 2023
This table lists the known, predicted, or suspected pharmacokinetic (PK) interactions between drugs used for the
treatment or prevention of HIV-associated opportunistic infections (OIs). Many of the drugs listed in this table may
also interact with antiretroviral (ARV) drugs. Clinicians should see the Drug–Drug Interactions tables in the most
current Adult and Adolescent Antiretroviral Guidelines to assess interaction potentials between OI drugs and ARV
drugs.
Throughout the table, three recommendations are commonly used when concomitant administration of two drugs
may lead to untoward consequences. The rationales for these recommendations are summarized below:
Do not coadminister.
There is either strong evidence or strong likelihood that the PK interaction cannot be managed with a dose
modification of one or both drugs and will or may result in either—
• Increase in concentrations of one or both drugs, which may lead to excessive risk of toxicity; or
• Decrease in concentrations of one or both drugs, which may render one or both drugs ineffective.
Coadministration should be avoided, if possible.
There is a potential for significant PK interactions. If other more favorable options exist, clinicians are advised to
consider changing components of the regimen to accommodate a safer or more effective regimen. However,
coadministration of the drugs may be necessary when there are no other acceptable therapeutic options that provide a
more favorable benefit-to-risk ratio. Therapeutic drug monitoring, if available, may facilitate any necessary dose
adjustments.
Use with caution.
Drug combinations are recommended to be used with caution when—
• PK studies have shown a moderate degree of interaction of unknown clinical significance; or

• Based on the known metabolic pathway of the two drugs, there is a potential for PK interaction of unknown
clinical significance.
Rifamycin-Related Induction Interactions

Rifamycin antibiotics are potent inducers of Phase 1 and Phase 2 drug metabolizing reactions. They also affect
various transporters. When a rifamycin antibiotic must be combined with an interacting drug, close monitoring for
clinical efficacy of the coadministered agent is advised. Therapeutic drug monitoring, if available, may facilitate any
necessary dose adjustments.
• Rifampin (also known as rifampicin): Interactions may not be apparent in the first several days of rifampin
therapy. However, with daily doses of rifampin, enzyme induction increases over a week or more. Based on
limited data, larger daily doses of rifampin (e.g., 1,200 mg or more) appear to produce the same maximum
induction as lower doses, but the induction effect occurs more rapidly.
Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV D-1
• Rifabutin: In general, rifabutin as a cytochrome P450 3A4 (CYP3A4) inducer is about 40% of the potency of
rifampin, but this can vary by substrate and enzymatic reaction.
• Rifapentine: In general, daily rifapentine is at least as potent an inducer as rifampin. However, the potential for
drug interactions with once-weekly rifapentine is not well studied. Reduced exposure of concurrent drugs that
are CYP3A4 substrates is likely to occur with once-weekly rifapentine, with the extent varying by drug.
Pharmacodynamic Interactions
Pharmacodynamic interactions are not addressed in this table. For example, many of the drug classes listed below
independently possess a risk for QTc prolongation, including azoles, macrolides, and certain anti-tuberculosis and
antimalarial medications. Coadministration of drugs in these classes may require monitoring for QTc prolongation,
particularly in patients with predisposing risk factors.
Therapeutic Drug Monitoring

Drug interactions can alter oral absorption or systemic clearance of drugs. More than one interaction can occur at the
same time, with potentially opposing effects. Therapeutic drug monitoring (TDM), if available, may facilitate any
necessary dose adjustments in these complicated patients. TDM allows the clinician to make informed,
individualized decisions about dose adjustments that are more precise than standardized dose adjustments based
upon anticipated, average effects. Drug names below marked with asterisk (*) are known to have assays available in
the United States and, typically, in Europe as well.
Note: To avoid redundancy, drug–drug interactions are listed only once by primary drug (listed alphabetically).
Subsequently, when an interacting agent becomes the primary drug, guideline users are referred to the entry for the
initial primary drug. See the Clarithromycin row for the first example of this format.
Effect on Primary and/or

Primary Drug Interacting Agent Concomitant Drug Recommendations
Concentrations
Artemether/ Clarithromycin ↑ lumefantrine expected Coadministration should be avoided,
Lumefantrine if possible. Consider azithromycin in
place of clarithromycin.
Erythromycin ↑ lumefantrine possible Do not coadminister. Consider

azithromycin in place of
erythromycin.
Fluconazole ↑ lumefantrine possible Coadministration should be avoided,

if possible. If coadministered, monitor
for lumefantrine toxicities.
Isavuconazole ↑ lumefantrine possible Coadministration should be avoided,

Itraconazole ↑ lumefantrine expected Coadministration should be avoided,

Mefloquine ↓ lumefantrine possible If mefloquine is administered

immediately before
artemether/lumefantrine, monitor for
decreased efficacy of
artemether/lumefantrine and
encourage food intake.
Posaconazole ↑ lumefantrine expected Coadministration should be avoided,

Rifabutina ↓ artemether, DHA, and lumefantrine Use with caution. Monitor for
expected antimalarial efficacy.
Rifampina Artemether AUC ↓ 89% Do not coadminister.
DHA AUC ↓ 85%
Lumefantrine AUC ↓ 68%
Rifapentinea ↓ artemether, DHA, and lumefantrine Do not coadminister.

expected
Voriconazole ↑ lumefantrine expected Coadministration should be avoided,


Concentrations
Atovaquone* Doxycycline Atovaquone concentration Dose adjustment not established; if
↓ approximately equal to 40% with coadministered, instruct patient to
tetracycline take atovaquone with fatty meal and
monitor for decreased atovaquone
No interaction study with doxycycline efficacy.
Rifabutina Atovaquone Css ↓ 34% Dose adjustment not established; if

coadministered, instruct patient to
Rifabutin Css ↓ 19% take atovaquone with fatty meal and
monitor for decreased atovaquone
efficacy.
Rifampina Atovaquone Css ↓ 52% Do not coadminister.
Rifampin Css ↑ 37%
Rifapentinea ↓ atovaquone expected Do not coadminister.
Bedaquiline* Clarithromycin ↑ bedaquiline expected Do not coadminister. Consider

clarithromycin.
Erythromycin ↑ bedaquiline possible Do not coadminister. Consider

erythromycin.
Fluconazole ↑ bedaquiline possible Coadministration should be avoided,

for bedaquiline toxicities.
Isavuconazole ↑ bedaquiline possible Coadministration should be avoided,

Itraconazole ↑ bedaquiline expected Coadministration should be avoided,

If coadministration is required for

>14 days, weigh the benefits of
therapy against the risks of
bedaquiline toxicities.
Posaconazole ↑ bedaquiline expected Coadministration should be avoided,


Concentrations
Rifabutina ↔ bedaquiline If coadministered, separate time of
administration; perform rifabutin TDM
↓ rifabutin possible
and adjust dose accordingly.
Rifampina Bedaquiline AUC ↓ 53% Do not coadminister.
Rifapentinea Bedaquiline AUC ↓ 55% (with daily Do not coadminister.

rifapentine)
Voriconazole ↑ bedaquiline expected Coadministration should be avoided,

Caspofungin Rifabutina ↓ caspofungin possible Monitor for antifungal efficacy. Dose

not established. Consider increasing
caspofungin dose to 70 mg/day or
switch to another echinocandin
(e.g., micafungin or anidulafungin).
Rifampina Caspofungin Cmin ↓ 30% If coadministered, caspofungin dose

should be increased to 70 mg/day.
Consider alternative echinocandin
Rifapentinea Daily Rifapentine Monitor for antifungal efficacy. Dose

not established. Consider increasing
• ↓ caspofungin expected caspofungin dose to 70 mg/day or
switch to another echinocandin
Weekly Rifapentine
• ↓ caspofungin possible
Chloroquine* Clarithromycin ↑ chloroquine expected Do not coadminister. Consider

clarithromycin.
Erythromycin ↑ chloroquine possible Do not coadminister. Consider

erythromycin.
Fluconazole ↑ chloroquine possible Coadministration should be avoided,

for chloroquine toxicities.
Isavuconazole ↑ chloroquine possible Coadministration should be avoided,

Itraconazole ↑ chloroquine expected Coadministration should be avoided,

Posaconazole ↑ chloroquine expected Coadministration should be avoided,


Concentrations
Rifabutina ↓ chloroquine expected Monitor for chloroquine efficacy.
Rifampina ↓ chloroquine expected Monitor for chloroquine efficacy.
Rifapentinea ↓ chloroquine expected Monitor for chloroquine efficacy.
Voriconazole ↑ chloroquine expected Coadministration should be avoided,

Clarithromycin* Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.
Bedaquiline See Bedaquiline. See Bedaquiline.
Chloroquine See Chloroquine. See Chloroquine.
Fluconazole Clarithromycin AUC ↑ 18% and No dose adjustment necessary in

Cmin↑ 33% patients with normal renal function.
Monitor for clarithromycin toxicity.
Isavuconazole ↑ isavuconazole and clarithromycin Coadministration should be avoided,

expected if possible. Consider azithromycin in
place of clarithromycin. If
coadministered, monitor for toxicities
of both isavuconazole and
clarithromycin. Role of isavuconazole
TDM has not been established.
Itraconazole ↑ itraconazole and clarithromycin Coadministration should be avoided,

expected if possible. Consider azithromycin in
of both itraconazole and
clarithromycin; perform itraconazole
and clarithromycin TDM and adjust
dose accordingly.
Mefloquine ↑ mefloquine expected Use with caution. Consider

clarithromycin. If coadministered,
monitor for mefloquine toxicity.
Posaconazole ↑ clarithromycin expected Coadministration should be avoided,

if possible. Consider azithromycin in
of clarithromycin; perform
clarithromycin TDM and adjust dose
accordingly.

Concentrations
Quinine ↑ quinine expected Do not coadminister. Consider
↑ clarithromycin possible clarithromycin.
Rifabutina Clarithromycin AUC ↓ 44% Use with caution. Consider

14-OH AUC ↑ 57% clarithromycin. If coadministered,
consider reducing rifabutin dose,
Rifabutin AUC ↑ 76% to 99% perform clarithromycin and rifabutin
TDM and adjust dose accordingly.
des-Rbt AUC ↑ 375% Monitor for rifabutin toxicities.
Rifampina Clarithromycin concentration ↓ 87% Do not coadminister. Use

Rifampin AUC ↑ 60% clarithromycin.
Rifapentinea ↓ clarithromycin expected Daily Rifapentine
↑ 14-OH and rifapentine expected • Do not coadminister.
Weekly Rifapentine
• Use with caution. Consider
clarithromycin.
If coadministered, monitor for

rifapentine toxicities and
clarithromycin efficacy; perform
clarithromycin and rifapentine TDM
and adjust doses accordingly.
Voriconazole ↑ clarithromycin expected Coadministration should be avoided,

if possible. Consider azithromycin in
of clarithromycin; perform
clarithromycin TDM and adjust dose
accordingly.
Dapsone* Rifabutina Dapsone AUC ↓ 27% to 40% Coadministration should be avoided,

if possible. Consider alternatives for
dapsone.
Rifampina Dapsone concentration ↓ 7-fold to Coadministration should be avoided,

10-fold and t1/2 ↓ from 24 hours to if possible. Consider alternatives for
11 hours dapsone.
Rifapentinea ↓ dapsone expected Coadministration should be avoided,

if possible. Consider alternatives for

Concentrations
dapsone.
Doxycycline Atovaquone See Atovaquone. See Atovaquone.
Rifabutina ↓ doxycycline possible Monitor closely for doxycycline

efficacy or consider alternative
therapy.
Rifampina Doxycycline AUC ↓ 59% Use with caution. Monitor closely for
doxycycline efficacy or consider
alternative therapy.
Rifapentinea Daily Rifapentine Use with caution. Monitor closely for

doxycycline efficacy or consider
• ↓ doxycycline expected alternative therapy.
Weekly Rifapentine
• ↓ doxycycline possible
Erythromycin Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.
Fluconazole ↑ erythromycin possible Do not coadminister. Consider

erythromycin.
Isavuconazole ↑ erythromycin and isavuconazole Do not coadminister. Consider

possible azithromycin in place of
erythromycin.
Itraconazole Itraconazole AUC ↑ 36% Do not coadminister. Consider

↑ erythromycin possible erythromycin.
Mefloquine ↑ mefloquine possible Do not coadminister. Consider

erythromycin.
Posaconazole ↑ erythromycin expected Do not coadminister. Consider

erythromycin.
Quinine ↑ quinine expected Do not coadminister. Consider

↑ erythromycin possible erythromycin.
Rifabutina ↓ erythromycin possible Use with caution. Consider

↑ rifabutin possible erythromycin. If coadministered,
monitor for erythromycin efficacy and

Concentrations
rifabutin toxicities; perform rifabutin
Rifampina ↓ erythromycin expected Consider azithromycin in place of

erythromycin. If coadministered,
monitor for erythromycin efficacy.
Rifapentinea ↓ erythromycin expected Consider azithromycin in place of

erythromycin. If coadministered,
monitor for erythromycin efficacy.
Voriconazole ↑ erythromycin expected Do not coadminister. Consider

erythromycin.
Fluconazole* Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.
Clarithromycin See Clarithromycin. See Clarithromycin.
Erythromycin See Erythromycin. See Erythromycin.
Mefloquine ↑ mefloquine possible Coadministration should be avoided,

for mefloquine toxicities.
Quinine ↑ quinine expected Coadministration should be avoided,

↑ fluconazole possible for quinine and fluconazole toxicity.
Rifabutina Rifabutin AUC ↑ 80% Use with caution. Monitor for rifabutin
toxicities. Perform rifabutin TDM;
↔ fluconazole may need to decrease rifabutin dose
to 150 mg/day.
Rifampina Fluconazole AUC ↓ 23% to 56% Monitor for antifungal efficacy; may
need to increase fluconazole dose.
Rifapentinea ↓ fluconazole expected Monitor for antifungal efficacy; may

need to increase fluconazole dose.
Glecaprevir/ Rifabutina ↓ glecaprevir and pibrentasvir Coadministration should be avoided,

Pibrentasvir possible if possible. Consider alternative
agents.
Rifampina Glecaprevir AUC ↓ 88% Do not coadminister.
Pibrentasvir AUC ↓ 87%

Concentrations
Rifapentinea ↓ glecaprevir and pibrentasvir Do not coadminister. Consider
expected alternative agents.
TDF TFV AUC ↑ 29% when Use usual dose. Monitor renal
coadministered as EFV/TDF/FTC function or consider TAF.
TAF ↔ TFV concentration when No dose adjustment

coadministered as EVG/c/TAF/FTC
Isavuconazole* Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.
Mefloquine ↑ mefloquine expected Coadministration should be avoided,


↑ isavuconazole possible for quinine and isavuconazole
toxicities.
Rifabutina ↓ isavuconazole expected Consider alternative agent(s). If

alternative agents are not available,
↑ rifabutin expected use with close monitoring for
isavuconazole antifungal activity and
rifabutin toxicity. Perform rifabutin
Rifampina Isavuconazole AUC ↓ 97% Do not coadminister. Consider

alternative antifungal and/or
antimycobacterial agent(s).
Rifapentinea Significant ↓ isavuconazole expected Do not coadminister. Consider

Itraconazole* Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.

Concentrations
Mefloquine ↑ mefloquine expected Coadministration should be avoided,

↑ itraconazole possible for quinine and itraconazole
toxicities; perform itraconazole TDM
and adjust dose accordingly.
Rifabutina Itraconazole AUC ↓ 70% Do not coadminister. Consider

↑ rifabutin expected antimycobacterial agent(s).
Rifampina Itraconazole AUC ↓ 64% to 88% Do not coadminister. Consider

Rifapentinea ↓ itraconazole expected Do not coadminister. Consider

Linezolid* Rifabutina ↓ linezolid possible Monitor for linezolid efficacy.
Rifampina Linezolid AUC ↓ 32% Monitor for linezolid efficacy. Perform

linezolid TDM and adjust dose
accordingly.
Rifapentinea Daily Rifapentine Daily rifapentine

• ↓ linezolid expected • Monitor for linezolid efficacy.
Perform linezolid TDM and adjust
Weekly Rifapentine dose accordingly.
• ↓ linezolid possible Weekly rifapentine
• Monitor for linezolid efficacy.
Mefloquine* Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.
Fluconazole See Fluconazole. See Fluconazole.
Isavuconazole See Isavuconazole. See Isavuconazole.
Itraconazole See Itraconazole. See Itraconazole.
Posaconazole ↑ mefloquine expected Coadministration should be avoided,


Concentrations
Rifabutina ↓ mefloquine possible Monitor for mefloquine efficacy.
Rifampina Mefloquine AUC ↓ 68% Do not coadminister. Use

alternative antimalarial drug or
rifabutin.
Rifapentinea ↓ mefloquine expected Do not coadminister. Use

alternative antimalarial drug or
rifabutin.
Voriconazole ↑ mefloquine expected Coadministration should be avoided,

Posaconazole* Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.
Mefloquine See Mefloquine. See Mefloquine.

↑ posaconazole possible for quinine toxicities.
Rifabutina Posaconazole AUC ↓ 49% Coadministration should be avoided,

if possible. If coadministered,
Rifabutin AUC ↑ 72% perform posaconazole and rifabutin
TDM and adjust doses accordingly;
monitor for clinical response to
posaconazole and rifabutin toxicities.
Rifampina Significant ↓ posaconazole expected Do not coadminister when treating

invasive fungal infections. If
coadministered for treatment of non-
invasive fungal infections, perform
posaconazole TDM and adjust dose
accordingly; monitor for clinical
response.
Rifapentinea ↓ posaconazole expected Daily Rifapentine

• Do not coadminister.
Weekly Rifapentine

Concentrations
• Coadministration should be
avoided, if possible. If
coadministered, perform
posaconazole TDM and adjust
dose accordingly; monitor clinical
response.
Quinine* Clarithromycin See Clarithromycin. See Clarithromycin.
Posaconazole See Posaconazole. See Posaconazole.
Rifabutina ↓ quinine possible Monitor for quinine efficacy.
↑ rifabutin possible Monitor for rifabutin toxicity.
Rifampina Quinine AUC ↓ 75% to 85% Do not coadminister.
Rifapentinea ↓ quinine expected Do not coadminister.
Voriconazole ↑ quinine expected Coadministration should be avoided,

for quinine toxicities.
Rifabutina* Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.
Atovaquone See Atovaquone. See Atovaquone.
Caspofungin See Caspofungin. See Caspofungin.
Dapsone See Dapsone. See Dapsone.
Doxycycline See Doxycycline. See Doxycycline.
Glecaprevir/Pibrentasvir See Glecaprevir/Pibrentasvir. See Glecaprevir/Pibrentasvir.

Concentrations
Linezolid See Linezolid. See Linezolid.
Quinine See Quinine. See Quinine.
Sofosbuvir/Velpatasvir ↓ velpatasvir, sofosbuvir expected Do not coadminister.
TAF ↓ TAF, TFV, TFV-DP expected If coadministered, monitor for HIV

and HBV treatment efficacy.
↑ TFV-DP expected versus TDF
alone Note: Interpretation extrapolated
from TAF and rifampin (see
Rifampin). FDA labeling
recommends not to coadminister.
TDF ↔ TDF, TFV, TFV-DP expected No dosage adjustment necessary.
Voriconazole Voriconazole AUC ↓ 79% Do not coadminister. Consider

Rifabutin AUC ↑ 4-fold antimycobacterial agent(s).
Coadministration may be considered

if both voriconazole and rifabutin
TDM is available to guide therapy.
Rifampina* Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.

Concentrations
Sofosbuvir/Velpatasvir Sofosbuvir AUC ↓ 72% Do not coadminister.
Velpatasvir AUC ↓ 82%
TAF TAF plus Rifampin If coadministered, monitor for HIV

• TAF AUC ↓ 56%
• TFV AUC ↓ 53% Note: FDA labeling recommends not
to coadminister.
• TFV-DP AUC ↓ 36%
Intracellular TFV-DP concentration is

4.2-fold greater than with TDF alone.
TDF TDF plus Rifampin 600 mg Daily No dosage adjustment necessary

• ↔ TFV
Voriconazole Voriconazole AUC ↓96% Do not coadminister. Consider

Rifapentinea* Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.

Concentrations
TAF Daily Rifapentine Daily Rifapentine

• ↓ TAF, TFV, TFV-DP expected • Do not coadminister.
Weekly Rifapentine Weekly Rifapentine

• ↔ TAF, TFV, TFV-DP expected • If coadministered, monitor for HIV
Note: FDA labeling recommends not

to coadminister.
TDF ↔ TDF, TFV, TFV-DP expected No dosage adjustment necessary.
Sofosbuvir/Velpatasvir ↓ sofosbuvir, velpatasvir expected Do not coadminister.
Voriconazole ↓ voriconazole expected Do not coadminister. Consider

Sofosbuvir*/ Rifabutina See Rifabutin. See Rifabutin.

Velpatasvir
Rifampina See Rifampin. See Rifampin.
Rifapentinea See Rifapentine. See Rifapentine.
TAF TFV AUC ↑ 52% (when No dosage adjustment.

RPV/TAF/FTC given with
SOF/VEL/VOX)
TDF TFV AUC ↑ 35% to 40% (when given Monitor for TDF toxicities.
with EVG/c/FTC or RPV/FTC)
Consider TAF in place of TDF.
TFV AUC ↑ 81% (when given with
EFV/FTC and SOF/VEL)
TFV AUC ↑ 39% (when given with

DRV/r/FTC and SOF/VEL/VOX)
Tenofovir* Glecaprevir/Pibrentasvir See Glecaprevir/Pibrentasvir. See Glecaprevir/Pibrentasvir.

Alafenamide
Rifabutina See Rifabutin. See Rifabutin.

Concentrations
Sofosbuvir/Velpatasvir See Sofosbuvir/Velpatasvir. See Sofosbuvir/Velpatasvir.
Tenofovir* Disoproxil Rifabutina See Rifabutin. See Rifabutin.

Fumarate
Sofosbuvir/Velpatasvir See Sofosbuvir/Velpatasvir. See Sofosbuvir/Velpatasvir.
Voriconazole* Artemether/Lumefantrine See Artemether/Lumefantrine. See Artemether/Lumefantrine.
Rifabutina See Rifabutin. See Rifabutin.

a Refer to the description of Rifamycin-Related Induction Interactions in the Table 4 introduction above.
* Drug names marked with asterisk (*) are known to have assays available in the United States and, typically, in Europe as well.
Key to Symbols
↑ = increase
↓ = decrease
↔ = no substantial change
Key: 14-OH = active metabolite of clarithromycin; AUC = area under the curve; Cmin = minimum concentration; Css = concentration at steady state;
des-Rbt = desacetyl rifabutin; DHA = dihydroartemisinin; DRV/r = darunavir/ritonavir; EFV = efavirenz; EVG/c = elvitegravir/cobicistat; FDA = U.S.
Food and Drug Administration; FTC = emtricitabine; HBV = hepatitis B virus; RPV = rilpivirine; SOF = sofosbuvir; t1/2 = half-life; TAF = tenofovir
alafenamide; TDF = tenofovir disoproxil fumarate; TDM = therapeutic drug monitoring; TFV= tenofovir; TFV-DP = tenofovir diphosphate;
VEL = velpatasvir; VOX = voxilaprevir
Table 5. Serious and/or Common Adverse Reactions Associated with Systemically Administered Drugs
Used to Treat or Prevent Opportunistic Infections

This table should not be considered a comprehensive list of all possible adverse reactions to each medication. For
additional information, clinicians should consult other appropriate resources, such as the U.S. Food and Drug
Administration prescribing information. For persons of childbearing potential, please refer to Table 7. Summary of
Pre-Clinical and Human Data on, and Indications for, Opportunistic Infection Drugs During Pregnancy for
information regarding adverse effect potential of these medications during pregnancy.
Drug(s) Adverse Reactions

Acyclovir • Crystalluria and nephrotoxicity secondary to obstructive urolithiasis, particularly after rapid high-dose
IV infusion. Risk is increased with dehydration or pre-existing renal impairment.
o Administer IV fluid hydration to reduce the risk for nephrotoxicity.
• Neurotoxicity with high doses (agitation, confusion, hallucination, seizure, coma), especially in patients
with renal impairment and/or older patients
• Thrombophlebitis at peripheral IV infusion site
• Nausea, vomiting, and headache
Adefovir • Nephrotoxicity, especially in patients with underlying renal insufficiency, predisposing comorbidities, or
taking concomitant nephrotoxic drugs
• Nausea and asthenia
Albendazole • Bone marrow suppression (i.e., pancytopenia, aplastic anemia, agranulocytosis, and leukopenia)
o Patients with liver disease, including hepatic echinococcosis, appear to be at higher risk.
• Hepatotoxicity
• Reversible alopecia
• Nausea, vomiting, headache, and dizziness
Amikacin • Nephrotoxicity
• Ototoxicity, both hearing loss and vestibular toxicity, are possible.
• Neuromuscular blockade, especially with myasthenia or Parkinson’s disease and rapid infusion of
large doses
Amphotericin B Deoxycholate and • Nephrotoxicity (lower incidence with liposomal formulations)

Lipid Formulations
• Infusion-related reactions, including fever, chills, rigors, flank or back pain, and hypotension (lower
incidence with liposomal formulations)
• Hypokalemia, hypomagnesemia, and hypocalcemia
• Transaminase and bilirubin elevations
Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV E-1

• Heart failure (rarely reported)
• Anemia
• Thrombophlebitis
• Headache, nausea, vomiting, and diarrhea
Anidulafungin • Refer to the row on Echinocandins.
Artemether/Lumefantrine • QTc prolongation

• Fever, chills, fatigue, arthralgia, and myalgia
• Headache, dizziness, asthenia, and insomnia
• Nausea, vomiting, diarrhea, abdominal pain, and anorexia
• Rash and pruritus
• Delayed hemolytic anemia
Artesunate • Acute renal failure requiring dialysis

• Hemoglobinuria and jaundice
• Post-treatment hemolysis that may require transfusion
• QTc prolongation and bradycardia
• Hypersensitivity reactions (anaphylaxis)
• Dizziness, nausea, and vomiting
Atovaquone • Hepatotoxicity
• Rash, nausea, vomiting, and diarrhea
• Fever, headache, and insomnia
Atovaquone/Proguanil • Abdominal pain, nausea, vomiting, anorexia, diarrhea, headache, asthenia, dizziness, and rash
• Reversible transaminase elevations
Azithromycin • Ototoxicity with prolonged use

• Hepatotoxicity
• Hypersensitivity reactions
• QTc prolongation
• Nausea, vomiting, diarrhea, and abdominal pain
Benznidazole • Photosensitivity and hypersensitivity reactions (including allergic dermatitis, TEN, and DRESS)
• Paresthesia and peripheral neuropathy, headache, and insomnia
• Bone marrow suppression
• Embryofetal toxicity
• Nausea, vomiting, abdominal pain, anorexia, and weight loss

Bedaquiline • QTc prolongation
• Hepatotoxicity
• Nausea, vomiting, anorexia, diarrhea, elevated amylase, arthralgia, headache, and skin rash
Bezlotoxumab • Exacerbation of congestive heart failure

• Nausea, pyrexia, and headache
Caspofungin • Refer to the row on Echinocandins.
Chloroquine and • Auditory and visual disturbances, including blurry vision. Retinal toxicity may occur with long-term use.
Hydroxychloroquine
• Cardiomyopathy
• Bone marrow suppression and hemolysis
• Neuropsychiatric changes, including extrapyramidal reactions, suicidal behavior, and convulsive
seizures
• Neuromyopathy (may occur with long-term use)
• Hypersensitivity reactions (including TEN, SJS, and EM)
• Severe hypoglycemia which may require adjustment of antidiabetic medications
• Photosensitivity, pruritus, skin pigmentation, and exacerbation of psoriasis
• Headache, nausea, vomiting, diarrhea, anorexia, abdominal pain, and hepatitis
Cidofovir • Nephrotoxicity, proteinuria, azotemia, proximal tubular dysfunction (normoglycemic glycosuria,

hypophosphatemia), and metabolic acidosis (including Fanconi’s syndrome)
o Administer IV fluid hydration and oral probenecid to reduce the risk for nephrotoxicity.
• Neutropenia and anemia
• Ocular hypotony and anterior uveitis/iritis
• Possibly carcinogenic and teratogenic; may cause hypospermia
• Gastrointestinal intolerance and diarrhea
• Asthenia, fever, headache, and alopecia
• Side effects most likely related to co-administration with probenecid are rash, nausea, vomiting,
anorexia, and gout exacerbation.
Ciprofloxacin • Refer to the row on Fluoroquinolones.
Clarithromycin • Hepatotoxicity
• Ototoxicity, including reversible hearing loss and tinnitus, with high doses or prolonged use
• Increased risk of cardiac complications or death in patients with heart disease
• Diarrhea

• Headache, nausea, vomiting, diarrhea, abdominal cramps, and dysgeusia
Clindamycin • Diarrhea, including C. difficile–associated diarrhea and colitis

• Metallic taste (with IV infusion), thrombophlebitis, and arrhythmia with rapid IV infusion
• Hypersensitivity reactions (including SJS and TEN)
• Nausea, vomiting, abdominal pain, and abnormal liver function tests
Clotrimazole (Troche) • Nausea, vomiting, anorexia, and metallic taste
Cycloserine • Neuropsychiatric toxicities, including convulsions, psychosis, somnolence, confusion, inability to

concentrate, hyperreflexia, headache, tremor, vertigo, paresis, dysarthria, depression (with suicidal
ideation), peripheral neuropathy, and seizures (particularly with higher doses and in patients with
history of chronic alcoholism).
o Administer with pyridoxine.
• Hypersensitivity reactions (including SJS), allergic dermatitis, and rash
Dapsone • Methemoglobinemia, hemolytic anemia, neutropenia, and agranulocytosis

o Do not use in patients with moderate to severe G6PD deficiency.
• Sulfone syndrome (fever, exfoliative dermatitis, lymphadenopathy, hepatic necrosis, and hemolysis)
• Phototoxicity and severe cutaneous reactions (including SJS and TEN)
• Drug-induced lupus erythematosus
• Hepatotoxicity and nephrotic syndrome
• Peripheral neuropathy
• Nausea and anorexia
Doxycycline • Pill-induced esophagitis/esophageal ulceration

• Intracranial hypertension
• Photosensitivity and skin hyperpigmentation
• Thrombophlebitis (with IV infusion)
• Nausea and vomiting
Echinocandins • Histamine-related infusion reactions (flushing, rash, pruritus, hypotension, and dyspnea) and
(Anidulafungin, Caspofungin, thrombophlebitis
Micafungin)
• Hypersensitivity reactions (including anaphylaxis and anaphylactoid reaction)
• Abnormal liver enzymes and hepatotoxicity
• Hypokalemia
• Hemolysis (micafungin)
• Embryo-fetal toxicity
• Diarrhea, nausea, vomiting, fever, and headache

Emtricitabine • Headache, nausea, and diarrhea
• Skin hyperpigmentation and rash (palms and soles)
Entecavir • Headache, fatigue, dizziness, and nausea
Ethambutol • Optic neuritis (dose- and duration-dependent) and peripheral neuropathy

• Headache, nausea, vomiting, anorexia, abdominal pain, and hyperuricemia/gout flare
Ethionamide • Postural hypotension, hepatotoxicity, hypothyroidism (with or without goiter), and hypoglycemia
• Dizziness, drowsiness, confusion, clumsiness, visual disturbances, and depression
o Administer with pyridoxine.
• Dose-dependent gastrointestinal side effects, including nausea, vomiting, anorexia, diarrhea,
abdominal pain, and metallic taste
• Photosensitivity and severe cutaneous reactions (including SJS, TEN, and DRESS)
• Gynecomastia, acne, hair loss, and impotence
Famciclovir • Nephrotoxicity (in patients with underlying renal disease)

Fidaxomicin • Nausea, vomiting, and abdominal pain
Flucytosine • Concentration-dependent (>100 mcg/mL) bone marrow suppression (anemia, neutropenia,

agranulocytosis, and thrombocytopenia)
• Hepatotoxicity
• Diarrhea, nausea, vomiting, and headache
• Rash, pruritus, and photosensitivity
Fluconazole • Hepatotoxicity, nausea, vomiting, diarrhea, and abdominal pain

• Reversible alopecia (with doses ≥400 mg/day for >2 months)
Fluoroquinolones (ciprofloxacin, • Restlessness, insomnia, nightmares, confusion, anxiety, paranoia, tremors, seizure, hallucinations,
levofloxacin, moxifloxacin) depression, suicidal thoughts, and attempted and completed suicide
• Tendonitis and tendon rupture (associated with age over 60, concurrent corticosteroids, diabetes, and
kidney, heart, and lung transplant)
• Diarrhea including C. difficile–associated diarrhea and colitis
• Photosensitivity/phototoxicity and severe cutaneous reactions (including SJS and TEN)
• Transaminase elevations and interstitial nephritis
• Anemia, thrombocytopenia, and leukopenia
• Arthralgia and myalgia

• Peripheral neuropathy and retinal detachment
• Hyper- and hypoglycemia, including hypoglycemic coma
• Vasculitis and aortic dissection
• Nausea, diarrhea, bloating, headache, dizziness, and malaise
Foscarnet • Nephrotoxicity and electrolyte imbalances (e.g., hypocalcemia, hypomagnesemia, hypophosphatemia,

hyperphosphatemia, hypokalemia)
• Paresthesia and seizure (associated with electrolyte imbalances)
• Anemia
• Nausea, vomiting, anorexia, and headache
• Penile ulceration
Fumagillin (Investigational) Oral Therapy

• Neutropenia, thrombocytopenia, vertigo, nausea, vomiting, diarrhea, anorexia, and abdominal cramps
Ocular Therapy
• Minimal systemic effect or local effect
Ganciclovir • Neutropenia, thrombocytopenia, anemia, and pancytopenia

• Carcinogenic and teratogenic potential and impaired fertility
• Nephrotoxicity
• Neuropathy
Glecaprevir/Pibrentasvir • Risk of hepatitis B virus reactivation

• Hepatic decompensation/failure in patients with advanced liver disease
• Mild headache, fatigue, nausea, and diarrhea
• Altered glucose tolerance in diabetic patients
Interferon-Alfa and Peginterferon- • Neuropsychiatric disorders (e.g., depression, suicidal ideation)

Alfa
• Neutropenia, anemia, and thrombocytopenia
• Flu-like syndrome (e.g., fever, headache, fatigue, myalgia)
• Hepatitis exacerbations, thyroid dysfunction, and alopecia
• Nausea, anorexia, diarrhea, and weight loss
• Development or exacerbation of autoimmune disorders and ocular effects (e.g., retinal hemorrhage,
retinal artery or vein obstructions, and cotton wool spots)

• Ischemic and hemorrhagic cerebrovascular events, cardiovascular and pulmonary disorders, hyper-
and hypoglycemia, diabetes, severe infection, and colitis
Isavuconazonium Sulfate • Hepatotoxicity and cholelithiasis

• Infusion-related reactions (hypotension, dyspnea, chills, dizziness, paresthesia, and hypoesthesia)
• Hypersensitivity reactions (including SJS)
• Shortening of QT interval
• Nausea, vomiting, diarrhea, headache, hypokalemia, dyspnea, and cough
Isoniazid • Hepatotoxicity and asymptomatic elevation in aminotransferase enzymes

• Peripheral neuropathy, paresthesia, seizures, and optic neuritis
o Administer with pyridoxine
• Nausea, diarrhea, and flushing
• Psychosis
• Hypersensitivity reactions (including TEN and DRESS)
• Arthralgia and lupus-like syndrome
Itraconazole • Congestive heart failure, edema, and hypokalemia

• Hepatotoxicity
• Hearing loss
• Neuropathy
• Gynecomastia
• Nausea, vomiting, diarrhea, and abdominal pain
Lamivudine • Nausea and vomiting
Levofloxacin • Refer to the row on Fluoroquinolones.
Linezolid • Anemia, neutropenia, and thrombocytopenia (especially with treatment lasting longer than 2–4 weeks
and renal insufficiency)
• Peripheral neuropathy and optic neuritis with long-term therapy
• Serotonin syndrome (especially in patients receiving concomitant serotonergic agents)
• Seizure (in patients with a history of seizure or with risk factors for seizure)
• Lactic acidosis, hypoglycemia, and hyponatremia
• Nausea, vomiting, diarrhea, and headache

Mefloquine • Depression, psychosis, anxiety, agitation, dizziness, headache, insomnia, and abnormal dreams
• QTc prolongation and arrhythmias (extrasystole and sinus bradycardia)
• Agranulocytosis and aplastic anemia
• Nausea, vomiting, diarrhea, and epigastric pain
Micafungin • Refer to the row on Echinocandins.
Miconazole Buccal Tablets • Dysgeusia, diarrhea, nausea, vomiting, upper abdominal pain, and headache
• Local reactions (e.g., oral discomfort, burning, pain, tongue/mouth ulceration, gingival pruritus,
swelling, and dry mouth)
• Hypersensitivity reaction (may occur in patients with known hypersensitivity reaction to milk product
concentrate)
Miltefosine • Nephrotoxicity and elevated transaminases and bilirubin

• Retinal degeneration
• Leukocytosis and thrombocytopenia
• Embryo-fetal toxicity and impaired fertility, scrotal pain, and impaired ejaculation
• Nausea, vomiting, diarrhea, anorexia, headache, and motion sickness
• Severe cutaneous reactions (including SJS)
Moxifloxacin • Refer to the row on Fluoroquinolones.
Nifurtimox • Patients with a history of brain injury, seizures, psychiatric disease, and serious behavioral alterations
may experience worsening of their conditions.
• Vomiting, abdominal pain, headache, decreased appetite, weight loss, nausea, pyrexia, rash,
polyneuropathy, insomnia, dizziness, and vertigo
• Hypersensitivity reactions with hypotension, angioedema, dyspnea, pruritus, rash or other severe skin
reactions
Nitazoxanide • Nausea, vomiting, diarrhea, abdominal pain, headache, and chromaturia
Nystatin (Oral Preparations) • Unpleasant taste, nausea, vomiting, anorexia, and diarrhea
Paromomycin • Nausea, vomiting, abdominal cramps, anorexia, rash, and headache

• Nephrotoxicity
o Inflammatory bowel disease and renal insufficiency may increase risk.
Penicillin G All Penicillin G Preparations

• Hypersensitivity (immediate or delayed reactions, including anaphylaxis), bone marrow suppression,
nausea, vomiting, diarrhea, and drug fever
• Jarisch-Herxheimer reaction when used for syphilis (occurs most frequently in persons with early
syphilis, high non-treponemal antibody titers, and prior penicillin treatment)

Benzathine Penicillin G and Procaine Penicillin G
• IM injection-site reactions (pain and erythema), procaine neuropsychiatric reactions (with high dose),
and neurovascular damage (due to inadvertent intravascular instead of IM injection)
Aqueous Crystalline Penicillin G (IV)

• Neurotoxicity at high doses—especially in patients with renal dysfunction—and hyperkalemia or
hypernatremia at high doses (depending on formulation)
Pentamidine • Nephrotoxicity, infusion-related hypotension, and thrombophlebitis

• QTc prolongation, arrhythmias (including Torsades de pointes), and electrolyte abnormalities
• Hypoglycemia, hyperglycemia, and diabetes mellitus
• Hepatotoxicity, pancreatitis, and GI intolerance
• Leukopenia and thrombocytopenia
• Embryotoxic
• Rash
Aerosolized Therapy
• Bronchospasm, cough, dyspnea, tachypnea, and metallic taste
Pentavalent Antimony (Sodium • Hepatotoxicity, transient rises in amylase and lipase, and pancreatitis
Stibogluconate) (Investigational)
• Cardiac toxicity with >20 mg/kg dose (prolonged QTc and T wave inversion)
• Leukopenia, anemia, and thrombocytopenia
• Arthralgia and myalgia
• Nausea, vomiting, abdominal pain, and anorexia
• Thrombophlebitis and rash
Posaconazole • Hepatotoxicity, QTc prolongation, and hypokalemia

• Pseudohyperaldosteronism
• Nausea, vomiting, diarrhea, abdominal pain, and headache
IV Infusion
• Thrombophlebitis, SBECD accumulation, and worsening renal function with IV formulation (especially in
patients with eGFR <50 mL/min per package labeling, but observational studies with IV voriconazole
suggest that this may not be a concern)
Primaquine • Methemoglobinemia, hemolytic anemia (use with caution in patients with mild-moderate G6PD
deficiency; do not use if severe G6PD deficiency), leukopenia, and neutropenia
• Abdominal cramps, nausea, vomiting, and dizziness

Pyrazinamide • Hepatotoxicity
• Polyarthralgia and myalgia
• Hyperuricemia/gout flare
• Thrombocytopenia and sideroblastic anemia
• Nausea, vomiting, flushing, rash, and photosensitivity
Pyrimethamine • Neutropenia, thrombocytopenia, and megaloblastic anemia

o Administer with leucovorin.
• Anorexia, vomiting, and rash
Quinine • QTc prolongation and cardiac arrythmias

• Cinchonism (tinnitus, vertigo, and blurred vision)
• Hemolytic anemia (including in patients with G6PD deficiency), thrombocytopenia, and agranulocytosis
• Vision abnormalities (e.g., photophobia, altered color perception, and blindness)
• Hypersensitivity reactions (including SJS and TEN)
• Hypoglycemia
Rifabutin • Uveitis (concentration-dependent)

• Neutropenia and thrombocytopenia
• Arthralgia
• Hepatotoxicity
• Rash and skin discoloration
• Nausea, vomiting, abdominal pain, diarrhea, and anorexia
• Red-orange discoloration of body fluids
Rifampin • Hepatotoxicity (cholestatic hepatitis)

• Thrombocytopenia and hemolytic anemia
• Renal failure
• Hypersensitivity reactions with flu-like syndrome
• Interstitial pulmonary disease
• Nausea, vomiting, anorexia, abdominal pain, flatulence, diarrhea, headache, confusion, and flushing,
rash
Rifapentine • Hepatotoxicity
• Anemia, neutropenia, and lymphopenia

• Arthralgia
• Rash and pruritis
• Nausea, vomiting, diarrhea, and anorexia
Sofosbuvir/Velpatasvir • Risk of hepatitis B virus reactivation

• Headache, fatigue, and anemia (associated with ribavirin co-administration)
• Altered glucose tolerance in diabetic patients
Streptomycin • Neurotoxicity including irreversible ototoxicity (both hearing loss and vestibular toxicity)
• Nephrotoxicity
• Neuromuscular blockade and respiratory paralysis (associated with rapid infusion of large
aminoglycoside doses)
Sulfadiazine • Severe cutaneous reactions (including SJS, EM, and TEN) and photosensitivity
• Anemia, neutropenia, agranulocytosis, and thrombocytopenia
• Crystalluria (nephrolithiasis, urolithiasis) and nephrotoxicity
• Hepatotoxicity
• Drug fever
• Peripheral neuritis, tinnitus, vertigo, and insomnia
• Nausea, vomiting, and headache
Tafenoquine • Decreased hemoglobin and methemoglobinemia and hemolytic anemia

o Do not use in patients with G6PD deficiency; may cause harm to fetuses and breastfeeding infants
who are G6PD deficient.
• Psychiatric adverse reactions (in patients with history of psychiatric illness)
• Hypersensitivity reactions (angioedema and urticaria)
• Visual disturbances
• Dizziness, nausea, vomiting, and headache
Tenofovir disoproxil fumarate • Renal insufficiency and Fanconi syndrome (proximal renal tubulopathy with hypophosphatemia,
hypouricemia, proteinuria, and normoglycemic glycosuria)
• Decrease in bone mineral density
Tenofovir alafenamide • Headache, abdominal pain, fatigue, and nausea

• Lower incidence of renal or bone toxicities than with tenofovir disoproxil fumarate
Trimethoprim-Sulfamethoxazole • Cutaneous reactions (in some cases SJS, EM, and TEN) and photosensitivity
• Anemia, neutropenia, agranulocytosis, and thrombocytopenia

• Hepatotoxicity
• Dose-dependent increase in serum creatinine (without change in GFR), interstitial nephritis,
crystalluria (in patients with inadequate hydration), and hyperkalemia (with high-dose TMP)
• Hypoglycemia and hyponatremia
• Drug fever
• Aseptic meningitis and pancreatitis
Valacyclovir • Neurotoxicity (e.g., agitation, confusion, hallucination, seizure, coma) with high doses, especially in
patients with renal impairment
• Nephrotoxicity
• Nausea, vomiting, abdominal pain, and headache
Valganciclovir • Bone marrow suppression

• Confusion, pyrexia, and tremor
• Nephrotoxicity
• Nausea, vomiting, and diarrhea
Voriconazole • Visual disturbances (e.g., abnormal vision, color vision change, and/or photophobia)
• Optic neuritis (associated with >28 days treatment)
• Headache, delirium, hallucination, peripheral neuropathy, and encephalopathy (associated with trough
>5.5 mcg/mL)
• Hepatotoxicity
• Photosensitivity and increased risk of skin cancer with long-term use
• Fluorosis and periostitis with high dose and/or prolonged use
• Fever, nausea, vomiting, chills, tachycardia, and peripheral edema
• SBECD accumulation with IV formulation and worsening renal function (especially in patients with eGFR
<50 mL/min per package labeling, but observational studies suggest that this may not be a concern)
Key: DRESS = drug reaction with eosinophilia and systemic symptoms; eGFR = estimated glomerular filtration rate; EM = erythema multiforme;
G6PD = glucose-6-phosphate dehydrogenase; GFR = glomerular filtration rate; GI = gastrointestinal; IM = intramuscular; IV = intravenous;
QTc = QT corrected for heart rate; SBECD = sulfobutylether cyclodextrin; SJS = Stevens-Johnson syndrome; TEN = toxic epidermal necrolysis; TMP
= trimethoprim
Table 6. Dosing Recommendations for Drugs Used to Treat or Prevent Opportunistic Infections
that Require Dosage Adjustment in Patients with Renal Insufficiency

Drug accumulation is the primary concern when renally cleared drugs are administered to patients
with reduced renal function. However, clearance is only one of two or more pharmacokinetic
parameters that affect a drug’s disposition. All drugs have a volume of distribution, which can be
altered. Also, oral drugs must be absorbed from the gastrointestinal tract.
Some patients with HIV or diabetes mellitus can also have reduced absorption of certain drugs.
Therefore, while a drug may require a dose reduction in renal failure based on reduced clearance
(i.e., increased concentrations), other factors—like an increased volume of distribution and reduced
oral absorption—may also affect drug concentrations (i.e., decrease concentrations). Therapeutic
drug monitoring (TDM), if available and appropriate, may facilitate any necessary dose adjustments
in these complicated patients. TDM allows the clinician to make informed, individualized decisions
about dose adjustments that are more precise than standardized dose adjustments based on estimated
creatinine clearance. Drug names below marked with asterisk (*) are known to have assays available
within the United States and typically in Europe as well.
Dosage Adjustment in Renal Insufficiency

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
Acyclovir* IV Dose 26–50 100% of dose IV every 12 hours
Serious HSV 10–25 100% of dose IV every 24 hours
• 5 mg/kg IV every 8 hours
<10 50% of dose IV every 24 hours
VZV Infections or HSV
HD 50% of dose every 24 hours; administer dose
encephalitis
after HD on day of dialysis.
• 10 mg/kg IV every
8 hours
PO Dose for Herpes 10–25 800 mg PO every 8 hours

Zoster: 800 mg PO five
times per day <10 800 mg PO every 12 hours
HD 800 mg PO every 12 hours; administer dose

after HD on day of dialysis
Adefovir 10 mg PO every 24 hours 30–49 10 mg PO every 48 hours
10–29 10 mg PO every 72 hours
HD 10 mg PO weekly; administer dose after HD
Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV F-1
Table 6. Dosing Recommendations for Drugs Used to Treat or Prevent Opportunistic
Infections That Require Dosage Adjustment in Patients with Renal Insufficiency

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
Amikacin* IV 15 mg/kg per day Use with caution in 15 mg/kg two to three times per week
For mycobacterial patients with renal
or Perform TDM to adjust dose, with target peak
infections insufficiency and
concentration 35–45 mcg/mL and trough
family history of
25 mg/kg three times per concentration <4 mcg/mL.
ototoxicity.
week
Administer dose after HD on days of dialysis.
Amphotericin B* 3–6 mg/kg IV per day (lipid N/A No dosage adjustment necessary; consider
formulation) alternative antifungals if renal insufficiency
occurs during therapy despite adequate
or
hydration.
0.7–1.0 mg/kg IV per day
(amphotericin B
deoxycholate)
Cidofovir 5 mg/kg IV on Day 0, Pretreatment SCr Cidofovir is not recommended unless benefits
repeat 5 mg/kg IV dose on >1.5 mg/dL outweigh risks. See “Pharmacokinetics of
Day 7, then 5 mg/kg IV cidofovir in renal insufficiency and in continuous
every 2 weeks or ambulatory peritoneal dialysis or high-flux
hemodialysis” for recommendations on renal
Give each dose with CrCl <55 mL/min dose adjustments.
probenecid and saline
hydration (see Table 2 for or
dosing instructions).
Proteinuria
≥100 mg/dL (≥2 +)
If SCr increases by Decrease to 3 mg/kg IV per dose.

0.3–0.4 mg/dL
above baseline
If SCr increases Discontinue therapy.

>0.5 mg/dL above
baseline
or
Proteinuria ≥3 +
Ciprofloxacin* 500–750 mg PO every 12 30–50 500–750 mg PO every 12 hours

hours
or
or
400 mg IV every 12 hours
400 mg IV every 8–12
hours <30 250–500 mg PO every 24 hours
or

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
400 mg IV every 24 hours
HD or PD 250–500 mg PO every 24 hours

or
200–400 mg IV every 24 hours; administer after

HD or PD on days of dialysis.
Clarithromycin* 500 mg PO every 12 hours 30–60 Usual dose unless used with an HIV PI or with
COBI, then reduce dose by 50%.
<30 250 mg PO twice daily
or
500 mg PO once daily
If used with an HIV PI or COBI, reduce dose by

75% (or consider using azithromycin as
alternative).
Cycloserine* 10–15 mg/kg/day PO in two 30–80 Usual dose; consider TDM and monitor for
divided doses (maximum toxicities.
1,000 mg/day); start at
250 mg once daily and <30 (not on HD) or 250 mg once daily or 500 mg three times per
increase dose per HD week
tolerability.
Perform TDM and adjust dose accordingly.
Target peak concentration Monitor for toxicities.
20–35 mcg/mL
Use with caution in patients with ESRD who are
not on dialysis.
Emtricitabine* (FTC) One 200-mg capsule PO CrCl^ or eGFR# Oral Capsules Oral Solution
once daily (mL/min)
or 30–49 200 mg every 48 hours 120 mg every

24 hours
240-mg solution PO once
daily 15–29 200 mg every 72 hours 80 mg every
24 hours
<15 and not on HD 200 mg every 96 hours 60 mg every

24 hours
HDa (administer 200 mg every 24 hours 240 mg every

dose after HD on 24 hours
days of dialysis)

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
Emtricitabine*/ One tablet (FTC 200 <30 and not on HD Coformulated tablet is not recommended.
Tenofovir* mg/TAF 25 mg) PO once
Alafenamide daily
(FTC/TAF)
(FDC Trade Name:
Descovy)
Note: Please refer to

product labels for
dosing HD One tablet daily
recommendations for
other ARV FDC
products containing
FTC/TAF.
Emtricitabine*/ One (FTC 200 mg/TDF 30–49 One tablet PO every 48 hours (monitor for
Tenofovir* 300 mg) tablet PO daily worsening renal function or consider switching
Disoproxil to TAF)
Fumarate (FTC/TDF)
<30 or HD Do not use coformulated tablet.
(FDC Trade Name:
Truvada) Use formulation for each component drug and
adjust dose according to recommendations for
Note: Please refer to the individual drugs.
product labels for
dosing
recommendations for
other ARV FDC
products containing
FTC/TDF.
Entecavir Usual Dose: 0.5 mg PO CrCl^ or eGFR# Usual Renal Dose 3TC-Refractory or
once daily (mL/min) Adjustment Decompensated
Liver Disease
For Treatment of 3TC-
Refractory HBV or for 30 to <50 • 0.25 mg PO every • 0.5 mg PO every
Patients with 24 hours, or 24 hours, or
Decompensated Liver
Disease: 1 mg PO once • 0.5 mg PO every • 1 mg PO every
daily 48 hours 48 hours
10 to <30 • 0.15 mg PO every • 0.3 mg PO every

24 hours, or 24 hours, or
• 0.5 mg PO every • 1 mg PO every
72 hours 72 hours

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
<10 or HD or • 0.05 mg PO every • 0.1 mg PO every
CAPD (administer 24 hours, or 24 hours, or
after HD on days
of dialysis) • 0.5 mg PO once every • 1 mg PO once
7 days every 7 days
Ethambutol* For MAI: 15 mg/kg PO <30 or HD Usual dose PO three times weekly (in patients
daily on HD, give dose after dialysis).
For MTB: 15–25 mg/kg PO

daily
(See the Dosing

Recommendations table in
the Mycobacterium PD Do not use in patients on PD. Consider
tuberculosis section for alternative MAI or MTB treatment (e.g.,
additional MTB dosing moxifloxacin).
recommendations.)
Perform TDM to guide optimal dosing.
Ethionamide* 15–20 mg/kg PO daily <30 or HD 250–500 mg PO once daily

(usually 250–500 mg PO
once or twice daily) Consider TDM.
Famciclovir* For Herpes Zoster: 500 40–59 500 mg PO every 12 hours

mg PO every 8 hours
20–39 500 mg PO every 24 hours
For HSV: 500 mg PO every
12 hours
<20 250 mg PO every 24 hours
HD 250 mg PO only on HD days, administer after

HD
Fluconazole* 200–1,200 mg PO or IV ≤50 Administer 100% of the indication-specific initial

every 24 hours (dose and dose, then adjust maintenance doses to 50% of
route of administration dose every 24 hours.
depends on type of OI)
HD Administer 100% of the indication-specific initial
dose, then adjust maintenance doses to full
dose three times per week after HD.
Flucytosine* 25 mg/kg PO every 6 hours 21–40 25 mg/kg PO every 12 hours
TDM is recommended for 10–20 25 mg/kg PO every 24 hours

patients to guide optimal
dosing (target peak serum <10 25 mg/kg PO every 48 hours
concentration 2 hours after
dose: 25-100 mcg/mL). If HD 25–50 mg/kg PO every 48–72 hours;
TDM is not possible, administer dose after HD on days of dialysis

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
monitor CBC twice weekly.
Foscarnet Induction Therapy for Dosage Dosage adjustment needed according to

CMV Infection: adjustment needed calculated CrCl/kg; consult product label for
180 mg/kg/day IV in two according to dosing table.
divided doses calculated CrCl/kg;
consult product
Maintenance Therapy for
label for dosing
CMV Infection or for
table.
Treatment of HSV
Infections: 90–120 mg/kg
IV once daily
Ganciclovir* Induction Therapy: 50–69 2.5 mg/kg IV every 12 hours

5 mg/kg IV every 12 hours
25–49 2.5 mg/kg IV every 24 hours
<10 or HD 1.25 mg/kg IV three times per week; administer

dose after HD on days of dialysis.
Maintenance Therapy: 50–69 2.5 mg/kg IV every 24 hours

5 mg/kg IV every 24 hours
<10 or HD 0.625 mg/kg IV three times per week;

administer dose after HD on days of dialysis.
Lamivudineb (3TC) 300 mg PO every 24 hours 15–29 150 mg PO once, then 100 mg PO every
24 hours
5–14 150 mg PO once, then 50 mg PO every

24 hours
<5 or HD 50 mg PO once, then 25 mg PO every

24 hours; administer dose after HD on days of
dialysis.
Lamivudine/ One (3TC 300 mg/TDF <50 Coformulated tablet is not recommended.
Tenofovir 300 mg) tablet PO every
Disoproxil 24 hours
Fumarate (3TC/TDF)
(FDC Trade Names:
Cimduo or Temixys)

product information

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
for dosing
recommendations for
other ARV FDC
products containing
3TC/TDF.
Levofloxacin* 500 mg (low dose) or 750– CrCl^ or eGFR# Low Dose High Dose
1,000 mg (high dose) IV or (mL/min)
PO daily
20–49 500 mg once, then 750 mg every
250 mg every 24 hours, 48 hours IV or PO
IV or PO
<20 or CAPD or 500 mg once, then 750 mg once, then

HD (administer 250 mg every 48 hours, 500 mg every
dose after HD on IV or PO 48 hours, IV or PO
days of dialysis)
Dose can be adjusted
based on serum
concentrations.
Para-aminosalicylic 8–12 g/day PO in two to <30 or HD 4 g PO twice daily; administer after HD on days
acid* three divided doses of dialysis.
Paromomycin 500 mg PO every 6 hours <10 Minimal systemic absorption. No dosage

adjustment necessary but monitor for
worsening renal function and ototoxicity in
patients with ESRD.
Peginterferon Alfa- 180 mcg SQ once weekly <30 135 mcg SQ once weekly
2a
HD 135 mcg SQ once weekly
May reduce to 90 mcg once weekly if severe

adverse effects or laboratory abnormalities
occur.
Penicillin G Neurosyphilis, Ocular 10–50 2–3 million units every 4 hours

(Potassium Syphilis, or Otosyphilis
or Sodium) or
• 3–4 million units IV every
4 hours, or 12–18 million units as continuous infusion
• 18–24 million units IV <10 2 million units every 4–6 hours, or 8–12 million
daily as continuous units as continuous infusion
infusion
HD or CAPD 2 million units every 4–6 hours, or 8 million
units as continuous infusion
Pentamidine 4 mg/kg IV every 24 hours <10 4 mg/kg IV every 48 hours
May reduce dose to

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
3 mg/kg IV daily in the
event of toxicities
Posaconazole* IV: 300 mg twice daily on <50 No dosage adjustment of oral dose in patients
Day 1; then 300 mg once with renal insufficiency. Higher variability in
daily serum concentrations observed in patients with
CrCl <20 mL/min.
Delayed-Release Tablet:
300 mg PO once daily Perform posaconazole TDM (target trough
concentration at least >1.25 mcg/mL for
Oral Suspension: 400 mg treatment).
PO twice daily
IV posaconazole is not recommended by the
manufacturer because of potential toxicity due
to accumulation of SBCD (vehicle of IV
product). However, an observational study did
not find worsening in renal function in patients
with CrCl <50 ml/min given SBCD.
Switch patients with CrCl <50 mL/min to oral

posaconazole when feasible.
Pyrazinamide* See the Mycobacterium <30 or HD 25–35 mg/kg/dose three times per week;
tuberculosis section for administer dose after HD on dialysis days
weight-based dosing
guidelines.
Quinine Sulfate* 650 mg salt (524 mg base) <10 or HD 650 mg once, then 325 mg PO every 12 hours
PO every 8 hours
Rifabutin* 5 mg/kg PO daily (usually <30 If toxicity is suspected, consider 50% of dose
300 mg PO daily) once daily and perform rifabutin TDM.
See the Mycobacterium

tuberculosis section and
Drug–Drug Interactions in
the Adult and Adolescent
Antiretroviral Guidelines for
dosage adjustment based
on interactions with ARVs.
Sofosbuvir* 400 mg PO daily <30 Not recommended. Up to 20-fold higher

sofosbuvir metabolite observed in patients with
this level of renal impairment.
Streptomycin 15 mg/kg IM or IV every Use with caution in 15 mg/kg two to three times weekly. Administer
24 hours patients with renal dose after dialysis on day of dialysis.
insufficiency.
or TDM is no longer available. Consider an
alternative aminoglycoside, as clinically
25 mg/kg IM or IV three

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
times per week appropriate.
Sulfadiazine 1,000–1,500 mg PO every ≤ 50 No data. Use alternative anti-toxoplasma

6 hours (1,500 mg every therapy.
6 hours for patients >60 kg)
Tenofovir* 25 mg PO daily <15 Not recommended

Alafenamide (TAF)
product labels for <15 on HD No dosage adjustment required. Administer
dosing dose after HD on days of dialysis.
recommendations for
other ARV FDC
products containing
FTC/TAF.
Tenofovir* 300 mg PO daily 30–49 300 mg PO every 48 hours (consider switching

Disoproxil to TAF for treatment of HBV)
Fumarate (TDF)
10–29 300 mg PO every 72–96 hours (consider
Note: Please refer to switching to alternative agent for treatment of
product labels for HBV)
dosing
recommendations for <10 and not on Not recommended
other ARV FDC dialysis
products containing
TDF. HD 300 mg PO once weekly; administer dose after
dialysis
Trimethoprim* / For PCP Treatment 15–30 5 mg/kg (TMP) IV every 12 hours, or two TMP-
Sulfamethoxazole SMX DS tablets PO every 12 hours
(TMP-SMX) • 5 mg/kg (of TMP
component) IV every <15 5 mg/kg (TMP) IV every 24 hours, or one TMP-
6–8 hours, or SMX DS tablet PO every 12 hours (or two
• Two TMP-SMX DS TMP-SMX DS tablets every 24 hours)
tablets PO every 8 hours
HD 5 mg/kg/day (TMP) IV, or two TMP-SMX DS
tablets PO; administer dose after HD on
dialysis day.
Consider TDM to optimize therapy (target TMP

concentrations: 5–8 mcg/mL)
For PCP Prophylaxis 15–30 Reduce dose by 50% (e.g., 1 SS tablet PO

daily)
• One TMP-SMX DS tablet
PO daily; <15 Reduce dose by 50% or use alternative agent

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
PO three times per week;
or
• One TMP-SMX SS tablet
PO daily
For Toxoplasmosis 15–30 5 mg/kg (TMP component) IV or PO every

Encephalitis (TE) 24 hours
Treatment: 5 mg/kg (TMP
component) IV or PO every <15 5 mg/kg (TMP component) IV or PO every
12 hours 24 hours or use alternative agent
For TE Chronic 15–30 Reduce dose by 50%.

Maintenance Therapy
<15 Reduce dose by 50% or use alternative agent.
twice daily, or
daily
For Toxoplasmosis 15–30 Reduce dose by 50%.

Primary Prophylaxis: One
TMP-SMX DS tablet PO <15 Reduce dose by 50% or use alternative agent.
daily
Valacyclovir* For Herpes Zoster: 1 g PO 30–49 1 g PO every 12 hours

three times daily
10–29 1 g PO every 24 hours
<10 500 mg PO every 24 hours
HD 500 mg PO every 24 hours; administer dose

after HD on days of dialysis
Valganciclovir Induction Therapy: CrCl^ or eGFR# Induction Maintenance

900 mg PO twice daily (mL/min)
40–59 450 mg PO twice daily 450 mg PO daily

Maintenance Therapy:
900 mg PO once daily 26–39 450 mg PO daily 450 mg PO every
48 hours
10–25 450 mg PO every 450 mg PO twice

48 hours weekly
<10 and not on Not recommended Not

dialysis recommended

Drug(s) Usual Dose
CrCl^ or eGFR#
Dose
(mL/min)
HD 200 mg (oral powder 100 mg (oral
formulation) PO three powder
Note: Clinical times per week after HD formulation) PO
efficacy of these three times per
doses has not week after HD
been established;
consider IV
ganciclovir.
Voriconazole* 6 mg/kg IV every 12 hours <50 IV voriconazole is not recommended by the

for two doses, then 4 mg/kg manufacturer because of potential toxicity due
IV every 12 hours to accumulation of SBCD (vehicle of IV
product). An observational study did not find
or worsening in renal function in patients with CrCl
<50 ml/min.
200–300 mg PO every
12 hours Switch patients with CrCl <50 ml/min to oral
voriconazole when feasible. No need for
dosage adjustment when the oral dose is used.
Perform TDM to adjust dose.
* Drug names marked with asterisk (*) are known to have assays available within the United States and typically in Europe as
well.
a The prescribing information for emtricitabine (Emtriva) recommends a dose of 200 mg every 96 hours for patients with CrCl
<15 mL/min or on hemodialysis. However, the prescribing information for several FDC products that contain emtricitabine
(including Descovy, Biktaryy, Genvoya, and Odefsey) recommends that the standard dose (emtricitabine 200 mg) can be given
once daily in these patients (on days of hemodialysis, give after completion of dialysis). The recommendation in this table
incorporates the dosing guidance from the FDC products.
b The prescribing information for lamivudine (Epivir) recommends dosage adjustment from 300 mg once daily to 150 mg once
daily for patients with CrCl 30–49 mL/min. However, the prescribing information for several FDC products that contain
lamivudine (including Epzicom, Dovato, and Triumeq) recommends no dose adjustment for CrCl 30–49 mL/min. The
recommendation in this table incorporates the dosing guidance from the FDC products.
^Creatinine Clearance Calculation

Male: Female:
(140 − 𝑎𝑎𝑎𝑎𝑎𝑎 𝑖𝑖𝑖𝑖 𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦) × 𝑤𝑤𝑤𝑤𝑤𝑤𝑤𝑤ℎ𝑡𝑡 𝑖𝑖𝑖𝑖 𝑘𝑘𝑘𝑘 (140 − 𝑎𝑎𝑎𝑎𝑎𝑎 𝑖𝑖𝑖𝑖 𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦𝑦) × 𝑤𝑤𝑤𝑤𝑤𝑤𝑤𝑤ℎ𝑡𝑡 𝑖𝑖𝑖𝑖 𝑘𝑘𝑘𝑘 × 0.85
72 × 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠 𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐 72 × 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠 𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐
#When estimating kidney function to facilitate drug dosing in patients with renal insufficiency, please refer to the drug’s
prescribing information and to National Institute of Diabetes and Digestive and Kidney Diseases’ “Determining Drug Dosing in
Adults with Chronic Kidney Disease” for a discussion on using CrCl based on the Cockcroft-Gault equation versus eGFR.
Key: 3TC = lamivudine; ARV = antiretroviral; CAPD = continuous ambulatory peritoneal dialysis; CBC = complete blood count;
CMV = cytomegalovirus; COBI = cobicistat; CrCl = creatinine clearance; DS = double strength; eGFR = estimated glomerular
filtration rate; ESRD = end-stage renal disease; FDC = fixed-dose combination; FTC = emtricitabine; HBV = hepatitis B virus;
HD = hemodialysis; HSV = herpes simplex virus; IM = intramuscular; IV = intravenous; MAI = Mycobacterium avium
intracellulare; MTB = Mycobacterium tuberculosis; N/A = not applicable; OI = opportunistic infection; PCP = Pneumocystis
pneumonia; PD = peritoneal dialysis; PI = protease inhibitor; PO = orally; SCr = serum creatinine; SQ = subcutaneous; SBCD =
sulfobutylether cyclodextrin; SS = single strength; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate; TDM =
therapeutic drug monitoring; TMP-SMX = trimethoprim-sulfamethoxazole; VZV = varicella zoster virus
Table 7. Summary of Pre-Clinical and Human Data on, and Indications for, Opportunistic
Infection Drugs During Pregnancy
Updated: February 11, 2020

FDA Pertinent Animal Reproductive and Human Recommended Use During

Drug
Categorya Pregnancy Data Pregnancy
Acyclovir B No teratogenicity in mice, rats, rabbits at human levels. Treatment of frequent or severe
Extensive experience in human pregnancy (>700 first- symptomatic herpes outbreaks
trimester exposures reported to registry); well-tolerated. or varicella
Adefovir C No increase in malformations at 23 times (rats) and 40 Not recommended because of

times (rabbits) human dose. Limited experience with use limited data in pregnancy.
human in pregnancy. Report exposures during
pregnancy to the Antiretroviral
Pregnancy Registry.
Albendazole C Embryotoxic and teratogenic (skeletal malformations) in Not recommended, especially

rats and rabbits, but not in mice or cows. Limited in first trimester. Primary therapy
experience in human pregnancy. for microsporidiosis in
pregnancy should be ART.
Amikacin C Not teratogenic in mice, rats, rabbits. Theoretical risk of Drug-resistant TB, severe MAC
ototoxicity in fetus; reported with streptomycin but not infections
amikacin.
Amoxicillin, B Not teratogenic in animals. Extensive experience in Susceptible bacterial infections

Amoxicillin/ human pregnancy does not suggest an increase in AEs.
Clavulanate,
and Ampicillin/
Sulbactam
Amphotericin B B Not teratogenic in animals or in human experience. Documented invasive fungal
Preferred over azole antifungals in first trimester if similar disease
efficacy expected.
Antimonials, Not FDA Antimony not teratogenic in rats, chicks, sheep. Three Use for therapy of visceral
Pentavalent approved cases reported of use in human pregnancy in second leishmaniasis not responsive to
(Stibogluconate, trimester with good outcome. Labeled amphotericin B or pentamidine.
Meglumine) as contraindicated in pregnancy.
Artesunate, C Embryotoxicity, cardiovascular and skeletal anomalies in Recommended by WHO as first-

Artemether, and rats and rabbits. Embryotoxic in monkeys. Human line therapy in second/third
Artemether/ experience, primarily in the second and third trimesters, trimester for P. falciparum and
Lumefantrine has not identified increased AEs. severe malaria. Pending more
data, use for malaria in first
trimester only if other drugs
are not available or have
failed. Report cases of exposure
to a WHO Anti-Malarial
Pregnancy Exposure Registry
when available.
Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV G-1

Drug
Atovaquone C Not teratogenic in rats or rabbits, limited human Alternate agent for
experience PCP, Toxoplasma gondii,
malaria infections
Azithromycin B Not teratogenic in animals. Moderate experience with use Preferred agent for MAC
in human pregnancy does not suggest AEs. prophylaxis or treatment (with
ethambutol), Chlamydia
trachomatis infection in
pregnancy
Aztreonam B Not teratogenic in rats, rabbits. Limited human Susceptible bacterial infections
experience, but other beta-lactam antibiotics have not
been associated with adverse pregnancy outcomes.
Bedaquiline B Not teratogenic in rats, rabbits. No experience in human Multidrug resistant TB when
pregnancy. effective treatment regimen
cannot otherwise be provided
Benznidazole Not FDA No animal studies. Increase in chromosomal aberrations Not indicated for chronic T.
approved in children with treatment; uncertain significance. No cruzi in pregnancy. Seek expert
human pregnancy data. consultation if acute or
symptomatic infection in
pregnancy requiring treatment.
Boceprevir B Not teratogenic in rats, rabbits. No human pregnancy Treatment of HCV currently
data. generally not indicated in
pregnancy
Capreomycin C Increase in skeletal variants in rats. Limited experience in Drug-resistant TB

human pregnancy; theoretical risk of fetal ototoxicity.
Caspofungin C Embryotoxic, skeletal defects in rats, rabbits. No Invasive Candida or Aspergillus i

experience with human use. nfections refractory to
amphotericin and azoles
Cephalosporins B Not teratogenic in animals. Extensive experience in Bacterial infections; alternate

human pregnancy has not suggested increase in adverse treatment for MAC
outcomes.
Chloroquine C Associated with anophthalmia, micro-ophthalmia at Drug of choice for malaria

fetotoxic doses in animals. Not associated with increased prophylaxis and treatment of
risk in human pregnancy at doses used for malaria. sensitive species in pregnancy
Cidofovir C Embryotoxic and teratogenic (meningocele, skeletal Not recommended

abnormalities) in rats and rabbits. No experience in
human pregnancy.
Ciprofloxacin and C Arthropathy in immature animals; not embryotoxic or Severe MAC infections;
Other Quinolones teratogenic in mice, rats, rabbits, or monkeys. More than multidrug resistant TB, anthrax,
1,100 cases of quinolone use in human pregnancy have bacterial infections
not been associated with arthropathy or birth defects.

Drug
Clarithromycin C Cardiovascular defects noted in one strain of rats and Treatment or secondary MAC
cleft palate in mice at high doses, not teratogenic in prophylaxis, if other choices
rabbits or monkeys. Two human studies, each with >100 exhausted
first-trimester exposures, did not show increase in defects
but one study found an increase in spontaneous abortion.
Clindamycin B No concerns specific to pregnancy in animal or human Treatment of anaerobic bacterial

studies. infections and used with quinine
for chloroquine-resistant malaria;
alternate agent for secondary
prophylaxis of Toxoplasma
Clofazimine C Not teratogenic in mice, rats, or rabbits. Limited No indications

experience reported (19 cases); no anomalies noted but
red-brown skin discoloration reported in several infants
exposed throughout pregnancy.
Clotrimazole C Not teratogenic in animals at exposures expected from Oral or

Troches treatment of oral or vaginal Candida. No increase in vaginal Candida infections and
adverse pregnancy outcomes with vaginal use. prophylaxis
Cycloserine C Not teratogenic in rats. No data available from human Drug-resistant TB

studies.
Dapsone C No animal data. Limited human experience does not Alternative for primary or
suggest teratogenicity; might displace bound bilirubin in secondary PCP prophylaxis
the neonate, increasing the risk of kernicterus. Case
reports of hemolytic anemia in fetus/infant with maternal
treatment.
Dasabuvir/ Not No AEs in mice, rats, rabbits during pregnancy or Therapy in pregnancy is not
Ombitasvir/ assigned lactation. No data in human pregnancy or breastfeeding. recommended because
Paritaprevir/ ribavirin, which is recommended
Ritonavir for concomitant use with this
drug, is contraindicated in
pregnancy.
Diphenoxylate C Limited animal and human data do not indicate Symptomatic treatment of
teratogenicity. diarrhea
Doxycycline and D Risk of hepatic toxicity increased with tetracyclines in No indications

Other Tetracyclines pregnancy; staining of fetal bones and teeth
contraindicates use in pregnancy.

Drug
Elbasvir/ Not No AEs in rats, rabbits during pregnancy or lactation. No May be considered for use in
Grazoprevir assigned data in human pregnancy or breastfeeding. patients who do not need
ribavirin if benefits felt to
outweigh unknown risks.
However, this drug is not
recommended for patients who
need ribavirin based on HCV
subtype or resistance because
ribavirin is contraindicated in
pregnancy.
Emtricitabine B No concerns in pregnancy from limited animal and As part of fully suppressive
human data. combination ARV regimen for
treatment of HIV, HBV. Report
exposures during pregnancy to
the Antiretroviral Pregnancy
Registry.
Entecavir C Animal data do not suggest teratogenicity at human Not recommended because of
doses; however, limited experience in human pregnancy. limited data in pregnancy. Use
as part of fully suppressive ARV
regimen with ARV agents active
against both HIV and HBV.
Report exposures during
Pregnancy Registry.
Erythromycin B Hepatotoxicity with erythromycin estolate in pregnancy; Bacterial and chlamydial

other forms acceptable. No evidence of teratogenicity. infections
Ethambutol B Teratogenic, at high doses, in mice, rats, rabbits. No Active TB and MAC treatment;
evidence of teratogenicity in 320 cases of human use for avoid in first trimester if possible
treatment of TB.
Ethionamide C Increased rate of defects (omphalocele, exencephaly, Active TB; avoid in first trimester
cleft palate) in rats, mice, and rabbits with high doses; not if possible
seen with usual human doses. Limited human data; case
reports of CNS defects.
Famciclovir B No evidence of teratogenicity in rats or rabbits, limited Recurrent genital herpes and
human experience. primary varicella infection.
pregnancy to the Famvir
Pregnancy Registry (1-888-669-
6682).

Drug
Fluconazole C Abnormal ossification, structural defects in rats, mice at Single dose may be used for
high doses. Case reports of rare pattern of craniofacial, treatment of
skeletal and other abnormalities in five infants born to vaginal Candida though topical
four women with prolonged exposure during pregnancy; therapy preferred. Not
no increase in defects seen in several series after single recommended for prophylaxis
dose treatment. during early pregnancy. Can be
used for invasive fungal
infections after first trimester;
amphotericin B preferred in first
trimester if similar efficacy
expected.
Flucytosine C Facial clefts and skeletal defects in rats; cleft palate in Use after first trimester if
mice, no defects in rabbits. No reports of use in first indicated for life-threatening
trimester of human pregnancy; may be metabolized to 5- fungal infections.
fluorouracil, which is teratogenic in animals and possibly
in humans.
Foscarnet C Skeletal variants in rats, rabbits and hypoplastic dental Alternate agent for treatment or
enamel in rats. Single case report of use in human secondary prophylaxis of life-
pregnancy in third trimester. threatening or sight-threatening
CMV infection.
Fumagillin Not FDA Caused complete litter destruction or growth retardation Topical solution can be used for
approved in rats, depending on when administered. No data in ocular microsporidial infections.
human pregnancy.
Ganciclovir and C Embryotoxic in rabbits and mice; teratogenic in rabbits Treatment or secondary
Valganciclovir (cleft palate, anophthalmia, aplastic kidney and pancreas, prophylaxis of life-threatening or
hydrocephalus). Case reports of safe use in human sight-threatening CMV infection.
pregnancy after transplants, treatment of fetal CMV. Preferred agent for therapy in
children.
Glecaprevir/ Not No AEs of glecaprevir in rats or of pibrentasvir in mice, Use may be considered for
Pibrentasvir assigned rabbits during pregnancy and lactation. No data in human hepatitis C if benefits outweigh
pregnancy or breastfeeding. unknown risks.
Imipenem and C/B Not teratogenic in animals; limited human experience. Serious bacterial infections
Meropenem
Imiquimod B Not teratogenic in rats and rabbits; eight case reports of Because of limited experience,
human use, only two in first trimester. other treatment modalities such
as cryotherapy or trichloroacetic
acid recommended for wart
treatment during pregnancy.

Drug
Influenza Vaccine C Not teratogenic. Live vaccines, including intranasal All pregnant people should
influenza vaccine, are contraindicated in pregnancy. receive injectable influenza
vaccine because of the
increased risk of complications
of influenza during pregnancy.
Ideally, people with HIV should
be on ART before vaccination to
limit potential increases in HIV
RNA levels with immunization.
Interferons C Abortifacient at high doses in monkeys, mice; not Not indicated. Treatment of HCV
Alfa, Beta, and teratogenic in monkeys, mice, rats, or rabbits. currently generally not
Gamma Approximately 30 cases of use of interferon-alfa in recommended in pregnancy.
pregnancy reported; 14 in first trimester without increase
in anomalies; possible increased risk of intrauterine
growth retardation.
Isavuconazole C Increased perinatal mortality in rats at exposures below Use alternate antifungals,
human exposure levels. Dose-related skeletal defects in especially in first trimester.
rats at exposures below human exposure levels. No data
in human pregnancy or breastfeeding.
Isoniazid C Not teratogenic in animals. Possible increased risk of Active TB; prophylaxis for
hepatotoxicity during pregnancy; prophylactic pyridoxine exposure or skin test conversion
50 mg/day should be given to prevent maternal and fetal
neurotoxicity.
Itraconazole C Teratogenic in rats and mice at high doses. Case reports Only for documented systemic
of craniofacial, skeletal abnormalities in humans with fungal disease, not prophylaxis.
prolonged fluconazole exposure during pregnancy; no Consider using amphotericin B
increase in defect rate noted among >300 infants born in first trimester if similar efficacy
after first-trimester itraconazole exposure. expected.
Kanamycin D Associated with club feet in mice, inner ear changes in Drug-resistant TB
multiple species. Hearing loss in 2.3% of 391 children
after long-term in utero therapy.
Ketoconazole C Teratogenic in rats, increased fetal death in mice, rabbits. None

Inhibits androgen and corticosteroid synthesis; may
impact fetal male genital development; case reports of
craniofacial, skeletal abnormalities in humans with
prolonged fluconazole exposure during pregnancy.
Lamivudine C Not teratogenic in animals. No evidence of teratogenicity HIV and HBV therapy, only as
with >3,700 first-trimester exposures reported to part of a fully suppressive
the Antiretroviral Pregnancy Registry. combination ARV regimen.
Report exposures to
the Antiretroviral Pregnancy
Registry.
Ledipasvir/ B No evidence of teratogenicity in rats or rabbits. No Treatment of HCV generally not

Sofosbuvir experience in human pregnancy. indicated in pregnancy.

Drug
Leucovorin C Prevents birth defects of valproic acid, methotrexate, Use with pyrimethamine when
(Folinic Acid) phenytoin, aminopterin in animal models. No evidence of use of pyrimethamine cannot be
harm in human pregnancies. avoided.
Linezolid C Not teratogenic in animals. Decreased fetal weight and Serious bacterial infections
neonatal survival at expected human exposures, possibly
related to maternal toxicity. Limited human experience.
Loperamide B Not teratogenic in animals. No increase in birth defects Symptomatic treatment of

among infants born to 89 women with first-trimester diarrhea after the first trimester
exposure in one study; another study suggests a possible
increased risk of hypospadias with first-trimester
exposure, but confirmation required.
Mefloquine C Animal data and human data do not suggest an Second-line therapy of
increased risk of birth defects, but miscarriage and chloroquine-resistant malaria in
stillbirth may be increased. pregnancy, if
quinine/clindamycin not
available or not tolerated.
Weekly as prophylaxis in areas
with chloroquine-resistant
malaria.
Meglumine Not FDA See Antimonials, pentavalent Therapy of visceral

approved leishmaniasis not responsive to
amphotericin B or pentamidine
Metronidazole B Multiple studies do not indicate teratogenicity. Studies on Anaerobic bacterial infections,
several hundred women with first-trimester exposure bacterial vaginosis,
found no increase in birth defects. trichomoniasis, giardiasis,
amebiasis
Micafungin C Teratogenic in rabbits; no human experience. Not recommended
Miltefosine Not FDA Embryotoxic in rats, rabbits; teratogenic in rats. No Not recommended
approved experience with human use.
Nifurtimox Not FDA Not teratogenic in mice and rats. Increased chromosomal Not indicated in chronic
approved aberrations in children receiving treatment; uncertain infection; seek expert
significance. No experience in human pregnancy. consultation if acute infection or
symptomatic reactivation of T.
cruzi in pregnancy.
Nitazoxanide B Not teratogenic in animals; no human data. Severely symptomatic

cryptosporidiosis after the first
trimester
Ombitasvir/ Not No AEs in mice, rats, rabbits during pregnancy or Ribavirin, recommended to be
Paritaprevir/ assigned lactation. No data in human pregnancy or breastfeeding. used with this drug, is
Ritonavir contraindicated in pregnancy so
therapy in pregnancy is not
recommended.

Drug
Para-Aminosalicylic C Occipital bone defects in one study in rats; not Drug-resistant TB
Acid (PAS) teratogenic in rabbits. Possible increase in limb, ear
anomalies in one study with 143 first-trimester exposures;
no specific pattern of defects noted, several studies did
not find increased risk.
Paromomycin C Not teratogenic in mice and rabbits. Limited human Amebic intestinal infections,
experience, but poor oral absorption makes toxicity, possibly cryptosporidiosis
teratogenicity unlikely.
Penicillin B Not teratogenic in multiple animal species. Vast Syphilis, other susceptible
experience with use in human pregnancy does not bacterial infections
suggest teratogenicity, other adverse outcomes.
Pentamidine C Embryocidal but not teratogenic in rats, rabbits with Alternate therapy for PCP and
systemic use. Limited experience with systemic use in leishmaniasis
human pregnancy.
Piperacillin- B Not teratogenic in limited animal studies. Limited Bacterial infections

Tazobactam experience in pregnancy but penicillins generally
considered safe.
Pneumococcal C No studies in animal pregnancy. Polysaccharide vaccines Initial or booster dose for
Vaccine generally considered safe in pregnancy. Well-tolerated in prevention of invasive
third-trimester studies. pneumococcal infections.
Pregnant people with HIV should
be on ART before vaccination to
limit potential increases in HIV
RNA levels with immunization.
Podophyllin and C Increased embryonic and fetal deaths in rats, mice but Because alternative treatments
Podofilox not teratogenic. Case reports of maternal, fetal deaths for genital warts in pregnancy
after use of podophyllin resin in pregnancy; no clear are available, use is not
increase in birth defects with first-trimester exposure. recommended; however,
inadvertent use in early
pregnancy is not indication for
abortion.
Posaconazole C Embryotoxic in rabbits; teratogenic in rats at similar to Not recommended

human exposures. No experience in human pregnancy.
Prednisone B Dose-dependent increased risk of cleft palate in mice, Adjunctive therapy for severe
rabbits, hamsters; dose-dependent increase in genital PCP; multiple other non-HIV-
anomalies in mice. Human data inconsistent regarding related indications
increased risk of cleft palate. Risk of growth retardation,
low birth weight may be increased with chronic use;
monitor for hyperglycemia with use in third trimester.
Primaquine C No animal data. Limited experience with use in human Alternate therapy for PCP,
pregnancy; theoretical risk for hemolytic anemia if fetus chloroquine-resistant malaria
has G6PD deficiency.

Drug
Proguanil C Not teratogenic in animals. Widely used in malaria- Alternate therapy and
endemic areas with no clear increase in adverse prophylaxis of P.
outcomes. falciparum malaria
Pyrazinamide C Not teratogenic in rats, mice. Limited experience with use Active TB
in human pregnancy.
Pyrimethamine C Teratogenic in mice, rats, hamsters (cleft palate, neural Treatment and secondary
tube defects, and limb anomalies). Limited human data prophylaxis of toxoplasmic
have not suggested an increased risk of birth defects; encephalitis; alternate treatment
because folate antagonist, use with leucovorin. of PCP
Quinidine C Generally considered safe in pregnancy; high doses Alternate treatment of malaria,
Gluconate associated with preterm labor. One case of fetal VIII- control of fetal arrhythmias
nerve damage reported.
Quinine Sulfate C High doses, often taken as an abortifacient, have been Treatment of chloroquine-
associated with birth defects, especially deafness, in resistant malaria
humans and animals. Therapeutic doses have not been
associated with an increased risk of defects in humans or
animals. Monitor for hypoglycemia.
Ribavirin X Dose-dependent risk of multiple defects (craniofacial, Contraindicated in early

central nervous system, skeletal, anophthalmia) in rats, pregnancy; no clear indications
mice, hamsters starting at below human doses. Reports in pregnancy.
of treatment during second half of pregnancy in nine
women without incident; first 49 cases in registry did not
suggest increased risk, but limited data.
Rifabutin B Not teratogenic in rats and rabbits; no specific concerns Treatment or prophylaxis of
for human pregnancy. MAC, active TB
Rifampin C Teratogenic at high doses in mice (cleft palate) and rats Active TB
(spina bifida) but not in rabbits. No clear teratogenicity in
humans.
Rifapentine C Embryofetal toxicity with increased rate of malformations Use alternate drugs in
and fetal loss noted in rats and rabbits. Limited pregnancy if possible.
experience in human pregnancy and lactation.
Simeprevir C Decreased fetal weights and increased skeletal variants Treatment of HCV currently
in mice at 4 times human exposure. Increased deaths generally not recommended in
and decreased fetal and neonatal growth and pregnancy.
developmental delay after in utero exposure in rats. No
experience in human pregnancy.
Sinecatechin C No evidence of teratogenicity in rats and rabbits after oral Not recommended based on
Ointment or intravaginal dosing. No experience in human lack of data.
pregnancy.

Drug
Sofosbuvir B No evidence of teratogenicity in rats or rabbits. No Treatment of HCV generally not
experience in human pregnancy. indicated in pregnancy.
Regimens including ribavirin and
interferon
are contraindicated in
pregnancy.
Sofosbuvir/ Not No AEs in mice, rats, rabbits during pregnancy or Could be used if benefits felt to
Velpatasvir assigned lactation. No data in human pregnancy or breastfeeding. outweigh unknown risks in
patients not needing ribavirin.
Ribavirin is contraindicated in
pregnancy, so not
recommended for patients
needing ribavirin based on
subtype or resistance.
Sofusbuvir/ Not No AEs in mice, rats, rabbits during pregnancy or Could be used if benefits felt to
Velpatasvir +/- assigned lactation. No data in human pregnancy or breastfeeding. outweigh unknown risks.
Voxilaprevir
Streptomycin D No teratogenicity in mice, rats, guinea pigs. Possible Alternate therapy for active TB
increased risk of deafness and VIII-nerve damage; no
evidence of other defects.
Sulfadiazine B Sulfonamides teratogenic in some animal studies. No Secondary prophylaxis of

clear teratogenicity in humans; potential for increased toxoplasmic encephalitis
jaundice, kernicterus if used near delivery.
Telaprevir B Not teratogenic in mice, rats. No human pregnancy data. Treatment of HCV currently
generally not indicated in
pregnancy.
Telbivudine B Not teratogenic in rats, rabbits. Limited experience in Not recommended because of
human pregnancy. limited data in pregnancy. Use
as part of fully suppressive ARV
regimen with ARV agents active
against both HIV and HBV.
Pregnancy Registry.
Tenofovir B No evidence of birth defects in rats, rabbits, or monkeys Component of fully suppressive
at high doses; chronic administration in immature animals ARV regimen in pregnant
of multiple species at 6–50 times human doses has led to people. Report exposures during
dose-specific bone changes ranging from decreased pregnancy to the Antiretroviral
mineral density to severe osteomalacia and fractures. Pregnancy Registry.
Clinical studies in humans (particularly children) show
bone demineralization with chronic use; clinical
significance unknown. No evidence of increased birth
defects in nearly 2,000 first-trimester exposures in
women.

Drug
Trichloroacetic Acid Not rated No studies. Used topically so no systemic absorption Topical therapy of non-cervical
and Bichloroacetic expected. genital warts
Acid
Trifluridine C Not teratogenic in rats, rabbits. Minimal systemic Topical agent for treatment of
absorption expected with topical ocular use. ocular herpes infections
Trimethoprim- C Teratogenic in rats and mice. Possible increase in Therapy of PCP during
Sulfamethoxazole congenital cardiac defects, facial clefts, neural tube and pregnancy. Primary and
urinary defects with first-trimester use. Unclear if higher secondary PCP prophylaxis in
levels of folate supplementation lower risk. Theoretical the second/third trimester;
risk of elevated bilirubin in the neonate if used near consider aerosolized
delivery. pentamidine in first trimester.
Recommend fetal ultrasound at
18–20 weeks after first-trimester
exposure.
Valacyclovir B Not teratogenic in mice, rats, and rabbits. Experience Treatment of HSV and varicella
with valacyclovir in pregnancy limited; prodrug of infections in pregnancy
acyclovir, which is considered safe for use in pregnancy.
Vancomycin C Not teratogenic in rats, rabbits. Limited human Serious bacterial infections
experience.
Voriconazole D Embryotoxic in rats, rabbits. Teratogenic in rats (cleft Not recommended

palate, hydronephrosis, and ossification defects). No
experience with human use.
a FDA has discontinued the assignment of drugs to pregnancy-risk letter categories in favor of a narrative approach. This table
includes both previously assigned risk categories for older drugs and key findings based on FDA narratives for unassigned
newer drugs.
Key: AE = adverse effect; ART = antiretroviral therapy; ARV = antiretroviral; CMV = cytomegalovirus; CNS = central nervous
system; FDA = Food and Drug Administration; G6PD = glucose-6-phosphate dehydrogenase; HBV = hepatitis B virus;
HCV = hepatitis C virus; HSV = herpes simplex virus; MAC = Mycobacterium avium complex; PCP = Pneumocystis pneumonia;
TB = tuberculosis; VIII nerve = vestibulocochlear nerve; WHO = World Health Organization

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Guidelines for the Prevention and Treatment of

How to Cite the Adult and Adolescent Opportunistic Infection Guidelines:

Updated: February 17, 2022

Coccidioidomycosis A new positive IgM or IgG Fluconazole 400 mg PO daily (BIII)

Histoplasma CD4 count ≤150 cells/µL Itraconazole 200 mg PO daily (BI)

Malaria Travel to disease-endemic Recommendations are the same for

Updated: June 14, 2023

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Therapy should be adjusted based on the

For patients with chronic diarrhea

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

• Ciprofloxacin 500–750 mg PO (or 400 • Add an aminoglycoside resistance.

Effective ART may reduce

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Secondary Prophylaxis Should Be

Note: Azithromycin- If no clinical response after

Effective ART may

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

• Topical azoles (clotrimazole, • Miconazole • Fluconazole 100 mg PO

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Duration of therapy has not

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Cryptococcosis Cryptococcal Meningitis Cryptococcal Meningitis Addition of flucytosine to

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

• For clinically stable patients with • Amphotericin B always be measured when

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

• Valganciclovir 900 mg PO every Chronic Maintenance reconstitution (AIII).

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Histoplasmosis Moderately Severe to Severe Moderately Severe to Itraconazole, posaconazole,

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Human Herpesvirus-8 Diseases Mild to Moderate KS (Localized MCD Corticosteroids should be

• PO valganciclovir or IV ganciclovir can

MCD Therapy Options (in Consultation

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

• Valganciclovir PO or Ganciclovir IV plus

Concurrent KS and MCD

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

• Podophyllin resin 10%–

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Cutaneous For Initial Infection Possible Options None

Choice of therapy is guided by the degree

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

For Disseminated Disease Caused by

For Ocular Infection

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

• Atovaquone 750 mg Whenever possible,

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Talaromycosis (Penicilliosis) Induction Therapy Induction Therapy Itraconazole is not

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

• 2 weeks (AI), followed by consolidation amphotericin B is not early as 1 week after

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

• Leucovorin dose can be increased to • Atovaquone 1,500 mg Atovaquone should be

Opportunistic Infection Preferred Therapy Alternative Therapy Other Comments

Herpes Zoster (Shingles) In patients with herpes