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HIV Opportunistic Infection Guidelines Updated

By Paul E. Sax, M.D.

May 8, 2013

Some very hard-working folks at the NIH, CDC and IDSA have updated the Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents, which are available for review here.

As with the previous versions (the prior iteration is from 2009), the OI Guidelines are comprehensive, exhaustively referenced (184 references for TB alone!), and authoritative. Note that the PDF version weighs in at 416 pages, so I doubt many people will be printing this out and carrying it around in their white coats. Fortunately, for the first time these Guidelines are also available in their entirety online in an HTML version, which is undoubtedly how most will access them, and certainly make them easier to update.

After a quick review (no, I have not read all 416 pages quite yet), here are a few of the notable changes, plus a couple of miscellaneous comments:

At the end of the document, there are several summary tables as well as this clear and useful figure with the recommended immunizations (click to enlarge):

Immunization Schedule for Human Immunodeficiency Virus (HIV)-Infected Adults

So I do have a few small quibbles/queries, but they are minor. Namely:

  1. How did they come up with the order of OIs? It seems to be more or less random. Here's how it starts -- PCP, toxo, cryptosporidia, microsporidia, TB, MAC, bacterial respiratory infections ... What the? Undoubtedly there's a rationale I'm not seeing.
  2. If you click on the "Endemic Mycoses" link along the left of the HTML version, you get three endemic mycoses (histo, blasto, cocci), plus two that are not generally thought of geographically, cryptococcus and aspergillus.
  3. Still not much love for beta glucan for PCP diagnosis. With the caveat that we've used the test now for years, which makes me far from impartial, it really is quite useful -- an HIV+ patient with advanced disease, respiratory symptoms and a beta glucan > 500 has PCP until proven otherwise.

Note that the panel responsible for these guidelines is inviting comment; just send an email to by May 21, 2013.

I'm sure if we ask nicely, they'll let us know how they came up with the order for the OIs ...

Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.

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