Guidelines for the Prevention and Treatment of Opportunistic Infections Among HIV-Exposed and HIV-Infected Children: Centers for Disease Control and Prevention et al., 58 MMWR 1 (2009)

These guidelines provide recommendations for health care workers for preventing, diagnosing and treating opportunistic infections (OIs) among children who are either living with or have been exposed to HIV, and who have not yet completed puberty. The guidelines represent an update of the guidelines last published in 2004. Major changes in the guidelines include (1) greater emphasis on the importance of antiretroviral therapy for preventing and treating OIs, especially those OIs for which no specific therapy exists; (2) information about the diagnosis and management of immunere constitution inflammatory syndromes; (3) information about managing antiretroviral therapy in children with OIs, including potential drug–drug interactions; (4) new guidance on diagnosing of HIV infection and presumptively excluding HIV infection in infants that affect the need for initiation of prophylaxis to prevent Pneumocystis jirovecii pneumonia (PCP) in neonates; (5) updated immunization recommendations for HIV-exposed and HIV-infected children, including hepatitis A, human papillomavirus, meningococcal, and rotavirus vaccines; (6) addition of sections on aspergillosis; bartonella; human herpes virus-6, -7, and -8; malaria; and progressive multifocal leukodystrophy (PML); and (7) new recommendations on discontinuation of OI prophylaxis after immune reconstitution in children.

The guidelines outline various opportunistic infections and, for each, provide a brief description of the epidemiology, clinical presentation, and diagnosis of the OI in children; prevention of exposure; prevention of disease by chemoprophylaxis and/or vaccination; discontinuation of primary prophylaxis after immune reconstitution; treatment of disease; monitoring for adverse effects during treatment; management of treatment failure; prevention of disease recurrence; and discontinuation of secondary prophylaxis after immune reconstitution.

The guidelines also provide additional information on related topics, such as how to make a clinical determination of whether a newborn has contracted HIV; the effectiveness of highly active antiretroviral therapy (HAART) in preventing and treating OIs; and the complications and obstacles in adhering to a HAART regimen. They clearly confirm that the decision of when to start HAART in a child with an OI depends on the individual child’s circumstances. The recommendations also provide information on the use of vaccines in HIV-positive children, stating that “[m]ost vaccines recommended for routine use can be administered safely to HIV-exposed or HIV-infected children” and “[a]ll inactivated vaccines can be administered safely to persons with altered immunocompetence.”

The guidelines, issued by the CDC/Department of Health and Human Services, are the joint recommendations of CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics.