Guidelines for Opportunistic Infections in HIV

to the editor: In our July 1997 article¹ on opportunistic infections and psychosocial stress in persons with human immunodeficiency virus (HIV), Dr. Gebhardt and I described the current U.S. Public Health Service and the Infectious Disease Society of America (USPHC/IDSA) guidelines. Our article also mentioned that the new guidelines were soon to be forthcoming. The updated guidelines were recently published.² The following are the most significant changes:

1. Prophylaxis for Mycobacterium avium complex (MAC) has moved from a B rating to an A (“standard of care”) rating. This means that, like prophylaxis for Pneumocystis carinii pneumonia, toxoplasmosis and Mycobacterium tuberculosis, MAC prophylaxis should always be offered when clinical and staging criteria are met.
2. Vaccination against Streptococcus pneumoniae in adults with a CD4⁺ count greater than 200 per mm³ (200 × 10⁶ per L) has moved from a B rating to an A (“standard of care”) rating. Thus, all adults in this category should receive pneumococcal vaccine polyvalent (Pneumovax).

The USPHC/IDSA guidelines also now emphasize (as we did in our article) the need to base initiating or continuing prophylaxis on the lowest (not necessarily the current) CD4⁺ cell count.