HIV
Corey Diamond, PharmD
In the dynamic landscape of HIV prevention and treatment, the U.S. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV are at the forefront.
Through a collaboration with NIH, CDC, and the HIV Medicine Association of the Infectious Diseases Society of America, the guidelines are continuously evolving to incorporate the latest advancements in prevention and treatment recommendations. The document undergoes regular updates, ensuring it remains a reliable resource in the ongoing battle against HIV, including some major revisions made within the past 6 months.
Mpox
The mpox chapter update to the NIH HIV guideline, which was previously under development, has been added as of July 24, 2023, as a response to the 2022 outbreak. Specifically, the new chapter guideline adds epidemiologic, diagnostic, prevention, and treatment considerations for people living with HIV.
Mpox is a rare viral disease that belongs to the same family of viruses as smallpox. The virus is primarily found in the regions of Central and West Africa. However, the large outbreak in May 2022 raised concerns for future outbreaks. Although mortality as a result of mpox infection is less than 1% in the general population, the death rate is higher for individuals with advanced HIV.
In terms of preventing mpox infection in HIV individuals, the guideline states that all people with HIV who have a potential for mpox exposure should be vaccinated. The JYNNEOS vaccine is the preferred vaccine and is administered in two doses 28 days apart. Additionally, the vaccine is recommended up to 14 days after mpox exposure as it may still provide some protection.
According to the guideline, individuals with HIV who have a contraindication to vaccination or advanced immunosuppression may be considered for two alternative PEP treatments: oral tecorvirmat 600 mg every 8 to 12 hours (based on weight) for 14 days, or a single dose of vaccinia immune globulin I.V. (VIGIV) 6000 to 9000 units/kg.
In terms of treating mpox infection in HIV individuals, the guideline authors recommend, foremost, that antiretroviral therapy be initiated as soon as possible. Additionally, several treatment modalities are available for severe mpox disease or for individuals at risk for severe disease (not virologically suppressed or who have CD4 counts <350 cells/mm³).
The NIH guideline recommends tecovirimat 600 mg by mouth every 12 hours (<120 kg) or every 8 hours (≥120 kg) for 14 days. Alternatively, tecovirimat 200 mg I.V. every 12 hours for 14 days (<120 kg) or 300 mg I.V. every 12 hours (≥120 kg) may be considered if concern exists regarding altered GI absorption capacity, the inability to take by mouth, or the extent of organ systems affected by mpox. Adjunctive therapy for severe mpox disease includes cidofovir, brincidofovir, and VIGIV.
Chagas disease
Chagas disease, also known as American trypanosomiasis, is a tropical parasitic infection caused by the protozoan parasite Trypanosoma cruzi. The disease is primarily found in Latin America, where it is transmitted to humans through the bite of infected triatomine bugs, also known as “kissing bugs.”
In the case of individuals with HIV, the immune system is less able to control the initial infection and prevent the progression of the disease to its chronic phase, which can lead to more severe complications over a lifetime.
Benznidazole and nifurtimox are two of the main antiparasitic drugs used to treat Chagas disease. The June 14, 2023, update of the NIH HIV guideline changes the recommended dosing for nifurtimox. Whereas previously the guideline recommended 8 mg/kg/day to 10 mg/kg/day, administered for 90 to 120 days as an alternative to benznidazole, the guideline now recommends administering nifurtimox 8 mg/kg/day to 10 mg/kg/day in three divided doses with food for 60 days.
Syphilis
Syphilis, which is caused by the bacterium Treponema pallidum, is linked to a higher likelihood of acquiring and transmitting HIV through sexual activity. The NIH guideline has added a section as of September 25, 2023, for post-exposure syphilis prophylaxis based on data from recent clinical trials in individuals with HIV.
In general, doxycycline 200 mg after unprotected sex in men and transgender women was associated with a 73% reduction in syphilis incidence rates. The evidence, however, is not robust at this point. The NIH guideline notes that other studies are underway regarding the use of doxycycline for the indication of PEP. ■