Prophylaxis for opportunistic infections in patients with HIV infection

Objective: To review the efficacy of chemoprophylaxis for opportunistic infections in persons infected with human immunodeficiency virus (HIV). Data Sources: English-language articles on the prevention of HIV-related opportunistic infections were identified through MEDLINE (1985 to 1993) and through review of abstracts presented at the International Conferences on AIDS, the Interscience Conferences on Antimicrobial Agents and Chemotherapy, and the National Conference on Human Retroviruses and Related Diseases. Study Selection: Importance was assigned in descending order to controlled clinical trials, uncontrolled trials and retrospective studies, and prospective observational studies. Data Synthesis: Persons infected with HIV who are at risk for Pneumocystis carinii pneumonia should receive prophylaxis, preferably with trimethoprimsulfamethoxazole. Alternative agents are aerosolized pentamidine, dapsone, and dapsone-pyrimethamine. Patients who are seropositive for Toxoplasma gondii may benefit from primary prophylaxis against toxoplasmosis using trimethoprim-sulfamethoxazole or dapsone- pyrimethamine. Life-long secondary prophylaxis is indicated for all patients previously treated for toxoplasmic encephalitis. Long-term suppressive therapy is required for all patients with cryptococcal meningitis and histoplasmosis, and many patients with recurrent mucosal candidiasis also benefit from long-term suppression. The role of primary prophylaxis of fungal infections, however, is uncertain. Rifabutin has been approved to prevent disseminated infection with Mycobacterium avium complex and is indicated for all patients with CD4 counts less than 100/mm³. Chemoprophylaxis with isoniazid for 12 months is indicated in all patients infected with HIV who have or are at high risk for M. tuberculosis infection. No effective primary prophylactic agent is available for cytomegalovirus disease, although several investigational drugs are being studied. Acyclovir is effective in decreasing recurrences of herpes simplex virus infection. The incidence of common bacterial infections is decreased by trimethoprim-sulfamethoxazole. Pneumococcal polysaccharide vaccine is recommended for adult patients infected with HIV, and Haemophilus influenzae type b conjugate vaccine is recommended for children infected with HIV. Conclusions: A growing number of infections related to the acquired immunodeficiency syndrome are preventable with currently available agents. Issues of drug interactions, toxicity, and cost-effectiveness will become increasingly important in the management of patients with advanced HIV disease.