- Dapsone 200 mg/week po + pyrimethamine 75 mg/week po + leucovorin 25 mg/week po
- Atovaquone 1500 mg/day ± pyrimethamine 25 mg/day + leucovorin 10 mg/day
IMMUNE RECONSTITUTION: The safety of discontinuing primary and secondary prophylaxis for toxo plasmosis is confirmed in prospective studies (J Infect Dis;181:1635; Clin Infect Dis 2006;41:79) and multiple observational studies (Lancet 2000;355:2217; J Infect Dis 2000;181: 1635; AIDS 1999;13: 1647; AIDS 2000;14:383; Ann Intern Med 2002; 137:239).
- Primary prophylaxis: Discontinue prophylaxis with CD4 count >200 cells/mm3 for >3 months; restart when CD4 count is <100-200 cells/mm3.
- Maintenance therapy: Discontinue prophylaxis with CD4 count >200 cells/mm3 for ≥6 months providing initial therapy for ≥6 wks has been completed and the patient is asymptomatic for toxoplasmosis. Some authorities would include MRI evaluation in this decision. Restart prophylaxis when CD4 count is <200 cells/mm3.
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M. avium complex (MAC)
INDICATION: CD4 count <50 cells/mm3 after ruling out active MAC infecion.
RISK: CD4 count <50 cells/mm3. The incidence of MAC with a CD4 <50 cells/mm3 and no HAART or prophylaxis is 20-40% (JInfect Dis 1997; 176:126; Clin Infect Dis 1993;17:7).
PREFERRED:
- Azithromycin 1200 mg po once weekly
- Clarithromycin 500 mg po bid
- Azithromycin 600 mg po 2 x /week
ALTERNATIVE : Rifabutin 300 mg po daily with dose adjustment for concurrent antiretroviral agents (pg ___).
IMMUNE RECONSTITUTION:It is safe to discontinue primary and secondary MAC prophylaxis with immune reconstitution (NEJM 1998;338:853; NEJM 2000;342:1085; Ann Intern Med 2000;133:493; J Infect Dis 1998;178:1446; HIV Med 2004;5:278).
- Primary prophylaxis: Discontinue prophylaxis with CD4 count >100 cells/mm3 for >3 months. Restart when CD4 count is <100 cells/mm3. The study that followed the largest group (592 patients) for the longest time (mean, 2.5 years) found only one case of MAC bacteremia after stopping primary prophylaxis (CID 2005; 41:549).
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