Review Question - QID 104896

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Human Immunodeficiency Virus (HIV) Opportunistic Infections CD4+ Count < 100 mm3 QID: 104896 (M2.ID.15.11)

QID 104896 (Type "104896" in App Search)

A 33-year-old HIV-positive male is seen in clinic for follow-up care. When asked if he has been adhering to his HIV medications, the patient exclaims that he has been depressed, thus causing him to not take his medication for six months. His CD4+ count is now 33 cells/mm3. What medication(s) should he take in addition to his anti-retroviral therapy?

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Fluconazole

2/30

Dapsone

0/30

Azithromycin and trimethoprim-sulfamethoxazole

70%

21/30

Azithromycin and fluconazole

2/30

Azithromycin, dapsone, and fluconazole

10%

3/30

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This patient has a very low CD4+ count of <50 cells/mm3, placing him at risk for acquiring various opportunistic infections. Of these opportunistic infections, azithromycin is used as prophylaxis for mycobacterium avium complex (MAC), and trimethoprim-sulfamethoxazole (TMP-SMX) for pneumocystis jirovecii pneumonia and toxoplasma gondii.

Primary prophylaxis for pneumocystis jirovecii pneumonia is needed in HIV+ positive patients as their CD4+ goes below 200 cells/mm3 with TMP-SMX. Below 100 cells/mm3, TMP-SMX also covers for toxoplasma gondii encephalitis. Below 50 cells/mm3, prophylaxis against disseminated MAC disease is needed with azithromycin. Disseminated MAC may present as fever, fatigue, weight loss, and at times, diarrhea.

The American Family Physician published USPHS/IDSA guidelines on preventing opportunistic infections in HIV/AIDS. It lists that azithromycin or clarithromycin are the preferred agents, with rifabutin being used if the other two cannot be tolerated. Disseminated MAC disease should be ruled out prior to prophylaxis.

Havlir et al. found in a randomized trial that azithromycin was more effective than rifabutin alone. The combination of rifabutin and azithromycin is more effective than azithromycin alone, but is not tolerated well.

Incorrect Answers:
Answer 1,4,5: Fluconazole is not used to prevent or treat MAC; it is used for fungal infections. Of note, routine prophylaxis against cryptococcus is not used in the management of patients with AIDS.
Answer 2,5: Dapsone can be used as an alternative agent to TMP-SMX for preventing PCP infection.