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Opportunistic infection / new diagnosis

  1. Order: CD4 count + viral load + resistance genotype
  2. Start ART ASAP: Integrase-based — bictegravir/emtricitabine/tenofovir alafenamide OR dolutegravir + 2 NRTIs
  3. OI prophylaxis: CD4 <200 → TMP-SMX (PCP); CD4 <50 → MAC prophylaxis (azithromycin) ONLY if not on/not responding to effective ART (rule out disseminated MAC first — DHHS OI)
  4. Advise partner notification

Order set

  • HIV Ag/Ab + confirmatory
  • CD4 + viral load
  • Genotype
  • OI + TB + hepatitis screen

Criteria

AdmitOpportunistic infection or severe presentation
ICURespiratory failure, shock, severe OI
DischargeOI treated, ART started/continued, prophylaxis + follow-up
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • CD4 <200 with symptoms
  • IRIS
  • Opportunistic infection
Differentials
  • Seroconversion illness
  • Other immunodeficiency
  • OIs
Common mistakes
  • Delaying ART
  • Forgetting OI prophylaxis
  • Not screening HBV before TAF/TDF; check HLA-B*5701 only if abacavir considered
  • Not offering rapid/same-day ART initiation (now standard — DHHS/IAS-USA)
Disposition & follow-up

Start ART promptly; OI prophylaxis by CD4; adherence support.

Discharge package
MedicationsART + OI prophylaxis by CD4
Follow-upHIV clinic; adherence support
VaccinationInactivated vaccines; avoid live if CD4 low
LifestylePartner notification, barrier protection
Warning symptomsNew infection, fever, breathlessness, neuro symptoms
💊 Treatment detail — doses & preparation
cART (e.g., BIC/TAF/FTC)HIV antiretroviral
DoseBictegravir 50 mg/tenofovir alafenamide 25 mg/emtricitabine 200 mg — 1 tablet OD
PreparationSingle-tablet regimen; same time daily
MonitorViral load at 4–8 wk; start within days of diagnosis; check interactions
Co-trimoxazole (TMP-SMX)antibiotic
DosePCP treatment: TMP 15–20 mg/kg/day IV/PO in 3–4 divided doses ×21 d; prophylaxis: 960 mg OD or 480 mg OD
PreparationIV: 480 mg/5 mL ampoule — dilute each 480 mg in 125 mL D5W, infuse over 60–90 min; PO 480/960 mg tablets
MonitorK⁺, creatinine (both rise), rash, marrow; FBC/U&E 2×/wk on high dose
Opportunistic infection screenprinciple
DoseCD4-guided prophylaxis: TMP-SMX if <200, azithromycin if <50
PreparationBaseline CD4/viral load/resistance panel
MonitorCD4 + VL q3–6 mo once stable
📖 DHHS / BHIVA HIVReviewed July 2026

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