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Preface
In 1994, the U.S. Public Health Service (USPHS) and the Infectious Diseases Society of America (IDSA) recognized that, although strategies were available to reduce the frequency of opportunistic infections in patients who have human immunodeficiency virus (HIV) infection, information regarding prevention of both exposure and disease often was published in journals not regularly reviewed by health-care providers.
In response, USPHS/IDSA developed comprehensive guidelines for health-care providers and patients that consolidated information pertaining to the prevention of opportunistic infections in persons infected with HIV. The resulting USPHS/IDSA guidelines were published in 1995 in the MMWR, Clinical Infectious Diseases, and the Annals of Internal Medicine, with an accompanying editorial in the Journal of the American Medical Association (1–4). The response to the 1995 guidelines (e.g., the many requests for reprints and observations from health-care providers) suggests that they have served as a valuable reference against which local policies regarding prevention of opportunistic infections could be compared. Because recommendations were rated on the basis of the strength of the evidence supporting them, readers were able to assess for themselves to which areas adherence was most important (5).
In the United States, opportunistic infections continue to produce morbidity and mortality among the estimated 650,000–900,000 persons who are infected with HIV, especially among the estimated 200,000–250,000 persons who are severely immunosuppressed (i.e., persons who have a CD4+ T-lymphocyte count of <200 cells/µL) (6-10). However, surveillance data indicate that the incidence of opportunistic infections has been changing in the United States. In HIV-infected men who have sex with men, Pneumocystis carinii pneumonia (PCP), toxoplasmic encephalitis, fungal infections, and disseminated Mycobacterium avium complex (MAC) disease have decreased in incidence (9).
Prophylactic regimens against opportunistic pathogens and more potent antiretroviral drugs appear to be important factors influencing this decline in incidence. However, these decreases have not been observed among HIV-infected injecting-drug users, suggesting that more emphasis should be placed on providing currently recommended chemoprophylactic agents to all persons who have HIV infection and who meet appropriate criteria for prophylaxis for opportunistic infections. The surveillance data also indicate that the incidence of some opportunistic infections is not decreasing among either men who have sex with men or injecting-drug users, indicating that preventive strategies need to be developed and applied to a wider spectrum of opportunistic infections. Because much new data concerning the prevention of opportunistic disease have emerged since 1994, the USPHS and the IDSA reconvened a working group on November 7-8, 1996, to determine which recommendations needed to be changed. Participants included representatives from federal agencies, universities, and professional societies, as well as community health-care providers and patient advocates.
Most attention was focused on recent data related to chemoprophylaxis against
disseminated MAC disease, cytomegalovirus (CMV), and fungal infections and
to immunization against Streptococcus pneumoniae. However, data concerning
all the common acquired immunodeficiency syndrome (AIDS)-associated pathogens
were reviewed, as appropriate. Factors considered in revising guidelines
included:
Consultants reviewed published manuscripts, abstracts, and material presented at professional meetings. However, guidelines were revised only if complete manuscripts providing data were available for review. A review of the data that served as the basis for the revisions, as well as the additional information discussed at the meet-ing but not deemed appropriate to justify a revision of the recommendations, will be published elsewhere (11).
The guidelines developed by the USPHS/IDSA working group were made available for public comment by an announcement in the Federal Register and in the MMWR, and the final document was approved by the USPHS and the IDSA, as well as by the American College of Physicians, the American Academy of Pediatrics, the Infectious Diseases Society of Obstetrics and Gynecology, the Society of Healthcare Epidemiologists of America, and the National Foundation for Infectious Diseases.
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