In addition to screening for specific opportunistic infections, as detailed here, regular monitoring of CD4 counts allows for early diagnosis and prompt treatment of opportunistic infections.[206]Clinical Info HIV.gov. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. Sep 2022 [internet publication].
Tuberculosis (TB)
All people living with HIV should be tested for latent TB infection (LTBI) regardless of their risk for TB.[1]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. 2025 [internet publication].
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/whats-new
[207]World Health Organization. WHO consolidated guidelines on tuberculosis: module 2: screening: systematic screening for tuberculosis disease. Mar 2021 [internet publication].
https://www.who.int/publications/i/item/9789240022676
[208]U.S. Preventive Services Task Force. Latent tuberculosis infection in adults: screening. May 2023 [internet publication].
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/latent-tuberculosis-infection-screening
Annual testing for latent infection is recommended for people living with HIV who are, or remain, at high risk for repeated or ongoing exposure to individuals with active TB.[1]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. 2025 [internet publication].
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/whats-new
Data from low TB incidence settings show that 12% of people living with HIV tested positive for LTBI, with a higher likelihood of positive results among those originating from TB-endemic countries or with prior exposure to TB.[209]van Geuns D, Arts RJW, de Vries G, et al. Screening for tuberculosis infection and effectiveness of preventive treatment among people with HIV in low-incidence settings. AIDS. 2024 Feb 1;38(2):193-205.
https://journals.lww.com/aidsonline/fulltext/2024/02010/screening_for_tuberculosis_infection_and.9.aspx
http://www.ncbi.nlm.nih.gov/pubmed/37991008?tool=bestpractice.com
People with negative diagnostic tests for LTBI, advanced HIV infection (CD4 count <200 cells/microlitre), and without any indications for initiating empirical LTBI treatment, should be re-tested for LTBI once they start antiretroviral treatment and attain a CD4 count of 200 cells/microlitre or greater.[1]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. 2025 [internet publication].
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/whats-new
Data from low-incidence TB countries show that preventative treatment for LTBI reduced TB incidence, with 20 individuals needing preventative treatment to prevent one case of active TB.[209]van Geuns D, Arts RJW, de Vries G, et al. Screening for tuberculosis infection and effectiveness of preventive treatment among people with HIV in low-incidence settings. AIDS. 2024 Feb 1;38(2):193-205.
https://journals.lww.com/aidsonline/fulltext/2024/02010/screening_for_tuberculosis_infection_and.9.aspx
http://www.ncbi.nlm.nih.gov/pubmed/37991008?tool=bestpractice.com
Toxoplasmosis
All people living with HIV should be tested for prior exposure to Toxoplasma gondii by measuring anti-Toxoplasma immunoglobulin G (IgG) upon initiation of care.[1]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. 2025 [internet publication].
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/whats-new
If results are positive, primary prophylaxis should be provided when CD4 count is below 100 cells/microlitre.[1]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. 2025 [internet publication].
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/whats-new
If results are negative, the individual should be counselled on avoidance of infection (avoidance of under-cooked meat and avoidance or proper handling of cat faeces).[1]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. 2025 [internet publication].
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/whats-new
Cryptococcosis
Routine testing for serum cryptococcal antigen in people newly diagnosed with HIV and no overt clinical signs of meningitis may be considered for individuals whose CD4 counts are ≤100 cells/microlitre, and particularly in those with CD4 counts ≤50 cells/microlitre. A positive test should prompt cerebrospinal fluid evaluation for meningitis.[1]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. 2025 [internet publication].
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/whats-new
[76]World Health Organization. Guidelines for diagnosing, preventing and managing cryptococcal disease among adults, adolescents and children living with HIV. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/9789240052178
Coccidioidomycosis
Asymptomatic individuals who reside in areas where coccidioidomycosis is endemic and have a CD4 count ≤250 cells/microlitre should have annual IgM and IgG serological screening for Coccidioides species.[210]Galgiani JN, Ampel NM, Blair JE, et al. 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis. Clin Infect Dis. 2016 Sep 15;63(6):e112-46.
https://academic.oup.com/cid/article/63/6/e112/2389093
http://www.ncbi.nlm.nih.gov/pubmed/27470238?tool=bestpractice.com