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What can be done for people who have severe immunosuppression?
Although one goal of antiviral therapy is to prevent the development of immune suppression, some individuals are already immunosuppressed when they first seek medical care. In addition, others may progress to that stage as a result of resistance to antiviral drugs. Nevertheless, every effort must be made to optimize antiviral therapy in these patients. In addition, certain specific antibiotics should be initiated, depending on the number of CD4 cells, to prevent the complications (that is, the opportunistic infections) that are associated with HIV immunosuppression. Guidelines for the prevention of opportunistic infections can be found at www.hivatis.org.
In summary, patients with a CD4 cell count of less than 200 should receive preventative treatment against Pneumocystis carinii (the opportunistic bacteria that causes pneumonia and is now known as Pneumocystis jiroveci) with trimethoprim/sulfamethoxazole (BactrimTM, SeptraTM), given once daily or three times weekly. If they are intolerant to that drug, patients can be treated with an alternative drug such as dapsone, or atovaquone (MepronTM). Those patients with a CD4 cell count of less than 100 who also have evidence of past infection with Toxoplasma gondii, which is usually determined by the presence of toxoplasma antibodies in the blood, should receive trimethoprim/sulfamethoxazole. Toxoplasmosis is an opportunistic parasitic disease that affects the brain and liver. If a person is using dapsone to prevent Pneumocystis carinii (P. jiroveci), pyrimethamine and leucovorin can be added once a week to their regimen to prevent toxoplasmosis. Finally, patients with a CD4 cell count of less than 50 should receive preventive treatment for Mycobacterium avium complex (MAC) infection with weekly azithromycin (ZithromaxTM), or as an alternative, twice daily clarithromycin (BiaxinTM) or mycobutin (RifabutinTM). MAC is an opportunistic bacterium that causes infection throughout the body.