HIV positive patients, including those receiving HAART should receive primary prophylaxis against P. carinii pneumonia if they have a CD4 count < 200 cells/|l or a history of oral/pharyngeal candidiasis or if they have a CD4 lymphocyte count <14% of total lymphocyte count, or if they have other AIDS-defining diagnoses, for example Kaposi's sarcoma, regardless of CD4 count. If close monitoring of CD4 counts (at least every three months) is not feasible then prophylaxis should be considered for patients with CD4 counts between 200 and 250 cells/|ul. Secondary prophylaxis is given to all HIV-infected patients after an episode of P. carinii pneumonia, regardless of CD4 count.

The prophylaxis regimen of choice is co-trimoxazole 960 mg once daily. A dose of 480 mg once daily or 960 mg three time a week are also effective and may be better tolerated by the patient. Co-trimoxazole also protects against bacterial infection and reactivation of cerebral toxoplasmosis. In patients who develop mild to moderate adverse reactions to co-trimoxazole, desensitisation may be attempted before changing to alternative therapy. Second-line prophylaxis (for those intolerant of, or unwilling to take, co-trimoxazole) include dapsone, with or without pyrimethamine, atovaquone or monthly nebulised pentamidine (300 mg given using a Respirgard II or similar nebuliser). There is a higher relapse rate of pneumocystis pneumonia with this regimen compared with that using co-trimoxazole. Some patients who relapse while receiving nebulised pentamidine have atypical chest radiographs with upper zone infiltrates which mimic tuberculosis. Atovaquone is as effective as dapsone or nebulised pentamidine but is much more expensive.

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