A newly diagnosed asymptomatic HIV-positive adult has a CD4 count of 190 cells/μL and a viral load of 60,000 copies/mL. ART is being initiated. Which additional intervention should be started now?

• A Azithromycin weekly as MAC prophylaxis
• B Aciclovir suppressive therapy
• C Itraconazole daily as histoplasma prophylaxis
• D Trimethoprim-sulfamethoxazole double strength daily ✓

Explanation

Primary prophylaxis against Pneumocystis jirovecii pneumonia with cotrimoxazole (TMP-SMX) is indicated once the CD4 count falls below 200 cells/μL, and it also protects against toxoplasmosis. Azithromycin prophylaxis for disseminated MAC is reserved for CD4 counts below 50 cells/μL. Histoplasma prophylaxis is considered below 150 cells/μL only in highly endemic regions. Aciclovir suppression is not standard based on CD4 count alone.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.