HIV-infected children and adults who have no evidence of immunity to varicella should avoid exposure to people with varicella or zoster (AIII). Household contacts of HIV-infected patients should receive varicella vaccine if they lack evidence of immunity to avoid the possibility of transmitting wild-type varicella-zoster virus (VZV) to their HIV-infected contacts (AIII). HIV-infected children aged 1 through 8 years without evidence of varicella immunity and whose CD4 T lymphocyte (CD4) cell counts are ≥15% should be considered for 2 doses of varicella vaccine, the first dose administered as early as age 12 to 15 months (or as soon as possible after the first birthday) and the second dose 3 months later (BII). Older children with comparable levels of immune function (i.e., CD4 cell counts ≥200 cells/mm3) who lack varicella immunity may be considered for 2 doses of varicella vaccine administered 3 months apart (BIII). Combination measles-mumps-rubella-varicella vaccine should not be administered to HIV-infected children (AIII). HIV-infected children with low CD4 percentages (<15%) should not be vaccinated against varicella (AIII). Vaccination of such children can be safely undertaken after reconstitution of their immune systems (CD4 percentage ≥15%) with combination antiretroviral therapy (cART) for at least 3 months (AII). Herpes zoster (HZ) vaccine should not be given to HIV-infected children (AIII). HIV-infected children and adolescents who:
lack evidence of immunity to varicella, and have a non-transient exposure to a contact with varicella or herpes zoster
should receive VZV immunoglobulin prophylaxis as soon as possible (ideally within 96 hours but potentially beneficial up to 10 days) after the close contact (AII). Many experts limit this recommendation to varicella- or zoster-exposed HIV-infected children who are considered to be severely immunocompromised (i.e., CDC Immunologic Category 3) especially if they have high HIV viral loads and would be classified in CDC Clinical Category C (BIII). When passive immunization is impossible, some experts recommend prophylaxis with acyclovir beginning 7 to 10 days after exposure, while others consider it prudent to wait until the first appearance of rash to start acyclovir therapy in VZV-susceptible and VZV-exposed, HIV-infected children (CIII). Acyclovir is the drug of choice for treating VZV infection in HIV-infected children (AI). Intravenous (IV) acyclovir is recommended for treating varicella in HIV-infected children with severe immunosuppression (i.e., CDC Immunologic Category 3) and those who have high fever, abdominal pain, respiratory symptoms, or numerous or deep, necrotic, or hemorrhagic skin lesions (AIII). Oral acyclovir should only be used to treat varicella in HIV-infected children who are in CDC Immunologic Category 1 or 2 and who have mild varicella disease (BIII). Acyclovir is the oral treatment of choice for zoster in HIV-infected children, given for 7 to 10 days, although longer durations of therapy should be considered if lesions are slow to resolve (AII*). Oral administration of acyclovir for HZ is considered safe for children with mild to moderate immune suppression (AII). Initial IV administration is recommended for HIV-infected children with severe immunosuppression (i.e., CDC Immunologic Category 3), extensive multidermatomal HZ, disseminated infection, visceral involvement, or otherwise complicated HZ (AII*). It can also be considered for trigeminal nerve or sacral dermatomal involvement. IV acyclovir should be continued until cutaneous lesions and visceral disease are clearly resolving (AIII), after which oral administration can be considered to complete the course of therapy—10 to 14 days in this situation (AIII). Recommended treatment for progressive outer retinal necrosis includes optimization of cART and IV anti-VZV therapy that includes combinations of systemic antivirals (acyclovir or ganciclovir plus foscarnet), frequently with twice-weekly intravitreal injections of ganciclovir and/or foscarnet (AIII). Adjunctive retinal surgery is sometimes recommended, along with corticosteroids and/or low-dose aspirin (BIII). Acute retinal necrosis can be treated with IV acyclovir for 10 to 14 days, followed by prolonged (i.e., 4–6 weeks) oral treatment (AIII). Alternatives to oral acyclovir in older adolescents include valacyclovir and famciclovir (AI*). The treatment of choice for acyclovir-resistant VZV is IV foscarnet for 7 days (AII*) or until no new lesions for at least 48 hours (AIII).
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