British HIV Association guidelines on the management of opportunistic infection in people living with HIV: The clinical management of non-tuberculous mycobacteria 2024

A wide spectrum of non-tuberculous mycobacteria (NTM) has been reported as isolates from or causes of disease in people living with human immunodeficiency virus (HIV). This is typically in the context of very advanced immunosuppression (CD4 count <50 cells/mm³) in the absence of virological suppression [1] and most individuals have presented with disseminated disease. Effective antiretroviral therapy (ART) has permitted control of viral replication, improvement in immune function and a significant decrease in the incidence of severe opportunistic infections [2-4], including disseminated Mycobacterium avium complex (DMAC) disease [3, 5, 6].

NTM are environmental organisms. Therefore it is important to determine, prior to treatment initiation, whether the organism is the cause of the disease process rather than a reflection of colonisation. With the exception of M. avium complex (MAC), there is limited evidence to guide the choice or duration of treatment and expert opinion should be sought from a clinician experienced in managing mycobacterial disease in the context of HIV or, if not available, in the context of immunosuppression or dissemination. Advice should also be sought from microbiologists (for drug susceptibility testing and interpretation), pharmacists or people with expertise and experience of managing mycobacterial disease in people without HIV. Also with the exception of MAC, most of the recommendations for the treatment of NTM have been extrapolated from trials of treatment for NTM pulmonary disease in individuals without HIV, although some evidence from early trials in populations with advanced HIV disease has added to this guidance.

Guidance on supporting people living with HIV with opportunistic infections, including NTM infections, can be found on the British HIV Association (BHIVA) website (https://www.bhiva.org/file/6225e44b53c49/OI-guidelines-supporting-patients.pdf).

A full review of these guidelines is due in 2029, with interim updates only if recommendations need updating in line with new data.

The scope, purpose and guideline topics were agreed by the writing group. The search (population, intervention, comparator and outcome [PICO]) questions were set and an independent systematic literature review performed. The Medline, Embase and Cochrane Library databases were searched and the literature reviewed to address each question. The PICO questions and search strategies are outlined in Appendix 1.

Further details of the methodology can be found on the BHIVA website (https://www.bhiva.org/file/5d514ec9b503d/OI-guidelines-methods-general.pdf), including the use of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to assess and grade the evidence.