This study was a multicenter, open-label, randomized controlled clinical trial designed to evaluate the efficacy and safety of glucocorticoids in preventing paradoxical immune reconstitution inflammatory syndrome (IRIS) in patients with AIDS complicated by opportunistic infections. A total of 262 HIV-infected patients with a baseline CD4⁺ T-cell count <100/μL, who were scheduled to initiate antiretroviral therapy and had opportunistic infections, were enrolled and randomly assigned in a 1:1 ratio to the prednisolone group or the control group. Participants in the treatment group received prednisolone at 40 mg/day for 14 days followed by 20 mg/day for 14 days, whereas the control group received no glucocorticoid intervention. All participants were followed for 12 weeks. The primary endpoint was the incidence of paradoxical IRIS within 12 weeks. Secondary endpoints included time to IRIS onset, duration of IRIS, mortality, hospitalization, serious adverse events, CD4⁺ T-cell counts, and HIV-RNA suppression. The findings will provide evidence-based support for the prevention of paradoxical IRIS.

Inclusion Criteria:

• Age ≥ 18 years;
• Confirmed HIV infection;
• Presence of HIV-related opportunistic infection(s), including non-tuberculous -mycobacterial infection, PJP, pneumonia, cryptococcal meningitis, Talaromyces marneffei infection, CMV retinitis, or PML;
• Baseline CD4 T-lymphocyte count < 100 cells/μL;
• Planned initiation of antiretroviral therapy;
• Willing to participate in this study, able to comply with all follow-up requirements, and able to provide written informed consent.

Exclusion Criteria:

• Presence of Kaposi sarcoma, pregnancy, or confirmed tuberculosis;
• Body weight < 40 kg;
• Severe hepatic dysfunction (ALT or AST > 5 times the upper limit of normal, ULN);
• Severe renal dysfunction (eGFR < 30 mL/min/1.73 m²);
• Baseline electrocardiogram (ECG) showing a QTc interval > 500 ms;
• Pregnant or lactating women;
• Contraindications to glucocorticoid use;
• Any other condition considered by the investigators to be unsuitable for participation in this study.