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Volume 344:159-167 January 18, 2001 Number 3 Next

	Full Text PDF Editorial by Girard, P.-M. Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background Prophylaxis against Pneumocystis carinii pneumonia is indicated in patients with human immunodeficiency virus (HIV) infection who have less than 200 CD4 cells per cubic millimeter and in those with a history of P. carinii pneumonia. However, it is not clear whether prophylaxis can be safely discontinued after CD4 cell counts increase in response to highly active antiretroviral therapy.

Methods We conducted a randomized trial of the discontinuation of primary or secondary prophylaxis against P. carinii pneumonia in HIV-infected patients with a sustained response to antiretroviral therapy, defined by a CD4 cell count of 200 or more per cubic millimeter and a plasma HIV type 1 (HIV-1) RNA level of less than 5000 copies per milliliter for at least three months. Prophylactic treatment was restarted if the CD4 cell count declined to less than 200 per cubic millimeter.

Results The 474 patients receiving primary prophylaxis had a median CD4 cell count at entry of 342 per cubic millimeter, and 38 percent had detectable HIV-1 RNA. After a median follow-up period of 20 months (388 person-years), there had been no episodes of P. carinii pneumonia in the 240 patients who discontinued prophylaxis (95 percent confidence interval, 0 to 0.85 episode per 100 person-years). For the 113 patients receiving secondary prophylaxis, the median CD4 cell count at entry was 355 per cubic millimeter, and 24 percent had detectable HIV-1 RNA. After a median follow-up period of 12 months (65 person-years), there had been no episodes of P. carinii pneumonia in the 60 patients who discontinued prophylaxis (95 percent confidence interval, 0 to 4.57 episodes per 100 person-years).

Conclusions In HIV-infected patients receiving highly active antiretroviral therapy, primary and secondary prophylaxis against P. carinii pneumonia can be safely discontinued after the CD4 cell count has increased to 200 or more per cubic millimeter for more than three months.

Source Information

From the Hospital Universitario Gregorio Marañón, Madrid (J.C.L.B.Q., J.C.); the Institut d'Investigacions Biomèdiques August Pi I Sunyer and Hospital Clinic Universitari, Barcelona (J.M.M., E.M., X.C.); the Ciudad Sanitaria La Paz, Madrid (J.M.P., J.G.); the Hospital de Bellvitge, Barcelona (D.P.); the Consejería de Sanidad Comunidad Autonoma de Madrid, Madrid (J.C.A.); the Hospital de Sant Pau, Barcelona (P.D.); the Hospital Ramón y Cajal, Madrid (J.L.C.); and the Hospital Universitari de la Vall d'Hebron, Barcelona (E.R.) — all in Spain. Presented in part at the 6th Conference on Retrovirus and Opportunistic Infections, Chicago, January 31–February 4, 1999, and at the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy, American Society for Microbiology, San Francisco, September 26–29, 1999.

Address reprint requests to Dr. Lopez at the Division of Infectious Diseases, Hospital Gregorio Marañón, Dr. Esquerdo 46, 28007 Madrid, Spain, or at juanclopez{at}retemail.es.

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