Pneumocystis jiroveci pneumonia prophylaxis is not required with a CD4+ T-cell count < 200 cells/μl when viral replication is suppressed

Publisher Website
Google Scholar
Abstract
Objective: To determine the safety of discontinuing Pneumocystis jiroveci pneumonia (PCP) prophylaxis, in patients on effective antiretroviral therapy with CD4+ T-cell counts that have plateaued at < 200 cells/μl. Methods: We prospectively evaluated a cohort of HIV infected patients at a multidisciplinary HIV clinic with sustained HIV RNA levels < 50 copies/ml and CD4+ T-cell counts that have plateaued at < 200 cells/μl and who have discontinued PCP prophylaxis. Results: Nineteen patients fulfilled the above criteria. Eleven had been taking daily trimethoprim–sulfamethoxazole, seven were receiving monthly aerosolized pentamidine, and one patient never received any prophylaxis. The median CD4+ T-cell count at the time of discontinuation and at the most recent determination were 120 (range, 34–184) and 138 (range, 6–201) cells/μl, respectively. To date, patients have been off PCP prophylaxis for a mean of 13.7 ± 10.6 months and a median of 9.0 (range 3–39) months for a total of 261 patient-months. To date, no patient has developed PCP. This is significantly different from the risk of developing PCP with a CD4+ T-cell count of < 200 cells/μl in untreated HIV infection (rate difference 9.2%; 95% confidence interval, 5.7 to 12.8%; P < 0.05). Conclusion: With sustained suppression of viral replication, PCP prophylaxis may not be necessary, regardless of CD4+ T-cell count. This illustrates a degree of immune recovery that occurs with virologic suppression that is not reflected in absolute CD4+ T-cell count or percentage and suggests that guidelines for P. jiroveci pneumonia prophylaxis may need to be re-evaluated.

This publication has 26 references indexed in Scilit: