Abstract
BackgroundHIV viral load (VL) is currently not part of the criteria for Pneumocystis jirovecii pneumonia (PCP) prophylaxis discontinuation, but suppression of plasma viremia with antiretroviral therapy may allow for discontinuation of PCP prophylaxis even with CD4 count <200 cells/µL.MethodsA systematic review was performed to determine the incidence of PCP in HIV-infected individuals with CD4 count <200 cells/µL and fully suppressed VL on antiretroviral therapy but not receiving PCP prophylaxis.ResultsFour articles examined individuals who discontinued PCP prophylaxis with CD4 count <200 cells/µL in the context of fully suppressed VL on antiretroviral therapy. The overall incidence of PCP was 0.48 cases per 100 person-years (PY) (95% confidence interval (CI) (0.06–0.89). This was lower than the incidence of PCP in untreated HIV infection (5.30 cases/100 PY, 95% CI 4.1–6.8) and lower than the incidence in persons with CD4 count <200 cells/µL, before the availability of highly active antiretroviral therapy (HAART), who continued prophylaxis (4.85/100 PY, 95% CI 0.92–8.78). In one study in which individuals were stratified according to CD4 count <200 cells/µL, there was a greater risk of PCP with CD4 count ≤100 cells/µL compared to 101–200 cells/µL.ConclusionPrimary PCP prophylaxis may be safely discontinued in HIV-infected individuals with CD4 count between 101–200 cells/µL provided the VL is fully suppressed on antiretroviral therapy. However, there are inadequate data available to make this recommendation when the CD4 count is ≤100 cells/µL. A revision of guidelines on primary PCP prophylaxis to include consideration of the VL is merited.
Highlights
The National Institutes of Health, the Centers for Disease Control and Prevention and the HIV (Human Immunodeficiency Virus) Medicine Association of the Infectious Diseases Society of America guidelines state that prophylaxis against Pneumocystis jirovecii pneumonia (PCP) may be discontinued safely in HIV-infected individuals when CD4 counts are maintained .200 cells/mL for over three months on antiretroviral therapy [1]. This recommendation was made when prospective observational and randomized controlled trials in the highly active antiretroviral therapy (HAART) era demonstrated that discontinuation of PCP prophylaxis was safe when a sustained CD4 count .200 cells/mL was achieved [2,3,4]
Medications used for PCP prophylaxis include trimethoprim/ sulfamethoxazole (TMP-SMX), pentamidine, dapsone and atovaquone
Our goal was to perform a systematic review of the published studies to determine the incidence of PCP in HIV-infected individuals with fully-suppressed plasma viral load (VL) on antiretroviral therapy who discontinued PCP prophylaxis with CD4 count,200 cells/mL
Summary
The National Institutes of Health, the Centers for Disease Control and Prevention and the HIV (Human Immunodeficiency Virus) Medicine Association of the Infectious Diseases Society of America guidelines state that prophylaxis against Pneumocystis jirovecii pneumonia (PCP) may be discontinued safely in HIV-infected individuals when CD4 counts are maintained .200 cells/mL for over three months on antiretroviral therapy [1]. This recommendation was made when prospective observational and randomized controlled trials in the highly active antiretroviral therapy (HAART) era demonstrated that discontinuation of PCP prophylaxis was safe when a sustained CD4 count .200 cells/mL was achieved [2,3,4]. HIV viral load (VL) is currently not part of the criteria for Pneumocystis jirovecii pneumonia (PCP) prophylaxis discontinuation, but suppression of plasma viremia with antiretroviral therapy may allow for discontinuation of PCP prophylaxis even with CD4 count ,200 cells/mL
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