Abstract
BackgroundRisk of pneumocystosis after discontinuation of primary or secondary prophylaxis among HIV-infected patients before CD4 counts increase to ≧200 cells/μL (early discontinuation) after receiving highly active antiretroviral therapy (HAART) is rarely investigated.MethodsMedical records of 660 HIV-infected patients with baseline CD4 counts <200 cells/μL who sought HIV care and received HAART at a university hospital in Taiwan between 1 April, 1997 and 30 September, 2007 were reviewed to assess the incidence rate of pneumocystosis after discontinuation of prophylaxis for pneumocystosis.ResultsThe incidence rate of pneumocystosis after HAART was 2.81 per 100 person-years among 521 patients who did not initiate prophylaxis or had early discontinuation of prophylaxis, which was significantly higher than the incidence rate of 0.45 per 100 person-years among 139 patients who continued prophylaxis until CD4 counts increased to ≧200 cells/μL (adjusted risk ratio, 5.32; 95% confidence interval, 1.18, 23.94). Among the 215 patients who had early discontinuation of prophylaxis after achievement of undetectable plasma HIV RNA load, the incidence rate of pneumocystosis was reduced to 0.31 per 100 person-years, which was similar to that of the patients who continued prophylaxis until CD4 counts increased to ≧200 cells/μL (adjusted risk ratio, 0.63; 95% confidence interval, 0.03, 14.89).ConclusionsCompared with the risk of pneumocystosis among patients who continued prophylaxis until CD4 counts increased to ≧200 cells/μL after HAART, the risk was significantly higher among patients who discontinued prophylaxis when CD4 counts remained <200 cells/μL, while the risk could be reduced among patients who achieved undetectable plasma HIV RNA load after HAART.
Highlights
Risk of pneumocystosis after discontinuation of primary or secondary prophylaxis among HIV-infected patients before CD4 counts increase to ^200 cells/μL after receiving highly active antiretroviral therapy (HAART) is rarely investigated
CD4 counts continued to increase with HAART, the median CD4 count of patients who had early discontinuation of prophylaxis at the end of observation was significantly lower than that of the patients who continued prophylaxis until CD4 increased to ^200 cells/μL (200 vs. 376 cells/μL)
The median duration of secondary prophylaxis for pneumocystosis was significantly shorter for the 145 patients who had early discontinuation of prophylaxis than for the 71 patients who continued prophylaxis until CD4 increased to ^200 cells/μL (2.7 vs. 4.0 months)
Summary
Risk of pneumocystosis after discontinuation of primary or secondary prophylaxis among HIV-infected patients before CD4 counts increase to ^200 cells/μL (early discontinuation) after receiving highly active antiretroviral therapy (HAART) is rarely investigated. With the widespread use of highly active antiretroviral therapy (HAART) after 1996, HIV-related mortality and the risks of several major opportunistic infections, such as Pneumocystis jirovecii pneumonia (formerly P. carinii pneumonia), disseminated Mycobacterium avium complex infection, and cytomegalovirus diseases, have significantly declined in patients receiving HAART [1,2,3]. Phylaxis for pneumocystosis can be discontinued in HIVinfected patients who respond favorably to HAART with an increase in CD4 counts to >200 cells/μL for >3 months. In a meta-analysis of 14 published studies, the incidence rate of pneumocystosis was estimated 0.24 per 100 PY and 0.20 per 100 PY in patients who discontinued primary and secondary prophylaxis, respectively, after CD4 counts increased to ^200 cells/μL [9]
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