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Stopping PCP Prophylaxis Appears Safe for Some HIV+ Patients

Once the most common opportunistic infection in AIDS, Pneumocystis carinii pneumonia (PCP) is now a rarity among HIV-infected patients taking combination antiretroviral therapy, and many clinicians suspect that these patients no longer need lifelong PCP prophylaxis with trimethoprim-sulfamethoxazole or other drugs. Two European studies address this issue.

One retrospectively examined data from more than 7,000 HIV-infected patients enrolled in an ongoing cohort study. About 3,000 were receiving PCP prophylaxis at the time they began combination therapy that included a protease inhibitor. Over two years, 319 patients stopped primary prophylaxis, and 59 stopped secondary prophylaxis, a median of 10 months after protease-containing treatment was begun. No cases of PCP were seen in either group after 247 person-years of follow up.

The second study prospectively followed 262 patients who had stopped primary PCP prophylaxis after at least three months of combination antiretroviral therapy. Median CD4 count at the time prophylaxis was stopped was 325 cells/mm³, and median viral load was 100 copies/ml. After almost a year of follow-up, no cases of PCP developed among these patients.

Comment: These results suggest that the risk for PCP becomes small enough with successful antiretroviral treatment that most patients may safely stop prophylaxis. But both groups of authors caution that prophylaxis should be continued for several months after CD4 cell counts rebound -- one editorialist suggests at least six months -- and the question of whether prophylaxis should be reinstituted if CD4 counts drop again remains to be answered.

— A Zuger

Published in Journal Watch General Medicine May 7, 1999

Citation(s):

Weverling GJ et al. Discontinuation of Pneumocystis carinii pneumonia prophylaxis after start of highly active antiretroviral therapy in HIV-1 infection. Lancet 1999 Apr 17 353 1293-1298.

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Feinberg J. Withdrawal of prophylaxis against Pneumocystis carinii pneumonia. Lancet 1999 Apr 17 353 1287-1287.

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Furrer H et al. Discontinuation of primary prophylaxis against Pneumocystis carinii pneumonia in HIV-1 infected adults treated with combination antiretroviral therapy. N Engl J Med 1999 Apr 29 340 1301-1306.

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Masur H and Kaplan J. Does Pneumocystis carinii prophylaxis still need to be lifelong?. N Engl J Med 1999 Apr 29 340 1356-1357.

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