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Safety of Stopping PCP Prophylaxis Reconfirmed

Results of several studies have demonstrated the safety of discontinuing primary Pneumocystis carinii pneumonia (PCP) prophylaxis when CD4 cell counts rise in HIV-infected patients taking antiretroviral drugs. The safety of stopping secondary prophylaxis in patients who have suffered 1 or more episodes of PCP now is reinforced by findings from 2 large European studies.

In an unblinded Spanish trial, researchers enrolled 587 patients receiving primary or secondary PCP prophylaxis, who had exhibited good CD4 cell responses to antiretroviral drugs (median CD4 cell count had risen from a nadir of 113/mm³ to > 300/mm³), and randomized them either to continued PCP prophylaxis or to prophylaxis discontinuation. No cases of PCP occurred after a median 19-month follow-up either among those who continued prophylaxis or among the 240 patients who discontinued primary prophylaxis. Similarly, among the 60 patients who discontinued secondary prophylaxis, no PCP cases occurred after a median 12-month follow-up; median CD4 cell count had risen from a nadir of 32/mm³ to > 400/mm³ during antiretroviral treatment.

In a second study, investigators reviewed data from 8 large European cohorts of HIV-infected patients: 325 patients who discontinued secondary PCP prophylaxis were identified. Their median nadir CD4 count was 50/mm³, and counts had risen to > 200/mm³ for a median of 11 months before PCP prophylaxis was stopped. No cases of recurrent PCP were seen after a median 13-month observation in these patients.

Comment: These results confirm, once again, that CD4 cells restored by successful antiretroviral therapy are functional for protection against PCP. One caveat: In these studies, most of the patients who stopped prophylaxis had reached undetectable levels of plasma HIV RNA. Whether these good results also apply to those with persistently detectable virus, despite good CD4 responses, awaits further data.

— A Zuger

Published in Journal Watch General Medicine January 30, 2001

Citation(s):

Lopez Bernaldo de Quiros JC et al. A randomized trial of the discontinuation of primary and secondary prophylaxis against Pneumocystis carinii pneumonia after highly active antiretroviral therapy in patients with HIV infection. N Engl J Med 2001 Jan 18 344 159-167.

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• Medline abstract (Free)

Ledergerber B et al. Discontinuation of secondary prophylaxis against Pneumocystis carinii pneumonia in patients with HIV infection who have a response to antiretroviral therapy. N Engl J Med 2001 Jan 18 344 168-174.

• Original article (Subscription may be required)
• Medline abstract (Free)