Important note: Information in this article was accurate in February 1999. The state of the art may have changed since the publication date.AIDSWEEKLY Plus; Monday, February 1, 1999
Daniel J. DeNoon, Senior Editor
The most deadly opportunistic infection among western AIDS patients is Pneumocystis carinii pneumonia (PCP). Trimethoprim- sulfamethoxazole (TMP/SMX; cotrimoxazole) is the drug combination of choice for PCP prevention. It is recommended for all HIV infected patients when their T-cell counts fall below 200 cells/(micro)L.
But can PCP prophylaxis be discontinued when T cell counts rise above 200 cells/(micro)L in patients receiving highly active antiretroviral therapy (HAART) regimens? The cautious answer, based on early follow-up data, is yes.
"The preliminary results of this study indicate that PCP prophylaxis can be stopped safely in HIV-1 infected patients whose CD4 counts have increased above 200 cells/(micro)L after treatment with HAART," wrote Margriet M.E. Schneider of Utrecht University Hospital, Netherlands, and colleagues in the journal The Lancet ("Discontinuation of Prophylaxis for Pneumocystis carinii pneumonia in HIV-1 Infected Patients Treated with Highly Active Antiretroviral Therapy," Lancet 1999 Jan 16;353(9148):201-3).
The Dutch study enrolled 78 patients with HIV infection who were actively taking PCP prophylaxis (62 for primary prevention and 16 for secondary prevention after a previous episode). All patients received HAART.
When patients' CD4 counts first rose above 200 cells/(micro)L there was a minimum of a one-month waiting period. If the increase in CD4 count was maintained, the patient ceased PCP prophylaxis (mean CD4 count at time of discontinuation was 347 cells/(micro)L).
With a mean follow-up of a little more than a year, nobody developed PCP. On average, patients discontinued PCP prophylaxis nearly 10 months after beginning HAART.
"This was evidently long enough to enable the T-cell repertoire to reconstitute and diversify, although 22 percent (34 percent) of patients stopped prophylaxis within 6 months of the start of HAART," Schneider et al. noted.
Of course, many questions remain. Does a CD4 count of 200 mean the same thing when a patient's T-cells are increasing as it does when they are decreasing? When is the best time to stop prophylaxis: at a specific T-cell count, or when functional T-cell studies suggest immune reconstitution? When should prophylaxis be restarted in patients in whom the effects of HAART are transient?
"Inclusion of additional patients, an immunological substudy, and a longer follow-up will provide data on which to base definite recommendations," Schneider et al. concluded.
The corresponding author for this study is Margriet M.E. Schneider, Department of Internal Medicine, Division of Infectious Diseases and AIDS, University Hospital Utrecht, PO Box 85500, 3508 GA Utrecht, Netherlands. Email: <m.m.e.schneider@digd.azu.nl>.
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