Important note: Information in this article was accurate in May 2000. The state of the art may have changed since the publication date.
Doctors first became aware of AIDS in the early 1980s when they began observing a range of life-threatening infections occurring in their patients. Doctors eventually found that giving their patients small, regular doses of antibiotics and other anti-microbial drugs helped to prevent many of the infections seen in AIDS. This practice is called prophylaxis.
Another major development in the field of treatment was the introduction of protease inhibitors (PIs). When used in combination with other anti-HIV drugs, PIs have dramatically reduced death rates due to complications from AIDS in North America, Western Europe and Australia. The combination of PIs and other anti-HIV drugs is called HAART - Highly Active Antiretroviral Therapy. HAART is effective because the combination dramatically reduces levels of HIV in the body and also helps the immune system to begin repairing itself.
The increased CD4+ cell counts and decreased viral load seen in people on HAART has encouraged their doctors to stop prescribing prophylaxis for certain complications of AIDS. This may not be a problem for people who have never developed symptoms of AIDS. In people who have had complications such as the life-threatening lung infection PCP or the sight threatening infection CMV retinitis, however, stopping prophylaxis can be risky. To find out if people who've had symptoms of AIDS can safely stop prophylaxis after taking HAART, researchers in Spain conducted a study involving 53 subjects. Their results suggest prophylaxis can be safely discontinued in some people with AIDS who have increased CD4+ counts and decreased viral load as a result of HAART.
Researchers recruited 58 HIV-positive subjects with the following characteristics:
Eight subjects had never been exposed to anti-HIV drugs before entering the study, while the remainder had used nucleoside analogues (nukes - AZT and similar drugs) alone. Once in the study, all subjects received two nukes and one PI. Once their CD4+ count rose above the 100 cell mark and viral load fell to fewer than 500 copies, usually after three months of HAART, doctors recommended that their subjects stop taking prophylaxis.
After 18 months of HAART, the group's average lab values were as follows:
Before subjects began HAART they were taking medication to prevent the following infections:
Results - drop-outs and infections
After 18 months of HAART, five subjects were lost to follow-up for the following reasons:
In the remaining 53 subjects, there were only two cases of serious infections:
One subject had a lymph node that was swollen with TB-causing bacteria despite a CD4+ count of 253 cells and a viral load below the 500-copy mark.
The other subject experienced a new bout of PCP. At the time this complication was diagnosed, her CD4+ count was 43 cells and viral load was above the 500,000 copy mark. The subject admitted having interrupted her anti-HIV therapy for six weeks because of side effects. After recovering from PCP, she changed her antiviral therapy and her CD4+ count rose above 200 cells and her viral load fell below 500 copies. Six months after recovering from PCP she stopped prophylaxis (Bactrim/Septra) and has not since had another bout of PCP.
The results of this study suggest that, in most cases, people who have sustained benefit as a result of HAART can safely stop taking prophylaxis provided they are able to continue using HAART.
1. Soriano V, Dona C, Rodriguez-Rosado R, et al. Discontinuation of secondary prophylaxis for opportunistic infections in HIV-infected patients receiving highly active antiretroviral therapy. AIDS 2000;14:383-386.
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