This study reported in the current issue of NEJM suggests a person is relatively safe in stopping PCP prophylaxis if their CD4 count rises to above 200 (CD4 count in study was 324) after starting HAART. But there is still a risk of getting PCP. Bactrim still may protect against toxo. Following the abstract below are a few points of concern to bear in mind.
Jules Levin, NATAP
Volume 340 Number 17 á 1301
The New England
Journal of Medicine
VOLUME 340 APRIL 29, 1999 NUMBER 17
DISCONTINUATION OF PRIMARY PROPHYLAXIS AGAINST PNEUMOCYSTIS CARINII PNEUMONIA IN HIV-1oINFECTED ADULTS TREATED WITH COMBINATION ANTIRETROVIRAL THERAPY
HANSJAKOB FURRER, M.D., MATTHIAS EGGER, M.D., MILOS OPRAVIL, M.D., ENOS BERNASCONI, M.D., BERNARD HIRSCHEL, M.D., MANUEL BATTEGAY, M.D., AMALIO TELENTI, M.D., PIETRO L. VERNAZZA, M.D., MARTIN RICKENBACH, M.D., MARKUS FLEPP, M.D., AND RAFFAELE MALINVERNI, M.D., FOR THE SWISS HIV COHORT STUDY*
Background. It is unclear whether primary prophylaxis against Pneumocystis carinii pneumonia can be discontinued in patients infected with the human virus (HIV) who are successfully treated with combination antiretroviral therapy. We prospectively studied the safety of stopping prophylaxis among patients in the Swiss HIV Cohort Study.
Methods. Patients were eligible for our study if their CD4 counts had increased to at least 200 cells per cubic millimeter and 14 percent of total lymphocytes while they were receiving combination antiret-roviral therapy, with these levels sustained for at least 12 weeks. Prophylaxis was stopped at study entry, and patients were examined every three months thereafter. The development of P. carinii pneumonia was the primary end point, and the development of toxoplasmic encephalitis the secondary end point.
Results. Of the 262 patients included in our analysis, 121 (46.2 percent) were positive for IgG antibodies to Toxoplasma gondii at base line. The median CD4 count at study entry was 325 per cubic millimeter (range, 210 to 806); the median nadir CD4 count was 110 per cubic millimeter (range, 0 to 240). During a median follow-up of 11.3 months (range, 3.0 to 18.8), prophylaxis was resumed in nine patients, and two patients died. There were no cases of P. carinii pneumonia or toxoplasmic encephalitis. The one-sided upper 99 percent confidence limit for the incidence of P. carinii pneumonia was 1.9 cases per 100 patient-years (based on 238 patient-years of follow-up). The corresponding figure for toxoplasmic encephalitis was 4.2 per 100 patient-years (based on110 patient-years of follow-up).
Conclusions. Stopping primary prophylaxis against P. carinii pneumonia appears to be safe in HIV-infected patients who are receiving combination antiretroviral treatment and who have had a sustained increase in their CD4 counts to at least 200 cells per cubic millimeter and to at least 14 percent of total lymphocytes. (N Engl J Med 1999;340:1301-6.)
Re- Stopping PCP Propylaxis
**Remember the followup is only 11 months
**If you read the article in NEJM you'll see the authors say there is still a risk for PCP even if your CD4 count rises above 200 due to HAART. There have been anecdotal reports of PCP occurring after a person had a CD4 increase due to HAART from below 200 to over 400.
**If you had an allergic reaction to Bactrim when first starting it but overcame that with desensitization, if you stop Bactrim and then have to restart it you may again have that problem of an allergic reaction