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 [Lopez JC, et al. NEJM 2001;344:159]: This is a randomized trial in which patients with immune reconstitution to a CD4 cell count >200 and viral load <5000 were randomized to continue or discontinue primary or secondary PCP prophylaxis. The study included 113 patients receiving secondary prophylaxis with a median CD4 count of 355/mm³ at the time of discontinuation. There were no cases of PCP with a median follow-up of 12 months.
Discontinuation of Secondary Prophylaxis Against Pneumocystis Carinii Pneumonia in Patients with HIV Infection Who Have a Response to Antiretroviral Therapy [Ledergerber B, et al. NEJM 2001;344:168]: This is an observational study with data from eight European cohorts concerning discontinuation of secondary PCP prophylaxis in 25 patients who had CD4 counts >200/mm³. During a median follow-up period of 13 months, there were no cases of PCP.
Comment: These two studies show convincing evidence that secondary PCP prophylaxis can be discontinued following immune reconstitution. Both state that the threshold to discontinue was a CD4 cell count of 200/mm³, but both showed a median CD4 cell count of 350/mm³ when this was actually done. Thus, the safety and efficacy of this tactic seems well verified, but the specific CD4 threshold when this should be done is less clear.
posted 1/26/2001

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