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Clinical question: In the era of combination antiretroviral therapy, what is the incidence of PcP among patients with CD4 counts less than 200 cells/µL across a spectrum of virologic suppression?

Background: The incidence of Pneumocystis jiroveci pneumonia (PcP) has decreased significantly with the advent of effective combination antiretroviral therapy (cART). Guidelines have historically recommended PcP prophylaxis for HIV patients once the CD4 cell count drops below 200 cells/µL. The incidence of PcP in the era of cART, and by extension the ongoing applicability of this traditional prophylaxis guideline, is uncertain.

Study design: Prospective observational cohort.

Setting: Twelve European HIV cohorts.

Synopsis: The investigators combined data from 12 prospective HIV cohorts representing 107,016 patient-years of follow-up (PYFU), with a median of 4.7 years. There were 11,932 PYFU for those with CD4 cell counts below 200 cells/µL. Across all CD4 cell counts, 76% of PcP infections occurred among patients with viral loads >10,000 copies/mL. Among all patients with CD4 cell counts from 101 cells/µL and 200 cells/µL, there was a nonsignificant trend towards lower PcP rates with prophylaxis. For the subset of patients with CD4 cell counts from 101 cells/µL and 200 cells/µL and viral load <400 copies/mL, PcP rates were quite low and no different among those taking and not taking prophylaxis.

Bottom line: PcP is uncommon in HIV patients taking cART with CD4 cell counts from 101 cells/µL and 200 cells/µL and viral load <400 copies/mL. Discontinuing prophylaxis might be safe in these well-controlled patients.

Citation: The Opportunistic Infections Project Team of the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE), Mocroft A, Reiss P, Kirk O, et al. Is it safe to discontinue primary Pneumocystis jiroveci prophylaxis in patients with virologically suppressed HIV infection and a CD4 cell count <200 cells/microL? Clin Infect Dis. 2010;51(5):611-619.

Reviewed for TH eWire by Alexis E. Shanahan, MD, Chad R. Stickrath, MD, Mel L. Anderson, MD, Section of Hospital Medicine, Denver VA Medical Center, Division of General Internal Medicine, University of Colorado

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