Discontinuation of secondary prophylaxis for opportunistic infections in HIV-infected patients receiving highly active antiretroviral therapy

Background: Immune reconstitution following the introduction of highly acti ve antiretroviral therapies (HAART) has lead to a remarkable reduction in t he incidence of opportunistic infections (OI) in subjects with advanced HIV disease. Moreover, discontinuation of primary prophylaxis for some OI can be attempted without risk in patients experiencing a favourable response to treatment. However, data on the feasibility of discontinuing secondary pro phylaxis are much more scarce, and restricted mainly to the withdrawal of m aintenance treatment for cytomegalovirus (CMV) retinitis. Patients and methods: Retrospective review of the clinical outcome at 18 mo nths in HIV-infected patients in whom discontinuation of secondary prophyla xis, for different OI, was recommended 3 months after the introduction of H AART, if both CD4 counts >100 x 10(6) CD4 lymphocytes/l and plasma HIV-RNA < 500 copies/ml had been achieved. Results: Fifty-three subjects were analysed. Secondary chemoprophylaxis was discontinued for the following OI: Pneumocystis carinii pneumonia (PCP) (n = 29), cerebral toxoplasmosis (n = 9), disseminated Mycobacterium avium co mplex infection (n = 7), CMV retinitis (n = 5), recurrent oroesophageal can didiasis (n = 5), Visceral leishmaniasis (n = 2), recurrent herpes tester ( n = 2), and chronic mucocutaneous herpes simplex infection (n = 1). In six individuals, OI prophylaxis was discontinued for two or more entities, Only two episodes of OI were recorded in these individuals during 18 months of follow-up. One developed tuberculous lymphadenitis despite having a good re sponse to treatment, and another suffered a new episode of PCP after volunt ary treatment interruption for 6 weeks. Conclusion: Secondary prophylaxis for OI can be attempted without major ris k in HIV-infected patients experiencing a favourable response to HAART. The benefit of this intervention should reduce costs, drug side-effects and ph armacologic interactions, and indirectly will improve patient's quality of life and adherence to antiretroviral treatment. (C) 2000 Lippincott William s & Wilkins.