Interruption of prophylaxis for major opportunistic infections in HIV-infected patients receiving triple combination antiretroviral therapy

Objective: To determine whether HIV-infected patients receiving highly acti ve antiretroviral therapy (HAART) and recovering a CD4 cell number above 20 0x10(6)/l may safely discontinue primary and secondary prophylaxes for majo r opportunistic infections. Design: Retrospective study of a single-center, prospectively constituted c ohort of 223 patients receiving HAART with a protease inhibitor, of whom 13 7 received at least one prophylaxis. Methods: Exhaustive informations on prophylaxis use, clinical and laborator y data were used to produce descriptive statistics on infectious events, du ration of HIV infection, time on HAART, time to prophylaxis interruption, l ength of follow-up and biological values at relevant time points. Results: Fifty-one patients with a history of severe immunodepression (medi an CD4 nadir: 62x10(6)/l), including 16 patients with CDC stage C infection , discontinued at least one prophylaxis. Primary or secondary P. carinii pn eumonia prophylaxis was discontinued in 43 patients: 1 first episode of PCP occurred after 2 months but no other episode was recorded after a median f ollow-up of 16 months. Toxoplasmosis primary or secondary prophylaxis, seco ndary cytomegalovirus prophylaxis and primary or secondary M. avium complex prophylaxes were discontinued in respectively 37, 5 and 5 bpatients, and n o event was recorded after respective follow-ups of 16, 7 and 15 months. Ni ne secondary and 2 primary acyclovir prophglaxes were discontinued, and two events were observed after 1 and 19 months; no other event was noted after a follow-up of 22 months. Conclusion: Prophylaxis for opportunistic infections could be safely interr upted in most of these severely immunodeficient patients recovering a CD4 c ell count above 200x10(6)/l on HAART. This confirms the efficiency of immun e restoration and is beneficial to patients but, since 3 infectious events were recorded, caution should be taken before making a decision based on im munological and virological considerations.