Underuse of primary Mycobacterium avium complex and Pneumocystis carinii prophylaxis in the United States

Background: Little is known about the rates of Mycobacterium avium complex (MAC) and Pneumocystis carinii (PCP) prophylaxis adherence to guidelines an d how they have changed after introduction of effective antiretroviral ther apy. Objective: To determine rates of primary prophylaxis for MAC and PCP and to evaluate the influence of sociodemographic characteristics. region, and pr ovider experience. Design: National probability sample cohort of HIV patients in care. Setting: One hundred sixty HIV health care providers. Patients: A total of 2864 patients interviewed in 1996 to 1997 (68% respons e) and 2267 follow-up interviews, representing 65% of surviving sampled pat ients (median follow-up, 15.1 months). Measurements: Use of prophylactic drugs, most recent CD4 count, sociodemogr aphics, and regional and total HIV patients/providers. Results: Of patients eligible for primary MAC prophylaxis (most recent CD4 count < 50/mm(3)), 41% at baseline and 40% at follow-up patients were treat ed. Of patients eligible for primary PCP prophylaxis (i.e., those with CD4 counts < 200/mm(3);). 64% and 72% were treated, respectively. MAC prophylax is at baseline was less likely in African American (adjusted odds ratio [OR ], 35; 95% confidence interval [CI], 0.20-0.59), Hispanic (OR, 27; 95% CI, 0.08-0.94) and less-educated (OR, 0.61; 95% Cl, 0.36-1.0) patients and more likely in U. S. geographic regions in the Pacific West (OR, 4.9; 95% Cl, 1 .0-23) and Midwest (OR, 6.4; 95% Cl, 1.2-33) and in practices with more HIV patients. Conclusions: Most eligible patients did not receive MAC prophylaxis; PCP pr ophylaxis rates were better but still suboptimal. Our results support outre ach efforts to African Americans, Hispanics, the less educated, and those i n the northeastern United States and in practices with fewer HIV patients.