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 active antiretroviral therapy (HAART) and recovering a CD4 cell number above 200x10(6)/l may safely discontinue primary and secondary prophylaxes for major opportunistic infections. Design: Retrospective study of a single-center, prospectively constituted cohort of 223 patients receiving HAART with a protease inhibitor, of whom 137 received at least one prophylaxis. Methods: Exhaustive informations on prophylaxis use, clinical and laboratory data were used to produce descriptive statistics on infectious events, duration of HIV infection, time on HAART, time to prophylaxis interruption, length of follow-up and biological values at relevant time points. Results: Fifty-one patients with a history of severe immunodepression (median CD4 nadir: 62x10(6)/l), including 16 patients with CDC stage C infection, discontinued at least one prophylaxis. Primary or secondary P. carinii pneumonia prophylaxis was discontinued in 43 patients: 1 first episode of PCP occurred after 2 months but no other episode was recorded after a median follow-up of 16 months. Toxoplasmosis primary or secondary prophylaxis, secondary cytomegalovirus prophylaxis and primary or secondary M. avium complex prophylaxes were discontinued in respectively 37, 5 and 5 bpatients, and no event was recorded after respective follow-ups of 16, 7 and 15 months. Nine 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 interrupted in most of these severely immunodeficient patients recovering a CD4 cell count above 200x10(6)/l on HAART. This confirms the efficiency of immune restoration and is beneficial to patients but, since 3 infectious events were recorded, caution should be taken before making a decision based on immunological and virological considerations.