Opportunistic Infection Prophylaxis Can Be Safely Dropped After CD4 Recovery

Therapy to prevent opportunistic infection relapses in HIV patients is often unnecessary after antiretroviral treatment, according to researchers in Europe. They reported their findings in the article "Safe Interruption of Maintenance Therapy Against Previous Infection with Four Common HIV-Associated Opportunistic Pathogens During Potent Antiretroviral Therapy" in the Annals of Internal Medicine (2002;137(4)239-250).

"The safety of interrupting maintenance therapy for previous opportunistic infections other than Pneumocystis carinii among patients with HIV infection who respond to potent antiretroviral therapy has not been well documented," according to Ole Kirk and colleagues with Hvidovre University Hospital in Hvidovre, Denmark, and other institutions in the Netherlands, Italy, Germany, France and Switzerland. Kirk and coauthors found that patients with even moderate levels of immune reconstitution after antiretroviral therapy have a very low risk of redeveloping opportunistic infections.

The researchers reviewed data from 358 patients who halted maintenance therapy against four conditions -- cytomegalovirus (CMV) disease, Mycobacterium avium complex (MAC), extrapulmonary cryptococcosis, and cerebral toxoplasmosis -- after a positive response to antiretroviral therapy. All of the patients were taking at least three antiretroviral agents, and all had achieved CD4 cell counts of at least 50 x 106 cells/L when prophylaxis was suspended, according to the report.

During the 781 person-years of follow up, only five patients suffered relapses, study data showed. In two cases, the relapsing patients' CD4 cell count was lower than 100 x 106 cells/L when prophylaxis was discontinued. Two of the other three relapses occurred in patients who halted infection prophylaxis while their CD4 cell counts remained below 200 x 106 cells/L. "Maintenance therapy against previous infection with CMV, MAC, Toxoplasma gondii, or Cryptococcus neoformans in patients with HIV infection can be interrupted after sustained CD4 count increases to greater than 200 (or possibly 100 to 200) x 106 cells/L for at least six months after the start of potent antiretroviral therapy," Kirk and colleagues concluded.

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