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Meta-Analysis
. 2011;6(12):e28570.
doi: 10.1371/journal.pone.0028570. Epub 2011 Dec 16.

Discontinuation of Pneumocystis jirovecii pneumonia prophylaxis with CD4 count <200 cells/µL and virologic suppression: a systematic review

Cecilia T Costiniuk  1 , Dean A Fergusson, Steve Doucette, Jonathan B Angel
Affiliations
Meta-Analysis

Discontinuation of Pneumocystis jirovecii pneumonia prophylaxis with CD4 count <200 cells/µL and virologic suppression: a systematic review

Cecilia T Costiniuk et al. PLoS One. 2011.

Abstract

Background: HIV viral load (VL) is currently not part of the criteria for Pneumocystis jirovecii pneumonia (PCP) prophylaxis discontinuation, but suppression of plasma viremia with antiretroviral therapy may allow for discontinuation of PCP prophylaxis even with CD4 count <200 cells/µL.

Methods: A systematic review was performed to determine the incidence of PCP in HIV-infected individuals with CD4 count <200 cells/µL and fully suppressed VL on antiretroviral therapy but not receiving PCP prophylaxis.

Results: Four articles examined individuals who discontinued PCP prophylaxis with CD4 count <200 cells/µL in the context of fully suppressed VL on antiretroviral therapy. The overall incidence of PCP was 0.48 cases per 100 person-years (PY) (95% confidence interval (CI) (0.06-0.89). This was lower than the incidence of PCP in untreated HIV infection (5.30 cases/100 PY, 95% CI 4.1-6.8) and lower than the incidence in persons with CD4 count <200 cells/µL, before the availability of highly active antiretroviral therapy (HAART), who continued prophylaxis (4.85/100 PY, 95% CI 0.92-8.78). In one study in which individuals were stratified according to CD4 count <200 cells/µL, there was a greater risk of PCP with CD4 count ≤100 cells/µL compared to 101-200 cells/µL.

Conclusion: Primary PCP prophylaxis may be safely discontinued in HIV-infected individuals with CD4 count between 101-200 cells/µL provided the VL is fully suppressed on antiretroviral therapy. However, there are inadequate data available to make this recommendation when the CD4 count is ≤100 cells/µL. A revision of guidelines on primary PCP prophylaxis to include consideration of the VL is merited.

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Conflict of interest statement

Competing Interests: C.T.C. is an Association of Medical Microbiology and Infectious Disease of Canada Astellas Post Residency Fellowship recipient. This does not alter the authors' adherence to all the PLoS ONE policies on sharing data and materials.

Figures

Figure 1
Figure 1. Flow diagram of literature search for systematic review.
Figure 2
Figure 2. Incidence of PCP in HIV-infected Individuals on Antiretroviral Therapy who Discontinue Prophylaxis with CD4+ Count <200 cells/µL with Suppressed Viral Load.
Figure 3
Figure 3. Incidence of PCP in HIV-infected Individuals in Various Situations.
See this image and copyright information in PMC

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