Discontinuing Prophylaxis against Recurrent Opportunistic Infections in HIV-Infected Persons: A Victory in the Era of HAART

The use of highly active antiretroviral therapy (HAART) has resulted in a remarkable decrease in morbidity and mortality among HIV-infected persons. The immune reconstitution resulting from successful use of HAART has raised the possibility that chemoprophylaxis against specific opportunistic infections—therapy that heretofore was considered required for life—might safely be discontinued. While several observational and randomized studies have provided strong support for this practice against first episodes of Pneumocystis carinii pneumonia, disseminated Mycobacterium avium complex (MAC) disease, and toxoplasmic encephalitis (1-3), data on discontinuation of prophylaxis after an episode of disease—so called “secondary prophylaxis” or chronic maintenance therapy—are sparse, except those for P. carinii pneumonia (4).

In 2001, the U.S. Public Health Service/Infectious Diseases Society of America Prevention of Opportunistic Infections Working Group suggested that secondary prophylaxis against P. carinii pneumonia, cytomegalovirus (CMV) retinitis, toxoplasmic encephalitis, MAC, and extrapulmonary cryptococcosis could be discontinued in patients who met specific criteria (5). These criteria, which differ for each disease, include completing a defined course of therapy, attaining certain CD4 T-lymphocyte counts, and having inactive disease. The Working Group spent considerable time evaluating whether the data were adequate to make these recommendations and concluded that although sufficient information was available for some diseases, additional data were welcome.

In this issue, Kirk and colleagues (6) provide important data on discontinuation of secondary prophylaxis after 379 episodes of CMV disease, MAC, toxoplasmic encephalitis, and extrapulmonary cryptococcosis in 358 patients from seven European cohorts. During 781 person-years of observation, only five episodes of recurrent disease were observed. These data are valuable because the numbers of discontinuations of secondary prophylaxis are larger than have been reported previously, therefore narrowing the confidence intervals around the estimates of incidence of disease recurrence. The upper 95% confidence limits of incidence …