Discontinuing prophylaxis for opportunistic infection: guiding principles

Management of Opportunistic Infection Prophylaxis in the Highly Active Antiretroviral Therapy Era

Prophylaxis and maintenance therapy against opportunistic infections are a mainstay of management of HIV-infected patients and have led to a significant improvement in quality of life and survival. Antiretroviral combination therapy (ART) has markedly changed the natural course of HIV infection. Incidence of opportunistic infections (OIs) has declined and survival after an OI has improved. Achieving a CD4 count of 200 cells/L after 6 months of ART is a valuable marker for low risk of OI afterwards. Therefore, recommendations on prophylaxis and maintenance therapy need to be redefined. Criteria for discontinuation, such as a CD4 count rise above threshold values and time above threshold values as response to ART, should be evaluated for the most frequent OIs. Reliable data in favor of discontinuation of primary prophylaxis against Pneumocystis carinii pneumonia, toxoplasmic encephalitis, and Mycobacterium avium infection have been published. Discontinuation of maintenance therapy against P. carinii pneumonia is possible, and may be safe against cytomegalovirus retinitis, M. avium, and cryptococcosis and toxoplasmosis in selected patients. Pharmacologic interactions between drugs used for OI prophylaxis and antiretroviral drugs need to be taken into account.