Am Fam Physician. 2000 Oct 15;62(8):1783-1784.
to the editor: In their excellent review1 of Pneumocystis carinii pneumonia (PCP) in patients infected with human immunodeficiency virus (HIV), Drs. Wilkin and Feinberg refer to the latest Public Health Service guidelines which “recommend discontinuation of primary PCP prophylaxis in patients whose CD4+ cell counts are sustained above 200 per mm3 for at least six months and who have well-controlled HIV viral loads.”2 This new recommendation is based on study results suggesting that patients who respond well to potent combination anti-retroviral therapy have protection against PCP and other opportunistic infections.3–6
Our experience at the Family Practice In-patient Service, San Francisco General Hospital, is consistent with this observation. Despite increasing numbers of total admissions to our service in recent years, the number of patients admitted with acquired immunodeficiency syndrome (AIDS), including those with PCP, have dropped dramatically since the emergence of potent antiretroviral therapy (see the accompanying figure).
Indeed, most patients admitted with acute PCP over the past few years have not been taking antiretroviral agents consistently. For the family physician caring for HIV-infected patients who are responders to potent combination antiretroviral therapy, omitting primary PCP prophylaxis while carefully monitoring for any signs of disease progression is a reasonable management strategy.
1. Wilkin A, Feinberg J. Pneumocystis carinii pneumonia: a clinical review. Am Fam Physician. 1999;60:1699–708.
2. 1999 USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with the human immunodeficiency virus. U.S. Public Health Service (USPHS) and Infectious Diseases Society of American (IDSA) MMWR Morb Mortal Wkly Rep. 1999;48:1–59.
3. Ledergerber B, Egger M, Erard V, Weber R, Hirschel B, Furrer H, et al. AIDS-related opportunistic illnesses occurring after initiation of potent antiretroviral therapy: the Swiss HIV Cohort Study. JAMA. 1999;282:2220–6.
4. Furrer H, Egger M, Opravil M, Bernasconi E, Hirschel B, Battegay M, et al. Discontinuation of primary prophylaxis against Pneumocystis carinii pneumonia in HIV-1-infected adults treated with combination anti-retroviral therapy. N Eng J Med. 1999;340:1301–6.
5. Weverling GJ, Mocroft A, Ledergerber B, Kirk O, Gonzales-Lahoz J, Monforte A, et al. Discontinuation of Pneumocystis carinii pneumonia prophylaxis after start of highly active antiretroviral therapy in HIV-1 infection. EuroSIDA Study Group. Lancet. 1999;353:1293–8.
6. Schneider MM, Borleffs JC, Stolk RP, Jaspers CA, Hoepelman AI. Discontinuation of prophylaxis for Pneumocystis carinii pneumonia in HIV-1-infected patients treated with highly active antiretroviral therapy. Lancet. 1999;353:201–3.
editor's note: This letter was sent to the authors of “Pneumocystis carinii Pneumonia: A Clinical Review,” who did not reply.
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