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.
editor's note: This letter was sent to the authors of “Pneumocystis carinii Pneumonia: A Clinical Review,” who did not reply.