No need for secondary Pneumocystis jirovecii pneumonia prophylaxis in adult people living with HIV from Europe on ART with suppressed viraemia and a CD4 cell count greater than 100 cells/µL. Journal of the International AIDS Society
Atkinson and Miro et al. assessed the influence of CD4 cell count, HIV viral load and use of antimicrobial prophylaxis on the occurrence of secondary Pneumocystis jirovecii (PjP) in people with HIV in Europe.
For the present study, patients from the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) who had previously experienced PjP pneumonia were considered. Adjusted incidence rates (IR) of secondary PjP stratified by use of PjP prophylaxis, HIV-RNA levels and CD4 cell count were estimated using Poisson regression. Authors considered an IR of less than 10 per 1000 person-years (PY) to be safe to discontinue or withhold antimicrobial prophylaxis.
The study included 10’467 individuals with a history of PjP pneumonia, contributing 74’295 PY of follow-up. The median age was 40 years (IQR 35–47), 19.9% were female, 39.6% were men having sex with men, and the median CD4 at baseline was 80 cells/µL (IQR 24–220). Within the study period, 373 secondary PjP events occurred (IR 5.0 per 1000 PY, 95% CI 4.5–5.6). In the absence of antimicrobial prophylaxis and with a HIV viral load below 400 cp/mL, incidence rates were less than 10/1000 PY in patients with a CD4 count between 101–200 cells/µL (IR 3.9 per 1000 PY, 2.0–5.8) and those with a CD4 count >200 cells/µL (IR 1.5 per 1000 PY, 1.2–1.8). Confidence intervals for IR spanned across 10/1000 PY in individuals with a CD4 cell count below 100, irrespective of HIV viral load. Interestingly, individuals with HIV viral loads >10’000 and a CD4 cell count > 200 cells/µL also had high incidence rates of secondary PjP (IR 10.3 per 1000 PY without prophylaxis, and IR 24.7 per 1000 PY with prophylaxis).
Taken together, this large-scale study found that the incidence of secondary PjP is below 10 per 1000 PY in individuals with a suppressed HIV viral load and CD4 counts above 100 cells/µL. Conversely, the incidence was above 10 per 1000 PY in patients with replicating HIV and a CD4 counts above 200 cells/µL, for which guidelines currently do not recommend antimicrobial prophylaxis. These findings implicate that secondary PjP prophylaxis may be withheld in patients with CD4 counts above 100 and effective ART, and confirm the importance of replicating HIV on the development of opportunistic infections, even in individuals with minimal HIV-induced immunosuppression.