对于病毒学抑制的 HIV 感染且 CD4 细胞计数<200 个/μL 的患者，停止原发性卡氏肺孢子虫肺炎预防是否安全？
Is it safe to discontinue primary Pneumocystis jiroveci pneumonia prophylaxis in patients with virologically suppressed HIV infection and a CD4 cell count <200 cells/microL?
出版信息
Clin Infect Dis. 2010 Sep 1;51(5):611-9. doi: 10.1086/655761.
BACKGROUND
Current guidelines suggest that primary prophylaxis for Pneumocystis jiroveci pneumonia (PcP) can be safely stopped in human immunodeficiency virus (HIV)-infected patients who are receiving combined antiretroviral therapy (cART) and who have a CD4 cell count >200 cells/microL. There are few data regarding the incidence of PcP or safety of stopping prophylaxis in virologically suppressed patients with CD4 cell counts of 101-200 cells/microL.
METHODS
The Opportunistic Infections Project Team of the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) included data from 23,412 patients from 12 European cohorts who started taking cART after 1997. Poisson regression was used to model incidence rate ratios (IRRs) of primary PcP.
RESULTS
There were 253 PcP cases during 107,016 person-years of follow-up (PYFU). Prophylaxis significantly reduced the incidence of PcP among patients with current CD4 cell counts 100 cells/microL (adjusted IRR, 0.41; 95% confidence interval [CI], 0.27-0.60) but not significantly among those with current CD4 cell counts of 101-200 cells/microL (adjusted IRR, 0.63; 95% CI, 0.34-1.17). The incidence of PcP among patients who had a current CD4 cell count of 100-200 cells/microL, who had a viral load <400 copies/mL, and who were receiving prophylaxis was 2.1 cases per 1000 PYFU (95% CI, 0.8-4.3 cases per 1000 PYFU; 7 events occurred during 3363 PYFU), whereas 1.2 cases per 1000 PYFU (95% CI, 0.2-4.5 cases per 1000 PYFU; 2 events occurred during 1614 PYFU) occurred among persons who were not receiving prophylaxis (adjusted IRR, 1.65; 95% CI, 0.33-8.15). Among patients who discontinued PcP prophylaxis after starting cART, the incidence of primary PcP was 0 cases per 1000 PYFU (95% CI, 0.0-2.7 cases per 1000 PYFU; 0 events occurred during 1363 PYFU) for patients who had a current CD4 cell count of 101-200 cells/microL and who were receiving cART.
CONCLUSIONS
The incidence of primary PcP among patients who had virologically suppressed HIV infection, were receiving cART, and who had CD4 cell counts >100 cells/microL was low irrespective of prophylaxis use. Discontinuation of prophylaxis may be safe in patients with CD4 counts of 101-200 cells/microL and suppressed viral load.
背景
目前的指南建议，对于正在接受联合抗逆转录病毒治疗（cART）且 CD4 细胞计数>200 个/微升的 HIV 感染者，可安全停止预防卡氏肺孢子菌肺炎（PcP）的初级预防。在 CD4 细胞计数为 101-200 个/微升的病毒学抑制患者中，关于 PcP 的发生率或停止预防的安全性的数据很少。
方法
协作观察性艾滋病毒流行病学研究在欧洲（COHERE）的机会性感染项目团队纳入了自 1997 年以来在 12 个欧洲队列中开始接受 cART 的 23412 名患者的数据。泊松回归用于模拟原发性 PcP 的发病率比值比（IRR）。
结果
在 107016 人年的随访（PYFU）期间，有 253 例 PcP 病例。预防显著降低了当前 CD4 细胞计数为 100 个/微升的患者（调整后的 IRR，0.41；95%置信区间 [CI]，0.27-0.60）发生 PcP 的风险，但对当前 CD4 细胞计数为 101-200 个/微升的患者（调整后的 IRR，0.63；95%CI，0.34-1.17）无显著影响。当前 CD4 细胞计数为 100-200 个/微升、病毒载量<400 拷贝/ml 且正在接受预防的患者中，PcP 的发生率为每 1000 PYFU 2.1 例（95%CI，0.8-4.3 例/1000 PYFU；7 例发生在 3363 PYFU 中），而未接受预防的患者每 1000 PYFU 1.2 例（95%CI，0.2-4.5 例/1000 PYFU；2 例发生在 1614 PYFU 中）（调整后的 IRR，1.65；95%CI，0.33-8.15）。在开始接受 cART 后停止预防 PcP 的患者中，当前 CD4 细胞计数为 101-200 个/微升且正在接受 cART 的患者，原发性 PcP 的发生率为每 1000 PYFU 0 例（95%CI，0.0-2.7 例/1000 PYFU；0 例发生在 1363 PYFU 中）。
结论
对于 HIV 感染病毒学抑制、正在接受 cART 治疗且 CD4 细胞计数>100 个/微升的患者，原发性 PcP 的发生率较低，无论是否使用预防。对于 CD4 计数为 101-200 个/微升且病毒载量抑制的患者，停止预防可能是安全的。
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