Failure to prescribe pneumocystis prophylaxis is associated with increased mortality, even in the cart era: results from the treat Asia HIV observational database

• Main Authors: Lim, P.L., Zhou, J.L., Ditangco, R.A., Law, M.G., Sirisanthana, T., Kumarasamy, N., Chen, Y.M.A., Phanuphak, P., Lee, C.K.C., Saphonn, V., Oka, S., Zhang, F.J., Choi, J.Y., Pujari, S., Kamarulzaman, Adeeba, Li, P.C.K., Merati, T.P., Yunihastuti, E., Messerschmidt, L., Sungkanuparph, S.
• Format: Article
• Published: Wiley Open Access 2012
• Subjects: R Medicine
• Online Access: http://eprints.um.edu.my/4578/

Background: Pneumocystis jiroveci pneumonia (PCP) prophylaxis is recommended for patients with CD4 counts of less than 200 cells/mm(3). This study examines the proportion of patients in the TREAT Asia HIV Observational Database (TAHOD) receiving PCP prophylaxis, and its effect on PCP and mortality. Methods: TAHOD patients with prospective follow up had data extracted for prophylaxis using co-trimoxazole, dapsone or pentamidine. The proportion of patients on prophylaxis was calculated for each calendar year since 2003 among patients with CD4 counts of less than 200 cells/mm3. The effect of prophylaxis on PCP and survival were assessed using random-effect Poisson regression models. Results: There were a total of 4050 patients on prospective follow up, and 90 of them were receiving combination antiretroviral therapy. Of those with CD4 counts of less than 200 cells/mm(3), 58 to 72 in any given year received PCP prophylaxis, predominantly co-trimoxazole. During follow up, 62 patients developed PCP (0.5 per 100 person-years) and 169 died from all causes (1.36/100 person-years). After stratifying by site and adjusting for age, CD4 count, CDC stage and antiretroviral treatment, those without prophylaxis had no higher risk of PCP, but had a significantly higher risk of death (incident rate ratio 10.8, p < 0.001). PCP prophylaxis had greatest absolute benefit in patients with CD4 counts of less than 50 cells/mm3, lowering mortality rates from 33.5 to 6.3 per 100 person-years. Conclusions: Approximately two-thirds of TAHOD patients with CD4 counts of less than 200 cells/mm3 received PCP prophylaxis. Patients without prophylaxis had significantly higher mortality, even in the era of combination ART. Although PCP may be under-diagnosed, these data suggest that prophylaxis is associated with important survival benefits.