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Title: Withholding primary PcP prophylaxis in virologically suppressed HIV patients: An emulation of a pragmatic trial in COHERE
Author: Atkinson, Andrew
Zwahlen, Marcel
Barger, Diana
D'Arminio Monforte, Antonella
De Wit, Stephane
Ghosn, Jade
Girardi, Enrico
Svedhem, Veronica
Morlat, Philippe
Mussini, Cristina
Noguera Julian, Antoni
Stephan, Cristoph
Touloumi, Giota
Kirk, Ole
Mocroft, Amanda
Reiss, Peter
Miró Meda, José M.
Carpenter, James R.
Furrer, Hansjakob
Keywords: Infeccions per VIH
Medicina preventiva
HIV infections
Preventive medicine
Issue Date: 25-May-2020
Publisher: Oxford University Press
Abstract: Background: Using data from the COHERE collaboration, we investigated whether primary prophylaxis for pneumocystis pneumonia (PcP) might be withheld in all patients on antiretroviral therapy (ART) with suppressed plasma human immunodeficiency virus (HIV) RNA (≤400 copies/mL), irrespective of CD4 count. Methods: We implemented an established causal inference approach whereby observational data are used to emulate a randomized trial. Patients taking PcP prophylaxis were eligible for the emulated trial if their CD4 count was ≤200 cells/µL in line with existing recommendations. We compared the following 2 strategies for stopping prophylaxis: (1) when CD4 count was >200 cells/µL for >3 months or (2) when the patient was virologically suppressed (2 consecutive HIV RNA ≤400 copies/mL). Patients were artificially censored if they did not comply with these stopping rules. We estimated the risk of primary PcP in patients on ART, using the hazard ratio (HR) to compare the stopping strategies by fitting a pooled logistic model, including inverse probability weights to adjust for the selection bias introduced by the artificial censoring. Results: A total of 4813 patients (10 324 person-years) complied with eligibility conditions for the emulated trial. With primary PcP diagnosis as an endpoint, the adjusted HR (aHR) indicated a slightly lower, but not statistically significant, different risk for the strategy based on viral suppression alone compared with the existing guidelines (aHR, .8; 95% confidence interval, .6-1.1; P = .2). Conclusions: This study suggests that primary PcP prophylaxis might be safely withheld in confirmed virologically suppressed patients on ART, regardless of their CD4 count.
Note: Reproducció del document publicat a:
It is part of: Clinical Infectious Diseases, 2020, vol. 73, num. 2, p. 195-202
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ISSN: 1058-4838
Appears in Collections:Articles publicats en revistes (IDIBAPS: Institut d'investigacions Biomèdiques August Pi i Sunyer)
Articles publicats en revistes (Cirurgia i Especialitats Medicoquirúrgiques)

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