@article{3102299,
    title = "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",
    author = "Atkinson, A. and Miro, J.M. and Mocroft, A. and Reiss, P. and Kirk, O. and Morlat, P. and Ghosn, J. and Stephan, C. and Mussini, C. and Antoniadou, A. and Doerholt, K. and Girardi, E. and De Wit, S. and Kraus, D. and Zwahlen, M. and Furrer, H. and De Wit, S. and Antoniadou, A. and Castagna, A. and Doerholt, K. and Fätkenheuer, G. and Raben, D. and Teira, R. and Zangerle, R. and Judd, A. and Zangerle, R. and Touloumi, G. and Warszawski, J. and Meyer, L. and Dabis, F. and Krause, M.M. and Leport, C. and Wittkop, L. and Wit, F. and Prins, M. and Bucher, H. and Gibb, D. and Fätkenheuer, G. and Del Amo, J. and Obel, N. and Thorne, C. and Pérez-Hoyos, S. and Hamouda, O. and Bartmeyer, B. and Chkhartishvili, N. and Noguera-Julian, A. and Antinori, A. and d’Arminio Monforte, A. and Brockmeyer, N. and Prieto, L. and Conejo, P.R. and Soriano-Arandes, A. and Battegay, M. and Kouyos, R. and Casabona, J. and Goetghebuer, T. and Sönnerborg, A. and Torti, C. and Sabin, C. and Teira, R. and Garrido, M. and Haerry, D. and Costagliola, D. and d’Arminio-Monforte, A. and del Amo, J. and Raben, D. and Chêne, G. and Judd, A. and Conejo, P.R. and Barger, D. and Schwimmer, C. and Termote, M. and Wittkop, L. and Frederiksen, C.M. and Raben, D. and Brandt, R.S. and Berenguer, J. and Bohlius, J. and Bouteloup, V. and Bucher, H. and Cozzi-Lepri, A. and Dabis, F. and d’Arminio Monforte, A. and Davies, M.-A. and del Amo, J. and Dorrucci, M. and Dunn, D. and Egger, M. and Guiguet, M. and Grabar, S. and Judd, A. and Lambotte, O. and Leroy, V. and Lodi, S. and Matheron, S. and Meyer, L. and Monge, S. and Nakagawa, F. and Paredes, R. and Phillips, A. and Puoti, M. and Rohner, E. and Schomaker, M. and Smit, C. and Sterne, J. and Thiebaut, R. and Thorne, C. and Wqetu, C. and van der Valk, M. and Wittkop, L. and the Opportunistic Infections Working Group of the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) study in EuroCOORD",
    journal = "Journal of the International Aids Society",
    year = "2021",
    volume = "24",
    number = "6",
    publisher = "John Wiley and Sons Inc",
    issn = "1758-2652",
    doi = "10.1002/jia2.25726",
    keywords = "virus RNA, adult;  antiretroviral therapy;  Article;  bacterial transmission;  CD4 lymphocyte count;  cohort analysis;  Europe;  female;  follow up;  human;  Human immunodeficiency virus infected patient;  Human immunodeficiency virus infection;  incidence;  infection risk;  injection drug user;  major clinical study;  male;  men who have sex with men;  opportunistic infection;  plasma;  Pneumocystis pneumonia;  recurrent infection;  risk factor;  secondary infection;  viremia;  virus load;  virus replication;  CD4 lymphocyte count;  complication;  Human immunodeficiency virus infection;  Pneumocystis carinii;  Pneumocystis pneumonia;  viremia, Adult;  CD4 Lymphocyte Count;  Europe;  HIV Infections;  Humans;  Pneumocystis carinii;  Pneumonia, Pneumocystis;  Viremia",
    abstract = "Introduction: Since the beginning of the HIV epidemic in resource-rich countries, Pneumocystis jirovecii pneumonia (PjP) is one of the most frequent opportunistic AIDS-defining infections. The Collaboration of Observational HIV Epidemiological Research Europe (COHERE) has shown that primary Pneumocystis jirovecii Pneumonia (PjP) prophylaxis can be safely withdrawn in patients with CD4 counts of 100 to 200 cells/µL if plasma HIV-RNA is suppressed on combination antiretroviral therapy. Whether this holds true for secondary prophylaxis is not known, and this has proved difficult to determine due to the much lower population at risk. Methods: We estimated the incidence of secondary PjP by including patient data collected from 1998 to 2015 from the COHERE cohort collaboration according to time-updated CD4 counts, HIV-RNA and use of PjP prophylaxis in persons >16 years of age. We fitted a Poisson generalized additive model in which the smoothed effect of CD4 was modelled by a restricted cubic spline, and HIV-RNA was stratified as low (<400), medium (400 to 10,000) or high (>10,000copies/mL). Results: There were 373 recurrences of PjP during 74,295 person-years (py) in 10,476 patients. The PjP incidence in the different plasma HIV-RNA strata differed significantly and was lowest in the low stratum. For patients off prophylaxis with CD4 counts between 100 and 200 cells/µL and HIV-RNA below 400 copies/mL, the incidence of recurrent PjP was 3.9 (95% CI: 2.0 to 5.8) per 1000 py, not significantly different from patients on prophylaxis in the same stratum (1.9, 95% CI: 0.1 to 3.7). Conclusions: HIV viraemia importantly affects the risk of recurrent PjP. In virologically suppressed patients on ART with CD4 counts of 100 to 200/µL, the incidence of PjP off prophylaxis is below 10/1000 py. Secondary PjP prophylaxis may be safely withheld in such patients. While European guidelines recommend discontinuing secondary PjP prophylaxis only if CD4 counts rise above 200 cells/mL, the latest US Guidelines consider secondary prophylaxis discontinuation even in patients with a CD4 count above 100 cells/µL and suppressed viral load. Our results strengthen and support this US recommendation. © 2021 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society."
}