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Atkinson A, Zwahlen M, Barger D, d’Arminio Monforte A, De Wit S, Ghosn J, Girardi E, Svedhem V, Morlat P, Mussini C, Noguera-Julian A, Stephan C, Touloumi G, Kirk O, Mocroft A, Reiss P, Miro JM, Carpenter JR, Furrer H. Withholding Primary Pneumocystis Pneumonia Prophylaxis in Virologically Suppressed Patients With Human Immunodeficiency Virus: An Emulation of a Pragmatic Trial in COHERE. Clin Infect Dis 2021; 73:195-202. [PMID: 32448894 PMCID: PMC8516510 DOI: 10.1093/cid/ciaa615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/19/2020] [Indexed: 01/06/2023] Open
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.
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Affiliation(s)
- Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Diana Barger
- University of Bordeaux, ISPED, Inserm Bordeaux Population Health, Team MORPH3EUS, UMR 1219, Bordeaux, France
| | | | - Stephane De Wit
- Department of Infectious Diseases, Saint Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jade Ghosn
- APHP, Nord-Université de Paris, Service des Maladies Infectieuses et Tropicales, Hôpital Bichat, Paris, France
- INSERM UMR 1137 IAME, Université de Paris, Faculté de Médecine, Paris, France
| | - Enrico Girardi
- Clinical Epidemiology Unit, National Institute for Infectious Diseases L. Spallanzani–IRCCS, Rome, Italy
| | - Veronica Svedhem
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Philippe Morlat
- University of Bordeaux, ISPED, Inserm Bordeaux Population Health, Team MORPH3EUS, UMR 1219, Bordeaux, France
- Centre Hospitalier Universitaire de Bordeaux (CHU), Services de Médecine Interne et Maladies Infectieuses, Bordeaux, France
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Unitat d´Infeccions, Servei de Pediatria, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Barcelona, Spain
- Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
- Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain
| | - Christoph Stephan
- Infectious Diseases Unit at Medical Center No. 2, Frankfurt University Hospital, Goethe University, Frankfurt, Germany
| | - Giota Touloumi
- Department of Hygiene, Epidemiology, and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ole Kirk
- CHIP, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Denmark
| | - Amanda Mocroft
- Centre for Clinical Research, Epidemiology, Modelling, and Evaluation (CREME), Institute for Global Health, University College London, London, United Kingdom
| | - Peter Reiss
- HIV Monitoring Foundation, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic–IDIBAPS, University of Barcelona, Barcelona, Spain
| | - James R Carpenter
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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Kunisaki KM, Janoff EN. Influenza in immunosuppressed populations: a review of infection frequency, morbidity, mortality, and vaccine responses. THE LANCET. INFECTIOUS DISEASES 2009; 9:493-504. [PMID: 19628174 DOI: 10.1016/s1473-3099(09)70175-6] [Citation(s) in RCA: 381] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patients that are immunosuppressed might be at risk of serious influenza-associated complications. As a result, multiple guidelines recommend influenza vaccination for patients infected with HIV, who have received solid-organ transplants, who have received haemopoietic stem-cell transplants, and patients on haemodialysis. However, immunosuppression might also limit vaccine responses. To better inform policy, we reviewed the published work relevant to incidence, outcomes, and prevention of influenza infection in these patients, and in patients being treated chemotherapy and with systemic corticosteroids. Available data suggest that most immunosuppressed populations are indeed at higher risk of influenza-associated complications, have a general trend toward impaired humoral vaccine responses (although these data are mixed), and can be safely vaccinated--although longitudinal data are largely lacking. Randomised clinical trial data were limited to one study of HIV-infected patients with high vaccine efficacy. Better trial data would inform vaccination recommendations on the basis of efficacy and cost in these at-risk populations.
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Affiliation(s)
- Ken M Kunisaki
- Pulmonary Section, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN 55417, USA.
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Gayet-Ageron A, Baratin D, Marceillac E, Allard R, Peyramond D, Chidiac C, Trepo C, Livrozet JM, Touraine JL, Ritter J, Sepetjan M, Fabry J, Vanhems P. The AIDS epidemic in Lyon: patient characteristics and defining illnesses between 1985 and 2000. HIV Med 2004; 5:163-70. [PMID: 15139982 DOI: 10.1111/j.1468-1293.2004.00205.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To define the characteristics of 1899 patients diagnosed with AIDS at Lyon University Hospitals (LUH) across four time periods corresponding to different antiretroviral eras, and to analyse the evolution of specific AIDS-defining illnesses (ADIs) with time. METHODS All AIDS patients at LUH between 1 January 1985 and 31 December 2000 were included in the study. The data were compared using the chi(2) test and one-way analysis of variance. RESULTS The absolute number of new AIDS cases increased by 30.3% between 1985 and 1995 but decreased by 26.5% between 1996 and 2000. The proportion of women with AIDS increased significantly (P<0.001) and mean age at diagnosis also increased significantly over time (P<0.001). The proportion of infection through heterosexual contact increased dramatically, while that through homo/bisexual intercourse or injection drug use (IDU) decreased significantly (P<0.001). The absolute number of ADIs declined with the introduction of highly active antiretroviral therapies (HAART) (P<10(-6)). Pneumocystis carinii pneumonia remained the leading ADI in 1996-2000 (23.3%). A significant increase in the proportion of non-Hodgkin's lymphoma (NHL) was observed over time (P<10(-5)) but the number of new NHL cases decreased during HIV infection after 1996. CONCLUSIONS The decline in the incidence of AIDS with the advent of HAART was confirmed in our hospital cohort. The gradual increase in the proportion of NHL among ADIs underscores the long latency period between infection with HIV and the achievement of an effect of HAART on HIV-associated lymphomagenesis.
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Affiliation(s)
- A Gayet-Ageron
- Department of Hospital Epidemiology, Edouard Herriot Hospital, Lyon, France
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