Successful discontinuation of therapy for disseminated Mycobacterium avium complex infection after effective antiretroviral therapy.
BACKGROUND
Highly active antiretroviral therapy (HAART) is associated with improvement or resolution of several HIV-associated opportunistic infections. Although prophylaxis against disseminated Mycobacterium avium complex infection may be successfully discontinued after a favorable response to HAART, the 1999 guidelines from the U.S. Public Health Service/Infectious Diseases Society of America recommend continuing therapy for disseminated M. avium complex infection, regardless of the response to HAART.


OBJECTIVE
To examine the outcome among patients with disseminated M. avium complex infection whose antimycobacterial therapy was discontinued after a favorable response to HAART.


METHODS
Retrospective chart review between May 2000 and May 2001.


METHODS
13 Canadian HIV clinics.


METHODS
52 HIV-infected adults (43 men; mean age, 37.3 years) in whom successful antimycobacterial therapy for disseminated M. avium complex infection was discontinued after a favorable virologic response to HAART.


METHODS
Survival, survival free of disseminated M. avium complex infection, and CD4(+) cell count responses.


RESULTS
At the time of diagnosis of disseminated M. avium complex infection, the median CD4(+) cell count was 0.016 x 10(9) cells/L, and the median plasma HIV RNA level was 90 000 copies/mL (plasma HIV RNA levels were available for only 21 patients). The patients received a median of 32 months of antimycobacterial therapy that included ethambutol plus either clarithromycin or azithromycin. When antimycobacterial therapy was discontinued, the median CD4(+) cell count was 0.23 x 10(9) cells/L and the median plasma HIV RNA level was less than 50 copies/mL. A median of 20 months after discontinuation of antimycobacterial therapy, only 1 patient had developed recurrent M. avium complex disease (37 months after stopping antimycobacterial therapy). This patient had stopped HAART 2 months earlier because of uncontrolled HIV viremia. Twenty months after stopping antimycobacterial therapy, the other 51 patients had a median CD4(+) cell count of 0.288 x 10(9) cells/L; 34 (67%) had undetectable plasma HIV RNA levels, and 8 (15%) had plasma HIV RNA levels of 50 to 1000 copies/mL.


CONCLUSIONS
Discontinuation of successful disseminated M. avium complex therapy after a successful response to HAART is safe and reduces patients' pill burdens, potential drug adverse effects, drug interactions, and costs of therapy.
Shafran
Stephen D
SD
University of Alberta, Edmonton, Alberta, Canada. shafran@uah.ualberta.ca
Mashinter
Laura D
LD
Phillips
Peter
P
Lalonde
Richard G
RG
Gill
M John
MJ
Walmsley
Sharon L
SL
Toma
Emil
E
Conway
Brian
B
Fong
Ignatius W
IW
Rachlis
Anita R
AR
Williams
Kurt E
KE
Garber
Gary E
GE
Schlech
Walter F
WF
Smaill
Fiona
F
Pradier
C
C
D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy*; D000293:Adolescent; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015270:Mycobacterium avium-intracellulare Infection / Q000188:drug therapy*; D012008:Recurrence; D012189:Retrospective Studies; D016896:Treatment Outcome; D019562:Viral Load; D028761:Withholding Treatment