title: Failure to prescribe pneumocystis prophylaxis is associated with increased mortality, even in the cART era: results from the Treat Asia HIV observational database.
abstract: BACKGROUND
  Pneumocystis jiroveci pneumonia (PCP) prophylaxis is recommended for patients with CD4 counts of less than 200 cells/mm3. 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/mm3, 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.
authors.affiliation: Tan Tock Seng Hospital, Singapore.
authors.forename: Poh-Lian
authors.initials: PL
authors.lastname: Lim
authors.forename: Jialun
authors.initials: J
authors.lastname: Zhou
authors.forename: Rossana A
authors.initials: RA
authors.lastname: Ditangco
authors.forename: Matthew G
authors.initials: MG
authors.lastname: Law
authors.forename: Thira
authors.initials: T
authors.lastname: Sirisanthana
authors.forename: Nagalingeswaran
authors.initials: N
authors.lastname: Kumarasamy
authors.forename: Yi-Ming A
authors.initials: YM
authors.lastname: Chen
authors.forename: Praphan
authors.initials: P
authors.lastname: Phanuphak
authors.forename: Christopher K C
authors.initials: CK
authors.lastname: Lee
authors.forename: Vonthanak
authors.initials: V
authors.lastname: Saphonn
authors.forename: Shinichi
authors.initials: S
authors.lastname: Oka
authors.forename: Fujie
authors.initials: F
authors.lastname: Zhang
authors.forename: Jun Y
authors.initials: JY
authors.lastname: Choi
authors.forename: Sanjay
authors.initials: S
authors.lastname: Pujari
authors.forename: Adeeba
authors.initials: A
authors.lastname: Kamarulzaman
authors.forename: Patrick C K
authors.initials: PC
authors.lastname: Li
authors.forename: Tuti P
authors.initials: TP
authors.lastname: Merati
authors.forename: Evy
authors.initials: E
authors.lastname: Yunihastuti
authors.forename: Liesl
authors.initials: L
authors.lastname: Messerschmidt
authors.forename: Somnuek
authors.initials: S
authors.lastname: Sungkanuparph
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality* / Q000517:prevention & control; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D001208:Asia; D018791:CD4 Lymphocyte Count; D003622:Dapsone / Q000627:therapeutic use; D016208:Databases, Factual; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010419:Pentamidine / Q000627:therapeutic use; D045363:Pneumocystis carinii / Q000502:physiology*; D011020:Pneumonia, Pneumocystis / Q000188:drug therapy* / Q000382:microbiology / Q000517:prevention & control*; D011446:Prospective Studies; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use
chemical_list: D019380:Anti-HIV Agents; D000935:Antifungal Agents; D010419:Pentamidine; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D003622:Dapsone