Question
Should I stop taking my PCP prophlaxis if my CD4 count has risen?
16 June 2023. Related: All topics, CD4 and viral load, Opportunistic infections, Stopping treatment.
I was diagnosed 6 months ago when hospitalised with PCP. I was quite seriously ill. Since then my CD4 count has increased to 230 (from 20) and viral load undetectable (from 100k).
I am still taking co-trimoxazole and valaciclovir daily as prophylaxes. I would like to stop – just because it’s fewer pills and fewer potential toxicities – but my consultant is not keen yet and says perhaps in 3 months time. Is he just being cautious as all I’ve read seems to indicate the likelihood of a relapse is now very small.
Answer
I’m very sorry to hear about your situation but nice to know that your CD4 count has risen from 20 to 230.
When your CD4 count was low level, you were at risk from opportunistic infections (OIs) such as PCP, cytomegalovirus (CMV) and toxoplasmosis. Co-trimoxazole and valaciclovir are used for different reasons.
Co-trimoxazole is used as treatment and prohylaxis (both primary and secondary) for PCP but is also works against toxoplasmosis. Because you had serious PCP, the caution to continue using it for a few months longer is probably a good idea. the risk of relapse is low but it is only one pill a day and this time should go quickly. In someone who has actually had PCP, the caution for discontinuing secondary prophylaxis is more important. If you never had PCP then discontinuing once your CD4 count is over 200 is usually fine (and some studies say lower than this may be fine).
In countries with high risk of malaria or severe bacterial infections, prophylaxis should continue, irrespective of CD4 count on ART. There are also different recommendations for children and in other specific circumstances. (WHO consolidated guidelines, 2021)
Valaciclovir is used to treat shingles and herpes simplex. If the valaciclovir is prescribed because of active herpes, then discontinuing is not really linked to your CD4 count. Continuing to use it will reduce the risk of future attacks. It is common for someone to continue prophylaxis if they have more than two outbreaks a year, and to continue this even if the CD4 count becomes much higher.
Your individual history is likely to be why your doctor advises you not to stop taking those prophylaxes. If your CD4 count continues to increase and stopping these drugs really make a difference to you, then your doctor is likely to agree, with careful monitoring.
This question was updated in June 2023 from a question first posted in November 2011.
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