A 30-year-old man started ART when his CD4 count was 140 cells/μL, receiving cotrimoxazole as Pneumocystis pneumonia prophylaxis. After 14 months his viral load is undetectable and his CD4 count has been sustained between 320 and 380 cells/μL for the last 5 months. What should be done regarding prophylaxis?
- A Stop cotrimoxazole now, since CD4 remains above 200 cells/μL for more than 3 months ✓
- B Continue lifelong cotrimoxazole regardless of counts
- C Switch to weekly dapsone-pyrimethamine permanently
- D Stop cotrimoxazole only once CD4 exceeds 500 cells/μL
Correct answer: A. Stop cotrimoxazole now, since CD4 remains above 200 cells/μL for more than 3 months
Explanation
Primary and secondary Pneumocystis prophylaxis can be safely discontinued when CD4 count rises above 200 cells/μL and stays there for at least 3 months on a suppressive ART regimen, because the risk of Pneumocystis pneumonia falls below the threshold justifying chemoprophylaxis. Lifelong continuation is unnecessary and adds toxicity such as hyperkalaemia and haemolysis in G6PD deficiency, which removes option B. The 500 cells/μL threshold belongs to no standard guideline for stopping this prophylaxis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.