Clinical Manifestations of AIDS in the Era of Pneumocystis Prophylaxis

Among patients infected with human immunodeficiency virus type 1 (HIV-1), early and widespread use of prophylactic regimens against Pneumocystis carinii is changing the pattern of illnesses related to the acquired immunodeficiency syndrome (AIDS). We conducted a subcohort analysis of 844 men with AIDS (87 percent of whom have since died) from a prospectively followed cohort of 2592 HIV-1-infected homosexual men. A total of 138 men received prophylaxis before the diagnosis of AIDS, but 39 (28 percent) nevertheless had P. carinii pneumonia at some time. Only four illnesses occurred more frequently in men who received P. carinii prophylaxis before the onset of AIDS: Mycobacterium avium complex disease, which developed in 33.4 percent, as compared with 17.3 percent of the 706 men who did not receive early prophylaxis; wasting syndrome (18.4 percent vs. 6.4 percent); cytomegalovirus disease (44.9 percent vs. 24.8 percent); and esophageal candidiasis (21.3 percent vs. 12.8 percent). Collectively, these four diseases accounted for the initial AIDS-related illness in 42.7 percent of those who received prophylaxis before the onset of AIDS, as compared with 10.7 percent of those who did not. During the three 6-month periods before the diagnosis of AIDS (0 to 6, >6 to 12, and >12 to 18 months), the geometric mean CD4+ cell counts were 48, 87, and 147 per cubic millimeter, respectively, in men who received prophylaxis against P. carinii, as compared with 118, 211, and 279 per cubic millimeter in those who did not. M. avium complex disease, esophageal candidiasis, wasting syndrome, and cytomegalovirus disease are more common in HIV-infected patients who have received prophylaxis against P. carinii than in those who have not. Prophylaxis may delay the first AIDS illness for 6 to 12 months., Early in the epidemic of the acquired immunodeficiency syndrome (AIDS), Pneumocystis carinii pneumonia occurred in 75 percent of patients with the syndrome¹,². The incidence of P. carinii pneumonia declined after 1988,³–⁶ however, as the use of primary and secondary prophylaxis against it⁴–⁹ (aerosolized pentamidine, trimethoprim-sulfamethoxazole, and dapsone) became common. Unlike antiretroviral therapies,¹⁰ these prophylactic regimens are not known to alter replication of human immunodeficiency virus type 1 (HIV-1) or human immune function, nor do they protect against other AIDS-related illnesses, except toxoplasmosis⁷,⁸,¹¹. Thus, prophylaxis against P. carinii pneumonia does not directly alter the…