A 38-year-old man with HIV (CD4 680, VL 350 for 4 years. Can prophylaxis be stopped?

Co-trimoxazole can only be stopped if the patient has never had PJP

Stop only when CD4 >500 for >5 years

Stop after exactly 12 months of ART

Prophylaxis must continue for life regardless of CD4

Stopping Co-trimoxazole Prophylaxis — SCE Infectious Diseases MCQ

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EasyHIV MedicineStopping Co-trimoxazole ProphylaxisSCE Infectious Diseases

A 38-year-old man with HIV (CD4 680, VL <50 on ART for 7 years) asks about stopping Co-trimoxazole prophylaxis. He has been on PJP prophylaxis since diagnosis (original CD4 was 150). His CD4 has been consistently >350 for 4 years. Can prophylaxis be stopped?

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Correct answer: A — Yes — Co-trimoxazole prophylaxis can be stopped when CD4 >200 cells/µL on ART for ≥3 months with sustained viral suppression

BHIVA guidelines recommend discontinuing PJP prophylaxis when CD4 has risen to >200 cells/µL for ≥3 months on effective ART (VL <50). At CD4 >200, the risk of PJP is extremely low. Prophylaxis should be restarted if CD4 drops below 200. For patients with a HISTORY of PJP (not this patient), some experts recommend a higher threshold (>200 for ≥6 months) or lifelong prophylaxis, though evidence supports safe discontinuation at CD4 >200. This patient's CD4 of 680 for 4 years clearly meets criteria for stopping.

Reference: BHIVA 2022 – OI guidelines; WHO 2021 – Co-trimoxazole prophylaxis