Immediate or deferred antiretroviral therapy (ART) in patients with PCP or cerebral toxoplasmosis

In a multicenter prospective study, HIV-positive patients with
Pneumocystis pneumonia (PCP) or cerebral toxoplasmosis,
were randomized to immediate ART or deferred ART. Immediate
ART was defined as starting treatment within 7 days of
diagnoses and deferred therapy was defined as starting ART
after completing treatment for the opportunistic infection
(OI). The plan was to include 210 patients but due to slow recruitment,
only 61 patients were included (50/61 had PCP). All
patients received ritonavir-boosted atazanavir in combination
with emtricitabine/tenofovir-disoproxil fumarate. Patients
were followed for 24 weeks. A combined primary endpoint was
used including death, new or recurring OI, and other grade 4
endpoints. In summary there were no differences between the
2 groups for the primary endpoint. There was also no difference
in the incidence of IRIS. The authors conclude that immediate
initiation of ART is recommended.

Ref; Schäfer et al. AIDS res Ther 2019; doi.org/10.1186/s12981-019-0250-2

Comment: It is hardly controversial to recommend immediate
ART in patients with PCP. 50 of 61 included patients had PCP.
When the study was planned, ritonavir-boosted atazanavir was
the preferred regimen which would not be the first choice at
the present time. The study was limited to PCP and cerebral
toxoplasmosis and did not include cases of cryptococcal meningitis
where deferred therapy is generally recommended.