Discontinuation of Mycobacterium avium complex prophylaxis in patients with antiretroviral therapy - Induced increases in CD4⁺ cell count: A randomized, double-blind, placebo-controlled trial

Background: Patients infected with HIV who experience increases in CD4⁺ cell counts are at reduced risk for opportunistic infections. However, the safety of discontinuing prophylaxis against Mycobacterium avium complex has been uncertain. Objective: To compare the rate of M. avium complex infection in patients with increased CD4⁺ cell counts who receive azithromycin and those receiving placebo. Design: Randomized, double-blind, placebo-controlled trial. Setting: 29 university-based clinical centers in the United States. Participants: 643 HIV-1-infected patients with a previous CD4⁺ cell count less than 0.05 x 10⁹ cells/L and a sustained increase to greater than 0.10 x 10⁹ cells/L during antiretroviral therapy. Intervention: Azithromycin, 1200 mg once weekly (n = 321), or matching placebo (n = 322). Measurements: Mycobacterium avium complex cultures, CD4⁺ cell counts, and clinical evaluations for AIDS-defining illnesses and bacterial infections were done every 8 weeks. Plasma HIV-1 RNA levels were measured at 16-week intervals. Results: During follow-up (median, 16 months), 2 cases of M. avium complex infection were reported among the 321 patients assigned to placebo (incidence rate, 0.5 event per 100 personyears [95% Cl, 0.06 to 1.83 events per 100 person-years]) compared with no cases among the 322 patients assigned to azithromycin (Cl, 0 to 0.92 events per 100 person-years), resulting in a treatment difference of 0.5 event per 100 person-years (Cl, -0.20 to 1.21 events per 100 person-years) for placebo versus azithromycin. Both cases were atypical in that M. avium complex was localized to the vertebral spine. Patients receiving azithromycin were more likely than those receiving placebo to discontinue treatment with the study drug permanently because of adverse events (8% vs. 2%; hazard ratio, 0.24 [Cl, 0.10 to 0.57]). Conclusions: Prophylaxis against Mycobacterium avium complex can safely be withdrawn or withheld in adults with HIV infection who experience increases in CD4⁺ cell count while receiving antiretroviral therapy.