The Impact of Absolute CD4 Count and Percentage Discordance on Pneumocystis Jirovecii Pneumonia Prophylaxis in HIV-Infected Patients

Current guidelines suggest that HIV-infected patients should receive chemoprophylaxis against Pneumocystis jirovecii pneumonia (PJP) if they have a cluster determinant 4 (CD4) count <200 cells/mm(3) or oropharyngeal candidiasis. Persons with CD4 percentage (CD4%) below 14% should also be considered for prophylaxis. Discordance between CD4 count and CD4% occurs in 16% to 25% of HIV-infected patients. Provider compliance with current PJP prophylaxis guidelines when such discordance is present was assessed. Electronic medical records of 429 HIV-infected individuals who had CD4 count and CD4% measured at our clinic were reviewed. CD4 count and percentage discordance was seen in 57 (13%) of 429. Patients with CD4 count >200 but CD4% <14 were significantly less likely to be prescribed PJP prophylaxis compared with those who had CD4 count <200 and CD4% >14 (29% versus 86%; odds ratio = 0.064, 95% confidence interval: 0.0168-0.2436; P < .0001). We emphasize monitoring both the absolute CD4 count and percentage to appropriately guide PJP primary and secondary prophylaxis.