{"id":8027,"date":"2016-03-20T10:46:17","date_gmt":"2016-03-20T14:46:17","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=8027"},"modified":"2016-03-20T15:59:40","modified_gmt":"2016-03-20T19:59:40","slug":"choosing-wisely-in-hiv-medicine-should-we-stop-giving-mac-prophylaxis","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/choosing-wisely-in-hiv-medicine-should-we-stop-giving-mac-prophylaxis\/2016\/03\/20\/","title":{"rendered":"“Choosing Wisely” in HIV Medicine — Should We Stop Giving MAC Prophylaxis?"},"content":{"rendered":"

\"mac<\/a>(Disclosure: \u00a0The following post represents personal opinion, and is in conflict with treatment guidelines.<\/a> Proceed at your own risk.)<\/em><\/p>\n

E-mail recently\u00a0from one of our outstanding first-year fellows:<\/p>\n

Hi Paul,
\nI’ve heard you recommended against the use of MAC [M. avium<\/em> complex]\u00a0prophylaxis in most settings in the modern HAART era. We admitted\u00a0a 21yo F patient, non-compliant with\u00a0meds, with a CD4 of 2. She has poor tolerance of pills in general which has been a major obstacle to her care.\u00a0Would you recommend against the use of MAC ppx in this patient? Even with a CD4 of 2?
\nThanks.<\/p>\n

It’s a great question, notwithstanding\u00a0the use of the term “HAART”. (I think she did that just to bug me<\/a>).<\/p>\n

In general, I’m not recommending MAC prophylaxis anymore, and here’s why:<\/p>\n

    \n
  1. It’s never been proven necessary\u00a0in the modern ART era.<\/strong>\u00a0For the record, this is the most relevant\u00a0placebo-controlled trial<\/strong>,<\/a> and it enrolled patients from 1992-1994—eons ago, ART-wise (only available HIV therapies were NRTIs). There’s certainly no controlled clinical trial since 1996, when effective ART became widely available.\u00a0This observational study<\/a><\/strong>\u00a0from the HIV Outpatient Study\u00a0(too bad it wasn’t the MACs cohort, ha ha) didn’t find any benefit, and this one<\/a>\u00a0<\/strong>from the early ART era was conducted in 1996-1997, a time when virologic suppression rates in clinical cohorts was 20-30%. Please tell me if I’m wrong and there are other\u00a0more relevant\u00a0studies.<\/li>\n
  2. Effective HIV therapy reduces MAC risk much more than azithromycin ever did.<\/strong> Disseminated MAC was, along with CMV retinitis, one of those dreaded “final common pathway” OIs that occurred late in HIV disease, almost exclusively in patients with longstanding severe immunosuppression. The incidence of both of these conditions—especially if you limit diagnoses to non-IRIS cases—has dropped dramatically.<\/li>\n
  3. Some of these advanced disease patients may have undiagnosed\u00a0MAC. <\/strong>It could be\u00a0clinical or subclinical, and you wouldn’t want to give low-dose “monotherapy” to them anyway. They might develop MAC IRIS, but do we have any evidence that MAC prophylaxis prevents MAC IRIS?<\/li>\n
  4. High-dose, weekly azithromycin has side effects.<\/strong>\u00a0These are mostly GI side effects, and I’d argue anything that might make it tougher for someone with a CD4 < 50 to\u00a0take ART is a bad thing.<\/li>\n
  5. Any antibiotic administered chronically selects for resistance, will alter the “microbiome.”<\/strong>\u00a0Although clinical studies of MAC prophylaxis didn’t find much macrolide resistance in M avium<\/em>, resistance to macrolides among other bacteria is widespread. And\u00a0one dose<\/a><\/strong> of an antibiotic can alter the microbiome.<\/li>\n
  6. It costs money.<\/strong> Not a lot, but something. And if it’s not doing any good, or even worse, distracting someone from taking ART, it’s bad value.<\/li>\n<\/ol>\n

    So could there be anyone<\/em> in whom I’d still recommend MAC prophylaxis? I suppose—but without much enthusiasm, and only if all the following criteria were met:<\/p>\n