DISCONTINUATION OF MAINTENANCE THERAPY IN PATIENTS WITH QUIESCENT CYTOMEGALOVIRUS RETINITIS AND ELEVATED CD4+ COUNTS

Objective: To determine whether maintenance therapy can be discontinue d safely in patients with quiescent cytomegalovirus retinitis (CMVR) a nd increased CD4+ counts after treatment with highly active antiretrov iral therapy (HAART). Design: A prospective observational case series. Participants: Eight human immunodeficiency virus (HIV)-positive patie nts with quiescent CMVR who were taking HAART and had CD4+ counts abov e 100 cells/mu l elected to discontinue anti-CMV maintenance treatment . Intervention: Biweekly-to-monthly indirect ophthalmoscopy and fundus photographs, monthly-to-quarterly CD4+ counts, and quarterly HIV vira l loads were ordered, Main Outcome Measures: Twelve previously affecte d eyes were examined for evidence of recurrent retinitis, which was de fined as any retinal whitening, border opacification, or expansion of areas of retinal pigment epithelial (RPE) atrophy greater than 750 mu m. Four previously unaffected fellow eyes were observed for new CMVR. Results: There was no reactivation or progression of retinitis in any patient during the mean follow-up interval of 11.4 months (range, 3-16 months). No previously unaffected eye developed CMVR, CD4+ remained e levated in all patients (range, 70-725; mean, 255). The HIV viral load ranged from undetectable to 139,000 copies. Conclusion: Discontinuati on of maintenance therapy may be considered in patients with HAART-ind uced elevated CD4+ counts above 100 cells/mu l, prolonged relapse-free intervals during the reconstitution period before CD4+ counts rise ab ove 100 cells/mu l, and completely quiescent retinitis characterized b y RPE scarring only. Reduced risks of drug toxicity and drug-resistant organisms are potential benefits. Close observation for evidence of r ecurrent retinitis is indicated.