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AA Obi, BG Gazzard, SM Mitchell; Discontinuation of Anti-CMV Maintenance Therapy and the Clinical Outcome of Cytomegalovirus Retinitis in AIDS Patients on HAART . Invest. Ophthalmol. Vis. Sci. 2002;43(13):1856.
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Purpose: To determine the long-term ocular effects of cytomegalovirus retinitis (CMVR) and if anti-cytomegalovirus maintenance therapy can be safely discontinued in patients responding to highly active antiretroviral therapy (HAART). Methods: Three-year prospective cohort study carried out at a tertiary HIV referral centre. Patients with AIDS were eligible for the study if they were receiving HAART, had quiescent CMVR and CD4+ counts of greater than 50 cells/µl for at least 3 months. Anti-CMV maintenance therapy was discontinued at enrolment and all patients were monitored for reactivation or progression of CMVR, extraocular CMV infection, ocular complications of CMVR, CD4+ and CD8+ T-cell counts, HIV-1 and CMV viral load. Results: Forty-four patients were recruited with a median follow-up of 122 weeks (range 14 -154 weeks). Median CD4+ and CD8+ counts and HIV viral load at entry were 295 cells/µl (range 63-853), 988 cells/µl (range 284-3611) and <50 copies/ml (range <50 -240,000) respectively. Median CD4+ and CD8+ counts increased during the study, while the median HIV viral load remained below the level of detection (<50 copies/ml). Two patients developed AIDS events during the study. CMV viral load was positive in only one patient following a marked drop in CD4 count shortly before death. No patient had progression of CMVR or developed extraocular CMV infection during the study. Thirty-two patients (73%) developed ocular complications secondary to CMVR. The major risk factors identified for the development of ocular complications were prior CMVR affecting more than 50% of the retina, zone 1 retinal involvement, the development of immune recovery uveitis (IRU) and prior retinal detachment surgery with insertion of silicone oil. The development of complications was significantly associated with poor vision of 6/18 or worse and increased visual morbidity. Conclusion: This study supports previous reports suggesting that maintenance therapy can be safely discontinued in selected patients responding to HAART, increasing their quality of life without having adverse effects on CD4+ or CD8+ counts, CMV or HIV viral load. This study also highlights the high incidence of vision-threatening complications occurring in AIDS patients receiving HAART, despite immune restoration and quiescence of CMVR and the importance of continued ophthalmic intervention.
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