Discontinuing anticytomegalovirus therapy in patients with cytomegalovirus retinitis and AIDS
- Departments of Ophthalmology and Medicine, Johns Hopkins University School of Medicine, and the Department of Epidemiology, Johns Hopkins University School of Hygiene and Public Health
- The Wilmer Eye Institute, The Johns Hopkins Hospital, 550 North Broadway, Suite 700, Baltimore, MD 21205, USA djabs{at}jhmi.edu
Cytomegalovirus (CMV) retinitis is the most common opportunistic ocular infection in patients with the acquired immune deficiency syndrome (AIDS).1 Before the advent of highly active antiretroviral therapy (HAART), CMV retinitis affected 30% of patients with AIDS at some time during the course of their disease.2 Cytomegalovirus retinitis is a late stage complication associated with low CD4+ T cell counts, typically less than 50 cells × 106/l.34 Cytomegalovirus retinitis was rare at CD4+ T cells >100 cells × 106/l.34 All of the available anti-CMV therapies suppress viral replication, but do not eliminate the virus. Unless immune reconstitution occurs, prolonged suppressive anti-CMV therapy (maintenance therapy) is required.15 Without immune reconstitution or maintenance therapy, CMV retinitis relapses within 3 weeks. As such, in the pre-HAART era, patients with CMV retinitis required lifetime maintenance anti-CMV therapy.
HAART consists of combination therapy for the human immunodeficiency virus (HIV), with at least three drugs, typically two nucleoside reverse transcriptase inhibitors and either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor. HAART can result in marked suppression of HIV replication, improvement in immune function, increases in CD4+ T cells, decreases in opportunistic infections, and improved survival.6 With HAART, there has been a 55%–95% reduction in the number of new cases of the CMV retinitis, and the decrease varies depending upon the population being served.6-8 However, CMV retinitis continues to occur, albeit at a reduced incidence, and there …
