Evaluation of the United States public health service guidelines for discontinuation of anticytomegalovirus therapy after immune recovery in patients with cytomegalovirus retinitis

Abstract

Purpose: To evaluate United States Public Health Service (USPHS) guidelines for discontinuing anticytomegalovirus (CMV) therapy in patients with AIDS who have immune recovery and quiescent retinitis after initiating highly active antiretroviral therapy.

Design: Cohort study of patients with CMV retinitis (Longitudinal Study of Ocular Complications of AIDS).

Methods: Participants had CMV retinitis and CD4+ T-cell counts of 50 cells/μL or fewer enrolled from 1998 through 2009 who demonstrated sustained immune recovery (2 consecutive CD4+ T-cell counts of 100 cells/μL or more at least 6 months apart) and inactive retinitis. Participants were classified into 2 groups according to anti-CMV treatment after immune recover: (1) continued anti-CMV therapy and (2) discontinued therapy. We evaluated survival, visual acuity, and CMV retinitis activity; we used propensity scores to adjust for confounding factors for these analyses.

Results: Of 152 participants reviewed, 71 demonstrated immune recovery, 37 of whom discontinued therapy and 34 of whom continued therapy. At immune recovery, participants continuing therapy tended to be older (44 vs 40 years; P = .09), have bilateral retinitis (53% vs 32%; P = .10), and have lower CD4+ T-cell counts (148 vs 207 cells/μL; P < .001). There were no statistical differences in any of the clinical outcomes (death, retinitis progress, visual acuity, or incidence of bilateral retinitis). Both groups lost visual acuity during follow-up, on average 1.2 letters per year (P < .01).

Conclusions: Discontinuation of anti-CMV therapy after immune recovery did not increase the risk of poor outcomes. These results support the current guidelines for discontinuation of anti-CMV therapy after achievement of sustained immune recovery.

Figure 1

Kaplan-Meir Curve of time to death in years after immune recovery by CMV treatment status. Cont CMV Rx = continued CMV treatment is represented by the solid line; D/C CMV Rx = discontinued CMV treatment is represented by the dashed line.

Figure 2

Boxplots of visual acuity (standard letters) in eyes with CMV retinitis at 6 month intervals starting at immune recovery. Circle and triangle represent outliers for the discontinued and continued treatment groups, respectively. Cont CMV Rx = continued CMV treatment is represented by the open boxes; D/C CMV Rx = discontinued CMV treatment is represented by the shaded boxes.