546   Discontinuation or Continuation of Maintenance Therapy for Cryptococcal Meningitis in Patients with AIDS Treated with HAART.

C. Mussini*, A. Cossarizza, P. Pezzotti, A. Antinori, A. De Luca, P. Ortolani, G. Rizzardini, N. Mongiardo, and R. Esposito.
Modena, Rome, Rimini, and Busto Arsizio, Italy.

Background:HAART has decreased the incidence of new episodes and recurrences of opportunistic infections in patients with AIDS. Different studies showed that it could be considered safe to discontinue primary prophylaxis for PCP and MAC infections. At this time, no data are available concerning discontinuation of maintenance therapy for cryptococcal meningitis.

Methods:An observational study on discontinuation (arm A) or continuation (arm B) of maintenance therapy for cryptococcal meningitis was conducted in 5 Italian centers. The end of follow-up was 11 September 2000.

Results:33 AIDS patients (30 males) who had a first episode of cryptococcal meningitis between October 1993 and December 1999 were evaluated. After a mean time on HAART of 24 months, 16/33 (48.5%) patients voluntarily discontinued maintenance therapy (arm A). The median age was 35.6 years in arm A and 35.0 years in arm B. The median CD4 count at the moment of meningitis was 48 cells/mL in arm A and 29 cells/mL in arm B. The median HIV viral load at that time was 5.57 log₁₀copies/mL in arm A and 4.72 log₁₀copies/mL in arm B. Cryptococcal antigen was detected in the serum and cerebrospinal fluid of all patients. The median duration of maintenance therapy was 24.9 months. Their mean CD4 count at the moment of discontinuation was 113 cells/ mL. Concerning HIV plasma viral load, 10 patients had less than 2.7 log₁₀copies/mL and 6 patients had a value between 3.5 and 5.7 log₁₀copies/mL. Cryptococcal antigen was detected in the sera of 8 patients. At the end of the observation period, the median CD4 count was 320 cells/mL in arm A and 275 cells/mL in arm B. The median plasma viral load was 2.14 log₁₀copies/mL in arm A and <1.7 log₁₀copies/mL in arm B. Cryptococcal antigen detected in the sera of only 2 patients. After a median time of observation of 15.2 months (28.3 patient-years) no new episode of cryptococcal meningitis was even suspected in patients who continued or discontinued maintenance therapy.

Conclusions:This observational study indicates that it could be safe to discontinue secondary prophylaxis for cryptococcal meningitis. The fact that 31% of patients did not show any recurrence despite the low number of CD4 cells and a detectable viral load suggests a possible direct effect of protease inhibitors on C. neoformans , as was described for Candida albicans .