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Cryptococcal Prophylaxis Stopping Criteria — SCE Infectious Diseases MCQ

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ModerateHIV MedicineCryptococcal Prophylaxis Stopping CriteriaSCE Infectious Diseases

A 50-year-old man on long-term Fluconazole suppression for recurrent cryptococcal meningitis (secondary prophylaxis) asks when it can be stopped. His CD4 has been >200 for 9 months on ART. VL is <50. Initial cryptococcal treatment was completed 14 months ago. Can prophylaxis be stopped?

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Correct answer: E — Not yet — secondary cryptococcal prophylaxis requires CD4 >200 for ≥12 months on ART, completed ≥12 months of antifungal therapy, AND undetectable VL; at 9 months above 200, he has not met the duration criterion

Cryptococcal secondary prophylaxis (Fluconazole 200 mg daily) discontinuation requires ALL criteria: (1) CD4 >200 cells/µL sustained for ≥12 months (not 9 as in this case), (2) suppressive ART with VL <50, (3) completed at least 12 months of total antifungal treatment (induction + consolidation + maintenance), (4) no symptoms of active cryptococcal disease. If CD4 drops below 200 after stopping, prophylaxis must be restarted. This patient needs 3 more months above CD4 200 before stopping.

Reference: BHIVA 2022 – OI guidelines; WHO 2022 – Cryptococcal; NICE 2024