Management of CMV Infections In HIV-Infected Patients

Abstract

CMV disease is an important complication of advanced HIV infection. CMV disease was the initial AIDS defining illness (ADI) in 8% of patients, and occurred during the lifetime of 29% of a large Australian AIDS cohort. In the 10 years from 1985 to 1994, the cumulative risk for CMV disease in the 2 years following an AIDS diagnosis rose to 40%.¹ After the introduction of highly active antiretroviral therapy (HAART), marked reductions in the incidence of CMV disease were noted by several investigators.^2–4 CMV retinitis accounts for 90% of cases of CMV disease, and occurs late in the course of HIV disease, as determined by the mean CD4 cell count at the time of diagnosis of 50 cells/ μ1 in 1989, and 10 cells/μl in 1995. The median time to development of CMV retinitis after the CD4 cell count falls below 50 cells/μl was 13 months in one study.⁵ A report of 5 patients diagnosed with CMV retinitis with CD4 cell counts greater than 195 cells/μl, revealed that 4 patients had CD4 cell counts below 50 cells/μl, and the fifth had a count below 85 cells/ μ1 5–24 weeks earlier when they initiated HAART. This suggests that individuals with advanced HIV immunodeficiency remain susceptible to CMV retinitis for at least 6 months after initiation of successful HAART.⁶ Improved outcomes for individuals with CMV retinitis have been noted with apparently longer times to relapse of CMV disease in those who are treated with HAART as well as specific anti-CMV therapy⁷. Selected patients with stable CMV retinitis successfully treated with HAART have not had reactivation of the CMV retinitis on discontinuation of the maintenance CMV treatment.^8–9