Treating HIV-associated cytomegalovirus retinitis with oral valganciclovir and intra-ocular ganciclovir by primary HIV c
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RESEARCH ARTICLE
Open Access
Treating HIV-associated cytomegalovirus retinitis with oral valganciclovir and intraocular ganciclovir by primary HIV clinicians in southern Myanmar: a retrospective analysis of routinely collected data Jillian Murray1†, Adelene Hilbig1*† , Theint Thida Soe1, Win Le Shwe Sin Ei1, Kyi Pyar Soe1 and Iza Ciglenecki2
Abstract Background: Cytomegalovirus retinitis (CMVR) is an opportunistic infection in HIV-infected people. Intraocular or intravenous ganciclovir was gold standard for treatment; however, oral valganciclovir replaced this in high-income countries. Low- and middle-income countries (LMIC) frequently use intraocular injection of ganciclovir (IOG) alone because of cost. Methods: Retrospective review of all HIV-positive patients with CMVR from February 2013 to April 2017 at a Médecins Sans Frontièrs HIV clinic in Myanmar. Treatment was classified as local (IOG) or systemic (valganciclovir, or valganciclovir and IOG). The primary outcome was change in visual acuity (VA) post-treatment. Mortality was a secondary outcome. Results: Fifty-three patients were included. Baseline VA was available for 103 (97%) patient eyes. Active CMVR was present in 72 (68%) eyes. Post-treatment, seven (13%) patients had improvement in VA, 30 (57%) had no change, and three (6%) deteriorated. Among patients receiving systemic therapy, four (12.5%) died, compared with five (24%) receiving local therapy (p = 0.19). Conclusions: Our results from the first introduction of valganciclovir for CMVR in LMIC show encouraging effectiveness and safety in patients with advanced HIV. We urge HIV programmes to include valganciclovir as an essential medicine, and to include CMVR screening and treatment in the package of advanced HIV care. Keywords: Cytomegalovirus, Retinitis, HIV/AIDS, South-East Asia, Comorbidity, Valganciclovir
Background Cytomegalovirus (CMV) is a late-stage opportunistic infection (OI) in people living with HIV/AIDS, causing retinitis and extra-ocular end-organ disease, and is associated with increased mortality in HIV cohorts [1–3]. Retinitis is the most frequent manifestation of CMV; initial retinal * Correspondence: [email protected] † Jillian Murray and Adelene Hilbig contributed equally to the authorship of the paper and are co-first authors. 1 Médecins Sans Frontières, Yangon, Myanmar Full list of author information is available at the end of the article
scarring can directly affect the optic disc or fovea contributing to vision impairment, and progressive necrosis results in retinal detachment and blindness [1, 4, 5]. CMV retinitis (CMVR) was a common cause of blindness among patients with HIV/AIDS in the preantiretroviral therapy (ART) era [6]. CMVR is now uncommon in high-income countries (HIC) following universal introduction of ART. Although access to ART has also improved in resource-limited settings, the proportion of people presenting to care with advanced HIV disease (CD4 count < 200 cells/μL) remains high, and
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