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HAART appears to prevent progress of CMV retinitis
Viral loads also remained low and CD4 counts increased significantly throughout the study.
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BETHESDA, Md. — A combination of anti-HIV drugs appears to help rejuvenate the immune systems of people with AIDS and prevent progression of cytomegalovirus (CMV) retinitis, according to a study in the Journal of the American Medical Association.
Fourteen patients with CMV retinitis enrolled in the study who took highly active anti-retroviral therapy (HAART) were able to stop taking their standard anti-CMV medications without progression of their retinitis. The study suggests that HAART may partially restore the immune system of people with AIDS, enabling them to fight some opportunistic infections.
“CMV retinitis is not progressing in patients who are receiving HAART, suggesting that somehow HAART is playing a role in strengthening the immune system,” said Carl Kupfer, MD, director of the National Eye Institute (NEI), which conducted the study in collaboration with the National Institute of Allergy and Infectious Diseases.
Dr. Kupfer said that HAART will change clinical practice and lead to a significant improvement in the quality of life for people with AIDS who have CMV retinitis. “Some patients will no longer have to take the standard anti-CMV treatments, which require life-long medication with a variety of anti-CMV drugs. These drugs can have serious side effects, including kidney toxicity and low blood cell counts, and may require daily intravenous administration,” he said. “HAART is expensive — it costs an estimated $15,000 annually per patient — but is significantly lower than standard anti-CMV treatment, which can range between $50,000 to $100,000 per patient each year.”
Prior to HAART, CMV retinitis would progress in many patients despite treatment, according to NEI Clinical Director Scott Whitcup, MD, study chairman and lead author of the study. “We found that none of the patients in the study had progression of their retinitis, despite being off of standard anti-CMV therapy for an average of 16 months, and in some cases for almost 2 years. This significant result adds to the body of evidence that some patients who have both CMV retinitis and immune recovery from using highly active anti-retroviral therapy may be able to stop their standard anti-CMV medications.”
Another indication of HAART’s success was that throughout the trial, viral loads remained low and CD4 counts in creased significantly.
Immune recovery is double-edged sword
---CMV retinitis is a common complication, occurring mostly in the later stages of AIDS and, prior to HAART’s availability, had been increasing in frequency as people with AIDS began to live longer. (Courtesy of the National Eye Institute, National Institutes of Health.)
Despite these positive findings, Dr. Whitcup noted that “to some degree, immune recovery is a double-edged sword. Although we are seeing better control of the CMV retinitis in patients on HAART, we’re also seeing more inflammation, or ‘immune recovery uveitis,’ in these eyes. In patients who took HAART, immune recovery uveitis is seen both in patients who remain on standard anti-CMV therapy and in patients who discontinue anti-CMV therapy. The cause of the inflammation is not clear and requires further study.”
CMV retinitis is a common complication, occurring mostly in the later stages of AIDS and, prior to HAART’s availability, had been increasing in frequency as people with AIDS began to live longer. CMV retinitis can cause blindness if left untreated, and previous NEI-supported studies had led to effective treatments for CMV retinitis.
The only people eligible for this trial were those with stable CMV retinitis who had an increase in levels of CD4+ T cell counts to .150 cells/mL and had been receiving HAART for at least 4 months. The study was not placebo-controlled; anti-CMV medications were stopped in all 14 patients.
Caution is advised
Although no patient in the study had progression of eye disease, Dr. Whitcup cautioned that there may be some patients whose rejuvenated immune systems may be unable to control CMV retinitis, even with HAART. Patients with CMV retinitis should undergo dilated eye exams. “The study results suggest that if their CMV is inactive and their CD4 counts have responded well to HAART, stopping their anti-CMV medications could be considered,” he said.
Editor’s note:
This article originally appeared in Infectious Disease News, a SLACK, Incorporated publication.
For Your Information:Reference:
- Carl Kupfer, MD, is director of the National Eye Institute. He can be reached at 31 Center Drive, MSC 2510, Bldg. 31, Room 6A03, Bethesda, MD 20892; (301) 496-2234; fax: (301) 496-9970. Dr. Kupfer did not participate in the preparation of this article.
- Scott Whitcup, MD, is clinical director at the National Eye Institute and study chairman and lead author of the study. He can be reached at National Eye Institute, 10/10S221, 10 Center Drive, MSC 1863, Bethesda, MD 20892-1863; (301) 496-9058; fax: (301) 496-7295. Dr. Whitcup did not participate in the preparation of this article.
- Whitcup SM, Fortin E, Lindblad AS, et al. Discontinuation of anticytomegalovirus therapy in patients with HIV infection and cytomegalovirus retinitis. JAMA. 1999;282:1633-1637.