Abstract
Introduction
Cytomegalovirus retinitis (CMVR) is an AIDS-defining opportunistic infection linked with late-stage HIV infection, and generally is associated with high mortality. CMVR burden in Africa is largely unknown, due to lack of screening and diagnostic capacity and limited access to treatment. In Maputo, Mozambique, Médecins Sans Frontières (MSF) has been working in collaboration with the Ministry of Health to support patients with advanced HIV disease (AHD), via clinics at the Centro de Referencia de Alto Mae (CRAM), and in the emergency department of Jose Macamo Hospital (JM). Here we describe the outcomes of integrating CMVR screening and treatment within AHD packages of care.
Methods
In CRAM and JM clinics, CMVR screening was introduced in February 2019, for adult HIV-positive patients with CD4 counts below 100 cells/µl. Trained non-ophthalmologist physicians carried out retinal examination on the fully dilated pupil using indirect ophthalmoscopy. Patients with active CMVR were treated with oral valganciclovir. Ophthalmoscopy was repeated every three weeks for active CMVR, and every six months for inactive CMVR. We analysed routinely collected data from the programme for February to November 2019.
Ethics
This study fulfilled the exemption criteria set by the MSF Ethics Review Board (ERB) for a posteriori analyses of routinely collected clinical data and thus did not require MSF ERB review. It was conducted with permission from Monica Rull, Medical Director, Operational Centre Geneva, MSF.
Results
Among 160 eligible patients with CD4 counts below 100 cells/µl in CRAM, and 721 in JM, 120 (75%) and 245 (34%) were screened, respectively. Absence of staff during nights and weekends was a major reason for the low screening rate. In CRAM, eight of 120 screened patients were diagnosed with CMVR (6.6%; six with active, and two, inactive CMVR). In JM, 13/245 screened patients were diagnosed (5.3%; 11 with active, and two, inactive CMVR). The combined CMVR prevalence was 5.7% (21/365). Mortality was high among hospitalised patients with CMVR in JM; seven of 13 (54%) patients died prior to treatment initiation, and two were lost to follow-up. Eight patients with active CMVR were treated with oral valganciclovir. At the end of the follow-up period for patients initiated on treatment, six patients were alive and in care (75%), and two (25%) had died. Overall, nine CMVR patients, of which all also had a presentation which included other opportunistic infections, died during follow-up (43%).
Conclusion
This is the first report of which we’re aware documenting AIDS-related CMV retinitis in Mozambique. CMVR prevalence was 5.7% among screened patients with AHD. Mortality was high. Although CMVR diagnosis with indirect ophthalmoscopy was feasible, we faced limitations in screening all at-risk patients, especially in JM. A key limitation is that ophthalmic screening does not permit diagnosis of other forms of CMV-related end-organ disease, or viraemia. There is an urgent need for early and rapid diagnosis of CMV infection, for example using assays for detecting CMV viraemia, as well as ensuring better and more affordable access to treatment with valganciclovir.
Conflicts of Interest
None declared.
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