Burden of HIV-related CMV retinitis

in resource-limited settings: a

systematic reviewsystematic review

Dr Nicolas Durier, TREAT Asia, amfAR

11th International Congress on AIDS in Asia and the Pacific

Bangkok, Thailand, November 18-22, 2013

• Cytomegalovirus (CMV) infection is very common, but

usually causes no disease in immuno-competent

persons.

• CMV reactivation can occur in people with severe

immuno-suppression. immuno-suppression.

• CMV retinitis (CMVr) is the most common

manifestation.

• Before combination antiretroviral therapy (ART), a

third of AIDS patients in the West developed CMVr.

• Untreated, CMVr leads to vision loss and blindness,

and is associated with increased mortality.

• CMVr can be treated:

• Injectable antiviral drugs (e.g. Ganciclovir, Foscarnet)

• Oral Valganciclovir

• Intra-ocular Ganciclovir

• Cost of treatment has been very high (~$8,000 per • Cost of treatment has been very high (~$8,000 per

course), and treatment has been unavailable in

resource-limited settings (RLS).

• Screening is rare. • The assumption has been that availability of ART would

overcome the problem.

• CMVr has been a neglected disease of the AIDS

pandemic.

• Conduct a systematic review of published studies

to determine the burden of CMV retinitis in RLS, as

part of work to improve access to treatment.

Clinical Infectious Diseases 2013 Nov; 57(9): 1351-61. fordn@who.int

Research Centre for Health Economics and Evaluation (ReCHEE)

Searched for publications, and presentations:

• 3 databases: PubMed, Embase, Lilacs

•3 conferences: IAS, CROI, meeting of AAO

Looked for:

•Studies published/presented 01/1996 – 04/2013:

•On CMV retinitis diagnosed by fundoscopic exam

within a cohort of ≥10 HIV-positive adult patients.

� 65 studies

� 24 countries

� N=20,280 patients

� Asia: 39 studies, N=12,931

2099 titles screened

2016 exclusions

� Asia: 39 studies, N=12,931

� Africa: 18 studies, N=4,325

� Latin America: 5 studies,

N=2,836

� Patients screening:

� 1993-2002: 18%

� 2003-2005: 32%

� 2006-2008: 24%

� 2009-2013: 26%

83 articles

screened

65 inclusions

15 additional

articles

12

unpublished

cohorts45 exclusions

Research Centre for Health Economics and Evaluation (ReCHEE)

• CD4 count at diagnosis of CMV retinitis (8 studies):o <50 cells in 73.4% of cases

o 50-100 in 15.6% of cases

o 100-200 in 8.3% of caseso 100-200 in 8.3% of cases

o >200 in 2.7% of cases

• Mortality (5 studies):o 22% of patients

• The prevalence of CMV retinitis in severely

immuno-compromised HIV patients in resource-

limited settings, notably in Asia, has been high,

and remains high.and remains high.

• Screening is rarely done in routine care.

• Specific treatment is usually unavailable.

• Even though the baseline CD4 count of patients

starting ART has increased over time*, the needs

to address CMVr remain very substantial.

* World Health Organization. Global update on HIV treatment 2013

Research Centre for Health Economics and Evaluation (ReCHEE)

• http://www.medicinespatentpool.org

• Mr Sandeep Juneja, Business Development

Director: sjuneja@medicinespatentpool.orgDirector: sjuneja@medicinespatentpool.org

• Mr Esteban Burrone, Head of Policy:

eburrone@medicinespatentpool.org

Nathan Ford, WHO

Zara Shubber, Imperial College, UK

Peter Saranchuk, MSF, South Africa

Sophia Pathai, LSHTM, UK

Daniel O’Brien, University of Melbourne, AustraliaDaniel O’Brien, University of Melbourne, Australia

Edward J Mills, University of Ottawa, Canada

Fernando Pascual, Medicines Patent Pool, Spain

Ellen t’ Hoen, Independent Consultant, France

Gary N. Holland, UCLA, USA

David Heiden, Seva Foundation, USA

Meg Doherty, WHO, Switzerland

Marco Vitoria, WHO, Switzerland

Research Centre for Health Economics and Evaluation (ReCHEE)