Cytomegalovirus Disease

Prevention of Exposure
HIV-infected persons who belong to risk groups with relatively low rates of seropositivity for cytomegalovirus (CMV) and who anticipate possible exposure to CMV (e.g., through blood transfusion or employment in a child-care facility) should be tested for antibody to CMV. These groups include patients who have not had male homosexual contact and those who are not injecting-drug users.

HIV-infected adolescents and adults should be advised that CMV is shed in se-men, cervical secretions, and saliva and that latex condoms must always be used during sexual contact to reduce the risk of exposure to CMV and to other sexually transmitted pathogens.

HIV-infected adults and adolescents who are child-care providers or parents of children in child-care facilities should be informed that they—like all children at these facilities—are at increased risk of acquiring CMV infection. Parents and other care-takers of HIV-infected children should be advised of the increased risk to children at these centers. The risk of acquiring CMV infection can be diminished by good hygienic practices such as hand washing.

HIV-exposed infants and HIV-infected children, adolescents, and adults who are seronegative for CMV and require blood transfusion should be administered only CMV antibody-negative or leukocyte-reduced cellular blood products in non-emergency situations.

Prevention of Disease
Prophylaxis with oral ganciclovir may be considered for HIV-infected adults and adolescents who are CMV seropositive and who have a CD4+ T-lymphocyte count of <50 cells/µL. Neutropenia, anemia, limited efficacy, lack of improvement in survival, and cost are among the issues that should be considered in decisions about whether to institute prophylaxis in individual patients. Acyclovir is not effective in preventing CMV disease, and valaciclovir is not recommended because of an unexplained trend toward increased mortality observed in persons who have AIDS and who were administered this drug for CMV prophylaxis. Therefore, neither acyclovir nor valaciclovir should be used for this purpose. The most important method for preventing severe CMV disease is recognition of the early manifestations of the disease. Early recognition of CMV retinitis is most likely when the patient has been educated on this topic. Patients should be made aware of the significance of increased "floaters" in the eye and should be advised to assess their visual acuity regularly by simple techniques such as reading newsprint. Regular funduscopic examinations performed by a health-care provider or specifically by an ophthalmologist are recommended by some experts for patients with low (e.g., <100 cells/µL) CD4+ T-lymphocyte counts.

Prevention of Recurrence
CMV disease is not cured with courses of the currently available antiviral agents (i.e., ganciclovir, foscarnet, or cidofovir). Chronic suppressive or maintenance therapy is indicated. Effective regimens include parenteral or oral ganciclovir, parenteral foscarnet, combined parenteral ganciclovir and foscarnet, parenteral cidofovir, and (for retinitis only) ganciclovir administration via intraocular implant. The intraocular implant does not provide protection to the contralateral eye or to other organ systems. In spite of maintenance therapy, recurrences develop routinely and require reinstitution of high-dose induction therapy or replacement of the implant.

M.S