Is Anti-CMV Treatment Necessary to Reduce CMV Viral Replication in Patients With HIV?

At present, close to 30% of individuals with HIV also have cytomegalovirus (CMV). Harmless in most people, CMV can cause extensive damage in immunocompromised individuals, specifically their lungs and liver. But due to treatment advances, those with HIV do not have to endure end-organ disease (EOD) from CMV. Is there an optimal treatment to reduce the CMV viral load in these patients?

Following interim results first presented at the 2017 Conference on Retroviruses and Opportunistic Infections, a team of investigators from Vall d’Hebron in Spain delivered their final results on such an investigation at this year’s virtual conference on viral load response to antiretroviral therapy (ART) compared with anti-CMV treatment.

“We hypothesize that immune reconstitution after initiation of [ART], rather than anti-CMV specific treatment, is the best strategy to clear CMV viremia in patients without EOD,” the authors noted.

Their prospective, observational 48-week study took place from September 2015 through July 2018 among 53 patients with both HIV and a CD4 TL count below 100; their median (interquartile range [IQR]) age was 43.5 (35.7-52.4) years. Thirteen patients did not complete the study, 6 (11.3%) of whom died. Treatment for all patients consisted of ART, while anti-CMV treatment was also administered to just those with CMV EOD.

Using quantitative polymerase chain reaction, measurements were taken at baseline and then at weeks 4, 12, 24, and 48, looking at the HIV and CMV viral loads, as well as CD4 TL count. Final, specific immune response (IFN-γ) was also defined at week 48.

The baseline median (IQR) CD4 TL and HIV viral loads were 30 (20-60) cells/mcL and 510,000 (186,000-1,300,000) copies/mL. By week 12, the CD4 TL count had risen to 150 (88-208) cells/mcL, and at week 48 it was 195 (130-310) cells/mcL. Conversely, the HIV viral loads dropped to 174 (24-497) copies/mL and 24 (24-99) copies/mL, respectively.

At baseline, CMV was detected in 18 (33.9%) patients compared with just 4 (10.0%) at week 12 and none at week 48. Thirty-eight (73.2%) patients had an IFN-γ response at baseline versus 28 (70.0%) at week 48. In addition, among the 40 patients who remained in the study through week 48, the IFN-γ response rose from a median (IQR) of 1.64 (0.16-5.52) at baseline to 2.53 (0.10-7.99) (P = .048).

“Even though patients had advanced HIV infection we found a high prevalence of specific CMV immune response at baseline that quantitatively increased at the end of the study,” the authors concluded. “CMV viremia gets suppressed after starting ART without specific anti-CMV treatment.”

Reference

Suanzes P, Albasanz A, Esperalba J, et al. CMV viremia in patients with advanced HIV infection: a 48-week. Presented at: Conference on Retroviruses and Opportunistic Infections; March 8-11, 2020; Boston, MA. Abstract 753. croiconference.org/sites/default/files/posters-2019/1430_12_Suanzes_00753.pdf.