Cytomegalovirus viral load kinetics in patients with HIV/AIDS admitted to a medical intensive care unit: a case for pre-emptive therapy.
BACKGROUND
Cytomegalovirus (CMV) infection is associated with severe diseases in immunosuppressed patients; however, there is a lack of data for pre-emptive therapy in patients with HIV/AIDS.


METHODS
This was a retrospective study, which enrolled patients diagnosed with HIV/AIDS (CD4<200 cells/μl), who had detectable CMV viral load (VL) during their stay in an adult medical intensive care unit between 2009-2012.


RESULTS
After screening 82 patients' records, 41 patients met the enrolment criteria. Their median age was 37 (interquartile range [IQR]: 31-46), and median CD4 count was 29 cells/μl (IQR: 5-55). Sixteen patients (39%) had serial measurements of CMV VL before treatment with ganciclovir. Patients whose baseline CMV VL values were between 1,000-3,000 copies/ml had significantly higher values (median of 14,650 copies/ml) on follow-up testing done 4-12 days later. Those with undetectable VLs at baseline testing had detectable VLs (median of 1,590 copies/ml) mostly within 20 days of follow-up testing. Patients who had VLs >1,000 copies/ml at baseline testing had significantly higher mortality compared to those who had <1,000 copies/ml {hazard ratio of 3.46, p = 0.003 [95% confidence interval (CI): 1.55-7.71]}. Analysis of the highest CMV VL per patient showed that patients who had VLs of >5,100 copies/ml and did not receive ganciclovir had 100% mortality compared to 58% mortality in those who received ganciclovir at VLs of >5,100 copies/ml, 50% mortality in those who were not treated and had low VLs of <5,100 copies/ml, and 44% mortality in those who had ganciclovir treatment at VLs of <5,100 copies/ml (p = 0.084, 0.046, 0.037, respectively).


CONCLUSIONS
This study showed a significantly increased mortality in patients with HIV/AIDS who had high CMV VLs, and suggests that a threshold value of 1,000 copies/ml may be appropriate for pre-emptive treatment in this group.
Department of Medical Virology, University of Pretoria/National Health Laboratory Service - Tshwane Academic Division (NHLS-TAD), Pretoria, South Africa.
Simnikiwe H
SH
Mayaphi
Department of Medical Virology, University of Pretoria/National Health Laboratory Service - Tshwane Academic Division (NHLS-TAD), Pretoria, South Africa.
Marieke
M
Brauer
Department of Medical Virology, University of Pretoria/National Health Laboratory Service - Tshwane Academic Division (NHLS-TAD), Pretoria, South Africa.
Daniel M
DM
Morobadi
Department of Medical Virology, University of Pretoria/National Health Laboratory Service - Tshwane Academic Division (NHLS-TAD), Pretoria, South Africa.
Ahmad H
AH
Mazanderani
Department of Medical Virology, University of Pretoria/National Health Laboratory Service - Tshwane Academic Division (NHLS-TAD), Pretoria, South Africa.
Rendani T
RT
Mafuyeka
Biostatistics unit, Medical Research Council, Pretoria, South Africa.
Steve A S
SA
Olorunju
Department of Internal Medicine, University of Pretoria, Pretoria, South Africa.
Gregory R
GR
Tintinger
Department of Internal Medicine, University of Pretoria, Pretoria, South Africa.
Anton
A
Stoltz
D000328:Adult; D000998:Antiviral Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D003587:Cytomegalovirus / Q000302:isolation & purification*; D003586:Cytomegalovirus Infections / Q000188:drug therapy*; D015774:Ganciclovir / Q000627:therapeutic use*; D015658:HIV Infections / Q000821:virology*; D006801:Humans; D007362:Intensive Care Units; D008875:Middle Aged; D019562:Viral Load
D000998:Antiviral Agents; D015774:Ganciclovir