Experience on Management of CMV Retinitis

Medécins Sans Frontiéres

Khin Nyein ChanMedical Coordinator, MSF

HIV program in Myanmar

• MSF HIV/ART program started since 2003

• 17 TB/HIV clinics – Yangon Region– Taninthayi Region– Kachin State– Shan State– Rakhine State

• >30,000 patients are on HAART

Waing Maw

Moe Gaung

What is CMV?

• Cytomegalovirus (CMV)• >90% of people are sero+ for CMV in

most developing countries • In immunocompromised host – re-activate • In AIDS patients, retina is the most

common site of disease• Accounts for >90% of HIV related

blindness• In RLS, CMV retinitis is the only clinical

manifestation of the disease that we can diagnose.

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44

MSF Clinic in Myanmar

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CMV Management

Treated with Intraocular injection of Gancyclovir and ART.CMV inactive after 5 consecutive weekly injections and currently under maintenance injection*.

34 yrs old male patient from Kyone Pyaw, Delta region (4-5 hrs drive one way)CD4 count 7 cells/mm3 and diagnosed with active CMV Retinitis (Lt eye)

* Maintenance 2 weeksx2, every 3 weeksx2, every 4 weeks (until the retinitis is completely inactive AND CD4 count >100 cell/ul and checked on > 3 month HAART)

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Management of CMV RetinitisStarted in 2006 – Clinic MD receive the training

from Dr. David Heiden*

*Consultant in uveitis, Department of Ophthalmology and Pacific Vision Foundation, California Pacific Medical Center, San Francisco, California

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Management of CMV Retinitis

• Criteria for screening1. CD4 count <100/mm32. Eye complaints that relate to “vision”3. Any patient with ophthalmic herpes zoster

(ASAP)4. Re screen 3 monthly as long as CD4 count is

<100/mm3

• Number screened in Kachin and Yangon (2011-2012) – 4069

• Number treated of those screened (2011-2012) – 335

• It is possible to prevent blindness due to CMV retinitis in HIV patients by primary care HIV clinicians where ophthalmologists are not available!

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Management of CMV Retinitis

Challenges• Providing treatment to very sick people

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n = 24,008

Baseline Median CD4 of 15+ years, ARV naïve patients9

Cd4 precision 60 days

2003

(n=10

0)

2004

(n=22

8)

2005

(n=73

4)

2006

(n=23

41)

2007

(n=33

07)

2008

(n=18

89)

2009

(n=33

18)

2010

(n=35

23)

2011

(n=48

43)

2012

(n=56

04)

50

100

150

200

7366 73

6696

182

127 128

84104

10

State/Division # ART (n=13,217)

Ayeyarwady 429

Bago 319

Chin 13

Kachin 2087

Kayar 8

Kayin 41

Magway 306

Mandalay 467

Mon 104

Rakhine 542

Sagaing 244

Shan 1853

Tanintharyi 21

Yangon 6632

China 150

Thailand 1

Challenges (cont.)

One dot represents

“10” patients

patient origins

2011 HIV-Cohort survey on “Origin of HIV patients registered”

1111

Challenges (cont.)

• Management of Pediatric patients

• Human Resource

• After being trained, it takes another 3-6 months practice to become highly proficient on CMV retinitis management

• Turnover of CMV experienced staff …• Interrupted program implementation

• Not just the eyes!!!

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Way forward…

• Continue prevention of blindness despite the challenges as this is the only option currently in the country

• Looking forward to the accessible simpler diagnosis and affordable simple pills…..

1313

Thank you