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Lowering the limit: reducing the CD4 T-cell threshold for ophthalmic screening in patients with HIV in an ethnically
Rupal Morjaria1, Vaneeta Sood2, Kaveh Manavi2
1Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom ; Nuffield Department of Ophthalmology, Oxford University Hospitals National Health Service Trust, Oxford, United Kingdom.
Insights
Ophthalmic screening of asymptomatic HIV patients with CD4 counts below 100 cells/mm(3) is not associated with missed cytomegalovirus (CMV) retinitis cases. Current screening practices are effective in the highly active antiretroviral therapy era.
Area of Science:
- Ophthalmology
- Infectious Diseases
- Immunology
Background:
- Cytomegalovirus (CMV) retinitis was a significant vision threat for HIV patients before effective antiretroviral therapy.
- The study evaluates the continued value of ophthalmic screening for asymptomatic HIV patients in the modern treatment era.
Purpose of the Study:
- To assess the efficacy of ophthalmic screening in asymptomatic HIV patients under current treatment protocols.
- To determine appropriate CD4 count thresholds for screening in line with global and UK data.
Main Methods:
- A retrospective chart review of HIV patients seen by a UK hospital's Ophthalmic Service.
- Data analyzed included CD4 counts, HIV RNA load, CMV status, and ocular manifestations before and after implementing a CD4 < 100 cells/mm(3) screening threshold.
Main Results:
- Seven of 51 patients exhibited HIV-related ophthalmic manifestations, all with lower CD4 counts (median 9 cells/mm(3)) compared to those with normal exams (median 175 cells/mm(3)).
- One case of sight-threatening CMV retinitis occurred in a patient with a CD4 count of 6 cells/mm(3).
- No missed or late-presenting CMV retinitis cases were identified in asymptomatic patients screened with CD4 counts below 100 cells/mm(3).
Conclusions:
- Screening asymptomatic HIV patients with CD4 counts below 100 cells/mm(3) appears adequate in the current highly active antiretroviral therapy era.
- The previous practice of screening patients with CD4 counts below 200 cells/mm(3) is no longer necessary for this population.
Background:
Before highly active antiretroviral therapy, cytomegalovirus (CMV) retinitis was a major threat to vision in individuals with HIV. We investigate whether ophthalmic screening of asymptomatic HIV patients still has value in the highly active antiretroviral therapy era and consider CD4 thresholds in line with the world literature and UK experience.
Methods:
A retrospective chart review was conducted of all patients seen by the HIV Ophthalmic Service of a UK university hospital both before (2007-2008) and after (2011-2012) introduction of a threshold of CD4 lower than 100 cells/mm(3). Data collected included CMV and HIV RNA load, CD4 cell counts and CD4 percentage, CMV-immunoglobulin G status, ocular symptoms, and evidence of HIV-related ocular disease.
Results:
In total, 54 patients were referred to the HIV ophthalmic service. Three patients failed to attend, resulting in complete data for 51 patients (n=24 for 2007-2008; n=27 for 2011-2012). Seven patients had ophthalmic manifestations of their HIV; these cases had lower CD4 counts than those with normal examinations (median [interquartile range], 9 [7-80] versus 175 [44-394]; P=0.0039; Mann-Whitney test). Six cases had HIV retinopathy without sight loss; one case had sight-threatening CMV retinitis associated with a CD4 count of 6 cells/mm(3).
Conclusion:
Before 2008, our practice was to screen all asymptomatic patients with CD4 counts lower than 200 cells/mm(3). Screening asymptomatic patients with CD4 counts below 100 cells/mm(3) was not associated with any missed or late-presenting cases of CMV retinitis in our HIV population.
