Current management of cytomegalovirus disease in patients with AIDS

Cytomegalovirus (CMV) infection is common in both homosexual and heterosexual HIV-infected patients, and causes disease in a substantial proportion of patients with AIDS and very low CD4+ cell counts. Both ganciclovir, an analog of the nucleoside guanosine, and foscarnet, an analog of pyrophosphate, are licensed for treatment of CMV retinitis. They may also have a role in the treatment of gastrointestinal disease caused by CMV. In the Studies of Ocular Complications of AIDS comparative trial the two agents were equally effective against CMV retinitis, but patients receiving foscarnet had significantly longer survival, even after adjusting for covariates including antiretroviral therapy. Ongoing studies are evaluating higher dosages of foscarnet for maintenance therapy and combined therapy with ganciclovir and foscarnet. Tolerance of ganciclovir therapy has been facilitated by adjunctive therapy with colony-stimulating factors. Because both ganciclovir and foscarnet must be administered by intravenous infusion and are associated with significant toxicities, other anti-CMV agents are under active development, including HPMPC and an oral formulation of ganciclovir. Management of CMV retinitis involves individualizing therapy, balancing side effects and administration requirements, and, in many clinical settings, the overall cost of treatment.