CMV is treated using powerful antiviral drugs. Like many viruses, CMV cannot be cured (i.e., cleared from the body); it can only be treated to stop it from causing disease. At the same time, treating some forms of CMV—such as CMV retinitis—does not usually reverse damage that has already occurred. It only prevents the disease from worsening.
In most cases, CMV treatment consists of two phases: induction therapy and maintenance therapy. Induction therapy is meant to treat the disease and usually takes two or three weeks. Maintenance therapy is intended to prevent the virus from causing disease again in the future. It used to be that, once CMV treatment was started, it was best to continue with maintenance therapy for life. However, researchers have shown that patients with CMV disease who experience a rebound in their CD4 cell counts due to current HIV treatments, can often stop their maintenance therapy, provided that their immune system remains healthy while on HIV drugs. According to the Department of Health and Human Services (DHHS), it is safe to consider stopping CMV maintenance therapy if the CD4 cell count remains above 100 to 150 cells for at least six months.
Treatment depends on the type and severity of CMV involved, as well as a person's CD4 cell count, his or her ability to adhere to treatment and possible interactions with other medications that are being taken. Antiretroviral therapy is also an important component of CMV treatment—it should be started, or optimized, to keep HIV viral load as low as possible and to boost the CD4 cell count.
The following table reviews the preferred (and alternative) CMV treatments recommended by the U.S. Department of Health and Human Services (DHHS), according to OI treatment guidelines published in June 2008:
Type of CMV
Induction Therapy
Maintenance Therapy
Retinitis (sight-threatening lesions)
Preferred:
Ganciclovir implant (Vitrasert; a tiny pellet that contains the CMV drug ganciclovir that is surgically implanted directly into the eye) PLUS twice-daily oral valganciclovir (Valcyte). Continued for two or three weeks.
Alternative:
Intravenous (IV) ganciclovir twice daily for two or three weeks, followed by IV ganciclovir once daily, OR
IV ganciclovir twice daily for two or three weeks, followed by oral valganciclovir once daily; OR
IV foscarnet (Foscavir) twice daily for two or three weeks, followed by once-daily IV infusions, OR
Once-weekly IV cidofovir (Vistide) for two weeks, followed by IV cidofovir given every two weeks. Cidofovir must be given with an oral medication called probenecid to help prevent kidney damage; saline hydration for the eyes is also necessary. However, cidofovir-probenicid should not be used by anyone with an allergy to sulfa-based medications, such as Bactrim.
Preferred:
Oral valganciclovir, 900mg once daily. The ganciclovir implant may need to be replaced after six months if the CD4 count remains below 100.
Alternative:
IV ganciclovir once daily, five- to seven-times a week. OR
IV foscarnet once daily, OR
IV cidofovir (Vistide) given every two weeks, along with probenecid and saline hydration.
Retinitis (non-sight-threatening lesions)
Twice-daily oral valganciclovir. Continued for two or three weeks.
Once-daily oral valganciclovir.
Esophagitis or colitis
IV ganciclovir (Cytovene) OR IV foscarnet (Foscavir) for three or four weeks, or until symptoms improve. Oral valganciclovir may be used if symptoms are not severe enough to interfere with proper absorption of the drug.
Generally not necessary, but should be considered after relapses.
Encephalitis or radiculopathy
IV ganciclovir PLUS IV foscarnet, used until symptoms improve.
Oral valganciclovir plus IV foscarnet, continued for life, unless CD4 counts improve.
Maintenance therapy for CMV retinitis can be discontinued, providing that there is no active disease and the CD4 count has remained above 100 cells for three to six months. However, it is important to have regular eye examinations, preferably every three months, to ensure that sight-threatening disease doesn't return.
In some cases, a person may experience immune recovery uveitis (IRU) after first starting antiretroviral therapy. This usually occurs only in people who have very low CD4 counts when they begin antiretroviral therapy, and have very large and rapid gains in CD4 cells. The cause is an over reaction by the newly strengthened immune system to existing CMV. An experienced opthamologist can help distinguish IRU from other causes. Symptoms include swelling of the eyes and vision loss. Treatment usually involves corticosteroid drops.
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