Cytomegalovirus viremia and risk of disease progression and death in HIV-positive patients starting antiretroviral therapy

COPD in People with HIV: Epidemiology, Pathogenesis, Management, and Prevention Strategies

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder characterized by airflow limitation and persistent respiratory symptoms. People with HIV (PWH) are particularly vulnerable to COPD development; PWH have demonstrated both higher rates of COPD and an earlier and more rapid decline in lung function than their seronegative counterparts, even after accounting for differences in cigarette smoking. Factors contributing to this HIV-associated difference include chronic immune activation and inflammation, accelerated aging, a predilection for pulmonary infections, alterations in the lung microbiome, and the interplay between HIV and inhalational toxins. In this review, we discuss what is known about the epidemiology and pathobiology of COPD among PWH and outline screening, diagnostic, prevention, and treatment strategies.

Cytomegalovirus viremia and advanced HIV disease: is there an argument for anti-CMV treatment?

INTRODUCTION

The role of cytomegalovirus (CMV) infection as a co-factor in HIV disease has been a topic of considerable interest since the beginning of the HIV pandemic. CMV is believed to function both as a co-factor in the progression of HIV infection, and as a contributor to enhanced disease for other opportunistic infections.

AREAS COVERED

In this special article, we review several recent studies that have enhanced our understanding of the role that CMV infection plays in the natural history of other HIV-related opportunistic infections. We review the clinical evidence that demonstrates how CMV viremia has emerged as an independent risk factor for the progression of infections such as those caused by C. neoformans and M. tuberculosis. We outline the biological underpinnings of the various hypotheses by which CMV, as an immunomodulatory virus, may modify the natural history of HIV-related infections.

EXPERT OPINION

Evidence suggests that active CMV replication, manifest as CMV viremia (DNAemia), may play a key role in driving progression of HIV-associated opportunistic infections. We propose that control of CMV replication, independent of the known benefit of HAART therapy on reducing CMV end-organ disease, could reduce the risk of disease and mortality attributable to opportunistic infections such as cryptococcosis and tuberculosis. This could be achieved by the targeted use of CMV antivirals. The advent of newer (and safer) orally bioavailable CMV antivirals has renewed interest in, and opportunities for, randomized controlled trials to evaluate CMV viremia as a modifiable risk factor in high-risk persons with HIV disease.

Predictors of early death risk among untransplanted patients with combined immunodeficiencies affecting cellular and humoral immunity: A multicenter report

BACKGROUND

There is an increased demand for hematopoietic stem cell transplant (HSCT) to treat various diseases including combined immunodeficiencies (CID), with limited worldwide availability. Variables affecting the decision regarding CID patients' prioritization for HSCT are not known. We aimed to determine general, clinical, and immunologic factors associated with the higher risk of early death (≤6 months after diagnosis) in untransplanted CID patients.

METHODS

Data collection was done retrospectively from five centers and included general patients' information, and clinical and laboratory variables. Inclusion criteria were untransplanted patients who are either dead or alive with a follow-up period ≥6 months after diagnosis.

RESULTS

Two hundred and thirty-six CID patients were reported by participating centers, of whom 111 were included in the study with a cumulative follow-up period of 278.6 years. Seventy-two patients died with the median age of death of 10.5 months. 35.1% of the patients succumbed within 6 months after the diagnosis. Having a history of Candida infections, sepsis or hepatomegaly was associated with an increased risk of early death. None of the other general or clinical variables was associated with such risk. Bivariate analysis of lymphocyte subsets showed that patients with the following counts: CD3⁺  < 100, CD4⁺  < 200, CD8⁺  < 50, or CD16⁺ CD56⁺ <200 cells/μl had increased risk of early death. In adjusted analysis, increased risk of early death was observed among patients with CD3⁺ count <100 cells/μl.

CONCLUSION

Combined immunodeficiencies patients with a history of Candida infections, sepsis, hepatomegaly, or severe T-lymphopenia should be given priority for HSCT to avoid early death.

Cytomegalovirus viremia as a risk factor for mortality in HIV-associated cryptococcal and tuberculous meningitis

OBJECTIVES

Cytomegalovirus (CMV) viremia is associated with increased mortality in persons with HIV. We previously demonstrated that CMV viremia was a risk factor for 10-week mortality in antiretroviral therapy (ART)-naïve persons with cryptococcal meningitis. We investigated whether similar observations existed over a broader cohort of HIV-associated meningitis at 18 weeks.

METHODS

We prospectively enrolled Ugandans with cryptococcal or tuberculous (TB) meningitis into clinical trials during 2015-2019. We quantified CMV DNA concentrations from stored baseline plasma or serum samples from 340 participants. We compared 18-week survival between those with and without CMV viremia.

RESULTS

We included 308 persons with cryptococcal meningitis and 32 with TB meningitis, of whom 121 (36%) had detectable CMV DNA. Baseline CD4⁺ T cell counts (14 vs. 24 cells/µL; P=0.07) and antiretroviral exposure (47% vs. 45%; P=0.68) did not differ between CMV viremic and non-viremic persons, respectively. The 18-week mortality was 50% (61/121) in those with CMV viremia versus 34% (74/219) in those without (P=0.003). Any detectable CMV viremia (aHR=1.60; 95%CI, 1.13-2.25; P=0.008) and greater viral load (aHR=1.22 per log₁₀ IU/mL increase; 95%CI, 1.09-1.35; P<0.001) were positively associated with all-cause mortality through 18 weeks.

CONCLUSIONS

CMV viremia at baseline was associated with a higher risk of death at 18 weeks among persons with HIV-associated cryptococcal or TB meningitis, and the risk increased as the CMV viral load increased. Further investigation is warranted to determine if CMV is a modifiable risk contributing to deaths in HIV-associated meningitis, versus its presence representing a biomarker of immune dysfunction.