Ocular Complications of HIV/AIDS in the Era of HAART

Millena G Bittencourt; Owhofasa O Agbedia; Hong T Liu; Rachel Annam; Yasir J Sepah; Henry Alexander Leder; Raafay Sophie; Mohamed Ibrahim; Abeer Akhtar; Anam Akhlaq; Diana V Do; Quan Dong Nguyen

Disclosures

Expert Rev Ophthalmol. 2012;7(6):555-564. 

In This Article

Abstract and Introduction

Abstract

Mortality associated with AIDS has declined after the introduction of highly active antiretroviral therapy (HAART) with fewer patients progressing to severe infections. This has affected the incidence and management of HIV complications to a great extent. The natural history, incidence, management and sequelae of a wide range of HIV-associated retinopathies, especially cytomegalovirus retinitis, have also drastically changed. The reduction in the incidence of ocular opportunistic infections due to HAART has been accompanied by a rise in the number of new HAART-associated syndromes such as immune recovery uveitis. Immune recovery uveitis is a HAART-dependent inflammatory response that may occur in patients with regressed cytomegalovirus retinitis and elevated CD4 count and has emerged as an important cause of ocular and visual morbidity.

Introduction

Three decades ago, before the emergence of AIDS, the majority of diseases now classified as AIDS chorioretinopathies were rare and seen only in patients who had organ transplant or certain forms of immune suppression.[1] Since then, the AIDS pandemic has resulted in approximately 60 million new infections; it is estimated that 33 million people currently live with HIV infection or AIDS.[201] HIV-associated eye disease is estimated to affect 50–75% of the HIV-infected population worldwide at some point during the course of the disease.[2] The prevalence and spectrum of HIV-related eye diseases differ geographically. For example, in southeast Asia, cytomegalovirus retinitis (CMVR) affects 27–33% of HIV-infected individuals[3] compared with 16.5% of HIV-infected individuals in sub-Saharan Africa, where complications affecting the anterior segment of the eye such as Herpes Zoster and Molluscum contagiosum are more frequent.[4–6]

The current accepted regimen for management of AIDS is highly active antiretroviral therapy (HAART), which is a combination therapy of two or more nucleoside reverse transcriptase inhibitors along with either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor. HAART is typically commenced when the patient demonstrates a low CD4 count (200–350 cells/mm3) and may be susceptible to opportunistic infections.[7] In patients with AIDS, the typical response to HAART is a reduction in viral load to below detectable levels and an increase in the CD4 cell count to normal levels. It indicates a restoration of the natural immune response, thus opportunistic infections may preclude the need for antibiotics and antiviral agents in the management of AIDS. Such restoration of the immune response has altered the natural history of AIDS-related chorioretinopathies, resulting in a subsequent modification in incidence and management strategies.

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