Training clinicians treating HIV to diagnose cytomegalovirus retinitis

Abstract

ProblemAcquired immunodeficiency syndrome (AIDS)-related cytomegalovirus (CMV) retinitis continues to be a neglected source of blindness in resource-poor settings. The main issue is lack of capacity to diagnose CMV retinitis in the clinical setting where patients receive care and all other opportunistic infections are diagnosed.ApproachWe developed and implemented a four-day workshop to train clinicians working in human immunodeficiency virus (HIV) clinics how to perform binocular indirect ophthalmoscopy and diagnose CMV retinitis. Workshops comprised both classroom didactic instruction and direct clinical eye examinations in patients with advanced AIDS. Between 2007 and 2013, 14 workshops were conducted in China, Myanmar and the Russian Federation.Local settingWorkshops were held with local clinicians at HIV clinics supported by nongovernmental organizations, public-sector municipal hospitals and provincial infectious disease referral hospitals. Each setting had limited or no access to locally- trained ophthalmologists, and an HIV-infected population with advanced disease.Relevant changesClinicians learnt how to do binocular indirect ophthalmoscopy and to diagnose CMV retinitis. One year after the workshop, 32/38 trainees in Myanmar did systematic eye examination for early diagnosis of CMV retinitis as standard care for at-risk patients. In China and the Russian Federation, the success rates were lower, with 10/15 and 3/5 trainees, respectively, providing follow-up data.Lessons learntSkills necessary for screening and diagnosis of CMV retinitis can be taught in a four-day task-oriented training workshop. Successful implementation depends on institutional support, ongoing training and technical support. The next challenge is to scale up this approach in other countries.

CMV Retinitis Diagnosis by Non-ophthalmologists

“…1 Given the lack of CMV retinitis screening for its HIV population, the Médecins Sans Frontières Yangon Project initiated a program in 2006 to train its AIDS physicians how to diagnose and treat CMV retinitis at the point-of-care. 2 An outside ophthalmologist (D.H.) designed and implemented a 4-day training program to transfer the skills of binocular indirect ophthalmoscopy for CMV retinitis diagnosis. The workshop has been repeated every year since.…”

Eye examination for early diagnosis of disseminated tuberculosis in patients with AIDS

“…Since 2007, indirect ophthalmoscopy has been taught to HIV/AIDS clinicians in Myanmar, China, and Russia. 63 In Myanmar, most patients newly diagnosed with HIV infection and having a CD4 count under 100 cells have routine retinal examination with indirect ophthalmoscopy by HIV clinicians at the point of care 63,64 and, although the initial motivation was for improved diagnosis of cytomegalovirus retinitis, 64 attention is increasingly being given to diagnosis of disseminated tuberculosis. Non-ophthalmologists can accurately diagnose cytomegalo virus retinitis with an indirect ophthalmoscope, which suggests that they would be able to reliably diagnose choroidal tuberculosis if given appropriate training.…”

Valganciclovir: A Review of Its Use in the Management of AIDS-Related Cytomegalovirus Retinitis

“…WHO has included routine Ophthalmoscopy for all patients presenting for ART initiation with low CD4+ cell counts (<100 cells/µL) in AIDS treatment guidelines. [7,8] At present, the antiviral drugs Ganciclovir, Foscarnet and Cidofovir are commonly used in the treatment of CMV infection and disease.However, these agents have a poor oral bioavailability and have the inconvenience and expense of intravenous administration.Valganciclovir is an oral pro-drug of Ganciclovir, with a 10-fold greater bioavailability than oral ganciclovir. Studies of the pharmacokinetics of valganciclovir among HIVinfected CMV sero-positive patients and liver transplant recipients suggest that it is as efficacious and safe as both oral and IV ganciclovir in immunedeficient patients.…”