Anti-HIV drugs save vision, improve outlook for AIDS patients

A new study from Johns Hopkins researchers shows the multiple anti-HIV drug regimen called highly active antiretroviral therapy (HAART) saves eyesight as well as lives. A second study led by Johns Hopkins researchers finds that among AIDS patients with longstanding vision problems, those who took HAART reported higher overall quality of life.

The Johns Hopkins team reported in the April issue of Archives of Ophthalmology that AIDS patients who received HAART had a 75 percent lower risk of visual impairment than those who did not. In the second, multicenter study, published in the May issue of the journal Ophthalmology, AIDS patients with vision loss reported a lower vision-related quality of life, although those who took HAART reported higher overall quality of life than those who did not.

AIDS patients are at high risk of vision loss from cytomegalovirus (CMV) retinitis, an infectious disease of the retina. Symptoms include “floaters” and permanent loss of central vision. With HAART, which became available in 1995, many patients’ immune systems seem to recover enough to control CMV retinitis. The condition at one time affected 30 percent of patients at some point during their lives, but has probably decreased to 7.5 percent with the advent of HAART, says John H. Kempen, M.D., Ph.D., lead author of both studies and assistant professor of ophthalmology and epidemiology. By the time CMV is diagnosed, Kempen says, many AIDS patients are already legally blind or have significant vision loss.

“AIDS patients should take HAART as soon as and as much as they can,” he says. “HAART often can save both their life and their vision.”

In the Archives study, Kempen and his team evaluated 648 AIDS patients seen at the Wilmer Eye Institute at Johns Hopkins between August 1983 and March 2000. Seventeen percent had 20/200 vision (the definition of legal blindness) at the time of diagnosis, while 33 percent had 20/50 vision — poor enough to restrict their ability to drive. Whites were less likely to have visual impairment, while injection drug users had a higher prevalence of visual impairment. Patients were followed monthly for disease progression.

One year later, 42 percent of 426 patients lost visual acuity equivalent to three lines on the vision chart, 30 percent lost the equivalent of six lines on the chart and 23 percent lost the equivalent of 10 lines on the chart. By one year after CMV retinitis diagnosis, the incidence of vision loss to the level of 20/50 vision was 34 percent and the incidence of vision loss to the level of 20/200 vision was 24 percent. Thus, within the first year after being diagnosed with CMV retinitis, over half (56 percent) had vision loss to the level of 20/50, and about a third (37 percent) were legally blind.

Ninety-three patients (126 eyes) received HAART during the study’s follow-up. Of these, 46 patients (64 eyes) had substantial improvement in their immunity, while 47 (62 eyes) did not. Those who received HAART had a much lower incidence of visual acuity loss compared with patients who did not receive the therapy, especially those who had improvement of their immunity.

In the second study, a report from the Longitudinal Study of Ocular Complications of AIDS, researchers at Johns Hopkins and 18 other centers across the country questioned 971 AIDS patients ages 13 and up about their quality of life related to vision and overall health. Patients were enrolled between September 1998 and March 2001. Fifty patients had newly diagnosed CMV retinitis, 212 patients had longstanding CMV retinitis of an average three years’ duration, and 709 patients had no CMV retinitis. Newly diagnosed patients tended to be female, younger and African-American. They were more likely to have detectable CMV DNA in their blood and had been diagnosed with AIDS more recently, so were less likely to be taking HAART.

The longstanding and newly diagnosed CMV retinitis groups scored substantially worse in vision-related quality of life than the group without CMV retinitis. However, general health-related quality of life scores for the longstanding CMV retinitis group tended to be similar to, or better than, those for patients without CMV retinitis, mostly due to the effects of HAART. Patients with newly diagnosed CMV retinitis tended to score worse on the general health-related quality of life scale.

The risk of vision loss study was supported by the National Eye Institute. Co-authors were Douglas A. Jabs, M.D., M.B.A.; Laura A. Wilson, M.Sc.; James P. Dunn, M.D.; Sheila K. West, Ph.D.; and James A. Tonascia, Ph.D.

The quality of life study also was supported by the National Eye Institute, as well as the National Center for Research Resources. Co-authors were Barbara K. Martin, Ph.D.; Albert W. Wu, M.D., M.P.H.; Bruce Barron, M.D.; Jennifer E. Thorne, M.D.; and Douglas A. Jabs, M.D., M.B.A.

Kempen, J.H. et al, “Risk of Vision Loss in Patients with Cytomegalovirus Retinitis and the Acquired Immunodeficiency Syndrome,” Archives of Ophthalmology, April 2003; Vol. 121: pages 466-476.

Kempen, J.H. et al, “The Effect of Cytomegalovirus Retinitis on the Quality of Life of Patients with the Acquired Immune Deficiency Syndrome in the Era of Highly Active Anti-retroviral Therapy,” Ophthalmology, May 2003.