1. Experience on Management of CMV Retinitis Medécins Sans Frontiéres Khin Nyein Chan Medical Coordinator, MSF

2. HIV program in Myanmar MSF HIV/ART program started since 2003 17 TB/HIV clinics –Yangon Region –Taninthayi Region –Kachin State –Shan State –Rakhine State >30,000 patients are on HAART Waing Maw Moe Gaung

3. What is CMV? Cytomegalovirus (CMV) >90% of people are sero+ for CMV in most developing countries In immunocompromised host – re-activate In AIDS patients, retina is the most common site of disease Accounts for >90% of HIV related blindness In RLS, CMV retinitis is the only clinical manifestation of the disease that we can diagnose. 3

4. 4 4 MSF Clinic in Myanmar

5. 55 CMV Management Treated with Intraocular injection of Gancyclovir and ART. CMV inactive after 5 consecutive weekly injections and currently under maintenance injection*. 34 yrs old male patient from Kyone Pyaw, Delta region (4-5 hrs drive one way) CD4 count 7 cells/mm3 and diagnosed with active CMV Retinitis (Lt eye) * Maintenance 2 weeksx2, every 3 weeksx2, every 4 weeks (until the retinitis is completely inactive AND CD4 count >100 cell/ul and checked on > 3 month HAART)

6. 6 Management of CMV Retinitis Started in 2006 – Clinic MD receive the training from Dr. David Heiden* *Consultant in uveitis, Department of Ophthalmology and Pacific Vision Foundation, California Pacific Medical Center, San Francisco, California

7. 7 Management of CMV Retinitis Criteria for screening 1.CD4 count <100/mm3 2.Eye complaints that relate to “vision” 3. Any patient with ophthalmic herpes zoster (ASAP) 4.Re screen 3 monthly as long as CD4 count is <100/mm3 Number screened in Kachin and Yangon (2011-2012) – 4069 Number treated of those screened (2011-2012) – 335

8. It is possible to prevent blindness due to CMV retinitis in HIV patients by primary care HIV clinicians where ophthalmologists are not available! 8 Management of CMV Retinitis

9. Challenges Providing treatment to very sick people 9 n = 24,008 9 Cd4 precision 60 days

10. 10 State/Division# ART (n=13,217) Ayeyarwady429 Bago319 Chin13 Kachin2087 Kayar8 Kayin41 Magway306 Mandalay467 Mon104 Rakhine542 Sagaing244 Shan1853 Tanintharyi21 Yangon6632 China150 Thailand1 Challenges (cont.) One dot represents “10” patients One dot represents “10” patients patient origins 2011 HIV-Cohort survey on “Origin of HIV patients registered”

11. 11 Challenges (cont.) Management of Pediatric patients Human Resource After being trained, it takes another 3-6 months practice to become highly proficient on CMV retinitis management Turnover of CMV experienced staff … Interrupted program implementation Not just the eyes!!!

12. 12 Way forward… Continue prevention of blindness despite the challenges as this is the only option currently in the country Looking forward to the accessible simpler diagnosis and affordable simple pills…..

13. 13 Thank you