Anti-cytomegalovirus preemptive therapy to prevent cytomegalovirus disease in HIV-infected patients: a systematic review

Background: HIV patients are at higher risk of contracting and developing into an asymptomatic form of CMV infection. This review aimed to evaluate the efficacy and safety of preemptive therapy for preventing CMV disease in HIV patients. Methods: The electronic search was conducted in MEDLINE/PubMed and CENTRAL from inception until 9 September 2022. Studies were included if they assessed the efficacy or safety of anti-CMV preemptive therapy compared to placebo or no therapy. Risk of bias were assessed using the Cochrane Risk of Bias tool for randomized trials version 2 or the Cochrane Collaboration Risk of Bias in Non-randomized Studies of Interventions. The random-effects model was used to calculate effect sizes. Results: We identified six RCTs (2135 participants) and four observational studies (395 participants), with five RCTs were performed before highly active antiretroviral therapy (HAART) era. Preemptive therapy did not reduce the incidence of CMV disease (RR 0.84, 95 CI: 0.59–1.18), yet reduced the RR of all-cause mortality rate by 26 (RR 0.85, 95 CI: 0.74–0.97) with a low quality of evidence. The incidence of neutropenia as an adverse event increased significantly (RR 2.47, 95 CI: 1.12–5.45) with moderate quality of evidence. Conclusions: With the advent of HAART, a limited number of studies have been performed to explore anti-CMV preemptive therapy due to the improved outcomes of HIV patients with CMV viremia. Therefore, optimal HAART should take precedence over anti-CMV preemptive therapy. The protocol for this review was registered in the Prospective Register of Systematic Reviews (CRD42020145765). © 2023 Society for Scandinavian Journal of Infectious Diseases.