Beyond CD4: Posterior segment findings and virologic-immunologic predictors in highly active antiretroviral therapy-naïve HIV patients

PURPOSE: To assess ocular findings in treatment-naïve people living with HIV (PLWH), focusing on posterior segment involvement, and to identify key virologic and immunologic predictors, including cytomegalovirus (CMV) retinitis and HIV-related retinopathy. DESIGN: Prospective cross-sectional study. METHODS: This study included 124 treatment-naïve PLWH who were referred for ophthalmologic screening at the time of HIV diagnosis. All participants underwent a comprehensive ophthalmic examination. Demographic and clinical data were collected, along with key immunologic and virologic markers: CD4+ and CD8+ T-cell counts, CD4/CD8 ratio, and plasma viral loads for both HIV and CMV, all measured prior to initiation of antiretroviral therapy. The primary outcome was the identification of posterior segment involvement, specifically CMV retinitis and HIV-related retinopathy, in relation to CD4 count, CD4/CD8 ratio, and CMV plasma load. RESULTS: Posterior segment involvement was observed in 29% of patients, most commonly CMV retinitis. Univariate analysis showed significant associations with age, CD4 count, CD4/CD8 ratio, log₁₀HIV plasma load, and log₁₀CMV plasma load. Multivariate analysis revealed that log₁₀CMV plasma load remained the strongest independent predictor of posterior segment involvement (OR: 1.630, P = 0.003). CMV retinitis was significantly associated with log₁₀CMV plasma load ( P < 0.001), with a threshold of 44.5 IU/mL (log₁₀ = 1.6470) demonstrating high sensitivity (85.7%) and negative predictive value (97.8%). For a higher threshold of 1370 IU/mL (log₁₀ = 3.1294), specificity was higher (90.0%) with a positive predictive value of 47.6%. HIV-related retinopathy correlated inversely with CD4/CD8 ratio ( P = 0.030). CONCLUSIONS: Early ophthalmologic screening is essential in PLWH with advanced immunosuppression. CMV DNA plasma load, CD4 count, and CD4/CD8 ratio are useful markers to identify patients at risk of vision-threatening complications.