COINFECTIONS
Expanded Vaccine Recommendations for Outbreak of Invasive Serogroup C Meningococcal Disease Among MSM in NYC
This brief presentation by Alison Ridpath is an update to our previous brief presentation on the epidemiology of IMD in NYC by Marci Layton, and the longer program with Don Weiss on the clinical features of IMD in NYC and Sheila Palevsky on vaccines to prevent IMD and other illnesses in our target populations (see below). This presentation calls attention to the more recent expanded recommendations to offer meningococcal vaccine to HIV-negative MSM at-risk as well as HIV-positive MSM in New York City.
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Clinical Features of Invasive Meningococcal Disease in HIV-infected MSM, and Immunizations in HIV-infected Adults
The number of deaths in NYC caused by invasive meningococcal disease (IMD) continues to increase. Are you prepared to diagnose this rapidly progressive disease in time to save lives? And are your eligible patients up-to-date on all targeted and routine immunizations? In this program Don Weiss will begin by discussing the clinical cases of IMD in MSM that are the cause the current health alert in NYC, and then Sheila Palevsky will review the preventive meningococcal vaccine recommendations for our patients at highest risk, as well as routine vaccines for all our HIV-positive patients.
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Update on the Invasive Meningococcal Disease Outbreak Among Men Who Have Sex With Men
If you work in NYC you have probably received the alerts about the cases of invasive meningococcal disease in MSM in our area, and we hope you have begun vaccinating your at-risk patients with one of the available meningococcal vaccines, or referring them to a center that does. This brief report by Dr. Marci Layton of the New York City Department of Health and Mental Hygiene, on invasive meningococcal disease and the current efforts to provide protective meningococcal vaccines to eligible HIV-positive MSM, was added on to the beginning of our October meeting as an urgent brief presentation.
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Primary-care Diagnosis and Treatment of Common Dermatological Problems in HIV Medicine
Skin problems are common in primary care, and in HIV medicine they can be especially challenging. With 30 years of experience caring for people with HIV and AIDS as both an internist and dermatologist, Pat Hennessey shares his library of images and extensive clinical insight regarding everything from Kaposi's sarcoma to itchy red bump disease.
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Historical Clues, Physical Signs, Laboratory Diagnosis & Treatment of Oral, Anogenital & Systemic STDs
Knowing when and how to successfully diagnose, treat, and counsel patients with sexually transmitted diseases is a skill that benefits our patients, their sexual partners and the public health. Syphilis, gonorrhea, Chlamydia, LGV, herpes, HPV, and even acute HIV can present in myriad ways, and the more efficient we are at suspecting, diagnosing, and treating these diseases, the better we are at preventing further spread.
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HIV Infection: Worse the Second Time?
HIV-1 coinfection and superinfection are not that uncommon, but few people talk about it, or the viral evolution that dual infections make possible. Davey Smith does talk about it, and if you have patients who think serosorting is safe, you will be better prepared to advise them about the risks and implications of HIV superinfection.
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Gastrointestinal Disease in HIV Infection
Before the introduction of HAART, bowel disorders including KS, CMV, and wasting were more common, but remembering and understanding these complications can still be helpful, and even life-saving, if you recognize them. Don Kotler's knowledge and experience in the diagnosis and treatment of gastrointestinal disease from the very beginning of the HIV epidemic qualifies him to speak not only about the more common GI problems today, but also the less frequent complications we must consider, and never forget.
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Learning From HIV: Pharmacology's Role In The Management Of Hepatitis C
Clinicians managing HIV disease have long been aware of drug interactions that affect therapeutic levels or increase risk of toxicity. And now, the introduction of antiretroviral drugs for the treatment of hepatitis C, called directly acting agents (DAA), demands a similar awareness of potential drug interactions, especially when treating HIV and HCV coinfection. Charlie Flexner, well known for his work in HIV drug-drug interactions, returned to PRN to discuss this emerging therapeutic challenge.
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Clinical Management Of Hepatitis C In Patients With And Without HIV Coinfection
There is great excitement about the introduction of directly acting agents for the treatment of chronic hepatitis C, and due to the experience that HIV clinicians already have with the use of antiretroviral agents, co-management of these diseases is optimal for patent care. In this lecture Andy Talal reviews recent advances in HCV monotherapy and implications for HIV-HCV coinfection.
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New Insights In Hepatitis B And HIV Coinfection
Hepatitis B coinfection should either be prevented through vaccination, or diagnosed and treated with HIV disease. Due to an increased risk for severe liver disease, drug resistance and hepatic flair in HIV-HBV coinfection, understanding the laboratory diagnosis and work-up for liver disease in our patients is essential. Marion Peters returns to PRN for an update on the diagnosis and co-management of these viral infections.
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The Path To Anal Cancer Prevention: Where We Are And Where We’re Going
With increasing awareness of human papillomavirus (HPV) infection and its link to anal cancer, and the even greater risk for HIV-positive men and women, HPV prevention and treatment is an integral part of HIV medicine. Joel Palefsky returns to PRN to review what is known about anal neoplasia and preventing anal cancer.
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Clinical Diagnosis And Treatment Of Common Anorectal Disease In MSM
The anorectal exam is a routine element of any comprehensive physical exam, but in the examination of MSM with or at risk for HIV disease, it is essential. In this lecture Steve Goldstone shows numerous photos of anorectal pathology and tells us what we can do about it.
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HIV-1 Dual Infection: Real or Imagined?
HIV-1 dual infection, coinfection or superinfection, happens and that it may happen rather frequently. Dual infection has identifiable consequences affecting clinical care of patients who already have HIV and are at continued risk of superinfection. To make matters worse, recombination can occur when two distinct viral variants infect the same cell, adding to the genetic diversity of HIV worldwide, and further complicating the development of a preventive vaccine.
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Anogenital Human Papillomavirus Coinfection and Associated Neoplasia in HIV-positive Men and Women
The incidence of anal intraepithelial neoplasia (AIN) and anal cancer, caused by human papillomavirus (HPV), is much higher in HIV-positive women and HIV-positive men who have sex with men (MSM) than in the general population, and highly active antiretroviral therapy (HAART) for HIV disease has had little or no impact on this trend. There is a growing need for definitive guidelines to assess for AIN in HIV-positive individuals, and with better treatment options available, it is even more crucial to identify these patients at an earlier stage. New York is the first state to institute recommendations for anal cytology screening in HIV-positive patients.
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Understanding and Managing Community-Acquired Methicillin-Resistant Staphylococcus Aureus Among HIV-Infected Persons
Methicillin-resistant Staphylococcus aureus (MRSA) has been recognized as an important pathogen in nosocomial settings for many years. More recently, serious methicillin-resistant S aureus infections from the community have been described... Since these initial reports, several groups have reported outbreaks of MRSA infections occurring outside of healthcare facilities, involving athletes, military personnel, and inmates in correctional facilities leading to the term community-acquired MRSA (CA-MRSA). CA-MRSA outbreaks in men who have sex with men (MSM) have been recently reported in several US cities, possibly associated with methamphetamine use and risky sexual behavior. This review summarizes the current knowledge of the epidemiology, clinical manifestations, diagnosis, and management of CA-MRSA infections with an emphasis on the HIV patient.
Virology And Clinical Management of Hepatitis B And HIV Coinfection
HBV infection is a dynamic disease and coinfection with HIV considerably complicates its diagnosis and management. The choice of antiviral therapy should be based on the need for HIV therapy, with control of HBV when HAART is initiated. Combination therapy should be used to avoid development of antiviral resistance. Continuous monitoring of HBV patients, regardless of need for treatment or history of seroconversion, is imperative to recognize reactivation and subsequent need for treatment, and to identify drug resistance and viral breakthrough early. Prompt changes in therapy when resistance emerges will reduce the development of compensatory mutations that will affect our ability to use newer therapies and lead to transmission of drug-resistant viruses in vaccinated individuals.
Diagnosis and Treatment of HPV-Related Squamous Intraepithelial Neoplasia
Anal cancer in the general population is less than one per 100,000 people and is one-tenth the current rate of cervical cancer in the United States. However, the incidence of anal cancer among HIV-negative men who engage in receptive anal intercourse with other men was up to 35/100,000—a rate on a par with the incidence of cervical cancer before routine Pap smears were initiated in the 1940s. Even more alarming is the incidence of anal cancer among gay men with AIDS-- reported to be twice that of men of the same age, race, and sexual orientation in the years before AIDS. In other words, the incidence of anal cancer may be greater than 70 of every 100,000 HIV-infected MSM who engage in receptive anal intercourse. Dr Stephen Goldstone discusses screening, diagnosis and treatment.
Screening and Treatment of Anal Intraepithelial Neoplasia to Prevent Anal Cancer: Where do we stand?
We are sure of the following facts: 1) anal HPV infection is very common among MSM; 2) the prevalence and incidence of the putative anal cancer precursor, high-grade squamous intraepithelial lesions (HSIL) are very high among MSM; 3) the annual incidence of anal cancer among MSM is unacceptably high; 4) each of the above is more common among HIV-positive MSM than HIV-negative MSM; and 5) combination antiretroviral therapy has little, if any, impact on HSIL. Taken together, these observations would suggest that we should be mounting all-out campaigns to educate people around these issues and immediately implement screening and treatment programs to prevent anal cancer, modeled after the highly successful programs to prevent cervical cancer.
Ulcerating STDs and HIV: A Cause for Concern
Sexually transmitted infections (STIs) are among the most common infectious diseases in the United States today. The potential for HIV transmission is enhanced by the presence of STIs, and ulcerative STIs are of particular concern. In the US, most sexually transmitted genital ulcers are caused by genital herpes (HSV). Syphilis and chancroid ulcers are less common. Lymphogranuloma venereum (LGV), is still considered rare in the United States, but it is emerging as a source of concern. To review the standard approaches to diagnosing and treating these four ulcerative STIs, Dr. Susan Blank from the New York City Department of Health addressed the PRN membership during a standing-room-only meeting.
Pathogenesis and Treatment of Human Immunodeficiency Virus and Chronic Hepatitis C Virus infection
HCV treatment in HIV-infected patients is complex and difficult for patients to tolerate, but promising results have been attained with PEG IFN and ribavirin combination therapy. Interferon will continue to be the backbone of HCV treatment for some time. In the future, HAART-like triple-therapy may prove to increase efficacy and tolerability, and, hopefully, shorten the duration of treatment. It is likely that resistance testing will guide treatment decisions using new antiviral agents. Trials of new treatment strategies involving current drugs and new agents in coinfected patients should expand the understanding of the most appropriate treatment protocols in this population.
Acute Hepatitis C Infection in HIV-Infected Men—an Emerging Epidemic
In the last few years, there have been a number of reports of acute HCV infection in the HIV-infected MSM in urban centers in Europe and in the US. An important finding from these studies is that in these populations of MSM, the major route of transmission appears to have been sexual, not parenteral. This article will review the literature relevant to acute HCV infection in HIV-infected MSM, with a focus on the research that has been performed regarding this recent epidemic.
TB and HIV Coinfection: Current Trends, Diagnosis and Treatment Update
The impact that HIV has on the pathogenesis of tuberculosis (TB) is clear. It is one of the most important risk factors associated with an increased risk of latent TB infection progressing to active TB disease. HIV-infected people have an annual risk of 5% to 15% of developing active TB once infected. TB is the most common opportunistic infection in people living with HIV worldwide. It is also the most common cause of death in HIV-positive adults living in developing countries, despite being a preventable and treatable disease. This paper describes the global epidemiology of TB and HIV coinfection with an emphasis on its relevance to New York City’s large immigrant population, followed by diagnosis and treatment challenges in these patients.
Update on HBV and HIV Coinfection: Pathogenesis and Treatment
The etiology and pathogenesis of hepatitis B virus (HBV) infection are complex. Recent studies concerning liver-related mortality in HIV/HBV coinfected patients show a high rate of liver-related mortality compared to HBV-monoinfected patients. The primary goal of treating chronic HBV infection is to suppress progression of liver disease by suppressing viral replication. The treatments approved for the management of chronic HBV infection include interferon alfa-2b, pegylated interferon alfa-2a, lamivudine, adefovir, and entecavir. Other treatments may include emtricitabine and tenofovir.
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Treatment of HCV in HIV and HCV Coinfection: What are the New Questions?
Dr. Francesca Torriani discusses the potential benefits tied to the treatment of chronic hepatitis C virus (HCV) infection in HIV-infected individuals. The most desired outcome of treatment—which is possible in both HCV-monoinfected and HIV/HCV-coinfected patients—is viral eradication. Additional but unproven benefits of anti-HCV therapy may be a reduction in inflammatory hepatic damage with regression of fibrosis and/or the risk of hepatocellular carcinoma, or to improve tolerability of antiretrovirals. There is also the public health component of HCV treatment: to render patients aviremic, thus reducing their chances of passing the virus on to others.
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Management of HIV/HCV Coinfection: An Update
While HIV/HCV-coinfected patients may not respond as well to pegylated interferon/ribavirin therapy as HCV-monoinfected patients, it’s clear that this drug combination can and does produce sustained virologic responses in a number of HIV/HCV-coinfected patients—much more so than standard interferon and ribavirin—and should now be viewed as optimal antiviral therapy for HCV in coinfection.
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Herpes Group Viruses and HIV Infection
In recent years we’ve identified a number of possibilities in the context of herpes infections, all of which will need to be evaluated in future studies. With herpes simplex virus 2 (HSV-2), we really may see reduced HIV transmission rates with the treatment and suppression of HSV-2 infection, even in patients without symptoms of disease. As for varicellovirus (VZV), we should be stepping up efforts to immunize our VZV-seronegative patients using the chickenpox vaccine, including HIV-positive patients with decent immunity. For cytomegalovirus, given the not-so-obvious ways in which it might contribute to HIV disease progression, there’s probably a need for additional data looking at the effects of pre-emptive therapy on mortality rates in HIV. Epstein-Barr virus (EBV) infection is being overlooked, and we need to study the effect of therapy on reducing EBV viral load and the benefit it may have in terms of reducing the risk of certain malignancies.
Coinfection with HIV and HBV: Diagnosis and Therapy
While chronic HBV disease in the setting of HIV is not listed as an AIDS-defining illness, it is undoubtedly an opportunistic infection in the setting of HIV coinfection. HIV-positive individuals, particularly those with suppressed immune systems, are less likely to respond to vaccination against hepatitis B and are more likely to develop chronic disease after being exposed to the virus. In addition, individuals coinfected with HIV and HBV are more likely to present with atypical serologies, to have higher HBV-DNA levels, and to experience more profound liver disease as a result of chronic infection. This article highlights much of the current thinking surrounding the pathogenesis, diagnosis, monitoring, and treatment of chronic hepatitis B in HBV-monoinfected and HIV/HBV-coinfected patients.
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Diagnosis and Management of HPV-Associated Anogenital Dysplasia in HIV-Infected Men and Women
For clinicians involved in the management of HIV-infected individuals, human papillomavirus (HPV) coinfection and its sinister sequelae--squamous intraepithelial lesions and invasive cervical or anal carcinoma--are proving to be a significant challenge. This article reviews the epidemiology, pathogenesis, diagnosis, monitoring, and management of cervical and anal dysplasia in the setting of HIV. “Data continue to emerge, supporting the diagnosis and management of cervical and anal dysplasia in HIV-infected patients,” said Dr. Joel Palefsky, who returned to PRN to discuss recent advances in the study and clinical care of HIV/HPV coinfection.
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When Two Infections Are Better Than One: The Exceptional Role of GB Virus-C (GBV-C) in HIV Disease
When it comes to HIV and hepatitis virus coinfections, the pages of The PRN Notebook have been filled with numerous reports highlighting the distressing prevalence and negative consequences of both hepatitis B virus (HBV) and hepatitis C virus (HCV) in HIV-infected individuals. However, it does not appear that all coinfections are harmful. In fact, some may be associated with a significant survival advantage-a theory that has many HIV experts both perplexed and excited.
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Bioterrorism and Smallpox Vaccination: Experience and Considerations
Smallpox, which is believed to have originated over 3,000 years ago in India or Egypt, is one of the most devastating diseases known to humanity. For centuries, repeated smallpox epidemics swept across continents, decimating populations in their wake. The disease, for which no effective treatment was ever developed, killed as many as 30% of those infected. Between 65% and 80% of survivors were marked with deep-pitted pockmarks, most prominent on the face. Blindness was another complication. In 18th century Europe, a third of all reported cases of blindness were because of smallpox.
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Update on HIV/HBV Coinfection: Pathogenesis and Treatment
It has been estimated that approximately 250 million people worldwide have chronic hepatitis B virus (HBV) infection. In the United States alone, an estimated 1.25 million people--0.35% of the U.S. population--have chronic HBV, defined as patients with a positive hepatitis B surface antigen (HBsAg) serology for more than six months. While hepatitis B vaccination programs are an important component of hepatitis B prevention strategies, they will not have an impact on those already living with this potentially fatal disease. Carriers of HBV are at increased risk of developing cirrhosis, hepatic decompensation, and hepatocellular carcinoma. Although most carriers do not develop hepatitic complications, 25% to 40% do go on to develop serious HBV-related manifestations during their lifetime.
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Sexually Transmitted Diseases in Review: The 2002 CDC STD Treatment Guidelines
Sexually transmitted diseases (STDs) are among the most common infectious diseases in the United States today, affecting more than 13 million men and women in this country each year. This article reviews six common STDs—genital herpes, syphilis, gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis—that can be considered in broad groups according to whether their major initial manifestations are 1) genital sores; 2) urethritis or cervicitis; and 3) vaginal discharge. The diagnostic and treatment recommendations, unless otherwise noted, reflect those specified by the CDC in the 2002 update.
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Therapeutic Implications of Acute Hepatitis C Infection
“Many more general practitioners and advocacy groups need to be aware of the signs and symptoms of acute HCV infection. Treatment may have a great deal to offer individuals who are in the initial stages of HCV infection, which can also reduce the possibility of spreading the virus on to others." In turn, it is imperative that people at known risk through needle-stick injuries or injection drug use be thoroughly screened. It might also serve clinicians well to consider people in discordant relationships with HCV-positive individuals to be at risk, contrary to current beliefs that HCV is not a sexually transmitted disease. "If we are to see treatment benefits, this will require identifying patients early enough to begin treatment or to enroll them in clinical trials, which may be our biggest challenge yet."
HIV and TB Coinfection
Tuberculosis (TB) is one of the most dreaded diseases that afflict mankind, yet over 50 years after effective drug treatment was introduced, more people died of TB last year than in recorded history—2 to 3 million deaths, or 1 death every 10 seconds. New recommendations including more aggressive screening and early treatment approaches, particularly among those at the greatest risk for TB: persons living with HIV and AIDS. This discussion of HIV and TB coinfection by Dr Wafaa El-Sadr includes treatment recommendations, drug-drug interactions and paradoxical response to treatment caused by immune restoration inflammatory syndrome.
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