Although we see Kaposi Sarcoma less frequently these days, it is far from gone, as we know from seroprevalence data for the causative virus, KSHV. We have had numerous talks at PRN over the past 30 years on the discovery of KSHV and the evolving therapies for the manifestations of KS. Now it is time to focus again on the silent sexual transmission of this infection and a reminder of the various manifestations of this disease in people living with HIV. In this presentation, Sheena Knights will share her recent research in the ongoing spread of KSHV in at-risk populations and health disparities that may still contribute to mortality among MSM with HIV.
The explosion of mpox that caught everybody by surprise and most severely affected our immunodeficient patients has receded, but is not gone. It is important now that mpox be included in our pantheon of sexually transmitted infections and include necessary preventive immunization for our patients at risk moving forward.
For men who have sex with men and for transgender women who have sex with men, acute or primary hepatitis C has been shown to be a sexually transmitted infection. Similarly, HCV reinfection has been shown to be sexually transmitted as well. It is of critical importance that we keep this in mind for our patients on PrEP to prevent HIV infection, as well as our patients living with HIV. In this presentation, Daniel S. Fierer explains the risks, the incidence, early diagnosis, and treatment strategies for both HCV primary infection and reinfection.
While precautions against disease transmission have been reduced in public gathering spaces, current recommendations for the general population do not really address the extra precautions and strategies necessary to protect our most vulnerable immune-compromised patients, including those with immune failure from HIV/AIDS and immune suppression from transplants or cancer chemotherapy. Understanding the unique needs of such patients as well as vaccine limitations and safety precautions are critically important to the well-being, quality of life, and survival of the immune-compromised. Don’t miss this important presentation by Angélica Cifuentes Kottkamp that dives into the details.
IDSA’s annual conference, IDWeek, is always a rich source of research information that pertains to our patient populations. This year, Raj Gandhi will focus on highlights from IDWeek on HIV, MPXV, and COVID-19. Don’t miss this important and timely update!
Our knowledge of, and clinical skills in diagnosis of, sexually transmitted infections are constantly evolving. It is critical that we are up to date on all of the STIs because patients often with more than one at a time. Culturally sensitive sexual histories and physical exams are critical for early diagnosis and treatment for interrupting chains of transmission in the communities that we serve. Don’t miss this STImulating update by Rosalyn Plotzker.
Monkeypox crashed into our communities earlier this year spreading like wildfire, especially in sexually active MSM. There were many diverse clinical presentations, so we have brought together a panel of NYC primary care providers to share their experiences in diagnosing this new sexually transmitted infection.
Immunizations are our best bet for combatting preventable disease in all people, young and old. And in our patients with and at-risk for HIV infection, immunizations have never been more important than in the topsy-turvy world of infectious diseases we are living through! Dr. Jane Zucker returns with critical updates to current vaccine recommendations in adults and adolescents and Dr. Tristan McPherson will add updates on current monkeypox (MPX) prevention strategies.
The last thing we need is another pandemic, but it looks like that is what is happening with Monkeypox (MPX), especially in men who have sex with men (MSM). This epidemic outside of endemic regions of Africa was first noted in England and other parts of Europe. Now that this infection is exploding in the United States, we have invited Sanjay Bhagani from the Royal Free in London to speak on his experiences dealing with MPX from the very beginning.
What are the post-acute sequelae of SARS-CoV-2 that define long COVID? Is it different in people living with HIV? This presentation by Keri Althoff will help you understand the phenotypes and possible mechanisms of long COVID. Dr. Althoff will also focus on the manifestations of long COVID in people living with HIV.
Evidence-based treatment options for COVID-19 in non-hospitalized patients are expanding. In this presentation Raj Gandhi will discuss the most current approaches to treating non-hospitalized patients with COVID-19, as well as important considerations for hospitalized patients. Additionally, Dr. Gandhi will summarize our current understanding of COVID-19 in people living with HIV.
How does HIV coinfection affect the epidemiology, progression and treatment of hepatitis C (HCV)? In this presentation, Brianna Norton will bring you up-to-date on the natural progression of liver disease in HIV/HCV coinfected individuals and discuss the differences in HCV epidemiology among HIV/HCV coinfected versus HCV monoinfected individuals. Dr. Norton will also discuss drug-drug interactions between HIV antiretrovirals and HCV directly-acting-antivirals.
Diagnosis and prevention of anal cancer has long been an important element of HIV Medicine. In this presentation, Stephen Goldstone returns to speak on the most recent data demonstrating success of the HPV vaccine. He will also discuss wide-field ablation of high-grade squamous epithelial lesions (HSIL) and whether treating HSIL is reducing anal cancer in those at highest risk.
Up-to-date knowledge of COVID-19 vaccines, newer vaccine options under development, and the evidence for and against booster shots have never been more important during this pandemic. Kristen Marks will discuss these issues as well as adverse events secondary to COVID-19 vaccines, and common vaccine management questions.
What clinicians and researchers have learned over these past 18 months during the COVID-19 pandemic is of critical importance to us now and may help us change outcomes for this as well as future pandemics. Jügen Rockstroh’s thoughtful presentation will provide an update on COVID-19 epidemiology, diagnostics, treatments and vaccines from a European perspective.
Does COVID-19 infection contribute to liver disease? And does pre-existing liver disease affect the course of COVID-19 outcomes? In this presentation, Elizabeth Verna addresses these important questions and also explains how the COVID-19 pandemic has impacted the care of patients with chronic liver disease including the initiatives regarding viral hepatitis elimination.
Despite the vaccine roll-out, new cases of COVID-19 persist; hence we still need tounderstand and optimize the treatments available to us, as well as those in development. In this comprehensive presentation, Davey Smith discusses current treatments as well as antiviral drugs in development for COVID-19.
We all worry about co-infections in our patients living with HIV/AIDS and their potential outcomes. This is especially true in the COVID-19 pandemic. In this presentation, Dr. Sarah Braunstein, from the New York City Department of Health and Mental Hygiene, will discuss the intersection of HIV and COVID-19 in New York City and the growing evidence for higher risk of adverse COVID-19-related outcomes among people with HIV.
In this crucial and timely presentation, Susan Little compares and contrasts currently available mrna vaccines to each other and to the pending adenovirus and protein subunit vaccines in development. Dr. Little covers other important topics including vaccine hesitancy, limits on currently available data, and how to report adverse experiences in your patient population during post-licensure surveillance.
From our experience with HIV, we all appreciate the impactof viral mutations. In this PRN presentation, Jonathan Li discusses the evolution, viral escape, persistence, reinfection and novel strains of Sars-CoV-2 and how they are affecting the current COVID-19 pandemic.
Dr. Mark Mulligan, Director, NYU Langone Vaccine Center describes the current landscape of COVID vaccine research.
This program is up-to-the-minute with a focus on New York City’s current role in COVID prevention, the emerging science during this public health emergency, and how we can learn from our HIV experience to manage the current pandemic.
COVID-19 epidemic in Europe: What have we learned? And does underlying HIV-infection make a difference?
What European clinicians and researchers have recently learned in these unprecedented times is of critical importance to us now and may help us change future outcomes.
Are all your patients up to date on vaccines? In these troubled times of “vaccine hesitancy,” internet misinformation, and clinician burnout, it is important that we take the time to make sure all of our patients, especially those living with HIV or asking for PrEP, are up to date on all their vaccines. This presentation by Jane Zucker will give you the information you need to confidently inform and advise your patients about immunizations and get the job done right.
If you are not already treating hepatitis C in your patients who may be injecting drugs, why not? What barriers are holding you back? This compelling presentation by Brianna Norton targets the evidence-based studies that address the fears and misconceptions as well as the safety, efficacy and cost-effeciency of HCV treatment, even in patients who continue to inject illicit drugs. It all boils down to harm reduction, getting serious about eliminating hepatitis C, and knowing that, just as with HIV, treatment of HCV prevents further transmissions. And you can do it!
The kinds of sexually transmitted infections as well as their optimal treatments, in our patient with or at risk for HIV, are evolving and increasingly problematic. Recently, there was another cluster of sexually transmitted cases of hepatitis A in NYC, multi-drug-resistant GC remains a threat, lymphogranuloma venereum is a treatment problem especially when it is rectal, and mycoplasma genitalium (MGen) is on the rise. Being up to date on the diagnosis and treatment of STIs, and what do do when treatment fails, is important not just for your patients’ well-being but for their partners as well. Don’t miss this important update by Anna Huang on the other STIs we are presently seeing in the era of U = U and PrEP, and what you need to know to more effectively interrupt their chains of transmission.
The newer drugs we now have to treat Hepatitis C have never been more tolerable, efficacious, or easier to use. And better yet, they can be used safely in acute HCV, people who continue to inject drugs, and even in people with end-stage liver disease and cirrhosis. If you are not already treating your patients with HCV, now is the time to watch this exciting program by Kristen Marks, and consider expanding your practice to treat and cure your patients with hepatitis C. Yes, its curable, and you can do this!
Current data shows that anal cancer is increasing in general population and will remain the most common preventable cancer in our HIV-positive patients. So, what can we do to help prevent HPV-associated anal cancer? The preventive HPV vaccine is safe and highly efficacious, but what about anal cancer prevention in our patients already infected with oncogenic strains of HPV? This presentation by Joel Palefsky will bring you up-to-date on all current prevention modalities, how to evaluate your patients at risk, efforts to block progression to cancer, and scientific advances that may help us improve screening and prevention moving forward.
Injection drug use is a growing problem across the country, and a well-known risk for transmission of hepatitis C. But can HCV in our patients who continue to inject drugs be successfully be treated? Does HIV/HCV coinfection decrease the odds for success? Can they be re-infected with HCV once cured? Will treatment of HCV in in these patients help stop the HCV epidemic? Unlike HIV, HCV is now curable, but we will never end the HCV epidemic if we cannot adequately serve our most vulnerable populations. This important program grapples with the barriers, both real and imagined, that stand in our way.
This past year was another bad year for influenza, and a good reminder that vaccines can play an important role in the prevention of many infections, and even cancer, in our patients living with, and at risk for HIV disease, including the meningococcal vaccine, and vaccines for HAV, HBV, and HPV, just to name a few. But when should we offer them? How many can we give at one time. If and when are certain vaccines contraindicated? And how can we help our patients keep track of their vaccines in an online registry? Dr. Jane Zucker answers all of these questions, and more, in this important and stimulating presentation.
While we are still struggling to find a cure for HIV, we are already over the finish line with HCV. The combination treatments that we currently have for HCV are so effective and well-tolerated, in fact, that further drug development has been discontinued! In this program, Jordan Feld fills you in on the success of available HCV treatment options and urges you to join the effort to diagnose and treat HCV in your practice. HCV can be cured, and now it is time for us to see that our patients who need treatment get it!
In New York City, the number new HIV infections is dropping, thanks to PrEP (pre-exposure prophylaxis) and U=U (undetectable equals untransmittable). But with a simultaneous decrease in condom use, sexually transmitted bacterial infections are rising—especially the big three: syphilis, gonorrhea and Chlamydia. This important presentation, by Dr Susan Blank from the NYC DOHMH, will bring you up to date on the epidemiology and impact of these bacterial STIs in our communities, especially in MSM who are most highly affected, and women of child-bearing age who are most vulnerable to catastrophic outcomes. Dr Blank also targets best practices for treatment of these bacterial STIs, while reducing the risks for treatment failure and development of drug resistance.
The treatment of HCV, even in the presence of HIV coinfection, just keeps getting better. This program reviews the advances in HCV treatments, but focuses on the newest direct-acting antvirals (DAAs) for the treatment of HCV monoinfection, as well as HCV/HIV coinfection. Dr Muir also calls attention to recent DAA drug safety issues, regarding the activation of HBV, in people with past or current HBV while on DAA therapy for HCV, and how to monitor patients with current or prior HBV during and following DAA treatment of HCV.
Hepatitis C infection is on the rise among young persons in New York State and across the country, and, although HCV can be sexually transmitted in MSM, new HCV infections are predominantly in people who inject illicit drugs. But although 80% of people who inject drugs are willing to receive HCV treatment, only 1 to 2 percent are treated each year. Meanwhile, those who are untreated continue transmitting HCV to others, even though the HCV cure rates with the new DAAS are excellent-- even for active drug users. Yes, reinfection with HCV is possible, but the incidence is low, and as we have learned with HIV, treatment as prevention can also help slow the HCV epidemic. Don’t miss this important presentation by Brianna Norton on overcoming the barriers to treating HCV and HCV/HIV coinfection in people who inject drugs.
How safe and effective are the new hepatitis C drugs when they are taken along with drugs that treat HIV? And vice versa? And what about interactions with drugs our patients need for other health problems, or over-the-counter products our patients choose to take with or without our knowledge? As treatments for HCV and HIV continue to change, this presentation by Charles Flexner will help you stay up to date on drug-drug interactions, so that you can ask the right questions, make more informed treatment choices, warn your patients about potential dangers, and increase the odds that your patients will achieve their desired treatment outcomes.
HIV and HBV testing, prevention, and treatment go hand-in-hand, because our patients at highest risk for one, are also at high risk for the other. And HIV exacerbates the dangers of HBV coinfection. Drugs used for HIV treatment and HIV PrEP will also treat chronic hepatitis B, but cannot guarantee against acute HBV infection. But we have long had a vaccine to protect against HBV infection that we can offer to all people at risk for, or infected with HIV. This important presentation reviews the epidemiology, laboratory testing, treatment and prevention of hepatitis B that may otherwise be overlooked or misunderstood.
The advances in the successful treatment of chronic HCV just keep coming, and the annual meeting of the AASLD – “the liver meeting” – spotlights these scientific and clinical advances best. In this program, Dost Sarpel reviews the current HCV treatment state-of-the-art, with important notes from the recent liver meeting in San Francisco.
Remember cytomegalovirus? The AIDS-defining sight- and life-threatening complications of CMV coinfection from the pre-HAART era are rarely seen today. But CMV is still with us, sexually transmitted, chronic, incurable, and contributing to inflammation and non-AIDS morbidity in people aging with well-managed HIV.
Chronic hepatitis C is curable and the treatment is simpler and more effective than ever. But it is estimated that only half of the people with chronic HCV infection have been diagnosed and the other la are unaware that they have it and can transmit it to other people, and that without treatment it can lead to liver failure, liver transplant, or liver cancer. To change this disastrous situation before people reach end-stage, we have a mandate in New York State to assure primary care providers are asking, testing, and referring candidates for HCV treatment. But shouldn’t we be doing this anyway, even without a mandate? Screening is easy, and referral to care is getting easier too. Don’t miss this important lecture on ways that you can help, and new approaches to assure patient access to ongoing care and treatment.
Syphilis Diagnostics, Still Clear as Mud; Syphilis Therapeutics, Not So Much.
Maximizing Syphilis Treatment: Is That History of Penicillin Allergy Real?
As PrEP against HIV gains momentum there is a possibility we will see other STDs consequent to an increase in condomless sex, including syphilis. But how can we best treat syphilis when there is a history of penicillin allergy? In this practical but important program two speakers will tackle the various aspects of syphilis diagnosis, staging, optimizing treatment in penicillin allergic patients, as well as the indications for skin testing for antibiotic hypersensitivity.
The recent outbreak of Ebola in West Africa and the fear it caused worldwide are a vivid reminder of reactions to the AIDS epidemic years ago. Both infections are of zoonotic origin, and capable of producing stigma, discrimination, fear and denial. In this program, Dr. El-Sadr discusses how lessons learned in the early years of the HIV epidemic, including community mobilization, human rights measures, workforce innovations, laboratory systems and outreach activities have contributed to a rational and science-based response to contain and control Ebola transmission.
Special 5-Minute Public Health Announcement: After a lull in reported cases, there has been a recent cluster of Invasive Menigococcal Disease, even in some men who had already received the recommended preventive vaccines. Demetre Daskalakis, in his newly appointed role at the New York City Department of Health and Mental Hygiene, discusses the details of these disturbing new cases in this special brief public health announcement to the PRN audience.
Special 5-Minute Public Health Announcement: With the frequency of international travel to NYC and the potential for travelers returning from areas of Africa affected by Ebola, this brief presentation on the Ebola epidemic was added to PRN’s August 2014 meeting as a public health service for primary-care providers. It is important for all clinicians in NYC to be familiar with relevant travel history, the signs and symptoms of Ebola, and the triage of suspected cases.
In HIV-HCV coinfection, liver-related death remains the number one cause of death, led by decompensated cirrhosis, but also including liver cancer and post-transplant complications. But HCV is curable. The indications for HCV treatment in HCV/HIV co-infected patients are no different than in patients with HCV mono-infection, and the same treatment regimens can be used in HIV-coinfected patients as in patients without HIV infection, since the virological results have been shown to be identical. The role of primary care, especially providers with HIV treatment experience, is critical in identifying candidates for HCV treatment earlier, and securing treatment with newer directly acting agents that more effectively reverse the outcomes of this life-threatening coinfection.
Bacterial STIs in NYC: Epidemiological Trends, Diagnostic Considerations and Management Issues in People With or At Risk for HIV Disease
If you have a patient with a sore throat or rectal complaints are you requesting a thorough sexual history and appropriate STD testing? The threat of sexually transmitted bacterial diseases—not just the usual suspects, but also drug-resistant gonorrhea, lymphogranuloma venereum and mycoplasma genitalium -- is increasing even as HIV prevention shows promise of improvement. At this strategic point in time, it is prudent to review the most current recommendations for bacterial STI diagnosis and treatment in the era of oral sex, HIV-serosorting, HIV pre-exposure prophylaxis and condomless sex.
Hepatitis C coinfection can be cured in HIV-positive patients, and extends life. HCV-related liver disease including hepatocellular carcinoma have become major causes of death in HIV disease, but the treatment for this life-threatening coinfection has gotten better and will soon be even easier. Or as Doug Dieterich says: “It’s a really good time to have hepatitis C.” In this video he explains what he means as he discusses the history of HCV treatment, recent advances and future improvements supported by current and ongoing research.
The increasing incidence of anal cancer, especially in HIV-infected individuals is a cause of great concern, and efforts to reduce the risk for progression to cancer are underway internationally. But can vaccines designed for the prevention of infection with oncogenic Human papillomavirus (HPV) infection also have a therapeutic effect in reducing the recurrence of high-grade anal neoplasia in HIV-infected men? This interesting new work by Stephen Goldstone suggests that this may be so.
Hepatitis C is the most common chronic blood-borne infection in the United States and HCV-related cirrhosis is projected to peak over the next 10 years. New York State has recently mandated that primary care providers offer one-time HCV antibody testing to all baby boomers—the birth cohort from 1945 to 1965—because this is a treatable and curable disease that too often remains undiagnosed until the end stages. Earlier screening and diagnosis of hepatitis C, followed by linkage to care, could save many lives. In this lecture Dr Perumalswami discusses the details of this public health effort in the broader context of viral hepatitis coinfection in people with HIV disease.
The epidemic of sexually transmitted hepatitis C in men who have sex with men (MSM) is phylogenetically distinct from clusters of HCV in injection drug users, and clinicians caring for MSM, especially those who are HIV-positive, need to be on the look-out. While acute hepatitis C infection may clear spontaneously, this is far less likely to occur in patients who are HIV-coinfected, and coinfection worsens the prognosis for chronic HCV. Understanding the risks and knowing how to diagnose acute HCV infection is important because early treatment of HCV may improve patient outcomes while interrupting the chain of transmission. And newer direct acting agents (DAAs) for the treatment of HCV may lead to interferon-free treatment options that reduce treatment-related side-effects in this curable disease.
Many interferon-sparing and interferon-free regimens for the treatment of hepatitis C are in development, and simpler dosing with fewer side effects is the goal. With these advances, it is hoped that current trials will lead to higher cure rates in both HCV monoinfection and HIV-HCV coinfection.
Hepatitis C is the major cause of life threatening liver disease worldwide, and a leading cause of death in HIV-coinfected individuals. The treatment of hepatitis C and HCV-HIV coinfection is difficult, but chronic HCV can be cured. The treatment of hepatitis C continues to improve, with new direct-acting agents and the hope for interferon-free regimens in the future.
SPECIAL BRIEF REPORT: 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.
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.
SPECIAL BRIEF REPORT: 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.
Human papillomavirus (HPV) is the most common sexually transmitted infection and HPV-associated anal cancer is an increasing concern, especially for HIV-infected patients. Anal HPV infection and associated anal intraepithelial neoplasia (AIN) are highly prevalent in HIV-infected men and women. Due to this increased risk, screening programs for AIN in all HIV-infected individuals, and routine vaccination of HIV-infected patients 9-26 years of age, should be strongly considered. Further research is needed to expand our treatment and prevention options for this life-threatening complication.
With effective antiretroviral therapy, people with HIV are living longer and the burden of cancer in this population continues to increase. Malignancies are more common and occur earlier in HIV-positives than in the general population. The increased risk for both AIDS-defining and non-AIDS-defining cancers in HIV positive populations have clear implications for cancer prevention, screening and evidence-based therapies, yet patients with HIV and cancer have historically been under-represented on cancer clinical trials.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
“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."
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.