Carole Khaw, MD, on Treating STIs in Individuals With HIV
Individuals with HIV and other sexually transmitted infections (STIs) have higher morbidity and mortality rates than individuals with HIV alone or STIs alone. In addition, there has recently been a significant increase in STI incidence among individuals with HIV.
It is because of this increased prevalence that HIV innovation forums are held around the world. The 2017 forum was held in Australia, the theme of which was proactive management of STIs in people living with HIV.
To summarize the forum’s findings, Carole Khaw, MD—who is a consultant sexual health physician in the Infectious Diseases Unit of the Adelaide Sexual Health Centre at the Royal Adelaide Hospital in Australia—and colleagues transcribed an article for AIDS Research and Therapy.1 She also answered our burning questions.
CONSULTANT360: Which STIs are most common among patients with HIV infections? What is the connection?
Carole Khaw: Epidemics of STIs including gonorrhea, syphilis, hepatitis C virus (HCV), and Mycoplasma genitalium have been seen in HIV-positive patients with dramatic increases in incidences of these infections in this population. Managing these STIs is important to reduce the associated increased morbidity and mortality.
The increased incidence of syphilis in HIV-positive patients is thought to be due to a transmission synergy from biological phenomenon like mucosal ulceration or risk behavior (decreased safer sex practices).
HCV is a common coinfection in HIV-positive patients, increasing morbidity and mortality in these patients. Clusters of HCV strains in HIV-positive patients who acquire HCV through intravenous drug use and sex (irrespective of mode of infection) have been shown, demonstrating the importance of understanding transmission networks.
In an Australian study, M genitalium has been found to be more common in HIV-positive patients with proctitis symptoms
C360: There has been a significant increase in the incidence of STIs in HIV-positive patients. What factors have contributed to this increase?
CK: Many factors have been thought to contribute to the increase in STI incidence in HIV-positive patients, including the availability of effective treatment for HIV, increased STI testing, the use of pre-exposure prophylaxis (PrEP), decreasing condom use, the use of social media in the wider community, and the increase in antimicrobial resistance.
C360: What type of proactive management is best for these STIs?
CK: Screening and appropriate testing for these STIs as indicated is important. For example, with syphilis, regular testing should be considered in HIV-positive patients especially if clinically indicated and if patients are at high risk of acquiring infection. It is important to be aware that complications (ie, neurological invasion) may be more common in HIV-positive patients and should be actively managed.
Screening for HCV in HIV-positive patients may also be appropriate on a yearly basis and, if positive, consideration of treatment with direct-acting antiretrovirals in this population.
Data acquisition on antimicrobial sensitivities and antimicrobial stewardship is important to prevent ongoing epidemics and emergence of resistance.
Although not mentioned previously, human papillomavirus (HPV), especially oncogenic strains, can be sexually transmitted and contribute to the high rates of anal cancer in HIV-positive patients. Consideration of digital rectal examination annually in older HIV-positive patients may be a useful strategy as well as vaccination for HPV.
C360: Are there any additional requirements for patients? With low therapy adherence rate in the United States, how can health care providers ensure these requirements are met?
CK: HIV-positive patients, who continually engage in high-risk sex, should be encouraged to have regular STI screenings, including using self-collected swabs/urine for gonorrhea, chlamydia, and M genitalium (if symptomatic), as well as regular syphilis and hepatitis serology—hepatitis A, B, and C. Immunization should be considered if patients are not immune to hepatitis A and B.
Screening for cervical and anal cancer and HPV vaccination are also important considerations.
Ensuring adequate and early treatment of infections and encouraging compliance are vital in the management of STIs in these patients. Ways to increase adherence should be actively pursued.
Partner notification, adequate testing and treatment of partners are important requirements.
Accurate surveillance, monitoring of treatment failure, and resistance testing (eg, macrolide resistance testing for M genitalium) are also a priority.
Finally, the education of health care professionals and the community in STIs would contribute to improved management.
C360: What are the key takeaway messages for health care providers for patients with HIV plus an STI?
CK: The key takeaways include:
- Increase testing of STIs in HIV-positive patients, especially in those who continue to engage in high-risk sex.
- Administer prudent and appropriate treatment of the infections with elimination of the microbe.
- Promote awareness and prevention of antimicrobial resistance with good antimicrobial stewardship.
- Decrease risk-taking behavior and increase harm minimization.
- Notify partners regarding testing and treatment of partners.
- Increase awareness of drug-drug interactions.
- Khaw C, Richardson D, Matthews G, Read T. Looking at the positives: proactive management of STIs in people with HIV. 2018;15(28). https://doi.org/10.1186/s12981-018-0216-9.