Managing Comorbidities and Coinfections in HIV: Interview With Rajesh T. Gandhi, MD
|This article is part of Infectious Disease Advisor's coverage of IDWeek 2017™, which took place in San Diego, CA. Our staff will be reporting on the latest breaking research and clinical advances in infectious diseases. Check back regularly for highlights from IDWeek 2017.|
SAN DIEGO — Rajesh T. Gandhi, MD, director of HIV Clinical Services and Education at Massachusetts General Hospital in Boston, spoke with Infectious Disease Advisor at IDWeek™ 2017 about coinfections and comorbidities in HIV.
HIV and Sexually Transmitted Infections
My name is Raj Gandhi. I am a physician at Massachusetts General Hospital in Boston, and I'm here at IDWeek in San Diego.
One of the sessions that I found most clinically relevant was on coinfections and comorbidities.1-3 As our patients are doing well on antiretroviral therapy (ART), it is incumbent on us to manage them appropriately for coinfections that they might have, as well as comorbidities, so this session was really focused on that topic. There were 3 great talks that were given: one was on HIV and sexually transmitted infections (STIs) and presented by Susan Philip, MD, MPH, from San Francisco.1 There were a couple of points that I took away from this session. One is that STIs are incredibly common in people with HIV, and we need to be screening for them. What she pointed out is that you cannot just screen at 1 site; you have to do what she calls “3-site screening,” which involves genital screening but also oropharynx and rectum. If you do just one site, you're likely to miss a STI.
She also made the point — which has been known for some time but really stressed in this presentation — that a lot of times STIs are asymptomatic. So, unless you screen for them, you are not going to find them and you are not going to be able to treat the patient appropriately. She pointed out that for most STIs, treatment of individuals who are HIV positive is similar to people without HIV. For trichomonas in women, there are some specific recommendations that differ for women with HIV compared with recommendations for those without HIV.
HIV in the Brain
The next talk was given by Shibani Mukerji, MD, PhD, from Massachusetts General Hospital. Dr Mukerji talked about HIV and the brain.2 She first talked about neurocognitive impairment. She pointed out that although HIV dementia is really rare in people on ART, milder forms of HIV-related neurocognitive impairment are really quite common. As a result, we should be screening for them, although the best method to screen for them is still unknown. She also pointed out that ART penetrates into the cerebrospinal fluid (CSF), but the data behind that for treating HIV-related neurocognitive impairment is still not definitive. Therefore, we need more studies on that.
The last point she made — and this is a very important point — is that you should think about CSF escape of HIV in a person who is doing well but then has an acute or subacute deterioration in their neurocognitive function. What you should then do is a lumbar puncture to look for escape of HIV into the CSF. This is very rare, but it does occur, and she pointed out some situations where you might want to think about it.
HIV and Human Papillomavirus
The last talk was by Timothy Wilkin, MD, MPH from Weill Cornell Medicine in New York City, and he provided a masterful overview of HIV and human papillomavirus (HPV).3 HPV is very common in people with HIV, and he gave us some guidelines as to screening for HPV. If you see HPV on a Papanicolau test, either through dysplasia, or through positive DNA testing, he reiterated the importance of referring for high-resolution anoscopy to look for precancerous lesions. He did point out that it is not widely available, but it is becoming more so in some of the bigger centers. He said that we should be looking for the results of the ANCHOR study [Topical or Ablative Treatment in Preventing Anal Cancer in Patients with HIV and Anal High-Grade Squamous Intraepithelial Lesions; ClinicalTrials.gov Identifier NCT02135419], which is a large, randomized trial that is ongoing. It is going to tell us if treating dysplasia is better than close monitoring, or so-called “watchful waiting.”
Finally, Dr Wilkin gave some intriguing talks on oropharyngeal cancer and HPV. We will have to keep our eye out as to whether the vaccines for HPV prevent oropharyngeal cancer, as we don't know that yet.
The last comment I'll make is to get your patients immunized for HPV. There is now a 9-valent vaccine that protects against 9 different types of HPV. Get your patients immunized when they are young so that they will be protected against some of these complications.
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- Phillip S. Managing Comorbidities and co-infections in patients with HIV: HIV and STIs. Presented at: IDWeek 2017; October 4-8, 2017; San Diego, CA. Symposium 974.
- Mukerji S. Managing Comorbidities and co-infections in patients with HIV: HIV in the brain. Presented at: IDWeek 2017; October 4-8, 2017; San Diego, CA. Symposium 975.
- Wilkin T. Managing Comorbidities and co-infections in patients with HIV: HIV and HPV. Presented at: IDWeek 2017; October 4-8, 2017; San Diego, CA. Symposium 976.