Looking at the positives: proactive management of STIs in people with HIV

Abstract

Patients who are HIV-positive and co-infected with other sexually transmitted infections (STIs) are at risk of increased morbidity and mortality. This is of clinical significance. There has been a dramatic increase in the incidence of STIs, particularly syphilis, gonorrhoea, Mycoplasma genitalium and hepatitis C virus (HCV) in HIV-positive patients. The reasons for this are multifactorial, but contributing factors may include effective treatment for HIV, increased STI testing, use of HIV pre-exposure prophylaxis and use of social media to meet sexual partners. The rate of syphilis–HIV co-infection is increasing, with a corresponding increase in its incidence in the wider community. HIV-positive patients infected with syphilis are more likely to have neurological invasion, causing syndromes of neurosyphilis and ocular syphilis. HIV infection accelerates HCV disease progression in co-infected patients, and liver disease is a leading cause of non-AIDS-related mortality among patients who are HIV-positive. Since several direct-acting antivirals have become subsidised in Australia, there has been an increase in treatment uptake and a decrease in HCV viraemia in HIV-positive patients. The incidence of other sexually transmitted bacterial infections such as Neisseria gonorrhoeae and M. genitalium is increasing in HIV patients, causing urethritis, proctitis and other syndromes. Increasing antimicrobial resistance has also become a major concern, making treatment of these infections challenging. Increased appropriate testing and vigilant management of these STIs with data acquisition on antimicrobial sensitivities and antimicrobial stewardship are essential to prevent ongoing epidemics and emergence of resistance. Although efforts to prevent, treat and reduce epidemics of STIs in patients living with HIV are underway, further advances are needed to reduce the significant morbidity associated with co-infection in this patient setting.

Population prevalence of sexually transmitted infections in a high HIV burden district in KwaZulu-Natal, South Africa: Implications for HIV epidemic control

“…With the onset of the HIV epidemic interest in STIs has grown substantially as both share a complex, synergistic bidirectional relationship (Wasserheit, 1992;Barnabas et al, 2011;Looker et al, 2017). Evidence suggests that for HIV positive individuals, persistent high risk behaviours increase susceptibility to STIs (Erbelding et al, 2003;Chen et al, 2007;Lurie et al, 2014;Khaw et al, 2018), and advancing HIV infection may increase the frequency of STI treatment failures (Wolday et al, 2004;Unemo et al, 2017;Khaw et al, 2018). Conversely, asymptomatic or symptomatic STIs strongly predict susceptibility to HIV, enhance HIV shedding at genital mucosal sites and increase infectiousness from HIV positive individuals (Mwatelah et al, 2019).…”

Ocular Syphilis with HIV Co-infection

“…25 Neurosyphilis has been found to have a greater association with HIV positive individuals, with asymptomatic neurosyphilis occurring in 70% of early syphilis cases. 14,16,[25][26][27][28][29][30] RPR titer greater than or equal to 1:32 and co-infection of HIV were found to be more closely linked to neurosyphilis. 25,28,31…”

“…17 A reactive CSF-VDRL confirms the diagnosis of neurosyphilis, however a negative result does not automatically rule out the diagnosis as sensitivity ranges from 30-70%. 17,26 In asymptomatic cases, LP with CSF analysis is necessary for the diagnosis of neurosyphilis.…”

Beyond the HIV Care Continuum and Viral Suppression: Broadening the Scope of Quality Metrics for Total HIV Patient Care

“…2,3 The Centers for Disease Control and Prevention reports that almost half of PWH in the United States have the virus under control, defined as a viral load test of <200 copies/mL. 4 While this demonstrates incredible progress toward improving HIV testing and treatment, it is juxtaposed by increases in other comorbidities among PWH, such as type II diabetes mellitus, 5,6 obesity, [7][8][9][10] sexually transmitted infections (STIs), [11][12][13] and psychiatric and substance use (SU) disorders. 14,15 These upward trends expose the need to expand the definition of high-quality HIV care.…”