WASHINGTON — Clinicians should be proactive in checking their HIV patients for herpes and syphilis because of the risk of coinfection, Dr. Connie Celum said at the Ryan White CARE Act meeting on HIV treatment.
“If you don't look for STDs in HIV patients, you won't find them,” said Dr. Celum of the University of Washington, Seattle.
Individuals with STDs are two to five times more likely than those without STDs to become infected with HIV if they are exposed through sexual contact, according to data from the Centers for Disease Control and Prevention.
Comorbid STDs often go undetected in HIV patients, but an HIV-infected person who is coinfected with an STD is more likely to transmit HIV than an HIV-infected person without a comorbid STD.
Genital herpes is the most common sexually-transmitted infection among HIV-positive persons, Dr. Celum said. Previous studies have shown that the herpes virus (HSV-2) increases one's risk of acquiring HIV and increases HIV RNA levels in plasma and in the genital tract; the presence of herpes also makes a person more likely to transmit HIV.
Conversely, the presence of HIV can reactivate herpes that has been dormant. HIV also increases the frequency of HSV-2 shedding in persons with herpes and increases the risk of acquiring and transmitting the herpes virus. A recent study by Dr. Celum and her colleagues at the University of Washington found that 50 HIV-positive men with herpes were 2.7 times more likely to shed the herpes virus orally, compared with 59 HIV-negative men with herpes (J. Infect. Dis. 2006;194:420–7).
A key question is, if you suppress herpes, can you reduce the likelihood of HIV infection? Suppression of herpes may be a strategy that buys more time for researchers who continue to work on other HIV treatments and interventions, Dr. Celum said.
Data from a proof-of-concept study including 140 women coinfected with HIV and herpes showed that treating herpes with valacyclovir significantly reduced HIV levels in plasma and the genital tract. The results were presented at the Conference on Retroviruses and Opportunistic Infections earlier this year, but useful clinical data are still 1–2 years away, she said.
Most herpes patients shed the virus in the genital tract. Although highly active antiretroviral treatment (HAART) may reduce symptoms of herpes, it does not reduce subclinical herpes shedding. Even if suppressing herpes infections with HAART can suppress the viral load in HIV patients, it remains to be seen whether treating herpes also reduces the likelihood of HIV infection.
Clinicians should also be vigilant in evaluating their HIV patients for syphilis because the annual incidence of syphilis is rising, especially among men who have sex with men, Dr. Celum explained.
The reasons for the resurgence of syphilis remain unclear, but some epidemiologic data suggest that improved therapy for HIV and improved survival and well-being among HIV patients may be driving the increase in cases, particularly among men who have sex with men. Most clinicians have limited experience in diagnosing syphilis, and they may not know it when they see it. Syphilis is a great imitator; the appearance of rashes and other signs of secondary syphilis vary from person to person.
Syphilis rashes may be widespread or subtle. The rashes are not usually itchy or vesicular, but they may include papules, macules, pustules, or ring- or lens-shaped lesions. A syphilis rash appears on the palms and soles in 60% of cases, not 100% of cases, so look elsewhere on the body for signs of infection after checking the palms and soles, Dr. Celum said. These symptoms usually appear after the chancres of primary syphilis have resolved.
Syphilis manifestations are especially easy to miss in HIV-positive patients on HAART because these patients often develop rashes that resemble syphilis as a side effect of the medication.
Consequently, Dr. Celum recommends maintaining a high level of suspicion for syphilis in HIV-positive patients because of the increased risk of HIV transmission. She suggests treating for syphilis in possible as well as definite cases, and re-examining the patients clinically and serologically every 6 months.
The most current treatment guidelines for syphilis and other STDs are available on the Centers for Disease Control and Prevention Web site at www.cdc.gov/std