Feedback AAD 2018


Infectious Diseases

HIV in 2018

Presented by: Kieron S. Leslie, MD, MBBS, MRCP, DTM&H
Associate Clinical Professor, Department of Dermatology, University of California, San Francisco, CA, USA

HIV is still very prevalent on a global scale with 37 million people infected, only 21 million of which are on antiretroviral therapy (ART). In the United States alone, more than 1.1 million people are infected, two thirds of which have access to care while the remaining either do not have access to care or are unaware of their HIV positive status. The most affected groups are 1) black men who have sex with men (MSM), 2) Hispanic MSM, and 3) heterosexual black women.

Pre-exposure prophylaxis (PrEP) is one approach to proactive prevention in which patients are given emtricitabine/tenofovir once daily. PrEP has shown a 92% reduction in risk of HIV infection, and is recommended in the following patients:

  • HIV positive partner
  • MSM who have had unprotected anal sex or sexually transmitted diseases (STDs) in past 6 months
  • Heterosexual men and women who have unprotected sex with high-risk partners
  • Intravenous drug users.

Eosinophilic folliculitis can present in patients with HIV positive status. Patients have severe itching and often demonstrate CD4 counts below 200 cells/mm3. Effective treatments in these patients include itraconazole 200-400 mg/day (anti-eosinophil migration effect), permethrin (desiccator), phototherapy, and retinoids. Patients often resolve on their own after approximately 4-6 months, if not treated.

Immune reconstitution inflammatory syndrome may occur when HIV patients discontinue ART. Dermatological manifestations might include infections (most commonly warts), inflammation (including eosinophilic folliculitis), and autoimmune conditions. It is important to note that the symptoms may persist from 2 weeks to a year after the initiation of therapy.

Patients with HIV have a higher incidence of psoriasis development with a hazard ratio of 1:8. Psoriasis symptoms are especially worse when CD4 counts fall below 200 cells/mm3, however, likely to respond to treatment with ART as first-line therapy, topical steroids, phototherapy, and retinoids.

The use of biologics has been explored in this population but there are concerns regarding its use. Suggested therapy for HIV patients is aimed at optimizing ART therapy, stabilizing CD4 and viral load, and exercising caution with TNF-α blockers.1

Warts are common in HIV patients and may present in the mouth, on soles of feet, hands, or as Epidermodysplasia verruciformis. Presentation is often worse with low CD4 counts, and symptoms may persist in spite of ART. These patients also have a higher risk of cancer development.

Anal cancer is steadily increasing in MSM despite use of ART.2 While anal pap smears are an option, they are not currently recommended by the Centers for Disease Control and Prevention (CDC) because of a lack of data and subsequent intervention in the prevention of anal cancer. Instead, annual digital rectal exams are recommended in all HIV positive patients. Both New York State and San Francisco Department of Health recommend annual pap smears on HIV positive MSM, history of anogenital condyloma, and women with history of abnormal cervical/vulvar cytologic abnormalities.3 Patients with abnormal anal pap smears should be referred for anoscopy.2,3

Kaposi’s sarcoma (KS) is more prevalent in patients with HIV and suggested treatment is use of ART. However, some patients may not respond as well and may require more substantial treatment in the case of systemic involvement. Additionally, research suggests that older patients with aging immune systems are more likely to have presentation of Kaposi’s sarcoma despite high CD4 counts and low viral loads.4

Skin cancer is dramatically increased in patients with HIV, including malignant melanoma, non-melanoma skin cancer, basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma.5

In fact, HIV-positive subjects had a twofold higher incidence rate of non-melanoma skin cancers compared to general population.5 This study revealed that squamous cell carcinomas, but not basal cell carcinomas were associated with immunodeficiency.

Key Messages

  • HIV infection continues to present a significant problem both in the United States and worldwide.
  • HIV infected patients have an increased likelihood of developing various abnormal dermatological manifestations.
  • ART is often the first line of therapy in HIV-positive patients and has demonstrated significant improvement in alleviation of symptoms.


Present disclosure: The presenter has reported that no relationships exist relevant to the contents of this presentation.

Written by: Debbie Anderson, PhD

Reviewed by: Victor Desmond Mandel, MD



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