Tag Archives: antiretroviral therapy

HIV treatment: Antiretroviral therapy increases risk of syphilis

HIV treatment could increase people’s susceptibility to developing another sexually transmitted infection, syphilis. Highly active antiretroviral therapy (HAART) could indeed deregulate the body’s immune response to the bacteria that causes syphilis.

Introducing HAART has been a turning point in the fight against HIV and Aids. The drugs, which are now taken by millions globally, successfully reduce the risk of the virus developing resistance, decrease mortality rates, and improve HIV patients’ quality of life.

Since the turn of the century, it is estimated that the number of new infections fell by 35% and Aids-related death by 28% – alongside prevention, the distribution of antiretroviral therapy was key to this success.

However, the fact that HAART is so effective has led to unexpected problems. Many people have started to believe that transmission is now much less likely and that getting infected with HIV is not a death sentence anymore. As a result sexual risk-taking is believed to be on the rise.

This is particularly the case among men who have sex with men, with many engaging in unprotected sex. This leaves them vulnerable to other sexually transmitted diseases and data shows that there has been a rapidly escalating outbreak of chlamydia, gonorrhoea and infectious syphilis in this group in recent years.

However, among men already infected with HIV, the rate of syphilis infection has grown more rapidly than that of other sexually transmitted infections, leading scientists to investigate whether HIV treatments could increase people’s susceptibility to the disease.

Bacteria Treponema pallidum

The team, led by Dr Michael Rekart from the University of British Columbia, reviewed scientific literature to analyse the impact of HAART on behavioural and immune system changes. The data they collected enabled them to create risk models to assess the likelihood of syphilis infection – in which people taking HAART were predicted to have more sexual partners and to have greater susceptibility to Treponema pallidum, the bacteria responsible for syphilis.

The models suggest that both factors combined – having a greater number of partners and a greater susceptibility to the bacteria – produced a peak in the number of infections that was greater than that associated with either factor alone.

Syphilis Bacterium. Treponema Pallidum Subsp. Pallidum On Cultures Of Cotton Tail Rabbit Epithelium Cells Sf1Ep. Treponema Pallidum Is The Causative Agent Of Syphilis. In The United States Over 35 600 Cases Of Syphilis Were Reported By Health Officials In 1999. (Photo By BSIP/UIG Via Getty Images)

Syphilis Bacterium. Treponema Pallidum Subsp. Pallidum On Cultures Of Cotton Tail Rabbit Epithelium Cells Sf1Ep. Treponema Pallidum Is The Causative Agent Of Syphilis. In The United States Over 35 600 Cases Of Syphilis Were Reported By Health Officials In 1999. (Photo By BSIP/UIG Via Getty Images)

The scientists also came up with an explanation as to why HAART increases susceptibility to Treponema pallidum. Reviewing biological evidence available in past research, they say that active antiretroviral therapy may alter the innate and acquired immune responses in ways that enhance susceptibility to Treponema pallidum. This heightened susceptibility could be a major factor in the rising incidence of syphilis in HIV-positive men who have sex with men.

The complete findings are now published in the BMJ.

A number of limitations

The study provides new ways to consider the rising number of syphilis infections, but it does not in any way suggest that people should stop taking HAART. Instead, the focus should be on prevention and on explaining that these drugs do not stop other sexually transmitted diseases.

A number of limitations to the study can be highlighted. In an editorial, three scientists have warned that the reason why syphilis cases appear to be more prevalent than other sexually transmitted infections is that gonorrhoea and chlamydia are often asymptomatic, and most cases are often missed because extragenital testing is not performed.

HAART has saved many lives and improved the quality of life of HIV-positive patients (Bruce Forster)

HAART has saved many lives and improved the quality of life of HIV-positive patients (Bruce Forster)

Additionally, the models greatly simplify reality. Taking HAART does not necessarily increase the number of sexual partners and does not look at couples’ dynamics in sufficient details. “They assume that all partnerships have the same level of syphilis risk, whereas the reality may be more complicated… They model increased behavioural risk through increasing number of partnerships, but do not capture other aspects of transmission risk, such as decreased use of condoms within partnerships”, the scientists note.

Likewise, they do not include in the models how being at a different stages of an HIV infection influences the risk of getting syphilis.

However, the findings are interesting because they remind health professionals that effectively treating and preventing HIV should not limit their efforts to control other sexually transmitted infections.

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Book Review: Chronic Pain & HIV: A Practical Approach

chronic_pain_book_2016

Recent studies suggest many individuals with HIV have chronic pain. Estimates range from 39 percent all the way to 85 percent. Chronic pain is an important co-morbid condition in individuals with HIV, as it is common and causes substantial disability.

In the current HIV treatment era, HIV is a chronic disease with a near-normal life expectancy. However, individuals with HIV can have higher rates of other health problems than the general population.

A new reference guide for HIV care providers, “Chronic Pain and HIV: a practical approach,” offers insight into the assessment, diagnosis, testing and management of various chronic pain problems in patients with HIV.

Lead editor Jessica Merlin, M.D., an assistant professor in the University of Alabama at Birmingham School of Medicine Division of Infectious Diseases and Division of Geriatrics, Gerontology and Palliative Care, says the guide addresses issues that HIV care providers have when trying to provide relief to HIV patients with chronic pain, including pharmacological and non-pharmacological therapies.

“Chronic pain is increasingly recognized as an important co-morbidity in HIV-infected patients, and may influence adherence to antivirals and retention in care,” Merlin said. “Individuals with HIV also have higher rates of mental illness and addiction than the general population. HIV, mental illness and addiction are all highly stigmatized health problems, further compounding patients’ suffering.”

HIV and the medications once used to treat the disease can lead to nerve pain in the hands and feet in as many as 40 percent of patients. Also, for reasons that are not well-understood, patients with HIV may have a high burden of musculoskeletal pain, like joint pain, back pain and more widespread pain.

Non-pharmacologic treatments are an important mainstay of therapy, including graded exercise, complementary and alternative therapies, and behavioral therapies. Importantly, behavioral therapies are among the safest and most effective treatments for chronic pain. In 2014, Merlin was awarded a K23 Career Development Award from the National Institute of Mental Health. She is working on developing and pilot-testing a behavioral intervention that is specifically tailored to improving chronic pain in individuals with HIV.

Ideally, when medications are used, they should be prescribed alongside non-pharmacologic therapies.

“A multimodal approach is the most effective approach,” Merlin said. “Our book helps front-line HIV primary care providers use this approach with their patients.”

Medications such as opioids may not be as effective, and carry significant risks.

“Chronic pain can be challenging to manage to begin with, and even more challenging to manage in the setting of mental health and addiction problems found in individuals with HIV,” Merlin said. “Long-term treatment with opioids, such as morphine, oxycodone and others, has been commonly used to treat chronic pain in general and in individuals with HIV. Opioid therapy carries risks such as worsening of mood, development of addiction and overdose, and these risks can be heightened in the presence of pre-existing mental illness and addiction.”

Studies suggest that HIV care providers may feel unprepared to treat chronic pain.

“Managing chronic pain is rewarding; but it can be challenging, and is often not taught in HIV providers’ medical training,” Merlin said. “This book is the first practical guide on the topic for HIV care providers, and fills an important need.”

Chronic Pain & HIV: A Practical Approach is available from 22nd April 2016, available at Amazon.

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