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

(2018) 15:28 Khaw et al. AIDS Res Ther https://doi.org/10.1186/s12981-018-0216-9 AIDS Research and Therapy Open Access REVIEW Looking at the positives: proactive management of STIs in people with HIV Carole Khaw1,2*, Daniel Richardson3,4, Gail Matthews5 and Tim Read6,7 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-AIDSrelated 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. Keywords: HIV, Co-infection, HCV, Hepatitis C, Syphilis, Antimicrobial resistance, Gonorrhoea, Proctitis Background In this paper, we summarise the presentations from the 2017 HIV Innovation Forum in Australia on the theme of “Proactive Management of STIs in People Living with HIV” The three presentations given under this theme were ‘Syphilis Co-infection In Patients who are HIV positive’, ‘Elimination HCV and HIV Co-infection In Australia’ and ‘Proctitis and Antimicrobial Resistance in the HIV clinic’. It should be emphasised that our objective in translating the key messages of these presentation’s into this report was not to offer a comprehensive systematic review of the topics, but to communicate, educate and summarise the useful overviews and practical clinical advice offered by all invited speakers. The report is therefore deliberately succinct. We hope that this format makes the information conveyed accessible to busy clinicians. We have seen epidemics of sexually transmitted infections (STI), including syphilis, gonorrhoea, Mycoplasma genitalium and hepatitis C virus (HCV), in HIV-infected patients. The emergence of antimicrobial resistance has compounded some of these epidemics. Understanding how to manage sexually transmitted co-infections in people living with HIV is vital for reducing morbidity and mortality in this patient population and combating these epidemics. *Correspondence: 1 Adelaide Sexual Health Centre (Clinic 275), Infectious Diseases Unit, Royal Adelaide Hospital, 275 North Terrace, Adelaide, SA 5000, Australia Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Khaw et al. AIDS Res Ther (2018) 15:28 Page 2 of 7 Syphilis co‑infection in patients who are HIV‑positive Syphilis is a STI caused by the pathogenic spirochaete Treponema pallidum subsp. pallidum. The spirochaete varies from 6 to 15 μm in length and is 0.2 μm in width. With a doubling time of 30 to 50 h, T. pallidum is very difficult to culture in vitro [1]. Closely-related pathogenic treponemes cause endemic syphilis syndromes, such as bejel, yaws and pinta. History, diagnosis and treatment of syphilis Bony remains from archaeological digs suggestive of syphilitic osteitis have been found in Europe and these pre-date the widely accepted timing of syphilis introduction to the continent (circa 1492) by approximately 100 years [2]. However, it can be difficult to distinguish whether these were a consequence of other treponemal infections. The spread of syphilis in Europe was rapid between 1492 and 1493, following the discovery of the Americas, with Christopher Columbus creating trade routes between the Americas and Europe, and the invasion of Naples by King Charles of France and his 50,000 soldiers. Historically, syphilis research has been shrouded in controversy, as evidenced by the Oslo [3], Tuskagee [4] and Guatemala [5] experiments. The natural history of untreated syphilis in immunocompetent individuals is understood following human inoculation [6] and observational studies [7], with clearly defined stages and characteristic manifestations. Laboratory testing is an important aspect of syphilis diagnosis and management. Tests can be categorised as direct detection, treponemal tests and non-treponemal tests (Table 1) [8]. Historical treatments for syphilis included heat treatment, mercury treatment and salvarsan (arsenic) treatment. Currently, the preferred treatment for syphilis is penicillin G. Cerebrospinal fluid (CSF) studies have shown that standard benzathine penicillin (penicillin G) does not yield good CSF concentrations. However, this does not correlate with treatment failure [9]. Oral doxycycline is as effective as parenteral penicillin in the treatment of early syphilis [9–12]. Most international guidelines suggest benzathine penicillin for early syphilis, unless there is evidence of neurological disease either clinically or from CSF examination, in which case a neuropenetrative regimen should be used, such as procaine penicillin or a prolonged course of doxycycline, with careful follow-up. The use of intravenous penicillin G is also common in the treatment of n (...truncated)