Skin Diseases in the Era of Highly Active Antiretroviral Therapy

With the increasing number of HIV-infected patients receiving highly active antiretroviral therapy (HAART), the shift in their dermatologic profile becomes less characteristic of AIDS-defining illnesses.

Retrospective review of mucocutaneous pathology among patients seen at HIV-Dermatology Clinic from January 2009 to December 2013.

Among 534 patients, there were 68.4% males and 31.6% females, with 8.7-year average duration of infection; 82.8% were receiving HAART. Kaposi sarcoma was the only relatively frequent AIDS-defining disease. Fungal and viral infections were common, with human papilloma virus (HPV) as the most frequent overall. Benign and premalignant tumors were associated with HAART and CD4 >200/mm3 (P < .05). Psoriasis was prevalent among patients without HAART (P < .05). Prurigo was associated with lower CD4 count (P < .001).

Patients receiving HAART are faced with chronic skin problems such as benign and premalignant tumors, and HPV infection adds to their neoplastic predisposition. Further research is recommended to develop protocols for treating psoriasis and screening for HPV-associated neoplasia among patients.

Keywords skin diseases, HIV, HAART

Patients living with HIV infection are usually afflicted with skin diseases, and their variability and severity often reflect their level of immune deficiency. Ranging from infections, inflammations, and neoplasms, these can lead physicians to the initial diagnosis of HIV infection or can manifest the various stages of its disease evolution. In addition to this is the problem of drug reactions and iatrogenic effects as well as the reactivation of certain diseases alongside immune reconstitution while receiving highly active antiretroviral therapy (HAART).1

The epidemiologic profile of dermatologic illnesses in relation to HIV varies between countries. This is mainly affected by economic and political factors pertaining to the availability of HAART, as well as the risk-taking behavior of patients. In Portugal, a few years after the recognition of HIV (1985-1991), the mucocutaneous manifestations were dominated by AIDS-defining conditions, such as oropharyngeal candidiasis and Kaposi sarcoma, as well as the aggravation of more common conditions, such as herpes simplex virus (HSV) infection, herpes zoster, dermatophytosis, seborrheic dermatitis, and drug-related skin disorders.2 However, for the past 5 years, there has been a decreasing trend in terms of the number of new HIV-infected cases but with an increasing number of people living with the infection alongside the increasing number of patients receiving HAART.3 These observations result to a less number of opportunistic infections, but instead there is the emergence of medical problems that were less common before4 and a shift to more chronic forms of illnesses.

This study aims to have a descriptive measure of the current epidemiology of mucocutaneous pathology among HIV-positive patients, based on the referrals to the dermatology clinic of a tertiary hospital in Lisbon, Portugal, from 2009 to 2013. By understanding the trend and identifying shifts in the epidemiologic burden of disease, the authors hope to identify areas that can be bases for future research in assessing the economic burden of HIV in the field of dermatology and hence aid in the formulation of new policies and planning of resource allocation.5

Clinical Data

We accessed data from the electronic records of all HIV-infected patients on their first consult at the Specialized HIV Clinic of the Dermatology Service of Hospital de Santa Maria during the period of January 2009 to December 2013. These include in-hospital referrals as well as those referred from other hospitals in Greater Lisbon area. Dermatologic diagnoses were based on clinical data and, if needed, laboratory and pathologic correlations as in the case of malignant neoplasms. The medical ethics board of the hospital approved the study.

Statistical Analysis

The primary outcome variable was the frequency rate of identified skin diseases among the study participants, classified according to those receiving and not receiving HAART. We also determined the mean CD4 count for each diagnosis. The secondary outcome variables were the significant correlation of each diagnosis with the patient’s HAART status and the significant difference in the mean CD4 count among the diagnoses.

We analyzed the data statistically using IBM Statistical Package for the Social Sciences (SPSS) version 22. We used summary statistics, where N is the total number of HIV-infected patients included in the study. For the analysis of the secondary outcome variables, we used Pearson χ2 test (P < .05) to check for correlations between categorical data. For parametric data, we used independent samples t test at the same significance level.

Epidemiologic Profile

We initially assessed a total of 564 patients, of which 5% did not have CD4 count available on record. In the end, we included a total of 534 patients, of which 68.4% were males and 31.6% were females. They were mostly Caucasians with 18% non-Caucasians. The mean age at the time of dermatologic consult was 44.6 years (standard deviation [SD] = 11.9), whereas the mean age at initial HIV diagnosis was 36 years (SD = 11.9), both values with no significant difference between the genders. The average duration of HIV infection was 8.7 years (SD = 6.4). The primary mode of HIV transmission was heterosexual, with 18% being men having sex with men (MSM). History of intravenous (IV) drug use was identified in 21.8%, of which 96.6% were Portuguese and 98.3% were heterosexuals. Also, the majority of the study population had HIV-1, with 3.9% HIV-2, of which 76% were non-Caucasians.

In this study, around 82.8% were receiving HAART at the time of their dermatologic consult. Almost all (96.4%) of them were compliant, with no significant difference between genders. The 3.4% of those who were not compliant were all heterosexuals. In this case, noncompliance was significantly correlated with the history of IV drug use (P < .05).