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Persons with HIV-associated Kaposi's sarcoma (KS) experience three co-existing stigmatizing health conditions: skin disease, HIV, and cancer, which contribute to a complex experience of stigmatization and to delays in diagnosis and treatment. Despite the importance of stigma among these patients, there are few proven stigma-reduction strategies for HIV-associated malignancies. Using qualitative methods, we explore how people with HIV-associated KS in western Kenya between August 2022 and 2023 describe changes in their stigma experience after participation in a multicomponent navigation strategy, which included 1) physical navigation and care coordination, 2) video-based education with motivational survivor stories, 3) travel stipend, 4) health insurance enrollment assistance, 5) health insurance stipend, and 6) peer mentorship. A purposive sample of persons at different stages of chemotherapy treatment were invited to participate. Participants described how a multicomponent navigation strategy contributed to increased knowledge and awareness, a sense of belonging, hope to survive, encouragement, and social support, which served as stigma mitigators, likely counteracting the major drivers of intersectional stigma in HIV-associated KS., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Although HIV-associated Kaposi sarcoma (KS) is frequently diagnosed at an advanced stage in sub-Saharan Africa, reasons for diagnostic delays have not been well described., Methods: We enrolled patients >18 years with newly diagnosed KS between 2016 and 2019 into the parent study, based in western Kenya. We then purposively selected 30 participants with diversity of disease severity and geographic locations to participate in semistructured interviews. We used 2 behavioral models in developing the codebook for this analysis: situated Information, Motivation, and Behavior framework and Andersen model of total patient delay. We then analyzed the interviews using framework analysis., Results: The most common patient factors that delayed diagnosis were lack of KS awareness, seeking traditional treatments, lack of personal efficacy, lack of social support, and fear of cancer, skin biopsy, amputation, and HIV diagnosis. Health system factors that delayed diagnosis included previous negative health care interactions, incorrect diagnoses, lack of physical examination, delayed referral, and lack of tissue biopsy availability. Financial constraints were prominent barriers for patients to access and receive care. Facilitators for diagnosis included being part of an HIV care network, living near health facilities, trust in the health care system, desire to treat painful or disfiguring lesions, and social support., Conclusions: Lack of KS awareness among patients and providers, stigma surrounding diagnoses, and health system referral delays were barriers in reaching KS diagnosis. Improved public health campaigns, increased availability of biopsy and pathology facilities, and health provider training about KS are needed to improve early diagnosis of KS., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The most effective treatment for advanced AIDS-associated Kaposi sarcoma is paclitaxel or pegylated liposomal doxorubicin (PLD); neither is routinely used in sub-Saharan Africa due to limited availability and high cost. We examined the clinical impact, costs, and cost-effectiveness of paclitaxel or PLD in Kenya, compared with etoposide or bleomycin-vincristine., Methods: In this study, we use the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-International Model to project clinical outcomes and costs among people living with HIV and advanced Kaposi sarcoma on antiretroviral therapy. We compared four different treatment strategies: etoposide, bleomycin-vincristine, paclitaxel, or PLD. We derived cohort characteristics and costs from the Kenyan Academic Model for Providing Access to Healthcare network, and adverse events, efficacy, and mortality from clinical trials. We projected model outcomes over a lifetime and included life expectancy, per-person lifetime costs, and incremental cost-effectiveness ratios (ICERs). We conducted budget impact analysis for 5-year total costs and did deterministic and probabilistic sensitivity analyses to evaluate the effect of uncertainty in input parameters., Findings: We found that paclitaxel would be more effective than bleomycin-vincristine and would increase life expectancy by 4·2 years per person. PLD would further increase life expectancy by 0·6 years per person. Paclitaxel would be the most cost-effective strategy (ICER US$380 per year-of-life-saved compared with bleomycin-vincristine) and would remain cost-effective across a range of scenarios. PLD would be cost-effective compared with paclitaxel if its price were reduced to $100 per cycle (base case $180 per cycle). Implementing paclitaxel instead of bleomycin-vincristine would save approximately 6400 life-years and would increase the overall 5-year Kenyan health-care costs by $3·7 million; increased costs would be primarily related to ongoing HIV care given improved survival., Interpretation: Paclitaxel would substantially increase life expectancy and be cost-effective compared with bleomycin-vincristine for advanced AIDS-associated Kaposi sarcoma in Kenya and should be the standard of care. PLD would further improve survival and be cost-effective with a 44% price reduction., Funding: US National Institutes of Health and Massachusetts General Hospital., Translation: For the Swahili translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests EEF is the Section Editor for Global Health & Equity for the British Journal of Dermatology. EPH has royalties from UpToDate. All other authors declare no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: The experience of stigma can be multifaceted for people with HIV and cancer. Kaposi's sarcoma (KS), one of the most common HIV-associated cancers in sub-Saharan Africa, often presents with visible skin lesions that may put people at risk for stigmatization. In this way, HIV-associated KS is unique, as people with KS can experience stigma associated with HIV, cancer, and skin disease simultaneously. The aim of this study is to characterize the intersectionality of HIV-related, cancer-related and skin disease-related stigma in people living with HIV and KS., Methods: We used a convergent mixed-methods approach nested within a longitudinal study of people with HIV-associated KS in western Kenya. Between February 2019 and December 2020, we collected quantitative surveys among all participants and conducted semi-structured interviews among a purposive sample of participants. Quantitative surveys were adapted from the abridged Berger HIV Stigma Scale to assess overall stigma, HIV-related stigma, cancer-related stigma, and skin disease-related stigma. Qualitative data were coded using stigma constructs from the Health Stigma and Discrimination Framework., Results: In 88 semi-structured interviews, stigma was a major barrier to KS diagnosis and treatment among people with HIV-associated KS. Participant's stories of stigma were dominated by HIV-related stigma, more than cancer-related or skin disease-related stigma. However, quantitative stigma scores among the 117 participants were similar for HIV-related (Median: 28.00; IQR: 28.0, 34.0), cancer-related (Median: 28.0; IQR: 28.0, 34.8), and skin disease-related stigma (Median: 28.0; IQR: 27.0, 34.0). In semi-structured interviews, cancer-related and skin disease-related stigma were more subtle contributors; cancer-related stigma was linked to fatalism and skin-related stigma was linked to visible disease. Participants reported resolution of skin lesions contributed to lessening stigma over time; there was a significant decline in quantitative scores of overall stigma in time since KS diagnosis (adjusted β = -0.15, p <0.001)., Conclusions: This study highlights the role mixed-method approaches can play in better understanding stigma in people living with both HIV and cancer. While HIV-related stigma may dominate perceptions of stigma among people with KS in Kenya, intersectional experiences of stigma may be subtle, and quantitative evaluation alone may be insufficient to understand intersectional stigma in certain contexts., (© 2022 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Purpose: Kaposi sarcoma (KS), an endothelial cell tumor associated with KS herpesvirus (KSHV), remains among the most common malignancies occurring with HIV infection (HIV-KS). As an oral anti-inflammatory, antiangiogenic, and immunomodulatory agent, lenalidomide is potentially an attractive alternative to standard chemotherapy for KS., Experimental Design: The primary objectives of this phase I/II trial were to determine the maximum tolerated dose (MTD) and response rates for lenalidomide in HIV-KS. Secondary objectives included correlating response with natural killer (NK) and T-cell subsets, plasma cytokines, viral copy number, and KSHV gene expression in biopsies. Four dose levels of oral lenalidomide taken 21 consecutive days of 28-day cycles were evaluated in adults with HIV-KS on antiretroviral therapy with controlled viremia., Results: Fifteen and 23 participants enrolled in phases I and II, respectively, 76% of whom had received prior KS therapy. The MTD was not reached, declaring 25 mg as the recommended phase II dose (RP2D). The most frequent adverse events were neutropenia, fatigue, leukopenia, and diarrhea. Of the 25 evaluable participants receiving RP2D, 60% responded. Correlative studies performed in a subset of participants demonstrated a significant increase in proportions of blood T cells with T-regulatory phenotype, and plasma cytokines trended toward a less inflammatory pattern. Clinical response was associated with loss of KSHV transcription., Conclusions: Lenalidomide is active in HIV-KS. The most common adverse events were manageable. With 60% of participants receiving RP2D obtaining a partial response and <10% discontinuing due to adverse events, the response and tolerability to lenalidomide support its use in HIV-KS. See related commentary by Henry and Maki, p. 2485., (©2022 American Association for Cancer Research.)

Purpose: Evaluate the effectiveness of compression while receiving chemotherapy compared with chemotherapy alone in the treatment of HIV-associated Kaposi sarcoma (KS) lymphedema., Methods: A randomized controlled trial was conducted in a single oncology clinic in western Kenya (NCT03404297). A computer-generated randomization schedule was used to allocate treatment arms. Randomized block design was used for stratification by lymphedema stage. Participants were HIV positive adults age ≥ 18 years on antiretroviral therapy with biopsy-proven KS associated with leg lymphedema and being initiated on chemotherapy. The intervention was 10 weeks of weekly clinic-based application of two-component paste compression bandages. The primary outcome was change in the Lower Extremity Lymphedema Index (LELI) score from week 0 to week 14. The secondary outcomes were change in the Lymphedema Quality of Life measure (LYMQOL) and change in the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 score from week 0 to week 14. Blinded outcome assessments were conducted., Results: Of 30 participants randomly assigned, 25 eligible patients (chemotherapy [control], n = 13; compression plus chemotherapy [intervention], n = 12) returned at week 14. Change in LELI, LYMQOL, and EORTC QLQ-C30 scores between week 14 and week 0 did not significantly differ by arm. The mean (standard deviation) change in LELI score was -25.9 (34.6) for the control arm compared with -13.3 (29.5) for the intervention arm, P = .340. The difference (95% CI) in the change in LELI score was -12.6 (-39.3 to 14.1)., Conclusion: Future studies evaluating a 14-week change in LELI for KS lymphedema should assume a standard deviation of approximately 30. Lessons learned from this pilot trial should inform the development of a larger, multicenter trial to evaluate the effectiveness of compression for KS lymphedema., Competing Interests: Rakhi KarwaConsulting or Advisory Role: Abbott Laboratories, Direct Relief, Becton Dickinson Naftali BusakhalaResearch Funding: Lilly (Inst) Toby MaurerEmployment: Maurer Dermatology AssociatesLeadership: Maurer Dermatology AssociatesStock and Other Ownership Interests: Maurer Dermatology AssociatesHonoraria: Symposia MedicusConsulting or Advisory Role: Medweb Sonak D. PastakiaEmployment: Abbott Laboratories, Becton DickinsonConsulting or Advisory Role: Abbott Laboratories, Becton DickinsonNo other potential conflicts of interest were reported.

Background: Rapid case ascertainment (RCA) refers to the expeditious and detailed examination of patients with a potentially rapidly fatal disease shortly after diagnosis. RCA is frequently performed in resource-rich settings to facilitate cancer research. Despite its utility, RCA is rarely implemented in resource-limited settings and has not been performed for malignancies. One cancer and context that would benefit from RCA in a resource-limited setting is HIV-related Kaposi sarcoma (KS) in sub-Saharan Africa., Methods: To determine the feasibility of RCA for KS, we searched for all potential newly diagnosed KS among HIV-infected adults attending three community-based facilities in Uganda and Kenya. Searching involved querying of electronic medical records, pathology record review, and notification by clinicians. Upon identification, a team verified eligibility and attempted to locate patients to perform RCA, which included epidemiologic, clinical and laboratory measurements., Results: We identified 593 patients with suspected new KS. Of the 593, 171 were ineligible, mainly because biopsy failed to confirm KS (65%) or KS was not new (30%). Among the 422 remaining, RCA was performed within 1 month for 56% of patients and within 3 months for 65% (95% confidence interval: 59 to 70%). Reasons for not performing RCA included intervening death (47%), inability to contact (44%), refusal/unsuitable to consent (8.3%), and patient re-location (0.7%)., Conclusions: We found that RCA - an important tool for cancer research in resource-rich settings - is feasible for the investigation of community-representative KS in East Africa. Feasibility of RCA for KS suggests feasibility for other cancers in Africa., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Kaposi's sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Worldwide, the availability of antiretroviral therapy (ART) has improved KS survival. In resource-rich settings, survival has also benefited from chemotherapy, which is widely available. Little is known, however, about the epidemiology of chemotherapy use for HIV-associated KS in resource-limited regions such as sub-Saharan Africa., Methods: We identified all patients newly diagnosed with HIV-related KS from 2009 to 2012 in the 26-clinic AMPATH network, a large community-based care network in Kenya. We ascertained disease severity at diagnosis, frequency of initiation of chemotherapy, and distribution of chemotherapeutic regimens used. Indications for chemotherapy included AIDS Clinical Trial Group T1 stage and/or "severe" disease defined by WHO KS treatment guidelines., Results: Of 674 patients diagnosed with KS, charts were available for 588; 61% were men, median age was 35 years, and median CD4 at KS diagnosis was 185 cells/μl. At time of diagnosis, 58% had at least one chemotherapy indication, and 22% had more than one indication. For patients with a chemotherapy indication, cumulative incidence of chemotherapy initiation (with death as a competing event) was 37% by 1 month and 56% by 1 year. Median time from diagnosis to chemotherapy initiation was 25 days (IQR 1-50 days). In multivariable regression, patients with > 3 chemotherapy indications at time of diagnosis had a 2.30 (95% CI 1.46-3.60) increased risk of rapid chemotherapy initiation (within 30 days of diagnosis) compared to those with only one chemotherapy indication (p < 0.001). Initial regimens were bleomycin-vincristine (78%), adriamycin-bleomycin-vincristine (11%), etoposide (7%), and gemcitabine (4%)., Conclusions: A substantial fraction of patients with KS in East Africa are diagnosed at advanced disease stage. For patients with chemotherapy indications, nearly half did not receive chemotherapy by one year. Liposomal anthracyclines, often used in resource-rich settings, were not first line. These findings emphasize challenges in East Africa cancer care, and highlight the need for further advocacy for improved access to higher quality chemotherapy in this setting.

Objectives: We sought to characterize recent cases of toxic epidermal necrolysis (TEN) in HIV-infected patients at San Francisco General Hospital (SFGH), a large HIV referral center., Methods: This was a retrospective analysis of HIV-infected patients diagnosed with TEN from January 2001 to May 2014 at SFGH., Results: Ten cases of TEN were identified, 50% of which occurred in HIV-infected individuals. Among the HIV-associated cases, causative agents were trimethoprim-sulfamethoxazole (TMP-SMX; n = 2), atovaquone, clindamycin, and fluconazole. No antiretroviral agents were implicated., Conclusion: Although limited by small sample size, our experience is reflective of the well-recognized increased incidence of TEN in HIV-positive patients and suggests that antimicrobial agents, particularly TMP-SMX, are the most common causative agents in this population. As 3 of the 5 HIV-associated TEN cases were caused by potentially inappropriate or unnecessary use of antibiotics, our experience highlights the importance of judicious use of systemic medications in populations susceptible to severe adverse drug reactions.

Purpose of Review: As patients with HIV infection are living longer with their disease, we have seen the evolution of skin cancer in this population. Cancer registries have not documented the incidence and prevalence of these cancers but we do have relevant data from cohorts. This article attempts to bring to light the extent to which skin cancer is an issue in HIV disease both domestically and internationally., Recent Findings: Squamous cell cancer is increasing in incidence in the United States and elsewhere. The anatomic locations of skin cancer vary according to demographics, host factors, and environment. In this review, squamous cell cancer will be contrasted to the other skin cancers namely, melanoma, and basal cell cancers., Summary: As our HIV population ages, clinicians should be informed as to the relevant risk factors for development of skin cancer. With the increasing incidence of these cancers in the modern era of HIV, clinicians and researchers will be informed with regard to prevention and treatment strategies.

Background: HIV-associated Kaposi sarcoma (KS) is one of the most common malignancies in sub-Saharan Africa. The diagnosis is often based on clinical suspicion, without histopathologic confirmation. When biopsies are performed, the accuracy of interpretation by local pathologists is poorly understood. We assessed the accuracy of clinical suspicion and pathologic diagnosis of KS in 2 East African countries., Methods: At 2 large HIV care sites in Uganda and Kenya, we evaluated consecutive biopsies performed from October 2008 to January 2013 on HIV-infected adults with clinically suspected KS. Biopsies were interpreted by both local African pathologists and a group of US-based dermatopathologists from a high volume medical center. For the purpose of this analysis, the US-based dermatopathologist interpretation was used as the gold standard. Positive predictive value was used to characterize accuracy of local African clinical suspicion of KS, and concordance, sensitivity, and specificity were used to characterize accuracy of local pathologic diagnosis., Results: Among 1106 biopsies, the positive predictive value of clinical suspicion of KS was 77% (95% confidence interval: 74% to 79%). When KS was not histopathologically diagnosed, clinically banal conditions were found in 35%, medically significant disorders which required different therapy in 59% and life-threatening diseases in 6%. Concordance between African pathologists and US-based dermatopathologists was 69% (95% confidence interval: 66% to 72%). Sensitivity and specificity of African pathologic diagnoses were 68% and 89%, respectively., Conclusions: Among East African HIV-infected patients, we found suboptimal positive predictive value of clinical suspicion of KS and specific, but not sensitive, histopathologic interpretation. The findings call for abandonment of isolated clinical diagnosis of KS in the region and augmentation of local dermatopathologic services.

Background: Normal lipid metabolism and functioning of the peroxisome proliferator-activated receptor gamma (PPAR-gamma) in the sebaceous gland is critical to maintaining a normal hair follicle. Human immunodeficiency virus (HIV) infection affects lipid metabolism; some have hypothesized a link between PPAR-gamma function and lipodystrophy in HIV infection. Our objective was to determine whether lipodystrophy is associated with altered hair characteristics in HIV-infected women from the Women's Interagency HIV Study., Methods: Hair characteristics and scalp inflammation were assessed by an interviewer-administered questionnaire. Central lipohypertrophy and peripheral lipoatrophy were defined by self-report of moderate to severe fat gain in central body sites and fat loss in peripheral body sites, respectively confirmed by clinical examination. Additional covariates considered in the analyses included demographics, behavioral characteristics, medical history, and HIV-related factors., Results: There were 1037 women with data on all study variables; 76 women reported central lipohypertrophy, while only four women reported lipoatrophy. Women with central lipohypertrophy were more likely to be older, had a self-reported history of injection drug use, statin medication use, diabetes, elevated cholesterol, and have self-reported less hair and shorter eyelashes. After adjustment for age, central lipohypertrophy was associated with shorter eyelashes (OR 2.3; 95% CI 1.4-3.8)., Conclusions: Central lipohypertrophy was not associated with change in scalp hair texture or scalp inflammation in this cohort. Rather, we found an association between central lipohypertrophy and shorter eyelash length. This finding may be explained by an influence of prostaglandin E2 mediators on eyelash follicles., (© 2013 The International Society of Dermatology.)

Background: Pruritic papular eruption (PPE) of HIV is common in HIV-infected populations living in the tropics. Its aetiology has been attributed to insect bite reactions and it is reported to improve with antiretroviral therapy (ART). Its presence after at least 6 months of ART has been proposed as one of several markers of treatment failure., Objectives: To determine factors associated with PPE in HIV-infected persons receiving ART., Methods: A case-control study nested within a 500-person cohort from a teaching hospital in Mbarara, Uganda. Forty-five cases and 90 controls were enrolled. Cases had received ART for ≥ 15 months and had an itchy papular rash for at least 1 month with microscopic correlation by skin biopsy. Each case was individually matched with two controls for age, sex and ART duration., Results: Twenty-five of 45 cases (56%) had microscopic findings consistent with PPE. At skin examination and biopsy (study enrolment), a similar proportion of PPE cases and matched controls had plasma HIV RNA < 400 copies mL(-1) (96% vs. 85%, P = 0·31). The odds of having PPE increased fourfold with every log increase in viral load at ART initiation (P = 0·02) but not at study enrolment. CD4 counts at ART initiation and study enrolment, and CD4 gains and CD8(+) T-cell activation measured 6 and 12 months after ART commencement were not associated with PPE. Study participants who reported daily insect bites had greater odds of being cases [odds ratio (OR) 8·3, P < 0·001] or PPE cases (OR 8·6, P = 0·01)., Conclusions: Pruritic papular eruption in HIV-infected persons receiving ART for ≥ 15 months was associated with greater HIV viraemia at ART commencement, independent of CD4 count. Skin biopsies are important to distinguish between PPE and other itchy papular eruptions., (© 2013 British Association of Dermatologists.)

Pruritus will affect a majority of HIV-infected adults in the course of their disease, impacting their quality of life. Itchy skin conditions in the HIV-infected patient may be atypical in appearance and pose diagnostic and treatment challenges. Skin changes because of chronic scratching or the absence of skin findings despite ongoing pruritus should prompt investigations for underlying causes. The presence of pruritus or pruritic skin conditions and their response to therapy may be a barometer for changes in systemic inflammation, immune activation, and dysregulation because of infection with HIV and treatment with antiretroviral therapy., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Psoriasis is a chronic papulosquamous skin disease that is thought to be a T-cell-mediated autoimmune disorder of keratinocyte proliferation. The association between psoriasis and HIV infection seems paradoxical, but insights into the role of T-cell subsets, autoimmunity, genetic susceptibility, and infections associated with immune dysregulation might clarify our understanding of the pathogenesis of psoriasis with HIV in general. HIV-associated psoriasis can be clinically confusing because several comorbid skin disorders in patients with HIV can mimic psoriasis. Phenotypic variants such as a Reiter's syndrome or fulminant erythroderma provide diagnostic clues to underlying immunodeficiency. The management of moderate and severe HIV-associated psoriasis is challenging, although patients typically improve with highly active antiretroviral therapy. Conventional systemic treatments might be contraindicated or need dose adjustment to avoid toxicity. New biological treatments in this setting are promising and warrant further study., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

Objectives: To describe the incidence and risk factors for verrucae in HIV-infected and uninfected women., Design and Methods: A prospective study of 1790 HIV-infected and 772 uninfected women. Skin examinations and interviews were performed every 6 months over an 8-year study period. Data collected at each visit included antiretroviral therapy use since the prior visit, CD4 counts, HIV RNA loads, and location, description, and diagnosis of verrucae. Incidence rates of cutaneous and anogenital warts were determined., Results: Unadjusted cumulative incidence of cutaneous warts for HIV-uninfected women was 6.6%, 6.7% for HIV-infected women who initiated HAART, and 8.4% for HIV-infected, HAART-naïve women. The unadjusted cumulative incidence of anogenital verrucae for HIV-uninfected women was 9.3%, 28.4% for HIV-infected women who initiated HAART, and 25.1% for HIV-infected women who were HAART-naïve. Multivariate proportional hazard models revealed the following significant factors for the development of cutaneous verrucae among HIV-infected women: Black race [relative hazard (RH) = 0.50] and Hispanic ethnicity (RH = 0.38), compared to White race. Risk factors for anogenital verrucae were: more recent recruitment (RH = 0.63), human papillomavirus infection at baseline (RH = 1.85), decade of age (RH = 0.82), current smoker (RH = 1.40), lowest CD4 count (per 100 cells/microl) in the past 4 years (RH = 0.85), and log10 higher HIV viral load at the prior visit (RH = 1.34)., Conclusion: HIV-infected women had a significantly increased cumulative incidence of anogenital verrucae compared to HIV-uninfected women. Although HAART did not alter the risk of developing skin or anogenital warts, those with higher CD4 cell counts and lower HIV RNA levels had a lower risk of developing anogenital warts.

Background: Herpes zoster occurs at all CD4 cell counts in HIV-infected adults. It was hypothesized that even in the era of highly active antiretroviral therapy (HAART), zoster risk is higher in HIV-infected than uninfected women., Methods: Generalized estimating equations modeled self-reported occurrence of zoster between semiannual visits among 1832 HIV-infected and 489 HIV-uninfected women in the Women's Interagency HIV Study followed for up to 7.5 years., Results: A total of 337 (18.4%) HIV-infected and 7 (1.4%) HIV-uninfected women reported zoster at some time during follow-up. Using HIV-infected women with CD4 >750 cells/microL as the reference category, the odds ratios for reporting zoster since the prior visit were: 1.43 (95% CI 0.86-2.37) for CD4 500-749 cells/microL, 2.07 (95% CI 1.27-3.38) for CD4 350-499 cells/microL, 2.72 (95% CI 1.66-4.46) for CD4 200-349 cells/microL, and 3.16 (95% CI 1.92-5.18) for CD4 <200 cells/microL, compared with 0.11 (95% CI 0.046-0.26) for HIV-uninfected women. In multivariate analyses using visits from all HIV-infected women and only those who initiated HAART, lower CD4 cell count was more strongly associated with zoster incidence than were other clinical indicators., Conclusions: Herpes zoster is associated with degree of immunosuppression in HIV-infected women, but even women with high CD4 counts are at greater risk of zoster than HIV-uninfected women.

Context: A frequent cause of human immunodeficiency virus (HIV)-related morbidity in sub-Saharan Africa is a commonly occurring, intensely pruritic skin rash. The resulting scars are disfiguring and stigmatizing. Despite the substantial prevalence of pruritic papular eruption (PPE) among HIV-infected Africans, the cause has been elusive., Objective: To determine the etiology of PPE occurring in HIV-infected individuals., Design, Setting, and Patients: Cross-sectional study of HIV-infected patients with active PPE from clinics in Uganda conducted from May 19 through June 6, 2003. Enrollment occurred in the month preceding May 19. Each participant was clinically examined by 2 dermatologists, had laboratory studies performed, was administered an epidemiologic questionnaire, and had a skin biopsy of a new lesion evaluated by a dermatopathologist., Main Outcome Measures: Histological characteristics of new pruritic lesions. Other assessments included CD4 cell count, eosinophil count, and physician-assessed rash severity., Results: Of 109 patients meeting inclusion criteria, 102 (93.6%) completed the study. The CD4 cell counts in this study population were generally low (median, 46/microL) and inversely related to increasing rash severity (median CD4 cell counts: 122 for mild, 41 for moderate, and 9 for severe; P<.001 for trend). Eighty-six patients (84%; 95% confidence interval, 77%-91%) had biopsy findings characteristic of arthropod bites. Patients with arthropod bites on biopsy had significantly higher peripheral eosinophil counts (median, 330 vs 180/microL; P = .02) and had a trend toward lower CD4 cell counts (median, 40 vs 99/microL; P = .07) than those without histological evidence of arthropod bites., Conclusions: Pruritic papular eruption occurring in HIV-infected individuals may be a reaction to arthropod bites. We hypothesize that this condition reflects an altered and exaggerated immune response to arthropod antigens in a subset of susceptible HIV-infected patients.

Objective: To evaluate safety and efficacy of thalidomide in the treatment of prurigo nodularis in a group of human immunodeficiency virus (HIV)-infected patients whose condition was recalcitrant to standard treatment., Design: Prospective study., Setting: Outpatient dermatology and neurology clinic, both referral settings., Patients: Eight HIV-infected patients with refractory prurigo nodularis; a total of 10 met inclusion criteria, but 2 could not be followed up., Interventions: Treatment with thalidomide, 100 mg/d. Subjects were randomized after 1 month to receive 100 or 200 mg/d. If side effects were noted, the drug was reduced to a tolerable dose or discontinued. Subjects were monitored at baseline and monthly for degree of pruritus and total area of body involvement of prurigo nodularis. Sequential neurologic assessments were performed., Main Outcome Measures: Efficacy and toxic effects., Results: The dosage of thalidomide ranged from 33 to 200 mg/d. Eight subjects had a greater than 50% response in reduction of itch over 3.4 months (average). Seven subjects had a greater than 50% reduction of skin involvement over 5 months (average). Three subjects developed thalidomide peripheral neuropathy (TPN). There was no correlation between duration of treatment, daily or cumulative dose, and TPN. A change in the Neuropathy Impairment Score of 10 points was a good marker of TPN, as was a greater than 50% decrease in the sural sensory nerve action potential amplitude., Conclusions: Thalidomide reduced the signs and symptoms of prurigo nodularis in HIV-infected subjects. One third of subjects developed TPN, underscoring the importance of careful neurologic assessment.

The effect of highly active antiretroviral therapy (HAART) on skin diseases was evaluated in 878 human immunodeficiency virus type 1 (HIV-1)-infected women in the Women's Interagency HIV Study, a multicenter prospective study. HIV-1-infected women receiving HAART were less likely to have eczema, folliculitis, tinea pedis, and xerosis than were women who had not initiated HAART, independent of CD4+ cell count. Participants who had a prior history of a nadir CD4+ cell count of <200 cells/microL and recent CD4+ cell counts of 200-349 cells/microL were more likely to have eczema and xerosis than were women with a nadir CD4+ cell count of >200 cells/microL and recent CD4+ cell counts of >349 cells/microL. An HIV-1 RNA load of >100,000 copies/mL was associated with increased prevalence of herpes zoster infection (odds ratio, 6.10; 95% confidence interval, 2.00-18.65). History of injection drug use was associated with a higher prevalence of onychomycosis, tinea pedis, and xerosis. Molluscum contagiosum was more prevalent among younger women.

Bartonella infection can be difficult to diagnose, especially when it manifests as bacteremia, which is usually accompanied by nonspecific symptoms, such as fever. Therefore, we hypothesized that Bartonella infection represents an underrecognized cause of febrile illness. To determine the prevalence of Bartonella infection among patients presenting with fever, we evaluated 382 patients in San Francisco. Overall, 68 patients (18%) had evidence of Bartonella infection detected by culture, indirect fluorescent antibody testing, or polymerase chain reaction (PCR). Twelve patients (3%) had either Bartonella henselae or Bartonella quintana isolated from specimens of blood, tissue, or both or had DNA detected in tissue; all 12 had concomitant human immunodeficiency virus (HIV) infection. Bartonella antibodies were detected in 17% of febrile patients, including 75% of culture-positive or PCR-positive patients. In a nested, matched case-control study aimed at identifying clinical features of febrile illness associated with Bartonella infection, only bacillary angiomatosis and elevated alkaline phosphatase levels were associated with Bartonella infection (P< or =.03 for both). The prevalence of Bartonella infection among patients with late-stage HIV infection and unexplained fever is much greater than has previously been documented.

Objective: We attempted to determine the prevalence and predictors of skin disease in a cohort of women with and at risk for HIV infection., Methods: We analyzed baseline data from a multicenter longitudinal study of HIV infection in women., Results: A total of 2018 HIV-infected women and 557 HIV-uninfected women were included in this analysis. Skin abnormalities were reported more frequently among HIV-infected than uninfected women (63% vs 44%, respectively; odds ratio [OR] 2.10; 95% confidence interval [95% CI], 1.74-2.54). Infected women were also more likely to have more than 2 skin diagnoses (OR, 3.27; 95% CI, 1.31-8.16). Folliculitis, seborrheic dermatitis, herpes zoster, and onychomycosis were more common among HIV-infected women (P < .05). Independent predictors of abnormal findings on skin examination in the infected women were African American race (OR, 1.38; 95% CI, 1.07-1.77), injection drug use (OR, 2.74; 95% CI, 2.11-3.57), CD4(+) count less than 50 (OR, 1.68; 95% CI, 1.17-2.42), and high viral loads (100,000-499,999 = OR, 1.77; 95% CI, 1.32-2.37; > 499,999 = OR, 2.15; 95% CI, 1.42-3.27)., Conclusion: HIV infection was associated with a greater number of skin abnormalities and with specific dermatologic diagnoses. Skin abnormalities were also more common among women with CD4(+) cell depletion or higher viral load.

Objective: To characterize photosensitivity in HIV-infected individuals using minimal erythema dosage (MED) UVA (ultraviolet A light) and UVB (ultraviolet B light) photoprovocation light testing., Design: Prospective, controlled analytical study., Setting: University of California, San Francisco, between March 1995 and January 1997., Patients: 13 HIV-seropositive patients with clinical and pathological features consistent with photodermatitis, 13 HIV-seropositive patients with biopsy-proven eosinophilic foliculitis (EF), and 10 HIV-seropositive patients with CD4 (T helper cell) count below 200 cells/uL and no history of photosensitivity or EF., Intervention: Each patient underwent MED testing for UVB. All 13 patients with suspected photodermatitis underwent full photochallenge testing with UVA and UVB for up to 10 consecutive week days., Results: Mean MED to UVB in patients with clinical photosensitivity and EF was lower (p = 0.004 and p = 0.022 respectively) than that of patients without a clinical history of photodermatitis. There were no significant differences in mean CD4 count or Fitzpatrick skin type. Positive photochallenge tests (papular changes at site of provocative light testing) to UVB (9 of 13 patients) were much more common than reactions to UVA (3 of 13 patients) in the photodermatitis group. All patients with clinically active photodermatitis developed papular changes at the site of UVB photochallenge testing, but only 1 of 5 patients with photodermatitis in remission developed papular changes with UVB photochallenge testing. Seven of the 13 patients with photodermatitis had Native American ancestry. Photosensitive patients were commonly taking trimethoprim-sulfamethoxazole (TMP-SMX), but no more commonly than EF or control patients., Conclusions: Photosensitivity in HIV-infected individuals appears to be a manifestation of advanced disease. Most patients are sensitive to UVB. The most severely affected individuals are both UVB and UVA sensitive, and may show reactions to visible light. A significant Native American ancestry may be a risk factor for development of photodermatitis in patients with advanced HIV disease. Finally, patients with eosinophilic folliculitis may be subclinically photosensitive.

Background: Abnormal distributions of body fat have been reported in association with HIV infection, including cases of both regional loss and gain of fat., Objective: We describe the spectrum of abnormal fat distribution in HIV-positive patients., Methods: Patients were included if they demonstrated a lack of subcutaneous fat in the cheeks in the absence of generalized wasting. Patients were examined fully and photographed, and medical records were reviewed., Results: Fourteen patients were seen. Further abnormalities of body fat distribution were noted in all patients. We found a consistent pattern of fat loss in the cheeks, temples, and extremities as well as fat gain over the neck, upper back, mastoid processes, chest, and visceral abdomen., Conclusion: A consistent syndrome of body fat redistribution is seen in HIV-positive patients. A characteristic pattern of fat loss in the cheeks may serve as a specific marker of HIV-related fat redistribution.

Objectives: Mucocutaneous diseases are common in patients infected with human immunodeficiency virus (HIV). To identify cutaneous diseases for which HIV-infected people are at high risk, we sought those that are strongly associated with specific HIV-related oral lesions and with progression of HIV disease., Design: A cross-sectional study of HIV-positive outpatients referred to a university stomatology clinic for diagnosis and treatment of oral diseases. Each subject underwent both complete oral and cutaneous examinations., Results: Among 55 men, with a median age of 41 years and a median CD4 cell count of 125/microliter (range 0-950/microliter), 93% had active oral diseases or conditions, including candidiasis, hairy leukoplakia, ulcers, Kaposi's sarcoma (KS), and xerostomia, and 95% had skin conditions, including onychomycosis, dermatophytosis, seborrheic dermatitis, KS, folliculitis, xerosis, and molluscum contagiosum. Seborrheic dermatitis, xerosis, skin KS, and molluscum contagiosum were associated with oral HIV-sentinel lesions (oral candidiasis, hairy leukoplakia, and KS), with low CD4 cell counts, and with AIDS., Conclusion: Our results suggest that xerosis and seborrheic dermatitis may be early harbingers of HIV disease progression. Their roles as predictors warrant further study, based on their associations with low CD4 cell counts and AIDS and strong co-prevalence with one of the most common HIV-related oral lesions, oral candidiasis.

We sought to define the light microscopic features of eosinophilic folliculitis as it occurs in human immunodeficiency virus (HIV)-infected individuals. The histologic findings of 52 biopsies from 50 patients were graded and compared with six biopsies of suppurative folliculitis from HIV-infected individuals. In all patients, clinical examination showed an eruption of pruritic follicular papules, and the folliculocentric nature of the disorder was confirmed histologically. Perifollicular infiltrates of lymphocytes and eosinophils were identified in all study biopsies, and there was also spongiosis of follicular epithelium. The inflammatory reaction was focused at the level of the follicular isthmus and the sebaceous duct. In all biopsies, lymphocytes and/or eosinophils were present within spongiotic follicular epithelium, but intrafollicular neutrophils were rare. Sebaceous glandular inflammation, eosinophilic pustule formation, and follicular rupture were present in less than half of the biopsies. Small numbers of microbes (bacteria, yeast, Demodex) were identified in 25% of the study biopsies in routine or special stains, but the organisms were away from areas of inflammation and were interpreted as nonpathogenic flora. The biopsies of suppurative folliculitis differed in that neutrophils and macrophages predominated in the infiltrate, microorganisms were readily identified in the inflammatory reaction, and the involved follicle was often ruptured. We believe that eosinophilic folliculitis is a unique HIV-associated dermatosis distinguishable from other folliculitides and papular dermatitides by clinical examination and light microscopy. We present our diagnostic approach.

The use of methotrexate (MTX) has been contraindicated for treatment of severe psoriasis in HIV infection on the basis of six previously reported cases in which MTX appeared to potentiate opportunistic infections and accelerate HIV disease. We describe three HIV-infected patients who were given MTX for severe psoriatic arthritis. In two patients opportunistic infections did not develop. On the basis of survival data, it is not clear that use of MTX adversely affected the natural course of their HIV disease.

Background: Psoriasis associated with human immunodeficiency virus (HIV) infection has been reported to be severe and perhaps associated with decreased survival., Objective: Our purpose was to document the natural history, response to therapy, and effect of psoriasis and its treatment on survival in HIV-infected patients with psoriasis., Methods: This was an observational cohort study of 50 persons with psoriasis and HIV infection followed up during a 2-year period., Results: In one third of the patients the psoriasis appeared before 1978, the year when HIV seroconversion began in San Francisco (group I). In two thirds psoriasis developed after 1978 (group II). Group I had a lower mean age of onset (19 vs 36 years) and more commonly had a family history of psoriasis. Palmoplantar and inverse psoriasis were more common in group II. Severe psoriasis occurred in one fourth of this group (12 of 50 patients). The median survival in this group after diagnosis of acquired immunodeficiency syndrome (AIDS) was 19 months, which is comparable to the median survival for all AIDS patients diagnosed in San Francisco between 1984 and 1990., Conclusion: Psoriasis in the setting of HIV disease may be mild, moderate, or severe. Standard therapies and zidovudine are effective in management. Survival does not seem to be adversely affected by the presence of psoriasis or its therapy.