Guidelines for Prevention and Treatment of Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults Opportunistic Infections in HIV-Infected Adults and Adolescentsand Adolescents

Human Herpesvirus-8 Slide SetHuman Herpesvirus-8 Slide Set

Prepared by the AETC National Resource Center based on recommendations from the CDC,

National Institutes of Health, and HIV Medicine Association/Infectious Diseases Society of America

May 20132 www.aidsetc.org

About This PresentationAbout This Presentation

These slides were developed using recommendations published in May 2013. The intended audience is clinicians involved in the care of patients with HIV.

Users are cautioned that, because of the rapidly changing field of HIV care, this information could become out of date quickly. Finally, it is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.

– AETC National Resource Center

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May 20133 www.aidsetc.org

HHV-8 Disease: HHV-8 Disease: EpidemiologyEpidemiology

Associated with Kaposi sarcoma (KS) (all forms) and certain neoplastic and lymphoproliferative disorders (primary effusion lymphoma [PEL]), multicentric Castleman disease)

HHV-8 seroprevalence in United States: 1-5% Higher in MSM regardless of HIV serostatus (20-

77%) Higher in some Mediterranean countries (10-20%)

and parts of sub-Saharan Africa (30-80%)

May 20134 www.aidsetc.org

HHV-8 Disease: HHV-8 Disease: Epidemiology Epidemiology (2)(2)

Pathogenesis of HHV-8 disease is unclear KS and PEL usually seen in advanced

immunosuppression (CD4 count <200 cells/µL), but can occur at any CD4 count

KS incidence up to 30% among AIDS patients in United States before use of effective ART

Dramatically lower incidence in recent years ART prevents and may regress KS lesions Ganciclovir, foscarnet, and cidofovir given for CMV

treatment may prevent or suppress KS Castleman disease and PEL remain rare

May 20135 www.aidsetc.org

HHV-8 Disease: HHV-8 Disease: Clinical ManifestationsClinical Manifestations

Most with chronic HHV-8 infection are asymptomatic Acute infection may cause fever, rash,

lymphadenopathy, bone marrow failure, occasional rapid progression to KS

Castleman disease: generalized adenopathy, fever; may progress to multiorgan failure

PEL: pleural, pericardial, or abdominal effusions; mass lesions are less common

May 20136 www.aidsetc.org

HHV-8 Disease: HHV-8 Disease: Clinical Manifestations Clinical Manifestations (2)(2)

KS presentation varies widely Most have nontender,

purplish, indurated skin lesions

Intraoral lesions are common

Visceral dissemination may occur

Credit: P. Volberding, MD; UCSF Center for HIV Information Image Library

May 20137 www.aidsetc.org

HHV-8 Disease: HHV-8 Disease: DiagnosisDiagnosis

Routine screening for HHV-8 is not indicated Quantitation of HHV-8 by PCR has no

established role in diagnosis KS: biopsy Consult with specialist for diagnosis of other

suspected HHV-8 disease

May 20138 www.aidsetc.org

HHV-8 Disease: HHV-8 Disease: PreventionPrevention

Preventing Exposure HHV-8 shedding in saliva and genital secretions

may transmit HHV-8 to uninfected partners Interventions to prevent exposure to HHV-8 not

likely to be highly effective, have not been validated; are not recommended

Preventing Disease Toxicity of anti-HHV-8 therapy outweighs

potential benefits Early initiation of ART likely to be most

effective prevention measure

May 20139 www.aidsetc.org

HHV-8 Disease: HHV-8 Disease: TreatmentTreatment ART for all: initiate or optimize Limited studies of HHV-8-specific agents

KS: Ganciclovir, foscarnet may regress lesions; cidofovir ineffective

in 1 study Chemotherapy if visceral KS; consider if widely disseminated

cutaneous KS Castleman disease:

Preferred: valganciclovir 900 mg PO BID for 3 weeks or ganciclovir 5 mg/kg IV Q12H for 3 weeks or valganciclovir 900 mg PO BID + zidovudine 600 mg PO Q6H for 7-12 days

Alternative: rituximab for 4-8 weeks (effective as alternative or adjunctive therapy; associated with subsequent exacerbation or emergence of KS)

PEL: Chemotherapy IV ganciclovir or PO valganciclovir may be useful adjunct

Consult with specialist

May 201310 www.aidsetc.org

HHV-8 Disease: HHV-8 Disease: Starting ARTStarting ART

Early ART initiation is likely to prevent KS and PEL

ART should be given to all with KS, muticentric Castleman disease, or PEL

Insufficient evidence to support specific ARV regimens

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HHV-8 Disease:HHV-8 Disease: Monitoring and Monitoring and Adverse EventsAdverse Events

IRIS reported in HHV-8-infected patients who initiate ART KS: new onset KS or exacerbations of

previously stable disease Castleman disease: clinical decompensation PEL: no data

ART is key component of therapy and should not be delayed

May 201312 www.aidsetc.org

HHV-8 Disease:HHV-8 Disease: Preventing RecurrencePreventing Recurrence

ART recommended for all with HHV-8 disease May prevent KS progression or recurrence

May 201313 www.aidsetc.org

HHV-8 Disease: HHV-8 Disease: Considerations in Considerations in PregnancyPregnancy

HHV-8 seropositivity does not appear to affect pregnancy outcome; screening for HHV-8 not indicated

Antiviral therapy for HHV-8 infection during pregnancy is not recommended

Diagnosis as in nonpregnant women For treatment, consult with specialist Perinatal transmission occurs infrequently, higher

risk with higher maternal antibody titer; may be associated with increased infant mortality

May 201314 www.aidsetc.org

Websites to Access the GuidelinesWebsites to Access the Guidelines

http://www.aidsetc.org http://aidsinfo.nih.gov

May 201315 www.aidsetc.org

This presentation was prepared by Susa Coffey, MD, for the AETC National Resource Center in May 2013

See the AETC NRC website for the most current version of this presentation:

http://www.aidsetc.org

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