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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Users are cautioned that, because of the rapidly changing field of HIV care, this information could become out of date quickly.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
http://www.aidsetc.org
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
May 201311 www.aidsetc.org
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
About This Slide SetAbout This Slide Set