HIV Guidelines Make Special HPV Recommendations for Gay Men

Get vaccinated for human papillomavirus (HPV) up until age 40 years of age.
Gay and bisexual men with HIV should get vaccinated for human papillomavirus (HPV) up until age 40, according to updated guidelines from the European AIDS Clinical Society (EACS), released this week at the 16th European AIDS Conference. And others with HIV should be vaccinated until age 26, the guidelines state.
"We wanted to make a strong point that patients with HIV infection, and gay men in particular, should get vaccinated," said Georg Behrens, MD, PhD, from the Hannover Medical School in Germany, who is chair of the comorbidities subcommittee of the EACS guidelines panel.
This differs from the US guidelines, which call for both men and women to be vaccinated for HPV until age 26 if they weren't vaccinated as preteens or teenagers, but make no special recommendations for gay or bisexual men.
Emerging data show that HPV-related cancers are growing in prevalence in all people with HIV, including gay men.

HPV-related Cancers

People with HIV are 19 times more likely than those without HIV to be diagnosed with anal cancer, and women with HIV are three times more likely to be diagnosed with cervical cancer, according to the National Cancer Institute.
Gay men with HIV are nearly five times as likely as those without HIV to develop anal cancer, one study reports (J Acquir Immune Defic SynDr2008;48:491-499).
A poster also presented at the meeting showed that gay men with HIV who are older than 50 years have a lifetime risk for HPV-related anal cancers of 2.8%, which the Australian researchers called "alarmingly high." In contrast, women younger than 50 years have a lifetime risk for anal cancer of 0.2%.
But until this year, EACS guidelines for HPV vaccination did not include men at all, said Dr Behrens. This is the case for guidelines from many countries, including his home of Germany.
"As chair of the panel, I was surprised" by the recommendation, Dr Behrens acknowledged. "But there was more or less agreement that we should move forward with this."
The recommendations are part of a larger "rigorous approach to screening for detection of precancers under the guidelines," said Lene Ryom, MD, PhD, from the University of Copenhagen, who is assistant guidelines coordinator.
Although the effect of the vaccine on adults who have already encountered high-risk strains of HPV is unclear, the aggressiveness of anal and other HPV cancers warrant the change, Dr Ryom told Medscape Medical News. 

Antiretrovirals, Comorbidities, and ICU Guidelines

The new guidelines also include updates related to antiretroviral therapy. Dolutegravir plus rilpivirine combination therapy has been added as an option, reflecting results from the SWORD 1 and 2 trials.
Possible cardiovascular events associated with darunavir are now mentioned, reflecting findings from the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study. The combination of lopinavir plus ritonavir — an old regimen — has been removed as an option. And a description of when to use the older formulation of tenofovir instead of the new prodrug tenofovir alafenamide has been added.
But the most comprehensive guidance comes in discussions about comorbidities, drug–drug interactions, and doctors in the intensive care unit who care for severely ill people with HIV.
"I said, 'this must be included in the EACS guidelines'," said Manuel Battegay, MD, from the University Hospital of Basel in Switzerland, who is guidelines coordinator. "It's always the same question from intensive care: Can we give this ARV, and how — in the tube, or crushed, or whatever?"
For example, he pointed out, tenofovir should be swallowed whole, not chewed, broken, cut, or crushed, whereas other drugs can be dissolved in water.
The updated guidelines also include comorbidity sections on pulmonary disease and nonalcoholic fatty liver disease. And for the comorbidity section on solid organ transplant, it is recommended that the same criteria applied to the general public be applied to people living with suppressed HIV.
Overall, the guidelines move the field toward helping patients through a long life with HIV, said Dr Ryom.
The decision to use a specific antiretroviral or to switch regimens should be made on the basis of a patient's risk profile. "Throughout the guidelines, there's a strong aim toward doing personalized medicine. A lot of energy goes into making those particular considerations with your patients," she added.
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