Incidence of oral candidiasis and oral hairy leukoplakia in HIV-infected adults in North Carolina

Feasibility, Acceptability, and Preliminary Effects of a Video-Based Intervention for Smoking Cessation Among People with HIV in Kathmandu, Nepal: A Single-Armed Pilot Study

Despite the evidence of the disproportionate burden of tobacco use among people with HIV (PWH), little effort has been made to design and test smoking cessation interventions for PWH in resource-limited countries. We assessed the feasibility, acceptability, and preliminary effects of a video-based smoking cessation intervention consisting of eleven 3-8-minute sessions among PWH in Nepal, a lower-middle-income country. Guided by the phased-based model, our 3-month intervention focused on setting the quit date, smoking cessation, and abstinence maintenance. We screened 103 PWH over three weeks for our single-arm trial, with 53 considered eligible and 48 recruited (91%). Forty-six participants watched all video clips, while two watched 7-9. All participants were retained at a 3-month follow-up. The 1-week point prevalence abstinence (self-report supported with expired carbon monoxide levels < 5ppm) at 3-month follow-up was 39.6%. Most (90%) participants reported "very much" or "much" comfort with watching the videos on their smartphones, and all would recommend the intervention to other PWH who smoke. Overall, our pilot trial demonstrated the feasibility, acceptability, and high-level efficacy of the video-based smoking cessation intervention highlighting its potential for scaling up in Nepal and other resource-limited countries.

Prevalence of oral lesions in patients with AIDS: a systematic review and meta-analysis

Background Oral lesions are considered to be early clinical signs which may predict the progression of patients with acquired immune deficiency syndrome (AIDS). Due to the lack of a comprehensive study that includes oral lesions in people with AIDS, the global prevalence of oral lesions in people with AIDS was estimated by combining preliminary studies' results using meta-analysis.Material and methods Databases including PubMed, Science Direct and Scopus were searched using keywords as 'HIV', 'AIDS', 'oral candidiasis', 'Kaposi Sarcoma', 'LinearGingival Erythema' and OR operators, AND and NOT. After the elimination of duplicate documents, articles that met the inclusion criteria were selected. Quality assessment was performed based on the Newcastle-Ottawa Scale. After combining the results of preliminary studies, an overall estimate of each lesion was reported. Ninety-five studies met the criteria for inclusion in this meta-analysis.Results The global prevalence of 21 oral lesions in HIV-infected patients was estimated. The overall prevalence of oral candidiasis, pseudomembranous candidiasis, oral hairy leukoplakia, Kaposi sarcoma and erythematous candidiasis was as follows: 35% (95% CI: 28-42), 19% (95% CI: 15-22), 12% (95% CI: 11-14), 5% (95% CI: 4-6) and 18% (95% CI: 14-22).Conclusion The present meta-analysis showed that oral lesions have a high prevalence in patients with AIDS. Dentists should consider that the clinical appearance of the oral cavity reflects the overall systemic health of the patient. As such, oral lesions may be linked to underlying immunosuppression caused by AIDS.

Oral health status and treatment needs among HIV/AIDS patients attending antiretroviral therapy center in Western India: A cross-sectional study

Aims and Objectives:

Human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) is a major public health problem across the globe. Among 37.9 million people are living with HIV in the world and 21.40 lakh are in India itself. The aim of this study was to assess the oral mucosal, periodontal, and dentition status of HIV/AIDS patients attending ART (antiretroviral therapy) center in Jaipur city, India.

Methods and Materials:

A total of 588 HIV/AIDS subjects at the ART center in Jaipur city were examined. Oral mucosal, periodontal, and dentition status was recorded using a modified WHO Oral Health Assessment form 1997. A pilot study was conducted among 50 patients. The data were analyzed using Statistical Package for the Social Sciences (SPSS) software, version 20.0. The statistical tests that were applied for the analysis included Chi-square test, Fisher exact test, and one-way analysis of variance (ANOVA).

Results:

Of 588 study subjects examined, 65.6% were men and 34.4% were women. Candidiasis was the most prevalent oral lesion (32.5%) followed by acute necrotizing gingivitis (26%), hyper melanotic pigmentation (15.8%), and ulcerations (8.7%), respectively. Oral hairy leukoplakia was observed in only 3.9% and not a single case of Kaposi's sarcoma was reported. Buccal mucosa (36.7%) was the most common site of the presence of oral mucosal lesions. The mean decayed, missing, and filled teeth (DMFT) score was 4.03 ± 1.54. Almost all the subjects needed one or other form of dental treatment. Only 12% of the patients had healthy periodontium.

Conclusion:

Candidiasis was the most prevalent oral lesion. Efforts should be made to meet the increased treatment needs in these patients.

[Research progress on occupational exposure and protection from acquired immunodeficiency syndrome in stomatological departments]

Acquired immunodeficiency syndrome (AIDS) is an infectious disease caused by human immunodeficiency virus (HIV). The disease is highly infectious, quickly spreads, and has a high fatality rate. Hence, it is a major concern in public health, and an important subject in the prevention and treatment of infectious diseases. The medical staff of stomatological departments, which handle the diagnosis and treatment of oral diseases, are at particularly high risk of occupational exposure to HIV/AIDS. This study summarizes the HIV/AIDS epidemic status, disease transmission routes, oral lesions in HIV/AIDS patients, occupational exposure, and occupational protection in stomatological departments.

A brief tobacco dependence intervention for people living with HIV in Nepal: results of a quasi-experimental study

Introduction

There is evidence of increased morbidity, decreased quality of life, and premature mortality in people living with HIV (PLHIV) who smoke tobacco compared to PLHIV who do not smoke tobacco. Evidence-based screening for tobacco dependence, pharmacological treatment, and treatment monitoring and education into relapse prevention are not readily available in low- and middle-income countries (LMIC). We evaluated the effects of a brief tobacco dependence intervention in improving knowledge on the health effects of smoking and intention to quit smoking in PLHIV in Nepal, a low-income country in south Asia.

Methods

Using a quasi-experimental design, we assigned 59 smokers to participate in the intervention and 67 in the control group. The 1.5 h smoking cessation intervention emphasized harms of smoking, reasons for smoking and quitting, causes of relapse in previous quit attempts, and quitting strategies. We collected data at baseline and immediately post-intervention.

Results

Findings indicate that a brief smoking cessation intervention produced a significant increase in smoking-related knowledge and intention to quit among PLHIV. The positive effects of our intervention remained significant after adjusting for potential confounders.

Conclusions

Our brief tobacco dependence intervention was effective in improving knowledge on the health effects of smoking and intention to quit among PLHIV. Further studies are required to evaluate the effectiveness of our intervention in increasing smoking cessation among PLHIV in LMIC.

Integrated Analysis of Clinical and Microbiome Risk Factors Associated with the Development of Oral Candidiasis during Cancer Chemotherapy

Oral candidiasis is a common side effect of cancer chemotherapy. To better understand predisposing factors, we followed forty-five subjects who received 5-fluorouracil- or doxorubicin-based treatment, during one chemotherapy cycle. Subjects were evaluated at baseline, prior to the first infusion, and at three additional visits within a two-week window. We assessed the demographic, medical and oral health parameters, neutrophil surveillance, and characterized the salivary bacteriome and mycobiome communities through amplicon high throughput sequencing. Twenty percent of all subjects developed oral candidiasis. Using multivariate statistics, we identified smoking, amount of dental plaque, low bacteriome and mycobiome alpha-diversity, and the proportions of specific bacterial and fungal taxa as baseline predictors of oral candidiasis development during the treatment cycle. All subjects who developed oral candidiasis had baseline microbiome communities dominated by Candida and enriched in aciduric bacteria. Longitudinally, oral candidiasis was associated with a decrease in salivary flow prior to lesion development, and occurred simultaneously or before oral mucositis. Candidiasis was also longitudinally associated with a decrease in peripheral neutrophils but increased the neutrophil killing capacity of Candida albicans. Oral candidiasis was not found to be associated with mycobiome structure shifts during the cycle but was the result of an increase in Candida load, with C. albicans and Candida dubliniensis being the most abundant species comprising the salivary mycobiome of the affected subjects. In conclusion, we identified a set of clinical and microbiome baseline factors associated with susceptibility to oral candidiasis, which might be useful tools in identifying at risk individuals, prior to chemotherapy.

Epstein-Barr virus in the pathogenesis of oral cancers

Epstein-Barr virus (EBV) is a ubiquitous gamma-herpesvirus that establishes a lifelong persistent infection in the oral cavity and is intermittently shed in the saliva. EBV exhibits a biphasic life cycle, supported by its dual tropism for B lymphocytes and epithelial cells, which allows the virus to be transmitted within oral lymphoid tissues. While infection is often benign, EBV is associated with a number of lymphomas and carcinomas that arise in the oral cavity and at other anatomical sites. Incomplete association of EBV in cancer has questioned if EBV is merely a passenger or a driver of the tumorigenic process. However, the ability of EBV to immortalize B cells and its prevalence in a subset of cancers has implicated EBV as a carcinogenic cofactor in cellular contexts where the viral life cycle is altered. In many cases, EBV likely acts as an agent of tumor progression rather than tumor initiation, conferring malignant phenotypes observed in EBV-positive cancers. Given that the oral cavity serves as the main site of EBV residence and transmission, here we review the prevalence of EBV in oral malignancies and the mechanisms by which EBV acts as an agent of tumor progression.

Hairy leukoplakia; lessons learned: 30-plus years

Well into the fourth decade of the HIV/AIDS pandemic, we can look back on the early years, the initial discoveries, and the broad sweep of the progress of our understanding of the nature, causes, and significance of the oral lesions seen in those infected with the virus. Prominent among these is oral hairy leukoplakia (HL), a previously unknown lesion of the mouth associated with Epstein-Barr virus (EBV) and initially seen only in people with AIDS, in the then-recognized risk groups, or those shown to be HIV positive. Subsequently, it became clear that the distribution of HL extends well beyond the HIV spectrum. In this brief review, we consider the clinical and histological features of HL, discuss how it was discovered, explore its cause, diagnosis, relationship with AIDS, pathogenesis, significance in EBV biology, options for management, and how it changes with HIV/AIDS therapy.

Retrospective analysis of the clinical behavior of oral hairy leukoplakia in 215 HIV-seropositive patients

Oral manifestations are common findings in human immunodeficiency virus (HIV) infected patients and frequently influence the overall health. Oral hairy leukoplakia (OHL) is strongly associated with HIV infection demonstrating its relationship with the individual's immune status and progression of immunosuppression. This study aims to retrospectively evaluate OHL in HIV patients, analyzing its incidence, demographic aspects and possible changes in clinical and epidemiological profile of the disease over 17 years. The records of 1600 HIV-infected patients were reviewed. The data were correlated and analyzed, considering HIV exposure category, age, gender, harmful habits, CD4 level, use and type of antiretroviral. OHL was observed in 215 (13.4%) patients. Most were men in the fourth decade of life, 171 (79.5%) and 112 (52,1%) respectively, but an increase in the incidence of OHL among female patients and those in the fifth decade of life was observed. Tobacco smoking was the most frequent harmful habit reported by 114 (68%) patients. OHL occurred mostly in patients with CD4 counts between 200 and 500 cells/mm3 35 (55.5%). The lower incidence of OHL was found among patients using at least one non-nucleoside reverse transcriptase inhibitor (NNRTI). OHL is related to CD4 count, use of ARVT and tobacco smoking and is also more prevalent in men in the fourth decade of life. These characteristics were recognized in absolute values, but when verifying the behavior over the years we noticed that the incidence of OHL is decreasing and its epidemiological characteristics changing.

Oral Lesions of HIV Disease and HAART in Industrialized Countries

The epidemiology of HIV-related oral disease in industrialized nations has evolved following the initial manifestations described in 1982. Studies from both the Americas and Europe report a decreased frequency of HIV-related oral manifestations of 10–50% following the introduction of HAART (highly active antiretroviral therapy). Evidence suggests that HAART plays an important role in controlling the occurrence of oral candidosis. The effect of HAART on reducing the incidence of oral lesions, other than oral candidosis, does not appear as significant, possibly as a result of low lesion prevalence in industrialized countries. In contrast to other oral manifestations of HIV, an increased prevalence of oral warts in patients on HAART has been reported from the USA and the UK. HIV-related salivary gland disease may show a trend of rising prevalence in the USA and Europe. The re-emergence of HIV-related oral disease may be indicative of failing therapy. A range of orofacial iatrogenic consequences of HAART has been reported, and it is often difficult to distinguish between true HIV-related oral disease manifestations and the adverse effects of HAART. A possible association between an increased risk of oral squamous cell carcinoma and HIV infection has been suggested by at least three epidemiological studies, with reference to the lip and tongue. These substantial and intensive research efforts directed toward enhancing knowledge regarding the orofacial consequences of HIV infection in the industrialized nations require dissemination in the wider health care environment.

The Influence of Social Support on Smoking Cessation Treatment Adherence Among HIV+ Smokers

INTRODUCTION

The high prevalence of smoking among people living with HIV is a significant problem. Nonadherence to smoking cessation pharmacotherapy is a barrier for successfully quitting. The current study investigated the extent to which social support variables impact adherence and cessation.

METHODS

Participants were 444 HIV+ smokers who provided data on nicotine patch adherence, social support, and smoking. We conducted a path analysis to estimate (1) the effects of six social support indicators at baseline on nicotine patch adherence; (2) the effect of patch adherence on 7-day point prevalence smoking at 6-month follow-up; and (3) the indirect effects of social support indicators on 7-day point prevalence smoking at 6-month follow-up via patch adherence.

RESULTS

The tested model demonstrated good fit as indicated by the comparative fit index, root mean square error of approximation, and weighted root mean square residual (0.94, 0.02, and 0.51, respectively). Path analysis results indicated greater social support network contact was associated with higher levels of nicotine patch adherence (β = .13, P = .02), greater patch adherence was associated with a lower probability of 7-day point prevalence smoking at 6-month follow-up (β = -.47, P < .001) and greater social support network contact (β = -.06, P = .03) had a significant indirect effect on 7-day point prevalence smoking at 6-month follow-up via patch adherence.

CONCLUSIONS

Findings have implications for smoking cessation interventions that seek to capitalize on the beneficial effects of social support. Such efforts should account for the role that frequency of contact may have on nicotine patch use and other treatment-related mechanisms.

Dynamic analysis of oral Candida carriage, distribution, and antifungal susceptibility in HIV-infected patients during the first year of highly active antiretroviral therapy in Guangxi, China

BACKGROUND

Highly active antiretroviral therapy (HAART) as an effective therapy for immune reconstruction among patients with HIV/AIDS might have influence on oral Candida status. We investigated oral Candida carriage, distribution, and antifungal susceptibility dynamically during the first year of HAART among adult HIV-infected patients in Guangxi, China.

METHODS

Forty-five adult HIV-infected patients who received their first year HAART in the AIDS clinic of the Guangxi Center for Disease Control (CDC) and 31 healthy individuals were recruited. Clinical information and oral examinations were obtained. Oral rinses taken from patients at baseline, 3, 6, 12 months during HAART, respectively, were cultured, and Candida species were identified following standard microbiological techniques. In vitro antifungal susceptibilities were tested by the broth microdilution method.

RESULTS

The oral Candida load decreased gradually in the 45 patients with HIV/AIDS during the first year of HAART (P < 0.050). Among 176 Candida isolates, Candida albicans (114/176) was the predominant species, and Candida parapsilosis (23/62) was the most common non-albicans species. We found the frequency of resistance to fluconazole and itraconazole of Candida isolated from our samples increased (P < 0.05) after 12 months of HAART. In addition, the frequency of C. albicans isolates resistant to fluconazole and itraconazole was on the rise (P < 0.05).

CONCLUSIONS

The Candida load decreased with increased CD4(+) T cell counts, and C. albicans was still the prevailing species. Further, a trend toward more frequent in vitro resistance to fluconazole and itraconazole was observed. Our results provide reference for treatment and prevention of oral candidiasis among this population.

ESCMID* guideline for the diagnosis and management of Candida diseases 2012: patients with HIV infection or AIDS

Mucosal candidiasis is frequent in immunocompromised HIV-infected highly active antiretroviral (HAART) naive patients or those who have failed therapy. Mucosal candidiasis is a marker of progressive immune deficiency. Because of the frequently marked and prompt immune reconstitution induced by HAART, there is no recommendation for primary antifungal prophylaxis of mucosal candidiasis in the HIV setting in Europe, although it has been evidenced as effective in the pre-HAART era. Fluconazole remains the first line of therapy for both oropharyngeal candidiasis and oesophageal candidiasis and should be preferred to itraconazole oral solution (or capsules when not available) due to fewer side effects. For patients who still present with fluconazole-refractory mucosal candidiasis, oral treatment with any other azole should be preferred based on precise Candida species identification and susceptibility testing results in addition to the optimization of HAART when feasible. For vaginal candidiasis, topical therapy is preferred.

Smoking as a risk factor for oral candidiasis in HIV-infected adults

OBJECTIVE

We aimed to examine if smoking is an independent predictor of oral candidiasis (OC) among HIV-1 infected persons.

METHODS

The cross-sectional part of this study evaluated 631 adult dentate HIV-1 seropositive persons examined for OC from 1995-2000 at the University of North Carolina Hospitals in Chapel Hill, NC. In the second part, from the above sample, a total of 283 individuals who were free of HIV-associated oral diseases at baseline were followed up for 2 years to assess incident OC events. Data collected from medical record review, interview questionnaires, and clinical examinations were analyzed using chi-squared tests and t-tests. Logistic regression models were developed for prevalent OC employing the likelihood ratio test, whereas Poisson regression models were developed for assessing cumulative incidence of OC. These models included a variety of independent variables to adjust for confounding.

RESULTS

Thirteen percent of participants had OC only; 4.6% had OC with Oral Hairy Leukoplakia; and 69.7% had neither. Smoking was associated with OC in all models [prevalent OC - current smokers: logistic regression - Odd ratio (95% CI) = 2.5 (1.3, 4.8); Incident OC - current smokers: Poisson regression (main effects model) - Incidence rate ratio (95% CI) = 1.9 (1.1, 3.8)]. Other Poisson regression models suggested evidence for effect modification between CD4 cell count and incident OC by smoking.

CONCLUSION

Smoking is an independent risk factor for the development of OC in HIV-1 infected persons, and the risk of OC is modified by CD4 cell count which measures strength of the immune system.

The CD4 lymphocyte count and risk of clinical progression

PURPOSE OF REVIEW

The CD4 lymphocyte count was identified as a key predictor of risk of AIDS defining diseases almost 20 years ago, early in the HIV epidemic. Several issues concerning its use to predict AIDS have arisen since. These include the difference between short and long-term prediction, the use of CD4 percentage compared with absolute counts, the impact of antiretroviral therapy on the predictive value of the CD4 count, the role relative to other markers such as viral load, the derivation of scores to predict AIDS diseases, the use of CD4 count as a surrogate endpoint, the role of the CD4 count nadir compared with the current value and the differential ability to predict different AIDS diseases.

RECENT FINDINGS

All the above issues have been clarified further and this process has continued through 2004 and 2005. These developments are briefly described in this review.

SUMMARY

The CD4 count remains the strongest short-term predictor of risk of AIDS so far identified in both treated and untreated patients and should continue to be a mainstay of monitoring for both untreated and treated patients.

Miconazole mucoadhesive tablet for oropharyngeal candidiasis

Oropharyngeal candidiasis is a commonly encountered problem in daily clinical practice. Topical therapies for oropharyngeal candidiasis are considered preferable to systemic therapies in most patient populations. However, traditional topical therapies have limitations including short contact time with the oral mucosa and the need for multiple doses each day. Miconazole mucoadhesive tablet has recently been approved in Europe (Loramyc®) and the USA (Oravig™) for the treatment of oropharyngeal candidiasis. This tablet adheres to the oral mucosa and provides sustained local release of miconazole over a period of several hours with just one daily application. This article reviews the pharmacology, safety and efficacy of this novel agent.

Low prevalence of varicella zoster virus and herpes simplex virus type 2 in saliva from human immunodeficiency virus-infected persons in the era of highly active antiretroviral therapy

OBJECTIVES

Human herpesviruses, e.g., herpes simplex virus (HSV) type 1, Epstein-Barr virus, and cytomegalovirus, appear in saliva at greater frequency in persons infected with human immunodeficiency virus (HIV) than in healthy individuals. However, it is not known if varicella zoster virus (VZV) and HSV-2 appear simultaneously during HIV infection at greater frequency in saliva in this era of highly active antiretroviral therapy (HAART). The aim of this study was to investigate the prevalence and amounts of VZV and HSV-2 in the saliva of HIV-infected orally asymptomatic patients.

STUDY DESIGN

Quantitative polymerase chain reaction was used to investigate the prevalence, quantity, risk, and correlations of salivary VZV and HSV-2 from 59 HIV-seropositive individuals and 53 healthy control subjects in a case-control cross-sectional study. Seventy-eight percent of the HIV-seropositive patients (46 out of 59) were taking HAART.

RESULTS

VZV DNA was detected in the saliva of 5.1% (3 out of 59) of the HIV-positive group and in only 1 healthy control 1.9% (1 out of 53; P = .62). The amount of VZV DNA in the expressors was low, generally <1,100 copies/mL, with no observed difference between the HIV-positive group and the control subjects (P = 1.0). HSV-2 DNA was not detected in either group. In the HIV-infected group, VZV shedding occurred in those on HAART, but was not associated with oral lesions, specific CD4(+) or CD8(+) T-cell levels, or demographic factors.

CONCLUSIONS

Varicella zoster virus was detected at low prevalence in the saliva of HIV-infected persons, whereas HSV-2 was not detected in the saliva of this cohort. HAART does not appear to diminish the risk for asymptomatic VZV shedding.

Review: the need for smoking cessation among HIV-positive smokers

Most HIV-positive persons in the U.S. smoke cigarettes. Despite substantial clinical advances in HIV care in the era of highly active antiretroviral therapy (HAART), HIV-positive persons are at high risk of tobacco-related disease and death. HIV-positive persons have complex social, economic, psychiatric, and medical needs that may impact smoking behavior and response to smoking cessation interventions, but there is a dearth of research on smoking cessation interventions tailored to HIV-positive persons. HIV care providers should treat tobacco use with the array of evidence-based smoking cessation treatments available, updating their clinical practice as new data emerge. This article reviews the literature on the health consequences of tobacco use in HIV-positive persons, the treatment of tobacco dependence, and the research to date on smoking cessation interventions in HIV-positive persons, and it presents recommendations for future research and intervention.

Oral manifestations as predictors of immune suppression in a HIV-/AIDS-infected population in south India

The objectives of the study are to evaluate the relationship between common HIV-related oral lesions and absolute CD4+ count, age, gender, and medication used and to assess the sensitivity, specificity, positive and negative predictive value of oral manifestations for low absolute CD4+ counts. HIV-positive patients, 200, from south India were selected, whose absolute CD4+ counts were determined within 2 weeks of oral examination. Sociodemographic data was obtained using a structured questionnaire. Oral manifestations were diagnosed according to presumptive criteria of EEC-clearinghouse classification (1993). Four or more concurrent oral lesions were statistically significant with low CD4+ counts <200 cells/mm3 (P = 0.005). The highest and lowest mean CD4+ cell counts were seen in individuals with linear gingival erythema (LGE; 172.5 cells/mm(3)) and pseudomembranous candidiasis (PC; 87 cells/mm(3)), respectively. Smoking, age (<35 years), and males had a positive association with oral hairy leukoplakia (OHL; P < 0.05). Patients with CD4+ counts < 200 cells/mm(3) were associated with 15 times greater risk of PC and four times at greater risk for occurrence of any oral manifestation. Concurrent oral manifestations (>or=4) were good predictors (80-100%) of severe immune suppression. In most resource poor countries where facilities for undertaking CD4+ counts are not available, the presence of concurrent oral manifestations may be used as an indicator of deteriorating immune status.

Risk indicators for HIV-associated jointly occurring oral candidiasis and oral hairy leukoplakia

Joint occurrence of two or more diseases may impact their transmission, clinical presentation, management approaches, and treatment efficacy. Although oral candidiasis (OC) and oral hairy leukoplakia (OHL) are the most commonly occurring opportunistic oral diseases of HIV-infected patients, literature describing their joint occurrence is sparse. The purpose of this project was to develop an explanatory multivariable model for joint occurrence of OC and OHL (OC-OHL). This cross-sectional study examined 631 adult dentate HIV-1 seropositive persons for OC and OHL from 1995-2000 at the University of North Carolina Hospitals in Chapel Hill, NC. Data collected from medical record review, interviews and clinical examinations were analyzed using chi(2) tests, t itests, and nonparametric tests. Multivariable proportional odds models were developed, using the likelihood ratio test and adjusting for several demographic, behavioral, and biological factors. Thirteen percent of participants had OC only; 12.8% had OHL only; 4.6% had OC-OHL; whereas 69.7% had neither. Occurrence of OC-OHL was independently associated with CD4+ counts less than 200 cells per microliter (adjusted odds ratio [OR] (95% confidence interval {CI}) = 13.4 (6.6, 27.2) and CD4+ counts 200-499 cells per microliter (OR = 3.9 [1.9, 8.1]); current smokers (OR = 2.3 [1.4, 3.8]); and whites (OR = 1.7 [1.1, 2.5]). Combination antiretroviral therapy was protective (OR = 0.5 [0.3, 0.9]). In an HIV-1-infected population, lower CD4+ cell counts and smoking were important independent risk indicators for joint occurrence of OC and OHL.

Oral Lesions as Clinical Markers of Highly Active Antiretroviral Therapy Failure: A Nested Case-Control Study in Mexico City

BACKGROUND

Clinical markers that may predict virological failure during highly active antiretroviral therapy (HAART) have not been evaluated adequately. The aim of the present study was to evaluate the usefulness of human immunodeficiency virus (HIV)-related oral lesions as clinical predictors of virological failure in HIV-infected patients receiving HAART.

METHODS

A nested case-control study was conducted within a cohort of 1134 HIV-infected patients receiving HAART who attended the AIDS Clinic of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in Mexico City during the period 1997-2005. Case patients were patients who, after achieving an undetectable viral load, had at least 1 viral load determination > or = 2000 copies/mL while receiving treatment. Control subjects were patients who, after achieving an undetectable viral load, continued to have undetectable viral loads during the follow-up period. There were 2-3 control subjects for each case patient, matched according to duration of follow-up. Oral examinations were blinded to viral loads and CD4+ lymphocyte counts. Analyses were performed with multivariate conditional logistic regression models, and associations were shown as odds ratios (ORs) with 95% confidence intervals (CI). Positive predictive values were calculated.

RESULTS

The target cohort consisted of 431 HIV-infected individuals; 47 case patients and 132 control subjects underwent complete oral examinations and formed the basis of the analysis. At the visit at which an undetectable viral load was determined, case patients and control subjects showed a similar frequency of HIV-related oral lesions (21.3% vs. 17.4%) (OR, 1.39; 95% CI, 0.57-3.38; P=.47). At the visit at which virological failure was determined, case patients showed a higher risk for HIV-related oral lesions (OR, 14.5; 95% CI, 4.21-49.94; P<.001) and oral candidosis (OR, 26.2; 95% CI, 3.34-205.9; P<.001) than did control subjects. The positive predictive value of HIV-related oral lesions and oral candidosis to identify patients who experienced virological failure while receiving HAART was 80% and 83%, respectively.

CONCLUSIONS

HIV-related oral lesions and, specifically, oral candidosis may be considered to be clinical markers of virological failure in HIV-infected patients receiving HAART.

Oral lesions in HIV-positive dental patients--one more argument for tobacco smoking cessation

OBJECTIVE

To determine the prevalence of oral lesions associated with human immunodeficiency virus (HIV) in a population of dental patients and analyze its association with psycho-social variables and biological markers.

STUDY DESIGN

The dental charts of 415 dental patients consecutively treated between May and July 2005 in a dedicated HIV dental clinic were reviewed. Oral soft tissue examinations, psycho-social and medical variables were extracted and recorded for each patient. Ethnicity, gender, HIV treatment, peripheral CD(4) counts and tobacco usage were analyzed in correlation with oral lesions associated with HIV.

RESULTS

Fifty-five percent of all subjects had at least one oral lesion associated with HIV, with oral candidiasis, salivary gland enlargement and oral hairy leukoplakia being the most commonly observed conditions. Gender and ethnicity did not correlate with a higher prevalence in lesions. However, tobacco smoking correlated significantly with a higher prevalence of oral lesions, independent of CD(4) counts.

CONCLUSIONS

These findings suggest that oral lesions remain commonly observed morbidities among HIV-infected dental patients independent of gender and ethnicity and that tobacco usage is a major and often underestimated risk factor for those lesions.

Management of oral lesions in HIV-positive patients

HIV/AIDS is currently the leading cause of death in Africa and the fourth leading cause of death worldwide. This systematic review of the literature was conducted to evaluate the evidence for treatment of the most common oral lesions associated with HIV: oral candidiasis with or without oropharyngeal involvement (OPC), oral hairy leukoplakia (OHL), recurrent aphthous-like ulcerations (RAU), oral Kaposi's sarcoma (OKS), orolabial herpes simplex infection (HSV), oral herpes zoster infection (VZV), intraoral or perioral warts (HPV), and HIV-associated periodontal diseases. Treatment of HIV-associated salivary gland disease is addressed in a different section of this World Workshop. We found the largest body of evidence for treatment of OPC in HIV patients. Future trials will be needed to test drugs currently in development for treatment of Candida strains that are resistant to existing therapies. There were no double blind, placebo-controlled randomized clinical trials (RCT) for topical treatment of OHL, and only one RCT for systemic treatment of the lesion with desciclovir. Systemic thalidomide was the only drug tested in RCT for treatment or prevention of RAU. Only 1 double-blind RCT comparing vinblastine and sodium tetradecyl sulfate was identified for localized treatment of OKS. Three drugs (famciclovir, acyclovir, and valaciclovir) were shown to be effective in randomized, double-blind trials for treatment or suppression of mucocutaneous HSV lesions in HIV patients. In all 3 trials, the effects of these medications on orolabial HSV lesions were not reported separately. There were no double-blind, placebo-controlled RCT testing topical treatments for orolabial HSV lesions in HIV patients. No trials testing treatments of oral VZV were identified. There were no double-blind, placebo-controlled RCT for treatment of HIV-associated intraoral or perioral warts or periodontal diseases. In conclusion, there is a need for well-designed RCTs to assess the safety and efficacy of topical and systemic treatments of most oral mucosal and perioral lesions in HIV patients. There is also a need to develop newer drugs for treatment of resistant fungal and viral microorganisms. Finally, standardized outcome measures should be developed for future clinical trials to allow comparisons of studies using different populations.

HIV-Related Oral Lesions, Demographic Factors, Clinical Staging and Anti-Retroviral Use

BACKGROUND

The aim of the present study was to compare the prevalence of HIV-related oral lesions (HIV-OL) between two health centers for HIV in Mexico City and to analyze the factors that, in addition to combined antiretroviral therapy (CART) and low CD4(+), may be associated with possible differences in prevalence.

METHODS

A cross-sectional observational study was performed between January 2000 and February 2003 at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), a specialized referral center for HIV/AIDS patients and the Clínica Especializada Condesa (CEC), a primary care center for HIV-infected individuals without social security insurance. A consecutive sample of HIV-infected individuals had an oral examination based on established clinical criteria. Demographic, clinical and laboratory data were obtained. Independent association of each factor with specific HIV-OL was assessed by logistic regression modeling.

RESULTS

Eight hundred fifty individuals were examined (INCMNSZ: 479; CEC: 371). Hairy leukoplakia (HL), periodontal disease (PD) and Kaposi's sarcoma (KS) were independently associated with the study site [odds ratio (OR) = 1.7 (95% confidence interval (CI): 1.1-2.4), OR = 4.2 (95% CI: 1.3-13), OR = 10.1 (95% CI: 2.7-38.2), respectively], being more frequent in CEC patients. HL was independently associated with men having sex with men OR = 1.7 (95% CI: 1.1-2.8). All HIV-OL were independently associated with CD4(+) counts and, with the exception of PD and KS, with time under CART.

CONCLUSIONS

The present comparative study showed that several factors were associated with a difference in prevalence of oral lesions found in two AIDS clinics located in Mexico City. Severe immune suppression, CART duration and the study site were associated with HIV-OL. Further investigation into factors such as socioeconomic determinants associated with HIV-OL is warranted.

Risk factors for oral hairy leukoplakia in HIV-infected adults of Brazil

BACKGROUND

Oral hairy leukoplakia (OHL) may be an indicator of the progression of Human Immunodeficiency Virus (HIV)-induced immuno-depression, and the evaluation of risk factors leading to OHL is important in the management of these HIV-infected patients. However, there are few studies that analyze risk factors leading to OHL in the Brazilian population. The aim of this case-control study is to present data about prevalence rates and risk factors leading to OHL in a sample of HIV-infected adults in Brazil.

METHODS

This case-control study included 111 HIV-infected patients treated at a clinic for sexually transmitted diseases and HIV. In the initial examinations with dentists, variables were collected from all patients. Diagnosis of OHL was performed in accordance with the International Classification System and cytological features. The Fisher and the chi-squared tests were used for statistical analysis. The proportional prevalence and odds ratio were estimated.

RESULTS

Outcome presented a positive, statistically significant association among the presence of OHL and viral load of 3000 copies/mul or greater (P = 0.0001; odds ratio (OR) = 5.8), presence of oral candidiasis (P = 0.0000; OR = 11.1), previous use of fluconazole (P = 0.0000; OR = 24.6), and use of systemic acyclovir (P = 0.032; OR = 4.3). Antiretroviral medication presented a negative, statistically significant association with the presence of OHL (P = 0.002; OR = 8.4).

CONCLUSIONS

Prevalence of OHL was 28.8%. Viral load, oral candidiasis, previous use of fluconazole, and systemic acyclovir were determined to be risk factors for OHL. Antiretroviral medication proved to be protective against the development of OHL.

(A3) HIV Phenotypes, oral lesions, and management of HIV-related disease

Workshop participants discussed: the role of HIV subtypes in disease; the treatment of oral candidiasis; the relationship between and among viral load, CD4+ counts, oral candidiasis and oral hairy leukoplakia, pigmentation; and the development of a reliable oral index to predict disease progression. Regarding HIV, the literature revealed that Type I (HIV-I), in particular group M, is involved in the majority (90%) of documented infections, and groups N and O to a lesser extent. Viral envelope diversity led to the subclassification of the virus into nine subtypes, or clades-A-D, F-H, J, and K-each dominating in different geographical areas. HIV-2, currently occurring mostly in West Africa, appears to be less virulent. No evidence could be produced of any direct impact of type, subtype, or clade on oral lesions, and participants believed that further research is not feasible. Oral candidiasis in patients from resource-poor countries should be prevented. When the condition does occur, it should be treated until all clinical symptoms disappear. Oral rinsing with an antimicrobial agent was suggested to prevent recurrence of the condition, to reduce cost, and to prevent the development of antifungal resistance. Lawsone methyl ether, isolated from a plant (Rhinacanthus nasutus leaves) in Thailand, is a cost-effective mouthrinse with potent antifungal activity. Evidence from a carefully designed prospective longitudinal study on a Mexican cohort of HIV/AIDS patients, not receiving anti-retroviral treatment, revealed that the onset of oral candidiasis and oral hairy leukoplakia was heralded by a sustained reduction of CD4+, with an associated sharp increase in viral load. Analysis of the data obtained from a large cohort of HIV/AIDS patients in India could not establish a systemic or local cause of oral melanin pigmentation. A possible explanation was a dysfunctional immune system that increased melanin production. However, longitudinal studies may contribute to a better understanding of this phenomenon. Finally, a development plan was presented that could provide a reliable prediction of disease progression. To be useful in developing countries, the index should be independent of costly blood counts and viral load.