Awareness of Kaposi's sarcoma-associated herpesvirus among men who have sex with men

HIV-associated cancers and lymphoproliferative disorders caused by Kaposi sarcoma herpesvirus and Epstein-Barr virus

SUMMARYWithin weeks of the first report of acquired immunodeficiency syndrome (AIDS) in 1981, it was observed that these patients often had Kaposi sarcoma (KS), a hitherto rarely seen skin tumor in the USA. It soon became apparent that AIDS was also associated with an increased incidence of high-grade lymphomas caused by Epstein-Barr virus (EBV). The association of AIDS with KS remained a mystery for more than a decade until Kaposi sarcoma-associated herpesvirus (KSHV) was discovered and found to be the cause of KS. KSHV was subsequently found to cause several other diseases associated with AIDS and human immunodeficiency virus (HIV) infection. People living with HIV/AIDS continue to have an increased incidence of certain cancers, and many of these cancers are caused by EBV and/or KSHV. In this review, we discuss the epidemiology, virology, pathogenesis, clinical manifestations, and treatment of cancers caused by EBV and KSHV in persons living with HIV.

Macrophages drive KSHV B cell latency

Kaposi's sarcoma herpesvirus (KSHV) establishes lifelong infection and persists in latently infected B cells. Paradoxically, in vitro B cell infection is inefficient, and cells rapidly die, suggesting the absence of necessary factor(s). KSHV epidemiology unexpectedly mirrors that of malaria and certain helminthic infections, while other herpesviruses are ubiquitous. Elevated circulating monocytes are common in these parasitic infections. Here, we show that KSHV infection of monocytes or M-CSF-differentiated (M2) macrophages is highly efficient. Proteomic analyses demonstrate that infection induces macrophage production of B cell chemoattractants and activating factor. We find that KSHV acts with monocytes or M2 macrophages to stimulate B cell survival, proliferation, and plasmablast differentiation. Further, macrophages drive infected plasma cell differentiation and long-term viral latency. In Kenya, where KSHV is endemic, we find elevated monocyte levels in children with malaria. These findings demonstrate a role for mononuclear phagocytes in KSHV B cell latency and suggest that mononuclear phagocyte abundance may underlie KSHV's geographic disparity.

Nonepidemic Kaposi sarcoma in a young man

Kaposi sarcoma (KS) is an angioproliferative tumour with four widely recognized epidemiological forms: endemic, epidemic, iatrogenic and classic. However, the increasing evidence of KS in human immunodeficiency virus (HIV)-seronegative men who have sex with men (MSM) has led to the recent appearance of a new category, nonepidemic KS. Nonepidemic KS is still unknown by many physicians and may lead to a notable anxiety to the patient and unnecessary explorations. Our aim was to reflect this reality and raise awareness of the existence and peculiarities of this new variant. We report a case of a KS diagnosed in a young HIV-negative man, previously managed with a notable confusion by other practitioners. The patient had high risk behaviour for infection with KS-associated herpes virus. Repeated negative HIV tests confirmed the diagnosis of nonepidemic KS. Extracutaneous involvement was not suspected. Surgical excision of the tumour was performed, achieving complete response with no relapses in the following months. Nonepidemic KS is a new entity described in young MSM, characterized by few lesions, infrequent visceral involvement and with good prognosis. We emphasize the importance for clinicians to recognize this cutaneous tumour to prompt proper evaluation and better counselling.

Kaposi sarcoma

Kaposi sarcoma (KS) gained public attention as an AIDS-defining malignancy; its appearance on the skin was a highly stigmatizing sign of HIV infection during the height of the AIDS epidemic. The widespread introduction of effective antiretrovirals to control HIV by restoring immunocompetence reduced the prevalence of AIDS-related KS, although KS does occur in individuals with well-controlled HIV infection. KS also presents in individuals without HIV infection in older men (classic KS), in sub-Saharan Africa (endemic KS) and in transplant recipients (iatrogenic KS). The aetiologic agent of KS is KS herpesvirus (KSHV; also known as human herpesvirus-8), and viral proteins can induce KS-associated cellular changes that enable the virus to evade the host immune system and allow the infected cell to survive and proliferate despite viral infection. Currently, most cases of KS occur in sub-Saharan Africa, where KSHV infection is prevalent owing to transmission by saliva in childhood compounded by the ongoing AIDS epidemic. Treatment for early AIDS-related KS in previously untreated patients should start with the control of HIV with antiretrovirals, which frequently results in KS regression. In advanced-stage KS, chemotherapy with pegylated liposomal doxorubicin or paclitaxel is the most common treatment, although it is seldom curative. In sub-Saharan Africa, KS continues to have a poor prognosis. Newer treatments for KS based on the mechanisms of its pathogenesis are being explored.

HIV-Associated Cancers and Related Diseases

Clusters of cases of pneumocystis pneumonia and Kaposi’s sarcoma in New York and California in men who had sex with men were early harbingers of the acquired immunodeficiency syndrome (AIDS) epidemic.1 The syndrome was also soon noted to be associated with a high incidence of aggressive B-cell lymphomas. As the AIDS definition crystallized, Kaposi’s sarcoma, aggressive B-cell lymphomas, and invasive cervical cancer were considered to be AIDS-defining cancers when they developed in patients with human immunodeficiency virus (HIV) infection.2 Additional cancers are now known to be associated with HIV (Table 1 ). The term HIV-associated cancer is used here to describe this larger group of cancers (both AIDS-defining and non–AIDS-defining cancers) that have an increased incidence among patients with HIV infection. In addition, incidental cancers also may develop in patients with HIV infection.

Knowledge of HIV infection and other sexually transmitted diseases among men who have sex with men in Finland

Background

The purpose of this study was to describe what is known about HIV infection and other sexually transmitted diseases, infection transmission routes, care, and sources of information, from the viewpoint of men having sex with men.

Methods

National data (n = 2,072) was collected from June to August 2010 in Finland as part of a joint internet-based survey conducted in 38 countries (EMIS, European MSM Internet Sex Survey).

Results

The respondents’ age, place of residence, highest education and employment status were statistically significantly related to how often the respondent sought information on HIV, testing and treatments, and what they knew about infection transmission routes. The respondents’ information seeking behavior was not seen as active regarding HIV infection and other sexually transmitted diseases.

Conclusions

We should also consider the possibility of using internet-based interventions, especially in smaller and northern catchment areas, in order to improve the knowledge level of men having sex with men.

AIDS-related Kaposi's sarcoma in Brazil: trends and geopolitical distribution

BACKGROUND

AIDS-related Kaposi's sarcoma (KS) is a unique model of the relationship between viral infection, immunity, environmental, and genetic factors in viral cancers. The goal was to determine the distribution of KS cases among Brazilian geopolitical regions, looking at the ecological relationship with median CD4 cell count.

METHODS

Ecological study using Brazilian National Diseases Reporting Databases: 1982-2009. Subjects ≥ 13 years of age who have KS cited in their AIDS reporting form were selected, and demographic and HIV exposure data were collected.

RESULTS

We found 11,731 KS cases in the period, with a prevalence of 2.4% among AIDS cases; 88% were male, and 68% lived in the Southeast region, which accounted for 59% of AIDS cases. The regional and national prevalence trends were similar, although the highest proportion among women was found in the North region, which has the lowest number of both AIDS and KS cases. Heterosexual transmission accounted for 87% of HIV among women compared to 18% among men. Fifty-seven percent of all KS cases were diagnosed before antiretroviral therapy (ART). Injection drug use accounted for 11% of KS cases. Median survival was 472 days before the ART era and 1482 after it (P < 0.001). Median CD4 counts increased in all regions in the period as ART coverage expanded, and a resulting correlating decline in KS cases was observed.

CONCLUSIONS

Prevalence of KS declined after the introduction of ART in all regions of Brazil, suggesting individual protection conveyed by ART.

Use of saliva as a lubricant in anal sexual practices among homosexual men

OBJECTIVES

Compared with other sexually active adults, men who have sex with men (MSM) are more frequently infected with several pathogens including cytomegalovirus, hepatitis B virus, and Kaposi sarcoma-associated herpesvirus. Because one common element between these organisms is their presence in saliva, we evaluated saliva exposure among MSM in a heretofore relatively unrecognized route-via use of saliva as a lubricant in anal sex.

METHODS

MSM in a San Francisco population-based cohort were interviewed regarding use of saliva by the insertive partner as a lubricant in various anal sexual practices.

RESULTS

Among 283 MSM, 87% used saliva as a lubricant in insertive or receptive penile-anal intercourse or fingering/fisting at some point during their lifetime; 31%-47% did so, depending upon the act, in the prior 6 months. Saliva use as a lubricant was more common among younger men and among HIV-infected men when with HIV-infected partners. Even among MSM following safe sex guidelines by avoiding unprotected penile-anal intercourse, 26% had anal exposure to saliva via use as a lubricant.

CONCLUSIONS

Among MSM, use of saliva as a lubricant is a common, but not ubiquitous, practice in anal sex. The findings provide the rationale for formal investigation of whether saliva use in this way contributes to transmission of saliva-borne pathogens in MSM.