HIV: travel

The main aim of this chapter is to provide clinicians with the information they need to know about giving advice and managing people living with HIV, who are intending to travel outside the UK. This information is also relevant to other developed countries. Travel to some developing countries poses substantial risk of infections, especially to those with immunodeficiency. Some countries have entry restrictions to people living with HIV. The chapter gives sources of information on these matters. The chapter explains the importance of planning travel well in advance, so that patients receive and complete the necessary vaccinations. The chapter also provides advice on food and water consumption, and traveller’s diarrhoea, as well as actions required by the traveller according to their CD4 count.

HIV: cardiovascular disorders

This chapter discusses key cardiovascular conditions that effect people who live with HIV. HIV can lead to direct effect on the heart and the drug treatments may modify risk factors for heart disease. The chapter reviews the epidemiology of heart diseases in people who live with HIV . Specific disease processes are discussed, including cardiomyopathy, pericardial effusion, myocarditis, and endocarditis. Effect of HIV treatment on cardiovascular risk is discussed. Cardiovascular disease in people who live with HIV is reviewed with a focus on lifestyle changes, and effect of drugs on the heart and risk factors for heart disease. Risk profiling of cardiovascular disease is outlined with some discussion of treatment.

HIV: disorders of the eye

Although the incidence of ocular complications of HIV declined significantly with the wide availability of effective antiretroviral therapy, they are still important and require close collaboration between the HIV physician and the ophthalmologists. This chapter describes the ophthalmic manifestations of HIV infection, tabulated according to the anatomy of the eye. HIV-related conditions and opportunistic infections are described. Particular reference and details are given to important eye infections, such as CMV retinitis, ophthalmic herpes zoster, acute retinal necrosis, and progressive outer retinal necrosis.

HIV: diagnosis and assessment

The World Health Organization has set a target to achieve by 2030 that 90% of people with HIV are aware of their diagnosis, 90% of those are on treatment, and 90% of these have an undetectable viral load. People with HIV who are not aware of their diagnosis are more likely to be diagnosed late with increased morbidity and mortality, and 50% of new transmissions are from people unaware of their status. This chapter describes the challenges in increasing testing and diagnosis, recommendations for HIV testing, and initial assessment and management of those newly diagnosed with HIV infection.

HIV: introduction and epidemiology

This chapter provides background information to the events that led to the discovery of HIV. Previously fit young men who have sex with men presented with certain infections and cancers, coupled with severe immune deficiency, which was later given the name acquired immune deficiency syndrome (AIDS). This chapter gives information about the origin of HIV and its link to simian immunodeficiency viruses (SIVs). This chapter provides information on the geographical, and the epidemiological differences between HIV-1 and HIV-2. The chapter also explains the biological implications of HIV types and subtypes. Risk factors and transmission routes are also discussed, in addition to UK and worldwide HIV prevalence data.

Cervical neoplasia

Cervical neoplasia provides an overview of the 4th most common malignancy in women worldwide, including the premalignant phase. Specific terminology used in cytology and histology (including atypia, dyskaryosis, cervical intraepithelial neoplasia (CIN), cervical glandular intraepithelial neoplasia (CGIN) and invasive cervical cancer (ICC) are explained, and the epidemiology and risk factors (with an emphasis on human papilloma virus (HPV)) for this common malignancy are included. Clinical presentation is outlined. Cervical screening is discussed, including the role of HPV testing, and both the British Association for Cytopathology/NHS cervical screening program 2013 classification of cervical cytology and the Bethesda system (used more widely worldwide) are explained. Diagnosis includes colposcopic examination of the cervix, and the management of both CIN and cervical cancer are included. HPV vaccination, pregnancy, and women living with HIV (including ICC as AIDS-defining) are discussed.

Anogenital dermatoses

Ano-genital dermatoses provides information on the following anogenital skin conditions: common benign lesions/anomalies (angiokeratomas, Fordyce spots, epidermoid cysts, epidermal naevi, haemangioma, idiopathic calcinosis of the scrotum, melanocytic naevi, nabothian follicles, pearly penile papules, pigmentary changes, prominent hair follicles, seborrheic keratosis, skin tags, vulval papillae); degenerative condition (ovarian failure); infective conditions (tinea cruris, erythrasma); inflammatory conditions (irritant and contact dermatitis, seborrhoeic dermatitis, fixed drug eruption, psoriasis, lichen planus, plasma cell balanitis, lichen sclerosus, hidradenitis suppuritiva); ulcerative conditions (aphthous ulcers, Lipschutz ulcers, Behçet’s disease, erythema multiforme/Stevens–Johnson syndrome, pyoderma gangrenosum, pemphigus vulgaris); premalignant conditions and malignant conditions (extramammary Paget’s disease, squamous intraepithelial neoplasia). The chapter ends with a table of options for steroids of differing strengths.

Proctocolitis and enteric sexually acquired infections

This chapter describes the important causes of sexually acquired enteric infections, proctitis, and proctocolitis. The key terms are defined, and the epidemiology and clinical presentations of the conditions are discussed. The bacterial, viral, and parasitic infections are reviewed. Common sexually transmitted causes of proctitis include Neisseria gonorrhoeae, Chlamydia trachomatis (D-K and LGV genotypes), and syphilis; these are on the increase. Non-sexual transmitted causes are outlined, as these can cause proctocolitis and need to be considered in the differential, but can often be distinguished with good history taking. Key investigations are outlined. Specific treatment of some of these are discussed, where not referred to elsewhere.

Tropical genital and sexually acquired infections

Chancroid, Lymphogranuloma venereum (LGV) and donovanosis (or Granuloma inguinale) are sexually transmitted infections caused by Haemophilus ducreyi, Chlamydia trachomatis L1, L2, or L3 serotypes, and Klebsiella granulomatis, respectively. They are mostly prevalent in tropical and sub-tropical regions of the world, although LGV has become prevalent in men who have sex with men in the UK, and the rest of western Europe and northern America following epidemics that occurred in or after 2003. Nucleic acid amplification techniques have made the diagnosis more accurate and several oral antibiotic regimens are effective. This chapter also lists some other usually non-sexually transmitted parasitic infections that may affect the genitalia.

Epididymo-orchitis

Epididymo-orchitis is inflammation of the epididymis +/– testes, usually caused by sexually transmitted pathogens in younger men (<35) and urinary pathogens in older men. Symptoms include testicular pain and swelling, often in combination with symptoms of urethritis (e.g. discharge, dysuria) or urinary tract infection (e.g. dysuria, frequency). Complications can include chronic epididymitis, abscess, hydrocele. and infertility. Common sexually transmitted pathogens include chlamydia, gonorrhoea, and Mycoplasma genitalium, while non-sexually acquired organisms include coliforms such as Escherichia coli. This chapter details diagnosis, and differential diagnosis of testicular pain and swelling, as well as investigations, and management of epididymo-orchitis, including partner notification and follow up.