Editing Sexually Transmitted Infections (section)

== HIV/AIDS ==

* '''HIV is a single stranded RNA retrovirus that infects CD4 helper T cells and dendritic cells'''
* '''The HIV envelope precursor protein gp160 is cleaved into gp 120 and gp41'''
* '''Factors associated with increased risk of seroconversion with HIV after a needle stick (4):'''
*# '''Deep as opposed to superficial exposure'''
*# '''Visible blood on the injuring device'''
*# '''Prior placement of the injuring device in an artery or vein'''
*# '''Patient dying within 2 months of the exposure'''
* '''Diagnosis and Evaluation'''
** '''The initial test is a screening test for antibodies, the conventional or rapid enzyme immunoassay (EIA).''' The initial result can be obtained in 30 minutes.
** '''Positive or reactive screening tests must be confirmed by a supplemental antibody test, Western blot and indirect immunofluorescence assay (IFA), or virologic test, the HIV-1 RNA assay. A positive confirmation test result establishes the diagnosis'''
** '''HIV is detectable in 95% of patients within 3 months after infection. During this initial 3-month period, the “window” period, the screening test result may be negative but the person may still be infected. Viral load assay is the best diagnostic test to detect HIV in the acute phase of infection'''
** '''The diagnosis of AIDS is made if the CD4 count is < 200 cells/mm3 or if there is a serious opportunistic infection, neoplasm, or other life-threatening condition.'''
* '''Urologic manifestation of HIV'''
*# '''Infections'''
*## '''Interaction with other STIs'''
*##* '''Testing for HIV is recommended in anyone with a diagnosed STI or who is at risk for an STI'''
*##* Genital ulcers bleed frequently during intercourse, potentially leading to increased infectiousness.
*## '''Kidney infections'''
*##* '''Persons with HIV infection are more likely to develop clinical TB if infected, including renal and other extrapulmonary disease'''
*##** Mycobacterial infection of the kidney is detected at autopsy in 6-23% of AIDS patients
*##* Other kidney infections that occur in AIDS include CMV, aspergillus and toxoplasma
*## '''Prostatitis'''
*##* Prostate infection may be more common in men with HIV
*##* Prostatitis is usually caused by E. coli, but in HIV-infected males, many other organisms can cause prostate infection, including S. aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, Serratia marcescens, Salmonella Typhi, Mycobacterium tuberculosis and Mycobacterium avium intracellulare, and CMV. Fungal infections also can cause prostatitis, particularly in immunocompromised patients with T-cell counts < 200 cells/μL.
*##* In men with HIV, cultures should be performed not only for the usual bacteria, but also for more atypical organisms including aerobes, anaerobes, fungi, and M. tuberculosis
*## '''UTI'''
*##* Incidence of bacteruria is related to CD4 counts and viral load
*##* Unusual organisms may cause UTIs, including CMV
*# '''Testis, epididymis, and SVs'''
*#* '''HIV in semen is the main vector for transmission and can persist despite high loads of ART'''
*#* '''The most common intrascrotal pathology in men with HIV/AIDS is''' '''testicular atrophy'''. This can arise from endocrine imbalances, febrile episodes, malnutrition, testicular infections, and toxic effects of therapy
*#* '''HIV itself is thought to be cytotoxic to germ and Sertoli cells'''
*#* '''The testes may also be directly infected by opportunistic infections'''
*#* In combination with extra-testicular causes, '''testosterone levels fall''' with progressive HIV disease
*# '''Erectile dysfunction'''
*#* '''Prevalence higher in HIV-infected men than uninfected'''
*#* '''HIV patients taking ART should be started on the lowest dose possible of PDE5 inhibitors'''
*#** PDE5 inhibitors depend on CYP3A for clearance, and all protease inhibitors and non-nucleoside reverse transcriptase inhibitors are inhibitors of CYP3A to some extent. This can lead to a significant increase in the serum dose of PDE5 inhibitors
*#*** See 2018 AUA Erectile Dysfunction Guideline Notes for dosing adjustments required with use of PDE5i
*# '''Renal function'''
*#* The classic clinical presentation of '''HIV-associated nephropathy''' is rapidly progressive azotemia with severe proteinuria, often nephrotic range, and little or no peripheral edema
*#* Polymorphism of Apolipoprotein-1 is associated with development of HIV-associated nephropathy (HIVAN) in African-American patients
*# '''Voiding dysfunction'''
*#* '''Increased incidence of LUTS'''
*# '''Hematuria'''
*#* Higher rate of microscopic hematuria but HIV patients should be evaluated similarly to other individuals
*# '''Stones'''
*#* One of the complications of some medications for treatment of HIV is stone formation. The protease inhibitors specifically may cause stone formation.
*#* Indinavir can form crystals in the urine. '''Indinavir stones are typically radiolucent on both plain film and CT scan but can also be mixed with calcium and appear radiopaque'''
*#* '''Newer inhibitors''' including lopinavir, atazanavir, amprenavir, and nelfinavir '''have also been associated with the development of stones, but with less frequency than reported for indinavir'''
*#* In patients with protease stones and in whom conservative management is possible as a first-line step, discontinuation of the drug and hydration should be tried
*#* '''Another type of stone reported to be more common in HIV patients is ammonium acid urate stones,''' possibly reflecting chronic diarrhea and malnutrition of chronic disease
*# '''Neoplasms'''
*** Compared with the general population, patients with HIV have a greater risk to develop not only non–AIDS-defining cancers with a viral pathogenesis but also non–virus-related cancers
*** '''AIDS-defining cancers (3):'''
***# '''Kaposi sarcoma (KS)'''
***#* '''Most relevant for the urologist given the possibility of KS lesions on the penis'''
***# '''Non-Hodgkin lymphoma'''
***# '''Invasive cervical cancer''' in females
*** '''Kaposi sarcoma'''
**** See Penile Tumors Chapter Notes
**** '''Human herpes virus 8''' (KSHV/HHV-8), a double-stranded DNA virus '''is the causative pathogen in > 90% of cases'''
**** Typically manifests with disseminated pigmented skin lesions, a few millimeters to several centimeters, from pink to purple or brown, often associated with edema and lymph node and visceral involvement in up to 50% of patients
***** See Figure
*** '''Non–AIDS-Defining Urologic Malignancies'''
**** '''HIV is associated with an increased risk of'''
****# '''Testicular tumours'''
****#* HIV-infected men are also at risk for testicular non-Hodgkin lymphoma
****# '''Kidney cancer'''
****# '''Penile cancer'''
****#* '''Note that the 2018 EAU Guidelines on Penile Cancer state that “penile cancer is not linked to HIV or AIDS”'''
**** '''HIV is not associated with increased risk of'''
****# '''Prostate cancer'''
****# '''Bladder cancer'''
****** Use caution in deciding to use intravesical BCG in the treatment of HIV-positive patients. The effectiveness of BCG is dependent on a functioning immune system, and therefore the agent is not typically used in immunocompromised patient