Use of Systemic Therapies for Treatment of Psoriasis in People Living with Controlled HIV: Inference-Based Guidance from a Multidisciplinary Expert Panel

• Published in: Dermatology and therapy 2022-05, Vol.12 (5), p.1073-1089
• Main Authors: Papp, Kim A., Beecker, Jennifer, Cooper, Curtis, Kirchhof, Mark G., Pozniak, Anton L., Rockstroh, Juergen K., Dutz, Jan P., Gooderham, Melinda J., Gniadecki, Robert, Hong, Chih-ho, Lynde, Charles W., Maari, Catherine, Poulin, Yves, Vender, Ronald B., Walmsley, Sharon L.
• Format: Article
• Language: English
• Subjects: Adverse and side effects; Antiviral agents; Complications and side effects; Dermatology; Dosage and administration; Drug therapy; Drugs; Evidence-based medicine; Guidelines; HIV; HIV patients; Human immunodeficiency virus; Immunodeficiency; Immunosuppression; Immunotherapy; Internal Medicine; Medicine; Medicine & Public Health; Oral and Maxillofacial Surgery; Plastic Surgery; Psoriasis; Quality of Life Research
• ISSN: 2193-8210; 2190-9172
• DOI: 10.1007/s13555-022-00722-0

Background People living with human immunodeficiency virus (PLHIV) have a similar prevalence of psoriasis as the general population, though incidence and severity correlate with HIV viral load. Adequately treating HIV early renders the infection a chronic medical condition and allows PLHIV with a suppressed viral load (PLHIV-s) to live normal lives. Despite this, safety concerns and a lack of high-level data have hindered the use of systemic psoriasis therapies in PLHIV-s. Objectives We aim to provide a structured framework that supports healthcare professionals and patients discussing the risks and benefits of systemic psoriasis therapy in PLHIV-s. Our goal was to address the primary question, are responses to systemic therapies for the treatment of psoriasis in PLHIV-s similar to those in the non-HIV population? Methods We implemented an inference-based approach relying on indirect evidence when direct clinical trial data were absent. In this instance, we reviewed indirect evidence supporting inferences on the status of immune function in PLHIV. Recommendations on systemic treatment for psoriasis in PLHIV were derived using an inferential heuristic. Results We identified seven indirect indicators of immune function informed by largely independent bodies of evidence: (1) functional assays, (2) vaccine response, (3) life expectancy, (4) psoriasis manifestations, (5) rate of infections, (6) rate of malignancies, and (7) organ transplant outcomes. Conclusions Drug-related benefits and risks when treating a patient with systemic psoriasis therapies are similar for non-HIV patients and PLHIV with a suppressed viral load and normalized CD4 counts. Prior to initiating psoriasis treatment in PLHIV, HIV replication should be addressed by an HIV specialist. Exercise additional caution for patients with a suppressed viral load and discordant CD4 responses on antiretroviral therapy. Plain Language Summary People living with human immunodeficiency virus (PLHIV) develop psoriasis as often as everyone else. We asked: what are effective and safe treatments when PLHIV need systemic therapy (pills or injections) for their psoriasis? HIV infection attacks the immune system. When HIV is not treated, the immune system declines. A less effective immune system makes it harder for the body to fight infections and certain cancers. Psoriasis is a skin condition caused by overactive immune cells. Effective psoriasis treatments reduce immune-cell activity. There are some concerns th