Although non-steroidal anti-inflammatory drugs are generally safe, it is still worth checking for interactions, because so many complex drugs are used in HIV. When in doubt, get help from infectious disease specialists, pharmacists or other resources. The members of the Department of Pharmacology at the University of Liverpool maintain a freely available drug–drug interaction resource that can be used to help safely prescribe drugs to HIV-positive patients.22
What Drugs Can Be Used Safely for Rheumatic Conditions in Patients Who Have HIV?
Many rheumatic conditions in patients with HIV can be managed with non-steroidal anti-inflammatory drugs or other therapies that are generally safe in these patients. However, a small proportion of patients receiving cART will also need disease-modifying drugs or biologics to control their disease.
Although published evidence is limited, it appears that these therapies can generally be safely prescribed if testing reveals that that CD4+ counts are above 200 cells/mm3 and the HIV viral activity is completely suppressed.4 Dr. Calabrese notes, “Certain drugs like hydroxychloroquine and sulfasalazine we feel pretty safe about, but antimetabolites like methotrexate or luflonomide or biologic drugs—this is serious business and people need to do this with interprofessional collaboration. Any immunosuppressive in an HIV-infected patient has to be done with active collaboration of the HIV-treating physician under all circumstances.” He adds, “A patient who is not well controlled for HIV will not be a good candidate for many therapies.”
This is an area of ongoing research. Dr. Calabrese is a co-author of recently published study examining the biologic drug TNF-α for refractory rheumatoid arthritis in patients who are also HIV positive. When carefully selected and monitored, these patients do not appear at greater risk of infection compared to patients without HIV.26
Key Points for Rheumatologists
1) Maintain a low threshold for HIV testing in the rheumatology office. Currently in the U.S., there are no specific recommendations on testing for HIV in the context of rheumatic care. However, the general public health recommendation is that healthcare providers should test everyone between the ages of 13 and 64 at least once for HIV, with repeated screenings recommended for persons at high risk of HIV. Patients should be informed so they can opt out if they wish, but pretest counseling is not necessary.27
Dr. Calabrese points out, “This is not observed by most physicians, even primary care physicians. When we are starting immunosuppressive therapy and particularly biologics, we routinely screen people for hepatitis B and hepatitis C. It is very simple to [add HIV]. Ask, ‘Have you ever been tested for HIV infection? We should do this at this time if it makes sense.’”