Does Human Immunodeficiency Virus (HIV) infection affect the frequency of Inflammatory Bowel Disease (IBD) exacerbations?

From the Guidelines

HIV infection may actually attenuate IBD, but this does not necessarily mean a decrease in IBD attacks, as the course of IBD did not differ between HIV-infected and non-HIV-infected patients in a recent large cohort study. When managing patients with both IBD and HIV, it is crucial to consider the potential interactions between the two conditions.

• IBD patients with HIV infection can be treated with immunosuppressive therapy when on antiretroviral therapy with stable CD4 counts and undetectable viral load, as stated in the ECCO guidelines 1.
• The CD4 count should be closely monitored, and HIV-infected patients with stable CD4 counts requiring immunosuppressants do not appear to be at increased risk of opportunistic infection 1.
• TNF-α activates viral replication and pathogenesis of HIV-1, which is an important consideration when using biologics to treat IBD in HIV-positive patients 1.
• Regular monitoring of CD4 counts and viral load is essential when managing IBD in HIV-positive patients, especially when using immunosuppressive therapies.
• A case series of seven HIV-infected patients on antiretroviral therapy treated with azathioprine for various inflammatory conditions, including IBD, showed no serious opportunistic infections either during or in the 6 months after stopping azathioprine treatment 1. However, the immune suppression caused by HIV is different from the targeted immunomodulation needed to control IBD inflammation, and HIV-related complications and opportunistic infections may worsen gastrointestinal symptoms, potentially mimicking or exacerbating IBD flares. Therefore, patients with both IBD and HIV require careful coordination between gastroenterologists and infectious disease specialists to manage both conditions effectively.

From the Research

Impact of HIV Infection on IBD Attacks

• The intersection of HIV and IBD remains unclear, but studies suggest that HIV infection may attenuate IBD attacks 2, 3, 4.
• A multicenter retrospective cohort study found that HIV-infected patients with IBD required less immunosuppressants and biologics, and their disease course was not significantly different from HIV-uninfected patients 2.
• A systematic review reported that the co-prevalence of IBD and HIV is around 0.1 to 2%, and some studies suggest that HIV infection may lead to a milder IBD phenotype with fewer disease relapses, especially when CD4+ counts are lower than 200 cells/µL 3.
• The pathophysiology of IBD and HIV suggests that HIV may attenuate inflammation in IBD through specific mechanisms, such as immune paucity in the GI tract 4.

Disease Course and Treatment

• The disease course of IBD in HIV-infected patients is not well understood, and more studies are needed to determine the safety and efficacy of IBD medications in this population 3, 4.
• Current guidelines for IBD treatment do not specifically address patients with concomitant HIV infection, and more research is needed to optimize treatment strategies for these patients 5, 6.
• The use of immunosuppressants and biologics in IBD-HIV infected patients is limited, despite growing evidence supporting their safety and efficacy 3.

Future Directions

• Further clinical studies are necessary to better understand the relationship between HIV and IBD, and to guide therapeutic decisions in the management of patients with IBD infected with HIV 3, 4.
• Personalized therapy plans based on genetic determinants, targeted mechanisms of action, and pharmacologic optimization may improve outcomes and minimize toxicities in IBD patients with concomitant HIV infection 5.