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Drug hypersensitivity in HIV infection

Peter, Jonnya,b,c; Choshi, Phutia,b; Lehloenya, Rannakoe J.c,d

Current Opinion in Allergy and Clinical Immunology: August 2019 - Volume 19 - Issue 4 - p 272–282
doi: 10.1097/ACI.0000000000000545
DRUG ALLERGY: Edited by Miguel Blanca and Paul Whitaker
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Purpose of review Immune-mediated adverse drug reactions (IM-ADRs) are many times more common in HIV-infected patients. Usual offending drugs include antiretroviral and antiinfectives, but the burden of specific drug IM-ADRs is population-specific; changing as new and fixed dose combinations enter the market, and drug-resistance patterns demand. This review considers recent literature on epidemiology, mechanisms, clinical management and prevention of IM-ADRs amongst persons living with HIV/AIDS.

Recent findings Epidemiological studies continue to describe high rates of delayed hypersensitivity to known offenders, as well as similar reactions in preexposure prophylaxis. IM-ADRs to oral and injectable integrase strand transfer inhibitors are reported with expanding use. The clinical spectrum and management of IM-ADRs occurring in HIV-infected populations is similar to uninfected; with exceptions such as a recently described severe delayed efavirenz DILI with high mortality. Furthermore, the context can be unique, such as the lower than expected mortality in a Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) cohort from a HIV/TB high burden setting. Programmatic data showing the near complete elimination of Abacavir drug hypersensitivity syndrome following implementation of HLA-B57:01 screening is a stellar example of how prevention is possible with mechanistic insight.

Summary IM-ADRs remain a challenge in persons living with HIV. The complexities posed by polypharmacy, overlapping drug toxicities, drug interactions, overlap of IM-ADRs with other diseases, limited alternative drugs, and vulnerable patients with advanced immunosuppression with high mortality, necessitate increased use of drug provocation testing, treat-through and desensitization strategies. There is an urgent need for improved diagnostics and predictive biomarkers for prevention, or to guide treat-through, rechallenge and desensitization approaches.

aDivision of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town

bAllergy and Immunology Unit, University of Cape Town Lung Institute

cCombined Drug Allergy Clinic, Groote Schuur Hospital

dDivision of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa

Correspondence to Professor Jonny Peter, Division of Allergy and Clinical Immunology, H52 Old Main Building, Groote Schuur Hospital, Observatory, 7925 Cape Town, South Africa. E-mail: Jonny.Peter@uct.ac.za

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