A. Phelan, Professor and Chairperson of the Department of Oral Pathology
and Director of the Diagnostic Pathology Laboratory, Division of
Biological Science, Medicine, and Surgery.
Therapy Use Among WIHS HIV+
young HIV-infected woman with candidiasis, xerostomia, and enlarged
salivary glands anxiously awaits a decision on her treatment.
course of action depends on the answers to several complex questions:
Are candidiasis and xerostomia a result of the patient’s HIV
infection, or a side effect of the potent antiviral drugs she is
taking? Will her salivary glands continue to grow if her viral load
increases? And what new oral health problems will she face should
her antiretroviral drug cocktail become ineffective?
As an investigator
on an NIH/ NIDCR grant (the NIDCR-supported oral health substudy
of the NIH- supported Women’s Interagency HIV Study [WIHS]),
I have been seeking answers to these and other questions for the
past seven years. WIHS is the world’s largest, longest-running
effort to compare the health of HIV-infected women with HIV-negative
women. Over 1,500 women are enrolled in WIHS, which began in 1995
under the joint auspices of seven federal agencies, including the
National Institute of Allergy and Infectious Diseases, the Centers
for Disease Control and Prevention, and the National Institute of
Dental and Craniofacial Research.
are enrolled in one of six regional health consortia, four of which
also conduct oral health substudies. NYUCD’s partners in the
New York regional consortium are Bronx-Lebanon Hospital Center/Montefiore
Medical Center, Beth Israel Medical Center, Mount Sinai Medical
Center, and Wadsworth Laboratories.
100 women participate in the NYUCD oral health substudy. The women
receive biannual physical exams at one of the participating hospitals,
followed by a separate oral health evaluation at NYUCD. The data
from the physical and oral exams, combined with additional analysis
of behavioral and lifestyle factors affecting the women’s
health, are sent to a central data bank, where they are made available
to investigators who analyze the data based on a wide range of factors.
These include the entire spectrum and course of HIV infection, as
well as treatment-related, endocrine, nutritional, health care utilization,
socioeconomic, and behavioral risk factors. Accordingly, my team
is in a privileged position to understand the changes that occur
in the oral cavity of HIV-infected women, including the long-term
changes caused by the widespread adoption of highly active, antiretroviral
(HAART) therapy. WIHS participants began taking these multi-drug
combinations in 1996, a year after the study began. Findings to
date include the following:
- Oral candidiasis
lesions occur in HIV-positive women with high viral loads and
low CD4+ counts who smoke. Candidiasis prevalence decreases as
a result of HAART therapy. Oral candidiasis is a very sensitive
marker of immune deficiency in HIV infection. Because oral candidiasis
can be an early sign of AIDS, oral health care providers who observe
it should counsel their patients about the importance of HIV testing.
But providers also need to evaluate the other potential causes
of candidiasis, which include systemic diseases such as diabetes
mellitus, local factors such as decreased salivary flow, and the
use of certain medications such as antibiotics and corticosteroids.
- In the first
multiyear study to examine caries progression in HIV-infected
individuals, WIHS determined that HIV-infected women have significantly
more caries than seronegative women. There are several possible
reasons for the difference, including microbial changes and the
use of medications that decrease salivary flow.
women have higher rates of salivary gland disease, as measured
by enlargement, tenderness, and absence of saliva, compared to
seronegative women. In addition, enlargement and tenderness of
some glands increase with higher viral loads.
and salivary gland hypofunction appear to be significantly higher
in HIV-positive women relative to a comparable group of at-risk
seronegative women. Immunosuppression levels measured by CD4+
cell counts were found to be strongly associated with xerostomia
and salivary gland hypofunction in these women.
The NIDCR is
expected to fund the WIHS oral health substudy for at least another
year. As the study progresses, I expect new insights to emerge that
could ultimately guide the planning and allocation of health care
resources for HIV-infected women. For example, the reappearance
of oral lesions could signal a weakening of HAART therapy’s
effectiveness and the need to adopt new HIV-treatment regimens.
And since one-third of HIV-infected subjects in my study also are
infected with the Hepatitis C virus (HCV), I hope to better understand
how HIV and HCV interact to affect oral health.
optimistic that researchers abroad who are intrigued by our findings
will want to collaborate with us on similar studies. Scientists
in Puerto Rico and Poland have shown an interest in such collaborative
studies. And this summer, Dr. Anthony T. Vernillo, a Professor of
Oral Pathology at NYUCD, hopes to gauge interest in collaborative
studies in Africa when he travels to Tanzania to present WIHS data
to the African chapter of the International Association for Dental