SANTA BARBARA, CALIF. — Add delusions of parasitosis to the list of “red flags” for possible HIV infection, Marcus Conant, M.D., said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.
“Every patient I've seen in 2 years with delusions of parasitosis—and I've seen more and more and more of them—is on crystal meth,” said Dr. Conant, a dermatologist in private practice in San Francisco.
What's the connection?
Crystal methamphetamine, a highly addictive drug, undermines judgment, heightens the sex drive, and is popular among populations where the incidence of HIV infection is rising, setting up a perfect formula for rapid HIV spread among users, he said.
Hallucinations are among the psychogenic properties of crystal methamphetamine use, driving many patients to a physician, with complaints of bugs crawling on or within the skin.
Dr. Conant explained that an estimated 1 million Americans are infected with HIV. About half are receiving treatment, a quarter do not require treatment yet or are not receiving drugs for other reasons, and the remaining quarter do not realize they have the disease.
The incidence is rising rapidly among women and minorities, as well as among young gay men who feel detached from the HIV-prevention messages heeded by older men who saw friends die very visible deaths in an era before the availability of antiretroviral drugs.
Crystal methamphetamine users may be having sex with individuals from any of those categories.
“You need to offer them an HIV test,” he advised.
Other “red flags” include presence of any major sexually transmitted disease, including cutaneous STDs such as genital herpes, genital warts, and even crab lice, Dr. Conant said.
He tells patients, “The way you caught this is the way you catch HIV.”
Opportunistic infections such as Kaposi's sarcoma, herpes zoster, and molluscum may also be tip-offs to HIV infection.
Systemic signs may include anemia, a low lymphocyte count, or low cholesterol.
Dr. Conant urged physicians to use their judgment.
“If you miss [suspecting HIV in] a 30-year-old man with a nipple ring and zoster on the chest, don't call me to testify that it was not below standard of care to offer him an HIV test,” he said.
When patients express reluctance to have an HIV test, he suggests telling them that you want “a look at your immune function to make sure cancer or leukemia isn't causing your problem.”
Many patients will then willingly agree to a CD4 count, which, if low, may be enough evidence to persuade them to consent to an HIV test.