Markedly increased duodenal villous surface apoptosis in patients taking pre‐exposure prophylaxis (PrEP) against human immunodeficiency virus

Abstract

AimsPre‐exposure prophylaxis (PrEP) consists of combination antiretroviral therapy and is increasingly utilized to prevent human immunodeficiency virus (HIV) in high‐risk populations. Two index cases noted during routine care showed markedly increased duodenal villous surface apoptosis in patients on PrEP. We sought to examine the prevalence of this finding and identify any clinicopathologic correlations.MethodsGastrointestinal biopsy specimens from 23 male patients aged 18–40 years taking PrEP and 23 control patients were reviewed. Patients with HIV, inflammatory gastrointestinal diseases, and celiac disease were excluded. Apoptoses were counted on surface epithelium and deep crypts. The highest apoptotic body count per tissue fragment was recorded. Clusters were defined as groups of ≥5 apoptoses. Apoptotic counts between patients taking PrEP and controls were compared using t‐tests.ResultsIn PrEP patients, the median age was 35 years (range 25–40) and 83% (19/23) were white. The control patients were demographically similar (median age: 32 years [range 23–40]; 70% [16/23] white). Duodenal apoptosis in villous surface epithelium was increased in PrEP patients, with 14/23 (60.9%) patients having ≥10 surface apoptoses compared to 2/23 (8.7%) controls (P = 2.1 × 10−3) and 14/23 (61%) having clusters compared to 3/23 (13%) controls (P = 2.0 × 10−3). There was no significant association between increased surface apoptosis or clusters and clinical symptoms or duration of PrEP use.ConclusionMarkedly increased villous surface apoptosis, particularly in clusters, is often seen in the duodenum of patients taking PrEP. Although the mechanism and significance are unknown, knowledge of this peculiar finding may prevent unnecessary additional testing.