Factors associated with pruritic papular eruption of human immunodeficiency virus infection in the antiretroviral therapy era


  • Funding sources Uganda AIDS Rural Treatment Outcomes. UARTO is supported by the National Institutes of Health (R01 MH054907, K24 MH87227 and P30 AI027763). S.L.C. was a recipient of the Roger Harman African Travelling Fellowship from the British Association of Dermatologists.
  • Conflicts of interest J.N.M. and D.B. are supported by the National Institutes of Health for their work with UARTO.



Pruritic papular eruption (PPE) of HIV is common in HIV-infected populations living in the tropics. Its aetiology has been attributed to insect bite reactions and it is reported to improve with antiretroviral therapy (ART). Its presence after at least 6 months of ART has been proposed as one of several markers of treatment failure.


To determine factors associated with PPE in HIV-infected persons receiving ART.


A case–control study nested within a 500-person cohort from a teaching hospital in Mbarara, Uganda. Forty-five cases and 90 controls were enrolled. Cases had received ART for ≥ 15 months and had an itchy papular rash for at least 1 month with microscopic correlation by skin biopsy. Each case was individually matched with two controls for age, sex and ART duration.


Twenty-five of 45 cases (56%) had microscopic findings consistent with PPE. At skin examination and biopsy (study enrolment), a similar proportion of PPE cases and matched controls had plasma HIV RNA < 400 copies mL−1 (96% vs. 85%, = 0·31). The odds of having PPE increased fourfold with every log increase in viral load at ART initiation (= 0·02) but not at study enrolment. CD4 counts at ART initiation and study enrolment, and CD4 gains and CD8+ T-cell activation measured 6 and 12 months after ART commencement were not associated with PPE. Study participants who reported daily insect bites had greater odds of being cases [odds ratio (OR) 8·3, < 0·001] or PPE cases (OR 8·6, = 0·01).


Pruritic papular eruption in HIV-infected persons receiving ART for ≥ 15 months was associated with greater HIV viraemia at ART commencement, independent of CD4 count. Skin biopsies are important to distinguish between PPE and other itchy papular eruptions.