A 34-year-old man presents with a 3-month history of numerous small, flesh-colored papules on his face, neck, and upper chest. Several lesions have a central dimple and occur in clusters. They are not painful and only mildly pruritic. He reports a 10-lb unintentional weight loss and recurrent oral thrush over the past year. Vitals are normal. Physical examination shows dozens of 2–5 mm dome-shaped, pearly papules with central umbilication. Which of the following patient characteristics is most strongly associated with a prolonged course and widespread distribution of this condition?