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Crane HM, Nance RM, Ruderman SA, Haidar L, Tenforde MW, Heckbert SR, Budoff MJ, Hahn AW, Drumright LN, Ma J, Mixson LS, Lober WB, Barnes GS, McReynolds J, Attia EF, Peter I, Moges T, Bamford L, Cachay E, Mathews WC, Christopolous K, Hunt PW, Napravnik S, Keruly J, Moore RD, Burkholder G, Willig AL, Lindstrom S, Whitney BM, Saag MS, Kitahata MM, Crothers KA, Delaney JAC. Venous Thromboembolism Among People With HIV: Design, Implementation, and Findings of a Centralized Adjudication System in Clinical Care Sites Across the United States. J Acquir Immune Defic Syndr 2024; 95:207-214. [PMID: 37988634 PMCID: PMC11151789 DOI: 10.1097/qai.0000000000003339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/30/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND People with HIV (PWH) are at increased risk for venous thromboembolism (VTE). We conducted this study to characterize VTE including provoking factors among PWH in the current treatment era. METHODS We included PWH with VTE between 2010 and 2020 at 6 sites in the CFAR Network of Integrated Clinical Systems cohort. We ascertained for possible VTE using diagnosis, VTE-related imaging, and VTE-related procedure codes, followed by centralized adjudication of primary data by expert physician reviewers. We evaluated sensitivity and positive predictive value of VTE ascertainment approaches. VTEs were classified by type and anatomic location. Reviewers identified provoking factors such as hospitalizations, infections, and other potential predisposing factors such as smoking. RESULTS We identified 557 PWH with adjudicated VTE: 239 (43%) had pulmonary embolism with or without deep venous thrombosis, and 318 (57%) had deep venous thrombosis alone. Ascertainment with clinical diagnoses alone missed 6% of VTEs identified with multiple ascertainment approaches. DVTs not associated with intravenous lines were most often in the proximal lower extremities. Among PWH with VTE, common provoking factors included recent hospitalization (n = 134, 42%), infection (n = 133, 42%), and immobilization/bed rest (n = 78, 25%). Only 57 (10%) PWH had no provoking factor identified. Smoking (46%), HIV viremia (27%), and injection drug use (22%) were also common. CONCLUSIONS We conducted a robust adjudication process that demonstrated the benefits of multiple ascertainment approaches followed by adjudication. Provoked VTEs were more common than unprovoked events. Nontraditional and modifiable potential predisposing factors such as viremia and smoking were common.
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Affiliation(s)
- Heidi M Crane
- Department of Medicine, University of Washington, Seattle, WA
| | - Robin M Nance
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Lara Haidar
- Department of Pharmacy, University of Manitoba, Manitoba, CA
| | - Mark W Tenforde
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance, CA
| | - Andrew W Hahn
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Jimmy Ma
- Department of Medicine, University of Washington, Seattle, WA
| | - L S Mixson
- Department of Medicine, University of Washington, Seattle, WA
| | - William B Lober
- Department of Medicine and Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Gregory S Barnes
- Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Justin McReynolds
- Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Engi F Attia
- Department of Medicine, University of Washington, Seattle, WA
| | - Inga Peter
- Department of Genetics, Mount Sinai University, New York NY
| | - Tesfaye Moges
- Department of Medicine, University of California, San Diego, CA
| | - Laura Bamford
- Department of Medicine, University of California, San Diego, CA
| | - Edward Cachay
- Department of Medicine, University of California, San Diego, CA
| | | | | | - Peter W Hunt
- Department of Medicine, University of California, San Francisco, CA
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Jeanne Keruly
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Greer Burkholder
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL
| | - Amanda L Willig
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL
| | - Sara Lindstrom
- Department of Genetics, University of Washington, Seattle, WA; and
| | | | - Michael S Saag
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mari M Kitahata
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Joseph A C Delaney
- Department of Medicine, University of Washington, Seattle, WA
- Department of Medicine, University of Manitoba, Manitoba, CA
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Patel K, Sikder O, Nair N, Wasserman S, Eikelboom JW. Venous Thromboembolism in Patients with Human Immunodeficiency Virus. TH OPEN 2023; 7:e226-e228. [PMID: 37497427 PMCID: PMC10368489 DOI: 10.1055/a-2110-5884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/07/2023] [Indexed: 07/28/2023] Open
Affiliation(s)
- Kashyap Patel
- School of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Omaike Sikder
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Nikhil Nair
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Rondebosch, Western Cape, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - John W. Eikelboom
- Thrombosis Service, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Zerangian N, Erabi G, Poudineh M, Monajjem K, Diyanati M, Khanlari M, Khalaji A, Allafi D, Faridzadeh A, Amali A, Alizadeh N, Salimi Y, Ghane Ezabadi S, Abdi A, Hasanabadi Z, ShojaeiBaghini M, Deravi N. Venous thromboembolism in viral diseases: A comprehensive literature review. Health Sci Rep 2023; 6:e1085. [PMID: 36778773 PMCID: PMC9900357 DOI: 10.1002/hsr2.1085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/25/2022] [Accepted: 01/19/2023] [Indexed: 02/09/2023] Open
Abstract
Venous thromboembolism (VTE) is known to be a common respiratory and/or cardiovascular complication in hospitalized patients with viral infections. Numerous studies have proven human immunodeficiency virus infection to be a prothrombotic condition. An elevated VTE risk has been observed in critically ill H1N1 influenza patients. VTE risk is remarkably higher in patients infected with the Hepatitis C virus in contrast to uninfected subjects. The elevation of D-dimer levels supported the association between Chikungunya and the Zika virus and the rise of clinical VTE risk. Varicella-zoster virus is a risk factor for both cellulitis and the consequent invasive bacterial disease which may take part in thrombotic initiation. Eventually, hospitalized patients infected with the coronavirus disease of 2019 (COVID-19), the cause of the ongoing worldwide pandemic, could mainly suffer from an anomalous risk of coagulation activation with enhanced venous thrombosis events and poor quality clinical course. Although the risk of VTE in nonhospitalized COVID-19 patients is not known yet, there are a large number of guidelines and studies on thromboprophylaxis administration for COVID-19 cases. This study aims to take a detailed look at the effect of viral diseases on VTE, the epidemiology of VTE in viral diseases, and the diagnosis and treatment of VTE.
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Affiliation(s)
- Nasibeh Zerangian
- Health Education and Health Promotion, Department of Health Education and Health Promotion, School of HealthMashhad University of Medical SciencesMashhadIran
| | - Gisou Erabi
- Student Research CommitteeUrmia University of Medical SciencesUrmiaIran
| | | | - Kosar Monajjem
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Maryam Diyanati
- Student Research CommitteeRafsanjan University of Medical SciencesRafsanjanIran
| | - Maryam Khanlari
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | | | - Diba Allafi
- Student Research CommitteeUrmia University of Medical SciencesUrmiaIran
| | - Arezoo Faridzadeh
- Department of Immunology and Allergy, School of MedicineMashhad University of Medical SciencesMashhadIran,Immunology Research CenterMashhad University of Medical SciencesMashhadIran
| | - Arian Amali
- Student Research Committee, Paramedical DepartmentIslamic Azad University, Mashhad BranchMashhadIran
| | - Nilufar Alizadeh
- Doctor of Medicine (MD), School of MedicineIran University of Medical SciencesTehranIran
| | - Yasaman Salimi
- Student Research CommitteeKermanshah University of Medical SciencesKermanshahIran
| | - Sajjad Ghane Ezabadi
- Student's Scientific Research Center, School of MedicineTehran University of Medical SciencesTehranIran
| | - Amir Abdi
- Student Research Committee, School of Medicine, Tehran Medical SciencesIslamic Azad UniversityTehranIran
| | - Zahra Hasanabadi
- Doctor of Medicine (MD), School of MedicineQazvin University of Medical ScienceQazvinIran
| | - Mahdie ShojaeiBaghini
- Medical Informatics Research Center, Institute for Futures Studies in HealthKerman University of Medical SciencesKermanIran
| | - Niloofar Deravi
- Student Research Committee, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
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Perkins MV, Joseph S, Dittmer DP, Mackman N. Cardiovascular Disease and Thrombosis in HIV Infection. Arterioscler Thromb Vasc Biol 2023; 43:175-191. [PMID: 36453273 PMCID: PMC10165851 DOI: 10.1161/atvbaha.122.318232] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/18/2022] [Indexed: 12/03/2022]
Abstract
HIV infection has transitioned from an acute, fatal disease to a chronic one managed by antiretroviral therapy. Thus, the aging population of people living with HIV (PLWH) continues to expand. HIV infection results in a dysregulated immune system, wherein CD4+ T cells are depleted, particularly in the gastrointestinal tract, disrupting the gut epithelial barrier. Long-term HIV infection is associated with chronic inflammation through potentially direct mechanisms caused by viral replication or exposure to viral proteins and indirect mechanisms resulting from increased translocation of microbial products from the intestine or exposure to antiretroviral therapy. Chronic inflammation (as marked by IL [interleukin]-6 and CRP [C-reactive protein]) in PLWH promotes endothelial cell dysfunction and atherosclerosis. PLWH show significantly increased rates of cardiovascular disease, such as myocardial infarction (risk ratio, 1.79 [95% CI, 1.54-2.08]) and stroke (risk ratio, 2.56 [95% CI, 1.43-4.61]). In addition, PLWH have increased levels of the coagulation biomarker D-dimer and have a two to ten-fold increased risk of venous thromboembolism compared with the general population. Several small clinical trials analyzed the effect of different antithrombotic agents on platelet activation, coagulation, inflammation, and immune cell activation. Although some markers for coagulation were reduced, most agents failed to reduce inflammatory markers in PLWH. More studies are needed to understand the underlying mechanisms driving inflammation in PLWH to create better therapies for lowering chronic inflammation in PLWH. Such therapies can potentially reduce atherosclerosis, cardiovascular disease, and thrombosis rates in PLWH and thus overall mortality in this population.
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Affiliation(s)
- Megan V. Perkins
- UNC Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sarah Joseph
- UNC Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dirk P. Dittmer
- UNC Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel Mackman
- UNC Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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5
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Bhoelan S, Borjas Howard J, Tichelaar V, Bierman W, Meijer K. Long-Term Trends of Coagulation Parameters in People Living With HIV Treated With Combined Antiretroviral Therapy. Clin Appl Thromb Hemost 2023; 29:10760296231165492. [PMID: 36972487 PMCID: PMC10052606 DOI: 10.1177/10760296231165492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Trends of coagulation parameters during long-term treatment with combination antiretroviral therapy (cART) are unclear. We followed 40 male subjects living with human immunodeficiency virus (HIV). Plasma levels of procoagulant parameters, factor VIII, von Willebrand factor and D-dimer, and anticoagulant parameter Protein S (PS), were measured before start and 3 months, 1 year, and 9 years after. Analyses were adjusted for cardiovascular risk factors (age, smoking, and hypertension) at baseline. At baseline, procoagulant parameters were markedly elevated and PS was in the lower range of normal. CD4/CD8-ratio improved during the complete follow-up period. In the first year, procoagulant parameters were decreasing, but at year 9 an increase was observed. After correction for cardiovascular risk factors, this increase was no longer present. PS remained stable during the first year and slightly increased from one to 9 years. This study indicates that decreasing immune activation by cART reverses the procoagulant state in HIV partially during the first year. These parameters increase in the long term despite an on-going decrease in immune activation. This increase might be related to established cardiovascular risk factors.
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Affiliation(s)
- Soerajja Bhoelan
- Department of Haematology, 10173University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Jaime Borjas Howard
- Department of Haematology, 10173University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Vladimir Tichelaar
- Department of Haematology, 10173University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Wouter Bierman
- Department of Internal Medicine, Division of Infectious Diseases, 10173University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Karina Meijer
- Department of Haematology, 10173University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
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Schapkaitz E, Jacobson BF, Libhaber E. Pregnancy Related Venous Thromboembolism-Associated with HIV Infection and Antiretroviral Therapy. Semin Thromb Hemost 2022; 49:355-363. [PMID: 36055274 DOI: 10.1055/s-0042-1754391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Human immunodeficiency virus (HIV) infection in pregnancy is associated with substantial morbidity and mortality. Improved access to effective antiretroviral therapy (ART) has shifted the spectrum of pregnancy-related complications among HIV-infected pregnant women. In addition to placental vascular complications and preterm delivery, increased rates of venous thromboembolism (VTE) have been described. HIV infection is characterized by immune activation, inflammation, and endothelial dysfunction, which contribute to the activation of coagulation and its prothrombotic consequences. Indeed, activated coagulation factors have been reported to be increased and natural anticoagulants reduced in HIV. Several mechanisms for this persistent prothrombotic balance on ART have been identified. These may include: co-infections, immune recovery, and loss of the gastrointestinal mucosal integrity with microbial translocation. In addition to the direct effects of HIV and ART, traditional venous and obstetric risk factors also contribute to the risk of VTE. A research priority has been to understand the mechanisms of VTE in HIV-infected pregnant women receiving suppressive ART and to translate this into HIV-specific thromboprophylaxis recommendations. Management requires a multidisciplinary approach and further studies are indicated to guide the prevention and management of pregnancy-associated VTE in this population. The current review describes the epidemiology, mechanisms, and management of VTE in HIV-infected women in pregnancy and the postpartum period.
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Affiliation(s)
- Elise Schapkaitz
- Department of Molecular Medicine and Hematology, University of Witwatersrand, Johannesburg, South Africa
| | - Barry F Jacobson
- Department of Molecular Medicine and Hematology, University of Witwatersrand, Johannesburg, South Africa
| | - Elena Libhaber
- Department of Research Methodology and Statistics, University of Witwatersrand, Johannesburg, South Africa
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7
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Elevated Risk of Venous Thromboembolism in People Living with HIV. Viruses 2022; 14:v14030590. [PMID: 35336997 PMCID: PMC8955815 DOI: 10.3390/v14030590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022] Open
Abstract
Human immunodeficiency virus (HIV) has been generally considered as a highly adaptive and rapidly evolving virus. It still constitutes a major public health problem all over the world despite an effective outcome in the prevention and reversal of the development and prognosis by using antiretroviral therapy. The salient question lies in the more frequent emergence of a series of comorbidities along with the prolongation of the life, which deeply affects the survival in such group. Venous thromboembolism (VTE) has been recognized to be the third most common cardiovascular condition within people living with HIV (PWH). In terms of its mechanism of action, the occurrence of VTE is quite multifactorial and complex in HIV. Prior exploration concerning the etiology of VTE in PWH identifies general, disease-specific, and miscellaneous factors for explaining its occurrence and development. VTE has constituted an important role in PWH and may increase its all-cause mortality. Therefore, it is quite necessary to understand VTE from the following aspects of epidemiology, pathophysiology, molecular mechanisms, and therapeutic interventions so as to balance the risks and benefits of anticoagulation and optimize corresponding treatment.
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8
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Schapkaitz E, Libhaber E, Jacobson BF, Gerber A, Rhemtula H, Büller HR. Profile of antiphospholipid antibodies in HIV-infected and HIV-uninfected women with a history of thrombosis. Int J Lab Hematol 2022; 44:635-642. [PMID: 35132770 DOI: 10.1111/ijlh.13805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/14/2022] [Accepted: 01/22/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Increased antiphospholipid antibodies (aPL) have been described in human immunodeficiency virus (HIV) infection. However, the association between aPL and the increased risk of thrombosis in HIV requires further clarification. METHODS We reviewed the medical records of 215 consecutive women with a history of thrombosis and/or obstetric complications (158 HIV-uninfected and 57 HIV-infected) between July 2017 and March 2021. Participants (n = 215) without clinical criteria manifestations for antiphospholipid syndrome were included as matched controls. Testing for lupus anticoagulant (LAC), anticardiolipin (aCL) and anti-beta2-glycoprotein1 (aβ2GP1) IgM and IgG was performed. RESULTS Thirty-two (10.1%) HIV-uninfected and 15 (13.2%) HIV-infected participants were positive at baseline for one of the five criteria aPL, with no statistically significant difference. The profile of the HIV-infected participants with thrombosis (n = 11) included LAC in 15.8%, aCL IgG in 3.5% and aβ2GP1 IgG in 1.8%. In contrast, the HIV-infected controls (n = 4), included aCL IgM in 1.8% and aβ2GP1 IgM in 5.3%. Only LAC was significantly associated with thrombosis (p < 0.003). On repeat testing, in a HIV-infected sub-population, 2/7 with thrombosis were positive, while 3/3 controls tested negative. CONCLUSION In contrast to earlier reports, the prevalence and expression of aPL in HIV-infected women with a history of thrombosis in the present study, in the era of antiretroviral therapy, were similar to HIV-uninfected women. Baseline LAC positivity was associated with a significantly increased risk for thrombosis in HIV. Future studies are recommended to explore additional coagulation abnormalities in HIV.
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Affiliation(s)
- Elise Schapkaitz
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Elena Libhaber
- HS Research Office and School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Barry F Jacobson
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Annika Gerber
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Haroun Rhemtula
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Dragovic B, Rymer J, Nwokolo N. Menopause care in women living with HIV in the UK - A review. J Virus Erad 2022; 8:100064. [PMID: 35242357 PMCID: PMC8866072 DOI: 10.1016/j.jve.2022.100064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/09/2022] [Indexed: 11/30/2022] Open
Abstract
Advances in HIV care over the last 30 years have transformed a virtually fatal condition into a chronic, manageable one. Antiretroviral therapy (ART) has dramatically changed the outlook for people living with HIV so that most individuals with well controlled disease have a normal life expectancy. As result of this increase in life expectancy, one-third of women living with HIV are of menopausal age. Adding to the shift in age distribution, rates of new HIV diagnosis are increasing in the over 50-year age group, likely the result of a combination of low condom use and perception of transmission risk and in women, an increased risk of HIV acquisition due to the mucosal disruption that accompanies vaginal atrophy. Many women living with HIV are unprepared for menopause, have a high prevalence of somatic, urogenital and psychological symptomatology and low rates of menopausal hormone therapy (MHT) use. Many women experience enormous frustration shuttling between their general practitioner and HIV care provider trying to have their needs met, as few HIV physicians have training in menopause medicine and primary care physicians are wary of managing women living with HIV, in part, because of fears about potential drug-drug interactions (DDIs) between MHT and ART. Several data gaps exist with regard to the relationship between HIV and the menopause, including whether the risk of HIV transmission is increased in virally-suppressed women with vaginal atrophy, whether or not menopause amplifies the effects of HIV on cardiovascular, psychological and bone health, as well as the safety and efficacy of MHT in women living with HIV. Menopausal women living with HIV deserve high quality individualised menopause care that is tailored to their needs. More research is needed in the field of HIV and menopause, primarily on cardiovascular disease and bone health outcomes as well as symptom control, and strategies to reduce HIV acquisition, encourage testing, and maintain older women in care in order to inform optimal clinical management.
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Affiliation(s)
- B. Dragovic
- St George’s University Hospitals NHS Foundation Trust, London, UK
- Guy’s and St Thomas' NHS Foundation Trust, London, UK
- Corresponding author. St George’s Hospital, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - J. Rymer
- Guy’s and St Thomas' NHS Foundation Trust, London, UK
- King’s College London, London, UK
| | - N. Nwokolo
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- ViiV Healthcare, Brentford, UK
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10
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Schapkaitz E, Libhaber E, Jacobson BF, Meiring M, Büller HR. von Willebrand factor propeptide-to-antigen ratio in HIV-infected pregnancy: Evidence of endothelial activation. J Thromb Haemost 2021; 19:3168-3176. [PMID: 34409729 DOI: 10.1111/jth.15502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/15/2021] [Accepted: 08/16/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Endothelial activation has been proposed as a potential mechanism for the increased risk of venous thromboembolism (VTE) in human immunodeficiency virus (HIV)-infected pregnancy. OBJECTIVES To assess the state of endothelial activation in HIV-infected pregnancy by measuring the von Willebrand factor (VWF) propeptide-to-antigen ratio, as an index of acute endothelial activation. METHODS VWF antigen and VWF propeptide were measured in HIV-negative participants (n = 85), HIV-infected virologically suppressed participants, (n = 89) and HIV-infected participants with HIV viral load (VL) of >50 copies/ml (n = 63) in each trimester. Results were correlated with multimer patterns and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS-13) antigen, activity, and antibody levels. RESULTS VWF propeptide-to-antigen ratio was increased, in the first, second, and third trimester, in the HIV-infected virologically suppressed group (1.7 ± 0.7, 1.7 ± 0.4, 1.6 ± 0.5) and the HIV-infected group with VL > 50 copies/ml (1.9 ± 0.9, 1.7 ± 0.9, 1.6 ± 1.1) compared to the HIV-negative group (1.4 ± 0.6, 1.3 ± 0.4, 1.2 ± 0.3, P < .05). Increased high molecular weight multimers were observed in the HIV-infected groups, despite only a mild reduction in ADAMTS-13 activity compared to the HIV-negative group (P < .001). No correlation was observed between VWF antigen or VWF propeptide and ADAMTS-13 activity. CONCLUSION HIV-infected virologically suppressed pregnant participants showed persistent endothelial activation. Future research should focus on whether endothelial activation contributes to the excess risk of pregnancy-related VTE.
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Affiliation(s)
- Elise Schapkaitz
- Department of Molecular Medicine and Hematology, Charlotte Maxeke Johannesburg Academic Hospital National Health Laboratory System Complex and University of Witwatersrand, Johannesburg, South Africa
| | - Elena Libhaber
- Department of Research Methodology and Statistics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Barry F Jacobson
- Department of Molecular Medicine and Hematology, Charlotte Maxeke Johannesburg Academic Hospital National Health Laboratory System Complex and University of Witwatersrand, Johannesburg, South Africa
| | - Muriel Meiring
- Department of Hematology and Cell Biology, University of Free State and National Health Laboratory Service, Bloemfontein, South Africa
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Centre, University of Amsterdam, the Netherlands
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11
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Plasmatic Coagulation Capacity Correlates With Inflammation and Abacavir Use During Chronic HIV Infection. J Acquir Immune Defic Syndr 2021; 87:711-719. [PMID: 33492017 DOI: 10.1097/qai.0000000000002633] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/21/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND D-dimer concentrations in people living with HIV (PLHIV) on combination antiretroviral therapy (cART) are increased and have been linked to mortality. D-dimer is a biomarker of in vivo coagulation. In contrast to reports on D-dimer, data on coagulation capacity in PLHIV are conflicting. In this study, we assessed the effect of cART and inflammation on coagulation capacity. SETTING We explored coagulation capacity using calibrated thrombin generation (TG) and linked this to persistent inflammation and cART in a cross-sectional study including PLHIV with viral suppression and uninfected controls. METHODS We used multivariate analyses to identify independent factors influencing in vivo coagulation (D-dimer) and ex vivo coagulation capacity (TG). RESULTS Among 208 PLHIV, 94 (45%) were on an abacavir-containing regimen. D-dimer levels (219.1 vs 170.5 ng/mL, P = 0.001) and inflammatory makers (sCD14, sCD163, and high-sensitive C-reactive protein) were increased in PLHIV compared with those in controls (n = 56). PLHIV experienced lower TG (reflected by endogenous thrombin potential [ETP]) when compared with controls, after correction for age, sex, and antiretroviral therapy. Abacavir use was independently associated with increased ETP. Prothrombin concentrations were strongly associated with ETP and lower in PLHIV on a non-abacavir-containing regimen compared with those in controls, suggesting consumption as a possible mechanism for HIV-associated reduction in TG. D-dimer concentrations were associated with inflammation, but not TG. CONCLUSIONS Abacavir use was associated with increased TG and could serve as an additional factor in the reported increase in thrombotic events during abacavir use. Increased exposure to triggers that propagate coagulation, such as inflammation, likely underlie increased D-dimer concentrations found in most PLHIV.
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Pretorius E. Platelets in HIV: A Guardian of Host Defence or Transient Reservoir of the Virus? Front Immunol 2021; 12:649465. [PMID: 33968041 PMCID: PMC8102774 DOI: 10.3389/fimmu.2021.649465] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/06/2021] [Indexed: 01/28/2023] Open
Abstract
The immune and inflammatory responses of platelets to human immunodeficiency virus 1 (HIV-1) and its envelope proteins are of great significance to both the treatment of the infection, and to the comorbidities related to systemic inflammation. Platelets can interact with the HIV-1 virus itself, or with viral membrane proteins, or with dysregulated inflammatory molecules in circulation, ensuing from HIV-1 infection. Platelets can facilitate the inhibition of HIV-1 infection via endogenously-produced inhibitors of HIV-1 replication, or the virus can temporarily hide from the immune system inside platelets, whereby platelets act as HIV-1 reservoirs. Platelets are therefore both guardians of the host defence system, and transient reservoirs of the virus. Such reservoirs may be of particular significance during combination antiretroviral therapy (cART) interruption, as it may drive viral persistence, and result in significant implications for treatment. Both HIV-1 envelope proteins and circulating inflammatory molecules can also initiate platelet complex formation with immune cells and erythrocytes. Complex formation cause platelet hypercoagulation and may lead to an increased thrombotic risk. Ultimately, HIV-1 infection can initiate platelet depletion and thrombocytopenia. Because of their relatively short lifespan, platelets are important signalling entities, and could be targeted more directly during HIV-1 infection and cART.
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Affiliation(s)
- Etheresia Pretorius
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
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Identification of two different coagulation phenotypes in people living with HIV with undetectable viral replication. Sci Rep 2021; 11:4383. [PMID: 33623050 PMCID: PMC7902813 DOI: 10.1038/s41598-021-83731-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 01/28/2021] [Indexed: 12/11/2022] Open
Abstract
Altered coagulation has been reported in people living with HIV (PLWH) with ongoing viral replication and may predispose to cardiovascular diseases. However, less is known about coagulation in PLWH with undetectable viral replication. In a cross-sectional observational study, we investigated whether HIV infection with undetectable viral replication is independently associated with activated partial thromboplastin time (APTT) and coagulation factor II-VII-X concentrations out of reference. Logistic regression analyses were used to assess the association of HIV infection with APTT and coagulation factor II-VII-X, after adjusting for age, sex, smoking status, alcohol consumption, BMI, diabetes and hsCRP. 936 PLWH with undetectable viral replication from the Copenhagen Co-morbidity in HIV infection study (COCOMO-study) and 2955 uninfected controls were included. Higher prevalence of short APTT was found in PLWH compared to controls (13.5% vs. 7.6%, P < 0.001). Furthermore, higher prevalence of low coagulation factor II-VII-X was found in PLWH than in controls (9.6% vs. 7.4%, P = 0.022). HIV was independently associated with short APTT (adjusted odds ratio (aOR) 2.3 (95% CI 1.7-2.9), P < 0.001) and low coagulation factor II-VII-X (aOR 1.4 (95% CI 1.0-1.9), P = 0.046). Few participants among PLWH and controls had both short APTT and low coagulation factor II-VII-X, 2.1% vs. 0.8%, respectively. We found evidence of both procoagulant (short APTT) and anticoagulant (low coagulation factor II-VII-X) alterations in PLWH with undetectable viral replication, and our findings suggest that two different coagulation phenotypes exist in participants with treated HIV infection.
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Schapkaitz E, Libhaber E, Rhemtula H, Gerber A, Jacobson BF, Chauke L, Büller HR. Pregnancy-related venous thromboembolism and HIV infection. Int J Gynaecol Obstet 2021; 155:110-118. [PMID: 33448037 DOI: 10.1002/ijgo.13596] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/15/2020] [Accepted: 01/11/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess risk factors for venous thromboembolism (VTE) in African women in order to guide thromboprophylaxis. METHODS A case-control study was performed at a specialist obstetric unit in South Africa from July 1, 2017 to June 30, 2020. We identified 128 cases with VTE and 640 controls, matched for gestation. RESULTS Prepartum risk factors associated with VTE included; medical comorbidities (odds ratios [OR] 5.32, 95% confidence intervals [CI] 1.82-15.56), human immunodeficiency virus (HIV) (OR 2.84, 95% CI 1.50-5.41), and hospital admission or immobility (OR 5.33, 95% CI 1.17-24.22). Postpartum, the following were identified as significant risk factors; medical comorbidities (OR 23.72, 95% CI 8.75-64.27), hospital admission or immobility (OR 13.18, 95% CI 5.04-34.49), systemic infection (OR 4.48, 95% CI 1.28-15.68), HIV (OR 3.20, 95% CI 1.49-6.87), pre-eclampsia and fetal growth restriction (OR 2.74, 95% CI 1.18-6.36), and postpartum hemorrhage (OR 4.38, 95% CI 1.75-10.97). Antiretroviral therapy, opportunistic infections, and viral load >50 copies/ml, however, were not associated with VTE risk among HIV-infected participants. CONCLUSION HIV was a significant risk factor for pregnancy-related thrombosis. This was independent of traditional HIV risk factors. As such, future studies are recommended to explore the mechanisms of thrombosis associated with HIV infection.
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Affiliation(s)
- Elise Schapkaitz
- Department of Molecular Medicine and Hematology, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Elena Libhaber
- HS Research Office and School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Haroun Rhemtula
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Annika Gerber
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Barry F Jacobson
- Department of Molecular Medicine and Hematology, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Lawrence Chauke
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Agrati C, Mazzotta V, Pinnetti C, Biava G, Bibas M. Venous thromboembolism in people living with HIV infection (PWH). Transl Res 2021; 227:89-99. [PMID: 32693031 DOI: 10.1016/j.trsl.2020.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
The risk of venous thromboembolism (VTE) and of recurrent VTE remain elevated in people living with HIV compared to controls still with contemporary antiretroviral therapy (ART). The pathophysiology of VTE in HIV is multi factorial and includes an interplay among traditional risk factors, HIV-specific factors, behavioral factors, exposure to ART and other therapies, coinfections, and co-morbidities.
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Affiliation(s)
- Chiara Agrati
- Cellular Immunology and Pharmacology Laboratory, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Valentina Mazzotta
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Carmela Pinnetti
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Gianluigi Biava
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Michele Bibas
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy.
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Teasdale CA, Hernandez C, Zerbe A, Chege D, Hawken M, El-Sadr WM. Changes in D-dimer after initiation of antiretroviral therapy in adults living with HIV in Kenya. BMC Infect Dis 2020; 20:508. [PMID: 32664854 PMCID: PMC7362533 DOI: 10.1186/s12879-020-05213-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background Increased coagulation biomarkers are associated with poor outcomes among people living with HIV (PLHIV). There are few data available from African cohorts demonstrating the effect of antiretroviral therapy (ART) on coagulation biomarkers. Methods From March 2014 to October 2014, ART-naïve PLHIV initiating non-nucleoside reverse transcriptase inhibitor-based ART were recruited from seven clinics in western Kenya and followed for up to 12 months. Demographics, clinical history and blood specimens were collected. Logistic regression models adjusted for intrasite clustering examined associations between HIV viral load and D-Dimer at baseline. Mixed linear effects models were used to estimate mean change from baseline to 6 months overall, and by baseline viral load, sex and TB status at enrollment. Mean change in D-dimer at 6 months is reported on the log10 scale and as percentage change from baseline. Results Among 611 PLHIV enrolled, 66% were female, median age was 34 years (interquartile range (IQR) 29–43 years), 31 (5%) participants had tuberculosis and median viral load was 113,500 copies/mL (IQR: 23,600-399,000). At baseline, 311 (50.9%) PLHIV had elevated D-dimer (> 500 ng/mL) and median D-dimer was 516.4 ng/mL (IQR: 302.7–926.6) (log baseline D-dimer: 2.7, IQR: 2.5–3.0). Higher baseline D-dimer was significantly associated with higher viral load (p < 0.0001), female sex (p = 0.02) and tuberculosis (p = 0.02). After 6 months on ART, 518 (84.8%) PLHIV had achieved viral load < 1000 copies/mL and median D-dimer was 390.0 (IQR: 236.6–656.9) (log D-dimer: 2.6, IQR: 2.4–2.8). Mean change in log D-dimer from baseline to 6 months was − 0.12 (95%CI −0.15, − 0.09) (p < 0.0001) indicating at 31.3% decline (95%CI −40.0, − 23.0) in D-dimer levels over the first 6 months on ART. D-dimer decline after ART initiation was significantly greater among PLHIV with tuberculosis at treatment initiation (− 172.1, 95%CI −259.0, − 106.3; p < 0.0001) and those with log viral load > 6.0 copies/mL (− 91.1, 95%CI −136.7, − 54.2; p < 0.01). Conclusions In this large Kenyan cohort of PLHIV, women, those with tuberculosis and higher viral load had elevated baseline D-dimer. ART initiation and viral load suppression among ART-naïve PLHIV in Kenya were associated with significant decrease in D-dimer at 6 months in this large African cohort.
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Affiliation(s)
- Chloe A Teasdale
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, 55 W125th Street, Room 543, New York, NY, 10027, USA. .,ICAP at Columbia University, Mailman School of Public Health, Columbia University, 22 W168th Street, New York, NY, 10032, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W168th Street, New York, NY, 10032, USA.
| | - Cecilia Hernandez
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, 22 W168th Street, New York, NY, 10032, USA
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, 22 W168th Street, New York, NY, 10032, USA
| | - Duncan Chege
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, 22 W168th Street, New York, NY, 10032, USA
| | - Mark Hawken
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, 22 W168th Street, New York, NY, 10032, USA
| | - Wafaa M El-Sadr
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, 22 W168th Street, New York, NY, 10032, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W168th Street, New York, NY, 10032, USA
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Rokx C, Borjas Howard JF, Smit C, Wit FW, Pieterman ED, Reiss P, Cannegieter SC, Lijfering WM, Meijer K, Bierman W, Tichelaar V, Rijnders BJA. Risk of recurrent venous thromboembolism in patients with HIV infection: A nationwide cohort study. PLoS Med 2020; 17:e1003101. [PMID: 32407386 PMCID: PMC7224453 DOI: 10.1371/journal.pmed.1003101] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/13/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Multiple studies have described a higher incidence of venous thromboembolism (VTE) in people living with an HIV infection (PWH). However, data on the risk of recurrent VTE in this population are lacking, although this question is more important for clinical practice. This study aims to estimate the risk of recurrent VTE in PWH compared to controls and to identify risk factors for recurrence within this population. METHODS AND FINDINGS PWH with a first VTE were derived from the AIDS Therapy Evaluation in the Netherlands (ATHENA) cohort (2003-2015), a nationwide ongoing cohort following up PWH in care in the Netherlands. Uninfected controls were derived from the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA) follow-up study (1999-2003), a cohort of patients with a first VTE who initially participated in a case-control study in the Netherlands who were followed up for recurrent VTE. Selection was limited to persons with an index VTE suffering from deep vein thrombosis in the lower limbs and/or pulmonary embolism (PE). Participants were followed from withdrawal of anticoagulation to VTE recurrence, loss to follow-up, death, or end of study. We estimated incidence rates, cumulative incidence (accounting for competing risk of death) and hazard ratios (HRs) using Cox proportional hazards regression, adjusting for age, sex, and whether the index event was provoked or unprovoked. When analyzing risk factors among PWH, the main focus of analysis was the role of immune markers (cluster of differentiation 4 [CD4]+ T-cell count). There were 153 PWH (82% men, median 48 years) and 4,005 uninfected controls (45% men, median 49 years) with a first VTE (71% unprovoked in PWH, 34% unprovoked in controls) available for analysis. With 40 VTE recurrences during 774 person-years of follow-up (PYFU) in PWH and 635 VTE recurrences during 20,215 PYFU in controls, the incidence rates were 5.2 and 3.1 per 100 PYFU (HR: 1.70, 95% CI 1.23-2.36, p = 0.003). VTE consistently recurred more frequently per 100 PYFU in PWH in all predefined subgroups of men (5.6 versus 4.8), women (3.6 versus 1.9), and unprovoked (6.0 versus 5.2) or provoked (3.1 versus 2.1) first VTE. After adjustment, the VTE recurrence risk was higher in PWH compared to controls in the first year after anticoagulant discontinuation (HR: 1.67, 95% CI 1.04-2.70, p = 0.03) with higher cumulative incidences in PWH at 1 year (12.5% versus 5.6%) and 5 years (23.4% versus 15.3%) of follow-up. VTE recurred less frequently in PWH who were more immunodeficient at the first VTE, marked by a better CD4+ T-cell recovery on antiretroviral therapy and during anticoagulant therapy for the first VTE (adjusted HR: 0.81 per 100 cells/mm3 increase, 95% CI 0.67-0.97, p = 0.02). Sensitivity analyses addressing potential sources of bias confirmed our principal analyses. The main study limitations are that VTEs were adjudicated differently in the cohorts and that diagnostic practices changed during the 20-year study period. CONCLUSIONS Overall, the risk of recurrent VTE was elevated in PWH compared to controls. Among PWH, recurrence risk appeared to decrease with greater CD4+ T-cell recovery after a first VTE. This is relevant when deciding to (dis)continue anticoagulant therapy in PWH with otherwise unprovoked first VTE.
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Affiliation(s)
- Casper Rokx
- Erasmus MC, University Medical Centre Rotterdam, Department of Internal Medicine, Section of Infectious Diseases, Rotterdam, the Netherlands
| | - Jaime F Borjas Howard
- University of Groningen, University Medical Centre Groningen, Department of Haematology, Groningen, the Netherlands
| | - Colette Smit
- HIV Monitoring Foundation, Amsterdam, the Netherlands
| | - Ferdinand W Wit
- Department of Global Health and Division of Infectious Diseases, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
| | - Elise D Pieterman
- Erasmus MC, University Medical Centre Rotterdam, Department of Internal Medicine, Section of Infectious Diseases, Rotterdam, the Netherlands
| | - Peter Reiss
- Department of Global Health and Division of Infectious Diseases, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne C Cannegieter
- Leiden University Medical Centre, Department of Clinical Epidemiology, Leiden, the Netherlands
| | - Willem M Lijfering
- Leiden University Medical Centre, Department of Clinical Epidemiology, Leiden, the Netherlands
| | - Karina Meijer
- University of Groningen, University Medical Centre Groningen, Department of Haematology, Groningen, the Netherlands
| | - Wouter Bierman
- University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, Infectious Diseases Service, Groningen, the Netherlands
| | - Vladimir Tichelaar
- University of Groningen, University Medical Centre Groningen, Department of Haematology, Groningen, the Netherlands
| | - Bart J A Rijnders
- Erasmus MC, University Medical Centre Rotterdam, Department of Internal Medicine, Section of Infectious Diseases, Rotterdam, the Netherlands
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