Pathogenesis, clinical course, and recent issues in HIV-1-infected Japanese hemophiliacs: a three-decade follow-up

Psychological support for people with hemophilia and HIV who suffer from cancer: A first national survey

Psychological support is necessary for people with hemophilia and HIV (PHH) who suffer from cancers. Most PHH are infected with not only HIV but also hepatitis C virus due to non-heat-treated blood coagulation factor products. PHH have a high risk of carcinogenesis, including liver cancer. Furthermore, many PHH present psychological problems, due to the great stress resulting from carcinogenesis and which impedes their cancer treatment. This study aimed to assess the psychological support system through a nationwide survey of healthcare workers caring for PHH at HIV care hospitals in Japan. The response rate was 49.1% (194/395), with a coverage rate of 74% (516/697) for PHH. Our findings indicated that psychologists were the most likely to be "coordinated" or "expected to coordinate" when PHH suffered from cancer (74%, multiple responses allowed). The most common reason for rating the adequacy of psychological support as "very good" or "good" was "easy collaboration with various professionals and medical teams". The number of HIV coordinator nurses and clinical psychologists per facility was 1.06 and 2.56, respectively. Our findings indicated more psychological support systems should be established in Japan, including reimbursement for psychological support for PHH.

Non-acquired immunodeficiency syndrome defining malignancies in people living with haemophilia and human immunodeficiency virus after direct-acting antiviral era

Non-acquired immunodeficiency syndrome-defining malignancies (NADMs) are the crucial cause of mortality in people living with haemophilia and human immunodeficiency virus (PLWHH). We aimed to analyse the types and characters of NADMs in PLWHH after approval of direct-acting antivirals (DAA), considering that most PLWHH are infected with hepatitis C virus (HCV). We conducted a nationwide questionnaire mail survey across 395 HIV core facilities in Japan between May 2022 and February 2023. Eight-year data from 64 respondent hospitals (n = 328 PLWHH; 2015-2022) were collected; 35 NADM cases were identified and analysed. Standardised cancer incidence ratios (SCIRs) were calculated. The median age of PLWHH with NADMs was 51 years (interquartile range: 47-62 years); the SCIR was 2.08 (95% confidence interval [CI]: 1.48-2.90) for all malignancies (including carcinoma in situ). Liver cancer accounted for most NADMs (43% [15/35]). The SCIRs of liver cancer (23.09 [95% CI: 13.92- 38.30]) and papillary thyroid cancer (9.38 [2.35-37.50]) significantly increased after adjusting for general Japanese male sex and age. Among PLWHH with liver cancers, 73% (11/15) achieved HCV-sustained virological response. Notably, for patients aged ≤ 50 years, 47% (7/15) were affected by liver cancers, and 27% (4/15) succumbed to NADMs. This study presents the largest survey of NADMs in PLWHH after DAA approval. Our findings emphasised the elevated risk of malignancies in PLWHH, underscoring the need for early cancer screening and preventive measures, particularly against liver cancers, even in younger PLWHH.

Investigating the Moderating Effect of HIV Status Disclosure on the Link Between Discrimination Experience and Psychological Distress Among People Living with HIV in Japan Infected Through Sexual Contact

BACKGROUND

There is a scarcity of research on the potential impact of disclosing HIV status to friends and family in moderating the adverse effects of discrimination on the mental health of people living with HIV (PLWH). This study assessed the experiences of discrimination and HIV status disclosure among PLWH in Japan, and evaluated their potential associations with psychological distress.

METHOD

Data were derived from a nationwide cross-sectional survey of PLWH conducted in Japan between 2019 and 2020. The interaction effects of HIV-related discrimination and HIV status disclosure on the psychological distress were examined using logistic and linear regression analyses.

RESULTS

The median age of the 804 respondents was 46 years old. Most respondents were male and 85.4% (687/804) identified as homosexuals or bisexuals. A total of 12.7% (102/804) of the respondents reported that they had recently experienced discrimination because of their HIV status. Experience of HIV-related discrimination was independently associated with high psychological distress (adjusted OR 2.02; 95% CI, 1.15-3.57), and HIV status disclosure to friends partially weakened the association between discrimination and the level of psychological distress (regression coefficient -3.115; p = 0.004).

CONCLUSION

While measures that aim to end discrimination remain vital, increasing the opportunities of PLWH to communicate with friends they feel comfortable disclosing their HIV status may also be helpful in protecting their mental health.

Coronary artery stenosis in Japanese people living with HIV-1 with or without haemophilia

An extremely high prevalence (12.2%) of moderate-to-severe coronary artery stenosis (CAS) was documented in asymptomatic Japanese haemophiliacs living with HIV-1 (JHLH) in our previous study. The cause of this phenomenon remains unknown. We conducted the CAS screening in people living with HIV-1 without haemophilia (PLWH without haemophilia) to compare the prevalence of CAS in JHLH and PLWH without haemophilia and to identify the risk factors including inflammation markers. Ninety-seven age-matched male PLWH without haemophilia who consulted our outpatient clinic between June and July 2021 were randomly selected, and 69 patients who provided informed consent were screened for CAS using coronary computed tomography angiography (CCTA). The number of JHLH cases was 62 in this study. The prevalence of moderate (> 50%) to severe (> 75%) CAS was significantly higher in JHLH [14/57 (24.6%) vs. 6/69 (8.7%), p = 0.015], and the ratio of CAS requiring urgent interventions was significantly higher [7 (12.3%) vs. 1 (1.4%), p = 0.013] in JHLH than in PLWH without haemophilia. Among the inflammatory markers, serum titres of intercellular adhesion molecule-1 (p < 0.05) and interleukin-6 (p < 0.05) in JHLH were significantly higher than those in PLWH without haemophilia. Although some patient demographics were different in the age-matched study, it might be possible to speculate that intravascular inflammation might promote CAS in JHLH.

Characteristics of 2-drug regimen users living with HIV-1 in a real-world setting: A large-scale medical claim database analysis in Japan

Background

Regimen simplification to 2-drug antiretroviral therapy (2-ART) may address potential tolerability issues, increase adherence, and reduce toxicity and potential drug-drug-interactions among people living with HIV-1 (PLWH). However, real-world treatment patterns and characteristics of 2-ART users are unclear.

Methods

This retrospective observational cohort study employed a large-scale medical claim database of Japanese hospitals to extract data on 4,293 PLWH aged ≥18 years with diagnosis of HIV and treated with any ART regimens between April 2008 and April 2019. A 2-ART cohort was compared with a 3-drug antiretroviral therapy (3-ART) cohort in terms of population characteristics, comorbid conditions, and treatment patterns. Treatment switching rates were calculated for each cohort followed by sensitivity analysis to confirm the robustness of the findings.

Results

There were 94 individuals identified in the 2-ART cohort. Compared to the standard 3-ART cohort (n = 3,993), the 2-ART cohort was older (median age 53 [IQR 44–64] vs 42 years [IQR 35–50]), with a lower proportion of males (87.2% vs 93.8%), higher Charlson Comorbidity Index (CCI) (median score 6 [IQR 5–8] vs 5 [IQR 4–6]), more co-medications (median 6 [IQR 4–11] vs 3 [IQR 2–7]), and a higher percentage of AIDS-defining conditions (66.0% vs 42.8%). The most common 2-ART were protease inhibitor (PI) + integrase strand transfer inhibitor (INSTI) and non-nucleoside reverse transcriptase inhibitor (NNRTI) + INSTI (33.0% and 31.9%, respectively). Overall, most of the regimens were nucleoside reverse transcriptase inhibitor (NRTI)-sparing (71.3%), with a decreasing trend over time (76.2% to 70.2%). ART regimen switch occurred more often in the 2-ART cohort than in the 3-ART cohort (33.0% vs 21.2%).

Conclusion

The profiles of individuals on 2-ART in Japan were demonstrated to be complex. Most were treated with NRTI-sparing regimens which may reflect an effort to reduce treatment-related toxicities.

National survey of hepatobiliary and pancreatic surgery in hemophilia patients in Japan

BACKGROUND

Approximately 8300 hemophiliacs are registered in Japan, but no comprehensive reports on hepatobiliary and pancreatic surgery (HBPS) have been conducted. This report investigates the current status of HPBS in hemophilia patients in Japan.

METHODS

The subjects were hemophiliac patients seen between January 1 2007, and December 31 2017, at facilities participating in this study among the facilities for performing high-difficulty cases nationwide designated by the Japanese Society for HBPS. A retrospective examination of short-term outcomes in 49 cases was conducted to assess patient background, disease, surgical procedure, and complications.

RESULTS

The types of hemophilia were A: 43 cases, B: four cases, and von Willebrand disease: two cases (hemophilia severity: mild 32, moderate seven, severe 10). The target malignant diseases for surgery were hepatocellular carcinoma (HCC) in 20 cases, intrahepatic cholangiocellular carcinoma (CCC) in four cases, combined HCC-CCC in two cases, hilar CCC in two cases, and pancreatic cancer in four cases. As for the surgical procedure, limited resection (subsegmentectomy and partial hepatectomy) was performed in 16 cases of HCC even with normal liver function tests. Pancreaticoduodenectomy and distal pacreatectomy were performed for pancreatic cancers as in the standard procedure. Postoperative complications were postoperative bleeding in two cases after hepatectomy and one after pancreatectomy in one case. When compared with Japanese National Clinical Data base, the complication rates after hepatectomy and pancreatectomy were not conspicuous in hemophilic patients.

CONCLUSIONS

As long as they are performed in qualified centers, complication rate is not increased in hemophilic patients undergoing HBPS.

AIDS at 40th: The progress of HIV treatment in Japan

Forty years have passed since the first five AIDS cases in Los Angeles were reported in 1981. Looking back at the history, these 40 years could be divided into 3 phases. During the first 15 years, when there was little efficacious therapy against HIV, clinical research was directed to develop diagnosis and treatment for opportunistic infections, mainly Pneumocystis jirovecii pneumonia. When combination antiretroviral therapy (cART) became available in 1996, taking cART had been troublesome to most patients following 10 years because some of them had severe side effects, diet restrictions, high pill burdens, drug interactions, etc. It was not easy for patients to keep high adherence and, therefore, the virus easily obtained drug resistance. Although the prognosis has been dramatically improved, patients had been still living with hard times during the second phase. Along with advancement of anti-retroviral drugs that have allowed simple treatment possible, their life expectancy has further improved and is reaching almost nearly the general population in the following 15 years. However, some patients have recently faced an additional load to treat life-related comorbidities and non-AIDS defining malignancies. The problem is that these diseases start to occur in the 40s- or 50s-year-old generations and that means HIV-infected persons are suffering from pre-mature aging. AIDS no longer signifies death. However, we still have a lot to improve for their quality of life.

Unexpected high prevalence of severe coronary artery stenosis in Japanese hemophiliacs living with HIV-1

To determine the prevalence of coronary artery stenosis (CAS) in Japanese hemophiliacs living with HIV- 1 (JHLH), a prospective study at AIDS Clinical Center, Tokyo, which provides care and treatment to nearly 10% of the JHLH was conducted. The study subjects were 76 JHLH who visited our clinic and received coronary computed tomography angiography (CCTA) between January through December 2019. CCTA with radiographic contrast media was used for CAS screening. Coronary artery calcium score (CACS) by CCTA, pulse wave velocity (PWV), electrocardiography, echocardiography, and chest radiography were also included to the screening process. Stenosis of 50% or more by CCTA was defined as moderate to severe CAS. All patients diagnosed with moderate to severe CAS were recommended to undergo coronary angiography (CAG). Among the 76 JHLH, 19 were excluded. Among the enrolled 57 patients, only 5 had complained of chest symptoms. Their median age was 47 years (interquartile range: 44-55 years), prevalence of hypertension 42.1%, diabetes mellitus 14.0%, dyslipidemia 38.6%, and smoking history 52.6%. Moderate to severe CAS was diagnosed in 14 patients by CCTA (24.6% of CCTA tested). Twelve patients agreed to undergo CAG. Seven patients were diagnosed as severe CAS by CAG (12.3% of CCTA received), although only 2 (28.6%) had chest symptoms. PWV and CACS were useful and significant non-invasive markers of moderate to severe CAS (p = 0.016, p < 0.001, respectively). In conclusions, our study identified high prevalence of severe CAS among JHLH. We recommend screening of all HIV-1-infected hemophiliacs with PWV and CACS, regardless of chest symptoms.

Full-genome analysis of hepatitis C virus in HIV-coinfected hemophiliac Japanese patients

AIM

More than 1400 Japanese hemophiliacs acquired HIV infection around 1983 through contaminated blood products imported from the USA, most of whom also acquired hepatitis C virus (HCV) infection. To delineate the HCV genetic relations in HIV-coinfected hemophiliacs, we analyzed stocked plasma samples of the patients seen at the largest referral center for HIV care in Japan.

METHODS

Hepatitis C virus full-genome sequences were amplified and determined using next-generation sequencing, and genotyping and phylogenetic analyses of these sequences were carried out. The results of these hemophiliacs were compared with those of previously studied HIV-coinfected Japanese non-hemophiliacs who had undergone similar analysis of HCV full-genome sequences.

RESULTS

From 1997 to the end of 2017, 72 HIV-infected Japanese hemophiliacs regularly visited our outpatient clinic. Of these, 51 patients had detectable plasma HCV-RNA. The HCV full genome was successfully amplified and sequenced in 50 patients. Not only HCV genotypes 1b (28%) and 2a (6%), which are common in Japan, but also HCV genotypes 1a (32%) and 3a (22%) were identified at high frequency. A single case of intergenotypic recombinant form (2b/1a) and a single case of mixed infection (1a and 3a) were also identified. Each sequence derived from hemophiliacs was more than 0.05 genetic distance away from the other sequences in phylogenetic analysis.

CONCLUSIONS

Various HCV genotypes were identified in Japanese hemophiliacs, a finding that reflects the HCV genotypic distribution in the USA. The genetic distance among them are the results of viral evolution in each patient plus HCV genetic diversity in the USA.