Opportunistic diseases among HIV-infected patients: a multicenter-nationwide Korean HIV/AIDS cohort study, 2006 to 2013

AIDS-defining events among people living with HIV who have been under continuous antiretroviral therapy for more than one year, a German cohort study 1999-2018

PURPOSE

This study examined the characteristics, incidence and prognostic factors of the first AIDS-defining condition developed after more than one year of continuous antiretroviral therapy (ART) among people living with HIV (PLHIV).

METHODS

We used data from two multicentre observational cohorts of PLHIV in Germany between 1999 and 2018. Our outcome was the first AIDS-defining event that occurred during follow-up after more than one year of continuous ART. Descriptive analyses at ART initiation, at the time of the AIDS event and of the most frequently observed types of AIDS-defining illnesses were performed. We calculated the incidence rate (IR) per 1000 person-years (PY) and used a bootstrap stepwise selection procedure to identify predictors of the outcome.

RESULTS

A total of 12,466 PLHIV were included in the analyses. 378 developed the outcome, constituting an overall IR of 5.6 (95% CI 5.1-6.2) AIDS events per 1000 PY. The majority of PLHIV was virally suppressed at the time of the event. Oesophageal candidiasis and wasting syndrome were the most frequently diagnosed AIDS-defining illnesses. We found a low CD4 count at ART initiation, a previous AIDS-defining condition and transmission through intravenous drug use to be meaningful prognostic factors of the outcome.

CONCLUSION

The overall rate of AIDS-defining events among PLHIV under long-term ART was low, highlighting the importance of continuous treatment. PLHIV who started ART with indicators of impaired immune functioning were more susceptible to disease progression, suggesting that the public health response should continue to focus on early and sustained treatment for all PLHIV.

Spectrum and mortality of opportunistic infections among HIV/AIDS patients in southwestern China

We describe the opportunistic infections (OIs) of HIV/AIDS to understand the spectrum, mortality, and frequency of multiple coinfected OIs among HIV/AIDS patients in southern China, where OIs are severe. We carried out a retrospective cohort study of hospitalized HIV-infected individuals at the Fourth People's Hospital of Nanning, Guangxi, China, from Jan. 2011 to May. 2019. The chi-square test was used to analyze cross-infection; the Kaplan‒Meier analysis was used to compare mortality. A total of 12,612 HIV-infected patients were admitted to this cohort study. Among them, 8982 (71.2%) developed one or more OIs. The overall in-hospital mortality rate was 9.0%. Among the patients, 35.6% coinfected one OI, and 64.4% coinfected more than two OIs simultaneously. Almost half of the patients (60.6%) had CD4 + T-cell counts < 200 cells/μL. Pneumonia (39.8%), tuberculosis (35.3%), and candidiasis (28.8%) were the most common OIs. Coinfected cryptococcal meningitis and dermatitis are the most common combined OIs. The rate of anaemia (17.0%) was highest among those common HIV-associated complications. Multiple OIs are commonly found in hospitalized HIV/AIDS patients in southwestern China, which highlights the need for improved diagnosis and treatment.

Alkaloids as Potential Anti-HIV Agents

BACKGROUND

Alkaloids are nitrogen-containing compounds that are naturally occurring and have a variety of biological activities, including antimicrobial properties. In this study, the authors used a molecular docking approach to evaluate the anti-HIV potential of 64 alkaloids.

METHODS

The authors used the Molegro Virtual Docker software to dock the alkaloids into the active sites of three HIV enzymes: protease, integrase, and non-nucleoside reverse transcriptase (NNRT). The docking scores were used to assess the potential of the alkaloids to inhibit the enzymes.

RESULTS

The results showed the alkaloids to have good potential to inhibit the enzymes. Tubocurarine and reserpine were found to be the most potent alkaloids, with docking scores of -123.776 and - 114.956, respectively.

CONCLUSION

The authors concluded that tubocurarine and reserpine could be further promoted as potential lead molecules for the development of new anti-HIV drugs.

Clinical characteristics of nontuberculous mycobacterial disease in people living with HIV/AIDS in South Korea: A multi-center, retrospective study

With the introduction of combination antiretroviral therapy (cART), the prevalence of human immunodeficiency virus (HIV)-associated nontuberculous mycobacteria (NTM) disease has declined. However, NTM diseases still occur in people living with HIV/acquired immunodeficiency syndrome (AIDS) (PLWHA). We analysed the clinical and microbiological features of NTM diseases in PLWHA in South Korea. PLWHA who were diagnosed with NTM diseases between January 2000 and March 2021 were retrospectively enrolled from five different hospitals in South Korea. Data on baseline demographics, HIV status, CD4+ T cell counts, viral load, past and current cART regimens, isolated NTM species, results of antimicrobial susceptibility tests, treatment regimens, and outcomes were collected by reviewing medical records. A total of 34 cases of NTM in PLWHA were included. Pulmonary and extrapulmonary NTM diseases accounted for 58.8% (n = 20) and 41.2% (n = 14), respectively. The lymph node was the most common site of extrapulmonary NTM disease (64.3%). The age at the time of NTM disease diagnosis was younger in the extrapulmonary NTM group than in the pulmonary NTM group (37.0 vs. 49.0 years). Mean CD4+ T cell counts at the time of NTM disease diagnosis was 186.6 cells/μL (range: 1–1394). Nine patients (26.5%) had fully suppressed viral loads at the time of NTM disease diagnosis. Mycobacterium avium complex (MAC) was the most common species found, followed by M. intracellulare and M. kansasii. MAC isolates were all susceptible to clarithromycin, but the rates of non-susceptibility to moxifloxacin, linezolid, ethambutol, and rifampin were 75%, 37.5%, 12.5%, and 12.5%, respectively. The average duration of treatment was 17 months and the mortality rate was 8.8%. NTM diseases may occur in PLWHA, even with completely suppressed viral loads. The identified clinical features of NTM diseases are essential for its clinical management in South Korea.

Determinants of virological failure among patients on first line highly active antiretroviral therapy (HAART) in Southwest Ethiopia: A case-control study

Background

Virological failure remains a public health concern among patients with human immunodeficiency virus (HIV) after treatment initiation. Ethiopia is one of the countries that aims to achieve the global target of 90-90-90 that aims to achieve 90% virological suppression, but there is a paucity of evidence on the determinants of virological failure. Therefore, the study is intended to assess determinants of virological treatment failure among patients on first-line highly active antiretroviral therapy (HAART) at Mizan Tepi University Teaching Hospital (MTUTH), Southwest Ethiopia.

Method

A hospital-based unmatched case-control study was conducted from 11 November to 23 December 2020, among 146 cases and 146 controls. All cases and controls were selected randomly using computer-generated random numbers based on their medical record numbers. During the document review, data were collected using checklists, entered into Epi-data version 4.0.2, and analyzed by SPSS version 25. A multivariable logistic regression analysis was done to identify the independent determinants of virological treatment failure.

Results

In this study, being male (adjusted odds ratio (AOR) = 1.89, 95% CI: 1.04, 3.47), substance use (AOR = 2.67, 95% CI: 1.40, 4.95), baseline hemoglobin (Hgb) < 12 mg/dl (AOR = 3.22, 95% CI: 1.82, 5.99), poor drug adherence (AOR = 3.84, 95% CI: 1.77, 5.95), restart ART medication (AOR = 2.45, 95% CI: 1.69, 7.35), and opportunistic infection (OI) while on HAART (AOR = 4.73, 95% CI: 1.76, 12.11) were determinants of virological treatment failure.

Conclusion

The study revealed that the sex of the patient, history of substance use, baseline Hgb < 12 mg/dl, poor drug adherence, restart after an interruption, and having OI through the follow-up period were determinants of virological failure. Therefore, program implementation should consider gender disparity while men are more prone to virological failure. It is also imperative to implement targeted interventions to improve drug adherence and interruption problems in follow-up care. Moreover, patients with opportunistic infections and restart HAART need special care and attention.

Spatiotemporal Clusters and Trends of Pneumocystis Pneumonia in Korea

This study determined the recent status and trend of <i>Pneumocystis jirovecii</i> pneumonia (PcP) in the non-human immunodeficiency virus (HIV) (non-HIV-PcP) and HIV (HIV-PcP) infected populations using data from the Health Insurance Review & Assessment Service (HIRA) and the Korea Disease Control and Prevention Agency (KDCA). SaTScan and Joinpoint were used for statistical analyses. Non-HIV-PcP cases showed an upward trend during the study period from 2010 to 2021, with the largest number in 2021 (551 cases). The upward trend was similar until 2020 after adjusting for the population. Seoul had the highest number of cases (1,597) in the non-HIV-PcP group, which was the same after adjusting for the population (162 cases/1,000,000). It was followed by Jeju-do (89 cases/1,000,000). The most likely cluster (MLC) for the non-HIV-PCP group was Seoul (Relative Risk (RR)=4.59, Log Likelihood Ratio (LLR)=825.531), followed by Jeju-do (RR=1.59, LLR=5.431). An upward trend was observed among the non-HIV-PcP group in the Jeju-do/Jeollanam-do/Jeollabuk-do/Gyeongsangnam-do/Busan/Daejeon/Daegu/Ulsan joint cluster (29.02%, LLR=11.638, <i>P</i><0.001) located in the southern part of Korea. Both women and men in the non-HIV groups showed an overall upward trend of PcP during the study period. Men in the 60-69 age group had the highest annual percentage change (APC 41.8) during 2014-2019. In contrast, the HIV groups showed a falling trend of PcP recently. Men in the 60-69 age group had the most decrease (APC -17.6) during 2018-2021. This study provides an analytic basis for health measures and a nationwide epidemiological surveillance system for the management of PcP.

Cancer Incidence Among Adults With HIV in a Population-Based Cohort in Korea

IMPORTANCE

In combination with a decreased risk of AIDS-defining cancers and improved survival of people infected with HIV, the burden of non-AIDS-defining cancer has increased markedly. Although a substantial number of studies have measured the cancer risk among people with HIV in developed countries, little research has been conducted on the risk of cancer in HIV-infected people in Asia.

OBJECTIVE

To examine the cancer incidence and the estimated risk of cancer among people in Korea infected with HIV compared with the general population.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study evaluated patients without cancer newly diagnosed with HIV from January 1, 2006, to December 31, 2018, using a nationwide population-based claims database embedded in the National Health Insurance Service database. Data were analyzed between December 6, 2021, and February 28, 2022.

EXPOSURES

Infection with HIV.

MAIN OUTCOMES AND MEASURES

Cancer incidence and standardized incidence rate (SIR) through indirect standardization.

RESULTS

A total of 11 552 individuals without cancer (10 444 male [90.4%]; mean [SD] age, 39.9 [11.2] years) diagnosed with HIV were identified. The SIR for all cancers was 1.68 (95% CI, 1.50-1.87) in men and 1.26 (95% CI, 0.89-1.64) in women. In men, the highest SIRs were for Kaposi sarcoma (SIR, 349.10; 95% CI, 196.10-502.20) and anal cancer (SIR, 104.20; 95% CI, 55.56-149.90). The incidence of non-Hodgkin lymphoma (SIR, 15.62; 95% CI, 11.85-19.39), Hodgkin lymphoma (SIR, 16.67; 95% CI, 4.32-29.02), and oropharyngeal cancer (SIR, 2.97; 95% CI, 1.36-4.58) in men infected with HIV was higher than in the general population. In women infected with HIV, an increased incidence of cervical cancer (SIR, 4.98; 95% CI, 1.29-8.66) and non-Hodgkin lymphoma (SIR, 11.78; 95% CI, 2.35-21.21) compared with the general population was observed. The SIR of thyroid cancer in patients with HIV was lower than in the general population in both men (SIR, 0.63; 95% CI, 0.27-0.99) and women (SIR, 0.48; 95% CI, 0.06-0.90).

CONCLUSIONS AND RELEVANCE

In this cohort study, cancer risks, especially AIDS-defining cancer and virus-related cancer, were elevated in people with HIV. Efforts for cancer prevention, screening, and better accessibility to medical care in HIV-infected people are warranted.

Time to occurrence, predictors, and patterns of opportunistic infections incidence among HIV-positive patients attending Antiretroviral Therapy Clinic of Salale University Comprehensive Specialized Hospital: A retrospective cohort study

Opportunistic infections (OIs) in HIV patients are infections that are more common or more severe as a result of HIV-mediated immunosuppression. The advances in the capacity of antiretroviral therapy (ART) have diminished the incidence of OIs. However, even in the ART era, HIV-related OIs continue to be major causes of hospitalization and mortality. Therefore, this study aims to identify time to occurrence, predictors, and patterns of OIs incidence among HIV-positive patients attending ART clinic of Salale University Comprehensive Specialized Hospital, Ethiopia. A retrospective cohort study was conducted between 1st September 2016 and 1st September 2021. All 419 patients diagnosed during the study period were recruited. Data were extracted from both patient medical records and ART logbooks. Stata-16 was used for data analysis. Follow-up time was calculated from the date of HIV diagnosis to the date of OIs occurrence or censoring. Cox proportional hazards regression model was used to identify the predictors of OIs incidence. The total person-time of the follow-up was 8656 person-months of observation. During the follow-up time, 199 (47.49%) of the patients had developed OIs. The incidence rate of OIs was 23 (95%CI: 20, 26) per 1000 person-months of observation. The median OIs free survival time was 36 (95%CI: 31, 40) months. Predictors such as residence, cd4 category, baseline hemoglobin level, ART side effects, isoniazid preventive therapy, and chronic disease comorbidity were significantly predicted OIs incidence. The study area's OIs incidence remained high, requiring prompt action. To reduce the morbidity and mortality associated with OIs, HIV-positive patients with the predictors of rural residence, low CD4 category, low baseline hemoglobin level, ART side effects, not taking IPT, and baseline chronic disease comorbidity necessitate close follow-up and monitoring. Thus, we recommend focused and evidence-informed strategies to address OIs burden and improve outcomes.

Predicting the risk of active pulmonary tuberculosis in people living with HIV: development and validation of a nomogram

BACKGROUND

Diagnosis of pulmonary tuberculosis (PTB) among people living with HIV (PLHIV) was challenging. The study aimed to develop and validated a simple, convenient screening model for prioritizing TB among PLHIV.

METHODS

The study included eligible adult PLHIV participants who attended health care in Yunnan, China, from January 2016 to July 2019. Participants included before June 2018 were in the primary set; others were in the independent validation set. The research applied the least absolute shrinkage and selection operator regression to identify predictors associated with bacteriological confirmed PTB. The TB nomogram was developed by multivariate logistic regression. The C-index, receiver operating characteristic curve (ROC), the Hosmer-Lemeshow goodness of fit test (H-L), and the calibration curves were applied to evaluate and calibrate the nomogram. The developed nomogram was validated in the validation set. The clinical usefulness was assessed by cutoff analysis and decision curve analysis in the primary set.

RESULT

The study enrolled 766 PLHIV, of which 507 were in the primary set and 259 in the validation set, 21.5% and 14.3% individuals were confirmed PTB in two sets, respectively. The final nomogram included 5 predictors: current CD 4 cell count, the number of WHO screen tool, previous TB history, pulmonary cavity, and smoking status (p < 0.05). The C-statistic was 0.72 (95% CI 0.66-0.77) in primary set and 0.68 (95% CI 0.58-0.75) in validation set, ROC performed better than other models. The nomogram calibration was good (H-L χ² = 8.14, p = 0.15). The area under the decision curve (0.025) outperformed the existing models. The optimal cutoff for screening TB among PLHIV was the score of 100 (sensitivity = 0.93, specificity = 0.35).

CONCLUSION

The study developed and validated a discriminative TB nomogram among PLHIV in the moderate prevalence of TB and HIV. The easy-to-use and straightforward nomogram would be beneficial for clinical practice and rapid risk screening in resource-limited settings.

Traditional Chinese Medicine for HIV-Associated Acute Herpes Zoster: A Systematic Review and Meta-Analysis of Randomized Trials

Background

Herpes zoster (HZ) is a common infection in individuals with acquired immunodeficiency syndrome (AIDS) patients. Traditional Chinese medicine (TCM) has been used widely in clinical practice for HZ, which remains not supportive of evidence. This review aimed to evaluate the effectiveness and safety of TCM in treating HIV-associated HZ.

Methods

Nine electronic databases were searched for randomized controlled trials (RCTs) testing TCM in treating HIV-associated HZ. Data were extracted on citations, interventions, and outcomes, by two authors independently. For the quality evaluation, Cochrane risk-of-bias tool 2.0 was used. Meta-analyses were performed by Revman5.3 software. Effect estimation presented as risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data with their 95% confidence interval (CI).

Results

Twelve RCTs (n = 644) were included; the majority of them had a high or unclear risk of bias. Meta-analysis showed that pain intensity (VAS 0–5) in the Chinese herbal medicine (CHM) group was lower than it in the drugs group (MD = −0.87, 95% CI [−1.69, −0.04], two trials, n = 93). Duration of herpes-related pain (days) of patients in the combination group was shorter than those in the drugs group (MD = −9.19, 95% CI [−16.73, −1.65], n = 144). The incidence of postherpetic neuralgia (PHN) in the combination group was lower than in the drugs group (RR = 0.49, 95% CI [0.25, 0.99], n = 202). As for cure rate (complete absence of pain and herpes), two trials showed that CHM was better than drugs (RR = 1.58, 95% CI [1.13, 2.22], n = 93), five trials showed combination treatment was better than drugs (RR = 1.40, 95% CI [1.08, 1.82], n = 224). The cure rate in the acupuncture group was more than that in the drugs group (RR = 1.99, 95% CI [1.18, 3.36], n = 120). Four trials reported adverse effects and found no serious adverse events occurred.

Conclusion

CHM and acupuncture demonstrate more benefits than drugs in pain relief, cure rate improvement, and incidence reduction of PHN. However, given the data limitation and TCM therapies' diversity, the conclusions need to be verified in future trials.

Effect of lipodystrophy on self-esteem and adherence to antiretroviral therapy in people living with HIV

The aim of this study was to determine the effect of lipodystrophy on self-esteem and adherence to antiretroviral therapy (ART) in people living with HIV (PLHIV). A cross-sectional and comparative study was carried out in an infection clinic, with 125 patients with lipodystrophy and 125 without lipodystrophy. Sociodemographic, clinical and epidemiological data were collected, using the Rosenberg Self-Esteem Scale and Assessment of Adherence to Antiretroviral Treatment Questionnaire (CEAT-VIH). Descriptive statistics and univariate and multivariate logistic regression analysis were used. Of the total sample, 57.2% had unsatisfactory self-esteem and 57.6% adequate adherence to ART. Self-esteem was lower in PLHIV with lipodystrophy (66.4%). PLHIV with monthly income less than or equal to two minimum wages (P < 0.001) and those with lipodystrophy had more unsatisfactory self-esteem (P < 0.001). Catholics had better self-esteem (P = 0.012), when compared to those without religion. Patients with monthly income less than or equal to two minimum wages (P = 0.021) and people with unsatisfactory self-esteem had more inadequate adherence to ART (P = 0.001). Catholics had better adherence to antiretrovirals (P = 0.007). In conclusion, lipodystrophy and low income negatively affect the self-esteem of PLHIV. Low income and unsatisfactory self-esteem make adherence to ART difficult. Religion is a protective factor for satisfactory self-esteem and adherence to antiretrovirals.

Effects of infections on the pathogenesis of cancer

Several studies have shown an inverse relationship between acute infections and cancer development. On the other hand, there is a growing evidence that chronic infections may contribute significantly to the carcinogenesis. Factors responsible for increased susceptibility to infections may include modifications of normal defence mechanisms or impairment of host immunity due to altered immune function, genetic polymorphisms, ageing and malnourishment. Studies have demonstrated that children exposed to febrile infectious diseases show a subsequent reduced risk for ovarian cancer, melanoma and many other cancers, while common acute infections in adults are associated with reduced risks for melanoma, glioma, meningioma and multiple cancers. Chronic inflammation associated with certain infectious diseases has been suggested as a cause for the development of tumours. Mechanisms of carcinogenesis due to infections include cell proliferation and DNA replication by mitogen-activated protein kinase pathway, production of toxins that affect the cell cycle and lead to abnormal cell growth and inhibition of apoptosis. This review was aimed to summarize the available evidence on acute infections as a means of cancer prevention and on the role of chronic infections in the development and progression of cancer.

Toxoplasma gondii infection in hospitalized people living with HIV in Spain, 1997 to 2015

Toxoplasma gondii infection was one of the most frequent AIDS-defining conditions in HIV-infected individuals until the advent of combination antiretroviral therapy. We aimed to assess the clinical load, coinfection, and mortality, as well as time trends for people living with HIV and hospitalized with Toxoplasma gondii infection, in Spain from 1997 to 2015. Retrospective observational analysis using the Spanish National Registry of Hospital Discharges. Information was retrieved for the study period using the International Classification of Diseases, 9th revision. There were 66,451,094 hospital admissions in Spain from 1997 to 2015, including 472,269 (0.71%) in people living with HIV. Toxoplasma gondii infection was registered in 9006 of these (overall prevalence 1.91%), making it the fifth most common opportunistic infection in hospitalized HIV-positive patients. Prevalence of Toxoplasma gondii infection declined in this group from 4.2% in 1997 to 0.8% in 2015 (p < 0.001), while mean age increased, from 35 years in 1997 to 44 years in 2015. The overall in-hospital mortality rate declined from 13.5% in 1997 to 8.9% in 2015, and it was higher in the concomitant presence of bacterial pneumonia (28.9% vs. 10.2%, p < 0.001), cryptosporidiosis (26.9% vs. 11.5%; p = 0.03), cytomegalovirus disease (18.2% vs. 11.2%, p < 0.001), Pneumocystis jiroveci pneumonia (31.5% vs. 10.5%, p < 0.001), leukoencephalopathy (19.8% vs. 11.78% p < 0.001), and wasting syndrome (29.3% vs 10.9%; p < 0.001). Toxoplasma gondii infection prevalence has significantly declined among hospitalized HIV-infected patients in Spain during the last two decades, coinciding with the widespread use of combination antiretroviral therapy.

Cryptosporidium infection among people living with HIV/AIDS in Ethiopia: a systematic review and meta-analysis

Studies on the prevalence of Cryptosporidium infection in People Living with HIV/AIDS (PLWHA) are inconsistent and heterogeneous. Therefore, this systematic review with meta-analysis was performed to assess the burden of the infection relative to the proportion of CD4 + T cell count among PLWHA in Ethiopia. Articles published before 15 May 2019, have been retrieved for this systematic review using five databases; PubMed, Scopus, Web of Science, Google Scholar and ProQuest, supplemented by the search for gray literature. The overall pooled prevalence and pooled Odds Ratio (OR) with their 95% Confidence Intervals (CI) were estimated using STATA 14 statistical Software. Of the 255 studies retrieved, 31 were considered for the final analysis. As many as 8,645 Ethiopians infected with HIV were included in the final quantitative synthesis. The overall pooled prevalence estimate of Cryptosporidium infection among PLWHA in Ethiopia was 11% (95%CI: 0.09-0.13). HIV-infected people with low CD4 + T cell count (CD4 < 200 cells/mm3) were 13.07 times more likely to become infected with Cryptosporidium than those with high CD4 + T cell count (CD4 > 500 cells/mm3) (OR: 13.07 (95%CI: 6.38-26.75). Cryptosporidium infection in PLWHA in Ethiopia showed decreasing patterns in 2001-2010, 2011-2014, and in 2015-2019, 14.6% (95%CI: 0.076-0.217), 12.71% (95%CI: 0.086-0.167) and 6.7% (95%CI: 0.044-0.090), respectively (p < 0.001). Though the pattern of Cryptosporidium infection in HIV-infected Ethiopians showed a declining trend; it remains a considerable problem that requires improvement in routine screening for Cryptosporidium in HIV-infected people, particularly with poor or declining CD4 + T cell count.

GOT SHINGLES? TEST FOR HIV. Severe shingles as first presenting infection in HIV/AIDS patient

Late diagnosis of HIV is associated with increased morbidity and mortality. Infected individuals need to be identified early and started on antiretroviral therapy to increase their survival and to limit transmission to the community. Historically speaking, late diagnosis has been a common occurrence in the United States, despite the majority of those patients having had a medical encounter in the year prior to their diagnosis. These visits represent missed opportunities for HIV testing and therefore delays in initiation of appropriate antiretroviral therapy. Herpes zoster is a common infection that may indicate a weakened immune system, and as such should prompt consideration for HIV testing, even in patients who lack or deny classic risk factors such as "risky sexual behavior" or drug use. Here, we present a case of severe herpes zoster in a middle aged woman with no other HIV risk factors, who was tested and found to be HIV positive. Her CD4 count at diagnosis was <200 cells/mcL, consistent with AIDS.

Estimation of the Number of HIV Infections and Time to Diagnosis in the Korea

BACKGROUND

Statistical data of undiagnosed people living with human immunodeficiency virus (PLHIV) are of great importance to human immunodeficiency virus (HIV) infection control. This study estimated the total number of PLHIV using nationwide claims data.

METHODS

This study used data of the incident HIV cases identified by the National Health Insurance System between 2009 and 2015. The number of patients with acquired immune deficiency syndrome (AIDS) was identified by diagnoses or prescription records. The estimated number of PLHIV and the time to diagnosis were calculated from the incident numbers of HIV and AIDS cases using the HIV Modeling Tool of the European Center for Disease Prevention and Control.

RESULTS

Between 2009 and 2015, a total of 7,033 PLHIV and 2,899 AIDS patients were diagnosed. In 2009, the number of incident HIV cases was 873 (460 AIDS patients), increasing to 995 (337 AIDS patients) in 2015. Besides, the estimated number of prevalent cases was 10,753 in 2009, compared to 14,880 in 2015. Patients visiting health facilities accounted for 42.9% (4,616/10,753) in 2009 and 64.1% (9,544/14,880) in 2015. In 2009, there were 8,363 (77.8%) undiagnosed HIV cases, experiencing a decline to 6,215 (41.8%) in 2015. It took a mean of 6.96 years to diagnose after HIV infection.

CONCLUSION

This study estimates the total burden of HIV infection in Korea for the first time using an internationally recognized HIV modeling tool. Claims data can be used to estimate the number of undiagnosed cases by identifying the total number of PLHIV and AIDS patients visiting health facilities.

History of Acquired Immune Deficiency Syndrome in Korea

The first human immunodeficiency virus (HIV) infection was reported in Korea in 1985. The number of HIV-infected persons domestically increased in the 1990s showing epidemic indigenousization. Since then, the number of new infections gradually increased every year, and recently more than 1,000 newly infected cases were reported per year. A total of 12,522 infected individuals have been reported up to 2015, of which 2,020 died. The male to female ratio was 15.4:1, and 34.2% of them were under 30 years old. The infection route was homosexual and bisexual contact in 60.1% of cases and heterosexual contact in 34.6% of cases. Candidiasis, Pneumocystis pneumonia, tuberculosis were common as a AIDS (acquired immune deficiency syndrome)-defining illness. But with the introduction of antiretroviral therapy in the late 1990s, non-AIDS defining illnesses such as metabolic complications, cardiovascular diseases, bone diseases, and neuropsychiatric disorders such as neurocognitive dysfunction, depression, and anxiety are emerging as new health problems. The management policy switched its focus from regulating and monitoring of HIV-infected persons to ensuring access to treatment and promotion of voluntary HIV testing in high-risk groups. Also as the age of the infected persons increases, a need for various supports such as social rehabilitation, life counseling, and welfare has emerged.

CD4 T cell count is inversely associated with lumbar spine bone mass in HIV-infected men under the age of 50 years

HIV-infected men under the age of 50 years had a lower bone mass compared to that of HIV-uninfected men. Lower CD4 T cell counts, independent of whether antiretroviral therapy (ART) was used, were associated with lower BMD. HIV-infected patients with low CD4 T cell counts may need follow-up and intervention regarding bone health, including younger patients.

INTRODUCTION

HIV-infected patients have a low bone mineral density (BMD) owing to multifactorial interaction between common osteoporosis risk factors and HIV-related factors, including chronic inflammation and ART. Although HIV infection and ART might affect bone metabolism, little data is available for patients aged under 50 years. We aimed to investigate the association of HIV infection-induced low CD4 T cell counts and ART with BMD in men aged under 50 years.

METHODS

We performed an age- and body mass index-matched case-control study. BMD values of HIV-infected and HIV-uninfected men (< 50 years) were compared, and HIV-infected men were stratified by CD4 T cell counts and ART use.

RESULTS

After adjusting confounders, HIV-infected men with CD4 T cell counts ≥ 500 cells/μL (n = 28) and < 500 cells/μL (n = 139) had lower BMD at the femoral neck (FN, p < 0.001) and total hip (TH, p < 0.001) than HIV-uninfected men (n = 167). HIV-infected men with CD4 T cell counts < 500/μL had lower BMD at the lumbar spine (LS, p = 0.034) than those with counts of ≥ 500 cells/μL, but not at FN and TH. The CD4 T cell count (γ = 0.169, p = 0.031) was positively correlated with BMD at LS. There was no significant difference in the BMD (p = 0.499-> 0.999) between the ART-naïve (n = 75) and ART-user group (n = 92).

CONCLUSIONS

Despite their relatively younger age, HIV-infected men had a lower BMD than HIV-uninfected men. Lower CD4 T cell counts, irrespective of ART, might result in lower bone mass.

Mortality-related risks in treatment-naive hospitalized AIDS patients with opportunistic infections in Southwest China

Aim: We aimed to profile the characteristics and analyze the risk factors related to mortality in treatment-naive hospitalized AIDS patients with opportunistic infections (OIs) in Southwest China. Materials & methods: Two hundred and four treatment-naive patients diagnosed with AIDS-related OIs that were hospitalized in our hospital were enrolled. Their demographics, medical data and prognosis were described and analyzed. Result: Most patients were middle-aged married or cohabiting males. The infections in the respiratory system were the major OIs and leading cause of mortality. High CRP and IL-6 were identified as independent risk factors predicting mortality. Conclusion: Middle-aged treatment-naive males were the major victims of AIDS-related OIs. Respiratory infection should be monitored, and early intervention should be applied to improve prognosis if there is high CRP or IL-6 found.

Comparison of Characteristics and Survival between Prospective and Retrospective Korea Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Cohort Studies

By comparing the data of prospectively and retrospectively enrolled cohorts, we evaluated whether the prospective cohort represented all patients in the retrospective cohort. The prospectively enrolled subjects were older and had lower CD4+ T cell counts, higher viral load. In addition, the initial antiretroviral treatment regimen of the prospective cohort consisted of less integrase strand transfer inhibitor-containing regimens. The 20-year survival rate was 51.8% in the prospective cohort and 84.6% in the retrospective cohort, respectively (P = 0.844). This study suggests the prospective cohort study may not represent all patients.

Korea HIV/AIDS Cohort Study: study design and baseline characteristics

The number of persons infected by HIV/AIDS has consistently increased in Korea since the first case of HIV/AIDS infection in 1985 and reached 15,208 by 2016. About 1,100 new patients with HIV/ AIDS infections have emerged every year since 2013. In Korea, the Korea HIV/AIDS Cohort Study was established for the evidenced-based prevention, treatment, and effective management of patients infected with human immunodeficiency virus (HIV) in December 2006. This study monitored 1,438 patients, who accounted for about 10% of all patients with HIV/AIDS in Korea, for 10 years with the following aims: (1) to develop an administrative system for the establishment of a HIV/AIDS cohort-based study; (2) to standardize methodologies and the case report forms; and (3) to standardize multi-cohort data and develop a data cleaning method. This study aims to monitor at least 1,000 patients (excluding those for whom investigation had been completed) per year (estimated number of patients who can be monitored by January 2018: 939). By December 2016, the sex distribution was 93.3% for men, and 6.7% for women (gender ratio, 13.9:1.0), and 98.9% of all participants were Korean. More than 50.0% of the participants were confirmed as HIV positive after 2006. This study reports competitive, long-term research that aimed to develop policies for the prevention of chronic infectious diseases for patients with HIV. The data collected over the last decade will be used to develop indices for HIV treatment and health promotion.

LOW CD4 LYMPHOCYTE COUNT RELATED RISK TO Pneumocystis jiroveci PNEUMONIA IN HIV/AIDS PATIENTS FROM BRONCHOALVEOLAR LAVAGE SPECIMENS USING REAL TIME PCR DETECTION

HIV and opportunistic infections remain a big problem especially in developing country. Pneumocystis jiroveci pneumonia is a prevalent infection  in HIV infected patient with high mortality rate. Diagnosis of Pneumocystis jiroveci pneumonia is mainly based on clinical evidence. Microbiological diagnosis is quite challenging since this microorganism cannot be cultured and is mainly based on microscopic examination. Microscopic examination with special staining is still a gold standard diagnosis for P. jiroveci infection.The objectives of this study was to describe CD4 lymphocyte profile and establish microbiological diagnosis with recent molecular method in PJP suspected HIV positive patients. Fiberoptic bronchoscopy of HIV infected patients with lower respiratory tract infection in Dr. Soetomo general hospital Surabaya were performed to collect bronchoalveolar lavage specimens  from December 2016 to April 2017 for identification of Pneumocystis jiroveci using real time PCR assay. Positive samples were then evaluated for  microscopic examination with Gommori Methenamine Silver staining for comparison. Patient’s CD4 lymphocyte count were gathered prior of admission. CD4 lymphocyte count from this study were very low with 61% of the patients were below 50 cells/ µL. There were five of  total thirteen patients (38,5%) with positive real time PCR assay (MSG gene)  and one patient was also positive with GMS staining showing characteristic cysts shape with dark centered area of P. jiroveci. Patient with positive microscopic examination showed no history of prophylactic therapy. Low CD4 lymphocyte count remains a strong risk factor of P. jiroveci pneumonia in HIV/AIDS patients. Real time PCR assay shows high value in detection of P. jiroveci regarding patient’s prophylactic status.

At the Nexus: How HIV-Related Immigration Policies Affect Foreign Nationals and Citizens in South Korea

Effective HIV prevention requires the protection and empowerment of marginalized groups at high risk of infection. However, many policies persist that stigmatize these groups and hinder HIV prevention efforts, including HIV-related travel restrictions. In the Republic of Korea, which requires HIV tests for certain visa categories, these restrictions negatively affect the national HIV response and access to accurate information on effective HIV prevention. In addition, they violate migrants' human rights to confidentiality and informed consent to testing and the rights of persons living with HIV (PLHIV) to privacy, work, medical care, bodily integrity, and freedom from discrimination. Furthermore, the discrimination and misconceptions perpetuated by this policy may be driving South Korea's burgeoning infection rates.

The Prevalence and Risk Factors of Renal Insufficiency among Korean HIV-Infected Patients: The Korea HIV/AIDS Cohort Study

BACKGROUND

Renal disease is one of the leading causes of morbidity and mortality among people infected with human immunodeficiency virus (HIV). However, there are very few published studies about renal insufficiency in HIV-infected persons in Asia, especially in South Korea.

MATERIALS AND METHODS

A cross-sectional study was performed to investigate the prevalence and risk factors of renal insufficiency, defined as <60 mL/min/1.73 m², in subjects in the Korea HIV/AIDS Cohort Study enrolled from 19 institutions between December 2006 and July 2013. Data at entry into the cohort were analyzed.

RESULTS

Of 454 enrolled subjects, 24 (5.3%) showed renal insufficiency at entry into the cohort. The mean age of patients in the renal insufficiency group was 5.28 years and the majority were male subjects (91.7%). All the patients were receiving antiretroviral agents, mostly protease inhibitor-based regimens (76.4%), for an average of 19 months. In univariate analysis, older age (P = 0.002), diabetes mellitus (DM) (P = 0.0002), unknown route of transmission (P = 0.007), and taking indinavir (P = 0.0022) were associated with renal insufficiency. In multivariable analysis, older age [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.03-1.12, P = 0.002], DM [OR 3.03, 95% CI 1.17-7.82, P = 0.022], unknown route of transmission [OR 6.15, 95% CI 1.77-21.33, P = 0.004], and taking indinavir [OR 3.07, 95% CI 1.17-8.05, P = 0.023] were independent risk factors of renal insufficiency.

CONCLUSION

The prevalence of renal insufficiency in HIV-infected subjects in this study was relatively low, similar to that in other countries. Aging, DM, and taking indinavir were significantly associated with decreased glomerular filtration rate. Furthermore, unknown route of transmission was an independent risk factor, which was interpreted as a reflection of patient compliance. Further studies on the incidence and risk factors of renal insufficiency during HIV infection using follow-up cohort data are necessary.