Atherosclerotic cardiovascular disease screening and management protocols among adult HIV clinics in Asia

OBJECTIVES

Integration of HIV and non-communicable disease services improves the quality and efficiency of care in low- and middle-income countries (LMICs). We aimed to describe current practices for the screening and management of atherosclerotic cardiovascular disease (ASCVD) among adult HIV clinics in Asia.

METHODS

Sixteen LMIC sites included in the International Epidemiology Databases to Evaluate AIDS - Asia-Pacific network were surveyed.

RESULTS

Sites were mostly (81%) based in urban public referral hospitals. Half had protocols to assess tobacco and alcohol use. Protocols for assessing physical inactivity and obesity were in place at 31% and 38% of sites, respectively. Most sites provided educational material on ASCVD risk factors (between 56% and 75% depending on risk factors). A total of 94% reported performing routine screening for hypertension, 100% for hyperlipidaemia and 88% for diabetes. Routine ASCVD risk assessment was reported by 94% of sites. Protocols for the management of hypertension, hyperlipidaemia, diabetes, high ASCVD risk and chronic ischaemic stroke were in place at 50%, 69%, 56%, 19% and 38% of sites, respectively. Blood pressure monitoring was free for patients at 69% of sites; however, most required patients to pay some or all the costs for other ASCVD-related procedures. Medications available in the clinic or within the same facility included angiotensin-converting enzyme inhibitors (81%), statins (94%) and sulphonylureas (94%).

CONCLUSION

The consistent availability of clinical screening, diagnostic testing and procedures and the availability of ASCVD medications in the Asian LMIC clinics surveyed are strengths that should be leveraged to improve the implementation of cardiovascular care protocols.

Early mortality after late initiation of antiretroviral therapy in the TREAT Asia HIV Observational Database (TAHOD) of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Asia-Pacific

OBJECTIVES

Early mortality among those still initiating antiretroviral therapy (ART) with advanced stages of HIV infection in resource-limited settings remains high despite recommendations for universal HIV treatment. We investigated risk factors associated with early mortality in people living with HIV (PLHIV) starting ART at low CD4 levels in the Asia-Pacific.

METHODS

PLHIV enrolled in the Therapeutics, Research, Education and AIDS Training in Asia (TREAT Asia) HIV Observational Database (TAHOD) who initiated ART with a CD4 count < 100 cells/μL between 2003 and 2018 were included in the study. Early mortality was defined as death within 1 year of ART initiation. PLHIV in follow-up for > 1 year were censored at 12 months. Competing risk regression was used to analyse risk factors with loss to follow-up as a competing risk.

RESULTS

A total of 1813 PLHIV were included in the study, of whom 74% were male. With 73 (4%) deaths, the overall first-year mortality rate was 4.27 per 100 person-years (PY). Thirty-eight deaths (52%) were AIDS-related, 10 (14%) were immune reconstituted inflammatory syndrome (IRIS)-related, 13 (18%) were non-AIDS-related and 12 (16%) had an unknown cause. Risk factors included having a body mass index (BMI) < 18.5 [sub-hazard ratio (SHR) 2.91; 95% confidence interval (CI) 1.60-5.32] compared to BMI 18.5-24.9, and alanine aminotransferase (ALT) ≥ 5 times its upper limit of normal (ULN) (SHR 6.14; 95% CI 1.62-23.20) compared to ALT < 5 times its ULN. A higher CD4 count (51-100 cells/μL: SHR 0.28; 95% CI 0.14-0.55; and > 100 cells/μL: SHR 0.12; 95% CI 0.05-0.26) was associated with reduced hazard for mortality compared to CD4 count ≤ 25 cells/μL.

CONCLUSIONS

Fifty-two per cent of early deaths were AIDS-related. Efforts to initiate ART at CD4 counts > 50 cell/μL are associated with improved short-term survival rates, even in those with late stages of HIV disease.

Long-term loss to follow-up in the TREAT Asia HIV Observational Database (TAHOD)

OBJECTIVES

With earlier antiretroviral therapy (ART) initiation, time spent in HIV care is expected to increase. We aimed to investigate loss to follow-up (LTFU) in Asian patients who remained in care 5 years after ART initiation.

METHODS

Long-term LTFU was defined as LTFU occurring after 5 years on ART. LTFU was defined as (1) patients not seen in the previous 12 months; and (2) patients not seen in the previous 6 months. Factors associated with LTFU were analysed using competing risk regression.

RESULTS

Under the 12-month definition, the LTFU rate was 2.0 per 100 person-years (PY) [95% confidence interval (CI) 1.8-2.2 among 4889 patients included in the study. LTFU was associated with age > 50 years [sub-hazard ratio (SHR) 1.64; 95% CI 1.17-2.31] compared with 31-40 years, viral load ≥ 1000 copies/mL (SHR 1.86; 95% CI 1.16-2.97) compared with viral load < 1000 copies/mL, and hepatitis C coinfection (SHR 1.48; 95% CI 1.06-2.05). LTFU was less likely to occur in females, in individuals with higher CD4 counts, in those with self-reported adherence ≥ 95%, and in those living in high-income countries. The 6-month LTFU definition produced an incidence rate of 3.2 per 100 PY (95% CI 2.9-3.4 and had similar associations but with greater risks of LTFU for ART initiation in later years (2006-2009: SHR 2.38; 95% CI 1.93-2.94; and 2010-2011: SHR 4.26; 95% CI 3.17-5.73) compared with 2003-2005.

CONCLUSIONS

The long-term LTFU rate in our cohort was low, with older age being associated with LTFU. The increased risk of LTFU with later years of ART initiation in the 6-month analysis, but not the 12-month analysis, implies that there was a possible move towards longer HIV clinic scheduling in Asia.

Cardiovascular disease-related mortality and factors associated with cardiovascular events in the TREAT Asia HIV Observational Database (TAHOD)

OBJECTIVES

With aging of the HIV-positive population, cardiovascular disease (CVD) increasingly contributes to morbidity and mortality. We investigated CVD-related and other causes of death (CODs) and factors associated with CVD in a multi-country Asian HIV-positive cohort.

METHODS

Patient data from 2003-2017 were obtained from the Therapeutics, Research, Education and AIDS Training in Asia (TREAT Asia) HIV Observational Database (TAHOD). We included patients on antiretroviral therapy (ART) with > 1 day of follow-up. Cumulative incidences were plotted for CVD-related, AIDS-related, non-AIDS-related, and unknown CODs, and any CVD (i.e. fatal and nonfatal). Competing risk regression was used to assess risk factors of any CVD.

RESULTS

Of 8069 patients with a median follow-up of 7.3 years [interquartile range (IQR) 4.4-10.7 years], 378 patients died [incidence rate (IR) 6.2 per 1000 person-years (PY)], and this total included 22 CVD-related deaths (IR 0.36 per 1000 PY). Factors significantly associated with any CVD event (IR 2.2 per 1000 PY) were older age [sub-hazard ratio (sHR) 2.21; 95% confidence interval (CI) 1.36-3.58 for age 41-50 years; sHR 5.52; 95% CI 3.43-8.91 for ≥ 51 years, compared with < 40 years], high blood pressure (sHR 1.62; 95% CI 1.04-2.52), high total cholesterol (sHR 1.89; 95% CI 1.27-2.82), high triglycerides (sHR 1.55; 95% CI 1.02-2.37) and high body mass index (BMI) (sHR 1.66; 95% CI 1.12-2.46). CVD crude IRs were lower in the later ART initiation period and in lower middle- and upper middle-income countries.

CONCLUSIONS

The development of fatal and nonfatal CVD events in our cohort was associated with older age, and treatable risk factors such as high blood pressure, triglycerides, total cholesterol and BMI. Lower CVD event rates in middle-income countries may indicate under-diagnosis of CVD in Asian-Pacific resource-limited settings.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Smoking and projected cardiovascular risk in an HIV-positive Asian regional cohort

OBJECTIVES

The aim of the study was to assess the prevalence and characteristics associated with current smoking in an Asian HIV-positive cohort, to calculate the predictive risks of cardiovascular disease (CVD), coronary heart disease (CHD) and myocardial infarction (MI), and to identify the impact that simulated interventions may have.

METHODS

Logistic regression analysis was used to distinguish associated current smoking characteristics. Five-year predictive risks of CVD, CHD and MI and the impact of simulated interventions were calculated utilizing the Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D) algorithm.

RESULTS

Smoking status data were collected from 4274 participants and 1496 of these had sufficient data for simulated intervention calculations. Current smoking prevalence in these two groups was similar (23.2% vs. 19.9%, respectively). Characteristics associated with current smoking included age > 50 years compared with 30-39 years [odds ratio (OR) 0.65; 95% confidence interval (CI) 0.51-0.83], HIV exposure through injecting drug use compared with heterosexual exposure (OR 3.03; 95% CI 2.25-4.07), and receiving antiretroviral therapy (ART) at study sites in Singapore, South Korea, Malaysia, Japan and Vietnam in comparison to Thailand (all OR > 2). Women were less likely to smoke than men (OR 0.11; 95% CI 0.08-0.14). In simulated interventions, smoking cessation demonstrated the greatest impact in reducing CVD and CHD risk and closely approximated the impact of switching from abacavir to an alternate antiretroviral in the reduction of 5-year MI risk.

CONCLUSIONS

Multiple interventions could reduce CVD, CHD and MI risk in Asian HIV-positive patients, with smoking cessation potentially being the most influential.

Human papillomavirus 16 (HPV16) and HPV52 E6-specific immunity in HIV-infected adults on combination antiretroviral therapy

OBJECTIVES

Human papillomavirus (HPV)-associated cancers disproportionately affect those infected with HIV despite effective combination antiretroviral therapy (cART). The primary aim of this study was to quantify HPV16 and HPV52 E6-specific interferon (IFN)-γ enzyme-linked immunospot (ELISPOT) T-cell responses, a correlate of protective immunity, in the first year following cART initiation and subsequently in those patients with suboptimal (sIR) and optimal (oIR) immune reconstitution.

METHODS

Ninety-four HIV-infected patients were recruited to the study; a longitudinal cohort of patients recruited just prior to commencing cART and followed up for 48 weeks (n = 27), and a cross-sectional cohort (n = 67) consisting of patients with sIR (CD4 T-cell count < 350 cells/μL) and oIR (CD4 T-cell count > 500 cells/μL) after a minimum of 2 years on cART. Controls (n = 29) consisted of HIV-negative individuals. IFN-γ ELISPOT responses against HPV16 and HPV52 E6 were correlated to clinical characteristics, anal and oral HPV carriage, T-cell maturational subsets, markers of activation, senescence and T-regulatory cells.

RESULTS

HPV16 and HPV52 E6-specific T-cell responses were detected in only one of 27 patients (3.7%) during the initial phase of immune recovery. After at least 2 years of cART, those who achieved oIR had significantly higher E6-specific responses (9 of 34; 26.5%) compared with those with sIR (2 of 32; 6.3%) (P = 0.029). Apart from higher CD4 T-cell counts and lower CD4 T-cell activation, no other immunological correlates were associated with the detection of HPV16 and HPV52 E6-specific responses.

CONCLUSIONS

HPV16 and HPV52 E6-specific IFN-γ T-cell responses, a correlate of protective immunity, were detected more frequently among HIV-infected patients who achieved optimal immune recovery on cART (26.5%) compared with those with suboptimal recovery (6.3%).

Toxoplasmosis in HIV and non HIV prisoners in Malaysia

This is the first Malaysian study to determine the trend and risk factors of Toxoplasma gondii infection in HIV and non-HIV among prisoners in terms of socio-demographic and behavioural characteristics, clinical presentations and haematological distributions. Blood samples from 303 participants, comprising 133 HIV positive and 170 HIV negative inmates were collected in EDTA and plain tubes. Two mls of each blood sample in plain tubes were centrifuged at 1500 rpm for 10 minutes and the sera obtained were subjected to ELISA for detection of Toxoplasma IgM and IgG antibody towards Toxoplasma antigen. Seropositive samples for Toxoplasma IgM or both Toxoplasma IgM and IgG were further tested with Novalisa Toxoplasma gondii IgG avidity test to rule out acute from latent infections. Blood in EDTA tubes were sent to Clinical Diagnostic Lab (CDL), University Malaya Medical Centre (UMMC), Kuala Lumpur for complete blood count and differential count analysis. Overall seroprevalence of anti-T. gondii antibodies was detected in 41.9% (127 out of 303) of the participants. Anti-T. gondii antibodies was detected in 63.2% (84 out of 133) of HIV positive subjects and in 25.3% (43 out of 170) of HIV negative subjects. Seroprevalence of anti-T. gondii antibodies was significantly higher in HIV positive than in HIV negative subjects (OR = 5.06; 95% CI = 3.09-8.30; p < 0.001). The rate of T. gondii seropositivity increased significantly in those aged 40 years and above, HIV positive individuals and those with history of drug abuse. White blood cells (WBCs), neutrophils and basophils counts decreased significantly in those infected with Toxoplasma. Creating awareness about T. gondii infection and follow-up of their status is recommended. Moreover, screening of T. gondii infection in HIV-infected individuals should be considered for better treatment and management, including control and prevention.

The effectiveness of compulsory drug treatment: A systematic review

BACKGROUND

Despite widespread implementation of compulsory treatment modalities for drug dependence, there has been no systematic evaluation of the scientific evidence on the effectiveness of compulsory drug treatment.

METHODS

We conducted a systematic review of studies assessing the outcomes of compulsory treatment. We conducted a search in duplicate of all relevant peer-reviewed scientific literature evaluating compulsory treatment modalities. The following academic databases were searched: PubMed, PAIS International, Proquest, PsycINFO, Web of Science, Soc Abstracts, JSTOR, EBSCO/Academic Search Complete, REDALYC, SciELO Brazil. We also searched the Internet, and article reference lists, from database inception to July 15th, 2015. Eligibility criteria are as follows: peer-reviewed scientific studies presenting original data. Primary outcome of interest was post-treatment drug use. Secondary outcome of interest was post-treatment criminal recidivism.

RESULTS

Of an initial 430 potential studies identified, nine quantitative studies met the inclusion criteria. Studies evaluated compulsory treatment options including drug detention facilities, short (i.e., 21-day) and long-term (i.e., 6 months) inpatient treatment, community-based treatment, group-based outpatient treatment, and prison-based treatment. Three studies (33%) reported no significant impacts of compulsory treatment compared with control interventions. Two studies (22%) found equivocal results but did not compare against a control condition. Two studies (22%) observed negative impacts of compulsory treatment on criminal recidivism. Two studies (22%) observed positive impacts of compulsory inpatient treatment on criminal recidivism and drug use.

CONCLUSION

There is limited scientific literature evaluating compulsory drug treatment. Evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms. Given the potential for human rights abuses within compulsory treatment settings, non-compulsory treatment modalities should be prioritized by policymakers seeking to reduce drug-related harms.

HIV-1 Tat biosensor: Current development and trends for early detection strategies

Human immunodeficiency virus (HIV) has infected almost 35 million people worldwide. Various tests have been developed to detect the presence of HIV during the early stages of the disease in order to reduce the risk of transmission to other humans. The HIV-1 Tat protein is one of the proteins present in HIV that are released abundantly approximately 2-4 weeks after infection. In this review, we have outlined various strategies for detecting the Tat protein, which helps transcribe the virus and enhances replication. Detection strategies presented include immunoassays, biosensors and gene expression, which utilize antibodies or aptamers as common probes to sense the presence of Tat. Alternatively, measuring the levels of gene transcription is a direct method of analysing the HIV gene to confirm the presence of Tat. By detection of the Tat protein, virus transmission can be detected in high-risk individuals in the early stages of the disease to reduce the risk of an HIV pandemic.

HIV and aging: insights from the Asia Pacific HIV Observational Database (APHOD)

OBJECTIVES

The proportion of people living with HIV/AIDS in the ageing population (>50 years old) is increasing. We aimed to explore the relationship between older age and treatment outcomes in HIV-positive persons from the Asia Pacific region.

METHODS

Patients from the Australian HIV Observational Database (AHOD) and the TREAT Asia HIV Observational Database (TAHOD) were included in the analysis. We used survival methods to assess the association between older age and all-cause mortality, as well as time to treatment modification. We used regression analyses to evaluate changes in CD4 counts after combination antiretroviral therapy (cART) initiation and determined the odds of detectable viral load, up to 24 months of treatment.

RESULTS

A total of 7142 patients were included in these analyses (60% in TAHOD and 40% in AHOD), of whom 25% were >50 years old. In multivariable analyses, those aged > 50 years were at least twice as likely to die as those aged 30-39 years [hazard ratio (HR) for 50-59 years: 2.27; 95% confidence interval (CI) 1.34-3.83; HR for > 60 years: 4.28; 95% CI 2.42-7.55]. The effect of older age on CD4 count changes was insignificant (p-trend=0.06). The odds of detectable viral load after cART initiation decreased with age (p-trend=< 0.0001). The effect of older age on time to first treatment modification was insignificant (p-trend=0.21). We found no statistically significant differences in outcomes between AHOD and TAHOD participants for all endpoints examined.

CONCLUSIONS

The associations between older age and typical patient outcomes in HIV-positive patients from the Asia Pacific region are similar in AHOD and TAHOD. Our data indicate that 'age effects' traverse the resource-rich and resource-limited divide and that future ageing-related findings might be applicable to each setting.

Prevalence of tuberculosis symptoms and latent tuberculous infection among prisoners in northeastern Malaysia

SETTING

There are currently no routine screening procedures for active tuberculosis (TB) or latent tuberculous infection (LTBI) in Malaysian prisons.

OBJECTIVE

To determine the prevalence and correlates of LTBI and active TB symptoms among Malaysian prisoners with and without human immunodeficiency virus (HIV) infection using the tuberculin skin test (TST) and the World Health Organization TB symptom-based screening instrument.

DESIGN

A cross-sectional survey of 266 prisoners was performed in Kelantan, Malaysia. Consenting participants underwent two-step TST and were screened for active TB symptoms. Standardized cut-offs of respectively ≥5 and ≥10 mm were used to define reactive TST among prisoners with and without HIV. Clinical and behavioral data were assessed and HIV-infected prisoners were stratified by CD4 status.

RESULTS

Overall LTBI prevalence was 87.6%, with significantly lower TST reactivity among HIV-infected than non-HIV-infected prisoners (83.6% vs. 91.5%, P < 0.05); however, TB symptoms were similar (16.9% vs. 10.1%, P = 0.105). On multivariate analysis, previous incarceration (aOR 4.61, 95%CI 1.76-12.1) was the only significant correlate of LTBI. Increasing age (aOR 1.07, 95%CI 1.01-1.13), lower body mass index (aOR 0.82, 95%CI 0.70-0.96) and TST-reactive status (aOR 3.46, 95%CI 1.20-9.97) were correlated with TB symptoms.

CONCLUSION

LTBI is highly prevalent, associated with previous incarceration, and suggests the need for routine TB screening on entry to Malaysian prisons.

Chikungunya infection in Malaysia: comparison with dengue infection in adults and predictors of persistent arthralgia

BACKGROUND

Chikungunya virus (CHIKV) and dengue virus (DENV) co-circulate in areas endemic with the Aedes mosquito vectors. Both viruses cause similar illnesses which may be difficult to distinguish clinically. CHIKV is also associated with persistent arthralgia.

OBJECTIVES

To compare and describe factors which differentiate between DENV and CHIKV infections on presentation; and to describe predictors of persistent arthralgia in CHIKV patients.

STUDY DESIGN

Patients aged >14 years diagnosed with acute CHIKV and DENV infections in Kuala Lumpur, Malaysia were retrospectively identified. Clinical and laboratory data were obtained from medical records, and compared. CHIKV patients were telephoned 15-24 months later and interviewed about persistent symptoms. Logistic regression analysis was performed.

RESULTS

A total of 53 CHIKV and 113 DENV patients were included. CHIKV patients were older and more likely to be female. CHIKV was independently associated with arthralgia and rash, while DENV was associated with myalgia, raised aspartate transaminase, and leucopaenia. Forty CHIKV patients were followed up, with a median duration of self-reported arthralgia of 3 months (range, 0-24 months). Eighteen (45%) had persistent arthralgia beyond 4 months, for which age >40 years was an independent predictor. At 1 year, 9 (22.5%) patients had arthralgia.

CONCLUSION

In Kuala Lumpur, selected clinical and laboratory predictors help to distinguish between DENV and CHIKV infections. Persistent arthralgia was a frequent sequel of CHIKV infection in this cohort.

Penicilliosis in lupus patients presenting with unresolved fever: a report of 2 cases and literature review

Penicilliosis is a rare occurrence among non human immunodeficiency virus (HIV) infected patients. We report here two cases of Penicillium marneffei infection in patients with systemic lupus erythematosus (SLE). Both patients had a recent flare of lupus and were on immunosuppressive drugs when they presented with prolonged fever without an obvious foci of infection, unresponsive to broad-spectrum antibiotics. They were leucopaenic upon admission, with rapid deterioration during the course of the illness. Diagnosis of penicilliosis via fungal isolation from blood culture was delayed resulting in the late initiation of antifungal agents. While both patients ultimately recovered, the delay in diagnosis led to a prolonged hospital stay with increased morbidity. Clinicians should be aware of this uncommon but emerging fungal pathogen in SLE patients and maintain a high index of suspicion in diagnosing this potentially fatal but treatable disease.

Isoniazid preventive therapy in correctional facilities: a systematic review

Tuberculosis (TB) remains a major cause of morbidity and mortality worldwide and the main cause of death in correctional facilities in middle- and low-income countries. Due to the closed environment and the concentration of individuals with TB-related risk factors, effective measures are required to control TB in such settings. Isoniazid preventive therapy (IPT) represents an effective and cost-effective measure. Despite international recommendations that IPT be integral to TB control, it is seldom deployed. A systematic review of interventions used to assess IPT initiation and completion in correctional facilities was conducted using published studies from two biomedical databases and relevant keywords. Additional references were reviewed, resulting in 18 eligible studies. Most (72%) studies were conducted in the United States and in jail settings (60%), with the main objective of improving completion rates inside the facility or after release. Studies that provided data about initiation and completion rates showed poor success in correctional facilities. Adverse consequences and treatment interruption ranged from 1% to 55% (median 5%) in reported studies; hepatotoxicity was the most prevalent adverse reaction. Despite its accelerating effect on the development of active TB, information on human immunodeficiency virus (HIV) status was provided in only half of the studies. Among the four studies where IPT effectiveness was assessed, the results mirror those described in community settings. Future studies require thorough assessments of IPT initiation and completion rates and adverse effects, particularly in low- and middle-income countries and where comorbid viral hepatitis may contribute significantly to outcomes, and in settings where TB and HIV are more endemic.

A large exposure to Brucella melitensis in a diagnostic laboratory

BACKGROUND

Brucella species are easily transmitted by aerosols and can be acquired in the laboratory.

AIM

To report the management of a large exposure to Brucella melitensis that occurred over six days in a hospital diagnostic laboratory.

METHODS

Fifty-one exposed staff were managed according to Centers for Disease Control and Prevention guidelines. A further 96 non-exposed laboratory staff were tested for seroprevalence. Testing was carried out using the Brucella sp. serum agglutination test.

FINDINGS

Twenty-seven people had high-risk exposure and 24 had low-risk exposure. High-risk staff were offered post-exposure prophylaxis. Twelve (44.4%) agreed to this, of whom eight (66.7%) completed the course. Overall compliance with serological follow-up at baseline, 2, 4, 6 weeks and 8 months was 45.9%. Despite this poor compliance there were no clinical brucellosis cases and no seroconversion in the 47.1% of staff tested at 8 months. Brucella sp. seroprevalence among all staff tested was 3/147 (2.0%).

CONCLUSION

Lack of experience with Brucella spp. and lack of policies for handling potentially hazardous organisms contributed to this prolonged exposure. As compliance with current recommendations may be poor, the optimum frequency of serological follow-up and target groups for prophylaxis should be reassessed. Laboratories in low- or non-endemic areas must prepare for potential isolation of Brucella spp. The impact of human brucellosis in Malaysia requires further study.

Profiles of men-who-have-sex-with-men seeking anonymous voluntary HIV counseling and testing at a community-based centre in Malaysia

Community-based HIV voluntary counseling and testing (VCT) services is an effective alternative for mapping the local demographics of at-risk populations for HIV as well as provide an acceptable and reliable means of early detection of HIV. We describe the profiles of men-who-have-sex-with-men (MSM) who sought VCT services in a community based centre in Kuala Lumpur.

Risk behaviour and HIV prevalence among men who have sex with men in a multiethnic society: a venue-based study in Kuala Lumpur, Malaysia

This research aimed to determine HIV prevalence, risk behaviour and knowledge of transmission methods among men who have sex with men (MSM) in Kuala Lumpur, Malaysia. Venue-day-time sampling (VDTS) was applied to identify venues where men congregate to solicit sex from other men. Participants recruited from clubs, massage parlours, saunas and one park self-completed a computerized behavioural questionnaire, were administered an oral rapid HIV test and given the opportunity to return later to receive full counselling and learn their HIV status. A total of 517 men were enrolled into the study. The majority were Malays (47.0%) and Chinese (43.7%). Twenty tested HIV positive (3.9%). Significant predictors of HIV infection included having unprotected anal sex with a casual partner (44.9% of participants, odds ratio [OR] = 2.99; 95% confidence interval [CI] 1.13-7.90; P = 0.027), having unprotected receptive anal sex (27.9%, OR = 2.71; 95% CI 1.10-6.54; P = 0.030) and having group sex (33.3%, OR = 3.95; 95% CI 1.55-10.09; P = 0.004). One in five participants (20.1% and 19.5%) did not believe that HIV could be transmitted through insertive or receptive anal sex, respectively. Risk behaviour is high and knowledge of HIV transmission methods was low among MSM in Kuala Lumpur. Future prevention efforts should focus on providing risk reduction education to this community.

Tumour necrosis factor haplotypes associated with sensory neuropathy in Asian and Caucasian human immunodeficiency virus patients

In human immunodeficiency virus (HIV) patients, neuropathy is a common adverse side effect to some antiretroviral treatments, particularly stavudine. As stavudine is cheap, it is widely used in Asia and Africa. We showed that increasing age and height moderately predict the development of neuropathy. This was improved by the inclusion of tumour necrosis factor (TNF)-1031 (rs1799964). To investigate this association, Malay (n = 64), Chinese (n = 74) and Caucasian patients (n = 37) exposed to stavudine were screened for neuropathy. DNA samples were genotyped for polymorphisms in the central major histocompatibility complex (MHC) near TNF, and haplotypes were derived. The haplotype group FVa6,7,8 (incorporating TNF-1031) was found to be associated with neuropathy in Chinese patients in bivariate analyses (P = 0.03), and in Malays and Chinese in a multivariate analysis correcting for age and height (P = 0.02, P = 0.03, respectively). This trend was also confirmed in Caucasians.

Prevalence and correlates of community re-entry challenges faced by HIV-infected male prisoners in Malaysia

HIV-infected prisoners face an inordinate number of community re-entry challenges. In 2007, 102 HIV-infected prisoners in Malaysia were surveyed anonymously within six months prior to release to assess the prevalence and correlates of community re-entry challenges. Staying out of prison (60.8%), remaining off drugs (39.2%), finding employment (35.3%) and obtaining HIV care (32.4%) were the re-entry challenges reported most frequently. Global stigma, negative self-image and public attitudes-related stigma were independently associated with challenges to obtaining HIV care. In multivariate analyses, those with previous incarcerations (adjusted odds ratio [AOR], 3.2; 95% confidence interval [CI], 1.4-7.6), higher HIV-related symptoms (AOR, 2.0; 95% CI, 1.0-4.1) and higher public attitudes-related stigma (AOR, 2.5; 95% CI, 1.2-5.1) had a significantly higher likelihood of identifying more re-entry challenges. Targeted interventions, such as effective drug treatment, HIV care and public awareness campaigns, are crucial for stemming the HIV epidemic and improving health outcomes among HIV-infected prisoners in Malaysia.

Measures of site resourcing predict virologic suppression, immunologic response and HIV disease progression following highly active antiretroviral therapy (HAART) in the TREAT Asia HIV Observational Database (TAHOD)

OBJECTIVES

Surrogate markers of HIV disease progression are HIV RNA in plasma viral load (VL) and CD4 cell count (immune function). Despite improved international access to antiretrovirals, surrogate marker diagnostics are not routinely available in resource-limited settings. Therefore, the objective was to assess effects of economic and diagnostic resourcing on patient treatment outcomes.

METHODS

Analyses were based on 2333 patients initiating highly active antiretroviral therapy (HAART) from 2000 onwards. Sites were categorized by World Bank country income criteria (high/low) and annual frequency of VL (> or = 3, 1-2 or <1) or CD4 (> or = 3 or <3) testing. Endpoints were time to AIDS/death and change in CD4 cell count and VL suppression (<400 HIV-1 RNA copies/mL) at 12 months. Demographics, Centers for Disease Control and Prevention (CDC) classification, baseline VL/CD4 cell counts, hepatitis B/C coinfections and HAART regimen were covariates. Time to AIDS/death was analysed by proportional hazards models. CD4 and VL endpoints were analysed using linear and logistic regression, respectively.

RESULTS

Increased disease progression was associated with site-reported VL testing less than once per year [hazard ratio (HR)=1.4; P=0.032], severely symptomatic HIV infection (HR=1.4; P=0.003) and hepatitis C virus coinfection (HR=1.8; P=0.011). A total of 1120 patients (48.2%) had change in CD4 cell count data. Smaller increases were associated with older age (P<0.001) and 'Other' HIV source exposures, including injecting drug use and blood products (P=0.043). A total of 785 patients (33.7%) contributed to the VL suppression analyses. Patients from sites with VL testing less than once per year [odds ratio (OR)=0.30; P<0.001] and reporting 'Other' HIV exposures experienced reduced suppression (OR=0.28; P<0.001).

CONCLUSION

Low measures of site resourcing were associated with less favourable patient outcomes, including a 35% increase in disease progression in patients from sites with VL testing less than once per year.

Chikungunya virus-associated death in Malaysia

Chikungunya virus (CHIKV) is a mosquito-borne alphavirus which causes fever, rash, and arthralgia. In the past, life-threatening complications were very rarely reported. However, during the recent worldwide outbreaks, there have been several reports of unusually severe complications and deaths. Malaysia is experiencing a nationwide outbreak of CHIKV, with over 10 000 patients affected since April 2008. We report the first case of culture-confirmed CHIKV-associated death in Malaysia, in a patient with fever, rash, acute exacerbation of pre-existing heart failure, rhabdomyolysis, and multiple organ failure. CHIKV infections may cause atypical, severe or fatal presentations.

Hepatitis C seropositivity is not a risk factor for sensory neuropathy among patients with HIV

BACKGROUND

Sensory neuropathy (SN) is common in patients with HIV. Hepatitis C (HCV) coinfection is often cited as an HIV-SN risk factor, but data to support this are lacking. This collaboration aimed to examine the association between HCV serostatus and SN risk among ambulatory HIV-positive patients.

METHODS

Patients with HIV were assessed in cross-sectional studies in Baltimore, Jakarta, Johannesburg, Kuala Lumpur, Melbourne, and Sydney for SN (defined by both supportive symptoms and signs). HCV seropositivity was assessed as an SN risk using a chi(2) test, followed by logistic regression modeling to correct for treatment exposures and demographics.

RESULTS

A total of 837 patients of African, Asian, and Caucasian descent were studied. HCV seroprevalence varied by site (Baltimore n = 104, 61% HCV+; Jakarta 96, 51%; Johannesburg 300, 1%; Kuala Lumpur 97, 10%; Melbourne 206, 16%; Sydney 34, 18%). HCV seropositivity was not associated with increased SN risk at any site, but was associated with reduced SN risk in Melbourne (p = 0.003). On multivariate analyses, the independent associations with SN were increasing age, height, and stavudine exposure. HCV seropositivity was not independently associated with an increased SN risk at any site, but associated independently with reduced SN risk in Baltimore (p = 0.04) and Melbourne (p = 0.06).

CONCLUSIONS

Hepatitis C (HCV) seropositivity was not associated with increased sensory neuropathy risk among HIV-positive patients at any site. While we were unable to assess HCV RNA or liver damage, the data suggest that HCV coinfection is not a major contributor to HIV-SN. HCV = hepatitis C; SN = sensory neuropathy.

Islam and harm reduction

Although drugs are haram and therefore prohibited in Islam, illicit drug use is widespread in many Islamic countries throughout the world. In the last several years increased prevalence of this problem has been observed in many of these countries which has in turn led to increasing injecting drug use driven HIV/AIDS epidemic across the Islamic world. Whilst some countries have recently responded to the threat through the implementation of harm reduction programmes, many others have been slow to respond. In Islam, The Quran and the Prophetic traditions or the Sunnah are the central sources of references for the laws and principles that guide the Muslims' way of life and by which policies and guidelines for responses including that of contemporary social and health problems can be derived. The preservation and protection of the dignity of man, and steering mankind away from harm and destruction are central to the teachings of Islam. When viewed through the Islamic principles of the preservation and protection of the faith, life, intellect, progeny and wealth, harm reduction programmes are permissible and in fact provide a practical solution to a problem that could result in far greater damage to the society at large if left unaddressed.

Immunological profiles of immune restoration disease presenting as mycobacterial lymphadenitis and cryptococcal meningitis

OBJECTIVES

A proportion of HIV patients beginning antiretroviral therapy (ART) develop immune restoration disease (IRD). Immunological characteristics of IRD were investigated in a cohort of HIV patients beginning therapy in Kuala Lumpur, Malaysia.

METHODS

Peripheral blood mononuclear cells were collected at weeks 0, 6, 12, 24 and 48 of ART from five patients experiencing IRD [two with cryptococcal and three with Mycobacterium tuberculosis (Mtb) disease], eight non-IRD controls who had begun ART with CD4 T-cell counts of <100 cells/microL and 17 healthy controls. Leukocytes producing interferon-gamma (IFNgamma) were quantified by enzyme-linked immunospot assay after stimulation with purified protein derivative (PPD), early secretory antigenic target-6 (ESAT-6), Cryptococcus neoformans or Cytomegalovirus antigens. Plasma immunoglobulin (IgG) antibodies reactive with these antigens were assessed by enzyme-linked immunosorbent assay. Proportions of activated (HLA-DR(hi)) and regulatory (CD25 CD127(lo) and CTLA-4(+)) CD4 T-cells were quantified by flow cytometry.

RESULTS

Plasma HIV RNA declined and CD4 T-cell counts rose within 8-27 weeks on ART. Mtb IRD patients displayed elevated IFNgamma responses and/or plasma IgG to PPD, but none responded to ESAT-6. Cryptococcal IRD occurred in patients with low baseline CD4 T-cell counts and involved clear IFNgamma and antibody responses to cryptococcal antigen. Proportions of activated and regulatory CD4 T-cells declined on ART, but remained higher in patients than in healthy controls. At the time of IRD, proportions of activated CD4 T-cells and regulatory CD4 T-cells were generally elevated relative to other patients.

CONCLUSIONS

Cryptococcal and Mtb IRD generally coincide with peaks in the proportion of activated T-cells, pathogen-specific IFNgamma responses and reactive plasma IgG. IRD does not reflect a paucity of regulatory CD4 T-cells.

Experience with the use of a first-line regimen of stavudine, lamivudine and nevirapine in patients in the TREAT Asia HIV Observational Database

BACKGROUND

The antiretroviral treatment (ART) combination of stavudine, lamivudine and nevirapine (d4T/3TC/NVP) is the most frequently used initial regimen in many Asian countries. There are few data on the outcome of this treatment in clinic cohorts in this region.

METHODS

We selected patients from the TREAT Asia HIV Observational Database (TAHOD) who started their first ART regimen with d4T/3TC/NVP. Treatment change was defined as cessation of therapy or the addition or change of one or more drugs. Clinical failure was defined as diagnosis with an AIDS-defining illness, or death while on d4T/3TC/NVP treatment.

RESULTS

The rate of treatment change among TAHOD patients starting d4T/3TC/NVP as their first antiretroviral treatment was 22.3 per 100 person-years, with lower baseline haemoglobin (i.e. anaemia) associated with slower rate of treatment change. The rate of clinical failure while on d4T/3TC/NVP treatment was 7.3 per 100 person-years, with baseline CD4 cell count significantly associated with clinical failure. After d4T/3TC/NVP was stopped, nearly 40% of patients did not restart any treatment and, of those who changed to other treatment, the majority changed to zidovudine (ZDV)/3TC/NVP and less than 3% of patients changed to a protease inhibitor (PI)-containing regimen. The rates of disease progression on the second-line regimen were similar to those on the first-line regimen.

CONCLUSION

These real-life data provide an insight into clinical practice in Asia and the Pacific region. d4T/3TC/NVP is maintained longer than other first-line regimens and change is mainly as a result of adverse effects rather than clinical failure. There is a need to develop affordable second-line antiretroviral treatment options for patients with HIV infection in developing countries.

Invasive meningococcal disease in the University of Malaya Medical Centre, Kuala Lumpur, Malaysia

BACKGROUND

Neisseria meningitidis (N. meningitidis) remains the leading worldwide cause of acute bacterial meningitis and fatal sepsis in healthy individuals.

MATERIALS AND METHODS

A total of 12 cases of N. meningitidis from patients with invasive meningococcal infections in University of Malaya Medical Centre, Kuala Lumpur during the years 1987-2004 were reviewed together with details of age, sex, disease, risk factors treatment and outcome of these patients.

RESULTS

Their ages ranged from 10 months to 64 years (median age 29.75 years). The male to female ratio was 1.42:1. Fever, neck stiffness, headache, vomiting and confusion were predominant symptoms. Upper respiratory tract viral infection and Hajj pilgrimage were directly associated with invasive meningococcal disease. Penicillin or ceftriaxone or both in some cases were administered as empirical therapy. All isolates were sensitive to penicillin, ceftriaxone, chloramphenicol and rifampicin. The case fatality ratio was 1:4. One Hajj pilgrim died despite having received polyvalent meningococcal vaccine. Amongst the survivors, two patients had neurological deficit, hearing loss and arthritis.

CONCLUSION

Early antimicrobial therapy has been shown to reduce these adverse outcomes. Clinicians need to be alerted to the presence of the disease in the community and the disease should be made notifiable within 24 hours of detection both for early treatment of cases and to facilitate contact tracing, institution of prophylactic treatment and prevention of secondary cases.

Faecal prevalence of extended-spectrum Beta-lactamase (ESBL)-producing coliforms in a geriatric population and among haematology patients

Antimicrobial resistance to the extended-spectrum cephalosporins is increasingly reported worldwide. In the local setting, nosocomial infections with multi-resistant Gram-negative bacilli are not uncommon and are a growing concern. However, there is limited data on the carriage rates of such organisms in the local setting. In May 2001, a prospective study was carried out to determine the enteric carriage rates of ceftazidime-resistant Gram negative bacilli (CAZ-R GNB) among residents of nursing homes and from in-patients of the geriatric and adult haematology wards of University Malaya Medical Centre. Ceftazidime-resistant Gram-negative bacilli (CAZ-R GNB) were detected in 25 samples (30%), out of which 6 were from nursing home residents, 5 from geriatric in-patients and 14 from the haematology unit. A total of 28 CAZ-R GNB were isolated and Escherichia coli (10) and Klebsiella pneumoniae (7) were the predominant organisms. Resistance to ceftazidime in E. coli and Klebsiella was mediated by extended-spectrum beta-lactamases (ESBLs). Although the majority of the CAZ-R GNB were from patients in the haematology ward, the six nursing home residents with CAZ-R GNB were enteric carriers of ESBL-producing coliforms. Prior exposure to antibiotics was associated with carriage of ESBL organisms and to a lesser extent, the presence of urinary catheters.

Kostmann's syndrome

Kostmann's syndrome is a rare congenital disorder of neutrophil production due to impairment of myeloid differentiation in the bone marrow, with the neutrophil count being characteristically less than 500 x 10(3) cells/l (normal: 2-7 x 10(9)/l). Severe persistent neutropenia results in an increased susceptibility to frequent bacterial infections. The condition can be treated with recombinant human granulocyte colony-stimulating factor (G-CSF). Although several articles have addressed the clinicopathological and haematological aspects of this disorder, little or no information has been available concerning the radiological findings in this disorder. This report summarizes the clinical features, radiological findings and management of a patient with Kostmann's syndrome.

MRI and CT findings of cryptococcal vaginitis

Cryptococcus neoformans is a yeast like fungus, which is commonly found in bird droppings, especially pigeons. Most cases of cryptococcal infections occur in immunocompromised patients or in those who are on long term immunosuppressant therapies. Cryptococcal infection usually presents as a meningoencephalitis or a pulmonary infection. Skin, bone and genital infections are very rare. We report the second case of vaginal cryptococcossis to be reported in English literature and the first to be imaged with CT and MRI.

Seroepidemiology of toxoplasmosis among HIV-infected patients and healthy blood donors

A cross-sectional study was carried out in University of Malaya Medical Centre, Kuala Lumpur. Blood samples from 100 HIV-infected patients and 203 Healthy Blood Donors (HBD) were collected and anti-Toxoplasma antibodies were detected by using conventional ELISA. The seroprevalence of toxoplasmosis in HIV/AIDS and Healthy Blood Donors were found to be 21% and 28.1% respectively. There was no significant association between the seroprevalence of toxoplasmosis and various possible risk factors i.e. contact with cat, consumption of undercooked meat and history of blood transfusion in both groups. No significant differences between Toxoplasma seroprevalence in HIV/AIDS and Healthy Blood Donors in association with presence of single or multiple risk factors were found. The mean CD4 count among HIV/AIDS patients in this study was 202.23 cell/cumm. There was no significant association between CD4 count and seropositivity for Toxoplasma antibodies in HIV/AIDS patients.

Non-sporulating Chrysosporium: an opportunistic fungal infection in a neutropenic patient

We report a case of an invasive infection with non-sporulating Chrysosporium species in a patient who was treated with chemotherapy for relapsed acute lymphoblastic leukemia. This patient presented with a persistent lobar pneumonia, skin lesions, and possible involvement of the central nervous system. The patient responded to treatment with amphotericin B and oral itraconazole.

Treatment of acute Nipah encephalitis with ribavirin

Nipah virus, a newly identified paramyxovirus caused a severe outbreak of encephalitis in Malaysia with high fatalities. We report an open-label trial of ribavirin in 140 patients, with 54 patients who were managed prior to the availability of ribavirin or refused treatment as control. There were 45 deaths (32%) in the ribavirin arm; 29 deaths (54%) occurred in the control arm. This represents a 36% reduction in mortality (p = 0.011). There was no associated serious side effect. This study suggests that ribavirin is able to reduce the mortality of acute Nipah encephalitis.

The presence of Nipah virus in respiratory secretions and urine of patients during an outbreak of Nipah virus encephalitis in Malaysia

OBJECTIVES

To study the excretion of Nipah virus in the upper respiratory secretions and urine of infected patients in relation to other clinical features.

METHODS

Isolation of Nipah virus from the respiratory secretions and urine was made in Vero cells and identified by indirect immunofluorescence assay using anti-Hendra specific hyperimmune mouse ascitic fluid and FITC-conjugated goat anti-mouse IgG.

RESULTS

During the peak outbreak of Nipah virus encephalitis in Malaysia, Nipah virus was isolated from the upper respiratory secretions and urine in eight of 20 patients who were virologically and/or serologically confirmed to be infected with the virus. From these eight patients, Nipah virus was isolated from six throat swab specimens, three urine specimens and only one nasal swab specimen. The positive virus isolation rate was related to the collection of these specimens during the early phase of the illness (P = 0.068). The presence of serum anti-Nipah specific IgM appeared to reduce the chance of isolating the virus (P = 0.049). There was no significant difference in the isolation rate with respect to the age, gender, ethnic group and clinical features associated with grave prognosis and mortality outcome of the patients.

CONCLUSION

This study shows that it is possible to be infected from secretions of infected patients, but epidemiological survey on close contacts so far did not suggest that human-to-human transmission is common.