De novo cancer-related death in Australian liver and cardiothoracic transplant recipients

Evidence is sparse on the relative mortality risk posed by de novo cancers in liver and cardiothoracic transplant recipients. A retrospective cohort study was conducted in Australia using population-based liver (n = 1926) and cardiothoracic (n = 2718) registries (1984-2006). Standardized mortality ratios (SMRs) were computed by cancer type, transplanted organ, recipient age and sex. During a median 5-year follow-up, de novo cancer-related mortality risk in liver and cardiothoracic recipients was significantly elevated compared to the matched general population (n = 171; SMR = 2.83; 95% confidence interval [95%CI], 2.43-3.27). Excess risk was observed regardless of transplanted organ, recipient age group or sex. Non-Hodgkin lymphoma was the most common cancer-related death (n = 38; SMR = 16.6; 95%CI, 11.87-22.8). The highest relative risk was for nonmelanocytic skin cancer (n = 23; SMR = 49.6, 95%CI, 31.5-74.5), predominantly in males and in recipients of heart and lung transplants. Risk of death from de novo cancer was high in pediatric recipients (n = 5; SMR = 41.3; 95%CI, 13.4-96.5), four of the five deaths were non-Hodgkin lymphoma. De novo cancer was a leading cause of late death, particularly in heart and liver transplantation. These findings support tailored cancer prevention strategies, surveillance to promote early detection, and guidelines for managing immunosuppression once cancer occurs.

Anal cancers attributed to human papillomavirus are more common in areas in Victoria, Australia, with higher HIV notifications

BACKGROUND

Anal cancer is more common in men who have sex with men with HIV. We aimed to determine if there was an association between anal squamous cell carcinoma (SCC) and HIV notifications in men in Victoria, Australia, at a population level.

METHODS

We calculated the male age-standardised incidence rates for anal SCC, brain cancer and colon cancer for each local government area (LGA) in Victoria from 1982 to 31 December 2010 using the Victorian Cancer Registry. Male HIV rates in each LGA were calculated using the Victorian HIV Registry.

RESULTS

There were 288 men diagnosed with anal SCC, 8793 with brain cancer and 23?938 with colon cancer in 57 LGAs. There were 3163 men notified with HIV during the same period in the same LGAs (range: 4-435 per LGA). There was a significant positive correlation (r=0.45, P<0.001, r(2)=0.20) between the age-standardised rate of anal SCC and the rate of HIV notifications in men in each LGA but no correlation between the male age-standardised rate of colon (Pearson's r=-0.11, P=0.40) or brain (r=-0.05, P=0.71) cancers, and the rate of HIV. The rate of anal cancer was ~50% higher in LGAs with the highest HIV notification rate (incidence rate ratio=1.47; 95% confidence interval: 1.10-1.97).

CONCLUSIONS

At a population level, about one in five cases (r(2)=0.20) of anal SCCs in men are explained by the rate of HIV notifications in that LGA.

Genital warts in young Australians five years into national human papillomavirus vaccination programme: national surveillance data

OBJECTIVE

To measure the effect on genital warts of the national human papillomavirus vaccination programme in Australia, which started in mid-2007.

DESIGN

Trend analysis of national surveillance data.

SETTING

Data collated from eight sexual health services from 2004 to 2011; the two largest clinics also collected self reported human papillomavirus vaccination status from 2009.

PARTICIPANTS

Between 2004 and 2011, 85,770 Australian born patients were seen for the first time; 7686 (9.0%) were found to have genital warts.

MAIN OUTCOME MEASURE

Rate ratios comparing trends in proportion of new patients diagnosed as having genital warts in the pre-vaccination period (2004 to mid-2007) and vaccination period (mid-2007 to the end of 2011).

RESULTS

Large declines occurred in the proportions of under 21 year old (92.6%) and 21-30 year old (72.6%) women diagnosed as having genital warts in the vaccination period-from 11.5% in 2007 to 0.85% in 2011 (P<0.001) and from 11.3% in 2007 to 3.1% in 2011 (P<0.001), respectively. No significant decline in wart diagnoses was seen in women over 30 years of age. Significant declines occurred in proportions of under 21 year old (81.8%) and 21-30 year old (51.1%) heterosexual men diagnosed as having genital warts in the vaccination period-from 12.1% in 2007 to 2.2% in 2011 (P<0.001) and from 18.2% in 2007 to 8.9% in 2011 (P<0.001), respectively. No significant decline in genital wart diagnoses was seen in heterosexual men over 30 years of age. In 2011 no genital wart diagnoses were made among 235 women under 21 years of age who reported prior human papillomavirus vaccination.

CONCLUSIONS

The significant declines in the proportion of young women found to have genital warts and the absence of genital warts in vaccinated women in 2011 suggests that the human papillomavirus vaccine has a high efficacy outside of the trial setting. Large declines in diagnoses of genital warts in heterosexual men are probably due to herd immunity.

Acceptability of digital anal cancer screening examinations in HIV-positive homosexual men

OBJECTIVES

Anal cancer is more common in HIV-positive homosexual men than in HIV-negative homosexual men and the general population. Earlier diagnosis leads to improved prognosis. We aimed to determine if regular anal inspection and digital examination of asymptomatic homosexual men attending for routine HIV care were acceptable and to record the rate of referral for diagnosis of potentially malignant anal lesions.

METHODS

We offered anal examinations to consecutive homosexual men with HIV infection aged ≥ 35 years during their routine HIV clinic visits, aiming to complete three examinations over a 12-month period. Acceptability questionnaires were completed at baseline and after each examination and doctors recorded examination findings and all resulting interventions. Hospital referral outcomes were collected and interventions were costed using the Australian Medical Benefits Schedule.

RESULTS

Of 142 men who were offered enrolment in the study, 102 [72%; 95% confidence interval (CI) 64-79%] participated. Following the initial anal examinations, four men were referred to surgeons. Cancer was excluded in three men (3%; 95% CI 1-8%) and one was diagnosed with anal squamous cell carcinoma (SCC). Three men had anoscopy performed at the time and two were referred for colonoscopy. Ninety-eight per cent (95% CI 93-100%) of respondents said that they would probably have the examination next time. The intervention was estimated to cost approximately Australian $16 per examination.

CONCLUSIONS

Regular anal digital examinations are an acceptable and inexpensive addition to the routine care of homosexual men with HIV infection.

Abstract 2540: Survival after cutaneous melanoma in kidney transplant recipients: a population-based matched cohort study

BACKGROUND

Early detection and tailored treatment algorithms have resulted in improved outcomes for patients with cutaneous melanoma. Solid organ transplant recipients are at elevated risk of melanoma, and may have poorer outcomes than non-transplant recipients, although the evidence is unreliable.

METHODS

We conducted a national, population-based, matched cohort study of de novo invasive cutaneous melanoma in Australian kidney transplant recipients and in randomly selected members of the general population matched for age, sex, state of residence, and year of diagnosis (1982-2003). Melanoma histopathological characteristics were extracted from cancer registry notifications and date of death was obtained by linkage with the National Death Index (1982-2011). Kaplan Meier curves and Cox proportional hazard models were used to analyse the overall survival of transplant and non-transplant recipients, adjusted for matching and histopathological characteristics.

RESULTS

Compared to non-transplant recipients (n=202), melanomas in transplant recipients (n=75) were more likely to have a higher AJCC pathologic stage (P=0.003) at diagnosis. Survival was significantly lower for recipients compared to non-recipients, overall and for stage I melanomas (P&lt;0.001). Transplantation was associated with a significantly increased risk of death (adjusted hazards ratio 8.06; 95% confidence interval, 3.92 to 16.6, P&lt;0.0001). Pathologic stage (P=0.0004) and histology (P=0.009) also independently predicted risk of death.

CONCLUSIONS

Transplant recipients have a markedly poorer outcome than non-recipients after melanoma diagnosis. A review of patient education and skin cancer screening guidelines is warranted. Treatment algorithms developed for the general population with melanoma do not appear to apply to transplant recipients.

Citation Format: Claire M. Vajdic, Alvin H. Chong, Patrick J. Kelly, Nicola S. Meagher, Marina T. van Leeuwen, Andrew E. Grulich, Angela C. Webster. Survival after cutaneous melanoma in kidney transplant recipients: a population-based matched cohort study. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2540. doi:10.1158/1538-7445.AM2013-2540

Decline in in-patient treatments of genital warts among young Australians following the national HPV vaccination program

BACKGROUND

There has been a rapid decline in the number of young heterosexuals diagnosed with genital warts at outpatient sexual health services since the national human papillomavirus (HPV) vaccination program started in Australia in 2007. We assessed the impact of the vaccination program on the number of in-patient treatments for genital warts.

METHODS

Data on in-patient treatments of genital warts in all private hospitals were extracted from the Medicare website. Medicare is the universal health insurance scheme of Australia. In the vaccine period (2007-2011) and pre-vaccine period (2000-2007) we calculated the percentage change in treatment numbers and trends in annual treatment rates in private hospitals. Australian population data were used to calculate rates. Summary rate ratios of average annual trends were determined.

RESULTS

Between 2000 and 2011, 6,014 women and 936 men aged 15-44 years underwent in-patient treatment for genital warts in private hospitals. In 15-24 year old women, there was a significant decreasing trend in annual treatment rates of vulval/vaginal warts in the vaccine period (overall decrease of 85.3% in treatment numbers from 2007 to 2011) compared to no significant trend in the pre-vaccine period (summary rate ratio (SRR) = 0.33, p < 0.001). In 25-34 year old women, declining trends were seen in both vaccine and pre-vaccine periods (overall decrease of 33% vs. 24.3%), but the rate of change was greater in the vaccine period (SRR = 0.60, p < 0.001). In 35-44 year old women, there was no significant change in both periods (SRR = 0.91, p = 0.14). In 15-24 year old men, there was a significant decreasing trend in annual treatment rates of penile warts in the vaccine period (decrease of 70.6%) compared to an increasing trend in the pre-vaccine period (SRR = 0.76, p = 0.02). In 25-34 year old men there was a significant decreasing trend in the vaccine period compared to no change in the pre-vaccine period (SRR = 0.81, p = 0.04) and in 35-44 year old men there was no significant change in rates of penile warts both periods, but the rate of change was greater in the vaccine period (SRR = 0.70, p = 0.02).

CONCLUSIONS

The marked decline in in-patient treatment of vulval/vaginal warts in the youngest women is probably attributable to the HPV vaccine program. The moderate decline in in-patient treatments for penile warts in men probably reflects herd immunity.

Latitude gradients for lymphoid neoplasm subtypes in Australia support an association with ultraviolet radiation exposure

Given the uncertainty surrounding solar ultraviolet radiation (UVR) exposure and risk of lymphoid neoplasms, we performed an ecological analysis of national Australian data for incident cases diagnosed between 2002 and 2006. Subtype-specific incidence was examined by latitude band (<29°S, 29-36°S, ≥37°S), a proxy for ambient UVR exposure, using multiple Poisson regression, adjusted for sex, age-group and calendar year. Incidence increased with distance from the equator for several mature B-cell non-Hodgkin lymphomas, including diffuse large B-cell [incidence rate ratio (IRR) = 1.37; 95% confidence interval (CI): 1.16-1.61 for latitude ≥37°S relative to <29°S], lymphoplasmacytic (IRR = 1.34; 95% CI: 1.12-1.61), mucosa-associated lymphoid tissue (IRR = 1.32; 95% CI: 0.97-1.80) and mantle cell lymphoma (IRR = 1.29; 95% CI: 1.05-1.58), as well as plasmacytoma (IRR = 1.52; 95% CI: 1.09-2.11) and plasma cell myeloma (IRR = 1.15; 95% CI: 1.03-1.27). A similar pattern was observed for several mature cutaneous T-cell neoplasms, including primary cutaneous anaplastic large cell lymphoma (IRR = 4.26; 95% CI: 1.85-9.84), mycosis fungoides/Sézary syndrome (IRR = 1.72; 95% CI: 1.20-2.46), and peripheral T-cell lymphoma not otherwise specified (NOS) (IRR = 1.53; 95% CI: 1.17-2.00). Incidence of mixed cellularity/lymphocyte-depleted (IRR = 1.60; 95% CI: 1.16-2.20) and nodular sclerosis Hodgkin lymphoma (IRR = 1.57; 95% CI: 1.33-1.85) also increased with distance from the equator. Many of these subtypes have a known association with infection or immune dysregulation. Our findings support a possible protective effect of UVR exposure on the risk of several lymphoid neoplasms, possibly through vitamin D-related immune modulation critical in lymphomagenesis.

Prevalence and predictors of high-grade anal intraepithelial neoplasia in a community-based sample of homosexual men

BACKGROUND

We report the prevalence and predictors for high-grade anal intraepithelial neoplasia (HGAIN) in community-based cohorts of HIV-negative and HIV-positive homosexual men in Sydney, Australia.

METHODS

A cross-sectional study of consecutive participants in both cohorts was performed in 2005 (204 HIV-negative and 128 HIV-positive men). Anal swabs collected by a research nurse underwent cytological analysis, using the ThinPrep procedure, and human papillomavirus (HPV) testing. Participants who had cytological abnormalities other than low-grade squamous epithelial lesions (SIL) were referred for high resolution anoscopy (HRA).

RESULTS

A total of 114 men had cytological abnormalities (24.3% of HIV-negative and 57.5% of HIV-positive men, odds ratio (OR)=4.21, 95% confidence interval (CI) 2.57-6.90). However, only three (2.3%) HIV-positive men and no HIV-negative men had high-grade SIL on anal cytology. Seventy-seven men were referred for HRA, of whom 63 (81.8%) attended. Histologically confirmed HGAIN was detected in 21 (33.3%). The prevalence of HGAIN was higher in HIV-positive men (10.8%) than in HIV-negative men (5.0%, OR=2.29, 95% CI 0.93-5.63, P=0.071). HGAIN was not related to age but was strongly associated with the detection of high-risk types of anal HPV (OR=10.1, 95% CI 1.33-76.2) rather than low-risk types (OR=1.97, 95% CI 0.74-5.25).

CONCLUSION

HGAIN was prevalent in homosexual men across all age groups and was more than twice as common in HIV-positive men compared with HIV-negative men. The presence of high-risk anal HPV was highly predictive of HGAIN.

Why a special issue on anal cancer and what is in it?

This editorial describes the contents of this special issue of Sexual Health devoted to anal cancer. The aim of the issue is to provide readers with information to assist them in making decisions about what to do about detecting anal cancer early in men who have sex with men with HIV. Should they be advocating screening? It discusses the epidemiology of HPV infection, anal intraepithelial neoplasia, and anal cancer in MSM, heterosexual men and women; anal cancer screening and treatment of anal cancer. And most importantly, what should be done about vaccinating boys with the HPV vaccine.

The epidemiology of anal cancer

Anal cancer comprises malignancies of the anal canal principally of two morphologic variants: squamous cell carcinoma (SCC) and adenocarcinoma. In most settings, SCC compromises more than 70% of cases. In the general population, anal cancer is uncommon, with age-standardised incidence rates mostly between 1 and 2 per 100000 per year. However, incidence of anal SCC is increasing by 1-3% per year in developed country settings. High-risk human papillomavirus (HPV) types can be detected in 80-90% of all anal SCC cases, making it second only to cervical cancer in the closeness of its association with this virus. HPV-16 can be detected in ~90% of HPV-positive cases of anal SCC. Case-control studies have demonstrated that sexual risk factors (homosexuality in men and multiple sexual partners in women) are strongly associated with anal cancer risk. Other risk factors include immune deficiency and tobacco exposure. Anal cancer rates are highest in homosexual men, particularly in those who are HIV-positive, in whom anal cancer is among the most common of all cancers. Vaccination against HPV holds great promise for anal cancer prevention for those not already HPV-infected. For the current generation of adult high-risk populations, screening programs to allow early detection and treatment are under investigation.

Comparison of de novo cancer incidence in Australian liver, heart and lung transplant recipients

Population-based evidence on the relative risk of de novo cancer in liver and cardiothoracic transplant recipients is limited. A cohort study was conducted in Australia using population-based liver (n = 1926) and cardiothoracic (n = 2718) registries (1984-2006). Standardized incidence ratios (SIRs) were computed by cancer type, transplanted organ and recipient age. Cox regression models were used to compare cancer incidence by transplanted organ. During a median 5-year follow-up, the risk of any cancer in liver and cardiothoracic recipients was significantly elevated compared to the general population (n = 499; SIR = 2.62, 95%CI 2.40-2.86). An excess risk was observed for 16 cancer types, predominantly cancers with a viral etiology. The pattern of risk by cancer type was broadly similar for heart, lung and liver recipients, except for Merkel cell carcinoma (cardiothoracic only). Seventeen cancers (10 non-Hodgkin lymphomas), were observed in 415 pediatric recipients (SIR = 23.8, 95%CI 13.8-38.0). The adjusted hazard ratio for any cancer in all recipients was higher in heart compared to liver (1.29, 95%CI 1.03-1.63) and lung compared to liver (1.65, 95%CI 1.26-2.16). Understanding the factors responsible for the higher cancer incidence in cardiothoracic compared to liver recipients has the potential to lead to targeted cancer prevention strategies in this high-risk population.

Are Australian sexual health clinics attracting priority populations?

To answer a key question (‘Are Australian sexual health clinics attracting priority populations?’), we used data from 44 Australian sexual health clinics between 2004 and 2011. We assessed the proportion of patients that were from priority populations (deemed to be at risk of sexually transmissible infections) and compared this to their proportions in the general population using data from Australian Bureau of Statistics and the Australian Study of Health and Relationships. A χ2-test was used. A total of 278 154 new patients attended during 2004–2011. The proportions from each priority population were significantly higher (P < 0.01 for all) than for the general population: young people aged 15–29 years (58.1% v. 20.1%), men who have sex with men (26.0% v. 6.0%), female sex workers (10.8% v. 0.5%), and Aboriginal and Torres Strait Islander people (4.2% v. 2.3%). This study confirms that Australian sexual health clinics attract higher proportions of priority populations and are thus meeting their mandate as defined in the 2010–2013 National Sexually Transmissible Infections Strategy.

14. Natural history of high-grade squamous intraepithelial lesions (HSIL) in homosexual men: early evidence from the Study of the Prevention of Anal Cancer (SPANC)

Background Screening for the anal cancer precursor HSIL is not recommended in national guidelines. A recent Cochrane review of HSIL treatment concluded there is no evidence of efficacy. In this context, we aimed to describe the natural history of anal HSIL, and association with human papillomavirus (HPV), in a community-recruited cohort of Australian homosexual men. Methods: The SPANC study is a three-year prospective study in men aged ≥35 years. At each visit, men undergo an anal swab for cytology and HPV genotyping (Roche Linear Array), followed by high-resolution anoscopy-aided biopsy. Anal HSIL is defined as having either anal intraepithelial neoplasia grade 2/3 on histology and/or HSIL/ASC-H on cytology. Results: Among 342 men recruited by March 2013, median age was 49 with 29% HIV positive. At baseline, prevalence of anal HSIL was 50% and 44% in the HIV-positive and HIV-negative groups, respectively (P = 0.303). Among those without HSIL at baseline, HSIL incidence was 28/100 person-years in both the HIV-positive and HIV-negative groups (P = 0.920). Among those with HSIL at baseline, the incidence of change to non-HSIL was 41 and 43/100 person-years (P = 0.851). Men with anal HPV16 at baseline were more likely to develop incident HSIL (57 vs 23/100 person-years, P = 0.010), and less likely to change to non-HSIL (18 vs 61/100 person-years, P = 0.001). Conclusions: Anal HSIL was highly prevalent in these homosexual men. Both incidence of HSIL and change to non-HSIL were common, and were closely associated with HPV16 status. HPV16 positivity may identify men with HSIL at higher risk of anal cancer.

Prevalence, incidence, and risk factors for human papillomavirus 16 seropositivity in Australian homosexual men

BACKGROUND

Human papillomavirus 16 (HPV16) has been causally associated with approximately 70% of anal cancers. This cancer is markedly increasing among homosexual men. There is limited knowledge of the epidemiology and natural history of anal HPV infection in homosexual men.

METHODS

Behavioral data and sera for antibodies to HPV16 L1 were collected annually for 1427 HIV-negative and 245 HIV-positive Australian homosexual men. Seroprevalence, seroincidence, and risk factors were calculated.

RESULTS

Among HIV-negative men, 25.4% were HPV16 seropositive at baseline compared with 44.3% of HIV-positive men. HPV16 seroincidence was 3.1/100 person-years among HIV-negative men and 1.3/100 person-years among HIV-positive men. Seroincidence among HIV-negative men remained >3% per year until 45 years of age, before declining. In multivariate analyses of data from HIV-negative men, seroprevalent HPV16 was associated with sexual risk behaviors and seropositivity for several viral sexually transmissible infections. Seroincident HPV16 was associated with younger age and unprotected anal intercourse with HIV-positive partners. Among men who predominantly practiced insertive anal intercourse, circumcision was associated with a 57% reduction in seroincident HPV16 (hazard ratio = 0.43, 95% confidence interval: 0.21-0.88, P = 0.021).

CONCLUSIONS

HPV16 seroincidence remained common in men until their mid 40s suggesting that vaccination may be protective in sexually active young gay men. Both HPV16 seroprevalence and seroincidence correlated well with markers of higher risk sexual activity, particularly receptive anal sexual practices. An association between circumcision and decreased HPV16 seroconversion in HIV-negative men who preferred the insertive position in anal sex was observed.

The prevalence of anal human papillomavirus among young HIV negative men who have sex with men

Men who have sex with men (MSM) especially those who are HIV positive are at risk for HPV-associated anal cancer. We systematically reviewed studies with data on the prevalence of vaccine preventable anal HPV among men who have sex with men aged 25 or younger and identified 6 studies. None of these studies were specifically designed to determine the prevalence of HPV in this population. Available data, albeit limited, suggest many young MSM may not already be HPV infected. Further studies using representative sampling focused on teenage MSM are required to confirm this.

Oral human papillomavirus in men having sex with men: risk-factors and sampling

BACKGROUND

Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma is becoming more common. We examined prevalence and risk factors for oral HPV among men who have sex with men (MSM) and compared sampling and transport methods.

METHODS

In 2010, 500 MSM (249 HIV-positive) attending Melbourne Sexual Health Centre answered a questionnaire, swabbed their mouth and throat and collected a gargled oral rinse sample. Half the oral rinse was transported absorbed in a tampon (to enable postage). HPV was detected by polymerase chain reaction, and genotyped by Roche Linear Array®. Men with HPV 16 or 18 were retested after six months.

RESULTS

Any HPV genotype was detected in 19% (95% confidence intervals (CI) 15-25%) of HIV-infected men and 7% (95% CI 4-11%) of HIV-negative men (p<0.001), and HPV 16 was detected in 4.4% (95% CI 2-8%) of HIV-infected men and 0.8% (0.1-2.8%) of HIV-negative men. Oral HPV was associated with: current smoking (adjusted odds ratio (aOR) 2.2 (95%CI: 1.2-3.9)), time since tooth-brushing (aOR per hour 0.87, 95%CI: 0.8-0.96) and number of lifetime tongue-kissing partners aOR 3.2 95%CI: (1.2-8.4) for 26-100 partners and 4.9 95%CI: (1.9-12.5) for>100 partners. Lifetime oral-penile sex partner numbers were significantly associated in a separate model: aOR 2.8(1.2-6.3) for 26-100 partners and 3.2(1.4-7.2) for>100 partners. HPV 16 and 18 persisted in 10 of 12 men after a median six months. Sensitivities of sampling methods compared to all methods combined were: oral rinse 97%, tampon-absorbed oral rinse 69%, swab 32%.

CONCLUSIONS

Oral HPV was associated with HIV infection, smoking, recent tooth-brushing, and more lifetime tongue-kissing and oral sex partners. The liquid oral rinse sample was more sensitive than a tampon-absorbed oral rinse or a self-collected swab.

Changes in metabolic, inflammatory and coagulation biomarkers after HIV seroconversion--the Health in Men (HIM) Biomarker Substudy

BACKGROUND

Biomarkers of inflammation, coagulation, lipids and vitamin D have been associated with cardiovascular and mortality risk in HIV-infected individuals. Scarce data exist on changes in these markers from pre- to post-HIV seroconversion.

METHODS

The study participants were drawn from the Health in Men Study, which recruited HIV-negative homosexual men. Participants with incident HIV infection (n=26) were compared with HIV-negative controls (n=52) matched on age at enrolment, date of visit and reported intravenous drug use. Levels of metabolic (lipids and vitamin D), inflammatory (C-reactive protein and interleukin-6) and coagulation (D-dimer and fibrinogen) biomarkers were measured at pre- and post-HIV seroconversion visits and corresponding visits for controls. Random-effect models were used to compare changes in markers between cases and controls.

RESULTS

The median gap between pre- and post-seroconversion or matched first and second visits in controls was 12 months. HIV seroconversion was associated with decline in high density lipoprotein (HDL-C; difference in mean change between cases and controls -0.14 mmol/l; 95% CI -0.22, -0.01; P=0.035). There were no significant differences in changes in other lipids, markers of inflammation, coagulation or vitamin D.

CONCLUSIONS

Decline in HDL-C seems to be the main proatherogenic change within 1-1.5 years after HIV seroconversion. HIV seroconversion was not associated with profound changes in other lipids, or markers of inflammation, coagulation and vitamin D. Longitudinal assessment of these markers in comparable population needs further assessment.

Cancer, immunodeficiency and antiretroviral treatment: results from the Australian HIV Observational Database (AHOD)

OBJECTIVES

The objective of the study was to conduct a within-cohort assessment of risk factors for incident AIDS-defining cancers (ADCs) and non-ADCs (NADCs) within the Australian HIV Observational Database (AHOD).

METHODS

A total of 2181 AHOD registrants were linked to the National AIDS Registry/National HIV Database (NAR/NHD) and the Australian Cancer Registry to identify those with a notified cancer diagnosis. Included in the current analyses were cancers diagnosed after HIV infection. Risk factors for cancers were also assessed using logistic regression methods.

RESULTS

One hundred and thirty-nine cancer cases were diagnosed after HIV infection among 129 patients. More than half the diagnoses (n = 68; 60%) were ADCs, of which 69% were Kaposi's sarcoma and 31% non-Hodgkin's lymphoma. Among the NADCs, the most common cancers were melanoma (n = 10), lung cancer (n = 6), Hodgkin's lymphoma (n = 5) and anal cancer (n = 5). Over a total of 21021 person-years (PY) of follow-up since HIV diagnosis, the overall crude cancer incidence rate for any cancer was 5.09/1000 PY. The overall rate of cancers decreased from 15.9/1000 PY [95% confidence interval (CI) 9.25-25.40/1000 PY] for CD4 counts < 100 cells/μL to 2.4/1000 PY (95% CI 1.62-3.39/1000 PY) for CD4 counts > 350 cells/μL. Lower CD4 cell count and prior AIDS diagnoses were significant predictors for both ADCs and NADCs.

CONCLUSIONS

ADCs remain the predominant cancers in this population, although NADC rates have increased in the more recent time period. Immune deficiency is a risk factor for both ADCs and NADCs.

Self-reported history of infections and the risk of non-Hodgkin lymphoma: an InterLymph pooled analysis

We performed a pooled analysis of data on self-reported history of infections in relation to the risk of non-Hodgkin lymphoma (NHL) from 17 case-control studies that included 12,585 cases and 15,416 controls aged 16-96 years at recruitment. Pooled odds ratios (OR) and 95% confidence intervals (95% CI) were estimated in two-stage random-effect or joint fixed-effect models, adjusting for age, sex and study centre. Data from the 2 years before diagnosis (or date of interview for controls) were excluded. A self-reported history of infectious mononucleosis was associated with an excess risk of NHL (OR = 1.26, 95% CI = 1.01-1.57 based on data from 16 studies); study-specific results indicate significant (I(2) = 51%, p = 0.01) heterogeneity. A self-reported history of measles or whooping cough was associated with an approximate 15% reduction in risk. History of other infection was not associated with NHL. We find little clear evidence of an association between NHL risk and infection although the limitations of data based on self-reported medical history (particularly of childhood illness reported by older people) are well recognized.

Comprehensive clinical care for men who have sex with men: an integrated approach

Men who have sex with men (MSM) have unique health-care needs, not only because of biological factors such as an increased susceptibility to infection with HIV and sexually transmitted infections associated with their sexual behaviour, but also because of internalisation of societal stigma related to homosexuality and gender non-conformity, resulting in depression, anxiety, substance use, and other adverse outcomes. Successful responses to the global HIV/AIDS epidemic will require the development of culturally sensitive clinical care programmes for MSM that address these health disparities and root causes of maladaptive behaviour (eg, societal homophobia). Health-care providers need to become familiar with local outreach agencies, hotlines, and media that can connect MSM with positive role models and social opportunities. Research is needed to understand how many MSM lead resilient and productive lives in the face of discrimination to develop assets-based interventions that build on community support. Optimum clinical care for sexual and gender minorities is a fundamental human right. MSM deserve to be treated with respect, and health-care providers need to interact with them in ways that promote disclosure of actionable health information.

Understanding trends in genital Chlamydia trachomatis can benefit from enhanced surveillance: findings from Australia

OBJECTIVES

To determine trends and correlates of chlamydia positivity among young heterosexuals attending Australian sexual health services and to compare these with population-based notification data.

METHODS

Data from 18 sexual health services and the national notification scheme were analysed. A χ2 test assessed trends in chlamydia positivity among young heterosexuals tested from 2006 to 2010, and logistic regression was used to determine correlates of positivity. Nucleic acid amplification tests were used throughout the study period.

RESULTS

During 2006-2010, 64 588 heterosexuals aged 15-29 years attended the sexual health services for the first time and the annual chlamydia testing rate was consistently >80%. Overall, chlamydia positivity increased by 12%, by 8.3% in heterosexual men (from 13.2% in 2006 to 14.3% in 2010; p-trend=0.04) and by 15.9% in women (from 11.3% in 2006 to 13.1% in 2010; p-trend<0.01). Independent correlates of chlamydia positivity in sexual health service patients were being aged 15-24 years, residing in a regional/rural area, being Aboriginal and/or Torres Strait Islander, being a non-Australian resident and attending in 2010 compared with 2006. Over the same period, the population-based notification rate increased by 43% against a background of a >100% increase in testing.

CONCLUSIONS

The sexual health service network suggests a moderate increase in chlamydia prevalence in young heterosexuals tested at sexual health services, in contrast to the steep increase shown by notifications. This highlights the caution needed in interpreting chlamydia trends without a corresponding testing denominator.

The impact of HIV seroadaptive behaviors on sexually transmissible infections in HIV-negative homosexual men in Sydney, Australia

BACKGROUND

Human immunodeficiency virus (HIV) seroadaptive behaviors, such as serosorting and strategic positioning, are being increasingly practised by homosexual men; however, their impact on sexually transmissible infections is unclear.

METHODS

Participants were 1427 initially HIV-negative men enrolled from 2001 to 2004 and followed to June 2007. Participants were tested annually for anal and urethral gonorrhoea and chlamydia, herpes simplex virus, and syphilis. In addition, they reported diagnoses of these conditions, and of genital and anal warts between annual visits, and sexual risk behaviors.

RESULTS

Compared with men who reported no unprotected anal intercourse (UAI), serosorting was associated with an increased risk of urethral (incidence: 6.06 vs. 3.56 per 100 person-years (PY), hazard ratio (HR) = 1.97, 95% confidence interval [CI]: 1.43-2.72) and anal (incidence 3.95 vs. 2.80 per 100 PY, HR = 1.62, 95% CI: 1.11-2.36) chlamydia. Compared with men who reported UAI with HIV nonconcordant partners, men who practised serosorting had significantly lower risk of incident syphilis (incidence 0.18 vs. 1.00 per 100 PY, HR = 0.21, 95% CI: 0.05-0.81) and urethral gonorrhoea (incidence 2.15 vs. 5.52 per 100 PY, HR = 0.61, 95% CI: 0.39-0.96). Compared with men who reported no UAI, strategic positioning was associated with an increased risk of urethral gonorrhoea (incidence 4.11 vs. 2.10 per 100 PY, HR = 1.72, 95% CI: 1.05-2.83) and chlamydia (incidence 8.71 vs. 3.56 per 100 PY, HR = 2.22, 95% CI: 1.55-3.18). Compared with men who reported receptive UAI, the incidence of anal gonorrhoea (incidence 1.48 vs. 3.83 per 100 PY, HR = 0.38, 0.20-0.74) and chlamydia (incidence 3.10 vs. 6.30 per 100 PY, HR = 0.44, 95% CI: 0.27-0.69) was significantly lower in those who practised strategic positioning.

CONCLUSION

For men who reported seroadaptive behaviors, rates of some bacterial sexually transmissible infections were higher than in men who reported no UAI. However, rates were lower than for men who reported higher HIV risk behaviors.