Hepatitis A virus immunity and vaccination among at-risk persons receiving HIV medical care

Burden of Vaccine-Preventable Diseases in People Living with HIV

Vaccine-preventable diseases (VPDs) pose a serious public health concern for people living with HIV (PLH). PLH experience a delayed and weakened response to many vaccines available, compared to the general population. Lower seroconversion rates, along with a decreased efficacy and durability of vaccines, increases the susceptibility of PLH to VPDs. Vaccination guidelines specifically targeting this population have been modified to overcome these challenges. However, vaccine uptake remains suboptimal due to multiple barriers, highlighting the need for further studies and the additional implementation of public health measures specifically tailored to PLH.

Low rate of vaccination and risk of incident hepatitis A among HIV-infected men who have sex with men in Seville, Southern Spain

BACKGROUND

Periodic outbreaks of hepatitis A (HAV) infection in men who have sex with men (MSM) have been reported. Low vaccination uptake in HIV-infected individuals could drive new outbreaks. We aimed at evaluating the incidence of and risk factors for HAV infection in people living with HIV (PLWH) in our area. We also assessed the rates of HAV vaccination.

METHODS

This was a prospective cohort study. 915 patients were included, 272 (30%) of them were anti-HAV seronegative at baseline.

RESULTS

Twenty-six (9.6%) susceptible individuals became infected. Incident cases peaked in 2009-2010 and 2017-2018. Incident HAV infection was independently associated with MSM [adjusted odds ratio (95% confidence ratio): 4.39 (1.35-14.27), p=0.014]. One hundred and five (38.6%) HAV seronegative patients were vaccinated, 21 (20%) of them did not respond, and one (1%) patient lost immunity against HAV. Four (29%) non-responders to vaccination showed incident HAV 5-9 years afterwards.

CONCLUSIONS

The incidence of HAV infection in a cohort of well-controlled PLWH remains low and stable, with intermittent outbreaks involving mainly non-immunized MSM. A significant proportion of PLWH remain susceptible to HAV infection due to insufficient vaccine uptake and limited response to vaccination. Importantly, patients not responding to HAV vaccination continue at risk of infection.

Delays in Hepatitis A vaccination in people with HIV in Houston, Texas between 2010 and 2018

Background

Studies have demonstrated low hepatitis A virus (HAV) vaccination rates among persons with HIV (PWH).

Methods

We conducted a retrospective study of persons entering HIV care at two clinics in Houston, Texas between 2010 and 2018. We defined those eligible for HAV vaccination as those who had no history of HAV vaccination and had a negative anti-HAV IgG at entry to care. Kaplan-Meier curves summarized time to receipt of HAV vaccines. The proportions of patients who received 1 and 2 HAV vaccines at 6, 12, and 24 months were estimated. Cox proportional hazards regression evaluated associations between patient characteristics and vaccination. Significant factors were included in a multivariable Cox proportional hazards model.

Results

Of 6,515 patients, 1372 were eligible for HAV vaccination. Of eligible patients, 29.2 % received 1 HAV vaccination at 6 months, 37.1 % at 12 months, and 47.8 % at 24 months. At 6 months, 10 % received 2 HAV vaccinations, 21.1 % at 12 months, and 33.4 % at 24 months. In multivariable analysis, men who have sex with men (adjusted HR 1.35, 95 % CI 1.06, 1.73) or those who had CD4 count ≥ 200 cells/µl (adjusted HR 2.52, 95 % CI 1.89, 3.37) had their second vaccination sooner than those who were not men who have sex with men or who had CD4 counts < 200 cells/µl, respectively. Patients > 50 years of age had their second vaccination sooner than those aged 30-50 years (adjusted HR 1.47, 95 % CI 1.08, 1.99). Those with active substance history had a longer time to second vaccination compared to those with no substance use history (adjusted HR 0.57, 95 % CI 0.40, 0.82).

Conclusions

HAV vaccination rates were low and highlight the need for effective solutions to address HAV immunization gaps in PWH, especially among young patients, those with active substance use disorders, and those with significant immunocompromise.

Vaccination and Trust in the National Health System among HIV+ Patients: An Italian Cross-Sectional Survey

BACKGROUND

This study aimed to evaluate the knowledge, attitudes, and practises (KAP) of individuals living with HIV (PLWH) regarding vaccines and their trust in the Italian national health system (NHS).

METHODS

A cross-sectional survey was conducted at Amedeo di Savoia Hospital in Turin, Italy, involving 160 HIV-positive patients. Descriptive statistics were utilised to analyse variables such as vaccination status and intention, perceived risk of infection, and disease severity. The infections were categorised into sexually transmitted diseases and other vaccine-preventable diseases.

RESULTS

Except for the perceived severity of infection, there were no significant differences in the percentages between the two infection groups for the variables examined. Concerning patients' perception of the Italian NHS, a high percentage of the sample believed in the information provided by healthcare workers (HCWs) (95.6%) and considered HCWs up-to-date on vaccines (93.1%). However, a considerable proportion expressed concerns about insufficient information on vaccine risks from HCWs (33.3%), perceived judgement by HCWs for vaccine refusal (40.3%), and suspected financial interests of HCWs in vaccination (19.5%).

CONCLUSIONS

Some HIV+ patients may hesitate to be vaccinated or hold misconceptions about the severity of certain infectious diseases. Additionally, there are concerns about trust in the Italian NHS and communication by HCWs.

Poor increase on HAV vaccination coverage among people living with HIV after an immunization-based intervention

OBJECTIVES

To assess HAV serologic and vaccination status among people who live with HIV (PLWH), and to evaluate the impact of a vaccination-based strategy on HAV-negative patients in Seville, Spain.

METHODS

Study with two time-overlapping phases: (i) cross-sectional study of HAV immunity prevalence among PLWH followed at a Spanish hospital between August 2019 and March 2020. (ii) Patients seronegative for HAV, reliably unvaccinated were included in a before-and-after quasi-experimental study, with an intervention focused on HAV vaccination according to national recommendations in force.

RESULTS

Six hundred and fifty-six patients were included, of which 111 [17%, 95% confidence interval (95% CI) 14-20%] were seronegative for HAV. Of these, 48 [43% (95% CI, 34-53%)] individuals were MSM. The absence of HAV immunity was attributed in 69 [62% (95% CI, 52-71%)] patients to non-referral to vaccination, followed by lack of achievement of a correct vaccination scheme [n=26; 23% (95% CI, 16-32%)]. After the program implementation, 96 [15% (95% CI, 12-18%)] individuals were seronegative (17% vs. 15%, p=0.256), of whom 42 [41% (95% CI, 32-51%)] were MSM. The absence of immunity after the intervention was mainly attributed to: adherence failure in 23 [24.0% (95% CI, 15.8-33.7%)] patients, on-course immunization scheme in 34 [33% (95% CI, 24-43%)] individuals and pending appointment at the vaccine delivery unit in 20 [20.8% (95% CI, 13.2-30.3%)] patients.

CONCLUSIONS

A sizeable proportion of PLWH remains susceptible for HAV infection in future outbreaks. A program based on referral to the vaccine delivery unit yields poor results, largely due to program adherence failures. New strategies are needed to increase HAV vaccination coverage.

Acute Hepatitis A and Hepatitis B Coinfection

Hepatitis A (HAV) has emerged in outbreaks across the United States particularly in at-risk populations such as men who have sex with men, as well as patients with a history of drug use, homelessness, and incarceration. Immunization among these high-risk populations remains underused. In this study, we describe a case of acute HAV and hepatitis B (HBV) coinfection in an MSM patient occurring in the period of these outbreaks. Clinical resolution of acute HAV and HBV coinfection was attained by 5 months from the time of initial hospitalization without viral hepatitis treatment. This case highlights the need for increased awareness of at-risk populations for HAV and HBV infection in promoting guideline-based vaccination efforts.

Missed Opportunities for Hepatitis A Vaccination Among MSM Initiating PrEP

The incidence of Hepatitis A virus (HAV) among the general population in the United States has decreased by over 95% since the introduction of HAV vaccination in 1995. However, 10% of all new HAV infections occur among men who have sex with men (MSM). However routine HAV is not part of standard of care for provision of PrEP services. Retrospective cohort analysis of MSM assessed for HIV prevention services between 1/1/2016 and 6/30/2017 to evaluate the rates of screening for anti-HAV seroprevalence and subsequent vaccination. HAV IgG was drawn on 96% (96/100) of the patients with 58% (56/96) of patients demonstrating serologic immunity. Of the 40 patients without evidence of immunity, 77% (29/40) returned for a subsequent visit, 48% (14/29) were provided HAV vaccination, and 29% (4/14) received at least two doses. Only 35% (14/40) of patients without documented immunity received HAV vaccination. Visits for PrEP initiation and monitoring in MSM patients are potential opportunities for ensuring HAV vaccination among this high-risk patient population. Public health agencies could optimize HAV vaccination of the high risk MSM by incorporating HAV screening into national PrEP guidelines.

Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020

HEPATITIS A IS A VACCINE-PREVENTABLE, COMMUNICABLE DISEASE OF THE LIVER CAUSED BY THE HEPATITIS A VIRUS (HAV). THE INFECTION IS TRANSMITTED VIA THE FECAL-ORAL ROUTE, USUALLY FROM DIRECT PERSON-TO-PERSON CONTACT OR CONSUMPTION OF CONTAMINATED FOOD OR WATER. HEPATITIS A IS AN ACUTE, SELF-LIMITED DISEASE THAT DOES NOT RESULT IN CHRONIC INFECTION. HAV ANTIBODIES (IMMUNOGLOBULIN G [IGG] ANTI-HAV) PRODUCED IN RESPONSE TO HAV INFECTION PERSIST FOR LIFE AND PROTECT AGAINST REINFECTION; IGG ANTI-HAV PRODUCED AFTER VACCINATION CONFER LONG-TERM IMMUNITY. THIS REPORT SUPPLANTS AND SUMMARIZES PREVIOUSLY PUBLISHED RECOMMENDATIONS FROM THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP) REGARDING THE PREVENTION OF HAV INFECTION IN THE UNITED STATES. ACIP RECOMMENDS ROUTINE VACCINATION OF CHILDREN AGED 12-23 MONTHS AND CATCH-UP VACCINATION FOR CHILDREN AND ADOLESCENTS AGED 2-18 YEARS WHO HAVE NOT PREVIOUSLY RECEIVED HEPATITIS A (HEPA) VACCINE AT ANY AGE. ACIP RECOMMENDS HEPA VACCINATION FOR ADULTS AT RISK FOR HAV INFECTION OR SEVERE DISEASE FROM HAV INFECTION AND FOR ADULTS REQUESTING PROTECTION AGAINST HAV WITHOUT ACKNOWLEDGMENT OF A RISK FACTOR. THESE RECOMMENDATIONS ALSO PROVIDE GUIDANCE FOR VACCINATION BEFORE TRAVEL, FOR POSTEXPOSURE PROPHYLAXIS, IN SETTINGS PROVIDING SERVICES TO ADULTS, AND DURING OUTBREAKS.

Factors associated with hepatitis A virus infection among HIV-positive patients before and after implementation of a hepatitis A virus vaccination program at a medical centre in central Taiwan

Background Taiwan government has promoted the administration of a hepatitis A vaccine at public expense for high-risk groups as a preventive measure after the outbreak of hepatitis A virus (HAV) infections in 2015. The aim of this study was to evaluate the efficacy of such vaccination policy in patients with human immunodeficiency virus (HIV).

METHODS

From January 2016 to July 2017, we enrolled 658 HIV-positive male participants. Participants were stratified into anti-HAV-positive (n = 165) and anti-HAV-negative (n = 493) groups. A total of 364 anti-HAV-negative patients received vaccination against HAV and were followed up for 1.5 years. A Cox regression model was used to estimate the effects of factors predicting positive anti-HAV detection after vaccination.

RESULTS

Patients with HIV had an anti-HAV-positive prevalence of 25.1% before vaccination. Of the 364 patients inoculated with the first dose of vaccine, 58.0% received the second dose. Seroresponse rates were 50.0% and 80.6%, respectively. Antibody production was 30.0% lower in patients with a CD4 T-cell count <200 cells/µL (adjusted relative risk (ARR) = 0.7; 95% confidence interval (CI) = 0.5-0.9) compared with those with 500 cells/µL. Hepatitis C co-infection reduced the production of antibodies by 50.0% (ARR = 0.5; 95% CI = 0.2-0.8).

CONCLUSION

This study suggests that vaccination against hepatitis A be administered when the immunity of an HIV-positive patient is strong. The promotion of the current vaccination policy against hepatitis A in Taiwan has improved the vaccination rate; the response rate for receiving one dose of the vaccine doubled.

Epidemiology of hepatitis A in Greece in the last decade: management of reported cases and outbreaks and lessons learned

Hepatitis A is a mandatory notifiable disease in Greece. Here, we present the epidemiological data for 2009-2018 and the results of outbreak investigations performed, and discuss future public health priorities.Overall, 1193 cases were reported; 320 migrants/refugees, 240 Roma, 112 travellers and 521 from the general population. The median age of the affected general population (37 years) had an increasing trend (from 30.8 years in 2009 to 40.5 in 2018, P < 0.001) and was significantly higher than that among Roma and migrants (7 and 8 years, respectively, P < 0.001). Twenty-two cases (2.2%) were unvaccinated patients with a chronic liver disease. Fifty clusters with 2-12 cases each were recorded; 44 were attributed to person-to-person transmission and six to food consumption. Three outbreaks accounting for 32.3% of the total number of recorded cases were identified; in 2013 among Roma (112 cases), in 2016 among refugees (188 cases) and in 2017 among men having sex with men (96 cases; 33 of them (34.4%) HIV-positive). The epidemiological data depict that improving living conditions and vaccination coverage of deprived populations, and informing adults on the disease focusing at faecal-oral transmission during sexual intercourse and travel should be the future public health priorities.

Hepatitis A virus infection in an HIV-positive man with previously confirmed immunity against hepatitis A virus

A Japanese man with human immunodeficiency virus (HIV) was detected 9 years ago to have a positive titer for hepatitis A virus (HAV) immunoglobulin (Ig) G, without a history of HAV infection or vaccination. His plasma HIV RNA was well-controlled on antiretroviral therapy for more than 6 years. He developed HAV infection with subsequent reduction of the HAV IgG titer. A decreasing HAV IgG in persons living with HIV might indicate the possibility of HAV reinfection and should prompt the consideration for additional vaccination.

HIV and the liver

Among individuals with HIV infection, liver disease remains an important cause of morbidity and mortality, even with the availability of agents that cure hepatitis C infection and suppress hepatitis B replication. The causes of liver disease are multifaceted and continue to evolve as the population ages and new etiologies arise. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis and hepatitis viruses such as A, D, and E have emerged even as hepatitis C has receded. Newer antiretroviral agents may increase risk of weight gain and subsequent fatty infiltration, and prior use of nucleotide-based therapies may continue to impact liver health. Several barriers including economics, social stigma, and psychiatric disease impact identification of liver disease, as well as management and treatment interventions. Hepatocellular carcinoma is emerging as a more common and late-diagnosed complication in those with HIV infection and liver disease.

Early Seroreversion After 2 Doses of Hepatitis A Vaccination in Human Immunodeficiency Virus-Positive Patients: Incidence and Associated Factors

Serological responses (Seroresponse) and durability of hepatitis A virus (HAV) vaccination are reduced among human immunodeficiency virus (HIV)-positive patients. Incidence of and associated factors with early seroreversion (loss of seroresponse) among HIV-positive patients who have achieved seroresponses after two doses of HAV vaccination remain unclear. In this multicenter study, we followed HIV-positive adults who had mounted seroresponses after completing two doses of HAV vaccination during a recent outbreak of acute hepatitis A between 2015 and 2017, a 1:4 case-control study was conducted to identify factors associated with seroreversion. Case patients were those with seroreversion, and controls were those with similar follow-up durations who were able to maintain seroresponses. During the study period, 49 of the 1,256 patients (3.9%) seroreverted after a median follow-up of 611 days. In a case-control study, seroreversion was more likely to occur in patients with a higher weight (adjusted odds ratio [aOR], 1.703; 95% confidence interval [CI], 1.292-2.323, per 10-kg increment) and HIV viremia at the time of vaccination (aOR, 2.922; 95% CI, 1.067-7.924), whereas positive seroresponse at 6 months of HAV vaccination and higher CD4 lymphocyte counts at vaccination were inversely associated with early seroreversion with an aOR of 0.059 (95% CI, 0.020-0.154) and 0.837 (95% CI, 0.704-0.979, per 100-cell/mm³ increment), respectively, in multivariable analyses. Conclusion: During an outbreak setting, early seroreversion following two-dose HAV vaccination occurred in 3.9% of HIV-positive patients. Lower and delayed seroresponses to HAV vaccination, a higher weight, and HIV viremia and lower CD4 lymphocyte counts at the time of HAV vaccination were associated with early seroreversion. Regular monitoring of seroresponse and booster vaccination might be warranted, especially in HIV-positive adults with predictors of early seroreversion.

Liver Disease in Human Immunodeficiency Virus Infection

Liver disease in human immunodeficiency virus (HIV) remains a main cause of morbidity and mortality. Liver-related morbidity and mortality can be caused by multiple etiologic factors, including opportunistic infections, direct and indirect effects of antiretrovirals, direct and indirect effects of HIV, and viral hepatitides. These factors present with varied liver pathophysiologic mechanisms that lead to abnormalities in liver enzymes and synthetic function test, followed by distinct clinical presentations. This article elucidates the direct effects on HIV in the liver and explores the diagnostic and management challenges in patients with HIV in the era of highly active antiretroviral treatment.