Co-infections of tuberculosis, hepatitis B or C viruses in a cohort of people living with HIV/AIDS in China: predictors and sequelae

Advanced HIV disease and associated factors among young people aged 15-24 years at a tertiary hospital in Sierra Leone: a cross-sectional study

BACKGROUND

Advanced HIV disease (AHD) in young people living with HIV (PLHIV) is an increasingly pressing public health issue in sub-Saharan Africa. Despite global progress in early HIV testing and reducing HIV-related deaths, many youths experience increased rates of HIV disease progression in sub-Saharan Africa. This study describes the burden, clinical manifestations, and factors for disease progression among young PLHIV aged 15 - 24 years seeking medical services at a major public hospital in Sierra Leone.

METHODS

We performed a cross-sectional analysis of routinely collected data for PLHIV patients aged 15 to 24 seen at Connaught Hospital in Sierra Leone between September 2022 and March 2023. We estimated the proportion of AHD in young PLHIV and performed logistic regression modelling to explore predictors of AHD. The statistical significance level was set at 0.05 for all statistical tests.

RESULTS

Of the 581 PLHIV that were reported, 238 (40.9%) were between the ages of 15 and 24 years, with a median age of 22 (20-24), and 151 (63.5%) were females. On review, 178 (74.8%) has initiated antiretroviral therapy regimen (ART); 117 (65.7%) were actively on ART for ≤ 6 months, while 114 (64%) had interruptions with their ART treatment. The overall prevalence of AHD was 41.6% (99/238); 46.7% (35/68) of young PLHIV at the HIV clinic, and 39.3% (64/163) of admission. Sex-Female (OR, 0.51; 95% CI, 0.28-0.94; p = 0.030), and Tertiary Education level (OR, 0.27; 95% CI, 0.10 - 0.78; p = 0.015) have significantly lower odds of AHD in the entire study population. While for inpatients, Age (young Adults) of PLHIV (OR, 1.23; 95% CI, 1.00-1.52; p = 0.047) had 1.23 times the odds of AHD compared to adolescents, and being female (OR, 0.27; 95% CI, 0.08-0.84; p = 0.024), Overweight-Body mass index (OR, 0.10; 95% CI, 0.01-0.77; p = 0.028), Tertiary Education level (OR, 0.08; 95% CI, 0.01-0.52; p = 0.008) have significantly lower odds of AHD. Common conditions reported for the AHD group in the medical wards are tuberculosis (13.58%), hepatitis B (6.13%), Kaposi sarcoma (3.07%), and oesophagal candidiasis (2.45%).

CONCLUSION

We reported a high prevalence of advanced HIV among young patients in a tertiary Hospital in Sierra Leone. One in two young PLHIV aged 15 to 24 years reported AHD, emphasizing the need to strengthen public health measures that address access to and retention of HIV services.

Prevalence and factors associated with advanced HIV disease among young people aged 15 - 24 years in a national referral hospital in Sierra Leone: A cross-sectional study

Background

Advanced HIV in young people living with HIV is an increasingly pressing public health issue in sub-Saharan Africa. Despite global progress in early HIV testing and reducing HIV-related deaths, many young people with HIV continue to experience HIV disease progression in sub-Saharan Africa. This study provides an overview of the prevalence, clinical manifestations, and factors associated with advanced HIV in young people seeking medical services in a major hospital in Sierra Leone.

Methods

We used a cross-sectional design to collect data from HIV patients aged 15 to 24 years at a major hospital in Sierra Leone between September 2022 and March 2023. Advanced HIV was defined as (i) CD4+ below 200 cells/mm3 or (ii) WHO clinical stage 3 or 4. Logistic regression models determined the association between observable independent characteristics and advanced HIV. The statistical significance level was set at 0.05 for all statistical tests.

Results

About 40% (231/574) of patients were recruited; 70.6% (163/231) were inpatients, and 29.4% (68/231) were outpatients. The mean age was approximately 21.6 years (SD ±2.43). The overall prevalence of advanced HIV was 42.9% (99/231), 51.5% (35/68) of outpatients, and 39.3% (64/163) of inpatients. Age of inpatients (OR, 1.23; 95% CI, 1.00-1.52; p= 0.047) was associated with a higher risk. Female sex (OR, 0.51; 95% CI, 0.28-0.94; p= 0.030), higher education (OR, 0.27; 95% CI, 0.10 - 0.78; p= 0.015), and Body Mass (OR, 0.10; 95% CI, 0.01-0.77; p= 0.028) were at lower risk of advance HIV. Common conditions diagnosed in this population are tuberculosis (13.58%), hepatitis B (6.13%), Kaposi sarcoma (3.07%), and esophageal candidiasis (2.45%).

Conclusion

We reported a high prevalence of advanced HIV among young patients in a referral Hospital in Sierra Leone. This emphasises the need to strengthen public health measures and policies that address challenges of access to HIV services.

Prevalence and risk factors of tuberculosis among people living with HIV/AIDS in China: a systematic review and meta-analysis

OBJECTIVE

To estimate the prevalence and risk factors associated with tuberculosis (TB) among people living with human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) in China.

METHODS

A systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. After the literature was screened based on the inclusion and exclusion criteria, STATA® version 17.0 software was used for the meta-analysis. The heterogeneity among study data was assessed using I2 statistics. Subgroup analysis and meta-regressions were performed to further explore the source of heterogeneity.

RESULTS

A total of 5241 studies were retrieved. Of these, 44 studies were found to be eligible. The pooled prevalence of HIV/TB co-infection was 6.0%. The risk factors for HIV/TB co-infection included a low CD4+ T cell count, smoking, intravenous drug use and several other sociodemographic and clinical factors. Bacillus Calmette-Guérin (BCG) vaccination history was a protective factor.

CONCLUSION

A high prevalence of TB was observed among people living with HIV/AIDS in China. Low CD4+ T cell count, smoking, and intravenous drug use were the primary risk factors for HIV/TB co-infection, whereas BCG vaccination history was a protective factor. Checking for TB should be prioritized in HIV screening and healthcare access.

SYSTEMATIC REVIEW REGISTRATION

Registered on PROSPERO, Identifier: CRD42022297754.

Hepatotoxicity and tuberculosis treatment outcomes in chronic liver disease

Background:

The treatment of tuberculosis (TB) is known to cause liver injury, however, there is limited data to guide optimal treatment for patients with chronic liver disease.

Methods:

We undertook a retrospective case series of patients with chronic liver disease and TB disease. The primary objective was to determine if there was a difference in the incidence of drug-induced liver injury (DILI) in patients with cirrhosis versus those with chronic hepatitis. Additionally, we sought to compare TB treatment outcomes, type and duration of therapy, and incidence of adverse events.

Results:

We included 56 patients (chronic hepatitis 40; cirrhosis 16). There were 33 patients (58.9%) who experienced DILI requiring treatment modification, with no significant difference between groups: 65% vs. 43.8%, p = 0.23. Patients with chronic hepatitis were more likely to receive treatment with standard first-line intensive phase therapy that included a combination of rifampin (RIF), isoniazid, and pyrazinamide (80.8% vs. 19.2%, p = 0.03) and any regimen than included isoniazid (92.5% vs. 68.8%, p = 0.04). The risk of DILI was higher when more hepatotoxic TB medications were used. Overall treatment success in this cohort was low (55.4%), with no significant difference between groups (62.5% vs. 37.5%, p = 0.14). Most patients with treatment success (97%) were able to tolerate a rifamycin.

Conclusions:

The risk of DILI is high, especially with the use of isoniazid, in patients with TB and chronic liver disease. This risk can be effectively mitigated with no difference in treatment outcomes in the presence of cirrhosis.

Tuberculosis among Ambulatory People Living with HIV in Guangxi Province, China: A Longitudinal Study

BACKGROUND

This study aims to determine the prevalence of TB among ambulatory people living with HIV in Guangxi Province, which experienced the biggest HIV epidemic in China.

METHODS

We undertook a longitudinal study in five HIV/AIDS designated hospitals randomly selected from Guangxi Province; all newly diagnosed HIV/AIDS outpatients from 2019 to 2021 were screened for TB and interviewed with a questionnaire.

RESULTS

A total of 4539 HIV/AIDS outpatients were enrolled, with 2886 (63.6%) men and 1653 (26.4%) women. The prevalence of TB/HIV coinfection was 0.8%, with a clear downward trend from 1.3% in 2019 to 0.4% in 2021 (p = 0.0011). The prevalence of LTBI was 24.3%, with no significant differences from 2019 to 2021. The percentages of AIDS, comorbidity, nine symptoms and abnormal chest X-ray of TB were higher than those of the other PLWH.

CONCLUSION

The prevalence of TB among ambulatory people with HIV in Guangxi Province was 14 times higher than the general population, and the annual declined TB prevalence indicated the effectiveness of TB and HIV control and prevention over recent years. The findings proved that symptom screening was insufficient for TB diagnosis and highlighted the importance of systematic TB screening at every visit to a health facility.

Prevalence and surveillance of tuberculosis in Yemen from 2006 to 2018

Tuberculosis is a major public health issue in Yemen, a country located at the southwestern tip of the Arabian Peninsula, while the situation of tuberculosis had been further exacerbated since the war started in 2015. The objective of this study is to investigate the incidence of tuberculosis in Yemen before the outbreak of COVID-19, from 2006 to 2018. During the 13-year period, 92 482 patients were enrolled in the TB programme records from the 22 governorates. Almost equal number of cases were diagnosed between males and females (a male to female ratio, 1.03:1). A notable rising incidence was observed in all age groups starting from 2011. The sharpest increase occurred in children under age 15, rising by 8.0-fold from 0.5 in the period 2006-2010 to 4.1 in the period 2011-2018. Paediatric TB accounted for 9.6% of all reported cases. In terms of the patient residence, incidence has more than doubled in Sana'a city, Sana'a Gov., Hajjah and Saadah. Concomitant diseases with tuberculosis included diabetes mellitus (14.0%), brucellosis (6.1%), hepatitis (6.0%), rheumatoid arthritis (4.3%), renal disorders (2.5%) and HIV infection (2.5%). Development of interventions to reduce tuberculosis incidence in children and concomitant communicable diseases is urgently needed.

Accounting for misclassified and unknown cause of death data in vital registration systems for estimating trends in HIV mortality

INTRODUCTION

Misclassification of HIV deaths can substantially diminish the usefulness of cause of death data for decision-making. In this study, we describe the methods developed by the Global Burden of Disease Study to account for the misclassified cause of death data from vital registration systems for estimating HIV mortality in 132 countries and territories.

METHODS

The cause of death data were obtained from the World Health Organization Mortality Database and official country-specific mortality databases. We implemented two steps to adjust the raw cause of death data: (1) redistributing garbage codes to underlying causes of death, including HIV/AIDS by applying methods, such as analysis of multiple cause data and proportional redistribution, and (2) reassigning HIV deaths misclassified as other causes to HIV/AIDS by examining the age patterns of underlying causes in location and years with and without HIV epidemics.

RESULTS

In 132 countries, during the period from 1990 to 2018, 1,848,761 deaths were reported as caused by HIV/AIDS. After garbage code redistribution in these 132 countries, this number increased to 4,165,015 deaths. An additional 1,944,291 deaths were added through correction of HIV deaths misclassified as other causes in 44 countries. The proportion of HIV deaths derived from garbage code redistribution decreased over time, from 0.4 in 1990 to 0.1 in 2018. The proportion of deaths derived from HIV misclassification correction peaked at 0.4 in 2006 and declined afterwards to 0.08 in 2018. The greatest contributors to garbage code redistribution were "immunodeficiency antibody" (ICD 9: 279-279.1; ICD 10: D80-D80.9) and "immunodeficiency other" (ICD 9: 279, 279.5-279.9; ICD 10: D83-D84.9, D89, D89.8-D89.9), which together contributed 77% of all redistributed deaths at their peak in 1995. Respiratory tuberculosis (ICD 9: 010-012.9; ICD 10: A10-A14, A15-A16.9) contributed the greatest proportion of all HIV misclassified deaths (25-62% per year) over the most years.

CONCLUSIONS

Correcting for miscoding and misclassification of cause of death data can enhance the utility of the data for analyzing trends in HIV mortality and tracking progress toward the Sustainable Development Goal targets.

Co-infection With Hepatitis B in Tuberculosis Patients on Anti-tuberculosis Treatment and the Final Outcome

Background The occurrence of both tuberculosis (TB) and concomitant hepatitis B virus (HBV) is likely to be associated with poor patient outcomes and poor treatment response. Objective To assess whether tuberculosis patients with concomitant hepatitis B virus infection were prone to poorer outcomes and treatment response. Methodology A case-control study was undertaken at the Tuberculosis Centre, DHQ Bagh Azad Kashmir and Pulmonology Department, Lady Reading Hospital, Peshawar, between March 2020 and August 2020. All patients with diagnosed tuberculosis and coinfection with hepatitis B were labeled as the case group while those with only tuberculosis acted as the control. All patients with tuberculosis were managed on a directly observed treatment strategy (DOTS). Non-compliant patients and those without complete data were excluded from the study. All data regarding socio-demographics, laboratory investigations, and clinical characteristics were recorded in a predefined proforma. Patients were considered to have good treatment outcomes when patients completed the treatment or had a negative smear at six months of treatment. The Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corp, Armonk, NY) was used for the data analysis. Results A total of 178 patients were enrolled in the study. It was found that patients with concomitant hepatitis B had significantly poorer outcomes as compared to patients who did not have hepatitis B (<0.001). Similarly, TB and hepatitis B patients were significantly associated with severe tuberculosis (<0.001) and required a higher frequency of retreatment (<0.001). Conclusion Our study reports a strong association between the treatment response of patients with tuberculosis with an added hepatitis B infection. Furthermore, a larger number of patients with hepatitis B had severe tuberculosis as compared to those without hepatitis B.

Hepatitis B Virus: Advances in Prevention, Diagnosis, and Therapy

Currently, despite the use of a preventive vaccine for several decades as well as the use of effective and well-tolerated viral suppressive medications since 1998, approximately 250 million people remain infected with the virus that causes hepatitis B worldwide. Hepatitis C virus (HCV) and hepatitis B virus (HBV) are the leading causes of liver cancer and overall mortality globally, surpassing malaria and tuberculosis. Linkage to care is estimated to be very poor both in developing countries and in high-income countries, such as the United States, countries in Western Europe, and Japan. In the United States, by CDC estimates, only one-third of HBV-infected patients or less are aware of their infection. Some reasons for these low rates of surveillance, diagnosis, and treatment include the asymptomatic nature of chronic hepatitis B until the very late stages, a lack of curative therapy with a finite treatment duration, a complex natural history, and a lack of knowledge about the disease by both care providers and patients. In the last 5 years, more attention has been focused on the important topics of HBV screening, diagnosis of HBV infection, and appropriate linkage to care. There have also been rapid clinical developments toward a functional cure of HBV infection, with novel compounds currently being in various phases of progress. Despite this knowledge, many of the professional organizations provide guidelines focused only on specific questions related to the treatment of HBV infection. This focus leaves a gap for care providers on the other HBV-related issues, which include HBV's epidemiological profile, its natural history, how it interacts with other viral hepatitis diseases, treatments, and the areas that still need to be addressed in order to achieve HBV elimination by 2030. Thus, to fill these gaps and provide a more comprehensive and relevant document to regions worldwide, we have taken a global approach by using the findings of global experts on HBV as well as citing major guidelines and their various approaches to addressing HBV and its disease burden.

Synthesis and Characterization of Long-Acting Darunavir Prodrugs

Antiretroviral therapy (ART) has improved the quality of life in patients infected with HIV-1. However, complete viral suppression within anatomical compartments remains unattainable. This is complicated by adverse side effects and poor adherence to lifelong therapy leading to the emergence of viral drug resistance. Thus, there is an immediate need for cellular and tissue-targeted long-acting (LA) ART formulations. Herein, we describe two LA prodrug formulations of darunavir (DRV), a potent antiretroviral protease inhibitor. Two classes of DRV prodrugs, M1DRV and M2DRV, were synthesized as lipophilic and hydrophobic prodrugs and stabilized into aqueous suspensions designated NM1DRV and NM2DRV. The formulations demonstrated enhanced intracellular prodrug levels with sustained drug retention and antiretroviral activities for 15 and 30 days compared to native DRV formulation in human monocyte-derived macrophages. Pharmacokinetics tests of NM1DRV and NM2DRV administered to mice demonstrated sustained drug levels in blood and tissues for 30 days. These data, taken together, support the idea that LA DRV with sustained antiretroviral responses through prodrug nanoformulations is achievable.

Sources and Impact of Work-Related Stress Among HIV/AIDS Health Care Providers in Guangxi, China: A Qualitative Research

Work-related stress can negatively impact health care providers' (HCPs) ability to provide care. We examined the sources of work-related stress experienced by HCPs who provided medical care for people living with HIV/AIDS and the impact of the stress on HCPs' well-being and work performance. We conducted in-depth interviews with 46 HIV/AIDS HCPs in Guangxi, China. The interviews were audio-recorded, transcribed, and imported into NVivo V.11 for data management and data analysis using a thematic approach. We found that the key sources of stress at work included general work-related sources and HIV/AIDS-related sources. All stress was seen to have a substantial impact on the HCPs' individual well-being, family and social life, and quality of care they provided. We recommended that government and health care facilities should take measures to improve institutional culture and professional development for HIV/AIDS HCPs. More professional training schemes should be provided to strengthen HCPs' competence, improve universal protection from occupational exposure, and reduce the stigma toward HIV/AIDS patients and their care providers.

Mortality risk in the population of HIV-positive individuals in Southern China: A cohort study

To evaluate the mortality risk in the HIV-positive population, we conducted an observational cohort study involving routine data collection of HIV-positive patients who presented at HIV clinics and multiple treatment centers throughout Guangxi province, Southern China in 2011. The patients were screened for tuberculosis (TB) and tested for hepatitis B (HBV) and C (HCV) virus infections yearly. Following the registration, the cohort was followed up for a 60-month period till the end-point (December 31, 2015). Univariable and multivariable Cox proportional hazards regression models were used to analyze the hazard ratio (HR) and 95% confidence interval (95% CI) for mortality after adjusting for confounding factors stratified by patients’ sociodemographic and behavioral characteristics. HRs were compared within risk-factor levels. With the median follow-up of 3.7-person years for each individual, 5,398 (37.8%) (of 14,293 patients with HIV/AIDS) died; among whom, 78.4% were antiretroviral therapy (ART)-naïve; 43.6% presented late; and 12.2% and 3.3% of patients had Mycobacterium tuberculosis (MTB) and HBV and HCV co-infection, respectively. Of individuals with CD4 counts, those with CD4 count >350 cells/μL formed 14.0% of those who died. Furthermore, gender [multivariable HR (95% CI):1.94 (1.68–2.25)], Han ethnicity [2.15 (1.07–4.32)], illiteracy [3.28 (1.96–5.5)], elementary education [2.91 (1.8–4.72)], late presentation [2.89 (2.46–3.39)], and MTB co-infection [1.28 (1.10–1.49)] strongly increased the all-cause mortality risk of HIV-positive individuals. The HR for ART-based stratification was 0.08 (0.07–0.09); and for HBV and HCV co-infection, HR was 1.02 (0.86–1.21). The findings emphasized that accessibility to HIV testing among high-risk populations and screening for viral hepatitis and TB co-infection are important for the survival of HIV-positive individuals. Initiating early ART, even for individuals with higher CD4 counts, is advisable to help increase the prolongation of lives within the community.

High Prevalence of HBV Lamivudine-Resistant Mutations in HBV/HIV Co-Infected Patients on Antiretroviral Therapy in the Area with the Highest Prevalence of HIV/HBV Co-Infection in China

OBJECTIVES

We aimed to determine the prevalence of hepatitis B virus (HBV) drug-resistant mutations in patients co- infected with HBV/human immunodeficiency virus (HIV), including both drug-naïve subjects and those who received antiretroviral therapy (ART) in Guangxi, where the prevalence of HIV/HBV co-infection is highest in China.

METHODS

Two hundred and three subjects co-infected with HBV/HIV were recruited, including 123 drug-naïve patients (group 1) and 80 who received ART (group 2). The polymerase gene of HBV in the serum of all study subjects was analysed.

RESULTS

The results showed that the prevalence of HBV drug-resistant mutations in group 2 (76.5%, 95% CI 56.3-96.7) was significantly higher than that in group 1 (1.4%, 95% CI -1.4 to 4.2; χ2 = 50.955, p < 0.05). The major pattern of lamivudine (3TC)-resistant mutations is L180M+M204I+L80I (35.7%). In total, 95% of subjects with resistant mutations had cross-resistance to telbivudine and entecavir. No putative tenofovir disoproxil fumarate (TDF) resistance change was found. Five subjects (6.5%) in group 2 had HBV viral loads over 10 × 106 copies/mL. Four of them had 3TC-resistant mutations. Multivariate analysis showed that ART was the only factor associated with the development of drug-resistant mutations.

CONCLUSION

Treating HIV in HIV/HBV co-infection with antiretroviral agents may result in a very high prevalence of HBV 3TC-resistant mutations. TDF could not completely suppress HBV replication.

Spatio-Temporal Epidemiology of Viral Hepatitis in China (2003-2015): Implications for Prevention and Control Policies

Viral hepatitis, as one of the most serious notifiable infectious diseases in China, takes heavy tolls from the infected and causes a severe economic burden to society, yet few studies have systematically explored the spatio-temporal epidemiology of viral hepatitis in China. This study aims to explore, visualize and compare the epidemiologic trends and spatial changing patterns of different types of viral hepatitis (A, B, C, E and unspecified, based on the classification of CDC) at the provincial level in China. The growth rates of incidence are used and converted to box plots to visualize the epidemiologic trends, with the linear trend being tested by chi-square linear by linear association test. Two complementary spatial cluster methods are used to explore the overall agglomeration level and identify spatial clusters: spatial autocorrelation analysis (measured by global and local Moran's I) and space-time scan analysis. Based on the spatial autocorrelation analysis, the hotspots of hepatitis A remain relatively stable and gradually shrunk, with Yunnan and Sichuan successively moving out the high-high (HH) cluster area. The HH clustering feature of hepatitis B in China gradually disappeared with time. However, the HH cluster area of hepatitis C has gradually moved towards the west, while for hepatitis E, the provincial units around the Yangtze River Delta region have been revealing HH cluster features since 2005. The space-time scan analysis also indicates the distinct spatial changing patterns of different types of viral hepatitis in China. It is easy to conclude that there is no one-size-fits-all plan for the prevention and control of viral hepatitis in all the provincial units. An effective response requires a package of coordinated actions, which should vary across localities regarding the spatial-temporal epidemic dynamics of each type of virus and the specific conditions of each provincial unit.

HIV-hepatitis B virus coinfection: epidemiology, pathogenesis, and treatment

: HIV infection has a significant impact on the natural history of chronic hepatitis B virus (HBV) infection, with increased levels of HBV DNA, accelerated progression of liver disease and increased liver-associated mortality compared with HBV monoinfection. Widespread uptake and early initiation of HBV-active antiretroviral therapy has substantially improved the natural history of HIV-HBV coinfection but the prevalence of liver disease remains elevated in this population. In this paper, we review recent studies examining the natural history and pathogenesis of liver disease and seroconversion in HIV-HBV coinfection in the era of HBV-active antiretroviral therapy and the effects of HIV directly on liver disease. We also review novel therapeutics for the management of HBV with a particular emphasis on clinical strategies being developed for an HBV cure and an HIV cure and their impact on HIV-HBV coinfected individuals.