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Incidence of Herpes Zoster in HIV-Infected Patients Undergoing Antiretroviral Therapy: A Systematic Review and Meta-analysis. J Clin Med 2021; 10:jcm10112300. [PMID: 34070645 PMCID: PMC8198877 DOI: 10.3390/jcm10112300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022] Open
Abstract
The incidence of herpes zoster (HZ) in patients infected with HIV is higher than that of the general population. However, the incidence of HZ in HIV patients receiving antiretroviral therapy (ART) remains unclear. This meta-analysis aimed to estimate the pooled incidence rate and risk factors for HZ in the post-ART era. We identified studies assessing the incidence of HZ in the post-ART era between 1 January 2000 and 28 February 2021, from four databases. Pooled risk ratios were calculated from 11 articles using a random-effects model. The heterogeneity of the included trials was evaluated by visually inspecting funnel plots, performing random-effects meta-regression and using I2 statistics. Of the 2111 studies screened, we identified 11 studies that were eligible for final inclusion in the systematic review and 8 studies that were eligible for a meta-analysis. The pooled incidence of HZ in the post-ART era (after the introduction of ART in 1997) was 2.30 (95% confidence interval (CI): 1.56-3.05) per 100 person years (PYs). The risks of incidence of HZ among people living with HIV included male sex (AOR: 4.35 (95% CI: 054-2.41)), men who have sex with men (AOR: 1.21 (95% CI: -0.76-1.13)), CD4 count < 200 cells/μL (AOR: 11.59 (95% CI: 0.53-4.38)) and not receiving ART (AOR: 2.89 (95% CI: -0.44-2.56)). The incidence of HZ is substantially lower among HIV infected patients receiving ART than those not receiving ART. Initiating ART immediately after diagnosis to treat all HIV-positive individuals is crucial to minimize the disease burden of HZ.
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Erdmann NB, Prentice HA, Bansal A, Wiener HW, Burkholder G, Shrestha S, Tang J. Herpes Zoster in Persons Living with HIV-1 Infection: Viremia and Immunological Defects Are Strong Risk Factors in the Era of Combination Antiretroviral Therapy. Front Public Health 2018; 6:70. [PMID: 29594092 PMCID: PMC5857573 DOI: 10.3389/fpubh.2018.00070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 02/20/2018] [Indexed: 12/30/2022] Open
Abstract
In a cohort of 4,225 persons living with human immunodeficiency virus type 1 (HIV-1) infection (PLWH) enrolled at a southeastern US clinic, the overall rate of incident herpes zoster (HZ) was 101 per 10,000 person-years (PY) between January 1999 and 2017, which nearly quadruples the rate reported for the general US population. In the same cohort, the median age of HZ diagnosis was 39.5 years [interquartile range (IQR) 31.5–49.2] in African American (AA) and 39.1 years (IQR 34.9–45.2) in European American (EA) PLWH, with the highest incidence seen in PLWH who were over 50 years old (144 and 93 per 10,000 PY in AA and EA, respectively, P = 0.18), showing no bias between men (100 per 10,000 PY) and women (101 per 10,000 PY). In multivariable models that were applicable to 245 HZ cases and 3,713 controls, age, nadir CD4+ T-cell (CD4) count, plasma viral load (VL), and duration of combination antiretroviral therapy were independent correlates of incident HZ (adjusted P ≤ 0.006 for all). Regardless of other factors, viremic PLWH (VL > 50 copies/mL) was at the highest risk of HZ [adjusted odds ratio (OR) > 3.0, P < 0.0001]. PLWH with a nadir CD4 count of ≥500 cells/μL showed a relatively low risk (adjusted OR = 0.48, P = 0.003). By contrast, similar risk estimates were observed with three advancing age groups (30–39, 40–49, and ≥50) when compared with age <30 (adjusted OR = 1.86–2.17, P ≤ 0.010). These findings indicate that efforts for HZ diagnosis and prophylaxis should target viremic PLWH who are over 30 years old and with CD4 count <500 cells/μL.
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Affiliation(s)
- Nathaniel B Erdmann
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Heather A Prentice
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Anju Bansal
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Howard W Wiener
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Greer Burkholder
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Sadeep Shrestha
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jianming Tang
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States.,Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States
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Kawai K, Hawkins CA, Hertzmark E, Francis JM, Sando D, Muya AN, Ulenga N, Fawzi WW. Impact of Antiretroviral Therapy on the Risk of Herpes Zoster among Human Immunodeficiency Virus-Infected Individuals in Tanzania. Am J Trop Med Hyg 2018; 98:396-401. [PMID: 29313475 DOI: 10.4269/ajtmh.17-0568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We examined the incidence of herpes zoster (HZ) before and after the initiation of antiretroviral therapy (ART), and risk factors for HZ among human immunodeficiency virus (HIV)-infected individuals in Tanzania. A cohort study was conducted among HIV-positive individuals enrolled in HIV care and treatment clinics in Dar es Salaam, Tanzania. A Cox proportional hazard model was used to examine the effect of ART on the risk of HZ after adjusting for sociodemographics and time-varying clinical and nutritional factors. Among 72,670 HIV-positive individuals, 2,312 incident cases of HZ (3.2%) occurred during the median follow-up of 15 months (interquartile range: 3-35). The incidence rate of HZ significantly declined from 48.9 (95% confidence interval [CI] = 46.7-51.0) per 1,000 person-years before ART to 3.7 (95% CI = 3.3-4.1) per 1,000 person-years after the initiation of ART (P < 0.001). The risk of HZ declined with longer duration on ART. Low CD4 cell count, older age, female sex, district of Dar es Salaam, and year of enrollment were independently associated with the risk of HZ in the multivariate analysis. Low body mass index and anemia were not associated with the risk of HZ. The risk of HZ substantially declined after ART initiation in this large cohort of HIV-infected individuals. Earlier initiation of ART could reduce the risk of HZ and other opportunistic infections among HIV-infected individuals in sub-Saharan Africa.
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Affiliation(s)
- Kosuke Kawai
- Clinical Research Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Claudia A Hawkins
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Joel M Francis
- Management and Development for Health, Dar es Salaam, Tanzania.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Aisa N Muya
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Management and Development for Health, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Bender Ignacio RA, Ramchandani MS, Laing KJ, Johnston CM, Koelle DM. T Cell Immunity to Varicella-Zoster Virus in the Setting of Advanced HIV and Multiple Varicella-Zoster Virus Recurrences. Viral Immunol 2016; 30:77-80. [PMID: 27870601 DOI: 10.1089/vim.2016.0097] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
A woman presented with at least four manifestations of varicella-zoster virus (VZV) infection, including central nervous system vasculitis, during her first 2 years of HIV infection. We evaluated her CD4 T cell responses to VZV given the infrequency with which multiple recurrences of VZV occurred, especially following immune reconstitution on antiretroviral therapy.
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Affiliation(s)
- Rachel A Bender Ignacio
- 1 Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington , Seattle, Washington.,2 Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - Meena S Ramchandani
- 1 Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington , Seattle, Washington
| | - Kerry J Laing
- 1 Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington , Seattle, Washington
| | - Christine M Johnston
- 1 Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington , Seattle, Washington.,2 Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - David M Koelle
- 1 Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington , Seattle, Washington.,2 Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center , Seattle, Washington.,3 Benaroya Research Institute , Seattle, Washington
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Ramadhani HO, Bartlett JA, Thielman NM, Pence BW, Kimani SM, Maro VP, Mwako MS, Masaki LJ, Mmbando CE, Minja MG, Lirhunde ES, Miller WC. The Effect of Switching to Second-Line Antiretroviral Therapy on the Risk of Opportunistic Infections Among Patients Infected With Human Immunodeficiency Virus in Northern Tanzania. Open Forum Infect Dis 2016; 3:ofw018. [PMID: 26949717 PMCID: PMC4776054 DOI: 10.1093/ofid/ofw018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/07/2016] [Indexed: 11/13/2022] Open
Abstract
Background. Due to the unintended potential misclassifications of the World Health Organization (WHO) immunological failure criteria in predicting virological failure, limited availability of treatment options, poor laboratory infrastructure, and healthcare providers' confidence in making switches, physicians delay switching patients to second-line antiretroviral therapy (ART). Evaluating whether timely switching and delayed switching are associated with the risk of opportunistic infections (OI) among patients with unrecognized treatment failure is critical to improve patient outcomes. Methods. A retrospective review of 637 adolescents and adults meeting WHO immunological failure criteria was conducted. Timely and delayed switching to second-line ART were defined when switching happened at <3 and ≥3 months, respectively, after failure diagnosis was made. Cox proportional hazard marginal structural models were used to assess the effect of switching to second-line ART on the risk of developing OI. Results. Of 637 patients meeting WHO immunological failure criteria, 396 (62.2%) switched to second-line ART. Of those switched, 230 (58.1%) were delayed. Switching to second-line ART reduced the risk of OI (adjusted hazards ratio [AHR], 0.4; 95% CI, .2-.6). Compared with patients who received timely switch after failure diagnosis was made, those who delayed switching were more likely to develop OI (AHR, 2.2; 95% CI, 1.1-4.3). Conclusion. Delayed switching to second-line ART after failure diagnosis may increase the risk of OI. Serial immunological assessment for switching patients to second-line ART is critical to improve their outcomes.
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Affiliation(s)
- Habib O Ramadhani
- Kilimanjaro Christian Medical Centre, Moshi; Tanzania; Department of Epidemiology, University of North Carolina, Chapel Hill
| | - John A Bartlett
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, and; Duke Global Health Institute, Durham, North Carolina
| | - Nathan M Thielman
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, and; Duke Global Health Institute, Durham, North Carolina
| | - Brian W Pence
- Department of Epidemiology , University of North Carolina , Chapel Hill
| | | | | | | | | | | | - Mary G Minja
- Kibosho Designated District Hospital , Moshi , Tanzania
| | | | - William C Miller
- Department of Epidemiology , University of North Carolina , Chapel Hill
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Shafran SD. Live attenuated herpes zoster vaccine for HIV-infected adults. HIV Med 2015; 17:305-10. [PMID: 26315285 DOI: 10.1111/hiv.12311] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2015] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Multiple guidelines exist for the use of live viral vaccines for measles-mumps-rubella (MMR), varicella and yellow fever in people with HIV infections, but these guidelines do not make recommendations regarding live attenuated herpes zoster vaccine (LAHZV), which is approved for people over 50 years in the general population. LAHZV is made with the same virus used in varicella vaccine. The incidence of herpes zoster remains increased in people with HIV infection, even when on suppressive antiretroviral therapy, and a growing proportion of HIV-infected patients are over 50 years of age. The purpose of this article is to review the use of varicella vaccine and LAHZV in people with HIV infection and to make recommendations about the use of LAHZV in adults with HIV infection. METHODS A PubMed search was undertaken using the terms 'herpes zoster AND HIV' and 'varicella AND HIV'. Reference lists were also reviewed for pertinent citations. RESULTS Varicella vaccine is recommended in varicella-susceptible adults, as long as they have a CD4 count > 200 cells/μL, the same CD4 threshold used for MMR and yellow fever vaccines. No transmission of vaccine strain Varicella zoster virus has been documented in people with HIV infections with a CD4 count above this threshold. LAHZV was administered to 295 HIV-infected adults with a CD4 count > 200 cells/μL, and was safe and immunogenic with no cases of vaccine strain infection. CONCLUSIONS It is recommended that LAHZV be administered to HIV-infected adults with a CD4 count above 200 cells/μL, the same CD4 threshold used for other live attenuated viral vaccines.
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Affiliation(s)
- S D Shafran
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Humes EA, Weinberger DM, Kudish KS, Hadler JL. Trends in hospitalizations with primary varicella and herpes zoster during the prevaricella and initial postvaricella and herpes zoster vaccine eras, connecticut, 1994-2012. Open Forum Infect Dis 2015; 2:ofv001. [PMID: 26034752 PMCID: PMC4438882 DOI: 10.1093/ofid/ofv001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/02/2015] [Indexed: 11/14/2022] Open
Abstract
Background. The introductions of the varicella vaccine in 1995 and herpes zoster (HZ) vaccine in 2006 have an ongoing potential to modify the epidemiology of both diseases. Analysis of data on hospitalizations can be conducted to examine trends in the occurrence of severe disease over time and to assess the possible impact of vaccination on the incidence of hospitalization. Methods. Statewide hospital discharge data 1994-2012 in Connecticut were used to identify individuals discharged with a diagnosis of varicella and the initial admissions of persons with a discharge diagnosis of HZ in the first or second diagnostic position. Trends in overall age-standardized and age group-specific hospitalization rates for preselected time intervals before and after the introduction of vaccines were examined using Poisson regression models or Mantel-Haenszel χ(2) tests. Results. Beginning in 2001, 5 years after the introduction of varicella vaccine, HZ hospitalization rates decreased significantly in individuals <15 years at an average rate of 19.4% per year through 2012. Among individuals ≥60 years, HZ hospitalization rates increased by 5.1% per year from 2001 to 2006 but decreased by 4.2% per year from 2007 to 2012. Primary varicella hospitalization rates declined 82.9% from the prevaccine era (1994-1995) to the 1-dose era (2001-2005) (P < .001). Rates further decreased significantly in the 2-dose era (2010-2012) among 5 to 9 year olds (100% decrease). Conclusions. Varicella vaccine seems to have had an impact on both varicella and HZ hospitalizations, and introduction of the HZ vaccine may be having an impact on HZ hospitalizations.
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Affiliation(s)
- Elizabeth A Humes
- Department of Epidemiology of Microbial Diseases , Yale School of Public Health , New Haven, Connecticut
| | - Daniel M Weinberger
- Department of Epidemiology of Microbial Diseases , Yale School of Public Health , New Haven, Connecticut
| | - Kathy S Kudish
- Connecticut Department of Public Health , Immunizations Program , Hartford
| | - James L Hadler
- Department of Epidemiology of Microbial Diseases , Yale School of Public Health , New Haven, Connecticut
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