Assessing index CD4 and associated outcomes at 1-year in a tertiary HIV clinic, KwaZulu-Natal

BACKGROUND

 Human immunodeficiency virus (HIV) management guidelines have evolved from initiating therapy at CD4 counts of ≤ 200 cells/m3 to implementing universal test and treat (UTT). This study aimed to assess whether in clinical practice, patients are presenting with higher baseline CD4 counts, describe the incidence of opportunistic infections and the proportion that achieved viral suppression.

METHODS

 A retrospective cohort design with convenience sampling was conducted. Cohort 1 included patients initiated on antiretroviral therapy (ART) between 01 January 2014 and 31 December 2014, when criteria were set at CD4 count ≤ 350 cells/mm3. Cohort 2 included patients initiated on ART between 01 January 2019 and 31 December 2019, during the UTT era.

RESULTS

 At ART initiation, the median CD4 cell was 170 cells/mm3 (interquartile range [IQR]: 85.5-287) in Cohort 1 cells/mm3 and 243 cells/mm3 (IQR: 120-411) in Cohort 2. Tuberculosis was the predominant OI in the group with CD4 cell count ≤ 200 cells/m3 in both Cohort 1 (26.8%) and Cohort 2 (27.9%), p = 0.039. At 1 year, virological suppression was achieved in only 77.7% and 84.7% of Cohorts 1 and 2 patients.

CONCLUSION

 A notable portion of patients at King Edward VIII Hospital's HIV clinic commenced ART with CD4 counts significantly below the recommended guideline thresholds.Contribution: The research revealed a delay in initiating ART. A comprehensive reevaluation is essential to pinpoint the factors contributing to this delay and to devise customised interventions.

Regulations of malaria in children with human immunodeficiency virus infection: A review

This comprehensive review explores the intricate relationship between 2 major global health challenges, malaria and HIV, with a specific focus on their impact on children. These diseases, both endemic in sub-Saharan Africa, create a dual burden that significantly elevates the risk of morbidity and mortality, particularly in children with compromised immune systems due to HIV. The review delves into the complex mechanisms by which these infections interact, from heightened clinical malaria frequencies in HIV-infected individuals to the potential impact of antiretroviral therapy on malaria treatment. Different research engines were utilized in writing this paper such as Web of Science, Google Scholar, Pubmed Central, ResearchGate, and Academia Edu. To address this critical health concern, the study identifies and discusses various regulatory and treatment strategies. It emphasizes the importance of daily cotrimoxazole prophylaxis and insecticide-treated nets in preventing malaria in children with HIV. The potential of antiretroviral protease inhibitors and mRNA-based vaccines as innovative solutions is highlighted. Additionally, the study underscores the significance of climate data and artificial intelligence in improving diagnostics and drug development. Furthermore, the review introduces the concept of genetically modified mosquitoes as a novel approach to vector control, offering a promising avenue to protect HIV-positive individuals from mosquito-borne diseases like malaria. Through a comprehensive analysis of these strategies, the study aims to provide a foundation for policymakers, healthcare professionals, and researchers to develop effective regulations and interventions that reduce the dual burden of malaria and HIV in children, improving public health outcomes in endemic regions.

Efficacy and Safety of Pre-Exposure Prophylaxis to Control HIV and Sexually Transmitted Infection Among Men Who Have Sex With Men: Protocol for a Single-Arm Interventional Study

BACKGROUND

Pre-exposure prophylaxis (PrEP) against HIV infection is a new approach that involves the prophylactic use of the anti-HIV drug Truvada (tenofovir disoproxil fumarate [TDF] and emtricitabine [FTC]) by people not infected with HIV.

OBJECTIVE

The objective of this investigator-initiated clinical study of PrEP was to evaluate the incidence of HIV and sexually transmitted infection (STI), safety and efficacy of PrEP in PrEP users, and their compliance with PrEP medication. The social, medical, and economic benefits of PrEP in Japan was assessed.

METHODS

This single-center feasibility study of PrEP was conducted at the National Center for Global Health and Medicine, Tokyo, Japan, where a cohort of men who have sex with men without HIV was established in January 2017. This single-arm interventional study compared the efficacy and safety of PrEP in a single group of men who have sex with men who participated in PrEP cohort studies. For reference, the cohort study participants who did not participate in the PrEP study were included for comparison. Blood samples were collected for storage at baseline and clinic visits at 1, 3, and 6 months after starting PrEP and every 3 months thereafter. The participants were administered with 1 tablet of Truvada once daily as PrEP. They underwent blood and anal swab tests 1 and 3 months after starting PrEP and then HIV and STI infection assessments at 3-month intervals. Blood samples were centrifuged at the AIDS Clinical Center Laboratory. PrEP safety was evaluated by monitoring serum creatinine levels for symptoms of renal function disorders. The primary end point was the incidence of HIV in PrEP users (100 person-years). The secondary end points were the incidence of STI in PrEP users (100 person-years), incidence of adverse events caused by Truvada, frequency of high-risk sexual activity, and adherence to periodic visits and medication.

RESULTS

The study protocol was reviewed and approved by the certified review board of the National Center for Global Health and Medicine (NCGM-C-003129-03) on April 20, 2020. Changes to the study plan were submitted for review by the certified review board and approved before implementation. Recruitment was completed on March 28, 2019, and the study was completed (last adult participant and last time point) on March 31, 2021. The data were analyzed, and the main results of the study have been published in a peer-reviewed journal.

CONCLUSIONS

The findings indicated that PrEP is a highly effective and feasible strategy against HIV infection in terms of prophylactic response, retention, and compliance.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000031040; https://tinyurl.com/3msdkeb8 and Japan Registry of Clinical Trials jRCTs031180134; https://tinyurl.com/2p88mhyr.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/50919.

Prevalence and Characteristics of Needle Stick and Sharp Injuries Among King Salman Armed Forces Hospital Personnel in Tabuk City: A Retrospective Hospital-Based Study

BACKGROUND

This study aimed to determine the prevalence and associated characteristics of needle stick and sharp injuries (NSSIs) among King Salman Armed Forces Hospital (KSAFH) personnel.

METHODS

Data was collected by reviewing all reported NSSIs among KSAFH personnel between January 2020 to December 2022.

RESULTS

The prevalence of NSSIs was 2.05%, with nurses being the most commonly affected. Most injuries occurred in patients' rooms/wards and among health care workers (HCWs) aged < 40 years. Of the injured workers, 93.8% were immunized against hepatitis B virus (HBV).

CONCLUSION

Educational and training programs targeting high-risk age groups and professions should be developed. Policies related to locations and situations where injuries occur frequently should be reviewed regularly to reduce the risk of NSSIs.

Determinants and outcomes of low birth weight among newborns at a tertiary hospital in Zambia: A retrospective cohort study

Context

Newborns' low birth weight (LBW) has been linked to early infant morbidity and mortality. However, our understanding of the determinants and outcomes of LBW in this population is still poor.

Aim

This study aimed to assess determinants and outcomes of LBW among newborns at a tertiary hospital.

Settings and Design

Retrospective cohort study at Women and Newborn Hospital in Lusaka Zambia.

Subjects and Methods

We reviewed delivery case records and neonatal files between January 1, 2018, and September 30, 2019, for newborns admitted to the neonatal intensive care unit.

Statistical Analysis Used

Logistic regression models were used to establish determinants of LBW and describe the outcomes.

Results

Women living with human immunodeficiency virus infection were more likely to deliver LBW infants (adjusted odds ratio [AOR] = 1.46; 95% confidence interval [CI]: 1.16-1.86). Other maternal determinants of LBW were; increased parity (AOR = 1.22; 95% CI: 1.05-1.43), preeclampsia (AOR = 6.91; 95% CI: 1.48-32.36), and gestational age <37 weeks compared to 37 weeks or more (AOR = 24.83; 95% CI: 13.27-46.44). LBW neonates were at higher odds of early mortality (AOR = 2.16; 95% CI: 1.85-2.52), developing respiratory distress syndrome (AOR = 2.96; 95% CI: 2.53-3.47), and necrotizing enterocolitis (AOR = 1.66; 95% CI: 1.16-2.38) than neonates with a birth weight of 2500 g or more.

Conclusions

These findings underscore the importance of effective maternal and neonatal interventions to reduce the risk of morbidity and mortality for neonates with LBW in Zambia and other similar settings.

A Giant Eyelid Molluscum Contagiosum Revealing an HIV Infection: A Case Report and Literature Review

Molluscum contagiosum (MC) is a common benign cutaneous viral infection. It can affect any part of the skin with a high propensity for facial skin, especially in human immunodeficiency virus (HIV) patients with low CD4 count. We report a case of a 16-year-old female patient who presented with a giant isolated right upper eyelid MC lesion that served as the first clinical indicator of her HIV infection and acquired immunodeficiency syndrome (AIDS). A final diagnosis of MC was made based on the history, clinical findings, and histopathological examination. Moreover, due to its vital location, large size, and atypical presentation, a surgical excision by simple unroofing and curettage was performed under local anesthesia to speed recovery, prevent corneal complications, and reduce transmission. Her follow-up visits showed satisfactory clinical and cosmetic outcomes. Patients presenting with giant atypical eyelid lesions must be thoroughly investigated for immunosuppressive states, especially HIV infection. MC can have atypical presentations in HIV patients. To our knowledge, this is one of a few cases in the literature reporting a giant isolated eyelid MC lesion leading to a diagnosis of HIV infection with AIDS.

Systematic review: Safety of surgical male circumcision in context of HIV prevention public health programmes

Background: Since the recommendation of voluntary medical male circumcision (VMMC) to reduce the risk of heterosexually acquired HIV, a number of adolescent boys and men in 15 priority countries in Africa have been circumcised. Our primary goal was to identify the incidence of adverse events (AEs) associated with VMMC and to assess the safety profile among adolescent boys 10 - 14 years. Methods: We searched the databases MEDLINE and Embase, WHO, and conference abstracts from 2005 to 2019. The incidence of AEs was estimated by type of AE, size of study and age. Results: We retained 40 studies. Severe and moderate AEs overall were estimated at 0.30 per 100 VMMC clients with wide variability per study type. A higher rate was noted in small and moderate scale programmes and device method research studies compared with larger scale programmes. There was a limited number of studies reporting AEs among younger adolescent boys and they had higher infection-related AEs than those aged 20 years and older. Case studies noted rare AEs such as necrotizing fasciitis, tetanus, and glans injury. Conclusions: AE rates were comparable to those from the randomized controlled trials (RCTs) that led to recommendations and implementation of VMMC in high HIV burden countries, despite being implemented in low resource settings. Clients over time have increasingly included adolescents under the age of 15 years. Studies suggest potentially higher risks in this age group. As VMMC services are sustained, patient safety surveillance systems and promoting a patient safety culture are crucial to identify and mitigate potential harms from medical male circumcision.

False-Positive Human Immunodeficiency Virus Results in COVID-19 Patients

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, which causes coronavirus disease 2019 (COVID-19) disease, was first described in 2019 and became a pandemic in 2020. Although it is possible for two viruses to co-infect together, a rarer phenomenon of false-positive results due to cross-reactivity between viruses is also possible. Herein, we present two cases of the false-positive human immunodeficiency virus (HIV) results in those infected with COVID-19. Both patients were screened for HIV and were initially found to be positive with the fourth-generation test. A subsequent blood test revealed no viral load, and an enzyme-linked immunosorbent assays (ELISA) test indicated no reactivity to HIV, thus the false initial screening test. SARS-CoV-2 is an enveloped RNA virus with its outer surface containing a spike-like glycoprotein, which allows it to recognize host cells and invade. HIV-1 gp41 and SARS-CoV-2 share several structural sequences and motifs. These similarities could explain cross-reactivity and false-positive results when screening for HIV in the presence of COVID. The presence of HIV must be confirmed through more specific laboratory tests such as ELISA.

Systematic review: Safety of surgical male circumcision in context of HIV prevention public health programmes

Background: Since the recommendation of voluntary medical male circumcision (VMMC) to reduce the risk of heterosexually acquired HIV, a number of adolescent boys and men in 15 priority countries in Africa have been circumcised. Our primary goal was to identify the incidence of adverse events (AEs) associated with VMMC and to assess the safety profile among adolescent boys 10 - 14 years. Methods: We searched the databases MEDLINE and Embase, WHO, and conference abstracts from 2005 to 2019. The incidence of AEs was estimated by type of AE, size of study and age. Results: We retained 40 studies. Severe and moderate AEs overall were estimated at 0.30 per 100 VMMC clients with wide variability per study type. A higher rate was noted in small and moderate scale programmes and device method research studies compared with larger scale programmes. There was a limited number of studies reporting AEs among younger adolescent boys and they had higher infection-related AEs than those aged 20 years and older. Case studies noted rare AEs such as necrotizing fasciitis, tetanus, and glans injury. Conclusions: AE rates were comparable to those from the randomized controlled trials (RCTs) that led to recommendations and implementation of VMMC in high HIV burden countries, despite being implemented in low resource settings. Clients over time have increasingly included adolescents under the age of 15 years. Studies suggest potentially higher risks in this age group. As VMMC services are sustained, patient safety surveillance systems and promoting a patient safety culture are crucial to identify and mitigate potential harms from medical male circumcision.

Acute Myeloid Leukemia in a Patient With Human Immunodeficiency Virus-Related High-Risk Myelodysplastic Syndrome

The human immunodeficiency virus (HIV) is a retrovirus that infects a subset of T lymphocytes referred to as CD4 T-helper cells. This insult to the quantity and quality of T lymphocytes leads to a significant compromise of the immune system and the development of an environment of abnormal immune activation. This aberrancy in the immune system increases the susceptibility to developing various malignancies. Hematological abnormalities like cytopenias are among the most common complications of HIV and acquired immunodeficiency syndrome (AIDS)-related lymphoid malignancies. Myelodysplastic syndrome (MDS), a disease of ineffective hematopoiesis causing dysplastic cells and hypercellular bone marrow, manifesting as pancytopenia, has been described in patients with HIV but is poorly documented in the medical literature. We present the case of a middle-aged male with longstanding HIV who developed severe pancytopenia secondary to high-risk MDS and eventually progressed to and died from acute myeloid leukemia (AML), a phenomenon infrequently reported as associated with HIV/AIDS. Patients with HIV/AIDS and cytopenias should get a detailed hematological evaluation so as not to miss or delay the AML diagnosis.

Use of Mogamulizumab for Cutaneous Adult T-cell Leukemia in a Patient Living With HIV

Human T-lymphotropic virus type 1 (HTLV-1) is known to cause a rare form of leukemia/lymphoma called adult T-cell leukemia/lymphoma (ATLL). Although ATLL is known to have a high co-infection rate with human immunodeficiency virus (HIV) in areas where both viruses are endemic, clinical trials, such as the phase three trial for mogamulizumab, continue to exclude patients living with HIV. We here describe the utilization and therapeutic course of mogamulizumab for ATLL in a patient living with HIV. Unfortunately, due to exclusion of patients with co-viral infections in trials, decisions regarding clinical care in these patients remain challenging with the need to rely on retrospective publications for safety and efficacy.

A curious case of gingival enlargement - From seropositive diagnosis for human immunodeficiency virus to periodontal management

Gingival enlargement may be a result of multifactorial etiology which includes local factors such as calculus, food lodgement, overhanging restorations, and overextended dentures as well as systemic conditions such as hormonal disturbances and blood dyscrasias. Acquired immune deficiency is a manifestation of immune disorder caused by a retrovirus Human Immunodeficiency Virus (HIV). The association of Acquired Immunodeficiency Syndrome or HIV with oral and periodontal lesions is highly significant. Seropositive patients usually present with periodontal diseases and atypical periodontal lesions. These clinical findings may prove to be a link for probing patients' systemic health. This case report describes one such case of a patient, unaware of HIV infection with localized gingival overgrowth, wherein detailed probing and investigation led to the diagnosis of underlying systemic condition as acquired immunodeficiency. Subsequently, antiretroviral therapy was started, and nonsurgical periodontal therapy was performed to resolve the gingival overgrowth.

The capacity of HIV in the blood and the cerebrospinal fluid depending on antiretroviral drugs

This study aimed to determine the capacity of HIV in the blood and cerebrospinal fluid of patients, depending on the reception of antiretroviral therapy (ART). Paired blood and cerebrospinal fluid samples were examined in 116 HIV-infected patients to determine the level of viral load in both biological fluids and the number of blood CD4+ lymphocytes. In patients receiving ART, the difference between the load of HIV in blood and cerebrospinal fluid (CSF) was significantly smaller than in untreated patients. Taking ART reduces the amount of HIV in the blood and CSF, but the dynamics of virus suppression in these biological fluids differ. The analysis revealed a statistically significant inverse relationship between the load of HIV in the blood and the number of CD4+ lymphocytes in untreated patients. There is a clear moderate positive correlation between the level of viremia and the clinical stage of HIV infection, as well as the duration of the disease. The number of CD4+ lymphocytes was expected to be inversely weakly correlated with the clinical stage of HIV infection and its duration. Accordingly, a direct correlation of mean strength was found between the levels of viral load in the blood and cerebrospinal fluid. There was a significant increase in the difference between the levels of HIV load in the blood and CSF compared with the average value in 25.6% of patients.

A Rare Form of Metastatic Melanoma in an HIV-Infected Patient - A Diagnosis to Remember

Malignant melanoma (MM), which is amongst the rarest skin cancers, still remains one of the deadliest and most likely to spread, and, in human immunodeficiency virus (HIV)-infected patients, generally has a more aggressive behaviour. Although gastrointestinal (GI) tract metastases are frequent, secondary symptomatic colonic disease is rare. We present the case of a 76-year-old HIV-infected patient, with a 15-month history of GI and constitutional symptoms and a previous diagnosis of malignant melanoma. Diagnostic workup revealed metastatic involvement of the cecum. This case highlights the need to bear in mind the metastatic involvement of the GI tract by MM, and MM itself, especially in HIV-infected patients.

Bipolar herpes simplex infection in an human immunodeficiency virus-infected individual

Herpes simplex infection is the most common infection among the human immunodeficiency virus-infected individuals. However, the atypical manifestations of herpes simplex virus may confound even an astute physician. Hand involvement is rarely associated with genital herpes infection and the involvement of widespread areas healing with debilitating scarring is uncommon.

Coinfection of Hepatitis B and Hepatitis C Virus in Patients With Human Immunodeficiency Virus

Background Coinfection of viral hepatitis and human immunodeficiency virus (HIV) is not uncommon in Pakistan. Coinfection of hepatitis B virus (HBV) and hepatitis C virus (HCV) with HIV is associated with a poor prognosis. The current study evaluated the occurrence of coinfection of HBV/HIV and HCV/HIV in Peshawar, Khyber Pakhtunkhwa, Pakistan.  Methodology  A prospective, observational study was conducted at Khushal Medical Center and Hayatabad Medical Complex (HMC) between February 2019 and April 2020. All patients with confirmed HIV positive serum samples aged above 18 years were eligible to apply for anonymous screening for hepatitis B and C virus markers. Sociodemographic data including patient's age, gender, marital status, occupation, employment status, and body mass index among others were documented on a predefined proforma. The presence of viral markers of HBV and HCV in HIV patients was the primary outcome of the study.  Results Out of the total of 650 HIV patients, 78 (12%) had coinfection with hepatitis virus. The mean age was 42.40 ± 10.96 years. Sixty-three (80.77%) patients had coinfection with hepatitis B virus infection while 15 (19.23%) had hepatitis C coinfection. No cases of triple infections were identified. It was found that patients infected with HIV/HBV were more frequent in the age group of 30 to 45 years (36; 85.71%) while the HIV/HCV patients were older, i.e. 72.72% were older than 45 years (p<0.001). The sexual route was strongly associated with HIV/HBV group compared to HIV/HCV group [51 (89.47%) vs. six (10.53%); p<0.0001].  Conclusion The current study highlighted the rate of coinfection of HBV and HCV in HIV-infected individuals in Pakistan. We found that four-fifths of patients had coinfection with HBV while only one-fifth had coinfection with HCV. These findings are consistent with the published literature revealing that HIV/HBV and HIV/HCV are common in developing countries. Young sexually active individuals are at a significantly higher risk of acquiring HIV/HBV infection than HIV/HCV. We advocate screening for these hepatitis viral markers in patients with HIV infection as well as their sexual partners. Further large-scale, multicentre, and multistate studies should be conducted to determine the burden of these communicable diseases.

Invasive Microsporum canis infection as a presenting complaint of late-diagnosed HIV infection

A 43-year-old male barber presented with 1 year history of a painful, itchy plaque on the dorsal hand. Microsporum canis was recovered from pus of the lesion. Serologic testing for human immunodeficiency virus (HIV) antibody was positive, with a CD4⁺ count of 81 cells per cubic millimeter. Invasive cutaneous Microsporum canis infection is uncommon and can be suggestive of HIV infection or other conditions of immunocompromise.

Psychiatric Comorbidities in Pediatric Inpatients With Human Immunodeficiency Virus Infection and Impact on Hospital Course: Inputs From a Case-Control Inpatient Study

Objectives In this study, we aimed to delineate psychiatric comorbidities in pediatric inpatients with versus without human immunodeficiency virus (HIV) infection and to measure its impact on the length of stay (LOS) and cost of treatment during hospitalization. Methodology We conducted a case-control study using the Nationwide Inpatient Sample and included 4,920 pediatric inpatients between the ages of six and 18 years who were sub-grouped by a comorbid diagnosis of HIV (N = 2,595) and non-HIV (N = 2,325) and matched for demographics (age, sex, and race) by propensity case-control matching. Logistic regression analyses were used to evaluate the adjusted odds ratio (aOR) of association for psychiatric comorbidities (depression, anxiety, post-traumatic stress disorder, psychosis, and drug abuse) in the HIV-positive compared with the HIV-negative (as reference category) pediatric inpatients. We measured the differences in the LOS and cost using the independent sample t-test. Results We found that the most prevalent psychiatric comorbidities in the HIV-positive group were anxiety (6.9%), drug abuse (6.6%), psychosis (6.4%), and depression (6.2%). The HIV-positive group had a significantly higher likelihood of comorbid psychosis (aOR: 1.82; 95% confidence interval [CI]: 1.38-2.40) and depression (aOR: 1.79; 95% CI: 1.36-2.36). The mean LOS per hospitalization episode was longer for the HIV-positive group (11.1 days vs. 6.0 days; P < 0.001) compared to the HIV-negative pediatric inpatients. Conclusions We found an increased risk of depression by 79% and psychosis by 82% in the HIV-positive pediatric population. These inpatients also had an extended hospitalization stay (by five days), adding to the healthcare economic burden.

Immune characteristics of human immunodeficiency virus/severe acute respiratory syndrome coronavirus 2 coinfection: A case report and mini-review

Since its first appearance in Wuhan, China, severe acute respiratory syndrome coronavirus 2 has rapidly spread throughout the world and has become a global pandemic. It remains unclear whether people living with human immunodeficiency virus are at an increased risk of coronavirus disease 2019 and severe disease manifestation; until now, the evidence regarding the outcomes from severe acute respiratory syndrome coronavirus 2 infection in people living with human immunodeficiency virus is still limited and conflicting. The clinical characteristics of seven patients of family cluster-onset coronavirus disease 2019 were reported, including the immune characteristics of one patient of human immunodeficiency virus/severe acute respiratory syndrome coronavirus 2 coinfection. In the patients of human immunodeficiency virus/severe acute respiratory syndrome coronavirus 2 coinfection, about 2 weeks after infection, it was observed that CD4 and CD8 count showed a downward trend and that of CD8 is more obvious; at the same time, lymphocytes showed a slight increase. CD4, CD8, and lymphocytes are in the plateau period from the second week to the fourth week. About 4 weeks after infection, all showed an increase, in which anti-coronavirus combined with antiviral therapy were given. The time for Nucleic Acid Testing to present as negative was 51 days. The other six patients in the family were non–human immunodeficiency virus infected, the familial cluster received parallel treatment, and the median time for the Nucleic Acid Testing to present as negative was 29 days. The patient of human immunodeficiency virus/severe acute respiratory syndrome coronavirus 2 coinfection presents an immune state of CD4’s and CD8’s dual lymphatic depletion. Human immunodeficiency virus should still be regarded as an important factor in future risk stratification models for coronavirus disease 2019.

Differential Diagnosis of Chorea-HIV Infection Delays Diagnosis of Huntington's Disease by Years

Background: There is a broad range of potential differential diagnoses for chorea. Besides rare, inherited neurodegenerative diseases such as Huntington’s disease (HD) chorea can accompany basal ganglia disorders due to vasculitis or infections, e.g., with the human immunodeficiency virus (HIV). The clinical picture is complicated by the rare occurrence of HIV infection and HD. Methods: First, we present a case suffering simultaneously from HIV and HD (HIV/HD) focusing on clinical manifestation and disease onset. We investigated cross-sectional data regarding molecular genetic, motoric, cognitive, functional, and psychiatric disease manifestation of HIV/HD in comparison to motor-manifest HD patients without HIV infection (nonHIV/HD) in the largest cohort of HD patients worldwide using the registry study ENROLL-HD. Data were analyzed using ANCOVA analyses controlling for covariates of age and CAG repeat length between groups in IBM SPSS Statistics V.25. Results: The HD diagnosis in our case report was delayed by approximately nine years due to the false assumption that the HIV infection might have been the cause of chorea. Out of n = 21,116 participants in ENROLL-HD, we identified n = 10,125 motor-manifest HD patients. n = 23 male participants were classified as suffering from HIV infection as a comorbidity, compared to n = 4898 male non-HIV/HD patients. Except for age, with HIV/HD being significantly younger (p < 0.050), we observed no group differences regarding sociodemographic, genetic, educational, motoric, functional, and cognitive parameters. Male HIV/HD patients reported about a 5.3-year-earlier onset of HD symptoms noticed by themselves compared to non-HIV/HD (p < 0.050). Moreover, patients in the HIV/HD group had a longer diagnostic delay of 1.8 years between onset of symptoms and HD diagnosis and a longer time regarding assessment of first symptoms by the rater and judgement of the patient (all p < 0.050). Unexpectedly, HIV/HD patients showed less irritability in the Hospital Anxiety and Depression Scale (all p < 0.05). Conclusions: The HD diagnosis in HIV-infected male patients is secured with a diagnostic delay between first symptoms noticed by the patient and final diagnosis. Treating physicians therefore should be sensitized to think of potential alternative diagnoses in HIV-infected patients also afflicted by movement disorders, especially if there is evidence of subcortical atrophy and a history of hyperkinesia, even without a clear HD-family history. Those patients should be transferred for early genetic testing to avoid further unnecessary diagnostics and improve sociomedical care.

Human immunodeficiency virus case detection and antiretroviral therapy enrollment among children below and above 18 months old: A comparative analysis from Cameroon

ABSTRACT

While pediatric human immunodeficiency virus (HIV) testing has been more focused on children below 18 months through prevention of mother to child transmission of HIV (PMTCT), the yield of this approach remains unclear comparatively to testing children above 18 months through routine provider-initiated testing and counselling (PITC). This study aimed at assessing and comparing the HIV case detection and antiretroviral therapy (ART) enrolment among children below and above 18 months of age in Cameroon. This information is required to guide the investments in HIV testing among children and adolescents.We conducted a cross-sectional study where we invited parents visiting or receiving HIV care in 3 hospitals to have their children tested for HIV. HIV testing was done using polymerase chain reaction (PCR) and antibody rapid tests for children <18 months and those ≥18 months, respectively. We compared HIV case detection and ART initiation between the 2 subgroups of children and this using Chi-square test at 5% significant level.A total of 4079 children aged 6 weeks to 15 years were included in the analysis. Compared with children <18 months, children group ≥18 months was 4-fold higher among those who enrolled in the study (80.3% vs 19.7%, P < .001); 3.5-fold higher among those who tested for HIV (77.6% vs 22.4%, P < .001); 6-fold higher among those who tested HIV+ (85.7% vs 14.3%, P = .24), and 11-fold higher among those who enrolled on ART (91.7% vs 8.3%, P = .02).Our results show that 4 out of 5 children who tested HIV+ and over 90% of ART enrolled cases were children ≥18 months. Thus, while rolling out PCR HIV testing technology for neonates and infants, committing adequate and proportionate resources in antibody rapid testing for older children is a sine quo none condition to achieve an acquired immunodeficiency syndrome (AIDS)-free generation.

Metabolic Control and Determinants Among HIV-Infected Type 2 Diabetes Mellitus Patients Attending a Tertiary Clinic in Botswana

PURPOSE

We primarily aimed at determining the prevalence of metabolic syndrome and abnormal individual metabolic control variables in HIV-infected participants as compared to HIV-uninfected participants given current concerns. Our secondary objective was to determine the predictors of metabolic syndrome and individual metabolic control variables among the study participants to guide future management.

PATIENTS AND METHODS

A descriptive, case-matched cross-sectional study for four months from 15th June 2019 to 15th October 2019 at Block 6 Diabetes Reference Clinic in Gaborone, Botswana. We compared the proportions of metabolic syndrome and individual metabolic control variables based on gender and HIV status by means of bivariate analysis (Chi-squared test or Fisher's exact test) to determine factors associated with metabolic control. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Overall, 86% of the study participants were found to have metabolic syndrome by International Diabetes Federation (IDF) criteria with 79.8% among HIV-infected and 89.1% among HIV-negative participants (p-value = 0.018). Older age was significantly associated with metabolic syndrome (p-value = 0.008). Female gender was significantly associated with metabolic syndrome as compared to male gender (P-value < 0.001), and with a statistically significant higher proportion of low HDL-C compared to males (P-value < 0.001). Female participants were significantly more likely to be obese as compared to males (P-value < 0.001). High triglycerides were more common in HIV-infected compared to HIV-negative participants (P-value = 0.004). HIV-negative participants were more likely to be obese as compared to HIV-infected participants (P-value = 0.003).

CONCLUSION

Metabolic syndrome is an appreciable problem in this tertiary clinic in Botswana for both HIV-infected and HIV-negative participants. Future prospective studies are warranted in our setting and similar sub-Saharan settings to enhance understanding of the role played by HAART in causing the metabolic syndrome, and the implications for future patient management.

Burkitt lymphoma associated with human immunodeficiency virus infection and pulmonary tuberculosis: A case report

INTRODUCTION

The association of human immunodeficiency virus (HIV) infection with Burkitt lymphoma is related to the presence of Epstein Barr virus infection and the impact of the HIV antigen on the expansion of B-polyclonal cells. In Southeast Europe, the association is rare, and recognizing this is important in the therapeutic decision to increase patient survival rate. The association of HIV with Burkitt lymphoma and tuberculosis is even more rarely described in the literature.

PATIENT CONCERNS

We present the case of a 40-year-old patient who presented with a 3-week history of fever (max. 38.7 °C), painful axillary swelling on the right side, lumbar pain, gait disorders, headache, and night sweats. Clinical manifestations included marked weight loss (about 30 kg in the last 2 months before his admission).

DIAGNOSIS

A LyCD4 count of 38/μL and a HIV1 viral load of 384,000/mm3, classified the patient into a C3 stage. A biopsy of the right axillary lymph node was performed for suspected ganglionic tuberculosis due to immunodeficiency. Histopathological examination confirmed the diagnosis of Burkitt lymphoma. Cultures on Löwenstein-Jensen medium from sputum harvested at first admission were positive for Mycobacterium tuberculosis.

INTERVENTIONS

Highly active antiretroviral therapy, chemotherapeutic agents for Burkitt lymphoma, anti-tuberculous drug therapy, neurosurgical intervention of spinal cord decompression, and antibiotic therapy of the associated bacterial infection.

OUTCOME

Burkitt lymphoma disseminated rapidly, with central nervous system, spinal cord, osteomuscular, adrenal, and spleen involvement. The evolution under treatment was unfavorable, with patient death occurring 6 months after diagnosis.

CONCLUSIONS

The association of HIV infection with Burkitt lymphoma and tuberculosis is rare in the highly active antiretroviral therapy (HAART) era, posing prompt and multidisciplinary therapeutic management issues. Similar cases of HIV-TB and Burkitt lymphoma association have been described, but none of the other cases showed the involvement of the central nervous system or of the bilateral adrenal glands.

Human immunodeficiency virus-associated pulmonary sarcoidosis in a Japanese man as a manifestation of immune reconstitution inflammatory syndrome

Asymptomatic pulmonary sarcoidosis can develop after starting antiretroviral therapy. The decision on whether to treat sarcoidosis with corticosteroids should be based on the disease severity.

Outcomes of coronary artery bypass grafting in patients with human immunodeficiency virus infection

Background

With early and effective antiretroviral therapy and improved survival for persons living with human immunodeficiency virus infection (PLHIV), this patient population now faces an increasingly elevated risk of cardiovascular disease. However, the data on outcomes after coronary artery bypass grafting (CABG) for revascularization of coronary artery disease (CAD) in HIV+ patients is limited.

Methods

We conducted a retrospective analysis of 16 patients undergoing isolated CABG at the Medical University of Vienna from 2005 to 2018, who were HIV+ on admission. The primary endpoint of the study was survival. Secondary endpoints included the components of major adverse cardiac and cerebrovascular events (MACCE): cardiovascular death, stroke, myocardial infarction (MI), and repeat revascularization.

Results

Patients were followed for a median of 49 months (range, 7‐142 months). Survival was 100% and 90% at 1 and 3 years after CABG, respectively. There were no strokes. MI and subsequent repeat revascularization were observed in two patients.

Conclusion

CABG provides excellent short‐ and midterm survival and freedom from MACCE in HIV+ patients with CAD requiring revascularization.

Primitive Neuroectodermal Tumor in a Child with Human Immunodeficiency Virus Infection: A Rare Association

Children with human immunodeficiency virus (HIV) infection are reported to have various malignancies, most common being Non-Hodgkin lymphoma. Despite higher risk of malignancies, brain tumors are infrequently described in these children. We report Primitive Neuroectodermal tumor (PNET) in a young boy with HIV infection. PNET has never been described in association with HIV infection. Though a causative association cannot be established, it does emphasize that with longer survivals on effective antiretroviral therapy, we may see a wide range of malignancies more frequently.

Directly observed therapy and risk of unfavourable tuberculosis treatment outcomes among an international cohort of people living with HIV in low- and middle-income countries

INTRODUCTION

Identification of persons living with human immunodeficiency virus (HIV)-associated tuberculosis (TB) at increased risk for unfavourable TB outcomes would inform efforts to improve such outcomes. We sought to identify factors associated with a decreased risk of unfavourable TB treatment outcomes among people living with HIV-infection (PLHIV) in low- and middle-income countries (LMIC), with a specific focus on directly observed therapy (DOT) compared with self-administered therapy (SAT) during the continuation phase of anti-TB therapy.

METHODS

We conducted a retrospective cohort study among adults diagnosed with HIV-associated TB in Africa, Asia and the Americas from 2012 to 2013; data were collected from 2012 to 2016. Unfavourable TB treatment outcomes (death during TB treatment, and TB treatment failure or recurrence) were defined according to World Health Organization criteria. Receipt of DOT was obtained at the site level and defined as ≥5 days of DOT per week. The person administering DOT and treatment location varied by site. Lack of receipt of DOT was defined as SAT. Multivariable logistic regression estimated the adjusted odds of unfavourable TB treatment outcomes.

RESULTS

Among 1862 adults with HIV-associated TB included, 252 (13.5%) had unfavourable TB outcomes (226 deaths, 26 recurrences/failures). Overall, 1825 (98%) received DOT in the intensive phase and 1617 (87%) received DOT in the continuation phase. DOT in the continuation phase was not significantly associated with unfavourable TB outcomes (aOR 1.43, 95% CI 0.86 to 2.38) compared to SAT. Body mass index (BMI) change during anti-TB treatment (per 2 units increase, aOR 0.74, 95% CI 0.68 to 0.82) and CD4+ count at TB diagnosis (200 vs. 50  cells/µL, aOR 0.54, 95% CI 0.39 to 0.73) were both independently associated with decreased odds of unfavourable TB treatment outcomes.

CONCLUSIONS

In this large, international cohort of people living with HIV-associated TB in LMIC who received intensive phase DOT, DOT during the continuation phase of anti-TB therapy was not associated with a decreased odds of unfavourable TB treatment outcomes compared to SAT. Randomized trials evaluating the effect of continuation-phase DOT on TB outcomes among PLHIV are needed.

Late presentation among patients with human immunodeficiency virus infection in Turkey

OBJECTIVE

Late presentation of the patients with human immunodeficiency virus (HIV) infection is associated with less favourable treatment responses, more accelerated clinical progression, and a higher mortality risk. Although HIV prevalence is low in Turkey, it is steadily increasing and the information about late presentation among HIV-positives is limited. We aimed to analyze the status of late presentation among HIV-positive patients in Turkey.

METHODS

All newly diagnosed HIV/AIDS patients from 2003 to 2016 were enrolled in this study by five dedicated centres in Istanbul, Turkey. Demographic data, CD4+ counts, and HIV RNA were collected from medical records and were transferred to a HIV database system. Late pre- sentation was defined as presentation for care with a CD4 count &lt; 350 cells/mm³ or presentation with an AIDS-defining event, regardless of the CD4 cell count. A medical literature search was done for the analysis of late presentation in Turkey.

RESULTS

The cohort included 1,673 patients (1,440 males, median age 35 years). Among them, 847 (50.6%) had an early diagnosis, with a CD count of more than 350 cells/mm³. The remaining 826 were late presenters. Among late presenters, 427 (25.5% of all, 51.7% of late presenters) presented with advanced HIV disease. Late presenters were more elderly and less educated. The gender seemed comparable between groups. Late presentation was more likely among married patients. Early presenters were more likely among homosexuals, those diagnosed in screening studies, and in lower HIV-RNA viral load category. There has been a decreasing trend among late presenters in 2011-2016 when compared to 2003-2011 period.

CONCLUSION

Current data suggest that half of HIV-infected patients present late in Turkey. In our cohort, those presented late were more elderly, less educated, married and had heterosexual intercourse. On admission, late presenters had more HIV-related diseases and were more likely in higher HIV-RNA category. In the cohort, men having sex with men were less likely late presenters. Efforts to reduce the proportion of late presentation are essential for almost every country. The countries should identify the risk factors of late presentation and should improve early diagnosis and presentation for HIV care.

In Human Immunodeficiency Virus primary infection, early combined antiretroviral therapy reduced γδ T-cell activation but failed to restore their polyfunctionality

Primary and chronic human immunodeficiency virus (HIV) infection alters γδ T-cell features. However, there is no evidence about early combined antiretroviral therapy (cART) and γδ T-cell dynamics. In the present study, HIV-positive individuals were divided into those with early primary infection (EPI) and those with late primary infection (LPI). The analysis of γδ T cells was performed by flow cytometry before and after therapy. Polyfunctional profile was assessed after in vitro peripheral blood mononuclear cell (PBMC) exposure to specific antigens. The results show that primary infection induced an expansion of Vδ1 T cells in LPI. Before treatment, a massive activation of γδ T-cell subsets was observed in both groups of patients, that correlated with disease progression and was significantly reduced after cART introduction. Despite this, CD107A-expressing Vδ1 T cells in both groups were significantly fewer than in healthy donors, but were restored by therapy introduction. Polyfunctional analysis of Vδ1 T cells from HIV-positive individuals revealed a lower frequency of CD107A⁺  CCL-4⁺ Vδ1 T-cell subsets than healthy donors that persists after therapy. Functional profile of Vδ2 was similar to that in healthy donors before therapy but, at 6 months, a lower frequency of CD107A, interferon-γ- or tumor necrosis factor-α-producing Vδ2 T cells was observed in the EPI group. Finally, individuals with LPI showed a lower frequency of quadruple-functional Vδ2 T-cell subset. In conclusion, during primary HIV infection, the baseline Vδ1 T-cell activation is correlated with immune reconstitution potential. Moreover, an altered γδ polyfunctional profile occurred, persisting after cART. Further studies are needed to understand whether a longer treatment of primary infection may increase γδ T-cell functionality.

The Phosphatidylinositol 3-Kinase p110α/PTEN Signaling Pathway Is Crucial for HIV-1 Entry

Human immunodeficiency virus type 1 (HIV-1) drives multiple signaling pathways to facilitate its cellular entry and replication. The interaction between HIV-1 envelope (env) protein and target cell surface CD4 first activates the phosphatidylinositol 3-kinase (PI3K)/Akt signaling pathway, and the subsequent interaction between HIV-1 env glycoprotein and CCR5/CXCR4 coreceptors establishes viral fusion and entry. Four isoforms of the class-I PI3K catalytic subunits (p110α, p110β, p110γ, and p110δ) have been identified so far, but the isoform(s) involved in the HIV-1 entry is still unknown. This study aimed to identify the PI3K isoform(s) using recently developed isoform-specific inhibitors and the roles of their negative regulators, phosphatase and tensin homolog deleted on chromosome 10 (PTEN) and homology 2 domain-containing inositol-5-phosphatase 1 (SHIP1), in HIV-1 infection. We found that the PI3K p110α isoform-specific inhibitor PIK-75 suppressed HIV-1 entry in HIV-1 permissive T cells, PM1 cells, and TZM-bl cells (HeLa cell-derived indicator cells that coexpress CD4, CCR5, and CXCR4) and decreased the HIV-1-induced phosphorylation of Akt. Moreover, wild-type PTEN (but neither phosphatase-deficient PTEN nor wild-type SHIP1) was a key regulator of HIV-1 entry. Cell-to-cell fusion by HIV-1 env-CD4 interaction was suppressed in the presence of PI3K p110α-specific inhibitor. These data suggest that the PI3K p110α/PTEN signaling pathway is indispensable for HIV-1 entry, including HIV-1 env-mediated cell-to-cell fusion.

Successful nonoperative management of high output enterocutaneous fistulae in high surgical risk HIV-positive patients: Two case reports and literature review

Management of enterocutaneous fistulae is challenging, often requiring a multidisciplinary approach. In high output fistulae, surgery is advocated after control of sepsis, adequate fluid and electrolyte repletion, and nutritional support. Surgery may, however, be contraindicated in the presence of sepsis and malnutrition. The presence of HIV infection brings extra challenges.

Treatment of drug-susceptible tuberculosis among people living with human immunodeficiency virus infection: an update

PURPOSE OF REVIEW

The present review describes recent advances in the treatment of drug-susceptible tuberculosis (DS-TB) among people living with human immunodeficiency virus (PLWH).

RECENT FINDINGS

Higher than standard rifampicin doses (>10 mg/kg/day) are well tolerated and have improved sterilizing activity. Standard pyrazinamide doses may result in low drug exposures; modeling reveals that higher doses (>25 mg/kg/day) may be required to reach target levels, although safety is unknown. Four-month fluoroquinolone-containing regimens are not recommended in the 2017 World Health Organization DS-TB treatment guidelines. These guidelines also recommend fixed-dose combination (FDC) therapy over single drug formulations based on patient preference, though FDC is not associated with improved outcomes. Treatment for 6 months is recommended, with an emphasis on expanded antiretroviral therapy (ART) coverage and monitoring for relapse among those not started on ART within 8 weeks of tuberculosis treatment. Directly observed therapy (DOT) is recommended over self-administered therapy, as is daily therapy over intermittent therapy - both are associated with better tuberculosis outcomes.

SUMMARY

Current WHO tuberculosis treatment guidelines recommend 6 months of daily tuberculosis treatment for PLWH who have DS-TB, and timely ART initiation. Higher rifampin and pyrazinamide doses may enhance treatment effectiveness, but safety data are needed. DOT and FDC therapy are recommended.

Impact of Aging, Cytomegalovirus Infection, and Long-Term Treatment for Human Immunodeficiency Virus on CD8+ T-Cell Subsets

Both healthy aging and human immunodeficiency virus (HIV) infection lead to a progressive decline in naive CD8⁺ T-cell numbers and expansion of the CD8⁺ T-cell memory and effector compartments. HIV infection is therefore often considered a condition of premature aging. Total CD8⁺ T-cell numbers of HIV-infected individuals typically stay increased even after long-term (LT) combination antiretroviral treatment (cART), which is associated with an increased risk of non-AIDS morbidity and mortality. The causes of these persistent changes in the CD8⁺ T-cell pool remain debated. Here, we studied the impact of age, CMV infection, and LT successful cART on absolute cell numbers in different CD8⁺ T-cell subsets. While naïve CD8⁺ T-cell numbers in cART-treated individuals (N = 38) increased to healthy levels, central memory (CM), effector memory (EM), and effector CD8⁺ T-cell numbers remained higher than in (unselected) age-matched healthy controls (N = 107). Longitudinal analysis in a subset of patients showed that cART did result in a loss of memory CD8⁺ T-cells, mainly during the first year of cART, after which memory cell numbers remained relatively stable. As CMV infection is known to increase CD8⁺ T-cell numbers in healthy individuals, we studied whether any of the persistent changes in the CD8⁺ T-cell pools of cART-treated patients could be a direct reflection of the high CMV prevalence among HIV-infected individuals. We found that EM and effector CD8⁺ T-cell numbers in CMV⁺ healthy individuals (N = 87) were significantly higher than in CMV^- (N = 170) healthy individuals. As a result, EM and effector CD8⁺ T-cell numbers in successfully cART-treated HIV-infected individuals did not deviate significantly from those of age-matched CMV⁺ healthy controls (N = 39). By contrast, CM T-cell numbers were quite similar in CMV⁺ and CMV^- healthy individuals across all ages. The LT expansion of the CM CD8⁺ T-cell pool in cART-treated individuals could thus not be attributed directly to CMV and was also not related to residual HIV RNA or to the presence of HIV-specific CM T-cells. It remains to be investigated why the CM CD8⁺ T-cell subset shows seemingly irreversible changes despite years of effective treatment.

CD4 cell counts and oral manifestations in HIV infected and AIDS patients

Context

Acquired immunodeficiency syndrome (AIDS) is an acronym for AIDS caused by a retrovirus known as human immunodeficiency virus (HIV) which breaks down the body's immune system leaving a patient vulnerable to a host of life-threatening opportunistic infections, neurological disorders or unusual malignancies. According to estimates by the World Health Organization and UNAIDS, 35 million people were living with HIV globally at the end of 2013. The first AIDS case in India was detected in 1986. Seldom studies have been conducted correlating these parameters with oral manifestations in the Indian population.

Aim

The present study was carried out to evaluate the CD4 cell counts and oral manifestations in HIV-infected and AIDS patients and to correlate them with the seronegative controls.

Methodology

This was a cross-sectional, hospital-based study on individuals who were divided into three groups, Group A consisting of 500 patients who were healthy controls without any systemic illness; Group B consisting of 500 patients who were diagnosed as HIV infected and Group C consisting of 500 patients diagnosed as AIDS patients depending on their CD4 cell counts. The permission from the Ethical Committee of the Institution as well as Superintendent of Government Hospital was obtained. Evaluation of CD4 cell counts in HIV-infected and AIDS patients was done using CyFlow Counter.

Results

The results were found to be statistically significant with the P < 0.001 for the CD4 cell counts. Oral manifestations revealed varied results with different levels of significance.

Conclusion

CD4 cell counts were significantly altered in HIV-infected and AIDS patients when compared with the controls while oral manifestations revealed varied results with different levels of significance.

Unsuspected human immunodeficiency virus infection presenting as immunoglobulin G4-related lymphadenopathy: a case report

Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is an immune-mediated condition characterized by infiltration of the involved organs by IgG4-bearing plasma cells. The prevalence of autoimmune diseases, associated with or occurring in patients with human immunodeficiency virus (HIV) infection, has been increasing. We describe a 58-year-old man with an undiagnosed HIV infection, which presented as chronic cervical lymphadenopathy with an elevated serum IgG4 and a very high IgE. Histologically, lymph nodes showed expanded sinusoids and burnt-out germinal centers with increased plasmacytic infiltration and collagen fiber deposition. The absolute number of IgG4+ plasma cells and the IgG4+/IgG+ plasma cell ratio was increased. The lymph nodes were enlarged and clinically the patient improved after steroid treatment. Nine months later, he was diagnosed with acquired immune deficiency syndrome, following presentation with a cavitary left lung lesion. Immunohistochemical studies on the previously resected lymph node revealed complete absence of CD4+ T-lymphocytes and increased CD8+ T-lymphocytes. The pathologic findings met the criteria of both HIV infection and IgG4-related lymphadenopathy. Our case demonstrates that further investigations for underlying HIV infection in a case of IgG4-RD are critical, especially when extremely elevated IgE is concomitantly present.

New-onset type 2 diabetes mellitus among patients receiving HIV care at Newlands Clinic, Harare, Zimbabwe: retrospective cohort analysis

OBJECTIVE

To assess the incidence and associated factors of Type 2 Diabetes Mellitus (T2DM) among people living with HIV (PLHIV) in Zimbabwe.

METHODS

We analysed data of all HIV-infected patients older than 16 years who attended Newlands Clinic between March 1, 2004 and April 29, 2015. The clinic considers patients whose random blood sugar is higher than 11.1 mmol/l and which is confirmed by a fasting blood sugar higher than 7.0 mmol/l to have T2DM. T2DM is also diagnosed in symptomatic patients who have a RBS >11.0 mmol/l. Risk factors for developing T2DM were identified using Cox proportional hazard models adjusted for confounding. Missing baseline BMI data were multiply imputed. Results are presented as adjusted hazard ratios (aHR) with 95% confidence intervals (95% CI).

RESULTS

Data for 4,110 participants were included: 67.2% were women; median age was 37 (IQR: 31-43) years. Median baseline CD4 count was 197 (IQR: 95-337) cells/mm3 . The proportion of participants with hypertension at baseline was 15.5% (n=638). Over a median follow-up time of 4.7 (IQR: 2.1-7.2) years, 57 patients developed T2DM; the overall incidence rate was 2.8 (95% CI: 2.1-3.6) per 1000 person-years of follow-up. Exposure to PIs was associated with T2DM (HR: 1.80, 95% CI: 1.04-3.09). In the multivariable analysis, obesity (BMI>30 kg/m2 ) (aHR=2.26, 95% CI: 1.17-4.36), age >40 years (aHR=2.16, 95% CI: 1.22-3.83) and male gender, (aHR=2.13, 95% CI: 1.22-3.72) were independently associated with the risk of T2DM. HIV-related factors (baseline CD4 cell count and baseline WHO clinical stage) were not independent risk factors for developing T2DM.

CONCLUSION

Although the incidence of T2DM in this HIV cohort was lower than that has been observed in others, our results show that risk factors for developing T2DM among HIV-infected people are similar to those of the general population. HIV-infected patients in sub-Saharan Africa need a comprehensive approach to care that includes better health services for prevention, early detection and treatment of chronic diseases especially among the elderly and obese.

Hemophagocytic lymphohistiocytosis in a patient with human immunodeficiency virus infection: A case report

Hemophagocytic lymphohistiocytosis (HLH), also termed hemophagocytic syndrome, is a severe, life-threatening inflammatory condition that results from an excessive, prolonged and ineffective immune response. The syndrome occurs due to overactive macrophages from the bone marrow or lymph tissue that phagocytose erythrocytes leukocytes and platelets. HLH in a patient with human immunodeficiency virus infection has rarely been studied. The present case study described an uncommon case of this syndrome in combination with human immunodeficiency virus infection in a patient, who eventually succumbed to severe infection and multiple organ failure following the refusal of medical treatment.

Single-institutional experience of clinicopathological analysis and treatment for lung cancer patients with human immunodeficiency virus infection

The advent of antiretroviral therapy has changed the disease spectrum constitution among patients living with human immunodeficiency virus (HIV), while the incidence of death due to non-AIDS-defining cancers, particularly lung cancer, continues to increase in the USA and Europe. However, the availability of detailed reports of the clinical characteristics of lung cancer among Asian populations is limited. The present study retrospectively analyzed the clinical characteristics, treatment regimens and outcomes of lung cancer patients with HIV who were treated in a single institution between 1988 and 2013. Of the 20 lung cancer patients living with HIV included in this study, 90% were diagnosed since 1996 in the post-antiretroviral era. The median CD4+ cell count was 373.5/µl, whereas 65% of the patients were diagnosed with adenocarcinoma and 30% with squamous cell carcinoma. Epidermal growth factor receptor mutations were detected in 3 (27%) of the 11 specimens for which data were available, of which 65% had advanced-stage disease. Of the 20 patients, 9 underwent surgery, 6 received radiotherapy and 5 received chemotherapy as a first-line treatment. Treatment was generally well-tolerated. The median survival period was 35.8 months for all stages and 14.0 months for advanced stages. The treatment outcomes in our institution were favorable in comparison with previous studies from the USA and Europe, although these findings may be due to ethnic differences or the efficacy of treatment for HIV and lung cancer.

Antiretroviral Therapy-induced Insulin Resistance and Oxidative Deoxy Nucleic Acid Damage in Human Immunodeficiency Virus-1 Patients

BACKGROUND AND OBJECTIVES

Insulin resistance (IR) is frequent in human immunodeficiency virus (HIV) infection and may be related to antiretroviral therapy (ART). Increased oxidative stress parameters and carbonyl protein are linked to insulin sensitivity. The present study is aimed to determine IR, its association with oxidative deoxy nucleic acid (DNA) damage in HIV-1-infected patients with different ART status.

MATERIALS AND METHODS

In this case-control study, a total 600 subjects were included. We used plasma levels of the oxidized base, 8-hydroxy-2-deoxyguanosine (8-OHdG), as our biomarker of oxidative DNA damage. 8-OHdG was measured with the highly sensitive 8-OHdG check enzyme-linked immunosorbent assay kit. IR was determined using homeostasis model assessment.

RESULTS

All subjects were randomly selected and grouped as HIV-negative (control group) (n = 300), HIV-positive without ART (n = 100), HIV-positive with ART first line (n = 100), and HIV-positive with ART second line (n = 100). IR and oxidative DNA damage were significantly higher in HIV-positive patients with second-line ART and HIV-positive patients with first-line ART than ART-naive patients. In a linear regression analysis, increased IR was positively associated with the increased DNA damage (odds ratio: 3.052, 95% confidence interval: 2.595-3.509) P < 0.001.

INTERPRETATION AND CONCLUSIONS

In this study, we observed that ART plays a significant role in the development of IR and oxidative DNA damage in HIV-positive patients taking ART. Awareness and knowledge of these biomarkers may prove helpful to clinicians while prescribing ART to HIV/AIDS patients. Larger studies are warranted to determine the exact role of ART in the induction of IR and DNA damage.

Prognostic Value of Transient Elastography in Human Immunodeficiency Virus-Infected Patients With Chronic Hepatitis C

BACKGROUND

Our objective was to study the prognostic value of liver stiffness (LS) in HIV-infected patients with chronic hepatitis C (CHC).

METHODS

We analyzed HIV-infected patients with compensated CHC and at least 1 determination of LS. The primary outcome was the occurrence of liver-related events (LRE), namely, decompensation or hepatocellular carcinoma, whichever occurred first. We selected patients without sustained viral response (SVR) or end-of-treatment response (ETR) during follow-up and allocated them to an estimation cohort (EC) and a validation cohort (VC).

RESULTS

The study population comprised 1292 patients. After a median follow-up of 5.8 years, 90 patients experienced LRE and 73 died. In the subgroup of 957 patients without SVR or ETR, the area under the receiver operating characteristic curves (AUROCs) (95% confidence interval [CI]) of LS for prediction of LRE in the EC (n = 634) and the VC (n = 323) were 0.87 and 0.88, respectively. The best cutoff value of LS to rule out LRE in the EC was 12 kPa, with a negative predictive value of 98.3% in the EC and 98.2% in the VC. Per each 1 kPa and 5 kPa increase above 12 kPa, the hazard ratio of LRE (taking into account death as a competing risk) was 1.07 (95% CI, 1.05-1.08) and 1.38 (95% CI, 1.31-1.46), respectively.

CONCLUSIONS

Liver stiffness is very accurate for predicting LRE in coinfected patients. Patients with an LS <12 kPa had a 98% probability of not developing LRE after a median follow-up of almost 6 years. Above the 12-kPa cutoff, the hazard of LRE increases proportionally with LS.

Clinical outcomes of routine opt-out antenatal human immunodeficiency virus screening: a systematic review

AIMS AND OBJECTIVES

To evaluate the clinical outcome of routine screening of human immunodeficiency virus in antenatal clinic settings.

BACKGROUND

Despite the growing advances in human immunodeficiency virus management, nearly 30% of the estimated 1·5 million seropositive pregnant women are undiagnosed. Routine opt-out testing is a strategy endorsed by the World Health Organization in to increase testing rates in clinical settings.

DESIGN

A systematic review of relevant published literature.

METHODS

A comprehensive electronic search for relevant studies in Science Direct, MEDLINE, SCOPUS, CINAHL and PubMed was conducted with search terms (Box 2). Hand searches were also conducted for additional resources. There were no geographical restrictions. Searches were restricted to English language and studies conducted between 1998-2015; totaling 1097 were retrieved and carefully appraised for review. Eighteen studies were eligible for review: eight from Africa, five from the United States, three from Europe, one from Australia and one from Asia.

RESULTS

Fourteen studies reported increases in human immunodeficiency virus testing rate. Following the introduction of routine testing, human immunodeficiency virus testing rates increased from values ranging from 68-99·9% with median value of 88%. The comparison studies reported testing uptake of 22-93·5% with median value of 59%. Maternal human immunodeficiency virus case detection rates nearly doubled following adoption of routine testing at values of 99 and 45% during opt-in. Linkage to treatment and care for prevention of vertical transmission was reported on six studies, and results ranged between 12·9-77·2%.

CONCLUSION

The findings show that irrespective of human immunodeficiency virus epidemiological scenarios, routine testing gave more women opportunity to learn their human immunodeficiency virus status and take measures for prevention of mother-to-child transmission of human immunodeficiency virus. Future studies should focus on identifying strategies to improving linkages to treatment and care for prevention of vertical transmission.

RELEVANCE TO CLINICAL PRACTICE

Understanding the contributions of Routine opt-out testing in antenatal clinic would help practitioners adopt the novel testing model for more mothers to learn their human immunodeficiency virus status for prevention of mother-to-child transmission.

A longitudinal study of immunological status in Chinese haemophiliacs: importance of the heat viral inactivation of factor concentrates. I. Immunological associations with the consumption of factor concentrates

Twenty-four of 117 cases of haemophilia A (20.5%) and none of 18 cases of haemophilia B reported in this study had an antibody to the human immuno-deficiency virus (HIV). Both groups of patients showed similar immunological alterations. HIV-seropositive haemophilia A patients had an increased CD8 cell count and a similarly decreased CD4/CD8 ratio as compared to HIV-seronegative haemophilia A patients. Multiple regression analysis for the association of CD4/CD8 ratio with HIV infection status and dosage of plasma products in haemophilia A and B patients, respectively, revealed that there was a significant negative association of ln(CD4/CD8) with dosage of factor VlII concentrates (P = 0.0435) and factor IX concentrates (P = O.O028), respectively. N o association occurred between CD4/CD8 ratio and HIV infection as well as dosage of other plasma products. These data indicate that the immunological abnormalities of our haemophilia A and B patients in their early years were primarily caused by various viral infections and/or a suppressive effect of allogeneic protein through infusion of factor concentrates and not caused simply by HIV infection.

Miliary tuberculosis in an Indian lady: Looking beyond miliary tuberculosis

Presence of miliary shadows in chest imaging in the appropriate clinical setting is often taken as a marker of miliary tuberculosis. If sputum is negative for acid -fast bacillus, empirical anti-tubercular therapy is given without securing a histological or microbiological diagnosis. We report a young female with human immunodeficiency virus infection who had miliary infiltrates on chest radiography. She was started on empirical anti-tubercular therapy. But an alternate diagnosis was achieved later with invasive sampling and ATT was stopped. This case illustrates the need for physicians to remain alert to diseases which mimic tuberculosis in presentation.

Emerging diseases in Bangladesh: Current microbiological research perspective

Bangladesh has experienced a variety of diseases caused by natural dissemination of an array of pathogenic microorganisms into the environment. While cures for these diseases largely depend on the medication strategies of physicians, determining the reasons for disease persistence as well for the onset of reinfection is also essential. Routine diagnosis of common diseases usually means treatment with a range of appropriate medicines; however, failure of these medications because of the drug resistance of microorganisms accompanied by a lack of alertness about the etiology of diseases often leads to fatal results. The present review reports on emerging diseases in Bangladesh and focuses on associated microbiological research into ongoing diseases including enteric, urinary tract, and malarial complications. The viruses associated with acquired immunodeficiency syndrome and hepatitis are also discussed.

Lung function abnormalities in HIV-infected adults and children

Despite the advent of antiretroviral therapy (ART), the human immunodeficiency virus (HIV) epidemic remains a global health crisis with a high burden of respiratory disease among infected persons. While the early complications of the epidemic were dominated by opportunistic infections, improved survival has led to the emergence of non-infectious conditions that are associated with chronic respiratory symptoms and pulmonary disability. Obstructive ventilatory defects and reduced diffusing capacity are common findings in adults, and the association between HIV and chronic obstructive pulmonary disease is increasingly recognized. There is synergism between viral factors, opportunistic infections, conventional influences like tobacco smoke and biomass fuel exposure, and potentially, the immunological effects of ART on the development of HIV-associated chronic obstructive lung disease. Pulmonary function data for HIV-infected infants and children are scarce, but shows that bronchiectasis and obliterative bronchiolitis with severe airflow limitation are major problems, particularly in the developing world. However, studies from these regions are sorely lacking. There is thus a major unmet need to understand the influences of chronic HIV infection on the lung in both adults and children, and to devise strategies to manage and prevent these diseases in HIV-infected individuals. It is important for clinicians working with HIV-infected individuals to have an appreciation of their effects on measurements of lung function. This review therefore summarizes the lung function abnormalities described in HIV-positive adults and children, with an emphasis on obstructive lung disease, and examines potential pathogenic links between HIV and the development of chronic pulmonary disability.

Prognostic factors of early death in a cohort of 162 adult haemophagocytic syndrome: impact of triggering disease and early treatment with etoposide

Reactive haemophagocytic syndrome is a life-threatening disease for which factors influencing the outcome remain unclear. We sought to identify determinants of early mortality in patients with reactive haemophagocytic syndrome by conducting a non-interventional retrospective multicentre study in three tertiary care teaching hospitals over a 6-year period. The medical files of 162 patients fulfilling our diagnostic criteria of haemophagocytic syndrome were reviewed. Patients were classified according to 30-d outcome following diagnosis. Thirty-three patients (20·4%) died within 30 d. Clinical features at diagnosis associated with 30-d death in univariate analysis were older age (P = 0·004), underlying lymphoma (P = 0·04), lower platelet count (P = 0·001) and elevated aspartate aminotransferase and lactate dehydrogenase (P = 0·04 both). The use of etoposide as a first-line treatment tended to be associated with a better outcome (P = 0·079). In multivariate analyses, increasing age, decreasing platelet count, underlying lymphoma and no etoposide in the management were associated with a poorer prognosis (P = 0·03, 0·01, 0·003 and 0·04, respectively). These prognostic factors could help to identify those patients more severely affected by reactive haemophagocytic syndrome, who should benefit from aggressive supportive care, combined with specific treatment of the precipitating factor.

Attitude and knowledge of dental students of National Capital Region regarding HIV and AIDS

Background:

India is estimated to have third highest number of Human Immunodeficiency Virus (HIV) infection in world with about 2.4 million people currently living with HIV/Acquired Immunodeficiency Syndrome (AIDS). There is a possibility of HIV transmission in the oral health care setting and thus adequate knowledge and proper attitude among dental students is vital to prevent the chances of transmission and for proper care of the patient.

Aims and Objectives:

The present study aimed to investigate the knowledge of dental students about HIV infection and their attitude toward treating HIV/AIDS patients and behaviour practiced.

Materials and Methods:

A cross-sectional survey was conducted among 600 dental students of different colleges present in National Capital Region (NCR). The students were from third and fourth year and they completed a predesigned questionnaire assessing the knowledge, attitude and willingness to treat HIV/AIDS patients. One-way analysis of variance (ANOVA) was applied to compare mean level of knowledge and attitude toward HIV/AIDS.

Result:

The results showed that only 28% students have excellent knowledge regarding HIV/AIDS. Certain misconceptions were prevalent regarding mode of transmission. It also shows that around 43% of the dental students have an overall negative attitude.

Conclusion:

The findings suggest that the students had adequate knowledge about HIV/AIDS and their attitude toward this group of people was significantly negative. There is need and scope to provide correct and detailed information on HIV/AIDS for dental students.

First reported cases of diffuse cutaneous leishmaniasis in human immunodeficiency virus positive patients in Jaipur District of Rajasthan, India

Diffuse cutaneous leishmaniasis (DCL) is characterized by the presence of a large number of lesions at several anatomic sites (head, limbs and trunk). The lesions include papules, nodules and areas of diffuse infiltration that do not ulcerate and reveal abundant parasites on histopathological examination. DCL and human immunodeficiency virus (HIV) co-infections are seldom reported. We report two cases of DCL in HIV positive patients without visceral involvement. DCL is emerging as a new opportunistic infection associated with HIV/acquired immunodeficiency syndrome.

Clinically relevant drug-drug interactions between antiretrovirals and antifungals

INTRODUCTION

Complete delineation of the HIV-1 life cycle has resulted in the development of several antiretroviral drugs. Twenty-five therapeutic agents belonging to five different classes are currently available for the treatment of HIV-1 infections. Advent of triple combination antiretroviral therapy has significantly lowered the mortality rate in HIV patients. However, fungal infections still represent major opportunistic diseases in immunocompromised patients worldwide.

AREAS COVERED

Antiretroviral drugs that target enzymes and/or proteins indispensable for viral replication are discussed in this article. Fungal infections, causative organisms, epidemiology and preferred treatment modalities are also outlined. Finally, observed/predicted drug-drug interactions between antiretrovirals and antifungals are summarized along with clinical recommendations.

EXPERT OPINION

Concomitant use of amphotericin B and tenofovir must be closely monitored for renal functioning. Due to relatively weak interactive potential with the CYP450 system, fluconazole is the preferred antifungal drug. High itraconazole doses (> 200 mg/day) are not advised in patients receiving booster protease inhibitor (PI) regimen. Posaconazole is contraindicated in combination with either efavirenz or fosamprenavir. Moreover, voriconazole is contraindicated with high-dose ritonavir-boosted PI. Echinocandins may aid in overcoming the limitations of existing antifungal therapy. An increasing number of documented or predicted drug-drug interactions and therapeutic drug monitoring may aid in the management of HIV-associated opportunistic fungal infections.