Hepatitis B Vaccination Uptake & Correlates of Serologic Response among HIV-Infected & Uninfected Men Who Have Sex with Men (MSM) in Bangkok, Thailand

BACKGROUND:

Vaccination against hepatitis B virus (HBV) is recommended for all HBV-susceptible men who have sex with men (MSM). There is limited information on correlates of immunity to HBV vaccination in this group. We present serologic response rates to hepatitis B vaccine and identify factors associated with impaired response among HIV-uninfected and HIV-infected Thai MSM.

METHODOLOGY:

HBV-susceptible volunteers were offered hepatitis B vaccination at months zero, one, and six. We measured baseline (pre-vaccination) total serum IgG and IgG subclasses (all participants), baseline CD4 count, and plasma HIV-1 viral load (PVL) (HIV+ participants). HBV serologies were retested at 12 months. Serologic responses were compared between all groups in men receiving three vaccine doses.

RESULTS:

511/651 HIV-negative and 64/84 HIV-positive participants completed the three-dose series. Response rates in HIV-uninfected and -infected participants were 90.1% vs. 50.0% (p<0.0001). Median pre-vaccination IgG was higher among non-responders than responders overall (1238.9.0 vs. 1057.0mg/dL, p=0.003) and among HIV-infected participants (1534.0 vs. 1244.5mg/dL, p=0.005), but not significantly among HIV-uninfected participants (1105.5 vs. 1054.3mg/dL, p=0.96). Pre-vaccination IgG1 and IgG3 levels were higher among HIV-positive than HIV-negative participants (median 866.0 vs. 520.3, and 105.8 vs. 83.1mg/dL, respectively, p<0.0001). Among HIV-infected participants, median CD4 count in non-responders was 378 cells/μL vs. 431 cells/μL in responders (p=0.20). Median PVL in non-responders was 64,800 copies/mL vs. 15500 copies/mL in responders (p=0.04). Participants with pre-vaccination plasma IgG >1550mg/dL and PVL >10,000 copies/mL were almost always non-responsive (p<0.01).

CONCLUSIONS:

HIV infection was associated with poor vaccine responses. High plasma viral load, elevated pre-vaccination total serum IgG and elevated pre-vaccination IgG1 are associated with poorer response to vaccination among HIV-infected MSM. In this group, the combination of high PVL and pre-vaccination total IgG is highly predictive of vaccine failure.

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By:   Chonwattana W1, Raengsakulrach B1, Holtz TH2, Wasinrapee P1, Tongtoyai J1, Chaikummao S1, Pattanasin S1, McNicholl JM3, van Griensven F4, Curlin ME5.

• 1Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand.
• 2Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand; Division of HIV/AIDS Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
• 3Division of HIV/AIDS Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
• 4Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand; Thai Red Cross Society AIDS Research Center, Bangkok, Thailand.
• 5Thailand Ministry of Public Health-U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand; Division of HIV/AIDS Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA. Electronic address: vdu7@th.cdc.gov. 

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HIV Infection Is Associated with Poor Outcomes for Patients with Anal Cancer in the Highly Active Antiretroviral Therapy Era

HIV status may affect outcomes after definitive chemoradiotherapy for anal cancer.

Here, we report a large series in the highly active antiretroviral therapy era comparing outcomes between HIV-positive and HIV-negative patients with anal cancer.

This was a retrospective chart review.

The study was conducted at an outpatient oncology clinic at large academic center.

A total of 107 patients were reviewed, 39 HIV positive and 68 HIV negative. All of the patients underwent definitive chemoradiation for anal cancer.

Data on patient characteristics, treatment, toxicity, and outcomes were collected. Overall survival, colostomy-free survival, local recurrence-free survival, and distant metastasis-free survival were analyzed.

Median follow-up was 15 months. HIV-positive patients were younger (median, 52 vs 64 years; p < 0.001) and predominantly men (82% men vs 49% men; p = 0.001). There were no significant differences in T, N, or stage groups. HIV-positive patients had a significantly longer duration from biopsy to start of chemoradiation (mean number of days, 82 vs 54; p = 0.042). There were no differences in rates of acute toxicities including diarrhea, fatigue, or dermatitis. HIV-positive patients had significantly higher rates of hospitalization (33% vs 15%; p = 0.024). The 3-year overall survival rate was 42% in HIV-positive and 76% in HIV-negative patients (p = 0.037; HR, 2.335 (95% CI, 1.032-5.283)). Three-year colostomy-free survival was 67% in HIV-positive and 88% in HIV-negative patients (p = 0.036; HR, 3.231 (95% CI, 1.014-10.299)). Differences in overall survival rates were not significant on multivariate analysis.

This study was limited by its retrospective design and small patient numbers.

In this cohort, HIV-positive patients had significantly worse overall and colostomy-free survival rates than HIV-negative patients. However, differences in survival were not significant on multivariate analysis. Additional studies are necessary to establish the etiology of this difference.

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By: Grew D1, Bitterman D, Leichman CG, Leichman L, Sanfilippo N, Moore HG, Du K.

• 1 Department of Radiation Oncology, New York University Langone Medical Center, New York, New York 2 Division of Hematology and Oncology, New York University Langone Medical Center, New York, New York 3 Department of Surgery, New York University Langone Medical Center, New York, New York.

 

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Ongoing Life Stressors & Suicidal Ideation among HIV-Infected Adults with Depression

Suicidal ideation is the most proximal risk factor for suicide and can indicate extreme psychological distress; identification of its predictors is important for possible intervention. Depression and stressful or traumatic life events (STLEs), which are more common among HIV-infected individuals than the general population, may serve as triggers for suicidal thoughts.

A randomized controlled trial testing the effect of evidence-based decision support for depression treatment on antiretroviral adherence (the SLAM DUNC study) included monthly assessments of incident STLEs, and quarterly assessments of suicidal ideation (SI). We examined the association between STLEs and SI during up to one year of follow-up among 289 Southeastern US-based participants active in the study between 7/1/2011 and 4/1/2014, accounting for time-varying confounding by depressive severity with the use of marginal structural models.

Participants were mostly male (70%) and black (62%), with a median age of 45 years, and experienced a mean of 2.36 total STLEs (range: 0-12) and 0.48 severe STLEs (range: 0-3) per month. Every additional STLE was associated with an increase in SI prevalence of 7% (prevalence ratio (PR) (95% confidence interval (CI)): 1.07 (1.00, 1.14)), and every additional severe STLE with an increase in SI prevalence of 19% (RR (95% CI): 1.19 (1.00, 1.42)).

There was a substantial amount of missing data and the exposures and outcomes were obtained via self-report; methods were tailored to address these potential limitations.

STLEs were associated with increased SI prevalence, which is an important risk factor for suicide attempts and completions.

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By: O'Donnell JK1, Gaynes BN2, Cole SR3, Edmonds A3, Thielman NM4, Quinlivan EB5, Shirey K6, Heine AD7, Modi R8, Pence BW3.

• 1University of North Carolina at Chapel Hill, Department of Epidemiology, United States. Electronic address: julie.k.odonnell@gmail.com.
• 2University of North Carolina at Chapel Hill School of Medicine, Department of Psychiatry, United States.
• 3University of North Carolina at Chapel Hill, Department of Epidemiology, United States.
• 4Duke University, Center for Health Policy, Duke Global Health Institute, United States.
• 5University of North Carolina at Chapel Hill, Institute for Global Health, Infectious Diseases and Center for AIDS Research, United States.
• 6Duke University School of Medicine, Department of Psychiatry, United States.
• 7University of North Carolina at Chapel Hill, Institute for Global Health and Infectious Diseases, United States.
• 8University of Alabama at Birmingham, Division of Infectious Diseases, United States. 

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First Visit Basics for HIV-Infected Patients: A Guide for Primary Care Providers

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Syphilis? An Unusual Cause of Surgical Emergency in a Human Immunodeficiency Virus-Infected Man

Below:  Histology slides of a fungating mass consistent with a rarely encountered presentation of Treponema pallidum infection in the anus. (A) A hematoxylin and eosin (H&E)-stained section shows a polypoid lesion composed of hyperplastic squamous epithelium overlying inflamed stroma (20×). (B) Higher power demonstrates a proliferation of blood vessels and dense inflammation (H&E stain, magnification ×100). (C and D) Swollen endothelial cells and thickened vessel walls are characteristic of, but not specific for, syphilis. The surrounding inflammation has a prominent plasma cell component (H&E stain, magnification ×400).

We report on a human immunodeficiency virus-infected man undergoing urgent anorectal surgery, with multi-centimeter fungating masses discovered inside the anus. Initial pathology was inconclusive. After the patient developed a disseminated rash postoperatively determined to be secondary syphilis, the anorectal pathology was reviewed and Treponema pallidum DNA was amplified by polymerase chain reaction from the mass.

A 43-year-old man presented to his human immunodeficiency virus (HIV) primary care provider reporting 2 weeks of worsening rectal pain and red blood in the toilet bowl. Four days after his symptoms started, he was seen by another provider, who visualized external hemorrhoids and prescribed symptomatic treatment. Eleven days later, his rectal pain was so severe that he could not sit in a chair, and he had severe pain with coughing, as well as difficulty voiding urine. He noted milky-pink discharge per rectum, soft formed stools, and no further bleeding. He had received a new diagnosis of HIV 4 months prior, with initial CD4 T-cell count of 567 cells/mL and HIV-1 viral load of 59 000 copies/mL. Other than experiencing symptoms consistent with acute retroviral syndrome approximately 2 years prior, he had no other medical concerns except essential hypertension. He smoked and drank moderately. He reported being sexually active with a single male partner for the last 2 years with last condomless receptive anal intercourse 2 weeks prior. Two months previously, a syphilis immunoglobulin (Ig)G enzyme immunoassay (EIA) test was negative, as were serologic tests for hepatitis A, B, and C. Current medications included amlodipine and Stribild (elvitegravir/cobicistat/emtricitabine/tenofovir), the latter begun 5 weeks previously. On exam, he was afebrile but appeared highly uncomfortable. His abdominal exam was normal and there was no inguinal lymphadenopathy. External rectal exam revealed erythema and induration in an area of 3 × 4 cm from the anal verge onto the right buttock, an external hemorrhoid, and a possible fissure. Rectal exam and anoscopy could not be performed due to pain. Laboratory investigations included normal complete blood count and liver function tests. Plasma HIV-1 viral load was 67 copies/mL. A rectal swab for Chlamydia trachomatisand Neisseria gonorrhoeae was negative by nucleic acid amplification. 

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Life Expectancy of HIV-Positive Individuals on Combination Antiretroviral Therapy in Canada

Below:  Life expectancy estimates at age 20 years, showing unadjusted and adjusted values, by clinical and sociodemographic characteristics at baseline

9997 individuals contributed 49,589 person-years and 830 deaths for a crude mortality rate of 16.7 [standard error (SE) 0.6] per 1000 person-years. When assigning death to 30 % of participants lost to follow-up, we estimated 1170 deaths and a mortality rate of 23.6 [SE 0.7] per 1000 person-years. The crude overall life expectancy at age 20 was 45.2 [SE 0.7] and 37.5 [SE 0.6] years after adjusting for LTFU. In the LTFU-adjusted analysis, lower life expectancy at age 20 was observed for women compared to men (32.4 [SE 1.1] vs. 39.2 [SE 0.7] years), for participants with injection drug use (IDU) history compared to those without IDU history (23.9 [SE 1.0] vs. 52.3 [SE 0.8] years), for participants reporting Aboriginal ancestry compared to those with no Aboriginal ancestry (17.7 [SE 1.5] vs. 51.2 [SE 1.0] years), and for participants with CD4 count <350 cells/μL compared to CD4 count ≥350 cells/μL at treatment initiation (36.3 [SE 0.7] vs. 43.5 [SE 1.3] years). Life expectancy at age 20 in the calendar period 2000–2003 was lower than in periods 2004–2007 and 2008–2012 in the LTFU-adjusted analyses (30.8 [SE 0.9] vs. 38.6 [SE 1.0] and 54.2 [SE 1.4]).

Life expectancy and mortality for HIV-positive individuals receiving ART differ by calendar period and patient characteristics at treatment initiation. Failure to consider LTFU may result in underestimation of mortality rates and overestimation of life expectancy.

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