Risk factors for toxoplasmosis in people living with HIV in the Asia-Pacific region.

INTRODUCTION: Toxoplasma gondii can cause symptomatic toxoplasmosis in immunodeficient hosts, including in people living with human immunodeficiency virus (PLWH), mainly because of the reactivation of latent infection. We assessed the prevalence of toxoplasmosis and its associated risk factors in PLWH in the Asia-Pacific region using data from the TREAT Asia Human Immunodeficiency Virus (HIV) Observational Database (TAHOD) of the International Epidemiology Databases to Evaluate AIDS (IeDEA) Asia-Pacific. METHODS: This study included both retrospective and prospective cases of toxoplasmosis reported between 1997 and 2020. A matched case-control method was employed, where PLWH diagnosed with toxoplasmosis (cases) were each matched to two PLWH without a toxoplasmosis diagnosis (controls) from the same site. Sites without toxoplasmosis were excluded. Risk factors for toxoplasmosis were analyzed using conditional logistic regression. RESULTS: A total of 269/9576 (2.8%) PLWH were diagnosed with toxoplasmosis in 19 TAHOD sites. Of these, 227 (84%) were reported retrospectively and 42 (16%) were prospective diagnoses after cohort enrollment. At the time of toxoplasmosis diagnosis, the median age was 33 years (interquartile range 28-38), and 80% participants were male, 75% were not on antiretroviral therapy (ART). Excluding 63 out of 269 people without CD4 values, 192 (93.2%) had CD4 ≤200 cells/µL and 162 (78.6%) had CD4 ≤100 cells/µL. By employing 538 matched controls, we found that factors associated with toxoplasmosis included abstaining from ART (odds ratio [OR] 3.62, 95% CI 1.81-7.24), in comparison to receiving nucleoside reverse transcriptase inhibitors plus non-nucleoside reverse transcriptase inhibitors, HIV exposure through injection drug use (OR 2.27, 95% CI 1.15-4.47) as opposed to engaging in heterosexual intercourse and testing positive for hepatitis B virus surface antigen (OR 3.19, 95% CI 1.41-7.21). Toxoplasmosis was less likely with increasing CD4 counts (51-100 cells/µL: OR 0.41, 95% CI 0.18-0.96; 101-200 cells/µL: OR 0.14, 95% CI 0.06-0.34; >200 cells/µL: OR 0.02, 95% CI 0.01-0.06), when compared to CD4 ≤50 cells/µL. Moreover, the use of prophylactic cotrimoxazole was not associated with toxoplasmosis. CONCLUSIONS: Symptomatic toxoplasmosis is rare but still occurs in PLWH in the Asia-Pacific region, especially in the context of delayed diagnosis, causing advanced HIV disease. Immune reconstitution through early diagnosis and ART administration remains a priority in Asian PLWH.

Integrating Routine Hematological and Extended Inflammatory Parameters as a Novel Approach for Timely Diagnosis and Prognosis in Sepsis Management.

Sepsis is one of the major causes of morbidity and mortality in hospitals, especially in low- and middle-income countries, and represents a challenge to health care providers to carry out early detection, and accurate diagnosis and prognosis with cost-effective diagnostic tools. An observational prospective study was conducted from December 2021 to December 2022 to investigate the extended inflammatory parameters (EIPs) for sepsis management and analyze the survival of septic patients in the emergency unit, intensive care unit (ICU) and inpatient ward. Patients suspected of having sepsis underwent a sequential organ failure assessment (SOFA) evaluation and had blood drawn for complete blood counts (CBCs). Significant changes were observed in various CBC parameters and EIPs, and the sepsis group was followed up with for 30-day mortality. The study highlighted a significant difference yet strong discriminatory power to differentiate sepsis with an AUC of 0.924 against the non-sepsis group and an AUC of 0.991 against the healthy control group using combination of white blood cells and EIPs. Furthermore, the study showed good predictive ability for 30-day mortality with a hazard ratio of 2.311. In summary, this study provides evidence that the utilization of EIPs may be valuable in diagnosing and predicting patient outcomes, and thus will be beneficial for sepsis management in the hospital.

Virological failure and treatment switch after ART initiation among people living with HIV with and without routine viral load monitoring in Asia.

INTRODUCTION: Viral load (VL) testing is still challenging to monitor treatment responses of antiretroviral therapy (ART) for HIV treatment programme in Asia. We assessed the association between routine VL testing and virological failure (VF) and determine factors associated with switching to second-line regimen. METHODS: Among 21 sites from the TREAT Asia HIV Observational Database (TAHOD), people living with HIV (PLHIV) aged ≥18 years initiating ART from 2003 to 2021 were included. We calculated the average number of VL tests per patient per year between the date of ART initiation and the most recent visit. If the median average number of VL tests was ≥ 0.80 per patient per year, the site was classified as a routine VL site. A site with a median < 0.80 was classified into the non-routine VL sites. VF was defined as VL ≥1000 copies/ml during first-line therapy. Factors associated with VF were analysed using generalized estimating equations with Poisson distribution. RESULTS: Of 6277 PLHIV starting ART after 2003, 3030 (48%) were from 11 routine VL testing sites and 3247 (52%) were from 10 non-routine VL testing sites. The median follow-up was 9 years (IQR 5-13). The median age was 35 (30-42) years; 68% were male and 5729 (91%) started non-nucleoside reverse-transcriptase inhibitor-based regimen. The median pre-ART CD4 count in PLHIV from routine VL sites was lower compared to non-routine VL sites (144 vs. 156 cells/mm3 , p <0.001). Overall, 1021 subsequent VF at a rate of 2.15 (95% CI 2.02-2.29) per 100 person-years (PY). VF was more frequent at non-routine VL sites (adjusted incidence rate ratio 2.85 [95% CI 2.27-3.59]) compared to routine VL sites. Other factors associated with an increased rate of VF were age <50 years and CD4 count <350 cells/mm3 . A total of 817 (13%) patients switched to second-line regimen at a rate of 1.44 (95% CI 1.35-1.54) per 100 PY. PLHIV at routine VL monitoring sites were at higher risk of switching than those at non-routine VL sites (adjusted sub-hazard ratio 1.78 95% CI [1.17-2.71]). CONCLUSIONS: PLHIV from non-routine VL sites had a higher incidence of persistent VF and a low switching regimen rate, reflecting possible under-utilized VL testing.

Correlation Between Clinical Manifestation and Radiological Findings In Pulmonary Tuberculosis-Human Immunodeficiency Virus Coinfection Patients In Sanglah Hospital, Bali, Indonesia.

BACKGROUND: Tuberculosis (TB) mono-infection has radiological features and typical clinical manifestations that are easily recognized by clinicians. These radiological features and clinical manifestations are often found to show atypical features in subjects coinfected with Tuberculosis- Human Immunodeficiency Virus (HIV), making TB diagnosis and early management challenging to establish. OBJECTIVE: The aim of this study was to determine the relationship between the clinical and radiological presentation of pulmonary TB patients with HIV coinfection at the Central General Hospital Sanglah, Bali. METHODS: This research was an observational analytic study with a cross-sectional method. A total of 54 TB-HIV coinfected patients were analyzed to their sociodemographic characteristics, clinical manifestations and chest radiographic features. RESULTS: The majority of subjects were of productive age (26-61 years), male (64.8%) and belonged to the heterosexual group (90.7%). Weight loss (75.9%), cough (64.8%) and oral candidiasis (53.7%) are the most common clinical manifestations found in subjects, especially in subjects with CD4+ >200 cells/mm3. Atypical radiological features such as infiltration/consolidation (59.3%), fibrosis (16.7%) and hillar lymphadenopathy (14.8%) are the most commonly obtained radiological features of the subjects. From the results of the bivariate analysis, it was found that radiological features in the form of infiltration/consolidation were more commonly found in subjects with CD4+ <200 cells/mm3 (OR=1.254; 95% CI 1.059-1.568). CONCLUSION: Based on the research that has been done, it can be concluded that there are no typical radiological features and clinical manifestations in patients with TB-HIV infection.

Incidence, clearance, persistence and factors related with high-risk anal HPV persistence in South-East Asian MSM and transgender women.

OBJECTIVES: Persistent anal high-risk human papillomavirus (HR-HPV) infection is a major risk factor for anal cancer among MSM and transgender women (TGW). We aimed to estimate incidence, clearance, and persistence of anal HR-HPV in HIV-positive and HIV-negative MSM and TGW, and to assess factors for HR-HPV persistence. DESIGN: Prospective cohort study. METHODS: MSM and TGW aged at least 18 years, were enrolled from Indonesia, Malaysia, and Thailand, then followed up 6-monthly for 12 months. Anal swabs were collected at every visit for HR-HPV genotypes to define anal HR-HPV incidence, clearance, and persistence. Logistic regression was used to evaluate factors associated with HR-HPV persistence. RESULTS: Three hundred and twenty-five MSM and TGW were included in this study, of whom 72.3% were HIV-positive. The incidence of anal HR-HPV persistence was higher in HIV-positive than HIV-negative MSM participants (28.4/1000 vs. 13.9/1000 person-months). HIV-positive participants had HR-HPV lower clearance rate than HIV-negative participants (OR 0.3; 95% CI 0.1-0.7). The overall persistence of HR-HPV was 39.9% in HIV-positive and 22.8% HIV-negative participants. HPV-16 was the most persistent HR-HPV in both HIV-positive and HIV-negative participants. HIV infection (aOR 2.87; 95% CI 1.47-5.61), living in Kuala Lumpur (aOR 4.99; 95% CI 2.22-11.19) and Bali (aOR 3.39; 95% CI 1.07-10.75), being employed/freelance (aOR 3.99; 95% CI 1.48-10.77), and not being circumcised (aOR 2.29; 95% CI 1.07-4.88) were independently associated with anal HR-HPV persistence. CONCLUSION: HIV-positive MSM and TGW had higher risk of persistent anal HR-HPV infection. Prevention program should be made available and prioritized for HIV-positive MSM and TGW where resources are limited.

Management of Systemic Steroid in HIV Patient with Toxoplasma Papillitis.

BACKGROUND: Toxoplasmosis is a zoonotic disease caused by Toxoplasma gondii. Ocular manifestations are seen in both congenital and acquired toxoplasmosis. These can include focal inflammation within or around the optic nerve head (papillitis). Purpose of this study is evaluating the efficacy of systemic steroid in HIV patient with toxoplasma papillitis. CASE PRESENTATION: We present a case report of a male, 46 years old with a decrease of visual acuity on the right eye for three weeks before admission to the hospital. An ophthalmology examination showed visual acuity of the right eye 1/60, mild dilatation of the pupil and posterior synechiae, vitreous was hazy, and fundus examination showed optic nerve head not well demarcated and hyperaemic with the good retina and macula reflex. Laboratory examination showed reactive anti-Toxoplasma immunoglobulin G. Patient had been treated with antiretroviral and anti-Toxoplasma drugs, then he was given steroid 250 mg intravenously four times per day for three days and tapering off orally. Visual acuity on the right eye improve from 1/60 became 6/60 after use of steroid on the third day. DISCUSSION: Steroid can improve visual acuity for toxoplasma papillitis in this patient. But the long term and close follow up in steroid therapy is needed.

Dengue infection in international travellers visiting Bali, Indonesia.

Background: Dengue, an acute febrile illness caused by infection with dengue virus (DENV), is endemic in Bali, Indonesia. As one of the world's most popular tourist destinations, Bali is regularly visited by domestic and international travellers, who are prone to infection by endemic pathogens, including DENV. Currently, limited data are available on the characteristics of dengue in travellers visiting Bali. Information on the epidemiology and virological aspects of dengue in these tourists is important to gain a better understanding of the dengue disease in international travellers. Methods: We performed a prospective cross-sectional dengue study involving foreign travellers visiting Bali, Indonesia in the period of 2015-17. Patients presenting at Kasih Ibu Hospital with fever and clinical symptoms of dengue were asked to participate in the study. Clinical and laboratory assessments were performed and sera were collected for molecular analysis, which included DENV serotyping, genome sequencing and phylogenetic analysis. Results: Among the 201 patients recruited, dengue was confirmed in 133 (66.2%) of them, based on detection of NS1 antigen and/or viral RNA. Of these, 115 (86.5%) manifested dengue fever (DF) and 18 (13.5%) dengue haemorrhagic fever (DHF). The temporal predominance of infecting DENV serotype was DENV-2 (48.7%), followed by DENV-3 (36.1%), DENV-1 (9.2%) and DENV-4 (3.4%). Phylogenetic analysis of DENV based on envelope gene sequences revealed that the source of DENVs was local endemic viruses. Conclusion: Our study confirms that dengue is one of the causes of fever in travellers visiting Bali. Although it is a cause of significant morbidity, the majority of patients only experienced mild DF, with only a small proportion developing DHF. We revealed that DENVs isolated were autochthonous. Accurate diagnosis, preventive measures and continuous disease surveillance will be useful for better management of dengue infection in travellers.

Prevalence of and risk factors for anal high-risk HPV among HIV-negative and HIV-positive MSM and transgender women in three countries at South-East Asia.

This study aimed to assess the prevalence of and associated risk factors for anal high-risk human papillomavirus (hr-HPV) infection among men who have sex with men (MSM) and transgender women (TGW) in Indonesia, Thailand, and Malaysia.This was baseline data from a prospective cohort study with clinic sites in Jakarta and Bali (Indonesia), Bangkok (Thailand), and Kuala Lumpur (Malaysia).MSM and TGW aged 18 years and older from Indonesia, Thailand, and Malaysia were enrolled. Demographic and behavioral characteristics were assessed, and anal samples were collected for HPV genotyping. Multivariate logistic regression models were used to assess risk factors for anal hr-HPV overall and among HIV-positive participants.A total of 392 participants were enrolled, and 48 were TGW. As many as 245 were HIV-positive, and 78.0% of the participants were on combination antiretroviral therapy (cART). Median CD4 count was 439 cells/mm and 68.2% had undetectable HIV-RNA. HIV-positive participants had significantly more hr-HPV compared to HIV-negative participants (76.6% vs 53.5%, P < .001). HPV-16 was the most common high-risk type (20%), whereas HPV-33, -39, and -58 were significantly more common among HIV-positive participants. HIV-positive participant significantly associated with anal hr-HPV infection compared with HIV-negative (OR: 2.87, 95% CI: 1.76-4.70, P ≤ .001), whereas among HIV-positive participants transgender identity had lower prevalence of hr-HPV infection (OR: 0.42, 95% CI: 0.19-0.91, P = .03).High-risk HPV infection was very common among MSM and TGW in South-East Asia. Overall, HIV-infection, regardless of cART use and immune status, significantly increased the risk, while among HIV-positive participants transgender identity seemed to decrease the risk of anal hr-HPV.