Syphilitic hepatitis and neurosyphilis: an observational study of Danish HIV-infected individuals during a 13-year period.

OBJECTIVE: Syphilis is an STI that potentially affects any organ. Syphilitic hepatitis and neurosyphilis have been reported in both HIV-uninfected and HIV-infected individuals. The aim of this study was to investigate syphilitic hepatitis and neurosyphilis among HIV-infected individuals during a 13-year period. METHODS: This retrospective study included all HIV-infected individuals ≥18 years diagnosed with syphilis between 1 May 2004 and 31 December 2016 in Copenhagen, Denmark. We used the unique 10-digit personal identification number assigned to all individuals in Denmark to link data from two nationwide registers to identify the patients. Patient files were revised to obtain clinical and laboratory data. RESULTS: A total of 509 episodes of syphilis were diagnosed in 427 HIV-infected individuals attending three hospitals in Copenhagen, Denmark. The majority of the patients were men (99.5%), and the majority of men were men who have sex with men (96%). Twenty-seven patients (6%) met the criteria for neurosyphilis, and the neurological symptoms included ocular and auditory abnormalities, headache, paraesthesia, vertigo, facial paresis, motor weakness and unexplained pain in the legs. The patients with neurosyphilis were diagnosed in the secondary stage (84%) and in the early latent (8%) or late latent (8%) stage. Among the patients tested for liver affection, 41% met the criteria for syphilitic hepatitis. The patients with syphilitic hepatitis were diagnosed in the secondary stage (82%), primary stage (10%), and in the early latent (5%) or late latent (3%) stage. CONCLUSIONS: The study emphasises that patients with syphilis, also those seen at STI clinics, should undergo a thorough clinical examination and questioning to reveal neurological symptoms. Identification of patients with neurosyphilis is crucial since these patients undergo a different treatment. The study also emphasises that syphilis should be considered as a diagnosis in sexually active patients with liver .

Trends in human immunodeficiency virus diagnoses among men who have sex with men in North America, Western Europe, and Australia, 2000-2014.

PURPOSE: The aim of the article was to investigate recent trends in human immunodeficiency virus (HIV) diagnosis rates among men who have sex with men (MSM) in high-income countries in North America, Western Europe, and Australia. METHODS: Data on annual rates of HIV diagnoses among MSM aged 15 to 65 years from 2000 to 2014 were collected from 13 high-income countries. Joinpoint regression software was used to empirically determine country-specific trend periods. Trends in HIV diagnosis rates and in the proportion of diagnoses occurring in young MSM aged 15 to 24 years were analyzed using Poisson regression and log-binomial regression, respectively. RESULTS: Six countries experienced an increasing trend from 2000 to 2007-08 followed by either a stable or declining trend through 2014. Five countries had recently increasing trends, and two countries had one stable trend from 2000 to 2014. All 13 countries experienced increases in the proportion of diagnoses occurring in young MSM. CONCLUSIONS: Since 2008, half of the 13 high-income countries examined experienced stable or decreasing trends. Still, some countries continue to experience increasing HIV trends, and young MSM are increasingly represented among new diagnoses. Efforts to support early sexual health promotion, reduce barriers to pre-exposure prophylaxis, and improve care engagement for young MSM are critical to addressing current HIV trends.

Characterisation of HIV-1 transmission clusters and drug-resistant mutations in Denmark, 2004 to 2016.

This study describes the prevalence of human immunodeficiency virus (HIV) drug resistance mutations among 1,815 patients in Denmark from 2004 to 2016 and characterises transmission clusters. POL sequences were analysed for subtype, drug resistance mutations and phylogenetic relationship. The prevalence of surveillance drug resistance mutations (SDRM) was 6.7%, while the prevalence of drug resistance mutations (DRM) with a clinical impact was 12.3%. We identified 197 transmission clusters with 706 patients. Patients 40 years or older were less likely to be members of a transmission cluster and patients in transmission clusters were less likely to be infected abroad. The proportion of late presenters (LP) was lower in active compared with inactive clusters. Large active clusters consisted of more men who have sex with men (MSM), had members more frequently infected in Denmark and contained a significantly lower proportion of LP and significantly fewer patients with DRM than small active clusters. Subtyping demonstrated that the Danish HIV epidemic is gradually becoming more composed of non-B subtypes/circulating recombinant forms. This study shows that active HIV-1 transmission has become increasingly MSM-dominated and that the recent increase in SDRM and DRM prevalence is not associated with more sustained transmission within identified transmission networks or clusters.

Undocumented migrant women in Denmark have inadequate access to pregnancy screening and have a higher prevalence Hepatitis B virus infection compared to documented migrants in Denmark: a prevalence study.

BACKGROUND: Pregnant residents of Denmark are tested by their GP for current infections with Hepatitis B virus (HBV), HIV and syphilis through the Danish pregnancy screening programme to identify infections and initiate interventions to prevent mother-to-child transmission. Documented migrants (DM) have access to this screening but undocumented migrants (UM) do not, instead relying on ad-hoc care from clinics run by non-governmental organisations. We aimed to assess screening frequency in UM and to compare prevalence of infection in UM with DM. METHODS: We obtained individual-level information on HBV, HIV and syphilis testing frequency and results for pregnant women attending three clinics specialising in care for UM between August 2011 and August 2014. We obtained aggregate data on the prevalence of the three infections for documented migrants from the Danish pregnancy screening programme and birth register between January 2011 and January 2014. Planned abortions were excluded from the study. We described demographic features of pregnant UM and estimated the screening frequency for HIV, HBV and syphilis. We compared prevalence of current infections in UM and DM by calculating standardised prevalence ratios (SPR). RESULTS: The three UM clinics registered 219 pregnancies qualifying for screening. Overall 43, 58 and 60 % of pregnant UM had a test result recorded for HBV, Syphilis and HIV respectively, compared to >99 % in the general Danish population including DM. The prevalence of HBV was higher in UM than in DM (SPR: 2.4; 95 % CI: 1.1-5.3). The SPR of 2 (95 % CI: 0.5-8.0) for HIV was not statistically significant, potentially due to small sample size of UM. None of the pregnant UM tested positive for Syphilis. CONCLUSIONS: Pregnant UM have a poorer chance of being tested for HIV, HBV and syphilis, despite having a higher prevalence of HBV than DM. We recommend giving systematic access to routine pregnancy screening to all UM to prevent mother-to-child transmission and to address the observed health care inequity.

Should travellers to rabies-endemic countries be pre-exposure vaccinated? An assessment of post-exposure prophylaxis and pre-exposure prophylaxis given to Danes travelling to rabies-endemic countries 2000-12.

BACKGROUND: Since 2000, a steady increase of vaccines used for both rabies Post-exposure prophylaxis (PEP) and rabies Pre-exposure prophylaxis (PrEP) given to Danish travellers was observed. This study aims to evaluate whether the increase of PEP and PrEP was due to increased travelling, increased awareness of the need for PrEP, or more animal bites per travel, leading to more PEP being administered, in order to assess the need for changing the recommendations. We also described in which countries Danish travelers most frequently reported possible exposure to rabies, and evaluated the timeliness of rabies PEP, including rabies immunoglobulin (RIG). METHODS: We included all Danes reported to the National Database for Rabies Treatment as having started rabies PEP either abroad or after returning to Denmark, between 2000 and 2012. Data on the yearly number of Danish travelers from 2004 to 2012 to Thailand were collected to calculate the incidence of animal bites at this destination. We also included data on rabies vaccines sold for PrEP or for booster vaccination in Denmark. RESULTS: PEP after possible exposure to rabies abroad increased yearly by 8.8 %. Likewise vaccines sold for PrEP increased by 8.2% annually. The number of Danish travelers to Thailand increased by 7.3% per year, resulting in a stable incidence of animal bites per 100,000 travelers. Seventy-five % started PEP in the country of exposure, while only 10 % received RIG. CONCLUSIONS: The yearly increase in PEP and PrEP are parallel to the yearly increase in number of travelers, and can thus be explained by the increased rate of traveling, and not by a rise in awareness of rabies risk or more bites per traveler.Even short term travelers should be given the option of including PrEP in their travel immunisation program, as PEP and especially RIG is not always available in rabies-endemic countries.

Phylogenetics of the Danish HIV epidemic: the role of very late presenters in sustaining the epidemic.

BACKGROUND: In Denmark, 300 new individuals are diagnosed with HIV every year, despite decades of public health campaigns aimed to raise awareness of potential risk behavior for HIV transmission. It is important to identify the driving forces of the epidemic, to enable more targeted campaigns. The role of very late presenters (VLPs, defined by a CD4 T-cell count of <200 cells/µL at the time of diagnosis) in driving the epidemic is currently not known and was investigated in this study. METHODS: We performed phylogenetic analysis to identify potential transmission clusters. One thousand five hundred fifteen partial polymerase sequences from 1515 newly diagnosed individuals in Denmark for whom clinical and epidemiological data existed were included in the study. RESULTS: We identified 46 epidemic clusters, including a total of 502 patients. Median cluster size was 7 patients (range, 4-82). Of the 460 VLPs, 20% were included in a cluster. Through multivariate analysis, it was found that the clusters mainly consisted of Danish individuals with homosexual and intravenous drug use risk behavior, infected in Denmark with subtype B. Large clusters contained significantly more homosexual transmission events, characterized by primary infections, younger age, higher CD4 cell count, and lower viral load compared with the small clusters that contained mostly heterosexual transmission events and VLP. CONCLUSION: Danish HIV epidemic is driven mainly by younger homosexual men diagnosed during primary HIV infection. VLPs appear more frequently in smaller clusters or as single branches in the phylogeny. The VLP contribution is not of significant importance from a transmission standpoint.

[The economic impact of an epidemic of hepatitis A among men who have sex with men]. / Hvad koster et udbrud af hepatitis A blandt maend, der har sex med maend?

INTRODUCTION: In 2004 Denmark had an epidemic of hepatitis A among men who have sex with men (MSM). We estimate the size and the economic impact of the epidemic and discuss possibilities to prevent new epidemics. MATERIALS AND METHODS: The size of the outbreak was estimated from notifications received by the Department of Epidemiology and the number of hepatitis A IgM positive specimens sent to the Department of Virology at Statens Serum Institut. The economical impact was estimated according to data on cost of illness from the National Board of Health and the results of the outbreak investigation. RESULTS: In 2004, 165 cases of hepatitis A in men > 17 years of age were reported compared with a yearly average of 25 cases in the previous 10 years. The size of the outbreak, adjusted for an estimated underreporting of 60% was 220 cases. The economical impact was EUR 650,000, or EUR 3,000 per case. CONCLUSION: Outbreaks of hepatitis A among men who have sex with men are reported from major European cities almost on an annual basis. In the case of an outbreak, we suggest the response should include a targeted information campaign in the MSM media, hygiene control at gay saunas, sex clubs and darkrooms and a free vaccination offer to MSM with frequent partners at locations frequented by MSM. Before an outbreak we propose that vaccination against hepatitis A be recommended to MSM with frequent partners.

[Incidence of HIV/AIDS in Denmark, 1990-2005]. / Forekomsten af hiv/aids i Danmark i perioden 1990-2005.

INTRODUCTION: AIDS was defined in 1981, and HIV has spread globally since then. Most of the Danish AIDS patients have been men who have sex with men (MSM). After the introduction of highly active antiretroviral therapy in the mid-1990s, the incidence of AIDS in Denmark decreased dramatically. This article presents a status report on HIV and AIDS epidemiology in Denmark at the beginning of 2005. MATERIALS AND METHODS: Data from the national surveillance systems for AIDS, which has been notifiable since 1983, and HIV, which has been notifiable since August 1990, were used. RESULTS: During the period 1 August 1990-31 December 2004, HIV infection was reported in 4,254 persons, 3,076 men (72%) and 1,178 women (28%). MSM accounted for 39% of the cases (50% of the Danes and 14% of the immigrants). Heterosexual transmission accounted for 45% (32% of the Danes and 73% of the immigrants). Intravenous drug users (IDU) accounted for 9%. In 2004, 124 out of 190 Danes reported with HIV were MSM (65%). A total of 2,530 people were reported with AIDS. From the mid-1990s, the number of cases reported annually dropped. In 2004, 51 cases and 31 AIDS deaths were reported. CONCLUSION: It is estimated that well over 5,000 people are living with HIV in Denmark; about 550 of these have been diagnosed with AIDS. The decrease in the AIDS incidence and in the yearly AIDS mortality has not been mirrored by a decrease in the yearly number of reported HIV cases. Of special concern is the rise in the number of reported HIV cases among MSM during the last few years. This may reflect an increase in unsafe sex, partly due to a conception of HIV as a treatable, chronic disease. Prevention strategies, especially among MSM, are still needed.