Agnès Libois

HIV and syphilis: when to perform a lumbar puncture?

Objectives: The objectives of this study were to determine predictive factors for neurosyphilis in HIV-infected patients with syphilis and optimize the use of lumbar puncture. Study Design: The authors reviewed 112 cases of HIV-infected patients with syphilis who underwent a lumbar puncture. Diagnosis of neurosyphilis was based on a cerebrospinal fluid white blood cells count ≥20/&mgr;L, and/or a reactive cerebrospinal fluid–Venereal Disease Research Laboratory, and/or a positive intrathecal T. pallidum antibody (ITPA) index. Results: Twenty-six of 112 had neurosyphilis. Neurologic manifestations and serum rapid plasma reagin (RPR) were associated with neurosyphilis (P = 0.036, P = 0.018, respectively). In multivariate analysis, log2RPR was still associated with neurosyphilis (P = 0.005). In patients without neurologic manifestations, the risk of neurosyphilis increases gradually with log2RPR. A serum RPR of 1/32 seems to be the best cutoff point to decide the performance or not of a lumbar puncture (sensitivity 100%, specificity 40%). Conclusion: In HIV-infected patients with syphilis, lumbar puncture could be restricted to those with neurologic manifestations or a serum RPR ≥1/32.

Prescription of Non-Occupational Post-Exposure HIV Prophylaxis by Emergency Physicians: An Analysis on Accuracy of Prescription and Compliance

We conducted a retrospective analysis of data from a prospective nPEP (non-Occupational Post Exposure Prophylaxis) registry based on patients consulting at one academic Emergency department located in Brussels, Belgium. We review here 1,357 cases consulting from January 2011 to December 2013.The objective of the study is to determine whether emergency physicians prescribe nPEP according to national guideline with support from IDS (infectious disease specialists). As this intervention has a high cost we wanted to verify correct allocation of treatment to high risk patients. Moreover we wanted to determine whether compliance to nPEP when prescribed by an Emergency Physician was different from literature reports. Finally we wanted to describe the population consulting for nPEP at our center. Emergency physicians prescribed nPEP more frequently in high risk exposures (98.6%) compared to intermediate risk exposures (53.2%); adequately allocating resources from a public health perspective. Appropriateness of prescription when evaluated according to nPEP Belgian guidelines was 98.8%.Compliance with nPEP prescribed by Emergency physicians was 60% in our study. Compliance was the highest in MSM (Men who have Sex with Men) while sexual assault victims showed the lowest compliance. Altogether this study suggests that Emergency physicians can safely and adequately prescribe nPEP when supported by a comprehensive guideline. Recognizing intrinsic differences within heterogeneous populations consulting for nPEP may improve compliance to this high-cost public health intervention.

Prolonged antiretroviral therapy is associated with fewer anal high-grade squamous intraepithelial lesions in HIV-positive MSM in a cross-sectional study

Objective HIV-positive men who have sex with men (MSM) are at increased risk of anal cancer. We evaluate the risk factors for anal high-grade squamous intraepithelial lesion (HSIL) (the precursor of anal cancer) in HIV-positive MSM. Methods In this cross-sectional study within a cohort, 320 HIV-positive MSM were screened by anal cytology followed by high-resolution anoscopy (HRA) in case of abnormal cytology. Risk factors for anal HSIL were analysed. Results Men were mostly middle-aged Caucasians with median CD4+ T lymphocytes of 638 cells/µL, 87% on combined antiretroviral therapy (cART) for a median of 5 years. 198 anal cytology samples were normal. In the 122 patients with abnormal cytology, HRA with biopsies were performed: 12% (n=15) normal, 36% (n=44) anal low-grade squamous intraepithelial lesion (LSIL) and 51% (n=63) anal HSIL. Comparing patients with or without anal HSIL (normal cytology or normal biopsy or LSIL), we found in multivariate analysis significantly fewer anal HSIL in patients with cART ≥24 months (OR 0.32 CI 95% 0.162 to 0.631, p=0.001). Conclusions Prolonged cART (≥24 months) is associated with fewer anal HSIL.

Treatment of anal dysplasia in HIV-positive men who have sex with men in a large AIDS reference centre

Objectives: Over the last few decades, incidence of anal cancer among HIV-positive men has been on the rise. In this context, programmes of screening and treatment of anal dysplasia which is a precursor of anal cancer have been developed. The aim of our study was to describe the efficiency, side effects and outcome of anal dysplasia treatment in a population of HIV-positive men who have sex with men (MSM). Methods: We performed a retrospective study of HIV-positive MSM who received treatment for anal dysplasia between May 2010 and February 2014 in the Saint-Pierre University Hospital, Brussels. The different treatments used were electrocautery (ECA), infrared coagulation (IRC), surgical treatment and imiquimod. Results: Seventy-three HIV-infected MSM were included in the study, counting 62% of HGAIN. Median age was 41 years. Eighty-one per cent were on HAART. Median CD4 cell count was 525 cell/mm³, and 65% had undetectable viral loads. A total of 139 therapeutic interventions were recorded during the study period, and two-thirds of the enrolled patients received more than one treatment. At 540 days of follow-up, the rate of treatment response was 62%. Fifty per cent of the persistent HGAIN were metachronous lesions. No severe adverse events were recorded but frequent treatment-associated discomfort was reported, such as pain, self-limited bleeding, infection and anal irritation. Conclusion: Treatment of anal dysplasia appears to be safe and to offer short-term efficiency. However, its long-term efficiency remains unknown, especially in the HIV-positive population in which spontaneous clearance is lower and rate of recurrence higher.

Adherence to HIV post-exposure prophylaxis: A multivariate regression analysis of a 5 years prospective cohort

BACKGROUND Non-occupational post-exposure prophylaxis (nPEP) is a recommended public health intervention after a sexual or percutaneous exposure to human immunodeficiency virus (HIV). METHODS We conducted a prospective observational study recording consultations for nPEP at a reference HIV center in Brussels, Belgium from January 2011 to December 2015. We recorded attendance to follow-up, reported completion of nPEP and pharmacy records to measure adherence. Multivariate logistic regressions were performed to identify independent risk factors for adherence to nPEP and attendance to first follow-up visit at the STI clinic. FINDINGS Among 1881 patients receiving nPEP, 66.4% had a documented completion of a 28-day course of nPEP and 87.3% attended their first follow-up clinic visit. MSM (OR, 1.40; 95%CI, 1.04-1.90), being a native Belgian (OR, 1.50; 95%CI, 1.18-1.90), older age (OR, 1.02; 95%CI, 1.01-1.04), being a sexual assault survivor (OR, 0.59; 95%CI, 0.38-0.91), having had a previous nPEP treatment (OR, 1.44; 95%CI, 1.02-2.02), consultation during daytime (OR, 1.35; 95%CI, 1.07-1.70) and benefitting from a health insurance (OR, 2.11; 95%CI, 1.58-2.89) were significant independent predictors for adherence to nPEP. Patients whose initial treatment was AZT/3TC/IDV/r had similar adherence than patients on d4T/3TC/LPV/r (OR, 0.898; 95%CI, 0.68-1.20). INTERPRETATION Multiple independent risk factors for nPEP retention into care and adherence are present at treatment initiation and might be targeted by tailored interventions. Sexual assault victims are overexposed to deleterious consequences of the lack of health insurance on compliance.

Prevalence of Mycoplasma genitalium in men with urethritis in a large public hospital in Brussels, Belgium: An observational, cross-sectional study

Background Mycoplasma genitalium (MG) is a cause of urethritis. While resistance to azithromycin is increasing, routine detection of MG is not performed in Belgium, where its prevalence is unknown. The aim of this study is to determine prevalence of MG in men with urethritis. Method and findings An “in-house” amplification assay detecting MG was performed on urine of men with complaints of urethritis who consulted the emergency unit or the Sexually Transmitted Infection clinic of our public hospital in Brussels. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) were tested on the same sample. A total of 187 men were tested. Prevalence of MG was 9% (95% Confidence Interval: 5 to 13.2%). CT was detected in 20%, NG in 22% and 56% of samples were negative for these three pathogens. Neither age, ethnic origin, sexual orientation nor HIV infection were associated with MG urethritis. Conclusion M. genitalium was identified in 9% of men with complaints of urethritis indicating that amplification assay detecting MG should be implemented in routine testing for those patients.

Belgian guidelines for non-occupational HIV post-exposure prophylaxis 2017

ABSTRACT We present the updated Belgian guidelines for the use of non-occupational HIV post-exposure prophylaxis (NONOPEP). This document is inspired by UK guidelines 2015, adapted to the Belgian situation and approved by all AIDS reference centers in Belgium. When recommended, NONOPEP should be initiated as soon as possible, preferably within 24 h of exposure but can be offered up to 72 h. The duration of NONOPEP should be 28 days. These current guidelines include epidemiologic estimations, which can be used to calculate the risk of infection after a potential exposure and help to decide whether or not to start prophylaxis. We review which medications to use in the context of the last Belgian NONOPEP convention, provide a checklist for initial assessment, and make recommendations for monitoring individuals receiving NONOPEP.

Hepatitis E virus (HEV): seroprevalence and HEV RNA detection in subjects attending a sexually transmitted infection clinic in Brussels, Belgium

Men who have sex with men (MSM) have an increased incidence of pathogens transmitted by the oro-fecal route. Hepatitis E virus (HEV) is an emerging cause of acute hepatitis and fecal shedding is observed during primary infection. We investigated whether MSM are at increased risk of HEV infection. Subjects who attended a sexually transmitted infection clinic in Brussels and had an HIV test performed between 1 June 2014 and 15 January 2016 were identified. A total of 576 samples were retrospectively screened for both total HEV IgG and HEV RNA. Samples positive for IgG were tested for IgM. MSM proportion was 31·1% (179/576). Overall HEV IgG prevalence was 9·03% (52/576) and was identical in MSM and heterosexual subjects. Among the IgG positive samples, 2/52 (3·84%) samples (both women) were positive for anti-HEV IgM. No sample was positive for HEV RNA. Age over 35 was the only risk factor significantly associated with HEV seropositivity (OR 2·07; 95% CI 1·16-3·67). In conclusion, MSM were not found to have an increased prevalence of HEV as previously reported in other European countries suggesting distinct dynamics of HEV infection in this group across Europe and increased age was associated with a higher risk of seropositivity.

Which empiric syndromic treatment for urethritis

Dear Editor, In the new European guideline on the management of non-gonococcal urethritis (NGU), it is recommended to confirm urethritis by urethral smear microscopy before treatment and to test male patients with urethritis for Mycoplasma genitalium when possible. The new preferred syndromic regimen for NGU is doxycycline 100mg twice daily for seven days. Second line includes azithromycin 500mg single dose, then 250mg for four days. Azithromycin 1 g is no longer recommended as first-line therapy because of the increased risk of inducing macrolide resistance of M. genitalium. However, in many settings, microscopy is not available to confirm urethritis and to exclude infection with Neisseria gonorrhoeae with a point-of-care diagnostic tool (e.g. Gram, methylene blue or gentian violet stain microscopy). As an example, in Belgium, only one centre performs microscopic examination at the sexually transmitted infection consultation in selected cases. A syndromic regimen is given at the first consultation (after specimen collection for laboratory testing) when symptoms are severe, purulent urethral discharge at exam is present or if there is a doubt about the compliance of the patient to return at the consultation. When a syndromic treatment is given and an infection with N. gonorrhoeae cannot be excluded, what is the best choice of treatment? This point is not clarified by this new European guideline on the management of NGU and will probably raise questions in many settings. Moreover, there is no FDA-approved test for M. genitalium, which is only routinely available in a few settings. The prevalence of M. genitalium in patients with NGU is estimated between 6 and 50%, and doxycycline is ineffective in more than 50%. Studies have shown an increase in macrolide resistance of M. genitalium and a decrease of microbiologic cure even after extended courses of azithromycin (five days) and after a single 2 g dose.