Davorka Lukas

Prevalence of Sexually Transmitted Infections Among Men Who Have Sex with Men in Zagreb, Croatia

We used respondent-driven sampling among men who have sex with men (MSM) in Zagreb, Croatia in 2006 to investigate the prevalence of HIV, other sexually transmitted infections and sexual behaviours. We recruited 360 MSM. HIV infection was diagnosed in 4.5%. The seroprevalence of antibodies to viral pathogens was: herpes simplex virus type-2, 9.4%; hepatitis A, 14.2%; hepatitis C, 3.0%. Eighty percent of participants were susceptible to HBV infection (HBs antigen negative, and no antibodies to HBs and HBc antigen). Syphilis seroprevalence was 10.6%. Prevalence of Chlamydia and gonorrhoea was 9.0%, and 13.2%, respectively. Results indicate the need for interventions to diagnose, treat and prevent sexually transmitted infections among this population.

Prevalence of HIV and sexually transmitted infections and patterns of recent HIV testing among men who have sex with men in Zagreb, Croatia

Objective To determine the prevalence of HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM) in Zagreb, Croatia, and assess correlates of testing for HIV in the past 12 months. Methods The authors carried out a bio-behavioural survey using respondent-driven sampling (RDS) from September 2010 to February 2011. Participants completed a questionnaire and were asked to provide blood, urine, oropharyngeal and rectal swabs for the detection of infections. Data were analysed using RDS Analysis Tool 6.0.1 and STATA V.8.0. Results A total of 387 MSM were recruited at the University Hospital for Infectious Diseases. The age range of recruited men was 18–57 years. HIV prevalence was 2.8% (95% CI 1.1% to 5.1%) (3.6%, unadjusted), lower than that found in the first RDS survey carried out in 2006 (4.5%, 95% 2.2% to 7.3%) (4.9%, unadjusted). The seroprevalence of herpes virus type 2 was 5.9% (6.9, unadjusted) and that of syphilis measured by Treponema pallidum haemagglutination assay was 7.6% (6.7%, unadjusted). The authors found urethral and/or rectal infections with Chlamydia trachomatis in 7.2% (8.5%, unadjusted) of men and gonoccocal in 2.7% (2.1%, unadjusted). HIV testing in the past 12 months was reported by 32.7% (38.9%, unadjusted). In the multivariate analysis, significant correlates of recent HIV testing were having more than three partners in the past 12 months and the knowledge of HIV status of a regular partner. Conclusions The results indicate that there might have not been a progression of an HIV and STI epidemic in the past 5 years among MSM in Croatia. Prevention should expand by providing better uptake of HIV and STI testing services, thus enabling timely treatment.

Comparison of four international cardiovascular disease prediction models and the prevalence of eligibility for lipid lowering therapy in HIV infected patients on antiretroviral therapy.

Aim To compare four cardiovascular disease (CVD) risk models and to assess the prevalence of eligibility for lipid lowering therapy according to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, European AIDS Clinical Society Guidelines (EACS), and European Society of Cardiology and the European Atherosclerosis Society (ESC/EAS) guidelines for CVD prevention in HIV infected patients on antiretroviral therapy. Methods We performed a cross-sectional analysis of 254 consecutive HIV infected patients aged 40 to 79 years who received antiretroviral therapy for at least 12 months. The patients were examined at the HIV-treatment centers in Belgrade and Zagreb in the period February-April 2011. We compared the following four CVD risk models: the Framingham risk score (FRS), European Systematic Coronary Risk Evaluation Score (SCORE), the Data Collection on Adverse Effects of Anti-HIV Drugs study (DAD), and the Pooled Cohort Atherosclerotic CVD risk (ASCVD) equations. Results The prevalence of current smoking was 42.9%, hypertension 31.5%, and hypercholesterolemia (>6.2 mmol/L) 35.4%; 33.1% persons were overweight, 11.8% were obese, and 30.3% had metabolic syndrome. A high 5-year DAD CVD risk score (>5%) had substantial agreement with the elevated (≥7.5%) 10-year ASCVD risk equation score (kappa = 0.63). 21.3% persons were eligible for statin therapy according to EACS (95% confidence intervals [CI], 16.3% to 27.4%), 25.6% according to ESC/EAS (95% CI, 20.2% to 31.9%), and 37.9% according to ACC/AHA guidelines (95% CI, 31.6 to 44.6%). Conclusion In our sample, agreement between the high DAD CVD risk score and other CVD high risk scores was not very good. The ACC/AHA guidelines would recommend statins more often than ESC/EAS and EACS guidelines. Current recommendations on treatment of dyslipidemia should be applied with caution in the HIV infected population.

Meningitis and radiculomyelitis caused by Angiostrongylus cantonensis.

To the Editor: Angiostrongylus cantonensis infection is endemic in regions such as Southeast Asia, China, the Pacific Basin, and the Caribbean, but international travel has spread the disease elsewhere, including Europe (1–10). Dissemination of the parasite to many regions has also occurred because of the ship-borne international migration of rats and the diversity of potential intermediate hosts. The target organ in humans is the central nervous system in which an eosinophilic reaction develops in response to dying larvae. We report a case of eosinophilic meningitis and lumbosacral myeloradiculopathy caused by A. cantonensis and present a review of cases of A. cantonensis infections from Europe. A 47-year-old merchant seaman was admitted to the University Hospital of Infectious Diseases, Zagreb, Croatia, in March, 2006 on the 17th day of illness because of fever, headache, vomiting, and constipation. At the end of the first week of illness, paresthesias developed in his feet; on the 10th day of illness, he also noticed difficulties with urination. He had returned from a 1-month trip to Southeast Asia (Malaysia and Singapore) 35 days before the onset of symptoms and recalled eating vegetables and salads. He also consumed shrimp, but he believed that they were from salt water. On physical examination, we noticed increased muscle tone, tremor of the tongue and upper limbs, and decreased deep tendon reflexes of the lower limbs. He experienced urinary retention, and catheterization was required. Saddle anesthesia was observed. There was no neck stiffness, and the results of the rest of the physical examination were normal. His blood leukocyte count was 11.5 × 109/L with 80% neutrophils, 12% lymphocytes, 4% monocytes, 2% basophils, and 2% eosinophils. Cerebrospinal fluid (CSF) analysis showed 320 cells/μL with 6.5% eosinophils (21 eosinophils/μL). Results of CSF testing by PCR for herpes simplex virus 1 (HSV-1) and HSV-2 DNA were negative, as were cultures for bacteria, mycobacteria, and fungi. Results of serum and CSF antibody tests for Borrelia burgdorferi, Treponema pallidum, HSV-1, HSV-2, tick-borne encephalitis virus, Toxoplasma gondii, Taenia solium, Toxocara spp., and Trichinella spp. were also negative. Results of stool examination for Ascaris lumbricoides, Trichuris trichiura, Taenia spp., Giardia intestinalis, Strongyloides spp., and Entamoeba histolytica were negative. The patient was also negative for HIV by ELISA. Magnetic resonance imaging scans of the brain and spine were unremarkable. A. cantonensis infection was diagnosed by immunoblot testing at the Department of Helminthology, Faculty of Tropical Medicine, Mahidol University, Bangkok. Antibodies against A. cantonensis 31-kDa antigen were detected in serum and CSF of the patient; antibodies against Gnathostoma spinigerum were not detected. Treatment was symptomatic; to lessen the headache, 4 lumbar punctures were performed. After 1 month, the patient’s general condition was greatly improved; however, minor symptoms such as diminished concentration, slow thinking, and mild headache persisted. Urinary retention lasted for 38 days, and the patient had occasional mild headaches and paresthesia in his feet for the next 5 months. Because large numbers of persons from Europe travel to destinations where angiostrongyliasis is endemic, it is somewhat surprising that the infection has been rarely described in Europe. In a Google and Medline Internet literature search, we identified 9 additional case reports and 1 report on a cluster of 5 A. cantonensis infections. The first report was in a 14-month-old child born in Tahiti who became ill in France in 1988 (1). Eight cases, as did our case, involved travelers returning to Europe after a visit to disease-endemic areas (2–9) (Table). Not all cases were serologically confirmed, most likely because antibody tests for A. cantonensis infection have not been widely available. In a retrospective cohort study, 5 French policemen, who returned from French Polynesia with severe headache and blood eosinophilia, were believed to have eosinophilic meningitis caused by A. cantonensis (10). However, CSF examination was performed in only 1 patient, and none of the cases were serologically confirmed. Table Epidemiologic and clinical findings from 11 reported case-patients with Angiostrongylus cantonensis infection, Europe* Definitive diagnosis of angiostrongyliasis would require identification of larvae or young adults in human tissue, such as the brain, CSF, and eye chamber, which is rarely achieved. Thus, the diagnosis is usually made on the basis of serologic test results. Specific A. cantonensis antigens (29 kDa, 31 kDa, and 32 kDa) were identified; antibodies against these antigens can be detected by ELISA, dot-blot ELISA, or Western blot. In most patients, A. cantonensis causes a benign and self-limiting disease; treatment is usually symptomatic. Data are limited, but mostly favorable, on the use of steroids, albendazole, and mebendazole. However, the administration of antihelmintics without steroids is not recommended because such treatment might elicit deleterious inflammatory responses to dying worms within the nervous system or ocular structures. In summary, the presence of headache, fever, and paresthesias in travelers returning from disease-endemic areas should alert clinicians to the possibility of eosinophilic meningitis caused by A. cantonensis. With growing international travel, physicians may encounter A. cantonensis infection more frequently.

Frequency of HIV-1 viral load monitoring of patients initially successfully treated with combination antiretroviral therapy

Background Although considered an essential tool for monitoring the effect of combination antiretroviral treatment (CART), HIV-1 RNA (viral load, VL) testing is greatly influenced by cost and availability of resources. Objectives To examine whether HIV infected patients who were initially successfully treated with CART have less frequent monitoring of VL over time and whether CART failure and other HIV-disease and sociodemographic characteristics are associated with less frequent VL testing. Methods The study included patients who started CART in the period 1999–2004, were older than 18 years, CART naive, had two consecutive viral load measurements of <400 copies/ml after 5 months of treatment and had continuous CART during the first 15 months. The time between two consecutive visits (days) was the outcome and associated factors were assessed using linear mixed models. Results We analyzed a total of 128 patients with 1683 visits through December 2009. CART failure was observed in 31 (24%) patients. When adjusted for the follow-up time, the mean interval between two consecutive VL tests taken in patients before CART failure (155.2 days) was almost identical to the interval taken in patients who did not fail CART (155.3 days). On multivariable analysis, we found that the adjusted estimated time between visits was 150.9 days before 2003 and 177.6 in 2008/2009. A longer time between visits was observed in seafarers compared to non-seafarers; the mean difference was 30.7 days (95% CI, 14.0 to 47.4; p<0.001); and in individuals who lived more than 160 kilometers from the HIV treatment center (mean difference, 16 days, p = 0.010). Conclusions Less frequent monitoring of VL became common in recent years and was not associated with failure. We identified seafarers as a population with special needs for CART monitoring and delivery.

Cardiovascular markers of inflammation and serum lipid levels in HIV-infected patients with undetectable viraemia

Successfully treated HIV‐infected patients may still have an increased risk for cardiovascular morbidity and mortality, which might be related not only to traditional risks, but also to inflammation and dyslipidemia induced by HIV and/or antiretroviral therapy [ 1 , 2 ]. We examined the relationship of serum lipid levels with plasma biomarkers of inflammation using a composite inflammatory burden score (IBS) from the following seven markers of inflammation: CD40L, tPA, MCP‐1, IL‐8, IL‐6, hCRP and P‐selectin.

Prevalence and concordance of high cardiovascular disease scores in HIV/AIDS patients from Croatia and Serbia with four international algorithms

We evaluated cardiovascular risks in HIV‐infected patients from Croatia and Serbia and the eligibility for statin therapy as recommended by the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, European AIDS Clinical Society (EACS) Guidelines and European Society of Cardiology and the European Atherosclerosis Society (ESC/EAS) guidelines for cardiovascular disease (CVD) prevention [ 1 – 3 ].

Cardiovascular markers of inflammation and serum lipid levels in HIV-infected patients with undetectable viremia

Patients successfully treated for HIV infection still have an increased risk for cardiovascular morbidity and mortality, which might be related not only to traditional risks, but also to inflammation and dyslipidemia. We examined the relationship of serum lipid levels with plasma biomarkers of inflammation using a composite inflammatory burden score (IBS) based on individual (>75th percentile) measurements from the following seven markers: CD40L, tPA, MCP-1, IL-8, IL-6, hCRP and P-selectin. IBS was categorized as 0 (none of the biomarkers >75th percentile), 1, 2 and 3 or more scores. Correlations between the IBS and lipid parameters were examined by ordered logistic regression proportional odds models to estimate the odds of more elevated biomarkers. 181 male patients with undetectable HIV-viremia were included into the study. In the multivariate model, a one-unit increase (mmol/L) of total cholesterol and triglycerides was associated with a 1.41-fold (95% CI, 1.13–1.76) and 1.37-fold (95% CI, 1.18–1.60) increased odds of having a greater IBS, respectively. Those with an IBS score ≥1 compared to none had 2.14 (95% CI, 1.43–3.20) higher odds of having a one-unit increased total cholesterol/HDL-cholesterol ratio. In successfully treated HIV-infected persons dyslipidemia was associated with inflammation.