Vassilios Paparizos

HIV-1-related Hodgkin lymphoma in the era of combination antiretroviral therapy

The risk of Hodgkin lymphoma (HL) is increased in patients infected with HIV-1. We studied the incidence and outcomes of HL, and compared CD4⁺ T-cell trajectories in HL patients and controls matched for duration of combination antiretroviral therapy (cART). A total of 40 168 adult HIV-1-infected patients (median age, 36 years; 70% male; median CD4 cell count, 234 cells/μL) from 16 European cohorts were observed during 159 133 person-years; 78 patients developed HL. The incidence was 49.0 (95% confidence interval [CI], 39.3-61.2) per 100,000 person-years, and similar on cART and not on cART (P = .96). The risk of HL declined as the most recent (time-updated) CD4 count increased: the adjusted hazard ratio comparing more than 350 with less than 50 cells/μL was 0.27 (95% CI, 0.08-0.86). Sixty-one HL cases diagnosed on cART were matched to 1652 controls: during the year before diagnosis, cases lost 98 CD4 cells (95% CI, -159 to -36 cells), whereas controls gained 35 cells (95% CI, 24-46 cells; P < .0001). The incidence of HL is not reduced by cART, and patients whose CD4 cell counts decline despite suppression of HIV-1 replication on cART may harbor HL.

Immune response to hepatitis A vaccination in HIV-infected men in Greece

HIV-infected patients are at increased risk for acquiring hepatitis A virus (HAV) infection. We evaluated the seroconversion rate (anti-HAV antibodies ≥ 20 mIU/ml) and the geometric mean antibody titres (GMTs) in a group of 351 HIV infected men, who had received two doses of a hepatitis A vaccine. We analysed blood samples collected at one, six, 12 and 18 months following the administration of the second dose of the vaccine. The seroconversion rate one month after the second dose of the vaccine was 74.4% (260/351). At month 18 after the end of vaccination, 56.1 % of the subjects remained seropositive. GMTs were 315, 203,153 and 126 mIU/ml at months 1,6, 12, and 18, respectively. Logistic regression revealed that the CD4 count is the only factor affecting response to vaccination (P = 0.019). A higher response rate and higher GMTs were observed in patients with CD4 counts ≥500 cells/mm3 (76.6%) than in patients with CD4 counts 200–499 cells/mm3. In conclusion, even in patients with near-normal CD4 counts, the response to the hepatitis A vaccine is impaired.

Incidence determinants of gonorrhea, chlamydial genital infection, syphilis and chancroid in attendees at a sexually transmitted disease clinic in Athens, Greece

Objective  To determine the specific impact on the incidence rate of some demographic and behavioral characteristics in outpatients with four bacterial sexually transmitted diseases (STDs).

Determinants of genital wart case detection rates among STD clinic attendees in Athens, Greece

Background and objective  To report significant sociodemographic and behavioral outpatient characteristics associated with the diagnosis of genital warts.

Early syphilis affects markers of HIV infection

The objective of this study was to investigate if early syphilis infection affects markers of HIV infection; CD4 T cells and viral load (VL). A retrospective study was performed on 160 HIV-positive patients (111 receiving antiretroviral therapy [ART] and 49 without ART). Early syphilis diagnosis was made in HIV patients during their follow-up at the HIV/AIDS Unit at a Greek Dermatology and Venereology Unit. The patients’ blood tests were available at the time of diagnosis, as well as before and 12 weeks after early syphilis diagnosis. CD4 T cell counts and VL levels were measured. It was found that syphilis infection had a negative impact on the CD4 T cell counts in both groups, with reduced CD4 T cell counts observed in 84.6% (99/111) and 79.5% (39/49) of patients receiving and not receiving ART, respectively. After treatment for syphilis, CD4 T cell counts returned to pre-treatment levels in most patients, especially those receiving ART. There was a slight and transient VL increase. Patients receiving ART had a 27% increase in VL, compared to 71.4% among patients not receiving ART. Although the VL increase was slight (41–14,000 copies/ml) in the group under treatment, 4–5% (5/111) patients did not return to pre-treatment levels. Moreover, viral mutations associated with treatment resistance were identified in these patients. Early syphilis accelerates and complicates the progression of HIV infection. Early diagnosis and treatment of syphilis may prevent infection-associated complications in most instances. Consequently, prevention of syphilis and other sexually transmitted infections is of great importance for patients infected with HIV.

The Influence of a HAART regimen on the expression of HIV-associated Kaposi sarcoma.

To the Editor: The wide use of highly active antiretroviral therapy (HAART) based on HIV-1 protease inhibitors (PIs) has resulted in a steady decline in the incidence of Kaposi sarcoma (KS) and tumor regression in individual cases. Conversely, nonnucleoside reverse transcriptase inhibitor (NNRTI)–based HAART regimens have been implicated in KS relapse. In this cross-sectional study, the risk of switching from PIs to NNRTIs in patients with an ongoing or past history of KS has been epidemiologically approached in a study population of 45 patients: 3 women and 42 male homosexuals. Twenty-one were exposed for various reasons to NNRTIs after a previous exposure to PIs. The remaining 24 received solely PIs. Exposure has been estimated in months. The CD4 count (cells/mm) and viral load have also been evaluated (Table 1). Statistical analysis was carried out using 1-way analysis of variance and the Bonferroni P value for paired differences. Of the total KS cases (n = 55, 1996 to date) in the study, 8 patients with KS who discontinued treatment and 2 patients treated with triple-nucleoside reverse transcriptase (NRTI) therapy are not included. There was not any relapse or new case of KS in patients on PIs (n = 724 total PI-exposed population). It is of interest that of the 7 cases of KS expression in patients on NNRTIs, 4 were the first expression of KS after switching from PIs to NNRTIs and 3 were relapses. Thus, in the overall population exposed to NNRTIs (n = 604), the empiric probability for a first tumor manifestation was 0.7% (4 of 604 patients); conversely, that for a relapse based on the grounds of preexisting KS history, was 17.6% (3 of 17 patients, 95% confidence interval [CI]: 3.8 to 43.4). Thus, the probability of relapse was found to be much higher than that of new expression of KS (Fisher exact test, P = 0.0003; odds ratio [OR] = 37.5; 95% CI: 5.9 to 220). Overall KS was expressed within 25.7 ± 23.1 (6 to 60) months. Statistical analysis did not allocate any other risk-related parameter (see Table 1). Age, duration of exposure to PIs, and CD4 cells/mm did not differ among the 3 groups. Both NNRTI-treated patient groups had a longer overall antiretroviral treatment duration (follow-up) as compared with those treated only with PIs. There was no difference in exposure solely to PIs and duration of NNRTI treatment, however. In agreement with previous case report studies, relapse and any new expression of KS was found to be unrelated to immunologic or virologic failure of NNRTI-based HAART. Conversely, PIs have direct antiangiogenic, anti-KS, and antitumor effects. Withdrawal of PIs and switching to NNRTIs is a potentially major risk factor, especially on the grounds of past KS history, and should be carried out with caution.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

Background We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America. Methods We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs). Results We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions. Conclusions Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Adherence to hepatitis A virus vaccination in HIV-infected men who have sex with men.

Although vaccination against hepatitis A virus (HAV) is essential for human immunodeficiency virus (HIV)-infected patients, the uptake of HAV vaccine is reported to be very low. From 2007 to 2012, 912 HIV-infected men in Athens, Greece were screened for exposure to HAV. Two doses of an HAV vaccine were recommended to 569 eligible patients. Reminder cards with scheduled vaccination visits were given to each patient. Among eligible patients, 62.2% (354/569) received both doses. Patients who were fully vaccinated compared with non-adherent patients were natives, older, had undetectable HIV viral load, higher CD4 T cell counts and lower nadir CD4 T cell counts. Multivariate logistic regression revealed that the patient’s country of origin (p = 0.024; OR = 2.712; 95% CI, 1.139–6.457), CD4 T cell count (p < 0.001) and nadir CD4 T cell count (p < 0.001) were factors directly associated with adherence. In conclusion, adherence to HAV vaccination was better than in previously published data. Because many of the factors related to vaccination completion are parameters of HIV infection, it appears that physician interest in HIV care and vaccination planning is crucial to enhancing vaccine uptake.

Evaluation of a convenient vaccination schedule against hepatitis B in HIV-patients with undetectable HIV viral load

Vaccination against hepatitis B virus (HBV) is recommended for all HIV-positive individuals but the standard schedule is not satisfactory. High or more doses have also been studied with variable results. We compared a vaccination schedule with a higher dose but fewer shots to the standard scheme (HBVaxPro 40 μg versus Engerix 20 μg at 0, 1, and 6 months). Of the 63 patients vaccinated with HBVaxPro 79%, 65% and 47% seroconverted at month 1, 12 and 24 after vaccination, respectively. A total of 137 patients received Engerix and showed lower response rates (68%, 53% and 38%, respectively). Anti-HBs titers in the Engerix group were also lower with a statistically significant difference. In patients younger than 55 years HBVaxPro was 3 times more likely to provoke a response compared with Engerix (OR = 3, p = 0.006). In conclusion, HBVaxPro 40 μg at 3 doses could be proposed as a more robust and acceptable alternative.

HPV vaccine acceptability in high-risk Greek men

ABSTRACT HPV is associated with malignancy in men, yet there is a lack of data on HPV knowledge, vaccine acceptability, and factors affecting vaccine acceptability in Greek men. This study aims to identify determinants of knowledge and willingness to vaccinate against HPV among high-risk Greek men. Men (n = 298) between the ages of 18 and 55 were enrolled from the STI and HIV clinics at “Andreas Syggros” Hospital in Athens, Greece from July-October 2015. Participants completed a survey on demographics, economic factors, sexual history, HPV knowledge, and vaccine acceptability. The majority of participants were younger than 40 (76.6%) and unmarried (84.6%). Our sample was 31.2% MSM (men who have sex with men), and 20.1% were HIV-positive. Most participants (>90%) were aware that HPV is highly prevalent in both men and women; however, fewer identified that HPV causes cancers in both sexes (68%) and that vaccination protects men and women (67%). Amongst participants, 76.7% were willing to vaccinate themselves against HPV, 71.4% an adolescent son, and 69.3% an adolescent daughter. HIV-positive men were more likely to be willing to vaccinate themselves (OR 2.83, p = .015), a son (OR 3.3, p = .015) or a daughter (3.01, p = .020). Higher income levels were associated with increased willingness to vaccinate oneself (OR 1.32, p = .027), a son (1.33, p = .032) or daughter (1.34, p = .027). Although there is a HPV knowledge gap, HPV vaccine acceptability is high despite lack of vaccine promotion to Greek men. Future studies should include lower-risk men to adequately inform public health efforts.