Prevalence of syphilis, neurosyphilis and associated factors in a cross-sectional analysis of HIV infected patients attending Bugando Medical Centre, Mwanza, Tanzania.

BACKGROUND: HIV-syphilis co-infection can enhance the rapid progression of early or late latent syphilis to neurosyphilis and can cause catastrophic neurological complications. In studies in Mwanza, syphilis affects ~ 8% of healthy outpatients and studies done in the 1990s have suggested that up to 23.5% of HIV-syphilis co-infected patients also have neurosyphilis. METHODOLOGY: This was a cross sectional study in which adult HIV infected patients who were hospitalized or attending the outpatient Care and Treatment Clinic (CTC) were interviewed using a structured questionnaire and screened for syphilis using serum Treponema Pallidum Hemagglutination Assay (TPHA). Blood was also taken for CD4+ T cells and viral load. Those who were found to have syphilis underwent neurological examination for any neurologic deficit and were offered a lumbar puncture. RESULTS: The prevalence of syphilis in HIV infected patients was found to be 9.6%. The majority of patients were female (72.5%) and median age was 42 years [interquartile range, 32-50]. Most patients were on ART (99.4%). In the study population of 1748 participants, 9.6% were TPHA positive; the majority (89.2%) reported not knowing their syphilis status and not previously been treated. One hundred and forty-one participants with syphilis had neurological examinations performed. Four of these had abnormal findings that necessitated a lumbar puncture. Neurosyphilis was confirmed in one patient (0.7%). CONCLUSION: The high prevalence of syphilis in HIV infected patients indicates that there is a need to increase efforts in targeting this population to reduce sexually transmitted infections. Screening for syphilis should be done for all HIV patients given the high prevalence of the infection and the risk that aggressive forms of neurosyphilis can occur despite recovery of CD4+ T cell counts in untreated syphilis.

Schistosomiasis and HIV-1 viral load in HIV-infected outpatients with immunological failure in Tanzania: a case-control study.

BACKGROUND: Schistosoma sp. infection has been shown to interact with HIV-1 by modifying susceptibility to the virus and impacting AIDS outcome, but very little is known about the potential impact of Schistosoma sp. infection on the efficiency of antiretroviral treatment (ART) in HIV-1 infected individuals. One study suggested increased immunological failure in patients infected with schistosomes compared to those uninfected. To our knowledge, no report exists on the virological response to ART in schistosome-infected individuals. In addition, viral load in HIV-1 infected individuals changes over the course of the HIV infection. This study assessed the impact of HIV-1/Schistosoma sp. co-infections on viral load in people with immunological failure on ART, taking into account the duration of HIV-1 infection. METHODS: We enrolled HIV-1 infected Tanzanian adults over 18 years of age who had used first line ART for more than 6 months and were identified to have immunological failure by the WHO criteria (50% drop from peak CD4 count, or CD4 count equal to or below baseline after 6 months of ART, or CD4 count below 100cells/mm3 after 1 year of ART). Patients were also tested for schistosome infection by microscopy for ova in urine and stool and by circulating anodic antigen (CAA) levels in serum. The duration of HIV-1 infection was calculated using baseline CD4+ T-cell (CD4) counts determined at enrollment. Univariable and multivariable analyses were conducted to compare viral loads in schistosome infected and uninfected patients. RESULTS: A total of 188 patients were enrolled. After univariable analysis, female sex, lower peak CD4 counts, lower current CD4 counts, anemia, and shorter time infected with HIV-1 were all significantly associated with higher viral load. Schistosome infection was not associated with viral load even after adjusting for sex, current CD4 counts and duration of HIV-1 infection. CONCLUSIONS: The current study of HIV-infected patients with immunological failure on ART suggests that once ART is introduced, ART is the dominant driver of viral load and schistosome infection may no longer have an impact.

Decreased Sensitivity of Schistosoma sp. Egg Microscopy in Women and HIV-Infected Individuals.

It has been postulated that impaired host immunity due to HIV infection reduces parasite egg excretion. Schistosoma/HIV interactions have also been shown to differ by sex. We hypothesized that egg excretion would vary based on both HIV status and sex. We examined data from more than 1,700 participants in eight studies conducted in northwest Tanzania between 2010 and 2016. Schistosoma infection was defined by circulating anodic antigen (CAA) serum levels ≥ 30 pg/mL and/or egg positivity in either stool by Kato Katz method or urine by filtration. We used multivariable analyses to determine the impact of confounding factors such as sex, age, previous praziquantel treatment, and worm burden as measured by serum CAA level, on the relationship between egg excretion and HIV status. HIV-infected individuals were significantly less likely to excrete schistosome eggs than HIV-uninfected individuals, even after controlling for worm burden and sex (OR = 0.6 [0.4, 0.9], P = 0.005). Furthermore, after controlling for worm burden and HIV status, women had lower odds of egg excretion than men (OR = 0.4 [0.3, 0.5], P < 0.001). Sensitivity of egg microscopy was lower in HIV-infected women than HIV-uninfected men (41% versus 61%, P < 0.001), whereas sensitivity in women remained low in both groups (33% versus 37%, P = 0.664). Our study is the first to report that women with Schistosoma infection excrete fewer eggs than men for a given worm burden, regardless of HIV the status. These findings suggest that guidelines for use of microscopy to diagnose Schistosoma infections in HIV-infected individuals and in women merit reconsideration.

Increased hepatotoxicity among HIV-infected adults co-infected with Schistosoma mansoni in Tanzania: A cross-sectional study.

INTRODUCTION: Little is known about hepatotoxicity in patients with schistosome and HIV co-infections. Several studies have reported increased liver enzymes and bilirubin levels associated with schistosome infection. We investigated whether HIV-infected adults on antiretroviral therapy who had S. mansoni co-infection had a higher prevalence of hepatotoxicity than those without. METHODOLOGY/PRINCIPAL FINDINGS: We determined the presence and grade of hepatotoxicity among 305 HIV-infected outpatients who had been on medium-term (3-6 months) and long-term (>36 months) antiretroviral therapy in a region of northwest Tanzania where S. mansoni is hyperendemic. We used the AIDS Clinical Trial Group definition to define mild to moderate hepatotoxicity as alanine aminotransferase, alanine aminotransferase, and/or bilirubin elevations of grade 1 or 2, and severe hepatotoxicity as any elevation of grade 3 or 4. We determined schistosome infection status using the serum circulating cathodic antigen rapid test and used logistic regression to determine factors associated with hepatotoxicity. The prevalence of mild-moderate and severe hepatotoxicity was 29.6% (45/152) and 2.0% (3/152) in patients on medium-term antiretroviral therapy and 19.6% (30/153) and 3.3% (5/153) in the patients on long-term antiretroviral therapy. S. mansoni infection was significantly associated with hepatotoxicity on univariable analysis and after controlling for other factors associated with hepatotoxicity including hepatitis B or C and anti-tuberculosis medication use (adjusted odds ratio = 3.0 [1.6-5.8], p = 0.001). CONCLUSIONS/SIGNIFICANCE: Our work demonstrates a strong association between S. mansoni infection and hepatotoxicity among HIV-infected patients on antiretroviral therapy. Our study highlights the importance of schistosome screening and treatment for patients starting antiretroviral therapy in schistosome-endemic settings. Additional studies to determine the effects of schistosome-HIV co-infections are warranted.

HIV drug resistance mutations following poor adherence in HIV-infected patient: a case report.

Acquired HIV drug resistance following poor adherence is common. We report a case of HIV-infected patient with poor CD4 gain and self reported poor adherence. Investigations revealed high viral load and resistance to NRTIs and NNRTIs with sensitivity to boosted PIs. HIVDR mutations create treatment challenges in resource limited settings.