Abstract
BackgroundFollowing migration from Schistosoma and Strongyloides endemic to non-endemic regions, people remain at high risk for adverse sequelae from these chronic infections. HIV co-infected persons are particularly vulnerable to the serious and potentially fatal consequences of untreated helminth infection. While general screening guidelines exist for parasitic infection screening in immigrant populations, they remain silent on HIV positive populations. This study assessed the seroprevalence, epidemiology and laboratory characteristics of these two parasitic infections in a non-endemic setting in an immigrant/refugee HIV positive community.MethodsBetween February 2015 and 2018 individuals born outside of Canada receiving care at the centralized HIV clinic serving southern Alberta, Canada were screened by serology and direct stool analysis for schistosomiasis and strongyloidiasis. Canadian born persons with travel-based exposure risk factors were also screened. Epidemiologic and laboratory values were analyzed using bivariate logistic regression. We assessed the screening utility of serology, direct stool analysis, eosinophilia and hematuria.Results253 HIV positive participants were screened. The prevalence of positive serology for Schistosoma and Strongyloides was 19.9 and 4.4%, respectively. Age between 40 and 50 years (OR 2.50, 95% CI 1.13–5.50), refugee status (3.55, 1.72–7.33), country of origin within Africa (6.15, 2.44–18.60), eosinophilia (3.56, 1.25–10.16) and CD4 count < 200 cells/mm3 (2.46, 1.02–5.92) were associated with positive Schistosoma serology. Eosinophilia (11.31, 2.03–58.94) was associated with positive Strongyloides serology. No Schistosoma or Strongyloides parasites were identified by direct stool microscopy. Eosinophilia had poor sensitivity for identification of positive serology. Hematuria was not associated with positive Schistosoma serology.ConclusionPositive Schistosoma and Strongyloides serology was common in this migrant HIV positive population receiving HIV care in Southern Alberta. This supports the value of routine parasitic screening as part of standard HIV care in non-endemic areas. Given the high morbidity and mortality in this relatively immunosuppressed population, especially for Strongyloides infection, screening should include both serologic and direct parasitological tests. Eosinophilia and hematuria should not be used for Schistosoma and Strongyloides serologic screening in HIV positive migrants in non-endemic settings.
Highlights
Following migration from Schistosoma and Strongyloides endemic to non-endemic regions, people remain at high risk for adverse sequelae from these chronic infections
In people living with Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (PLWHA), Immune Reconstitution Inflammatory Syndrome (IRIS), the use of corticosteroids to control IRIS [5,6,7,8,9,10,11,12,13,14], and the increase in the invasive S. stercoralis filariform larvae with anti-retroviral therapy (ART) initiation likely all play a role [7, 15] in the increased risk of St hyperinfection and disseminated disease
At the time of serology 30.6% of participants had a new diagnosis of HIV and 53.0% were on ART
Summary
Following migration from Schistosoma and Strongyloides endemic to non-endemic regions, people remain at high risk for adverse sequelae from these chronic infections. Immune suppression, including hematologic malignancy, organ transplantation, Human T-cell Lymphotrophic virus-1 infection and initiation of anti-retroviral therapy (ART) are risk factors for St hyperinfection syndrome, which is characterized by high parasite burden, and disseminated disease [4]. In people living with Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (PLWHA), Immune Reconstitution Inflammatory Syndrome (IRIS), the use of corticosteroids to control IRIS [5,6,7,8,9,10,11,12,13,14], and the increase in the invasive S. stercoralis filariform larvae with ART initiation likely all play a role [7, 15] in the increased risk of St hyperinfection and disseminated disease. Helminth treatment has a positive impact on untreated HIV infection; decreases in HIV VL are observed when persons are dewormed and treatment of schistosomiasis slows the decline in CD4 count [20,21,22]
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