Ischemic stroke in HIV infection patients.

By Junior Bazile Moderator | 19 Mar, 2017

Cerebra-vascular lesions (particularly vasculitis) are common in many types of patients. HIV infected patients are not exempt from such lesions. In this study whose abstract can be found below, the researchers aimed at providing insights into the contributions of HIV infection stage, antiretroviral therapy (ART) and vascular risk factors to the occurrence of ischaemic stroke in HIV-infected patients.
The authors concluded that they found association between illegal drug uses, HIV replication and some traditional vascular risk factors with the occurrence of ischemic cerebral events. They advocate for the addressing of vascular risk factors in HIV patients apart from controlling the infection with ART.

Here is the abstract:
Objectives: The aim of the study was to provide insights into the contributions of HIV infection stage, antiretroviral therapy (ART) and vascular risk factors to the occurrence of ischaemic stroke in HIV-infected patients.

Methods: We performed a case–control study of HIV-infected patients followed in our clinic. We compared patients hospitalized between January 2006 and June 2014 with an ischaemic stroke or transient ischaemic attack to age- and gender-matched controls without stroke.

Results: Of 2146 patients followed in our clinic, we included 23 cases (20 men and three women; mean age 51.3 years) and 23 controls. Eighty-three per cent of cases had had a stroke and 17% a transient ischaemic attack. According to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, small-vessel occlusion was the most frequent aetiology, followed by large-artery atherosclerosis and cardioembolism. Compared with controls, stroke was statistically significantly associated with diabetes, smoking and low concentrations of high-density lipoprotein (HDL) cholesterol. Illegal drug use, a low CD4 count and a high viral load were also associated with ischaemic cerebral events. There were no statistically significant differences between cases and controls in Centers for Disease Control and Prevention (CDC) HIV stage, CD4 count nadir and HIV infection time-to-event. No statistically significant differences were found concerning ART or treatment compliance.

Conclusions: In our single centre study, we found associations of illegal drug use, HIV replication and some traditional vascular risk factors with the occurrence of ischaemic cerebral events. The paradigm of the care of HIV-infected patients is changing. Concomitant diseases in the ageing patient with HIV infection, including cerebrovascular disease, must also be addressed in view of their impacts on morbidity and mortality. Apart from controlling the HIV infection and immunosuppression with ART, vascular risk factors must also be addressed.

For those interested in the full text, it can be found here:





Gonzo Manyasi Replied at 4:52 AM, 20 Mar 2017

Thanks Junior Bazile for this very interesting piece. Definitely worth
addressing where it may seem to commonly occur. You've rekindled my 30
year-old interest in vasculitis!

Gonzo Manyasi Replied at 5:32 AM, 20 Mar 2017

Junior Bazile, while looking up the link you provided on Ischemic stroke
in HIV patients, I came across this equally exciting piece. I hope the
group finds it useful.

[image: Description:]

*People on Treatment With Suppressed HIV Levels Can't Transmit Virus -

By Andrew M. Seaman

March 09, 2017

(Reuters Health) - When the human immunodeficiency virus (HIV) is
successfully suppressed with antiretroviral therapy (ART), people with HIV
can't transmit the virus to others, according to a coalition of community
health and HIV/AIDS organizations.

The AIDS United Public Policy Committee issued a statement March 6 saying
virally suppressed people on treatment can't pass HIV to others, and it
recommending that healthcare providers and educators share this message
with the public.

"Substantial evidence strongly demonstrates that a person living with HIV
who has a sustained, undetectable viral load cannot sexually transmit HIV
to another person," the statement says.

"We feel that the science is very strong on this and felt comfortable
making that statement," said Ronald Johnson, AIDS United's vice president
of policy and advocacy in Washington, D.C.

An expert not involved in the coalition told Reuters Health she didn't
completely agree - but she did say the risk of transmission in such cases
would be "negligible."

People who start ART can be virally suppressed within 12 to 24 weeks,
according to the U.S. Department of Health and Human Services (HHS). Viral
suppression can be lifelong if people stay on ART.

Over 1.2 million people in the U.S. are currently living with HIV,
according to the Centers for Disease Control and Prevention. Of those, 86
percent are aware of their diagnosis, 37 percent are on treatment to stop
the virus from replicating and 30 percent are virally suppressed.

A study published last year in JAMA examined the risk of transmission
between a person living with well-controlled HIV and their HIV-negative

Among 548 opposite-sex and 340 same-sex couples having unprotected sex,
only 11 of the HIV-negative partners became positive over about a year and
a half of follow up. None of the new infections could be traced back to the
partners with HIV. ((

Those researchers and others, however, did not go so far as to say the risk
of transmission is zero. They emphasized that more data is needed -
particularly for condomless anal sex.

"We felt looking at these studies, there is substantial evidence that we
can come to the conclusion that people living with HIV that have sustained
and undetectable viral load cannot transmit HIV," Johnson told Reuters

Dr. Michelle Cespedes, associate professor of infectious disease at Icahn
School of Medicine at Mount Sinai in New York, said it's impossible to say
transmission would never occur with condomless sex.

"To say there is absolutely no risk is maybe a little overstating it, but
based on the evidence to date it’s a reasonable conclusion," said Cespedes,
who was not involved with the AIDS United statement but described the risk
as negligible.

She said she always recommends condoms and she offers pre-exposure
prophylaxis (PrEP) to HIV-negative patients, which also significantly
reduces their risk of contracting the virus.

The new statement calls for the HHS Antiretroviral Guidelines Committee to
examine the issue and update its language. It also calls for laws and
policies regarding HIV in the U.S. to be modernized to reflect current

Johnson said such changes, along with public knowledge that people living
with HIV can't transmit the infection while on treatment and virally
suppressed, will reduce stigma.

AIDS United also endorsed a consensus statement last year issued by the
Prevention Access Campaign that made a similar determination about the risk
of HIV transmission when the virus is suppressed.


AIDS United 2017.

Reuters Health Information © 2017

Cite this article: People on Treatment With Suppressed HIV Levels Can't
Transmit Virus - HIV/AIDS Group. *Medscape*. Mar 08, 2017.

Junior Bazile Moderator Replied at 5:47 AM, 23 Mar 2017

Thank you very much Gonzo for your contribution. This is an important topic that you have brought up: Can people who have undetectable viral load still transmit HIV infection?
I know that there are many researchers focusing nowadays on this very important issue. According to many studies conducted, apparently people with suppressed level of HIV, cannot transmit the infection even if they are still considered infected because they still have the virus in their blood stream but at a very very low level.
I will be reading more on this.


Dr. Subarna Shrestha Replied at 6:25 PM, 28 Mar 2017

Great to see this here.

Zulfiya Tilloeva Replied at 4:27 AM, 29 Mar 2017

Thank you very much Dr. Bazile and Dr.Gonzo for this discussion.
With regards,

Andrew Mujugira Replied at 10:53 AM, 29 Mar 2017

A JAMA editorial published last year discussed the safety of condomless sex with virologically suppressed HIV-infected individuals. It recommended that "clinicians and public health professionals need to formulate a message to share with HIV-infected individuals and their sexual partners. Certainly health care professionals should encourage all HIV-infected individuals to initiate and adhere to ART. Patients also could be informed that available data indicate that viral suppression along with the use of condoms results in an extraordinarily low risk of transmission among heterosexual couples and that although data are limited, this is likely to be true for MSM.

Clinicians can further emphasize to patients that the use of condoms is an important measure to prevent transmission of STIs and advise them that having a virologically suppressed partner does not protect the HIV-uninfected person from acquiring HIV from other individuals outside the relationship. The importance of the latter message is emphasized by the 11 nonphylogenetically linked transmission events observed in the PARTNER study by Rodger et al and the 20% of transmission events among nonstudy related partners observed in HPTN 052 by Cohen et al.

For individuals who want to routinely or intermittently not use condoms with an HIV-infected partner, clinicians can indicate that the risk of HIV transmission appears small in the setting of continued viral suppression, emphasizing that the duration the HIV-infected partner needs to be virologically suppressed before achieving optimal protection is unknown, although appears to be for at least 6 months, based on the best available data. Moreover, clinicians need to be clear that even though the overall risk for HIV transmission may be small, the risk is not zero and the actual number is not known, especially for higher-risk groups such as MSM. Although more research is needed with larger numbers of couples and longer follow-up, it is not known if or when such data will emerge.

Consequently, for now, clinicians and public health officials must share the data that exist in an honest and understandable way so that serodiscordant couples can be fully informed when individualizing their decision making about sexual practices."

JAMA. 2016 Jul 12;316(2):149-51

Junior Bazile Moderator Replied at 6:46 AM, 30 Mar 2017

Thank you Andrew for this great piece. It is a very sensitive issue and I think that the take home message should be that the risk is not zero even if the actual number is not know. So the risk is minimal but there is still risk. Clinicians and Public Health Professionals have a big responsibility when addressing such topics with serodiscordant couples and it is important to make sure that the message is correctly understood.