Treatment and Concomitant Infections in Refugees From the Ukraine With HIV

The Russian invasion on 24 February 2022 started a movement of refugees from Ukraine to Europe. In Germany, more than one million refugees from Ukraine were registered by the end of 2022 (1). Currently, data on the health status and the prevalence of chronic infectious diseases in this population are scarce. In Ukraine, people living with HIV (PLHIV) account for approximately 0.9% of the adult population (2); of these, 62% receive antiretroviral therapy (ART). Approximately 3% of the Ukrainians live with chronic hepatitis C (3). The prevalence of chronic hepatitis B is 1%, measured as HBs antigen prevalence (3). Tuberculosis (TB) incidence was 71/100 000 population in 2021; 20% of TB-infected patients are co-infected with HIV and more than 35% have multidrug resistance/rifampicin resistance (MDR/RR) (4).

The aim of our study was to assess the treatment status and prevalence of any potential co-infections among HIV-infected Ukrainian refugees. The findings of this study are intended to improve treatment strategies and resource planning for Ukrainian refugees in Germany.

Methods

We retrospectively obtained information on the treatment history as well as data from routine diagnostic testing in virology, microbiology, laboratory chemistry, and immunology from the medical records of adults with HIV infection who visited one of the five outpatient clinics for infectious diseases in Hamburg, Germany, between February and December 2022, and who had fled Ukraine because of the current conflict. The Ethics Committee of the Medical Association of Hamburg was informed about the data collection (300218-WF).

Results

We included 104 PLHIV from five HIV outpatient clinics in our study (69% female; patients’ mean age: 41 years). The diagnosis of HIV infection was known in 103/104 patients already before their flight from Ukraine; only one female patient was diagnosed in Hamburg on the basis of an AIDS-defining clinical condition. All patients with a known HIV diagnosis had already received ART in Ukraine and 84% (87/104) were taking an ART regimen at the time of initial presentation. Thirteen patients reported a brief interruption in treatment due to their flight (range, 7–31 days), while three had discontinued therapy for three months or longer (range 90–270 days). 75% (77/102) showed a suppressed viral load at initial presentation and 14% (14/102) had a viral load greater than 500 copies/mL (range 1500–1 100 000 copies/mL). ART had been maintained for a median of six years (range 0–25 years), and HIV diagnosis had been known for nine years (range 0–26 years).

The mean CD4 count at initial presentation was 630/µL (range 12–1380/µL). Eight patients had marked immunodeficiency with CD4 cell counts below 200/µl (normal >500/µL). 18 patients reported a history of AIDS-defining clinical condition (TB, pneumocystis jiroveci pneumonia, cerebral toxoplasmosis, Kaposi‘s sarcoma).

In Ukraine, 69% of PLHIV received a dolutegravir (DTG)-based regimen, in most cases a single-tablet regimen. 22% had received an efavirenz (EFV)-based ART. Other drugs used were lopinavir/ritonavir (6%) and bictegravir (2%). HIV drug resistance testing was performed in 31 individuals. No relevant viral drug resistance to the ART regimen used was detected that would have necessitated an adjustment of treatment.

38 of 102 (37%) patients had hepatitis C antibodies and of these 24 knew of their positive test result. 13 persons had an active (chronic) hepatitis C infection with detectable HCV viral load. All patients who attended regular follow-up appointments received hepatitis C treatment. In a total of three persons (3%), HBs antigen was detected as an indicator of acute or chronic hepatitis B. There was no HB viral load on ART. Testing of partners and children were offered to the patients.

A total of 12 (12%) of all patients reported having had tuberculosis in the past or currently. Two persons were currently receiving treatment for active TB (one MDR) and an abdominal MDR TB was diagnosed in another person at the University Medical Center Hamburg-Eppendorf.

Interferon-gamma release assay (IGRA) screening was successfully performed in 52 patients, of whom 16 (31%) had a positive result. No further active TB was diagnosed based on clinical history, physical examination, laboratory testing, and diagnostic radiography. Patients with latent TB were offered chemoprevention according to current guidelines.

Table 1

Demographic data

Table 2

Antiretroviral therapies in Ukraine

Discussion

With the exception of one patient, all PLHIV had already been diagnosed in Ukraine and had received ART there. A large proportion of Ukrainian refugees in Germany are women, a fact that is also reflected in the demographics of the current cohort. In most cases, their flight did not cause an interruption in ART, or if so, only for a short period of time. In most cases, the HIV infection was well controlled with suppressed viral load and good immune status with >500 CD4 cells/µL.

The antiretroviral agents used in Ukraine are consistent with the German therapy guidelines; however, they are often not available as a combination drug. Splitting therapy or switching to an alternative regimen is easily achieved in most patients.

Active concomitant infections with hepatitis C (13%), hepatitis B (3%) and tuberculosis (3%) were significantly more common in our cohort compared to German PLHIV (5).

While we report only one patient with newly diagnosed HIV infection, a higher incidence of chronic infectious diseases in refugees from Ukraine should be considered and appropriate screening for possible co-infections should be performed, especially in PLHIV.

Hanna Matthews, Anna Koval, Katharina Völker, Sandra Hertling, Christian Hoffmann, Guido Schäfer, Stefan Unger, Julian Schulze zur Wiesch, Anja-Dorothee Hüfner, Sabine Jordan, Olaf Degen, Stefan Schmiedel

Conflict of interest statement

JS received reimbursement of travel costs and congress fees from Gilead and EASL.

KV received consulting fees and lecture fees from Viiv Healthcare, Gilead Sciences and MSD.

The remaining authors declare that no conflict of interest exists.

Translated from the original German by Ralf Thoene, MD

Manuscript received on 14 February 2023, revised version accepted on 23 April 2023.

Cite this as:
Matthews H, Koval A, Völker K, Hertling S, Hoffmann C, Schäfer G, Unger S, Schulze zur Wiesch J, Hüfner AD, Jordan S, Degen O, Schmiedel S: Treatment and concomitant infections in refugees from the Ukraine with HIV. Dtsch Arztebl Int 2023; 120: 540–1. DOI: 10.3238/arztebl.m2023.0110

References

1. Statistisches Bundesamt, Ukraine, Gesellschaft. www.destatis.de/DE/Im-Fokus/Ukraine/Gesellschaft/_inhalt.html (last accessed on 29 June 2023).

2. UNAIDS, Länderbericht Ukraine. www.unaids.org/en/regionscountries/countries/ukraine (last accessed on 29 June 2023).

3. EASL, Joint Statement: Ensuring high-quality viral hepatitis care for refugees from Ukraine. https://easl.eu/publication/easl-who-and-ecdc-joint-statement-ensuring-high-quality-viral-hepatitis-care-for-refugees-from-ukraine/ (last accessed 29 June 2023)

4. World Health Organisation (WHO) Tuberculosis profile: Ukraine. https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22UA%22 (last accessed on 29 June 2023).

5. Jansen K, Thamm M, Bock CT, et al.: High prevalence and high incidence of coinfection with Hepatitis B, Hepatitis C, and Syphilis and low rate of effective vaccination against Hepatitis B in HIV-Positive men who have sex with men with known date of HIV seroconversion in Germany. PLoS One 2015; 10: e0142515