Prevalence of hepatitis C and hepatitis B infection in the HIV-infected population of France, 2004

Our objective was to estimate the prevalence of HCV and HBV co-infection among HIV-infected adults in France and describe the epidemiological characteristics of co-infected patients and their clinical management. A one-day national cross-sectional survey was conducted in 2004. A random and proportional probability sample design was used, based on the number of AIDS cases reported since 1999 by hospital wards. Weighted estimations were computed. HIV-infected adults (out/in-patients) were included after consent. Data were collected on demographic criteria, HIV, HCV and HBV infections, as well as on antiviral therapies. Overall, 1849 HIV-infected patients were included. The prevalence of anti-HCV or HCV RNA positivity (HCV co-infection) was 24.3% [95% confidence interval (CI): 21.3-27.6] and varied from 3.1% in men who had sex with men to 92.8% in injecting drug users (IDUs). The prevalence of positive HCV RNA was 17.0% [95% CI:14.7-19.4]. The prevalence of HBs antigen (Ag) or HBV DNA positivity was 7.0% [95% CI: 5.9-8.1] and varied with the continent of birth from 2.1% in Northern Africa to 10.8% in sub-Saharan Africa. The prevalence of HIV-HCV-HBV co-infection was 1.6% [95% CI: 1.0-2.4], mostly IDUs (83.3%). A severe liver disease (cirrhosis or hepatocellular carcinoma) was diagnosed in 24.7% of the positive HCV RNA patients.This study confirmed the burden of HCV infection in French HIV-infected patients and described for the first time in France the epidemiological characteristics of HIV-HBV co-infection. Furthermore, it stresses the severity of liver disease related to HCV in HIV-infected population.

Prevalence of hepatitis C and hepatitis B infection in the HIV-infected population of France, 2004

Our objective was to estimate the prevalence of HCV and HBV co-infection among HIV-infected adults in France and describe the epidemiological characteristics of co-infected patients and their clinical management. A one-day national cross-sectional survey was conducted in 2004. A random and proportional probability sample design was used, based on the number of AIDS cases reported since 1999 by hospital wards. Weighted estimations were computed. HIV-infected adults (out/in-patients) were included after consent. Data were collected on demographic criteria, HIV, HCV and HBV infections, as well as on antiviral therapies. Overall, 1849 HIV-infected patients were included. The prevalence of anti-HCV or HCV RNA positivity (HCV co-infection) was 24.3% [95% confidence interval (CI): 21.3-27.6] and varied from 3.1% in men who had sex with men to 92.8% in injecting drug users (IDUs). The prevalence of positive HCV RNA was 17.0% [95% CI:14.7-19.4]. The prevalence of HBs antigen (Ag) or HBV DNA positivity was 7.0% [95% CI: 5.9-8.1] and varied with the continent of birth from 2.1% in Northern Africa to 10.8% in sub-Saharan Africa. The prevalence of HIV-HCV-HBV co-infection was 1.6% [95% CI: 1.0-2.4], mostly IDUs (83.3%). A severe liver disease (cirrhosis or hepatocellular carcinoma) was diagnosed in 24.7% of the positive HCV RNA patients. This study confirmed the burden of HCV infection in French HIV-infected patients and described for the first time in France the epidemiological characteristics of HIV-HBV co-infection. Furthermore, it stresses the severity of liver disease related to HCV in HIV-infected population.

Liver-related mortality in human-immunodeficiency-virus-infected patients between 1995 and 2003 in the French GERMIVIC Joint Study Group Network (MORTAVIC 2003 Study)

The objective of the present study was to determine mortality because of end-stage liver disease (ESLD) in a nationwide population of HIV-infected patients, 7 years following the introduction of highly active antiretroviral therapy (HAART). All departments of internal medicine and infectious diseases from the GERMIVIC Study Group prospectively recorded all deaths in HIV-infected patients during 2003. Fifty-nine departments, following a total of 20 940 HIV-infected patients, participated in the study. Results were compared with those of previous surveys conducted using similar methodology in 1995, 1997 and 2001. Among 215 deaths observed during 2003, 101 (46.9%) were related to AIDS, 27 (12.6%) to ESLD and 87 (40.5%) to other causes. Mortality because of ESLD represented 23.7% of non-AIDS-related deaths. Patients dying from ESLD had chronic hepatitis because of hepatitis C virus (HCV) in 92.6% of cases and moderate (30-60 g) or high (>60 g) alcohol consumption (43.5% and 26.0%, respectively). In this population, deaths because of ESLD were 1.5% in 1995, 6.6% in 1997, 14.3% in 2001 and 12.6% in 2003. The prevalence of hepatocellular carcinoma as a cause of death remained high in 2003 but stable when compared with 2001 (25%vs 14.8%). Treatment of hepatitis C in patients who died from ESLD was more frequent in 2003 (44.4%) than in 2001 (26.3%). Seven years after the introduction of HAART, ESLD associated with HCV infections is a leading cause of mortality in HIV-infected patients, which did not increase between the years 2001 and 2003.

[Hepatic steatosis: an emerging cause of cirrhosis in HIV patients]

Hepatic steatosis is an emerging cause of morbidity in antiretroviral therapy (ART)-experienced HIV patients. The influence of steatosis on fibrosis is poorly understood. We report two cases of rapid evolution of disseminated macrovacuolar steatofibrosis to cirrhosis. Both patients had no history of alcohol abuse, nor intravenous drug use and were tested negative for HCV (PCR RNA) and had no HBS antigen. Patient 1 had a past history of hypertrygliceridemia, but controlled with dietetic measures for 4 years prior to biopsy. The first hepatic biopsy showed a disseminated macrovacuolar steatosis (>80%). The patient had then cytolysis and an uncontrolled HIV viral load. The second biopsy was performed two years later, and HIV was controlled by a new line of ART. It showed a regression of the steatosis (10%) and a progression of the fibrosis with signs of cirrhosis. Patient 2 had a long history of HIV infection. He also had an uncontrolled dyslipidemia. The first biopsy was realised during a period of uncontrolled HIV infection and elevated liver enzymes. The biopsy showed a major macrovacuolar steatosis (>80%). The second biopsy was realised 6 years after and showed the same steatosis and signs of cirrhosis. The HIV infection was then under control. Observations reported here show a rapid evolution of liver steatosis to cirrhosis in HIV positive / HCV negative patients, despite the control of HIV infection. The implication of HAART remains unclear. In the era of HAART, liver steatosis can rapidly evoluate to cirrhosis without any risk factor except ART.

Genital tract actinomycosis caused by Actimyces israëlii

We report a case of actinomycosis caused by actinomyces israelii, related to the removal of intrauterine device (IUD). Diagnosing actinomycosis is difficult but should be considered in the event of any acute abdominal problems in a woman carrying an IUD. All abdominal organs may be affected. Even with a disseminated infection, the combination of appropriate antibiotic therapy (penicillin G) and surgery ensures a full recovery in most cases.

Infection à virus Chikungunya : revue générale par temps d'épidémie

The Chikungunya virus is an alpha arbovirus, first identified in 1953, transmitted by Aedes, mosquitoes, responsible for a little documented uncommon acute specifically tropical disease. Its main symptoms are fever, a rash, and debilitating arthralgia. An unprecedented Chikungunya epidemic is ongoing on the Reunion Island (775,000 inhabitants) with over 244,000 reported and 205 deaths (directly or indirectly linked) as of April 20 2006. Aedes albopictus, long present on the island, is the assumed vector. It had already been identified as the vector for type 2 Dengue fever in 1997-1978 (200,000 cases) for type 1 Dengue fever in 2004 (300 cases). After the Grande Comore Island epidemic, the first cases were reported in the Reunion Island in March 2005. The epidemic was a surprise because of its unexpected emergence, its magnitude, and clinical cases rarely or never described before: severe forms, central neurological involvement, hepatic cytolyse, severe lymphopenia, severe dermatological involvement, deaths, and neonatal infections. This is the first manifestation of the intrusion CHK virus on the island, which benefits from a sub-tropical climate, but also of an occidental healthcare environment, with a non-immune population. This is also the first time that a Chikungunya epidemic is described in this part of the world.

[Efficacy of peginterferon plus ribavirin for HIV-HCV co-infection. Results of the APRICOT study]

Until the publication in 2004 of the Apricot, ACTG 5071, and ANRS Ribavic trials, data about the treatment of patients coinfected with HIV and HCV were sparse. The international Apricot study included 868 HIV-HCV-coinfected patients naive of all HCV treatments. They were randomized into 3 groups for 48 weeks of hepatitis C treatment by peginterferon alpha-2a + ribavirin, or peginterferon alpha-2a + placebo, or interferon alpha-2a + ribavirin. Six months after treatment stopped, sustained virologic response (the principal efficacy criterion, intention-to-treat analysis) was observed in 40% of patients treated by peginterferon + ribavirin (29% for the nonresponsive genotype 1, and 62% for genotypes 2 and 3), 20% of those receiving peginterferon + placebo, and 12% of those in the group of nonpegylated interferon + ribavirin. This study also validated the positive and negative predictive values of viral load analyzed at 12 weeks of treatment; it was best for patients in genotypes 2 and 3. The factors associated with the best virologic response were a non-1 genotype and a low HCV viral load (< 800,000 IU/mL). As pointed out in the guidelines of the last European consensus conference on coinfection, the combination of peginterferon + ribavirin is currently the reference treatment for chronic hepatitis C. It should also be the preferred treatment for patients with HIV-HCV coinfection.

« L'observance thérapeutique au cours de l'infection VIH, une approche multidisciplinaire »

Since HIV infection has become a chronic disease, antiretroviral therapy is now used on a long-term basis. Response to treatment is conditioned by numerous inter-dependent factors, including non-compliance, which can result in failure of the therapeutic regimen. Although compliance is crucial for long-term efficacy of the treatment, it is a dynamic factor, and therefore difficult to evaluate. This literature review proposes a multidisciplinary approach to treatment adherence during HIV infection, and deals with the following questions: how should adherence and non-adherence be defined? How are they correlated to the treatment response? How is adherence measured in trials and cohorts, as well as in clinical practice? By what factors is it influenced? What tools can be implemented to improve adherence? The interaction between adherence and response to antiretroviral therapy requires communication between clinicians, healthcare providers, patients, virologists, pharmacologists, and the companies responsible for developing drugs. The pharmaceutical industry must sustain its efforts to ensure a balance between demands for efficacy and adherence when developing new drugs. And the methods implemented by numerous healthcare teams plead in favour of a dynamic approach to adherence, with the active participation of all.

Vaccins préventifs anti-VIH

The devastation caused by the HIV pandemic will probably not be quelled until a safe and effective vaccine has been developed that is also affordable and available in the developing countries where the impact of this virus is most severe. Considerable progress has been made over the past several years in the search for a vaccine against HIV: roughly 30 different types are currently being investigated in phase I/II clinical trials. Major scientific challenges nonetheless still remain. An ideal vaccine would elicit both neutralizing antibodies and cytotoxic T lymphocytes (CTL) and, perhaps, mucosal immune response. The precise correlates of immunity have not been defined. Recombinant live vector-based vaccines, lipopeptides, and plasmid DNA have all been shown to induce CTL. The different forms of prime-boost vaccine strategies currently being tested in numerous clinical trials provide reasons for hope.

Impact of Newly Available Drugs on Clinical Progression in Patients with Virological Failure after Exposure to Three Classes of Antiretrovirals

Objective

To study the prognosis of HIV-infected patients with virological failure after exposure to three classes of antiretroviral drugs (ARVs).

Design

Cohort study. Setting: French Hospital Database on HIV.

Patients

Patients previously exposed to at least two nucleoside reverse transcriptase inhibitors (NRTIs), two protease inhibitors and one non-NRTI, with viral load (VL) values of >5000 copies/ml after the exposure criteria were met and a new treatment initiated between 1998 and 2001 with VL >5000 copies/ml.

Main outcome measures

Risk of new AIDS-defining-events (ADEs) or death from first introduction of a drug never used before occurring between 1998 and 2001 defined as baseline.

Results

The main baseline characteristics of the 1092 patients were: previous ADE in 49% of cases, median CD4 cell count 181 μl, median VL 4.9 log10 copies/ml, median duration of ARV therapy 5.0 years and previous exposure to a median of nine ARVs. The crude progression rates were 20.1/100 patient-years among patients included in 1998, 15.1 in 1999, 11.1 in 2000 and 8.6 in 2001. After adjustment for baseline characteristics, the calendar year of inclusion was associated with the risk of clinical progression ( P<0.001). When the types of newly available drugs used at baseline or during follow-up were introduced into the model, year of inclusion was no longer associated with the risk of clinical progression ( P=0.42), while exposure to amprenavir/r, lopinavir/r, abacavir or tenofovir was associated with a lower risk.

Conclusions

The clinical prognosis of heavily pretreated patients experiencing virological failure improved between 1998 and 2001, mainly thanks to the use of newly available drugs with more favourable resistance profiles.

[Febrile pseudotumor lesion of the arm. Atypical presentation of Shulman syndrome]]

INTRODUCTION

The diagnostic approach when confronted with a pseudo-tumoral lesion and fever is difficult since it evokes an infectious, rheumatismal inflammatory or even systemic disease.

OBSERVATION

A 39 year-old Vietnamese man was hospitalised for polyarthralgia if the arm and fever (39 degrees C). He was treated with non-steroidal anti-inflammatories, which were only partially effective. Biological examinations revealed a severe inflammatory syndrome and cytolysis three-fold higher than normal. Since the infectious, rheumatismal and immunological explorations were negative and in view of the appearance of a pseudo-tumoral inflammatory lesion of the left arm concomitant to infiltration of the underlying muscle revealed on MRI, a muscle biopsy was performed showing eosinophilic fasciitis. Diagnosis of Shulman's syndrome was made and the affection rapidly improved with corticosteroids.

COMMENTS

The presentation of our patient was atypical for several reasons: his Vietnamese origin, the initial fever peak at 39 degrees C, the unilateral involvement, the severe inflammatory syndrome, the initial absence of hypereosinophilia, the visceral involvement and notably myositis are all uncommon in Shulman's syndrome. Hence, it is important to rule out its differential diagnosis from local edematous scleroderma, which does not share the same prognosis.

CD4 T cell recovery is slower in patients experiencing viral load rebounds during HAART

To determine whether viral load rebounds during HAART impact on CD4+ T cell recovery and immune reconstitution, we studied a prospective cohort of 355 antiretroviral naive patients enrolled to be randomized in a trial of three strategies of induction/maintenance HAART. The extent of immune reconstitution in blood through 72 weeks of antiretroviral treatment was evaluated. Lymphocyte subset markers (CD4, CD8, CD45RA, CD62L, CD16, CD19), activation markers (HLA-DR, CD38, CD25) were performed by cytometry analysis. Our results showed that plasma HIV-1 RNA was suppressed to below 500 copies per ml through week 72 in 240 patients (group 1) while the remaining 115 patients experienced at least one viral rebound (group 2). At baseline, CD4 cell count was higher and HIV-1 RNA was lower in group 1 than in group 2. Over 72 weeks, mean increase in CD4+ T cell count was 0.32 cell/mm3/day in group 1 and only 0.14 cell/mm3/day in group 2 (P < 0.0001). However, the patterns of changes in CD4+ and CD8+ T cell subsets during therapy were very similar across the two groups with only subtle and very limited differences. We conclude that permanent control of HIV replication could be necessary for faster immune reconstitution.

Changes in AIDS-related lymphoma since the era of highly active antiretroviral therapy

HIV infection is associated with a high incidence of AIDS-related lymphomas (ARLs). Since the use of highly active antiretroviral therapy (HAART), the incidence of AIDS-defining illnesses has decreased, leading to a significant improvement in survival of HIV-infected patients. The consequences of HAART use on ARL are under debate. This study compared the incidence and the characteristics of ARL before and after the use of HAART in a large population of HIV-infected patients in the French Hospital Database on HIV (FHDH) and particularly in 3 centers including 145 patients with proven lymphoma. Within the FHDH, the incidence of systemic ARL has decreased between 1993-1994 and 1997-1998, from 86.0 per 10 000 to 42.9 per 10 000 person-years (P < 10(-30)). The incidence of primary brain lymphoma has also fallen dramatically between the periods, from 27.8 per 10 000 to 9.7 per 10 000 person-years (P < 10(-11)). The analysis of 145 cases of ARL in 3 hospitals showed that known HIV history was longer in the second period than in the first period among patients with systemic ARL (98 versus 75 months; P <.01). Patients had a higher number of CD4 cells at diagnosis during the second period (191 versus 63/microL, P = 10(-3)). Survival of patients with systemic ARL also increased between the periods (from 6 to 20 months; P =.004). Therefore, the profile of ARL has changed since the era of HAART, with a lower incidence of systemic and brain ARL. The prognosis of systemic ARL has improved.