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Pimentel V, Pingarilho M, Sebastião CS, Miranda M, Gonçalves F, Cabanas J, Costa I, Diogo I, Fernandes S, Costa O, Corte-Real R, Martins MRO, Seabra SG, Abecasis AB, Gomes P. Applying Next-Generation Sequencing to Track HIV-1 Drug Resistance Mutations Circulating in Portugal. Viruses 2024; 16:622. [PMID: 38675962 PMCID: PMC11054263 DOI: 10.3390/v16040622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/02/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The global scale-up of antiretroviral treatment (ART) offers significant health benefits by suppressing HIV-1 replication and increasing CD4 cell counts. However, incomplete viral suppression poses a potential threat for the emergence of drug resistance mutations (DRMs), limiting ART options, and increasing HIV transmission. OBJECTIVE We investigated the patterns of transmitted drug resistance (TDR) and acquired drug resistance (ADR) among HIV-1 patients in Portugal. METHODS Data were obtained from 1050 HIV-1 patient samples submitted for HIV drug resistance (HIVDR) testing from January 2022 to June 2023. Evaluation of DRM affecting viral susceptibility to nucleoside/tide reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), and integrase strand transfer inhibitors (INSTIs) was performed using an NGS technology, the Vela Diagnostics Sentosa SQ HIV-1 Genotyping Assay. RESULTS About 71% of patients were ART naïve and 29% were experienced. Overall, 20% presented with any DRM. The prevalence of TDR and ADR was 12.6% and 41.1%, respectively. M184V, T215S, and M41L mutations for NRTI, K103N for NNRTI, and M46I/L for PIs were frequent in naïve and treated patients. E138K and R263K mutations against INSTIs were more frequent in naïve than treated patients. TDR and ADR to INSTIs were 0.3% and 7%, respectively. Patients aged 50 or over (OR: 1.81, p = 0.015), originating from Portuguese-speaking African countries (PALOPs) (OR: 1.55, p = 0.050), HIV-1 subtype G (OR: 1.78, p = 0.010), and with CD4 < 200 cells/mm3 (OR: 1.70, p = 0.043) were more likely to present with DRMs, while the males (OR: 0.63, p = 0.003) with a viral load between 4.1 to 5.0 Log10 (OR: 0.55, p = 0.003) or greater than 5.0 Log10 (OR: 0.52, p < 0.001), had lower chances of presenting with DRMs. CONCLUSIONS We present the first evidence on TDR and ADR to INSTI regimens in followed up patients presenting for healthcare in Portugal. We observed low levels of TDR to INSTIs among ART-naïve and moderate levels in ART-exposed patients. Regimens containing PIs could be an alternative second line in patients with intermediate or high-level drug resistance, especially against second-generation INSTIs (dolutegravir, bictegravir, and cabotegravir).
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Affiliation(s)
- Victor Pimentel
- Global Health and Tropical Medicine (GHTM), Associate Laboratory in Translation and Innovation Towards Global Health (LA-REAL), Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa (UNL), Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (M.P.); (C.S.S.); (M.M.); (M.R.O.M.); (S.G.S.); (A.B.A.)
| | - Marta Pingarilho
- Global Health and Tropical Medicine (GHTM), Associate Laboratory in Translation and Innovation Towards Global Health (LA-REAL), Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa (UNL), Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (M.P.); (C.S.S.); (M.M.); (M.R.O.M.); (S.G.S.); (A.B.A.)
| | - Cruz S. Sebastião
- Global Health and Tropical Medicine (GHTM), Associate Laboratory in Translation and Innovation Towards Global Health (LA-REAL), Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa (UNL), Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (M.P.); (C.S.S.); (M.M.); (M.R.O.M.); (S.G.S.); (A.B.A.)
- Centro de Investigação em Saúde de Angola (CISA), Caxito, Angola
- Instituto Nacional de Investigação em Saúde (INIS), Luanda, Angola
| | - Mafalda Miranda
- Global Health and Tropical Medicine (GHTM), Associate Laboratory in Translation and Innovation Towards Global Health (LA-REAL), Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa (UNL), Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (M.P.); (C.S.S.); (M.M.); (M.R.O.M.); (S.G.S.); (A.B.A.)
| | - Fátima Gonçalves
- Laboratório de Biologia Molecular, Serviço de Patologia Clínica, Unidade Local de Saúde Lisboa Ocidental, Hospital Egas Moniz, 1349-019 Lisbon, Portugal; (F.G.); (J.C.); (I.C.); (I.D.); (S.F.); (P.G.)
| | - Joaquim Cabanas
- Laboratório de Biologia Molecular, Serviço de Patologia Clínica, Unidade Local de Saúde Lisboa Ocidental, Hospital Egas Moniz, 1349-019 Lisbon, Portugal; (F.G.); (J.C.); (I.C.); (I.D.); (S.F.); (P.G.)
| | - Inês Costa
- Laboratório de Biologia Molecular, Serviço de Patologia Clínica, Unidade Local de Saúde Lisboa Ocidental, Hospital Egas Moniz, 1349-019 Lisbon, Portugal; (F.G.); (J.C.); (I.C.); (I.D.); (S.F.); (P.G.)
| | - Isabel Diogo
- Laboratório de Biologia Molecular, Serviço de Patologia Clínica, Unidade Local de Saúde Lisboa Ocidental, Hospital Egas Moniz, 1349-019 Lisbon, Portugal; (F.G.); (J.C.); (I.C.); (I.D.); (S.F.); (P.G.)
| | - Sandra Fernandes
- Laboratório de Biologia Molecular, Serviço de Patologia Clínica, Unidade Local de Saúde Lisboa Ocidental, Hospital Egas Moniz, 1349-019 Lisbon, Portugal; (F.G.); (J.C.); (I.C.); (I.D.); (S.F.); (P.G.)
| | - Olga Costa
- Biologia Molecular, Serviço de Patologia Clínica, Centro Hospitalar de Lisboa Central, 1150-199 Lisbon, Portugal; (O.C.); (R.C.-R.)
| | - Rita Corte-Real
- Biologia Molecular, Serviço de Patologia Clínica, Centro Hospitalar de Lisboa Central, 1150-199 Lisbon, Portugal; (O.C.); (R.C.-R.)
| | - M. Rosário O. Martins
- Global Health and Tropical Medicine (GHTM), Associate Laboratory in Translation and Innovation Towards Global Health (LA-REAL), Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa (UNL), Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (M.P.); (C.S.S.); (M.M.); (M.R.O.M.); (S.G.S.); (A.B.A.)
| | - Sofia G. Seabra
- Global Health and Tropical Medicine (GHTM), Associate Laboratory in Translation and Innovation Towards Global Health (LA-REAL), Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa (UNL), Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (M.P.); (C.S.S.); (M.M.); (M.R.O.M.); (S.G.S.); (A.B.A.)
| | - Ana B. Abecasis
- Global Health and Tropical Medicine (GHTM), Associate Laboratory in Translation and Innovation Towards Global Health (LA-REAL), Instituto de Higiene e Medicina Tropical (IHMT), Universidade NOVA de Lisboa (UNL), Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (M.P.); (C.S.S.); (M.M.); (M.R.O.M.); (S.G.S.); (A.B.A.)
| | - Perpétua Gomes
- Laboratório de Biologia Molecular, Serviço de Patologia Clínica, Unidade Local de Saúde Lisboa Ocidental, Hospital Egas Moniz, 1349-019 Lisbon, Portugal; (F.G.); (J.C.); (I.C.); (I.D.); (S.F.); (P.G.)
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Caparica, 2829-511 Almada, Portugal
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Zhang H, Wu P, Li J, Li M. Prevalence and analysis of acquired and transmitted integrase strand transfer inhibitor-associated HIV-1 drug resistance in Chongqing, China. Virulence 2023; 14:2278254. [PMID: 37941373 PMCID: PMC10653698 DOI: 10.1080/21505594.2023.2278254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/11/2023] [Indexed: 11/10/2023] Open
Abstract
In this study, we examined the occurrence of acquired and transmitted drug resistance to integrase strand transfer inhibitor (INSTI) in HIV-1 strains in Chongqing (China) for guiding for the routine testing of INSTI-associated HIV-1 genotype resistance. Plasma samples were obtained from HIV-1 patients at Chongqing Public Health Medical Center from July 2019 to August 2022. Besides, amplification, sequence, and analysis of the portion of the HIV-1 pol gene that encodes the integrase protein were implemented to identify INSTI resistance. Integrase sequence data was harvested for a comprehensive cohort of 1032 patients infected with HIV-1. This cohort consisted of 564 ART-naive patients, 465 ART-treated patients, and 3 patients with an unknown treatment history. Within the study group, we identified INSTI resistance in 21 patients (2.03%, 21/1032), including 17 ART-treated patients (3.66%, 17/465). Among the ART-treated patients, 12 were INSTI-treated (11.76%, 12/102), 5 were INSTI-naive (1.38%, 5/363), and 4 were ART-ineffective patients (0.71%, 4/564). The prevalent major resistance mutation was Q148R (0.48%, 5/1032), while the most prevalent accessory resistance mutation was E157Q (1.65%, 17/1032). In light of the above, it is recommended that the incidence of accessory genotype analysis should be considered before starting any future INSTI-based therapy, especially in patients with drug resistance to NRTIs and NNRTIs and the reduction of INSTI sensitivity should be carefully monitored and investigated. Regular monitoring for resistance should be implemented after the use of INSTIs, and, importantly, ongoing monitoring of the decreasing susceptibility to INSTIs is crucial following the initiation of treatment with INSTIs.
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Affiliation(s)
- Huizheng Zhang
- Central Laboratory, Chongqing Public Health Medical Center, Chongqing, China
| | - Ping Wu
- Department of Tuberculosis, Chongqing Public Health Medical Center, Chongqing, China
| | - Jungang Li
- Central Laboratory, Chongqing Public Health Medical Center, Chongqing, China
| | - Mei Li
- Central Laboratory, Chongqing Public Health Medical Center, Chongqing, China
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Gil H, Delgado E, Benito S, Moreno-Lorenzo M, Thomson MM. Factors associated with HIV-1 resistance to integrase strand transfer inhibitors in Spain: Implications for dolutegravir-containing regimens. Front Microbiol 2022; 13:1051096. [PMID: 36578581 PMCID: PMC9792149 DOI: 10.3389/fmicb.2022.1051096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/11/2022] [Indexed: 12/14/2022] Open
Abstract
Integrase strand transfer inhibitor (INSTI)-containing regimens in HIV-1-infected patients have experienced a global increase. Recently, WHO has emphasized the need to fast-track the transition to dolutegravir (DTG)-based antiretroviral (ARV) treatments. However, continued surveillance of INSTI resistance is recommended. In this study, clinical, epidemiological, and virological features associated with INSTI resistance diagnosed in Spain were analyzed. Samples collected between 2008 and 2021 from HIV-1-infected patients were analyzed in integrase, protease, and reverse transcriptase using Sanger population sequencing. ARV drug resistance was evaluated with the Stanford University HIVdb program. Among 2,696 patients, 174 (6.5%) had INSTI resistance, all of them to first-generation INSTIs, and 71 (2.6%) had also resistance to second-generation INSTIs. Of these, only 5 individuals were exposed to DTG as the only INSTI, in whom resistance development was associated with poor treatment adherence and/or resistance to other ARV classes. Of newly HIV-1-diagnosed individuals, 0.92% harbored INSTI-resistant viruses, with low prevalences maintained along time, and only one had low-level resistance to DTG. Persons who inject drugs, age over 39 years, resistance to other ARV classes, and longer time from diagnosis were associated with INSTI resistance (p < 0.001). Non-subtype B INSTI-resistant viruses lacked the Q148H + G140S resistance pathway and showed lower INSTI resistance levels than subtype B viruses. In conclusion, INSTI resistance is uncommon and associated with long-term infections, older age and additional resistance to other ARV drug classes, and is rare in newly diagnosed HIV-1 infections. Our results also support the preferential use of DTG-containing regimens in first-line treatments, although surveillance of INSTI resistance is encouraged.
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Fan W, Wang X, Zhang Y, Meng J, Su M, Yang X, Shi H, Shi P, Lu X. Prevalence of resistance mutations associated with integrase inhibitors in therapy-naive HIV-positive patients in Baoding, Hebei province, China. Front Genet 2022; 13:975397. [PMID: 36186451 PMCID: PMC9515489 DOI: 10.3389/fgene.2022.975397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Antiretroviral therapy (ART) regimens containing integrase strand transfer inhibitors (INSTIs) are the recommended treatment for human immunodeficiency virus type 1 (HIV-1)-infected patients in the most recent guidelines in China. In this study, we investigated INSTI resistance mutations in newly diagnosed therapy-naive HIV-positive patients in Baoding City, Hebei Province (China) to provide guidance for implementing routine INSTI-associated HIV-1 genotypic resistance testing. Plasma samples were collected from HIV-1-infected patients without treatment at Baoding People’s Hospital from January 2020 to December 2021. The part of HIV-1 pol gene encoding integrase was amplified, sequenced, and analyzed for INSTI resistance. Clinical data including demographic data, CD4+ T cell counts, HIV-RNA loads, and resistance mutations were collected. Treatment-naïve HIV-1 patients (n = 131) were enrolled. We identified ten genotypes, and the predominant genotype was CRF01_AE in 67 patients (51.15%), CRF07_ BC in 39 patients (29.77%), subtype B in 11 patients (8.40%), and other subtypes (CRF68_01B, 3.82%; CRF55_01B, 1.53%, CRF80_0107, 1.53%; URFs 1.53%; and CRF103_01B, CRF59_01B, and CRF65_cpx, 1.4% each). Four major (E138A, R263k, G140S, and S147G) and three accessory (H51Y, Q146QL, and S153F) INSTI-resistance mutations were observed (genotype CRF01_AE, three patients; genotype B, one patient; and genotype CRF07_BC, one patient), resulting in different degrees of resistance to the following five INSTIs: raltegravir, elvitegravir, dolutegravir, bictegravir, and cabotegravir. The overall resistance rate was 3.82% (5/131). All INSTI-resistant strains were cross-resistant. The primary INSTI drug resistance rate among newly diagnosed HIV-infected patients in Baoding was low, but monitoring and research on HIV INSTI resistance should be strengthened in Baoding because INSTI-based regimen prescriptions are anticipated to increase in the near future.
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Affiliation(s)
- Weiguang Fan
- Clinical Laboratory, The People’s Hospital of Baoding, Baoding, Hebei, China
| | - Xiaodong Wang
- Infection Division, The People’s Hospital of Baoding, Baoding, Hebei, China
| | - Yuchen Zhang
- Infection Division, The People’s Hospital of Baoding, Baoding, Hebei, China
| | - Juan Meng
- Infection Division, The People’s Hospital of Baoding, Baoding, Hebei, China
| | - Miaomiao Su
- Infection Division, The People’s Hospital of Baoding, Baoding, Hebei, China
| | - Xuegang Yang
- Infection Division, The People’s Hospital of Baoding, Baoding, Hebei, China
| | - Haoxi Shi
- Clinical Laboratory, The People’s Hospital of Baoding, Baoding, Hebei, China
| | - Penghui Shi
- Clinical Laboratory, The People’s Hospital of Baoding, Baoding, Hebei, China
- *Correspondence: Penghui Shi, ; Xinli Lu,
| | - Xinli Lu
- Department of AIDS Research, Hebei Provincial Center for Disease Control and Prevention, Shijiazhuang, Hebei, China
- *Correspondence: Penghui Shi, ; Xinli Lu,
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Pre-Treatment Integrase Inhibitor Resistance and Natural Polymorphisms among HIV-1 Subtype C Infected Patients in Ethiopia. Viruses 2022; 14:v14040729. [PMID: 35458459 PMCID: PMC9029575 DOI: 10.3390/v14040729] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/18/2022] [Accepted: 03/28/2022] [Indexed: 02/01/2023] Open
Abstract
Dolutegravir-based antiretroviral therapy (ART) has been scaled up in many developing countries, including Ethiopia. However, subtype-dependent polymorphic differences might influence the occurrence of HIV-drug-resistance mutations (HIVDRMs). We analyzed the prevalence of pre-treatment integrase strand transfer inhibitor (INSTI) HIVDRMs and naturally occurring polymorphisms (NOPs) of the integrase gene, using plasma samples collected as part of the national HIVDR survey in Ethiopia in 2017. We included a total of 460 HIV-1 integrase gene sequences from INSTI-naïve (n = 373 ART-naïve and n = 87 ART-experienced) patients. No dolutegravir-associated HIVDRMs were detected, regardless of previous exposure to ART. However, we found E92G in one ART-naïve patient specimen and accessory mutations in 20/460 (4.3%) of the specimens. Moreover, among the 288 integrase amino acid positions of the subtype C, 187/288 (64.9%) were conserved (<1.0% variability). Analysis of the genetic barrier showed that the Q148H/K/R dolutegravir resistance pathway was less selected in subtype C. Docking analysis of the dolutegravir showed that protease- and reverse-transcriptase-associated HIVDRMs did not affect the native structure of the HIV-1 integrase. Our results support the implementation of a wide scale-up of dolutegravir-based regimes. However, the detection of polymorphisms contributing to INSTI warrants the continuous surveillance of INSTI resistance.
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Ambrosioni J, Liévano JR, Berrocal L, Inciarte A, de la Mora L, González-Cordón A, Martínez-Rebollar M, Laguno M, Torres B, Ugarte A, Chivite I, Leal L, de Lazzari E, Miró JM, Blanco JL, Martinez E, Mallolas J. Real-life experience with bictegravir/emtricitabine/tenofovir alafenamide in a large reference clinical centre. J Antimicrob Chemother 2022; 77:1133-1139. [PMID: 35040990 DOI: 10.1093/jac/dkab481] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/01/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The use of bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) is mainly based on robust, pivotal clinical trials. OBJECTIVES To provide data on clinical use of BIC/FTC/TAF in real life. PATIENTS AND METHODS This was an observational, retrospective and single-centre study. We included all adult, treatment-naive (TN) and treatment-experienced (TE) people living with HIV (PLWH) starting BIC/FTC/TAF from 8 June 2018. We evaluated effectiveness [on treatment (OT), modified intention-to-treat (mITT) and intention-to-treat (ITT)], tolerability and safety in those patients who reached 6 months of follow-up (M6). RESULTS We included 1584 PLWH [213 TN (13%) and 1371 TE (87%)]. The median (IQR) follow-up was 16 (7-21) months, with 81% and 53% of PLWH reaching M6 and M12, respectively. By OT, mITT and ITT, HIV-RNA <50 copies/mL was 77%, 70% and 62% at M6 and 92%, 77% and 63% at M12 for TN PLWH and 94%, 89% and 83% at M6 and 93%, 85% and 78% at M12 for TE PLWH, respectively. In PLWH carrying an M184V/I substitution, OT RNA <50 copies/mL was 89.5% at M6. The median CD4 cell count increased from 329 to 511/μL in TN PLWH and from 630 to 683/μL in TE PLWH at M6. Of the total, 1148 (88%) PLWH continued on BIC/FTC/TAF at M6. The most frequent known reason for discontinuation was toxicity [42 (69%) cases]; only 7 cases were considered virological failures (0.6% of the total OT cohort at M6), with no emerging resistance substitutions. CONCLUSIONS In real life, BIC/FTC/TAF showed high rates of virological suppression and also in PLWH carrying lamivudine/emtricitabine resistance substitutions. The tolerability and safety of BIC/FTC/TAF were good, with high persistence observed for patients on this regimen at M6.
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Affiliation(s)
- Juan Ambrosioni
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jhon Rojas Liévano
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Leire Berrocal
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Alexy Inciarte
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Lorena de la Mora
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ana González-Cordón
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - María Martínez-Rebollar
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Montserrat Laguno
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Berta Torres
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ainoa Ugarte
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Iván Chivite
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Lorna Leal
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Elisa de Lazzari
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José M Miró
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José L Blanco
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Esteban Martinez
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Josep Mallolas
- HIV Unit, Infectious Disease Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
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