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N’takpé JB, Gabillard D, Moh R, Gardiennet E, Toni TD, Kouame GM, Badje A, Emieme A, Karcher S, Le Carrou J, Ménan H, Danel C, Eholie SP, Rouzioux C, Anglaret X, Lambotte O. Elite and viremic HIV-1 controllers in West Africa. AIDS 2022; 36:29-38. [PMID: 34524145 PMCID: PMC8654265 DOI: 10.1097/qad.0000000000003072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/03/2021] [Accepted: 07/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Data on HIV-1 controllers in Africa are scarce. We report the proportion of HIV-1 controllers in a group of adults prospectively monitored with frequent viral load measurements as part of a clinical trial in West Africa. METHODS For the Temprano trial, antiretroviral therapy (ART)-naive HIV-1 infected adults with no criteria for starting ART were randomized to start ART immediately or defer ART until the WHO starting criteria were met. Plasma viral load was measured every 6 months. The trial follow-up was 30 months. We considered all Temprano participants randomized to defer ART. Patients with all semestrial viral <2000 copies/ml and still off ART at month 30 were defined as HIV-1 controllers. Controllers with all viral loads <50 copies/ml were defined as elite controllers, the rest as viremic controllers. RESULTS Of the 1023 HIV-1-infected adults randomized in the Temprano deferred-ART group, 18 (1.8%) met the criteria for classification as HIV controllers, of whom seven (0.7%) were elite controllers and 11 (1.1%) viremic controllers. The HIV-1 controllers had low peripheral blood mononuclear cell HIV-1 DNA and low inflammatory marker levels. They maintained high CD4+ cell count and percentages and had a low morbidity rate. DISCUSSION HIV controllers exist in Africa at a proportion close to that reported elsewhere. They represent a small fraction of all HIV-1-infected patients but raise important questions. Further studies should assess whether starting ART might represent more risk than benefit for some controllers, and where it does, how to identify these patients before they start ART.
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Affiliation(s)
- Jean Baptiste N’takpé
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
- Département de Dermatologie et Maladies Infectieuses, Université Felix Houphouët Boigny, Abidjan, Côte d’Ivoire
| | - Delphine Gabillard
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
| | - Raoul Moh
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
- Département de Dermatologie et Maladies Infectieuses, Université Felix Houphouët Boigny, Abidjan, Côte d’Ivoire
| | - Elise Gardiennet
- AP-HP, CHU Necker Enfants Malades, Université Paris Descartes, Paris, France
| | - Thomas-d’Aquin Toni
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
- CeDReS, CHU de Treichville, Abidjan, Côte d’Ivoire
| | - Gérard M. Kouame
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
- Département de Dermatologie et Maladies Infectieuses, Université Felix Houphouët Boigny, Abidjan, Côte d’Ivoire
| | - Anani Badje
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
- Département de Dermatologie et Maladies Infectieuses, Université Felix Houphouët Boigny, Abidjan, Côte d’Ivoire
| | - Arlette Emieme
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
- CeDReS, CHU de Treichville, Abidjan, Côte d’Ivoire
| | - Sophie Karcher
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
| | - Jérome Le Carrou
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
| | - Hervé Ménan
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
- CeDReS, CHU de Treichville, Abidjan, Côte d’Ivoire
| | - Christine Danel
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
| | - Serge P. Eholie
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
- Département de Dermatologie et Maladies Infectieuses, Université Felix Houphouët Boigny, Abidjan, Côte d’Ivoire
| | - Christine Rouzioux
- PACCI/ANRS Research Center
- Faculté de Médecine, Université Paris Descartes, Paris
| | - Xavier Anglaret
- Inserm 1219, University of Bordeaux, IRD, Bordeaux, France
- PACCI/ANRS Research Center
| | - Olivier Lambotte
- AP-HP Paris Saclay, Hôpital Bicêtre, Clinical Immunology Department
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IDMIT/IMVA-HB), Le Kremlin Bicêtre, France
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Tymejczyk O, Brazier E, Yiannoutsos C, Wools-Kaloustian K, Althoff K, Crabtree-Ramírez B, Van Nguyen K, Zaniewski E, Dabis F, Sinayobye JD, Anderegg N, Ford N, Wikramanayake R, Nash D. HIV treatment eligibility expansion and timely antiretroviral treatment initiation following enrollment in HIV care: A metaregression analysis of programmatic data from 22 countries. PLoS Med 2018; 15:e1002534. [PMID: 29570723 PMCID: PMC5865713 DOI: 10.1371/journal.pmed.1002534] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 02/14/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The effect of antiretroviral treatment (ART) eligibility expansions on patient outcomes, including rates of timely ART initiation among those enrolling in care, has not been assessed on a large scale. In addition, it is not known whether ART eligibility expansions may lead to "crowding out" of sicker patients. METHODS AND FINDINGS We examined changes in timely ART initiation (within 6 months) at the original site of HIV care enrollment after ART eligibility expansions among 284,740 adult ART-naïve patients at 171 International Epidemiology Databases to Evaluate AIDS (IeDEA) network sites in 22 countries where national policies expanding ART eligibility were introduced between 2007 and 2015. Half of the sites included in this analysis were from Southern Africa, one-third were from East Africa, and the remainder were from the Asia-Pacific, Central Africa, North America, and South and Central America regions. The median age of patients enrolling in care at contributing sites was 33.5 years, and the median percentage of female patients at these clinics was 62.5%. We assessed the 6-month cumulative incidence of timely ART initiation (CI-ART) before and after major expansions of ART eligibility (i.e., expansion to treat persons with CD4 ≤ 350 cells/μL [145 sites in 22 countries] and CD4 ≤ 500 cells/μL [152 sites in 15 countries]). Random effects metaregression models were used to estimate absolute changes in CI-ART at each site before and after guideline expansion. The crude pooled estimate of change in CI-ART was 4.3 percentage points (95% confidence interval [CI] 2.6 to 6.1) after ART eligibility expansion to CD4 ≤ 350, from a baseline median CI-ART of 53%; and 15.9 percentage points (pp) (95% CI 14.3 to 17.4) after ART eligibility expansion to CD4 ≤ 500, from a baseline median CI-ART of 57%. The largest increases in CI-ART were observed among those newly eligible for treatment (18.2 pp after expansion to CD4 ≤ 350 and 47.4 pp after expansion to CD4 ≤ 500), with no change or small increases among those eligible under prior guidelines (CD4 ≤ 350: -0.6 pp, 95% CI -2.0 to 0.7 pp; CD4 ≤ 500: 4.9 pp, 95% CI 3.3 to 6.5 pp). For ART eligibility expansion to CD4 ≤ 500, changes in CI-ART were largest among younger patients (16-24 years: 21.5 pp, 95% CI 18.9 to 24.2 pp). Key limitations include the lack of a counterfactual and difficulty accounting for secular outcome trends, due to universal exposure to guideline changes in each country. CONCLUSIONS These findings underscore the potential of ART eligibility expansion to improve the timeliness of ART initiation globally, particularly for young adults.
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Affiliation(s)
- Olga Tymejczyk
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
- * E-mail:
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | - Constantin Yiannoutsos
- R.M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | - Kara Wools-Kaloustian
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Keri Althoff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | | | - Elizabeth Zaniewski
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | | | - Nathan Ford
- World Health Organization, Geneva, Switzerland
| | - Radhika Wikramanayake
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
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Song A, Liu X, Huang X, Meyers K, Oh DY, Hou J, Xia W, Su B, Wang N, Lu X, Xia H, Yang X, Chen H, Wu H. From CD4-Based Initiation to Treating All HIV-Infected Adults Immediately: An Evidence-Based Meta-analysis. Front Immunol 2018; 9:212. [PMID: 29487595 PMCID: PMC5816781 DOI: 10.3389/fimmu.2018.00212] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 01/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background The World Health Organization (WHO) Consolidated antiretroviral therapy (ART) guidelines set the CD4+ T-cell counts threshold to 500 cells/mm3 in 2013, and 2015 guidelines recommend treating all HIV-infected adults regardless of their CD4+ T-cell counts. To inform the decision-making around ART guidelines for people living with HIV, we systematically reviewed the literature to estimate differences in clinical benefits between individuals starting treatment with baseline CD4+ T-cell counts ≥500 cells/mm3 (early initiation) as compared to <500 cells/mm3 (deferred initiation). Methods We systematically searched the electronic databases and abstracts for randomized controlled trials (RCT) and observational studies. Outcomes were mortality, AIDS progression, AIDS or death, immunologic recovery, and virologic suppression. We pooled data across studies and performed analyses of effect sizes. Results We identified 13 studies comparing early and deferred treatment. The pooled risk ratio (RR) of mortality of 11 observational studies was 0.90 (95% CI 0.82–0.99), with moderate heterogeneity (I2 = 53%). The pooled RR for progression to AIDS from two observational studies was 0.77 (95% CI 0.47–1.24). Five observational studies found a pooled RR of death or AIDS of 0.94 (95% CI 0.93–0.95). For the outcome of immunologic recovery, defined as CD4+ T-cell counts reaching at least 800 cells/mm3 after ART, one observational study found early initiation of ART had an HR (hazard ratio) of 2.39 (95% CI 1.93–2.96). The pooled RR of viral suppression (a viral load <50 copies/ml) after 9 months from one cohort was 1.04 (95% CI 0.99–1.09). Conclusion Mortality risk and risk for AIDS appear to be reduced among people living with HIV with early initiation of ART, based on current WHO guidelines, as compared to those with deferred initiation of ART (<500 cells/mm3).
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Affiliation(s)
- Aixin Song
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xinchao Liu
- Infectious Diseases Department, Peking Union Medical College Hospital, Beijing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Kathrine Meyers
- The Aaron Diamond AIDS Research Center, New York, NY, United States
| | - Djin-Ye Oh
- The Aaron Diamond AIDS Research Center, New York, NY, United States
| | - Jianhua Hou
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Wei Xia
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Bin Su
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Ni Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Xiaofan Lu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Huan Xia
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xiaodong Yang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
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Eholié SP, Badje A, Kouame GM, N’takpe JB, Moh R, Danel C, Anglaret X. Antiretroviral treatment regardless of CD4 count: the universal answer to a contextual question. AIDS Res Ther 2016; 13:27. [PMID: 27462361 PMCID: PMC4960900 DOI: 10.1186/s12981-016-0111-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 07/12/2016] [Indexed: 02/06/2023] Open
Abstract
After a period where it was recommended to start antiretroviral therapy (ART) early, the CD4 threshold for treating asymptomatic adults dropped to 200/mm3 at the beginning of the 2000s. This was mostly due to a great prudence with regards to drug toxicity. The ART-start CD4 threshold in most international guidelines was then raised to 350/mm3 in 2006–2009 and to 500/mm3 in 2009–2013. Between 2012 and 2015, international guidelines went the last step further and recommended treating all HIV-infected adults regardless of their CD4 count. This ultimate step was justified by the results of three randomized controlled trials, HPTN 052, Temprano ANRS 12136 and START. These three trials assessed the benefits and risks of starting ART immediately upon inclusion (“early ART”) versus deferring ART until the current starting criteria were met (“deferred ART”). Taken together, they recruited 8427 HIV-infected adults in 37 countries. The primary outcome was severe morbidity, a composite outcome that included all-cause deaths, AIDS diseases, and non-AIDS cancers in the three trials. The trial results were mutually consistent and reinforcing. The overall risk of severe morbidity was significantly 44–57 % lower in patients randomized to early ART as compared to deferred ART. Early ART also decreased the risk of AIDS, tuberculosis, invasive bacterial diseases and Kaposi’s sarcoma considered separately. The incidence of severe morbidity was 3.2 and 3.5 times as high in HPTN052 and Temprano as in START, respectively. This difference is mostly due to the geographical context of morbidity. The evidence is now strong that initiating ART at high CD4 counts entails individual benefits worldwide, and that this is all the more true in low resource contexts where tuberculosis and other bacterial diseases are highly prevalent. These benefits in addition to population benefits consisting of preventing HIV transmission demonstrated in HPTN052, justify the recommendation that HIV-infected persons should initiate ART regardless of CD4 count. This recommendation faces many challenges, including the fact that switching from “treat at 500 CD4/mm3” to “treat everyone” not only requires more tests and more drugs, but also more people to support patients and help them remain in care.
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Wademan DT, Reynolds LJ. Interrogating concepts of care in the HIV care continuum: ethnographic insights from the implementation of a "Universal Test and Treat" approach in South Africa. AIDS Care 2016; 28 Suppl 3:52-8. [PMID: 26984394 DOI: 10.1080/09540121.2016.1161164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
South Africa currently sustains the largest antiretroviral treatment (ART) programme in the world. The number of people on ART is set to grow even more in the coming years as incidence remains stable, people on ART stay healthy, and guidelines for initiation become increasingly inclusive. The South African public health sector has increasingly relied on community- and home-based lay and professional "carers" to carry out the everyday tasks of rolling out the ART programme. Drawing on ethnographic research in one locality in the Western Cape, the paper explores the care practices of two such groups of carers implementing a 'Universal Test and Treat' (UTT) approach. The UTT approach being evlauated in this place is based on one model of the HIV treatment cascade, or care continuum, which focuses on the steps necessary to identify and link HIV-positive individuals to care and retain them in lifelong HIV treatment. In this context, community-based care workers are responsible for carrying out several discrete steps in the HIV care continuum, including testing people for HIV, linking HIV-positive individuals to care, and supporting adherence. In order to retain clients within the continuum, however, carers also perform other forms of labour that stretch their care work beyond more bounded notions of a stepwise progression of care. These broader forms of care, which can be material, emotional, social or physical in nature, appear alongside the more structured technical and biomedical tasks formally expected of carers. We argue that understanding the dynamics of these more distributed and relational forms of care is essential for the effective implementation of the care continuum, and of the UTT approach, in diverse contexts.
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Affiliation(s)
- Dillon T Wademan
- a Department of Sociology and Social Anthropology , Stellenbosch University , Private Bag X1, 7602, Matieland , South Africa
| | - Lindsey J Reynolds
- a Department of Sociology and Social Anthropology , Stellenbosch University , Private Bag X1, 7602, Matieland , South Africa.,b Population Studies and Training Center , Brown University , 68 Waterman St., Providence , RI 02912 , USA
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Gonçalves P, Kamdem ST. Reaching an AIDS-Free Generation in Côte d'Ivoire, Data Driven Policy Design for HIV/AIDS Response Programs. INTERNATIONAL JOURNAL OF SYSTEM DYNAMICS APPLICATIONS 2016. [DOI: 10.4018/ijsda.2016010104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Sub-Saharan Africa is home to 24.7 million people living with HIV of an estimated total of 35.0 million people globally in 2013. It also accounts for almost 70% of the new HIV infections globally. In West Africa, Cote d'Ivoire has the highest HIV prevalence, or 3.7% of the 2012 population, and the two virus types (HIV-1 & HIV-2) are present. From an epidemiological standpoint, these unique attributes make Cote d'Ivoire unique. At the same time, existing HIV/AIDS modeling policies have being developed from the data of countries that do not have these peculiarities. This research develops a formal system dynamics model capturing the evolution of HIV/AIDS in Cote d'Ivoire for four decades, starting in 1990. The findings include a development of HIV/AIDS behavior pattern over time that led to the proposal of evidence-based policies.
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Affiliation(s)
- Paulo Gonçalves
- Università della Svizzera Italiana (USI), Lugano, Switzerland
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Plazy M, Dabis F, Naidu K, Orne-Gliemann J, Barnighausen T, Dray-Spira R. Change of treatment guidelines and evolution of ART initiation in rural South Africa: data of a large HIV care and treatment programme. BMC Infect Dis 2015; 15:452. [PMID: 26497054 PMCID: PMC4620741 DOI: 10.1186/s12879-015-1207-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 10/12/2015] [Indexed: 11/24/2022] Open
Abstract
Background While WHO recommendations are to treat people earlier and earlier, it will considerably increase the number of HIV infected people eligible for antiretroviral therapy (ART). In South Africa, a country which carries one of the highest HIV burden worldwide, very few studies are available on the impact of the ART guidelines on time to ART initiation in both individuals with low CD4 count and those newly eligible for ART. We thus aimed to describe ART initiation percentages in a large HIV programme in rural KwaZulu-Natal, South Africa, according to the temporal changes of national ART eligibility guidelines from 2007 to 2012. Methods Adults who accessed the decentralized Hlabisa HIV treatment programme in 2007–2012 were included. Three periods following the temporal change of ART eligibility guidelines were defined (Period 1: until April 2010; Period 2: April 2010 - July 2011; Period 3: from August 2011). Percentages of ART initiation within three months of programme entry were estimated in men, in women of childbearing age (<40 years old) and in older women, and stratifying by CD4 count. Trend tests and logistic regression models were used to study the effects of change of guidelines on ART initiation percentages. Results In individuals with CD4 count ≤200 cells/μL (N = 5709 men, N = 6743 women <40 years old and N = 2017 older women), percentages of ART initiation did not differ over time (p trend = 0.25; 0.28; and 0.14, respectively). In individuals with CD4 count = 201–350 cells/μL (N = 2680 men, N = 6086 women <40 years old and N = 1415 older women), percentages of ART initiation significantly increased over time (p trend <0.01 for the three groups): from 6 % in Period 1 to 20 % in Period 2 to 40 % in Period 3 in women of childbearing age, and from 7 % to 8-10 % to 42 % in men and in older women. Conclusions As temporal changes of guidelines, percentages of ART initiation significantly increased in newly ART eligible people and did not decrease in individuals with very low CD4 counts. It will be crucial to continue verifying the evolution of these percentages of ART initiation with future recommendations reaching near-to-universal access to ART, to ensure that individuals most in need of ART receive it.
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Affiliation(s)
- Mélanie Plazy
- INSERM U897 - Centre Inserm Epidémiologie et Biostatistique, Bordeaux, France. .,Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université Bordeaux, Bordeaux, France.
| | - François Dabis
- INSERM U897 - Centre Inserm Epidémiologie et Biostatistique, Bordeaux, France. .,Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université Bordeaux, Bordeaux, France.
| | - Kevindra Naidu
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, KwaZulu-Natal, South Africa.
| | - Joanna Orne-Gliemann
- INSERM U897 - Centre Inserm Epidémiologie et Biostatistique, Bordeaux, France. .,Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université Bordeaux, Bordeaux, France.
| | - Till Barnighausen
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, KwaZulu-Natal, South Africa. .,Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA.
| | - Rosemary Dray-Spira
- INSERM, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Team of research in Social Epidemiology, F-75013, Paris, France. .,Pierre Louis Institute of Epidemiology and Public Health, Team of research in Social Epidemiology, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, F-75013, Paris, France.
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