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Newsum AM, Matser A, Schinkel J, van der Valk M, Brinkman K, van Eeden A, Lauw FN, Rijnders BJA, van de Laar TJW, van de Kerkhof M, Smit C, Boyd A, Arends JE, Prins M. Incidence of HCV Reinfection Among HIV-Positive MSM and Its Association With Sexual Risk Behavior: A Longitudinal Analysis. Clin Infect Dis 2021; 73:460-467. [PMID: 32459339 DOI: 10.1093/cid/ciaa645] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 05/21/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-positive men who have sex with men (MSM) are at high risk of hepatitis C virus (HCV) reinfection following clearance of HCV, but risk factors specifically for reinfection have never been comprehensively assessed. METHODS Using data from a prospective observational cohort study among HIV-positive MSM with an acute HCV infection (MOSAIC), the incidence of HCV reinfection following spontaneous clearance or successful treatment was assessed. A univariable Bayesian exponential survival model was used to identify risk factors associated with HCV reinfection. RESULTS In total, 122 HIV-positive MSM who had a spontaneously cleared or successfully treated HCV infection between 2003 and 2017 were included. During a median follow-up of 1.4 years (interquartile range [IQR] 0.5-3.8), 34 HCV reinfections were observed in 28 patients. The incidence of HCV reinfection was 11.5/100 person-years and among those with reinfection, median time to reinfection was 1.3 years (IQR 0.6-2.7). HCV reinfection was associated with receptive condomless anal intercourse, sharing of sex toys, group sex, anal rinsing before sex, ≥10 casual sex partners in the last 6 months, nadir CD4 cell count <200 cells/mm3, and recent CD4 cell count <500 cells/mm3. CONCLUSIONS Incidence of HCV reinfection was high and strongly associated with sexual risk behavior, highlighting the need for interventions to reduce risk behavior and prevent HCV reinfections among HIV-positive MSM.
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Affiliation(s)
- Astrid M Newsum
- Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, the Netherlands.,Division of Infectious Diseases, Amsterdam Infection and Immunity Institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Amy Matser
- Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Janke Schinkel
- Department of Medical Microbiology, Laboratory of Clinical Virology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc van der Valk
- Division of Infectious Diseases, Amsterdam Infection and Immunity Institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Kees Brinkman
- Department of Internal Medicine and Infectious Diseases, OLVG, Amsterdam, the Netherlands
| | - Arne van Eeden
- HIV Focus Center, DC Kliniek Lairesse, Amsterdam, The Netherlands
| | - Fanny N Lauw
- Department of Internal Medicine, Medical Center Jan van Goyen, Amsterdam, the Netherlands
| | - Bart J A Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Thijs J W van de Laar
- Department of Donor Medicine Research, Laboratory of Blood-Borne Infections, Sanquin Research, Amsterdam, the Netherlands.,Laboratory of Medical Microbiology, OLVG, Amsterdam, the Netherlands
| | - Marita van de Kerkhof
- Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, the Netherlands.,Division of Infectious Diseases, Amsterdam Infection and Immunity Institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Colette Smit
- Stichting HIV Monitoring, Amsterdam, the Netherlands
| | - Anders Boyd
- Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, the Netherlands.,Stichting HIV Monitoring, Amsterdam, the Netherlands
| | - Joop E Arends
- Department of Internal Medicine, Section Infectious Diseases, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maria Prins
- Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, the Netherlands.,Division of Infectious Diseases, Amsterdam Infection and Immunity Institute, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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van Santen DK, van der Helm JJ, Touloumi G, Pantazis N, Muga R, Gunsenheimer-Bartmeyer B, Gill MJ, Sanders E, Kelleher A, Zangerle R, Porter K, Prins M, Geskus RB. Effect of incident hepatitis C infection on CD4+ cell count and HIV RNA trajectories based on a multinational HIV seroconversion cohort. AIDS 2019; 33:327-337. [PMID: 30325767 DOI: 10.1097/qad.0000000000002040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Most studies on hepatitis C virus (HCV)/HIV-coinfection do not account for the order and duration of these two infections. We aimed to assess the effect of incident HCV infection, and its timing relative to HIV seroconversion (HIVsc) in HIV-positive MSM on their subsequent CD4+ T-cell count and HIV RNA viral load trajectories. METHODS We included MSM with well estimated dates of HIVsc from 17 cohorts within the CASCADE Collaboration. HCV-coinfected MSM were matched to as many HIV monoinfected MSM as possible by HIV-infection duration and combination antiretroviral therapy (cART) use. We used multilevel random-effects models stratified by cART use to assess differences in CD4+ cell count and HIV RNA viral load trajectories by HCV-coinfection status. FINDINGS We matched 214 (ART-naive) and 147 (on cART) HCV-coinfected MSM to 5384 and 3954, respectively, matched controls. The timing of HCV seroconversion (HCVsc) relative to HIVsc had no demonstrable effect on HIV RNA viral load or CD4+ cell count trajectories. In the first 2-3 years following HCVsc CD4 cell counts were lower among HCV-coinfected MSM, but became comparable with HIV monoinfected MSM thereafter. In ART-naive MSM, during the first 2 years after HCVsc, HIV RNA viral load levels were lower or comparable with HIV monoinfected, tending to be higher thereafter. In MSM on cART, HCV had no significant effect on having a detectable HIV RNA viral load. INTERPRETATION Irrespective of the duration of HIV infection when HCV is acquired, CD4+ cell counts were temporarily lower following HCVsc, even when on cART. The clinical implications of our findings remain to be further elucidated.
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Boender TS, Smit C, Sighem AV, Bezemer D, Ester CJ, Zaheri S, Wit FWNM, Reiss P. AIDS Therapy Evaluation in the Netherlands (ATHENA) national observational HIV cohort: cohort profile. BMJ Open 2018; 8:e022516. [PMID: 30249631 PMCID: PMC6169757 DOI: 10.1136/bmjopen-2018-022516] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE In 1998, the AIDS Therapy Evaluation in the Netherlands (ATHENA) national observational HIV cohort was established to demonstrate the lifesaving effectiveness of triple combination antiretroviral therapy, including HIV-protease inhibitors, that had recently been made available for clinical use. Subsequently, the HIV Monitoring Foundation was established by the Dutch Ministry of Health, Welfare and Sport to continue ATHENA as an open cohort in order to continue the registration and monitoring of all HIV-positive people as an integral part of HIV care in all 26 HIV treatment centres in the Netherlands. PARTICIPANTS To date, a total of 25 036 participants have been enrolled in the cohort, with 263 600 person-years of follow-up. As of 1 January 2017, 19 035 HIV-1-positive participants were known to be in care: 18 824 adults (81% men and 19% women) and 211 children (47% boys and 53% girls). The remaining 6001 participants had either died (46%), were lost to care (29%) or had moved abroad (25%). FINDINGS TO DATE Today, with over 20 years of follow-up, the ATHENA cohort has provided extensive knowledge on HIV treatment, comorbidities and coinfections and created insight into the transmission dynamics of the HIV epidemic. FUTURE PLANS ATHENA continues to enrol and monitor HIV positive people entering HIV care in the Netherlands. Future research will continue to provide tangible input into HIV care and prevention policies in the Netherlands and internationally.
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Affiliation(s)
| | - Colette Smit
- Stichting HIV Monitoring, Amsterdam, the Netherlands
| | | | | | | | - Sima Zaheri
- Stichting HIV Monitoring, Amsterdam, the Netherlands
| | - Ferdinand W N M Wit
- Stichting HIV Monitoring, Amsterdam, the Netherlands
- Department of Global Health, Academic Medical Center of the University of Amsterdam, Amsterdam, the Netherlands
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Peter Reiss
- Stichting HIV Monitoring, Amsterdam, the Netherlands
- Department of Global Health, Academic Medical Center of the University of Amsterdam, Amsterdam, the Netherlands
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
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Stirrup OT, Copas AJ, Phillips AN, Gill MJ, Geskus RB, Touloumi G, Young J, Bucher HC, Babiker AG. Predictors of CD4 cell recovery following initiation of antiretroviral therapy among HIV-1 positive patients with well-estimated dates of seroconversion. HIV Med 2018; 19:184-194. [PMID: 29230953 PMCID: PMC5836945 DOI: 10.1111/hiv.12567] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To investigate factors that predict speed of recovery and long-term CD4 cell count in HIV-1 seroconverters initiating combination antiretroviral therapy (cART), and to quantify the influence of very early treatment initiation. We make use of all pre-treatment CD4 counts, because analyses using only a single observation at initiation may be subject to biases. METHODS We used data from the CASCADE (Concerted Action on SeroConversion to AIDS and Death in Europe) multinational cohort collaboration of HIV-1 seroconverters. We analysed pre- and post-treatment data of patients with seroconversion dates estimated January 2003-March 2014 (n = 7600 for primary analysis) using a statistical model in which the characteristics of recovery in CD4 counts are determined by multiple predictive factors. Secondary analyses were performed incorporating uncertainty in the exact timing of seroconversion to allow more precise estimation of the benefit of very early treatment initiation. RESULTS 'True' CD4 count at cART initiation was the strongest predictor of CD4 count beyond 3 years on cART. Allowing for lack of complete certainty in the date of seroconversion, CD4 recovery was more rapid for patients in whom treatment was initiated within 4 months. For a given CD4 count, higher viral load (VL) at initiation was strongly associated with higher post-treatment CD4 recovery. For other patient and drug characteristics, associations with recovery were statistically significant but small in magnitude. CONCLUSIONS CD4 count at cART initiation is the most important factor in predicting post-treatment recovery, but VL provides substantial additional information. If cART is initiated in the first 4 months following seroconversion, recovery of CD4 counts appears to be more rapid.
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Affiliation(s)
- OT Stirrup
- MRC Clinical Trials UnitUniversity College LondonLondonUK
| | - AJ Copas
- MRC Clinical Trials UnitUniversity College LondonLondonUK
| | - AN Phillips
- Research Department of Infection & Population HealthUniversity College LondonLondonUK
| | - MJ Gill
- Department of MedicineUniversity of CalgaryCalgaryABCanada
| | - RB Geskus
- Department of Clinical Epidemiology, Biostatistics and BioinformaticsAcademic Medical Center (AMC)AmsterdamThe Netherlands
- Department of Infectious DiseasesPublic Health Service of AmsterdamAmsterdamThe Netherlands
- Oxford University Clinical Research UnitWellcome Trust Major Overseas ProgrammeHo Chi Minh CityVietnam
- Nuffield Department of Clinical MedicineCentre for Tropical Medicine and Global HealthUniversity of OxfordOxfordUK
| | - G Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Medical SchoolNational and Kapodistrian University of AthensAthensGreece
| | - J Young
- Basel Institute for Clinical Epidemiology and BiostatisticsUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - HC Bucher
- Basel Institute for Clinical Epidemiology and BiostatisticsUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - AG Babiker
- MRC Clinical Trials UnitUniversity College LondonLondonUK
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Abstract
PURPOSE OF REVIEW Hepatocellular carcinoma (HCC) is becoming an important cause of mortality in patients with HIV, attributed to coinfection with hepatitis C virus, hepatitis B virus, and the longer survival advantage these patients are achieving after introducing the highly active antiretroviral therapy (HAART) regimens. RECENT FINDINGS In addition to hepatitis infection, immunosuppression secondary to HIV infection, direct impact of the virus on liver parenchyma, and the use of hepatotoxic antiretroviral drugs, all contribute to HCC pathogenesis. Screening is very important in this particular population; data on population-specific guidelines are still controversial and scarce. Liver transplantation remains the treatment of choice in eligible patients. Trials on sorafenib have not included patients with HIV; yet, we know from small retrospective series that it might be safe and effective. SUMMARY In the HAART era, HCC is arising as a common non-AIDS defining cancer with high impact on morbidity and mortality of HIV-infected patients. Candidates for liver transplantation should be offered this option regardless of HIV infection. Safety and efficacy of sorafenib and other treatment modalities should be further studied and offered as deemed applicable to HIV patients diagnosed with HCC.
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Kallas E, Huik K, Türk S, Pauskar M, Jõgeda EL, Šunina M, Karki T, Des Jarlais D, Uusküla A, Avi R, Lutsar I. T Cell Distribution in Relation to HIV/HBV/HCV Coinfections and Intravenous Drug Use. Viral Immunol 2016; 29:464-470. [PMID: 27564643 DOI: 10.1089/vim.2016.0057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Intravenous drug use (IDU) is one of the most important transmission routes for blood borne viruses, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). These infections alter the subset distributions of T cells; however, knowledge of such effects during HIV, HBV, and or HCV coinfection is limited. Therefore, we aimed to evaluate any associations between T cell distribution and the presence of HIV, HBV, and HCV coinfections among persons who inject drugs (PWID). Blood samples from 88 Caucasian PWID (mean age 30; 82% male) and 47 age-matched subjects negative for all three infections (mean age of 29; 83% male) were analyzed. The T cell markers CD3, CD4, CD8, CD45RA, CCR7, HLA-DR, and CCR5 were assessed using flow cytometry. Of the PWID, 40% were HIV+HBV+HCV+, 20% HBV+HCV+, 19% HCV+, and 13% negative for all three infections. The HIV+HBV+HCV+ PWID had lower percentages of CD4+ and higher percentages of CD8+ cells compared to triple negative PWID (p < 0.001 in all cases). The only difference between HBV+HCV+ with triple negative PWID was the lower CD4+ cell percentages among the former (52.1% and 58.6%, p = 0.021). Triple negative PWID had higher immune activation and number of CCR5+ cells compared to the controls. We suggest that the altered T cell subset distribution among PWID is mainly triggered by HIV infection and or IDU, while HBV and or HCV seropositivity has minimal additional effects on CD4+ cell distribution.
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Affiliation(s)
- Eveli Kallas
- 1 Department of Microbiology, Institute of Biomedicine and Translational Medicine, Faculty of Medicine, University of Tartu , Tartu, Estonia
| | - Kristi Huik
- 1 Department of Microbiology, Institute of Biomedicine and Translational Medicine, Faculty of Medicine, University of Tartu , Tartu, Estonia
| | - Silver Türk
- 1 Department of Microbiology, Institute of Biomedicine and Translational Medicine, Faculty of Medicine, University of Tartu , Tartu, Estonia
| | - Merit Pauskar
- 1 Department of Microbiology, Institute of Biomedicine and Translational Medicine, Faculty of Medicine, University of Tartu , Tartu, Estonia
| | - Ene-Ly Jõgeda
- 1 Department of Microbiology, Institute of Biomedicine and Translational Medicine, Faculty of Medicine, University of Tartu , Tartu, Estonia
| | - Marina Šunina
- 2 Department of Immunology, Institute of Biomedicine and Translational Medicine, Faculty of Medicine, University of Tartu , Tartu, Estonia
| | - Tõnis Karki
- 1 Department of Microbiology, Institute of Biomedicine and Translational Medicine, Faculty of Medicine, University of Tartu , Tartu, Estonia
| | - Don Des Jarlais
- 3 Icahn School of Medicine at Mount Sinai , New York, New York
| | - Anneli Uusküla
- 4 Institute of Family Medicine and Public Health, Faculty of Medicine, University of Tartu , Tartu, Estonia
| | - Radko Avi
- 1 Department of Microbiology, Institute of Biomedicine and Translational Medicine, Faculty of Medicine, University of Tartu , Tartu, Estonia
| | - Irja Lutsar
- 1 Department of Microbiology, Institute of Biomedicine and Translational Medicine, Faculty of Medicine, University of Tartu , Tartu, Estonia
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Natural history of liver disease and effect of hepatitis C virus on HIV disease progression. Curr Opin HIV AIDS 2016; 10:303-8. [PMID: 26248118 DOI: 10.1097/coh.0000000000000187] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Due to high prevalence rates, the hepatitis C virus (HCV) and the HIV cause two viral infections of global importance. Shared routes of transmission lead to a high number of dually infected individuals especially in specific populations such as intravenous drug users or people from highly endemic regions for both viruses. Treatment progress made in the field of HIV in the past three decades diminished the number of HIV patients who die from opportunistic infections and enabled a rise of HCV-associated liver disease in the HIV-HCV-coinfected population. RECENT FINDINGS An HIV-HCV coinfection is mainly characterized by a faster progression to liver cirrhosis that may lead to hepatic decompensation or the development of hepatocellular carcinoma (HCC). The treatment of HIV with highly active antiretroviral therapy (HAART) may only partly reverse this effect by the restoration of the immune system. Although no clear deleterious effect of HCV on the course of HIV infection is described, an increased HIV-associated and non-HIV-associated mortality has been described in patients not cured from their HCV infection. SUMMARY In this article, we review the latest knowledge on the natural course of HCV in the HIV-infected population, the role of HIV treatment, and the possible effects of HCV on HIV disease progression.
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Garriga C, García de Olalla P, Miró JM, Ocaña I, Knobel H, Barberá MJ, Humet V, Domingo P, Gatell JM, Ribera E, Gurguí M, Marco A, Caylà JA. Mortality, Causes of Death and Associated Factors Relate to a Large HIV Population-Based Cohort. PLoS One 2015; 10:e0145701. [PMID: 26716982 PMCID: PMC4696823 DOI: 10.1371/journal.pone.0145701] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 12/06/2015] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Antiretroviral therapy has led to a decrease in HIV-related mortality and to the emergence of non-AIDS defining diseases as competing causes of death. This study estimates the HIV mortality rate and their risk factors with regard to different causes in a large city from January 2001 to June 2013. MATERIALS AND METHODS We followed-up 3137 newly diagnosed HIV non-AIDS cases. Causes of death were classified as HIV-related, non-HIV-related and external. We examined the effect of risk factors on survival using mortality rates, Kaplan-Meier plots and Cox models. Finally, we estimated survival for each main cause of death groups through Fine and Gray models. MORTALITY RESULTS 182 deaths were found [14.0/1000 person-years of follow-up (py); 95% confidence interval (CI):12.0-16.1/1000 py], 81.3% of them had a known cause of death. Mortality rate by HIV-related causes and non-HIV-related causes was the same (4.9/1000 py; CI:3.7-6.1/1000 py), external was lower [1.7/1000 py; (1.0-2.4/1000 py)]. SURVIVAL RESULTS Kaplan-Meier estimate showed worse survival in intravenous drug user (IDU) and heterosexuals than in men having sex with men (MSM). Factors associated with HIV-related causes of death include: IDU male (subHazard Ratio (sHR):3.2; CI:1.5-7.0) and <200 CD4 at diagnosis (sHR:2.7; CI:1.3-5.7) versus ≥500 CD4. Factors associated with non-HIV-related causes of death include: ageing (sHR:1.5; CI:1.4-1.7) and heterosexual female (sHR:2.8; CI:1.1-7.3) versus MSM. Factors associated with external causes of death were IDU male (sHR:28.7; CI:6.7-123.2) and heterosexual male (sHR:11.8; CI:2.5-56.4) versus MSM. CONCLUSION AND RECOMMENDATION There are important differences in survival among transmission groups. Improved treatment is especially necessary in IDUs and heterosexual males.
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Affiliation(s)
- César Garriga
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
- Spanish Field Epidemiology Training Programme, National Centre for Epidemiology, Instituto de Salud Carlos III, Madrid, Spain
- * E-mail: (CG); (PGdO)
| | - Patricia García de Olalla
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- * E-mail: (CG); (PGdO)
| | - Josep M. Miró
- Hospital Clinic- August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Inma Ocaña
- Infectious Diseases, Hospital Vall de Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Hernando Knobel
- Internal Medicine-Infectious Diseases, Hospital del Mar, Barcelona, Spain
| | - Maria Jesús Barberá
- Infectious Diseases, Hospital Vall de Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victoria Humet
- Direcció General de Serveis Penitenciaris i de Rehabilitació, Departament de Justícia, Barcelona, Spain
| | - Pere Domingo
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep M. Gatell
- Hospital Clinic- August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Esteve Ribera
- Infectious Diseases, Hospital Vall de Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mercè Gurguí
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrés Marco
- Direcció General de Serveis Penitenciaris i de Rehabilitació, Departament de Justícia, Barcelona, Spain
| | - Joan A. Caylà
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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