A high rate of HIV-1 acquisition post immigration among migrants in Sweden determined by a CD4 T-cell decline trajectory model

Knowledge gaps related to HIV and condom use for preventing pregnancy: a cross-sectional study among migrants in Sweden

BACKGROUND

Information and knowledge of sexual and reproductive health and rights (SRHR) plays a crucial role in promoting safe sexual practices among young migrants. We aimed to assess the sociodemographic factors of migrants associated with knowledge of condoms and the prevention, treatment, and transmission of HIV to highlight the need for SRHR information, including comprehensive sexual health education.

METHODS

A cross-sectional survey was conducted (2018-2019) among migrants at Swedish language schools and high schools across Sweden. The survey included questions about knowledge of condom use for preventing pregnancy and HIV treatment and transmission. Descriptive statistics were calculated, and multivariable logistic regression analyses were performed to assess the responses to the knowledge questions and sociodemographic characteristics.

RESULTS

Out of 3430 respondents (median age: 35, interquartile range: 20), approximately 39% were unaware that condoms can prevent unplanned pregnancies. Only 58% of the respondents knew that condoms reduce the risk of contracting HIV. About 77% were unaware of HIV treatment, and 52% reported not knowing that a woman with HIV could transmit the virus to her baby during pregnancy or breastfeeding. Incorrect knowledge about condom use to prevent unwanted pregnancy was associated with several factors: younger age (15-19 years) adjusted odds ratio (aOR) 1.35; 95% confidence interval (CI), 1.02-1.79); female respondents (aOR: 1.68; 95% CI 1.36-2.07); lack of previous sexual health education (aOR: 2.57; 95% CI 2.11-3.13); low level of education (aOR: 1.30; 95% CI 1.04-1.61). Originating from the Americas, European, or sub-Saharan African regions was associated with a 34-42% decreased likelihood of incorrect knowledge that condoms can reduce the risk of HIV infection compared to respondents from the Middle East and North Africa (MENA). More than half (64%) of respondents reported needing more SRHR information.

CONCLUSIONS

We found significant knowledge gaps on HIV and condom use for preventing pregnancy among migrants in Sweden. Comprehensive sexual health education in language schools, along with information to newly arrived migrants from diverse regional backgrounds and targeted sexual health services to younger individuals, women, and those who lack sexual health education, are needed to address these information gaps and provide crucial SRHR education and information.

High proportion of post-migration HIV acquisition in migrant men who have sex with men receiving HIV care in the Paris region, and associations with social disadvantage and sexual behaviours: results of the ANRS-MIE GANYMEDE study, France, 2021 to 2022

BackgroundSome migrant men who have sex with men (MSM) acquire HIV in France.AimsWe investigated, in migrant MSM receiving HIV care in France, the (i) rate of post-migration-HIV acquisition in France, (ii) delay between arrival and HIV acquisition and (iii) factors affecting HIV acquisition within 1 year after migration.MethodsThis cross-sectional study focused on ≥ 18-year-old MSM born outside France, receiving HIV care in the Paris region. Information on migration history, socioeconomic condition, sexual activity, and health was collected in May 2021-June 2022 through self-administered questionnaires and medical records. Post-migration-HIV-acquisition rate and delay between arrival in France and HIV acquisition were estimated from biographical data and CD4+ T-cell counts. Predictors of HIV acquisition within 1 year after migration were determined using logistic regression.ResultsOverall post-migration HIV-acquisition rate was 61.7% (715/1,159; 95%CI: 61.2-62.2), ranging from 40.5% (95%CI: 39.6-41.6) to 85.4% (95%CI: 83.9-86.0) in participants from Latin America and North Africa. Among post-migration-HIV acquisitions, those within 1 year after migration represented 13.1% overall (95%CI: 11.6-14.6), being highest in participants from sub-Saharan Africa (25%; 95%CI: 21.5-28.3). Participants ≥ 15-years old at migration, with post-migration-acquired HIV, had a 7.5-year median interval from arrival in France to HIV acquisition (interquartile range (IQR): 3.50-14.75). Older age at arrival, region of origin (sub-Saharan Africa and Asia), degree of social disadvantage and numbers of sexual partners were independently associated with acquiring HIV within 1 year in France.ConclusionOur findings may guide HIV prevention policies for most vulnerable migrants to Europe.

Post-migration HIV acquisition: A systematic review and meta-analysis

Migrants in Europe face a disproportionate burden of HIV infection; however, it remains unclear if this can be prevented through public health interventions in host countries. We undertake a systematic review and meta-analysis to estimate post-migration HIV acquisition (PMHA) as a proportion of all HIV cases in European migrants. MEDLINE, EMBASE, Global Health, HMIC, and Cochrane Library were searched with terms capturing 'HIV', 'migration', and 'Europe'. Data relating to the proportion of HIV acquired following migration were extracted and random-effects model (REM) meta-analysis was undertaken to calculate a pooled estimate for the proportion of PMHA in European countries. Subgroup meta-analysis was undertaken for PMHA by migrant demographic characteristics and host country. Fifteen articles were included for systematic review following retrieval and screening of 2,320 articles. A total of 47,182 migrants in 11 European countries were included in REM meta-analysis, showing an overall PMHA proportion of 0.30 (95% CI: 0.23-0.38). Subgroup analysis showed no significant difference in PMHA between host country and migrant demographic characteristics. This work illustrates that migrants continue to be at high risk of HIV acquisition in Europe. This indicates the need for targeted screening and HIV prevention interventions, ensuring resources are appropriately directed to combat the spread of HIV.

A population-level application of a method for estimating the timing of HIV acquisition among migrants to Australia

INTRODUCTION

Australia has set the goal for the virtual elimination of HIV transmission by the end of 2022, yet accurate information is lacking on the level of HIV transmission occurring among residents. We developed a method for estimating the timing of HIV acquisition among migrants, relative to their arrival in Australia. We then applied this method to surveillance data from the Australian National HIV Registry with the aim of ascertaining the level of HIV transmission among migrants to Australia occurring before and after migration, and to inform appropriate local public health interventions.

METHODS

We developed an algorithm incorporating CD4⁺ T-cell decline back-projection and enhanced variables (clinical presentation, past HIV testing history and clinician estimate of the place of HIV acquisition) and compared it to a standard algorithm which uses CD4⁺ T-cell back-projection only. We applied both algorithms to all new HIV diagnoses among migrants to estimate whether HIV infection occurred before or after arrival in Australia.

RESULTS

Between 1 January 2016 and 31 December 2020, 1909 migrants were newly diagnosed with HIV in Australia, 85% were men, and the median age was 33 years. Using the enhanced algorithm, 932 (49%) were estimated to have acquired HIV after arrival in Australia, 629 (33%) before arrival (from overseas), 250 (13%) close to arrival and 98 (5%) were unable to be classified. Using the standard algorithm, 622 (33%) were estimated to have acquired HIV in Australia, 472 (25%) before arrival, 321 (17%) close to arrival and 494 (26%) were unable to be classified.

CONCLUSIONS

Using our algorithm, close to half of migrants diagnosed with HIV were estimated to have acquired HIV after arrival in Australia, highlighting the need for tailored culturally appropriate testing and prevention programmes to limit HIV transmission and achieve elimination targets. Our method reduced the proportion of HIV cases unable to be classified and can be adopted in other countries with similar HIV surveillance protocols, to inform epidemiology and elimination efforts.

Cohort profile: InfCareHIV, a prospective registry-based cohort study of people with diagnosed HIV in Sweden

PURPOSE

The Swedish InfCareHIV cohort was established in 2003 to ensure equal and effective care of people living with HIV (PLHIV) and enable long-term follow-up. InfCareHIV functions equally as a decision support system as a quality registry, ensuring up-to-date data reported in real time.

PARTICIPANTS

InfCareHIV includes data on >99% of all people with diagnosed HIV in Sweden and up to now 13 029 have been included in the cohort. InfCareHIV includes data on HIV-related biomarkers and antiretroviral therapies (ART) and also on demographics, patient-reported outcome measures and patient-reported experience measures.

FINDINGS TO DATE

Sweden was in 2015 the first country to reach the UNAIDS (United Nations Programme on HIV/AIDS)/WHO's 90-90-90 goals. Late diagnosis of HIV infection was identified as a key problem in the Swedish HIV-epidemic, and low-level HIV viraemia while on ART associated with all-cause mortality. Increased HIV RNA load in the cerebrospinal fluid (CSF) despite suppression of the plasma viral load was found in 5% of PLHIV, a phenomenon referred to as 'CSF viral escape'. Dolutegravir-based treatment in PLHIV with pre-existing nucleoside reverse transcriptase inhibitor-mutations was non-inferior to protease inhibitor-based regimens. An increase of transmitted drug resistance was observed in the InfCareHIV cohort. Lower efficacy for protease inhibitors was not due to lower adherence to treatment. Incidence of type 2 diabetes and insulin resistance was high in the ageing HIV population. Despite ART, the risk of infection-related cancer as well as lung cancer was increased in PLHIV compared with HIV-negative. PLHIV were less likely successfully treated for cervical precancer and more likely to have human papillomavirus types not included in current HPV vaccines. Self-reported sexual satisfaction in PLHIV is improving and is higher in women than men.

FUTURE PLANS

InfCareHIV provides a unique base to study and further improve long-term treatment outcomes, comorbidity management and health-related quality of life in people with HIV in Sweden.

Post-migration HIV acquisition among african immigrants in the U.S

BACKGROUND

African immigrants in the U.S. are more likely to have a late HIV diagnosis than U.S.-born people, potentially leading to onward transmission. We sought to determine the proportion of African-born people living with HIV (APLWH) who (1) had tested HIV negative prior to diagnosis, and (2) likely acquired HIV in the U.S.

METHODS

We interviewed APLWH from 2014 to 2017 and estimated the proportion with post-migration HIV acquisition based on clinical data, HIV testing history, immigration date, and behavioral data.

RESULTS

Of 179 participants, 113 (63%) were women. Less than half (44%) reported a negative HIV test prior to diagnosis. Among 142 (79%) participants with sufficient data to evaluate post-migration HIV acquisition, we estimate that 29% acquired HIV post-migration. Most APLWH acquire HIV prior to immigration.

DISCUSSION

Approximately one-quarter of APLWH acquire HIV post-migration and HIV testing is infrequent, highlighting the need for prevention efforts for African immigrants in the U.S.

Readmission Prediction for Patients with Heterogeneous Medical History: A Trajectory-Based Deep Learning Approach

Hospital readmission refers to the situation where a patient is re-hospitalized with the same primary diagnosis within a specific time interval after discharge. Hospital readmission causes $26 billion preventable expenses to the U.S. health systems annually and often indicates suboptimal patient care. To alleviate those severe financial and health consequences, it is crucial to proactively predict patients’ readmission risk. Such prediction is challenging because the evolution of patients’ medical history is dynamic and complex. The state-of-the-art studies apply statistical models which use static predictors in a period, failing to consider patients’ heterogeneous medical history. Our approach – Trajectory-BAsed DEep Learning (TADEL) – is motivated to tackle the deficiencies of the existing approaches by capturing dynamic medical history. We evaluate TADEL on a five-year national Medicare claims dataset including 3.6 million patients per year over all hospitals in the United States, reaching an F1 score of 87.3% and an AUC of 88.4%. Our approach significantly outperforms all the state-of-the-art methods. Our findings suggest that health status factors and insurance coverage are important predictors for readmission. This study contributes to IS literature and analytical methodology by formulating the trajectory-based readmission prediction problem and developing a novel deep-learning-based readmission risk prediction framework. From a health IT perspective, this research delivers implementable methods to assess patients’ readmission risk and take early interventions to avoid potential negative consequences.

Sexual risk-taking behaviors among young migrant population in Sweden

Background

Migration is a complex process of high uncertainty with adjustments to new contexts and experiences influencing individuals’ health. This study aims to assess the prevalence of self-reported sexual risk-taking behaviors among migrant youth population in Sweden, fulfilling the research gap in that field.

Methods

A pre-tested, web-based self-administered cross-sectional survey was used to collect data among 1563 migrant youth (15–25 years old) in Sweden. The survey was conducted in high schools and Swedish language schools for foreigners between December 2018 and November 2019. Pearson chi-square and t-tests were used to compare whether sociodemographic characteristics and migration status varied between those engaging in sexual risk behaviors or not. Multivariate logistic regression was used to determine the adjusted odds ratio of the key outcome variable and independent variables.

Results

There is a profound heterogeneity in migrant youth characteristics related to engagement in different sexual risk-taking behaviors. Those engaging in condomless sex were older, coming from the Americas and Europe, living longer in Sweden and came to live with their family. Belonging to the Islamic religion was a protective factor. Sex under the influence of drugs was related to those from Europe, and Middle East and North Africa (MENA) and coming to Sweden to work/study, where age was a protective factor. Living longer in Sweden, coming for work/study or to live with family had higher odds to engage in sex in exchange for gifts/money.

Conclusion

The results highlight the needed reconsideration of the broader system response that can influence migrant youth health outcomes and public health implications. The approach should consider and relate to sexual risk-taking behavior’s long-term consequences. Migrant youth background needs and knowledge should guide this response.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12996-2.

Discriminating Between Premigration and Postmigration HIV Acquisition Using Surveillance Data

BACKGROUND

Migrant populations are overrepresented among persons diagnosed with HIV in the European Union and the European Economic Area. Understanding the timing of HIV acquisition (premigration or postmigration) is crucial for developing public health interventions and for producing reliable estimates of HIV incidence and the number of people living with undiagnosed HIV infection. We summarize a recently proposed method for determining the timing of HIV acquisition and apply it to both real and simulated data.

METHODS

The considered method combines estimates from a mixed model, applied to data from a large seroconverters' cohort, with biomarker measurements and individual characteristics to derive probabilities of premigration HIV acquisition within a Bayesian framework. The method is applied to a subset of data from the European Surveillance System (TESSy) and simulated data.

FINDINGS

Simulation study results showed good performance with the probabilities of correctly classifying a premigration case or a postmigration case being 87.4% and 80.4%, respectively. Applying the method to TESSy data, we estimated the proportions of migrants who acquired HIV in the destination country were 31.9%, 37.1%, 45.3%, and 45.2% for those originating from Africa, Europe, Asia, and other regions, respectively.

CONCLUSIONS

Although the considered method was initially developed for cases with multiple biomarkers' measurements, its performance, when applied to data where only one CD4 count per individual is available, remains satisfactory. Application of the method to TESSy data, estimated that a substantial proportion of HIV acquisition among migrants occurs in destination countries, having important implications for public health policy and programs.

At-Risk Groups of Men Who Have Sex With Men Can Be Reached Through Community-Based HIV Testing in Denmark

This study evaluates whether the community-based HIV testing clinic Checkpoint could reach at-risk groups of men who have sex with men (MSM) and link patients to care. A prospective observational study of all Checkpoint visits during 2013-2016 and a retrospective registry study of all MSM diagnosed with HIV in Denmark during the same period were conducted. One percent of the 9,074 tests in Checkpoint were HIV-positive, accounting for 19% of all new HIV diagnoses among MSM in Denmark. Checkpoint testers reported frequent condomless anal sex. Two percent of migrant Checkpoint testers were HIV-positive compared to 1 % among Danish MSM. HIV-positive MSM identified through Checkpoint were significantly younger, more of them were migrant, and a smaller proportion were late testers compared to those testing through the conventional health care system. Checkpoint reaches at-risk populations of MSM and links patients successfully to care.

Who falls between the cracks? Identifying eligible PrEP users among people with Sub-Saharan African migration background living in Antwerp, Belgium

Introduction

This study produces an estimate of the proportion of eligible PrEP users among people of Sub-Saharan African background based on the Belgian PrEP eligibility criteria and examines associations with socio-economic and demographic characteristics.

Methods

We performed logistic regression analysis on data of a representative community-based survey conducted among Sub-Saharan African communities (n = 685) living in Antwerp.

Results

Almost a third (30.3%) of the respondents were eligible to use PrEP. Those who were male, single, lower educated, undocumented, and had experienced forced sex were more likely to be eligible for PrEP use. The findings highlight the importance of taking intra-, interpersonal and structural HIV risk factors into account.

Conclusions

The study shows high unmet PrEP needs in this population, especially among those with high vulnerability for HIV acquisition. A better understanding of barriers to PrEP use in this population group is needed to allow for equitable access.

Barriers to HIV testing as reported by individuals newly diagnosed with HIV infection in Sweden

Despite the availability of free and anonymous HIV testing almost 60% of Swedish patients are diagnosed late. Identifying predictors of different types of barriers could inform policy makers and health care of interventions to increase testing where needed. This cross-sectional study aimed to describe and analyze barriers to HIV testing as reported by Swedish patients newly diagnosed with HIV infection. N = 285 patients completed the 18-item Barriers to HIV Testing Scale - Karolinska Version. Descriptive analysis and logistic regressions were performed to assess the prevalence of barriers and to identify predictors for the different investigated barriers. Barriers to testing were reported by 60%. Approximately 67% of patients originating from Sweden, 50% from Sub-Saharan Africa and 75% from Eastern European/East Asian countries reported barriers. Patients who were younger and patients who self-initiated HIV testing, had greater odds of reporting a barrier than older individuals and those who were offered a test through screening or by a healthcare professional. To counteract barriers that still exist on an individual level, healthcare-initiated HIV testing could be offered more broadly and information about risks for transmission and effectiveness of HIV treatment still needs to be disseminated among both people born in Sweden and different migrant groups.

The Epidemiology of HIV Among People Born Outside the United States, 2010-2017

OBJECTIVE

Although some studies have reported a higher incidence of HIV infection among non-US-born people than among US-born people, national data on this topic are scarce. We compared the epidemiology of HIV infection between US-born and non-US-born residents of the United States and examined the characteristics of non-US-born people with diagnosed HIV infection by region of birth (ROB).

METHODS

We used a cross-sectional study design to produce national, population-based data describing HIV infection among US-born and non-US-born people. We analyzed National HIV Surveillance System data for people with HIV infection diagnosed during 2010-2017 and reported to the Centers for Disease Control and Prevention (CDC). We compared data on demographic characteristics, transmission risk category, and stage 3 infection (AIDS) classification within 3 months of HIV diagnosis, by nativity and ROB.

RESULTS

During 2010-2017, 328 317 children and adult US residents were diagnosed with HIV infection and were reported to CDC: 214 973 (65.5%) were US-born, 50 301 (15.3%) were non-US-born, and 63 043 (19.2%) were missing data on country of birth. After adjusting for missing country of birth, 266 147 (81.1%) people were US-born and 62 170 (18.9%) were non-US-born. This group accounted for 15 928 of 65 645 (24.2%) HIV diagnoses among girls and women and 46 242 of 262 672 (17.6%) HIV diagnoses among boys and men. A larger percentage of non-US-born people than US-born people had stage 3 infection (AIDS) at HIV diagnosis (31.2% vs 23.9%). Among non-US-born people with HIV diagnoses, 19 876 (39.5%) resided in the South.

CONCLUSIONS

Characterizing non-US-born people with HIV infection is essential for developing effective HIV interventions, particularly in areas with large immigrant populations.

Monitoring progress towards the first UNAIDS 90-90-90 target in key populations living with HIV in Norway

BACKGROUND

In line with the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, Norway aims for at least 90% of people living with HIV (PLHIV) to know their HIV-status. We produced current estimates of the number of PLHIV and undiagnosed population in Norway, overall and for six key subpopulations: Norwegian-born men who have sex with men (MSM), migrant MSM, Norwegian-born heterosexuals, migrant Sub-Saharan Africa (SSA)-born heterosexuals, migrant non-SSA-born heterosexuals and people who inject drugs.

METHODS

We used the European Centre for Disease Prevention and Control (ECDC) HIV Modelling Tool on Norwegian HIV surveillance data through 2018 to estimate incidence, time from infection to diagnosis, PLHIV, and the number and proportion undiagnosed. As surveillance data on CD4 count at diagnosis were not collected in Norway, we ran two models; using default model CD4 assumptions, or a proxy for CD4 distribution based on Danish national surveillance data. We also generated alternative overall PLHIV estimates using the Spectrum AIDS Impact Model, to compare with those obtained from the ECDC tool.

RESULTS

Estimates of the overall number of PLHIV in 2018 using different modelling approaches aligned at approximately 5000. In both ECDC models, the overall number undiagnosed decreased continuously from 2008. The proportion undiagnosed in 2018 was lower using default model CD4 assumptions (7.1% [95%CI: 5.3-8.9%]), than the Danish CD4 proxy (10.2% [8.3-12.1%]). This difference was driven by results for heterosexual migrants. Estimates for Norwegian-born MSM, migrant MSM and Norwegian-born heterosexuals were similar in both models. In these three subpopulations, incidence in 2018 was < 30 new infections, and the number undiagnosed had decreased in recent years. Norwegian-born MSM had the lowest estimated number of undiagnosed infections (45 [30-75], using default CD4 assumptions) and undiagnosed fraction (3.6% [2.4-5.7%], using default CD4 assumptions) in 2018.

CONCLUSIONS

Results allow cautious confidence in concluding that Norway has achieved the first UNAIDS 90-90-90 target, and clearly highlight the success of prevention strategies among MSM. Estimates for subpopulations strongly influenced by migration remain less clear, and future modelling should appropriately account for all-cause mortality and out-migration, and adjust for time of in-migration.

HIV outcomes among migrants from low-income and middle-income countries living in high-income countries: a review of recent evidence

PURPOSE OF REVIEW

Migrants living in high-income countries are disproportionately affected by HIV infection and frequently have characteristics associated with poor HIV clinical outcomes. HIV epidemiology among migrants is influenced by changes in migration patterns and variations in transmission risk behaviors. Here we review the recently published literature on known HIV outcomes among migrants from low-income and middle-income countries living in high-income countries.

RECENT FINDINGS

High proportions of migrants acquire HIV after migration, and this group frequently presents to care late. Once established in care, migrants are often more likely to experience worse HIV treatment outcomes compared with native populations. Multiple individual and structural factors influence HIV diagnosis and treatment outcomes among migrants, including disruption of social networks, increased sexual risk behaviors, communication barriers, limited access to care, and stigma. Few studies have examined interventions targeted at improving HIV outcomes among migrants.

SUMMARY

Stigma and limited access to care appear to be primary drivers of poor HIV outcomes among migrants in high-income countries. Addressing these disparities is limited by difficulties in identifying and monitoring this population as well as a lack of evidence regarding appropriate interventions for migrants living with HIV. Improving outcomes for this group requires interventions that are specifically targeted at this marginalized and growing population.

Challenges in modelling the proportion of undiagnosed HIV infections in Sweden

BackgroundSweden has a low HIV prevalence. However, among new HIV diagnoses in 2016, the proportion of late presenters and migrants was high (59% and 81%, respectively). This poses challenges in estimating the proportion of undiagnosed persons living with HIV (PLHIV).AimTo estimate the proportion of undiagnosed PLHIV in Sweden comparing two models with different demands on data availability and modelling expertise.MethodsAn individual-based stochastic simulation model of HIV positive populations (SSOPHIE) and the incidence method of the European Centre for Disease Prevention and Control (ECDC) HIV Modelling Tool were applied to clinical, surveillance and migration data from Sweden 1980-2016.ResultsSSOPHIE estimated that the proportion of undiagnosed PLHIV in 2013 was 26% (n = 2,100; 90% plausibility range (PR): 900-5,000) for all PLHIV, 17% (n = 600; 90% PR: 100-2,000) for men who have sex with men (MSM), 35% in male (n = 300; 90% PR: 200-700) and 34% in female (n = 400; 90% PR: 200-800) migrants from sub-Saharan Africa (SSA). The estimates for the ECDC model in 2013 were 21% (n = 2,013; 95% confidence interval (CI): 1,831-2,189) for all PLHIV, 15% (n = 369; 95% CI: 299-434) for MSM and 21% (n = 530; 95% CI: 436-632) for migrants from SSA.ConclusionsThe proportion of undiagnosed PLHIV in Sweden is uncertain. SSOPHIE estimates had wide PR. The ECDC model estimates were unreliable because migration was not accounted for. Better migration data and estimation methods are required to obtain reliable estimates of proportions of undiagnosed PLHIV in similar settings.

Important Gaps in HIV Knowledge, Attitudes and Practices Among Young Asylum Seekers in Comparison to the General Population

Migrants are disproportionately affected by HIV in many European countries, including Finland. We aimed to compare the HIV-related knowledge, attitudes and practices (KAP) of young asylum seekers to those of the general young adult population. Two cross-sectional surveys were conducted among 20- to 25-year-old young adults: The TIE study among asylum seekers (n = 47) and the World AIDS Day 2014 study among the general population (n = 485). Important gaps in HIV KAP were identified especially among the young asylum seekers. For the general young adult population, previous HIV testing was associated with female gender, better HIV knowledge and increased sexual activity. Health education concerning HIV needs to be further enforced among young adults in Finland. Due to poorer HIV knowledge, young asylum seekers might be especially vulnerable to HIV. The asylum process is a window of opportunity for health education and HIV testing.

Genetic divergence of HIV-1 B subtype in Italy over the years 2003-2016 and impact on CTL escape prevalence

HIV-1 is characterized by high genetic variability, with implications for spread, and immune-escape selection. Here, the genetic modification of HIV-1 B subtype over time was evaluated on 3,328 pol and 1,152 V3 sequences belonging to B subtype and collected from individuals diagnosed in Italy between 2003 and 2016. Sequences were analyzed for genetic-distance from consensus-B (Tajima-Nei), non-synonymous and synonymous rates (dN and dS), CTL escapes, and intra-host evolution over four time-spans (2003–2006, 2007–2009, 2010–2012, 2013–2016). Genetic-distance increased over time for both pol and V3 sequences (P < 0.0001 and 0.0003). Similar results were obtained for dN and dS. Entropy-value significantly increased at 16 pol and two V3 amino acid positions. Seven of them were CTL escape positions (protease: 71; reverse-transcriptase: 35, 162, 177, 202, 207, 211). Sequences with ≥3 CTL escapes increased from 36.1% in 2003–2006 to 54.0% in 2013–2016 (P < 0.0001), and showed better intra-host adaptation than those containing ≤2 CTL escapes (intra-host evolution: 3.0 × 10⁻³ [2.9 × 10⁻³–3.1 × 10⁻³] vs. 4.3 × 10⁻³ [4.0 × 10⁻³–5.0 × 10⁻³], P[LRT] < 0.0001[21.09]). These data provide evidence of still ongoing modifications, involving CTL escape mutations, in circulating HIV-1 B subtype in Italy. These modifications might affect the process of HIV-1 adaptation to the host, as suggested by the slow intra-host evolution characterizing viruses with a high number of CTL escapes.

Increase in transmitted drug resistance in migrants from sub-Saharan Africa diagnosed with HIV-1 in Sweden

OBJECTIVE

To study the trends of transmitted drug resistance (TDR) in HIV-1 patients newly diagnosed in Sweden, 2010-2016.

DESIGN

Register-based study including all antiretroviral therapy-naive patients ≥18 years diagnosed with HIV-1 in Sweden 2010-2016.

METHODS

Patient data and viral pol sequences were extracted from the national InfCareHIV database. TDR was defined as the presence of surveillance drug resistance mutations (SDRMs). A CD4 T-cell decline trajectory model estimated time of infection. Phylogenetic inference was used for cluster analysis. Chi-square tests and logistic regressions were used to investigate relations between TDR, epidemiological and viral factors.

RESULTS

One thousand, seven hundred and thirteen pol sequences were analyzed, corresponding to 71% of patients with a new HIV-1 diagnosis (heterosexuals: 53%; MSM: 34%). The overall prevalence of TDR was 7.1% (95% CI 5.8-8.3%). Nonnucleoside reverse transcriptase inhibitor (NNRTI) TDR increased significantly from 1.5% in 2010 to 6.2% in 2016, and was associated to infection and/or origin in sub-Saharan Africa (SSA). An MSM transmission cluster dating back to the 1990s with the M41L SDRM was identified. Twenty-five (1.5%) patients exhibited TDR to tenofovir (TDF; n = 8), emtricitabine/lamivudine (n = 9) or both (n = 8).

CONCLUSION

NNRTI TDR has increased from 2010 to 2016 in HIV-1-infected migrants from SSA diagnosed in Sweden, mirroring the situation in SSA. TDR to tenofovir/emtricitabine, used in preexposure prophylaxis, confirms the clinical and epidemiological need for resistance testing in newly diagnosed patients.

Recent increased identification and transmission of HIV-1 unique recombinant forms in Sweden

A temporal increase in non-B subtypes has earlier been described in Sweden by us and we hypothesized that this increased viral heterogeneity may become a hotspot for the development of more complex and unique recombinant forms (URFs) if the epidemics converge. In the present study, we performed subtyping using four automated tools and phylogenetic analysis by RAxML of pol gene sequences (n = 5246) and HIV-1 near full-length genome (HIV-NFLG) sequences (n = 104). A CD4⁺ T-cell decline trajectory algorithm was used to estimate time of HIV infection. Transmission clusters were identified using the family-joining method. The analysis of HIV-NFLG and pol gene described 10.6% (11/104) and 2.6% (137/5246) of the strains as URFs, respectively. An increasing trend of URFs was observed in recent years by both approaches (p = 0·0082; p < 0·0001). Transmission cluster analysis using the pol gene of all URFs identified 14 clusters with two to eight sequences. Larger transmission clusters of URFs (BF1 and 01B) were observed among MSM who mostly were sero-diagnosed in recent time. Understanding the increased appearance and transmission of URFs in recent years could have importance for public health interventions and the use of HIV-NFLG would provide better statistical support for such assessments.