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Candevir A, Kuscu F, Kurtaran B, Kömür S, İnal AS, Ertürk D, Taşova Y. Late Diagnosis in HIV with New and Old Definitions; Data from a Regional Hospital in Turkey. Int J Gen Med 2023; 16:4227-4234. [PMID: 37745135 PMCID: PMC10516126 DOI: 10.2147/ijgm.s424561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023] Open
Abstract
Background Late presentation for HIV care, continues to be a challenge, leading to increased morbidity, mortality, and society costs. The study aimed to determine the rates of late diagnosis (LD) and patient characteristics in Turkey, utilizing the new definition excluding recently infected. Methods The study included patients admitted to the hospital between 1998 and 2023, with at least 1 year of follow-up. Patients without a CD4 count at their initial admission were excluded. Two definitions of presentation were used: LD, (CD4<350 cells/mL or AIDS-defining event) and advanced disease (AD), (CD4<200 cells/mL or AIDS-defining event). Individuals with recent evidence of infection were reclassified as "not late". Results Out of the 914 patients meeting the criteria and the analysis focused on 794 treatment-naïve patients, with 90.6% being male and an average age of 36.0 ± 12.0 years. Using the previous definition, 48.9% were diagnosed as late, while the new definition identified 47.2%. A total of 183 patients (23%) were diagnosed with AD, and 25.9% of the diagnoses occurred during the COVID-19 Pandemic. The rate of LD increased during the pandemic compared to before (55.8% vs 44.2%, p=0.005), as did the rate of AD (30.1% vs 20.6%, p=0.007). There was no significant relationship between gender and LD. Patients with LD were older (median ages were 31 vs 36 in groups, p<0.001), had poorer virological response, higher mortality rates (4.8% vs 1.2%, p=0.003), and shorter survival compared to those without (log rank=0.004). Conclusion HIV patients with LD have poorer prognosis with older age as well as disruption of health services during the pandemic as risk factors. To improve outcomes, multicenter studies should investigate missed opportunities and specific risk factors in our region, and we should screen at-risk populations, promote awareness among underdiagnosed populations, and advocate testing even in disastrous situations.
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Affiliation(s)
| | - Ferit Kuscu
- Infectious Diseases, Çukurova University, Adana, Türkiye
| | | | - Süheyla Kömür
- Infectious Diseases, Çukurova University, Adana, Türkiye
| | - Ayşe Seza İnal
- Infectious Diseases, Çukurova University, Adana, Türkiye
| | - Damla Ertürk
- Infectious Diseases, Health Sciences University Izmir Tepecik Education and Research Hospital, İzmir, Türkiye
| | - Yeşim Taşova
- Infectious Diseases, Çukurova University, Adana, Türkiye
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Puła J, Kowalska J, Paciorek M, Bednarska A, Skrzat‐Klapaczyńska A, Horban A. Is the definition of late diagnosis correct? HIV Med 2022; 24:616-619. [PMID: 36478347 DOI: 10.1111/hiv.13450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The study analysed 1711 patients of the Hospital for Infectious Diseases in Warsaw diagnosed with HIV infection in 2008-2010 and 2016-2018. Research was conducted examining the changes in CD4 cell counts before starting antiretroviral (ARV) treatment in order to find people who were misclassified as late-diagnosed. METHODS Patients with late diagnosis were distinguished on the basis of the consensus definition. The Mann-Whitney U-test was used to analyse the change in CD4 cell counts before starting ARV treatment. RESULTS In the years 2008-2010, the CD4 count was remeasured before starting ARV treatment in 90 late-diagnosed patients. The median change in the CD4 count was 22 cells/μL. In 49 of these, the number of CD4 cells spontaneously increased before the start of treatment. We can suspect that these patients were misclassified as late-diagnosed. CONCLUSIONS The consensus definition of late diagnosis often leads to overestimation of the number of late-diagnosed patients. The crucial problem is a transient decline in the CD4 lymphocyte count in the acute phase of HIV infection. A potential solution is to introduce serum HIV viral load measurement into the definition.
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Affiliation(s)
- Joanna Puła
- Department of Infectious Diseases for Adults Medical University of Warsaw Warsaw Poland
- Hospital for Infectious Diseases Warsaw Poland
| | - Justyna Kowalska
- Department of Infectious Diseases for Adults Medical University of Warsaw Warsaw Poland
- Hospital for Infectious Diseases Warsaw Poland
| | - Marcin Paciorek
- Department of Infectious Diseases for Adults Medical University of Warsaw Warsaw Poland
- Hospital for Infectious Diseases Warsaw Poland
| | - Agnieszka Bednarska
- Department of Infectious Diseases for Adults Medical University of Warsaw Warsaw Poland
- Hospital for Infectious Diseases Warsaw Poland
| | - Agata Skrzat‐Klapaczyńska
- Department of Infectious Diseases for Adults Medical University of Warsaw Warsaw Poland
- Hospital for Infectious Diseases Warsaw Poland
| | - Andrzej Horban
- Department of Infectious Diseases for Adults Medical University of Warsaw Warsaw Poland
- Hospital for Infectious Diseases Warsaw Poland
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Croxford S, Stengaard AR, Brännström J, Combs L, Dedes N, Girardi E, Grabar S, Kirk O, Kuchukhidze G, Lazarus JV, Noori T, Pharris A, Raben D, Rockstroh JK, Simões D, Sullivan AK, Van Beckhoven D, Delpech VC. Late diagnosis of HIV: An updated consensus definition. HIV Med 2022; 23:1202-1208. [PMID: 36347523 PMCID: PMC10100195 DOI: 10.1111/hiv.13425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/04/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION In recent years, HIV testing frequency has increased, resulting in more people being diagnosed during seroconversion with a temporarily low CD4 count. Using the current consensus definition of late HIV presentation ('presenting for care with a CD4 count < 350 cells/μL or an AIDS-defining event, regardless of CD4 count') these individuals would be incorrectly assigned as being diagnosed late. METHODS In spring 2022, a European expert group convened to revise the current late HIV presentation consensus definition. A survey on data availability to apply this revised definition was sent to nominated European focal points responsible for HIV surveillance (n = 53). RESULTS Experts agreed that the updated definition should refer to late HIV diagnosis rather than presentation and include the following addition: People with evidence of recent infection should be reclassified as 'not late', with evidence of recent infection considered hierarchically. The individual must have: (i) laboratory evidence of recent infection; (ii) a last negative HIV test within 12 months of diagnosis; or (iii) clinical evidence of acute infection. People with evidence of being previously diagnosed abroad should be excluded. A total of 18 countries responded to the survey; 83% reported capturing CD4 count and/or AIDS at diagnosis through national surveillance, 67% captured last negative test and/or previous HIV diagnosis, 61% captured seroconversion illness at diagnosis and 28% captured incident antibody results. CONCLUSIONS Accurate data on late diagnosis are important to describe the effects of testing programmes. Reclassification of individuals with recent infection will help to better identify populations most at risk of poor HIV outcomes and areas for intervention.
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Affiliation(s)
| | - Annemarie Rinder Stengaard
- Centre of Excellence for Health, Immunity and Infections - CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Johanna Brännström
- Institution of Medicine, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden.,EuroTEST Steering Committee, Copenhagen, Denmark.,Department of Infectious Diseases, Venhälsan, Södersjukhuset, Stockholm, Sweden
| | - Lauren Combs
- Centre of Excellence for Health, Immunity and Infections - CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nikos Dedes
- EuroTEST Steering Committee, Copenhagen, Denmark.,European AIDS Treatment Group, Brussels, Belgium
| | - Enrico Girardi
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - Sophie Grabar
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique, Paris, France
| | - Ole Kirk
- Centre of Excellence for Health, Immunity and Infections - CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Giorgi Kuchukhidze
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Jeffrey V Lazarus
- EuroTEST Steering Committee, Copenhagen, Denmark.,ISGlobal, Barcelona Institute for Global Health, Hospital Clínic - University of Barcelona, Barcelona, Spain
| | - Teymur Noori
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Anastasia Pharris
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Dorthe Raben
- Centre of Excellence for Health, Immunity and Infections - CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jürgen K Rockstroh
- EuroTEST Steering Committee, Copenhagen, Denmark.,European AIDS Clinical Society, Brussels, Belgium.,University Hospital Bonn, Bonn, Germany
| | - Daniel Simões
- EuroTEST Steering Committee, Copenhagen, Denmark.,EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.,Coalition PLUS, Paris, France
| | - Ann K Sullivan
- UK Health Security Agency, London, UK.,EuroTEST Steering Committee, Copenhagen, Denmark.,European AIDS Clinical Society, Brussels, Belgium.,Directorate of HIV and Sexual Health, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Valerie C Delpech
- UK Health Security Agency, London, UK.,EuroTEST Steering Committee, Copenhagen, Denmark
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Kirwan PD, Croxford S, Aghaizu A, Murphy G, Tosswill J, Brown AE, Delpech VC. Re-assessing the late HIV diagnosis surveillance definition in the era of increased and frequent testing. HIV Med 2022; 23:1127-1142. [PMID: 36069144 PMCID: PMC7613879 DOI: 10.1111/hiv.13394] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/10/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Late HIV diagnosis (CD4 <350 cells/mm3 ) is a key public health metric. In an era of more frequent testing, the likelihood of HIV diagnosis occurring during seroconversion, when CD4 counts may dip below 350, is greater. We applied a correction, considering markers of recent infection, and re-assessed 1-year mortality following late diagnosis. METHODS We used national epidemiological and laboratory surveillance data from all people diagnosed with HIV in England, Wales, and Northern Ireland (EW&NI). Those with a baseline CD4 <350 were reclassified as 'not late' if they had evidence of recent infection (recency test and/or negative test within 24 months). A correction factor (CF) was the number reclassified divided by the number with a CD4 <350. RESULTS Of the 32 227 people diagnosed with HIV in EW&NI between 2011 and 2019 with a baseline CD4 (81% of total), 46% had a CD4 <350 (uncorrected late diagnosis rate): 34% of gay and bisexual men (GBM), 65% of heterosexual men, and 56% of heterosexual women. Accounting for recency test and/or prior negative tests gave a 'corrected' late diagnosis rate of 39% and corresponding CF of 14%. The CF increased from 10% to 18% during 2011-2015, then plateaued, and was larger among GBM (25%) than heterosexual men and women (6% and 7%, respectively). One-year mortality among people diagnosed late was 329 per 10 000 after reclassification (an increase from 288/10 000). CONCLUSIONS The case-surveillance definition of late diagnosis increasingly overestimates late presentation, the extent of which differs by key populations. Adjustment of late diagnosis is recommended, particularly for frequent testers such as GBM.
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Affiliation(s)
- Peter D Kirwan
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge,United Kingdom Health Security Agency, London,Corresponding author Contact details: Peter Kirwan, United Kingdom Health Security Agency, London, NW9 5EQ Phone: +44 (0)7837 723563,
| | | | | | - Gary Murphy
- United Kingdom Health Security Agency, London
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Evaluation of the Predictive Potential of the Short Acute Retroviral Syndrome Severity Score for HIV-1 Disease Progression in Individuals With Acute HIV Infection. J Acquir Immune Defic Syndr 2018; 74:e114-e117. [PMID: 28225720 DOI: 10.1097/qai.0000000000001263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Hirschel B. Primary HIV Infection. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00093-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Detection of Broadly Neutralizing Activity within the First Months of HIV-1 Infection. J Virol 2016; 90:5231-5245. [PMID: 26984721 DOI: 10.1128/jvi.00049-16] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/08/2016] [Indexed: 11/20/2022] Open
Abstract
UNLABELLED A fraction of HIV-1 patients are able to generate broadly neutralizing antibodies (bNAbs) after 2 to 4 years of infection. In rare occasions such antibodies are observed close to the first year of HIV-1 infection but never within the first 6 months. In this study, we analyzed the neutralization breadth of sera from 157 antiretroviral-naive individuals who were infected for less than 1 year. A range of neutralizing activities was observed with a previously described panel of six recombinant viruses from five different subtypes (M. Medina-Ramirez et al., J Virol 85:5804-5813, 2011, http://dx.doi.org/10.1128/JVI.02482-10). Some sera were broadly reactive, predominantly targeting envelope epitopes within the V2 glycan-dependent region. The neutralization breadth was positively associated with time postinfection (P = 0.0001), but contrary to what has been reported for chronic infections, no association with the viral load was observed. Notably, five individuals within the first 6 months of infection (two as early as 77 and 96 days postinfection) showed substantial cross-neutralization. This was confirmed with an extended panel of 20 Env pseudoviruses from four different subtypes (two in tier 3, 14 in tier 2, and four in tier 1). Sera from these individuals were capable of neutralizing viruses from four different subtypes with a geometric mean 50% infective dose (ID50) between 100 and 800. These results indicate that induction of cross-neutralizing responses, albeit rare, is achievable even within 6 months of HIV-1 infection. These observations encourage the search for immunogens able to elicit this kind of response in preventive HIV-1 vaccine approaches. IMPORTANCE There are very few individuals able to mount broadly neutralizing activity (bNA) close to the first year postinfection. It is not known how early in the infection cross-neutralizing responses can be induced. In the present study, we show that bNAbs, despite being rare, can be induced much earlier than previously thought. The identification of HIV-1-infected patients with these activities within the first months of infection and characterization of these responses will help in defining new immunogen designs and neutralization targets for vaccine-mediated induction of bNAbs.
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Sasse A, Florence E, Pharris A, De Wit S, Lacor P, Van Beckhoven D, Deblonde J, Delforge ML, Fransen K, Goffard JC, Legrand JC, Moutschen M, Piérard D, Ruelle J, Vaira D, Vandercam B, Van Ranst M, Van Wijngaerden E, Vandekerckhove L, Verhofstede C. Late presentation to HIV testing is overestimated when based on the consensus definition. HIV Med 2015. [PMID: 26222266 PMCID: PMC5034831 DOI: 10.1111/hiv.12292] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Objectives In 2011, a consensus was reached defining “late presenters” (LPs) as individuals presenting for care with a CD4 count < 350 cells/μL or with an AIDS‐defining event, regardless of CD4 count. However, a transient low CD4 count is not uncommon in recent infections. The objective of this study was to investigate how measurements of late presentation change if the clinical stage at the time of diagnosis is taken into account. Methods Case surveillance data for newly diagnosed patients in Belgium in 1998–2012 were analysed, including CD4 count at diagnosis, the presence of AIDS‐defining events, and recent infections (< 6 months) as reported by clinicians in the case of acute illness or a recent negative test. First, proportions of LPs were calculated according to the consensus definition. Secondly, LPs were reclassified as “nonlate” if infections were reported as recent. Results A total of 7949 HIV diagnoses were included in the study. Recent infections were increasingly reported over time, accounting for 8.2% of new infections in 1998 and 37.5% in 2012. The consideration of clinical stage significantly modified the proportion of LPs: 18.2% of men who have sex with men (MSM) diagnosed in 2012 would be classified as LPs instead of 30.9% using the consensus definition (P < 0.001). The proportion of patients misclassified as LPs increased significantly over time: 5% in MSM in 1998 vs. 41% in 2012. Conclusions This study suggests that low CD4 counts in recent infections may lead to overestimation of late presentation when applying the consensus definition. The impact of transient CD4 count on late presentation estimates should be assessed and, if relevant, the introduction of clinical stage in the definition of late presentation should be considered.
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Affiliation(s)
- A Sasse
- Scientific Institute of Public Health, Brussels, Belgium
| | - E Florence
- Instituut Tropische Geneeskunde Antwerpen, Antwerp, Belgium
| | - A Pharris
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - S De Wit
- CHU Saint-Pierre, Brussels, Belgium
| | - P Lacor
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - J Deblonde
- Scientific Institute of Public Health, Brussels, Belgium
| | - M-L Delforge
- Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - K Fransen
- Instituut Tropische Geneeskunde Antwerpen, Antwerp, Belgium
| | - J-C Goffard
- Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | - D Piérard
- Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - J Ruelle
- Université Catholique de Louvain, Brussels, Belgium
| | - D Vaira
- CHU de Liège, Liege, Belgium
| | - B Vandercam
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - M Van Ranst
- Katholieke Universiteit Leuven, Leuven, Belgium
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Braun DL, Kouyos R, Oberle C, Grube C, Joos B, Fellay J, McLaren PJ, Kuster H, Günthard HF. A novel Acute Retroviral Syndrome Severity Score predicts the key surrogate markers for HIV-1 disease progression. PLoS One 2014; 9:e114111. [PMID: 25490090 PMCID: PMC4260784 DOI: 10.1371/journal.pone.0114111] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/03/2014] [Indexed: 01/11/2023] Open
Abstract
Objective: Best long-term practice in primary HIV-1 infection (PHI) remains unknown for the individual. A risk-based scoring system associated with surrogate markers of HIV-1 disease progression could be helpful to stratify patients with PHI at highest risk for HIV-1 disease progression. Methods: We prospectively enrolled 290 individuals with well-documented PHI in the Zurich Primary HIV-1 Infection Study, an open-label, non-randomized, observational, single-center study. Patients could choose to undergo early antiretroviral treatment (eART) and stop it after one year of undetectable viremia, to go on with treatment indefinitely, or to defer treatment. For each patient we calculated an a priori defined “Acute Retroviral Syndrome Severity Score” (ARSSS), consisting of clinical and basic laboratory variables, ranging from zero to ten points. We used linear regression models to assess the association between ARSSS and log baseline viral load (VL), baseline CD4+ cell count, and log viral setpoint (sVL) (i.e. VL measured ≥90 days after infection or treatment interruption). Results Mean ARSSS was 2.89. CD4+ cell count at baseline was negatively correlated with ARSSS (p = 0.03, n = 289), whereas HIV-RNA levels at baseline showed a strong positive correlation with ARSSS (p<0.001, n = 290). In the regression models, a 1-point increase in the score corresponded to a 0.10 log increase in baseline VL and a CD4+cell count decline of 12/µl, respectively. In patients with PHI and not undergoing eART, higher ARSSS were significantly associated with higher sVL (p = 0.029, n = 64). In contrast, in patients undergoing eART with subsequent structured treatment interruption, no correlation was found between sVL and ARSSS (p = 0.28, n = 40). Conclusion The ARSSS is a simple clinical score that correlates with the best-validated surrogate markers of HIV-1 disease progression. In regions where ART is not universally available and eART is not standard this score may help identifying patients who will profit the most from early antiretroviral therapy.
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Affiliation(s)
- Dominique L. Braun
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- * E-mail: (DLB); (HFG)
| | - Roger Kouyos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Corinna Oberle
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christina Grube
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Beda Joos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jacques Fellay
- School of Life Sciences, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland; Institute of Microbiology, University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - Paul J. McLaren
- School of Life Sciences, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland; Institute of Microbiology, University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - Herbert Kuster
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Huldrych F. Günthard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- * E-mail: (DLB); (HFG)
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