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Lindh M, Brännström J, Reepalu A, Svedhem V, Mellgren Å. Factors associated with sex differences in viral non-suppression in the Swedish InfCareHIV cohort: An observational real-world study. HIV Med 2024; 25:540-553. [PMID: 38196293 DOI: 10.1111/hiv.13607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/16/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVES Women living with HIV are underrepresented in clinical trials assessing outcomes of antiretroviral treatment (ART), justifying the need for observational studies. We investigated differences in viral non-suppression between women and men in the Swedish InfCareHIV cohort and analysed results in relation to biological and socio-demographic variables and patient-reported outcome measures (PROMs). METHODS The study included people living with HIV (PLWH) aged ≥18 years, who initiated ART at least 6 months prior to inclusion. Data from the InfCareHIV registry 2011-2018 were collected. Associations between variables and HIV RNA ≥50 copies/mL were investigated in uni- and multivariable analyses using generalized estimating equations, providing relative risks (RRs) as effect size. RESULTS The study included 38% (n = 2981) women. Women were more likely to have HIV RNA ≥50 copies/mL than were men [RR = 1.20, 95% confidence interval (CI): 1.10-1.31]. After adjusting for origin and route of transmission, sex at birth was no longer associated with viral non-suppression. PROMs were available in 52.4% of PLWH, and items associated with viral non-suppression were impaired adherence in women (RR = 2.38, 95% CI: 1.79-3.17) and men (RR 1.84, 95% CI: 1.40-2.42), and experience of side effects in women (RR = 1.49, 95% CI: 1.10-2.02). CONCLUSIONS This observational study found a 20% higher relative risk of viral non-suppression in women than in men and the difference was associated with socio-demographic factors. The associations between PROMs and viral non-suppression varied between women and men. PROMs are important health outcomes that may identify PLWH in need of support to achieve viral non-suppression.
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Affiliation(s)
- Maria Lindh
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Södra Älvsborg Hospital, Department of Research, Education and Innovation, Borås, Sweden
- Department of Infectious Diseases, Södra Älvsborg Hospital, Borås, Sweden
| | - Johanna Brännström
- Division of Infection and Dermatology, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases/Venhälsan, South Hospital, Stockholm, Sweden
| | - Anton Reepalu
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Lund, Sweden
- Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
| | - Veronica Svedhem
- Division of Infection and Dermatology, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden
| | - Åsa Mellgren
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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Ganesan A, Hsieh HC, Chu X, Colombo RE, Berjohn C, Lalani T, Yabes J, Joya CA, Blaylock J, Agan BK. Low Level Viremia Is Associated With Serious non-AIDS Events in People With HIV. Open Forum Infect Dis 2024; 11:ofae147. [PMID: 38628953 PMCID: PMC11020230 DOI: 10.1093/ofid/ofae147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Indexed: 04/19/2024] Open
Abstract
Background The consequences of low-level viremia in people with HIV are unclear. We used data from the US Military HIV Natural History Study to examine the association of low-level viremia (LLV) and serious non-AIDS events (SNAEs). Methods Included participants initiated antiretroviral therapy after 1996 and had ≥3 viral loads (VLs) measured, using an assay with a lower limit of detection of <50 copies/mL, ≥6 months after antiretroviral therapy initiation. VLs were categorized as lower levels of LLV (51-199 copies/mL), higher level of low-level viremia (HLLV; 200-999 copies/mL), and (VF; ≥200 copies/mL on 2 or more successive determinations or a single VL ≥1000 copies/mL), and virologic suppression (VS; ie, VL <50 copies/mL). Viral blips (ie, VLs between 50 and 999 copies/mL that are preceded and succeeded by VL <50 copies/mL) were analyzed in the VS category. Cox proportional hazards models were used to examine the association of LLV and SNAEs, adjusted hazard ratios and 95% confidence intervals are presented. Results A total of 439 (17.4%) SNAEs were recorded among the 2528 participants (93% male, 40% Caucasian, 43% African American) followed for a median of 11 years. In 8.5% and 4.6% of the participants, respectively, LLV and HLLV were the highest recorded viremia strata. Compared with VS, SNAEs were associated with LLV (1.3 [1.2-1.4]), HLLV (1.6 [1.5-1.7]), and virologic failure (1.7 [1.7-1.8]). Conclusions The results of this study suggest that LLV is associated with the occurrence of SNAEs and needs further study.
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Affiliation(s)
- Anuradha Ganesan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Division of Infectious Diseases, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Hsing-Chuan Hsieh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Xiuping Chu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Rhonda E Colombo
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Infectious Disease Service, Madigan Army Medical Center, Tacoma, Washington, USA
| | - Catherine Berjohn
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Division of Infectious Diseases, Naval Medical Center San Diego, San Diego, California, USA
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Division of Infectious Diseases, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Joseph Yabes
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Division of Infectious Diseases, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Christie A Joya
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Division of Infectious Diseases, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Jason Blaylock
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Division of Infectious Diseases, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Brian K Agan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
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Lombardi F, Bruzzesi E, Bouba YR, Di Carlo D, Costabile V, Ranzenigo M, Maggiolo F, Castagna A, Callegaro AP, Zoncada A, Paolucci S, Micheli V, Renica S, Bezencheck A, Rossetti B, Santoro MM. Factors Associated with Low-Level Viremia in People Living with HIV in the Italian Antiviral Response Cohort Analysis Cohort: A Case-Control Study. AIDS Res Hum Retroviruses 2024; 40:80-89. [PMID: 37345697 DOI: 10.1089/aid.2023.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
Despite effective antiretroviral therapies (ARTs), a subset of people living with HIV (PLWH) still experience low-level viremia (LLV, i.e., 50-1,000 copies/mL). The present study compared PLWH experiencing LLV with those maintaining virological suppression (VS) and explored the potential impact of preexisting drug resistance and other factors on LLV. We conducted a retrospective, 1:1 matched case-control study within a cohort of drug-experienced VS subjects from the Italian Antiviral Response Cohort Analysis database, followed in the period 2009-2019. Cases were individuals experiencing LLV, while controls were those who maintained VS. Matching was for calendar year of first ART regimen. Preexisting drug resistance was calculated as cumulative genotypic susceptibility score (GSS) according to regimen administered at the observational period start. To explore the effect of cumulative GSS, treated as a binary variable (≥2 and <2) and other factors on LLV, we performed a logistic regression analysis. Within a main population of 3,455 PLWH, 337 cases were selected. Cases were comparable to the controls for both gender and age. However, cases showed that they had experienced a longer time since HIV diagnosis, a higher number of drugs previously administered, lower baseline CD4+ T cell count and a higher zenith viral load (VL). By multivariate analysis, we found that higher zenith VL [adjusted odds ratio (aOR) (95% confidence interval [CI]) 1.30 (1.14-1.48)], a cumulative usage of both PI [aOR (95% CI): 2.03 (1.19-3.48)] and InSTI [aOR (95% CI): 2.23 (1.47-3.38)] and a cumulative GSS <2 [aOR (95% CI) 0.67 (0.46-0.98)], were associated with a higher risk in developing LLV. In current high-efficacy ART era, in drug-experienced PLWH, the predictors of increased risk of LLV were the presence of preexisting drug resistance, higher zenith VL, and previous PI, and InSTI exposure.
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Affiliation(s)
- Francesca Lombardi
- UOC Malattie Infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elena Bruzzesi
- Infectious Diseases Unit, Università Vita-Salute San Raffaele, Milan, Italy
| | - Yagai Romeo Bouba
- Chantal BIYA International Reference Center for Research on HIV/AIDS Prevention and Management (CIRCB), Yaoundé, Cameroon
| | - Domenico Di Carlo
- Department of Biomedical and Clinical Sciences "L. Sacco", CRC Pediatric "Romeo and Enrica Invernizzi", University of Milan, Milan, Italy
| | - Valentino Costabile
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Martina Ranzenigo
- Infectious Diseases Unit, Università Vita-Salute San Raffaele, Milan, Italy
| | - Franco Maggiolo
- Department of Infectious Diseases, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Antonella Castagna
- Infectious Diseases Unit, Università Vita-Salute San Raffaele, Milan, Italy
- Infectious Diseases Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Stefania Paolucci
- Molecular Virology Unit, Division of Microbiology and Virology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Valeria Micheli
- Laboratory of Clinical Microbiology, Virology, and Bioemergencies, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Milan, Italy
| | - Silvia Renica
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | | | - Barbara Rossetti
- Infectious Diseases Unit, AUSL Toscana Sud-Est, Ospedale Misericordia Grosseto, Siena, Italy
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Elén S, Björkman P, Zazzi M, Böhm M, Bernal E, Sönnerborg A, Elvstam O. Low-level HIV viraemia during antiretroviral therapy: Longitudinal patterns and predictors of viral suppression. HIV Med 2024; 25:107-116. [PMID: 37721192 DOI: 10.1111/hiv.13541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 08/29/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVES Our objective was to characterize longitudinal patterns of viraemia and factors associated with viral suppression in people with HIV and low-level viraemia (LLV) during antiretroviral therapy (ART). METHODS We included people with HIV in the EuResist Integrated Database with LLV following ART initiation after 2005. LLV was defined as two or more consecutive viral load (VL) measurements of 51-199 copies/mL 30-365 days apart after >12 months of ART. Viraemia patterns were analyzed over 24 months. Factors associated with viral suppression at 12 months after LLV episodes were identified using univariable and multivariable logistic regression. RESULTS Of 25 113 people with HIV, 2474 (9.9%) had LLV. Among 1387 participants with 24 months of follow-up after LLV, 406 (29%) had persistent suppression, 669 (48%) had transient viraemic episodes, 29 (2%) had persistent LLV, and 283 (20%) had virological failure. Following LLV episodes, the proportion with detectable viraemia declined (p for trend <0.001 and 0.034, in the first and second year, respectively). At 12 months, 68% had undetectable VL, which was associated with suppression before LLV (adjusted odds ratio [aOR] 1.7; 95% confidence interval [CI] 1.2-2.4) and ART modification after LLV (aOR 1.6; 95% CI 1.0-2.4). The following factors were negatively associated with undetectable VL at 12 months: higher VL during LLV (aOR 0.57 per log10 copies/mL; 95% CI 0.37-0.89), injecting drug use (aOR 0.67; 95% CI 0.47-0.96), and regimens with protease inhibitors (aOR 0.65; 95% CI 0.49-0.87) or combined anchor drugs (aOR 0.52; 95% CI 0.32-0.85). CONCLUSION Most people with LLV did not experience sustained viral suppression during 24-month follow-up, supporting the association between LLV and inferior treatment outcome.
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Affiliation(s)
- S Elén
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - P Björkman
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
| | - M Zazzi
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - M Böhm
- Institute of Virology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - E Bernal
- Infectious Disease Unit. Reina Sofia Hospital, Murcia University and IMIB, Murcia, Spain
| | - A Sönnerborg
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - O Elvstam
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Infectious Diseases, Växjö Central Hospital, Växjö, Sweden
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Carlander C, Brännström J, Månsson F, Elvstam O, Albinsson P, Blom S, Mattsson L, Hovmöller S, Norrgren H, Mellgren Å, Svedhem V, Gisslén M, Sönnerborg A. Cohort profile: InfCareHIV, a prospective registry-based cohort study of people with diagnosed HIV in Sweden. BMJ Open 2023; 13:e069688. [PMID: 36931676 PMCID: PMC10030896 DOI: 10.1136/bmjopen-2022-069688] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
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.
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Affiliation(s)
- Christina Carlander
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Johanna Brännström
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases/Venhälsan, Södersjukhuset, Stockholm, Sweden
| | - Fredrik Månsson
- Department of Clinical Sciences, Lund University, Infectious Diseases Research Unit, Malmo, Sweden
| | - Olof Elvstam
- Department of Translational Medicine, Lund University, Lund, Sweden
- Department of Infectious Diseases, Växjö Central Hospital, Växjö, Sweden
| | - Pernilla Albinsson
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Lena Mattsson
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Sanne Hovmöller
- Department of Infectious Diseases, Sunderby Hospital, Lulea, Sweden
| | - Hans Norrgren
- Department of Clinical Sciences, Lund University Faculty of Science, Lund, Sweden
| | - Åsa Mellgren
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Veronica Svedhem
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Magnus Gisslén
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenbrug, Sweden
| | - Anders Sönnerborg
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
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Elvstam O, Malmborn K, Elén S, Marrone G, García F, Zazzi M, Sönnerborg A, Böhm M, Seguin-Devaux C, Björkman P. Virologic Failure Following Low-level Viremia and Viral Blips During Antiretroviral Therapy: Results From a European Multicenter Cohort. Clin Infect Dis 2022; 76:25-31. [PMID: 36100984 PMCID: PMC9825828 DOI: 10.1093/cid/ciac762] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/24/2022] [Accepted: 09/08/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND It is unclear whether low-level viremia (LLV), defined as repeatedly detectable viral load (VL) of <200 copies/mL, and/or transient viremic episodes (blips) during antiretroviral therapy (ART), predict future virologic failure. We investigated the association between LLV, blips, and virologic failure (VF) in a multicenter European cohort. METHODS People with HIV-1 who started ART in 2005 or later were identified from the EuResist Integrated Database. We analyzed the incidence of VF (≥200 copies/mL) depending on viremia exposure, starting 12 months after ART initiation (grouped as suppression [≤50 copies/mL], blips [isolated VL of 51-999 copies/mL], and LLV [repeated VLs of 51-199 copies/mL]) using Cox proportional hazard models adjusted for age, sex, injecting drug use, pre-ART VL, CD4 count, HIV-1 subtype, type of ART, and treatment experience. We queried the database for drug-resistance mutations (DRM) related to episodes of LLV and VF and compared those with baseline resistance data. RESULTS During 81 837 person-years of follow-up, we observed 1424 events of VF in 22 523 participants. Both blips (adjusted subhazard ratio [aHR], 1.7; 95% confidence interval [CI], 1.3-2.2) and LLV (aHR, 2.2; 95% CI, 1.6-3.0) were associated with VF, compared with virologic suppression. These associations remained statistically significant in subanalyses restricted to people with VL <200 copies/mL and those starting ART 2014 or later. Among people with LLV and genotype data available within 90 days following LLV, 49/140 (35%) had at least 1 DRM. CONCLUSIONS Both blips and LLV during ART are associated with increased risk of subsequent VF.
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Affiliation(s)
- Olof Elvstam
- Correspondence: O. Elvstam, Department of Infectious Diseases, Växjö Central Hospital, 35185 Växjö, Sweden ()
| | - Kasper Malmborn
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Sixten Elén
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Gaetano Marrone
- Department of Infectious Diseases and Clinical Virology, Karolinska University Hospital, Stockholm, Sweden
| | - Federico García
- Servicio de Microbiología, Hospital Clinico Universitario San Cecilio, Instituto de Investigacíon Ibs. Granada, Ciber de Enfermedades Infecciosas, CIBERINFEC, Granada, Spain
| | - Maurizio Zazzi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Anders Sönnerborg
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden,Department of Infecious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Böhm
- Institute of Virology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Carole Seguin-Devaux
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch sur Alzette, Luxembourg
| | - Per Björkman
- Department of Translational Medicine, Lund University, Malmö, Sweden,Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
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