Challenges for quality and utilization of real-world data for diffuse large B-cell lymphoma in REALYSA, a LYSA cohort

ABSTRACT

Real-world data (RWD) are essential to complement clinical trial (CT) data, but major challenges remain, such as data quality. REal world dAta in LYmphoma and Survival in Adults (REALYSA) is a prospective noninterventional multicentric cohort started in 2018 that included patients newly diagnosed with lymphoma in France. Herein is a proof-of-concept analysis on patients with first-line diffuse large B-cell lymphoma (DLBCL) to (1) evaluate the capacity of the cohort to provide robust data through a multistep validation process; (2) assess the consistency of the results; and (3) conduct an exploratory transportability assessment of 2 recent phase 3 CTs (POLARIX and SENIOR). The analysis population comprised 645 patients with DLBCL included before 31 March 2021 who received immunochemotherapy and for whom 3589 queries were generated, resulting in high data completeness (<4% missing data). Median age was 66 years, with mostly advanced-stage disease and high international prognostic index (IPI) score. Treatments were mostly rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisone (R-CHOP 75%) and reduced dose R-CHOP (13%). Estimated 1-year event-free survival (EFS) and overall survival rates were 77.9% and 90.0%, respectively (median follow-up, 9.9 months). Regarding transportability, when applying the CT's main inclusion criteria (age, performance status, and IPI), outcomes seemed comparable between patients in REALYSA and standard arms of POLARIX (1-year progression-free survival 79.8% vs 79.8%) and SENIOR (1-year EFS, 64.5% vs 60.0%). With its rigorous data validation process, REALYSA provides high-quality RWD, thus constituting a platform for numerous scientific purposes. The REALYSA study was registered at www.clinicaltrials.gov as #NCT03869619.

PrEP in the Context of Other HIV Risk Reduction Strategies Among Men Who Have Sex with Men: Results from the Flash! PrEP in Europe Survey

Combination HIV prevention covers a range of biomedical, behavioral, and socio-structural interventions. Despite the growing availability of pre-exposure prophylaxis (PrEP), it is not always accessible in European Centre for Disease Prevention and Control reporting countries and may not meet the needs of all at-risk populations. Based on the Flash! PrEP in Europe data, multiple correspondence analysis and hierarchical clustering were used to identify patterns in HIV prevention strategies among 9980 men who have sex with men (MSM). PrEP interest was evaluated among four identified clusters: (A) "high condom use, sometimes Treatment as Prevention (TasP)"; (B) "mix of methods, infrequent condom use"; (C) "high condom use, tendency to choose partners based on serological status" and (D) "moderate use of condoms mixed with other prevention strategies". Clusters B and D had higher PrEP interest. These results suggest that MSM use a range of behavioral and biomedical risk reduction strategies that are often combined. On-demand PrEP may meet the needs of MSM who infrequently use condoms and other prevention methods.

A French multicentric prospective prognostic cohort with epidemiological, clinical, biological and treatment information to improve knowledge on lymphoma patients: study protocol of the "REal world dAta in LYmphoma and survival in adults" (REALYSA) cohort

Background

Age-adjusted lymphoma incidence rates continue to rise in France since the early 80’s, although rates have slowed since 2010 and vary across subtypes. Recent improvements in patient survival in major lymphoma subtypes at population level raise new questions about patient outcomes (i.e. quality of life, long-term sequelae). Epidemiological studies have investigated factors related to lymphoma risk, but few have addressed the extent to which socioeconomic status, social institutional context (i.e. healthcare system), social relationships, environmental context (exposures), individual behaviours (lifestyle) or genetic determinants influence lymphoma outcomes, especially in the general population. Moreover, the knowledge of the disease behaviour mainly obtained from clinical trials data is partly biased because of patient selection.

Methods

The REALYSA (“REal world dAta in LYmphoma and Survival in Adults”) study is a real-life multicentric cohort set up in French areas covered by population-based cancer registries to study the prognostic value of epidemiological, clinical and biological factors with a prospective 9-year follow-up. We aim to include 6000 patients over 4 to 5 years. Adult patients without lymphoma history and newly diagnosed with one of the following 7 lymphoma subtypes (diffuse large B-cell, follicular, marginal zone, mantle cell, Burkitt, Hodgkin, mature T-cell) are invited to participate during a medical consultation with their hematologist. Exclusion criteria are: having already received anti-lymphoma treatment (except pre-phase) and having a documented HIV infection. Patients are treated according to the standard practice in their center. Clinical data, including treatment received, are extracted from patients’ medical records. Patients’ risk factors exposures and other epidemiological data are obtained at baseline by filling out a questionnaire during an interview led by a clinical research assistant. Biological samples are collected at baseline and during treatment. A virtual tumor biobank is constituted for baseline tumor samples. Follow-up data, both clinical and epidemiological, are collected every 6 months in the first 3 years and every year thereafter.

Discussion

This cohort constitutes an innovative platform for clinical, biological, epidemiological and socio-economic research projects and provides an opportunity to improve knowledge on factors associated to outcome of lymphoma patients in real life.

Trial registration

2018-A01332–53, ClinicalTrials.gov identifier: NCT03869619.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10433-4.

"Yes, I'm interested in taking PrEP!": PrEP interest among women respondents to the European community-based survey "Flash! PrEP in Europe"

The World Health Organization recommends pre-exposure prophylaxis (PrEP) for all populations at substantial risk of HIV infection, including women. However, data regarding PrEP interest among women is lacking, particularly in Europe. Factors associated with interest in using PrEP were assessed among women respondents to the Flash! PrEP in Europe (FPIE) survey. This community-based cross-sectional study, conducted in 12 European countries, aimed to assess PrEP knowledge and interest. “High objective risk” (HOR) was assessed using established risk criteria following EACS and CDC guidelines. Factors associated with interest in using PrEP were assessed in univariable and multivariable logistic regression models. Among 678 women, 12.5% (n = 85) were considered at HOR, 46.8% (n = 317) indicated prior PrEP knowledge and 18.0% (n = 122) reported interest in using PrEP. Among women at HOR, 40.0% (n = 34) were interested in PrEP. Factors significantly associated with PrEP interest in the final multivariable model were: younger age (18–29 years) (aOR 1.91[95CI: 1.07; 3.41]), bad self-perceived financial status (1.84[1.09; 3.11]), migrant status (south to north) (2.87[1.05; 7.89]), single or dating relationship status (1.93[1.23; 3.03]), sexual abuse history (1.86[1.17; 2.97]), “rather high”/ “high” self-perceived HIV risk (3.21[1.32; 7.81]), and HOR (2.49[1.42; 4.35]). These results show that women at HOR and those who perceived themselves to be at high risk are interested in using PrEP. There is a critical need for targeted information and improved access to PrEP to increase uptake of this HIV prevention tool to meet PrEP interest among women.

PrEP Interest Among Men Who Have Sex with Men in the Netherlands: Covariates and Differences Across Samples

Despite increased availability of pre-exposure prophylaxis (PrEP), PrEP uptake has remained low. To promote uptake, factors related to PrEP interest among relevant target populations warrant investigation. The aim of this study was to provide an analysis of PrEP interest among men who have sex with men (MSM) in the Netherlands, while taking study recruitment strategies into account. We recruited 154 MSM from an LGBT research panel (AmsterdamPinkPanel) and 272 MSM from convenience sampling. Both samples were part of the Flash! PrEP in Europe Survey and were compared on their PrEP interest, usage intentions, and sexual behavior. We conducted logistic regression analyses to discover variables associated with PrEP interest and intentions. Participants from the AmsterdamPinkPanel were less likely to use PrEP, had less knowledge of PrEP, and were less interested in PrEP than participants from convenience sampling. Significant covariates of PrEP interest were being single, more prior PrEP knowledge, sexual risk behaviors, such as not having used a condom during last sex and having ever used drugs in a sexual context, and not participating in the AmsterdamPinkPanel. Adding the recruitment strategy to the regression increased explained variance on top of predictors already described in the literature. Increased sexual risk behavior is related to increased PrEP interest and it helps to identify PrEP target groups. Recruitment strategies have a substantial impact on findings regarding PrEP interest and usage intentions. This study emphasizes the importance of using multiple strategies for recruiting participants to obtain a more comprehensive view of MSM's attitudes toward PrEP.

Prevalence and management of tuberculosis among people who use drugs in Abidjan, Ivory Coast

Background Although people who use drugs (PWUD) are a high-risk group for tuberculosis (TB), there is practically no data on TB prevalence in Ivory Coast. The aim of the study was to estimate pulmonary TB prevalence and assess the cascade of care with confirmed pulmonary TB (TB+) among PWUD in Abidjan. Methods The study targeted adult people who had used heroin and/or cocaine/crack in the previous six months. A first part consisted in a cross-sectional prevalence estimation survey using mobile facility testing in smoking spots. A multivariable logistic regression was performed to determine the factors associated with TB infection. In a second part, all participants who tested positive for pulmonary TB were offered follow-up for the duration of their treatment and invited to participate in a community-based support program (e.g. family mediation visits or self-support groups). Results Between October 2016 and May 2017, 545 PWUD were informed about the survey and 532 agreed to participate. Most of them were male (n = 484; 91.0%) single (n = 434; 81.6%), with an average age of 34.9 (SD 8.3) years. Drugs most commonly consumed were heroin and crack (n = 530; 99.6% and n = 353; 66.4% respectively) and were inhaled (i.e. smoked). Out of the 531 participants with an Xpert MTB/RIF® test result, 52 were diagnosed with pulmonary TB, i.e. a prevalence of 9.8%, 95% CI [7.5%-12.7%]. Among them, 17.3% had rifampicin-resistant TB. Factors significantly associated with TB infection in the multivariable analysis were: having been recruited in Treichville smoking spot (OR=2.0 [1.1 - 3.7]; p = 0.03), being unemployed (OR = 1.8 [1.0 - 3.4]; p = 0.05), and being co-infected with HIV (OR=3.3 [1.2 - 8.1]; p = 0.01); 60.0% of the patients were successfully treated. Conclusion TB prevalence among the PWUD is high. The community-based support model enables good treatment efficacy among this usually hard-to-reach population.

HIV and other sexually transmitted infections among female sex workers in Moscow (Russia): prevalence and associated risk factors

To estimate the prevalence and factors associated with HIV and five other STIs among outdoor female sex workers (OSFW) and indoor FSW (IFSW).

METHODS

Cross-sectional survey using respondent-driven sampling methodology. Participants answered a bio-behavioural questionnaire and were tested for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV), syphilis (lifetime contact) and Mycoplasma genitalium (MG). Weighted HIV and other STIs prevalence and 95% CIs were calculated. Weighted multivariate logistic regression was performed to identify factors associated with having at least one STI (including HIV).

RESULTS

Between October 2017 and July 2018, 385 FSW participants were recruited, among whom 206 (53.5%) were IFSW and 179 (46.5%) were OFSW. The mean age was 31.4 years. Weighted HIV prevalence was 3.1% (95% CI 1.5 to 7.0). Weighted prevalence of other STIs was: 4.1% (95% CI 2.2 to 8.0) for NG, 8.8% (95% CI 5.9 to 13.0) for CT, 12.7% (95% CI 8.6 to 18.0) for TV, 13.9% (95% CI 9.9 to 19.0) for syphilis (lifetime contact) and 14.9% (95% CI 10.5 to 21.0) for MG. STI prevalence was significantly higher among OFSW for CT, TV and MG (p<0.001). In total, 43.2% of the participants had at least one HIV/STI. Factors associated with having HIV/STI were being an OFSW (OR 3.29; 95% CI 1.72 to 6.27); being registered in another Russian region (2.61 (95% CI 1.05 to 6.48)); having never been tested for HIV (2.51 (95% CI 0.98 to 6.41)) and having a low level of knowledge regarding HIV transmission (4.88 (95% CI 0.96 to 24.78)).

CONCLUSION

Prevalence of HIV and STIs was high among FSW in Moscow. OFSW were more vulnerable to STIs. There is an urgent need to tailor programmes for sexual and reproductive health for FSW in Russia.

Combined Sexual Behavioral Profiles in HIV-Seronegative Men Who have Sex with Men in West Africa (CohMSM ANRS 12324-Expertise France)

Understanding the dynamics of HIV infection in men who have sex with men (MSM) can help improve efficiency in existing prevention strategies. We aimed to identify and describe the sexual behaviors of MSM most at risk of HIV infection in West Africa. HIV-negative MSM were provided a quarterly preventive follow-up package in the community-based cohort CohMSM. They completed face-to-face sociobehavioral questionnaires every 6 months. This sub-study on 520 participants used a baseline, 6-, 12- and 18-month data cluster analysis to categorize two profiles (high risk [HRE] and moderate risk [MRE] of exposure to HIV) based on three risky sexual practices over the previous 6 months. HRE-MSM (61%) were more engaged in receptive practices, had a higher proportion of inconsistent condom use during anal sex, and reported more sexual partners than MRE-MSM (39%). The proportion of HIV seroconversions observed during the first 18 months of follow-up using sexual behavioral profiles (92% are HRE-MSM) was higher than using the three risky sexual practices separately. Factors associated with the HRE-MSM profile were being younger (18-21 years), reporting stigma, and having had no female partner while being attracted only to men. Our findings suggest that in order to identify MSM most at risk of HIV infection, several risky sexual practices need to be evaluated in a combined approach. Prevention programs should pay particular attention to younger MSM, and implement activities addressing questions of MSM identity and stigma in order to reduce the dynamic of HIV infection in Western African MSM.

Transactional sex among men who have sex with men participating in the CohMSM prospective cohort study in West Africa

Although the HIV epidemic is generalized in West Africa, some population groups such as men who have sex with men (MSM), especially those engaged in transactional sex (TS), are thought to be particularly more vulnerable to HIV than others. However, few data are available to help identify their health-related needs with a view to implementing targeted prevention interventions. To fill this knowledge gap, we aimed to characterize MSM reporting TS (MSM-TS) and to identify factors associated with their sexual practices using data from the prospective cohort study CohMSM, which was conducted in Burkina Faso, Côte d’Ivoire, Mali and Togo. Three stigmatization sub-scores were constructed (experienced, perceived and internalized). The generalized estimating equation method was used for data analysis. Of the total 630 HIV-negative MSM recruited in CohMSM, 463, 410 and 244 had a follow-up visit at 6, 12 and 18 months, respectively. In a total of 1747 follow-up visits, 478 TS encounters were reported by 289 MSM-TS (45.9%). Of the latter, 91 regularly reported TS (31.5%), 55 (19.0%) stopped reporting TS after baseline, and 53 (18.3%) reported TS after baseline and 90 (31.1%) occasionally reported TS. The following variables, regarding the previous 6 months, were positively associated with TS: being younger (aOR[95%CI]:1.86[1.39–2.50]), less educated (aOR[95%CI]:1.49[1.09–2.03]), unmarried status (aOR[95%CI]:1.79[1.10–2.93]), satisfaction with current sex life (aOR[95%CI]:1.41[1.06–1.88]), group sex with men (aOR[95%CI]:2.07[1.46–2.94]), multiple male sexual partners (aOR[95%CI]:1.85[1.40–2.44]), receptive or versatile anal sex with male partners (aOR [95%CI]:1.48[1.12–1.96]), giving benefits in exchange for sex with a man (aOR[95%CI]:2.80[1.97–3.98]), alcohol consumption (aOR[95%CI]:1.44[1.08–1.93]) and drug use (aOR[95%CI]:1.82[1.24–2.68]) during sex, and finally experiencing stigmatization (aOR [95%CI]:1.15[1.07–1.25]). Condom use during anal sex (aOR[95%CI]:0.73[0.53–0.99]) was negatively associated with TS.

Changes in risky sexual behaviours among West African MSM enrolled in a quarterly HIV testing and counselling prevention programme (CohMSM ANRS 12324 - Expertise France)

OBJECTIVES

Whether regular HIV testing and counselling reduce risky sexual behaviours in African men who have sex with men (MSM) is still a matter for debate. We aimed to identify behavioural trajectories based on HIV risk exposure (HRE) and factors affecting their evolution.

METHODS

Data were collected from 621 HIV-negative West African MSM (Mali, Cote d'Ivoire, Burkina Faso and Togo) included in a community-based cohort providing quarterly HIV testing and counselling. Sociobehavioural data were collected every 6 months. HRE was defined as reporting inconsistent condom use during receptive anal sex with male partners of unknown HIV status in the previous 6 months. Using 18-month follow-up data, group-based trajectory modelling helped identify behavioural trajectories and determine the factors associated with their evolution. HIV seroconversions (n=67) were specified in each group trajectory.

RESULTS

Two distinct group trajectories were identified: medium-risk exposure MSM (ME-MSM) (61%, 6.4% of whom having seroconverted) and high-risk exposure MSM (HE-MSM) (39%, 17.5% of whom having seroconverted). A significant declining trend in the probability of reporting HRE over time ((95% CI)) was observed for HE-MSM (from 0.59 (0.48 to 0.70) at M0 to 0.31 (0.22 to 0.41) at M18), while it remained constant for ME-MSM (0.034 (0.0 to 0.079)). This can be explained by a progressive use of risk reduction strategies (less receptive anal sex, better knowledge of their partners' status and increasing condom use). Being younger, living in Burkina Faso, self-considering both a man and a woman and reporting a higher level of depression were all associated with HE membership. Among HE-MSM, HRE was higher in those practising transactional or group sex and those experiencing psychological harassment.

CONCLUSIONS

Quarterly HIV testing and counselling seem to reduce risky sexual behaviours in HIV-negative MSM at greatest risk of infection. Specific support for young MSM, focusing on identity and mental health, is needed to strengthen HIV prevention in West African MSM.

Male clients of male sex workers in West Africa: A neglected high-risk population

Research on male clients of male sex workers (MCMSW) has been neglected for a long time globally. We aimed to characterize MCMSW and to identify factors associated with their sexual practices using data from the prospective cohort study CohMSM conducted in Burkina Faso, Côte d'Ivoire, Mali and Togo. Our study focused on HIV-negative men who have sex with other men (MSM), recruited between 06/2015 and 01/2018 by a team of trained peer educators. Scheduled study visits at 6, 12 and 18 months included medical examinations, HIV screening, risk-reduction counselling and face-to-face interviews to collect information on their sociodemographic characteristics, sexual behaviours, and HIV risk-reduction strategies (HIV-RRS). Three stigmatization sub-scores were constructed (experienced, perceived and internalized). Mixed-effects logistic regression was used for data analysis. Of the 280 participants recruited at baseline, 238, 211 and 118, respectively, had a follow-up visit at 6, 12 and 18 months. Over a total of 847 visits, 47 transactional sex (TS) encounters were reported by 38 MCMSW (13.6%). Of the latter, only one participant reported systematic TS (2.6%), 18 (47.4%) stopped reporting TS after baseline, while 6 (15.8%) reported TS after baseline. Thirteen participants (34.2%) reported occasional TS. After adjusting for country of study and age, the following self-reported factors were associated with a greater likelihood of being MCMSW: protected anal sex, exclusively insertive anal sex with male sexual partners, avoidance of sex after consuming psychoactive products and experiencing stigmatization (all during the previous 6 months). The majority of MCMSW in this study practiced HIV-RRS with male sexual partners, including engaging in protected anal sex, avoidance of sex when consuming psychoactive products, and practising exclusively insertive anal sex.

Taking empowerment into account: the response of community-based organisations to the HIV care needs of men who have sex with men in West Africa (CohMSM ANRS 12324 - Expertise France)

Empowerment is an ongoing process through which individuals and communities appropriate power and acquire the capability to function autonomously. Research on empowerment in men who have sex with men (MSM) is lacking in community-based contexts. We investigated the relationship between willingness to be empowered and HIV care needs in West African MSM accessing community-based organisations' (CBO) services. Fifty-three interviews were administered to HIV-negative MSM participating in the CohMSM study (Mali, Burkina Faso, Côte d'Ivoire, Togo). Five indicators of empowerment were identified from a discourse analysis: (i) motivation to access HIV services, (ii) willingness to improve HIV services, (iii) desire to be involved in new activities, (iv) desire to participate in such services, (v) willingness to collaborate in decision making. Based on these indicators, participants were classified into two profiles: high (19/53, 36%) and low (34/53, 64%) level of willingness to be empowered (HWE, LWE). Using a thematic analysis, HWE participants were focused on collective benefit (preventive follow-up, questions about MSM identity), while LWE participants were centred on individual benefit (medical care). CBOs should consider empowerment as a tool to advance collective health benefits for MSM. To improve empowerment in MSM, specific training on issues regarding sexual identity and stigma is needed for CBO providers.

Interest in HIV pre-exposure prophylaxis in men who have sex with men in West Africa (CohMSM ANRS 12324 - Expertise France)

OBJECTIVE

To explore the interest in taking PrEP among Western African men who have sex with men (MSM).

METHODS

A cross-sectional survey was implemented at enrolment of HIV-negative MSM in a multiple centre community-based cohort study in four West African countries (Mali, Côte d'Ivoire, Burkina Faso, Togo). A standardised face-to-face questionnaire collected data on socio-demographic and behavioural characteristics over the previous 6 months. Descriptive analysis and multivariate logistic regression helped identify factors associated with the interest in taking PrEP.

RESULTS

Of 564 participants, 87% were interested in taking PrEP. Interest in PrEP was associated with inconsistent condom use for anal sex (adjusted odds ratio (aOR): 2.11; 95% confidence interval (CI) 1.21-3.67), transactional sex (aOR: 2.02; 95% CI 1.11-3.71), searching for male sexual partners on the Internet in the previous month (aOR: 1.86; 95% CI 1.01-3.43), having a high level of self-esteem (aOR: 1.20; 95% CI 1.06-1.36), having at least one sexually transmitted infections at enrolment (aOR: 5.08; 95% CI 1.40-18.4) and not being aware of PrEP (aOR: 2.03; 95% CI 1.04-3.96). Participants having sex with HIV-positive male partners (aOR: 0.28; 95% CI 0.11-0.74), those being more sexually attracted to women than to men (aOR: 0.20; 95% CI 0.07-0.89) and those reporting psychological and material support from close friends (aOR: 0.33; 95% CI 0.15-0.73) were less interested in taking PreP.

CONCLUSIONS

Western African HIV-negative MSM appear very interested in taking PrEP, especially those most at risk of HIV infection. PrEP implementation in a comprehensive prevention package should be considered urgently.

Empowering Malian women living with HIV regarding serostatus disclosure management: Short-term effects of a community-based intervention

OBJECTIVE

The objective of this study was to assess the short-term effects of Gundo-So-a program aimed at empowering Malian women living with HIV (WLHIV) regarding serostatus disclosure management.

METHODS

A pre-experimental study with two measures (one week before and four weeks after Gundo-So) was carried out. A 35-item questionnaire was administered to a convenience sample of 210 WLHIV. Six outcomes were considered: ability to decide whether or not to disclose HIV status, self-efficacy to keep HIV status a secret, self-efficacy to disclose HIV status, feeling crushed by the weight of secrecy, perceived physical health, and perceived psychological health. For each outcome, temporal changes associated with the intervention were assessed using linear regressions with random intercepts.

RESULTS

Statistically significant change was observed for all six outcomes between the pre- and post-intervention measures. Furthermore, several variables were associated with the baseline levels of the outcomes and the intervention effect.

CONCLUSION

The results suggest that Gundo-So empowers Malian WLHIV with regard to serostatus disclosure management, thus improving their perceived physical and psychological health.

PRACTICAL IMPLICATIONS

These results highlight the need for programs to empower WLHIV regarding serostatus disclosure, so that WLHIV can make free and informed decisions regarding serostatus disclosure.

An Assessment of Health Interventions Required to Prevent the Transmission of HIV Infection Among Men Having Sex with Men in Bujumbura, Burundi

Data regarding HIV among men having sex with men (MSM) in Burundi are scarce. In a context where same-sex practices are illegal, national recommendations including MSM have been issued in 2012. However, no study has been conducted to evaluate MSM's health needs, which would be useful to adapt recommendations and implement evidence-based interventions. This study aimed at identifying health needs expressed by MSM. A cross-sectional study was conducted in Bujumbura in 2014, in collaboration with the National Association for HIV positive people and AIDS patients. Fifty-one MSM, recruited during HIV prevention activities, self-completed a questionnaire. A descriptive analysis was conducted. Participants had a median age of 23 years, over 60 % declared being a member of an LGBT organisation and 76 % lived their homosexuality secretly or discretely. Over the last month, 67 % declared having had sex with a man and 32 % with a woman. In the previous 6 months, 40 % declared having systematically used a condom during sexual intercourse. In terms of health needs, 22 % did not use the services offered by HIV providers. Participants expressed needs in terms of prevention (access to rapid HIV tests, in a confidential setting, with counselling) and care (listening centre, free treatment, confidentiality). Medical expertise and being a good listener were the predominant healthcare staff qualities desired by participants. Results suggest that Burundian MSM represent an at-risk population, with low access to HIV services, in need of a comprehensive approach for HIV prevention, with community-based activities (HIV testing, counselling, prevention tools), psychological and social support.

HIV seropositivity and sexuality: cessation of sexual relations among men and women living with HIV in five countries

The sexuality of people living with HIV (PLHIV) is a key issue in the fight against HIV, as it influences both the dynamic of the epidemic and the quality of life of PLHIV. The present study examined the factors associated with cessation of sexual relations after HIV diagnosis among men and women in five countries: Mali, Morocco, Democratic Republic of the Congo, Romania and Ecuador. A community-based cross-sectional study was implemented by a mixed consortium [researchers/community-based organizations (CBO)]. Trained CBO members interviewed 1500 PLHIV in contact with CBOs using a 125-item questionnaire. A weighted multivariate logistic regression and a separate gender analysis were performed. Among the 1413 participants, 471 (33%) declared that they stopped having sexual relations after their HIV diagnosis, including 318 women (42%) and 153 men (23%) (p < .001). Concerning women, variables associated with the cessation of sexual relations in the final multivariate model were mainly related with relational factors and the possibility of getting social support (e.g., needing help to disclose HIV serostatus, feeling lonely every day, not finding support in CBOs, not being in a couple). Men's sexual activity was more associated with their representations and their perception of the infection (e.g., thinking they will have their HIV infection for the rest of their life, perceiving the HIV infection as a mystery, perceiving the infection as serious). Furthermore, the following variables were associated with both men and women sexual behaviours: being older, having suffered from serious social consequences after serostatus disclosure and not being able to regularly discuss about HIV with their steady partner. Results suggested clear differences between men and women regarding cessation of sexual relations and highlighted the importance of implementing gender-based tailored interventions that promote safe and satisfying sexuality, as it is known to have a positive impact on the overall well-being of PLHIV.

HIV serostatus disclosure: development and validation of indicators considering target and modality. Results from a community-based research in 5 countries

RATIONALE

HIV serostatus disclosure is a complex challenge for persons living with HIV (PLHIV). Despite its beneficial effects, it can also lead to stigmatization and rejection. The current lack of multi-dimensional measurement tools impede an in-depth understanding of the dynamic of disclosure.

OBJECTIVE

To develop and validate complex measures of serostatus disclosure.

METHODS

This international community based research study was performed by joint research teams (researchers/community based organizations (CBO)) in five countries (Democratic Republic of the Congo, Ecuador, Mali, Morocco and Romania). A convenience sample of 1500 people living with HIV (PLHIV) in contact with local CBO were recruited in 2011 (300 in each country). Face-to-face interviews were performed using a 125-item questionnaire covering HIV status disclosure to 23 potential disclosure targets and related issues (including personal history with HIV, people's reaction to disclosure, sexuality). A principal component analysis and a hierarchical cluster analysis were performed, in order to identify the main components of HIV disclosure, create measures and classify participants into profiles.

RESULTS

Patterns of disclosure were summarized using two main measures: direct and indirect disclosure. Disclosure to sexual partners, whether steady or not, was different from patterns of disclosure to other targets. Among the participants, three profiles emerged - labelled Restricted disclosure, Mainly indirect disclosure and Mainly direct disclosure, respectively representing 61%, 13% and 26% of the total sample. The profiles were associated with different aspects of PLHIV's lives, including self-efficacy, functional limitations and social exclusion. Patterns varied across the five studied countries.

CONCLUSION

Results suggest that multi-dimensional constructs should be used to measure disclosure in order to improve understanding of the disclosure process.

[Factors associated with contacting HIV/AIDS associations in Ecuador: results of a community study]

OBJECTIVE

To describe the profile of people living with HIV/AIDS (PLHA) who contact HIV/AIDS associations in Ecuador and to identify the factors related to that contact.

METHODS

In 2011, a cross-sectional community study was conducted in two hospitals in Guayaquil. Based on a 125-question survey administered to 300 adult PLHA, a weighted multivariate regression analysis was performed to identify the factors related to contact with an association

RESULTS

Of the 300 participants, 34 (11.3%) were in contact with an association. Being over the age of 35, scoring high on the self-efficacy scale, having suffered serious social consequences after disclosing their HIV status, being able to talk to friends about living with HIV, expressing the need to talk about living with HIV with a health professional, and scoring low on the index of the HIV status disclosure control effort were related to that contact.

CONCLUSIONS

The characteristics of the PLHA in contact with an association were: being over the age of 35, having suffered serious social consequences following disclosure of seropositivity, and feeling that their psychosocial needs were not being met by the health system in terms of the services provided. These people more easily managed their HIV status in their social milieu and displayed a greater ability to talk to friends about their seropositivity. This information is useful for community actors to maintain and support mobilization on HIV in Ecuador.

Factors associated with HIV voluntary disclosure of people living with HIV to their steady sexual partner in the Democratic Republic of the Congo: results from a community-based participatory research

Introduction

HIV disclosure to a steady sexual partner (SSP) is important both in preventing HIV transmission and improving the quality of life of people living with HIV (PLHIV). Its determinants have been poorly investigated in the Democratic Republic of the Congo. The study objective was to determine factors independently associated with voluntary disclosure to one's SSP in PLHIV receiving services from a Congolese community-based organization (CBO).

Methods

A community-based participatory research was performed and 300 PLHIV were interviewed by members of the CBO, using a standardized questionnaire. A multivariate logistic regression was used to determine the variables independently associated with disclosure.

Results

In this sample, 79 of the 127 participants (62%) included in the analysis declared having voluntarily disclosed their serostatus to their SSP. Declaring to be in a relationship (Odds Ratio (95% Confidence Interval): 4.2 (1.4-12.6)), having tested for HIV because of symptoms (2.5 (1.0-6.4)), having taken the test on one's own initiative (3.2 (1.3-8.0)), having felt sympathy and indifference from people when disclosing (6.0 (1.4-26.9) and 5.0 (1.1-22.8), respectively) as well as having a higher score of the “regular discussion about daily life with HIV” index (1.7 (1.1-2.5)) were significantly associated with disclosure to one's SSP.

Conclusion

Several individual and contextual factors were associated with voluntary disclosure to SSP in this study, highlighting the complex nature of the disclosure process. Interventions encouraging disclosure should be designed so as to adapt to one's personal life with HIV as well as psychosocial environment.

Hepatitis C virus acquisition among Egyptians: analysis of a 10-year surveillance of acute hepatitis C

OBJECTIVE

To identify current risk factors for hepatitis C virus (HCV) acquisition among Egyptians.

METHODS

Patients with acute HCV were identified through a surveillance system of acute hepatitis in four fever hospitals in Egypt between 2002 and 2012. Case-control analysis was conducted, cases being incident acute symptomatic HCV and controls being acute hepatitis A identified at the same hospitals. The questionnaire covered iatrogenic, community and household exposures to HCV in the 1-6 months prior to onset of symptoms. Multivariate models were built to identify risk factors associated with HCV acquisition among non-drug users and drug users separately.

RESULTS

Among non-drug users, hospital admission was independently associated with acute HCV infection (OR = 4.2, 95% CI = 1.7-10.5). Several iatrogenic procedures, for example admission in a surgery unit, sutures, IV injections and IV infusions, highly correlated with hospital admission, were also associated with acute HCV infection and could have been used in the final model instead of hospital admission. Among drug users, identified risk factors were multiple sexual relations (OR = 4.0, 95% CI = 1.1-14.7), intravenous drug use (OR = 3.9, 95% CI = 1.2-13.0) and shaving at the barbershops (OR = 8.7, 95% CI = 2.4-31.4). Illiteracy and marriage were significant risk factors in both groups.

CONCLUSION

Invasive medical procedures are still a major risk for acquiring new HCV infections in Egypt, as is illicit drug use in spreading HCV infection.

Did media attention of the 2009 A(H1N1) influenza epidemic increase outpatient antibiotic use in France?: A time-series analysis

Background

In France, the 2009 A(H1N1) influenza epidemic occurred between September 2009 and January 2010. Sparking widespread controversy, it was intensely reported in the media. Despite therapeutic inefficacy, antibiotic consumption and viral respiratory infections are positively correlated, particularly in France, where antibiotic overconsumption is well-known. We first determined the period when media coverage was high, and then compared, during this period, observed outpatient antibiotic consumption to estimated outpatient antibiotic consumption “without media attention”.

Materials and Methods

To evaluate media coverage, two online databases were consulted: Factiva and Europresse. To quantify outpatient antibiotic consumption, we used data on reimbursements of outpatient systemic antibiotics from the computerized databases of the two main National Health Insurance agencies. Influenza-like syndromes data came from the French GPs Sentinelles Network. Weekly time-series of antibiotic consumption were modeled by autoregressive moving-average models with exogenous inputs and interventions. Analyses were computed for the entire series and by age group (0–5, 6–15, 16–60, and >60 years).

Results

Media coverage was intense between April 2009 and January 2010. No effect on total outpatient antibiotic consumption was observed during the whole mediatic period. However, during the epidemic in France (September 2009-January 2010), we found an antibiotic underconsumption for the entire series, 0–5 and >60 years. Additionally, at the beginning of the pandemic, when cases were still outside France (June 2009-August 2009), we found an antibiotic overconsumption for patients >16 years.

Conclusion

The early period of A(H1N1) virus circulation compared with seasonal influenza or an overdeclaration of ILS cases might explain the antibiotic underconsumption observed during the period of active A(H1N1) virus transmission in France. At the pandemic onset, when uncertainty was high, the overconsumption observed for individuals >16 years might have been caused by alarmist media reporting. Additional analyses are needed to understand the determinants of antibiotic consumption during this period.

Survey of delivery of prophylactic immunoglobulins following exposure to a measles case

In France, almost 23,000 cases of measles and 10 deaths have been reported between January 2008 and August 2012. French health authorities recommend delivery of human polyvalent immunoglobulins in the event of exposure to a measles case for some categories of unvaccinated persons (children under the age of 12 months, immunocompromised persons and pregnant women), within six days after exposure and following laboratory confirmation of the contact case. We carried out a postal survey among 368 French hospital pharmacies to evaluate the number of persons affected by this measure between 1 January 2010 and 31 August 2011, to describe the characteristics of these patients and to evaluate the application of the recommendations in terms of delay between exposure and immunoglobulin delivery, and confirmation of the contact case. The response rate to the survey was 73%. In total, 400 immunoglobulin deliveries were listed, most of them for children under the age of one year, and 84% of the 250 administrations with available information occurred within six days after exposure, as recommended. However, only 48% of the 209 treated contacts with available information were laboratory-confirmed when the immunoglobulins were delivered. This survey is the first evaluation of this recommendation since its introduction in 2005 and suggests that the recommendations may need to be updated.

The phosphate transporter PiT1 (Slc20a1) revealed as a new essential gene for mouse liver development

BACKGROUND

PiT1 (or SLC20a1) encodes a widely expressed plasma membrane protein functioning as a high-affinity Na(+)-phosphate (Pi) cotransporter. As such, PiT1 is often considered as a ubiquitous supplier of Pi for cellular needs regardless of the lack of experimental data. Although the importance of PiT1 in mineralizing processes have been demonstrated in vitro in osteoblasts, chondrocytes and vascular smooth muscle cells, in vivo evidence is missing.

METHODOLOGY/PRINCIPAL FINDINGS

To determine the in vivo function of PiT1, we generated an allelic series of PiT1 mutations in mice by combination of wild-type, hypomorphic and null PiT1 alleles expressing from 100% to 0% of PiT1. In this report we show that complete deletion of PiT1 results in embryonic lethality at E12.5. PiT1-deficient embryos display severely hypoplastic fetal livers and subsequent reduced hematopoiesis resulting in embryonic death from anemia. We show that the anemia is not due to placental, yolk sac or vascular defects and that hematopoietic progenitors have no cell-autonomous defects in proliferation and differentiation. In contrast, mutant fetal livers display decreased proliferation and massive apoptosis. Animals carrying two copies of hypomorphic PiT1 alleles (resulting in 15% PiT1 expression comparing to wild-type animals) survive at birth but are growth-retarded and anemic. The combination of both hypomorphic and null alleles in heterozygous compounds results in late embryonic lethality (E14.5-E16.5) with phenotypic features intermediate between null and hypomorphic mice. In the three mouse lines generated we could not evidence defects in early skeleton formation.

CONCLUSION/SIGNIFICANCE

This work is the first to illustrate a specific in vivo role for PiT1 by uncovering it as being a critical gene for normal developmental liver growth.

Validation of a high-performance liquid chromatographic assay for the quantification of adenovirus type 5 particles

An anion-exchange-high-performance liquid chromatography (AE-HPLC) method for the quantification of adenovirus type 5 (Ad5) total particles was validated according to performance criteria of precision, specificity, linearity of calibration and range, limit of detection, limit of quantification, accuracy and recovery. The viral particles were detected by absorbance at 260 nm using photodiode array detector (PDA). Cesium chloride (CsCl) purified Ad5 and lysate samples were used for the validation of the method. Relative standard deviations (RSDs) for the inter-day, intra-day precision and reproducibility for both the lysate and the Ad5 standard were less than 10 and 2% for the peak area and retention time, respectively. The method was specific for Ad5 which was eluted at 8.0 min. The presence of DNA does not affect the recovery of Ad5 particles for accurate quantification. Based on the error in prediction to be less than 10%, the working range was established between 2 x 10(10) and 7 x 10(10) VP/ml with correlation coefficient of 0.99975, standard deviation of 6.14 x 10(9) VP/ml and a slope of 3.04 x 10(5) VP/ml. The recovery of the method varied between 88 and 106% in all of the lysate samples investigated which is statistically similar to 100% recovery at 95% confidence interval.

Improved high-performance liquid chromatographic method in the analysis of adenovirus particles

We developed a HPLC method on a novel continuous bed matrix (UNO Q, Bio-Rad) for the direct quantification of adenoviral type 5 (Ad5) particles produced in 293S Human Embryonic Kidney cells and compared this with an existing HPLC method on a conventional ion-exchange resin (Resource Q, Pharmacia). The 293S cell extract contained large amounts of DNA. This contaminated the viral peak on the Resource Q column and only after Benzonase treatment was it possible to quantify the viral particles in the cell extract. In contrast, the virus peak on the UNO Q column was resolved from the DNA which eliminates the need for pretreatment of the sample with Benzonase. Cross-analysis of the Ad5 fraction from the UNO Q column using a size-exclusion HPLC column revealed no additional contaminating peaks. We conclude that the purity of the Ad5 virus peak on the continuous bed matrix UNO Q column was superior to the purity of the virus on the conventional Resource Q column, which is essential for reliable quantification.

Social support processes: mediators of attachment state of mind and adjustment in late adolescence

This study examined the mediational link between attachment state of mind, social support processes and personal adjustment. The Adult Attachment Interview was administered to 62 adolescents during their college transition. At the end of high school and during their first semester in college, students completed questionnaires pertaining to primary and secondary appraisals; coping and personal adjustment were assessed through self- and peer-report questionnaires. A dismissing tendency was related to difficulty in getting assistance from peers and teachers and to peer-reported withdrawal. A preoccupied tendency was associated with stress regarding the transition, distrust in potential supporters, difficulty seeking help from teachers, and loneliness. Moreover, stress, distrust and help-seeking mediated the link between preoccupied attachment and loneliness, whereas the relation between dismissing attachment and withdrawal was not mediated by help-seeking. Cognitive and behavioral attachment processes are discussed.

Gonadotrophin storage patterns in the ewe during the oestrous cycle or after long-term treatment with a GnRH agonist

The storage pattern of gonadotrophins in the ewe pituitary was investigated during the oestrous cycle and after desensitization to GnRH using long-term treatment with a GnRH agonist, buserelin. Oestrous cycles in ewes were synchronized with progestagen sponges. Animals were allocated to two experiments. In the first, ewes were killed 36 h (before the preovulatory surge, n = 4), 48 h (end of the preovulatory surge, n = 5), 72 h (post-ovulation, n = 4) and 240 h (luteal phase, n = 3) after sponge removal. In the second experiment, another progestagen sponge was inserted in ewes 84 h after removal of the first sponge. Four ewes were infused continuously with buserelin (50 micrograms/day) for 15 days before killing. A further four ewes received no buserelin (controls). Pituitaries were collected and processed for immunocytochemistry to detect monohormonal (LH or FSH) and multihormonal (LH/FSH) cells. The percentages of LH or FSH immunoreactive cells in the pituitary were lower at the end of the preovulatory surge (7.4 +/- 0.3% and 1.2 +/- 0.3% respectively) compared with the other stages (11.4 +/- 0.5% and 5.4 +/- 0.7% respectively). Analysis of dual immunostaining showed the existence of monohormonal cells for LH and multihormonal cells (LH/FSH). No monohormonal cell for FSH was detected except at the end of the preovulatory surge when a few monohormonal FSH cells appeared (0.1 +/- 0.01% of pituitary cells). The percentage of monohormonal LH cells in the pituitary gland was similar in all studied stages of the oestrous cycle, whereas the percentage of multihormonal cells was lower at the end of the surge. In agonist-treated ewes, the percentages of LH or FSH immunoreactive cells (5.3 +/- 0.5% and 1.5 +/- 0.8% respectively) were decreased compared with controls (9.4 +/- 1% and 7.5 +/- 1.1% respectively). Analysis of the double immunostaining revealed a few monohormonal FSH cells (0.2 +/- 0.01% of pituitary cells) in agonist-treated ewes but not in controls. The percentage of monohormonal LH cells in the pituitary gland increased from 1.9 +/- 0.2% in controls to 3.8 +/- 0.3% in agonist-treated ewes, whereas multihormonal cells dropped from 7.5 +/- 1.1% to 1.3 +/- 0.7%. Our data suggest, therefore, that multihormonal cells contribute to gonadotrophin secretion, either during the preovulatory surge of the oestrous cycle or during the 'flare-up' effect initially induced by a GnRH agonist. Moreover, the appearance of monohormonal FSH cells in some conditions reflects a differential regulation of LH and FSH.

Aortic percutaneous transluminal valvuloplasty in elderly patients by balloon larger than aortic anulus

Twenty-four elderly patients (79 +/- 7 years) with long-standing calcified aortic stenosis have been divided in two comparable groups of 12. The first group was treated with 19 mm balloon percutaneous transluminal valvuloplasty, where the balloon diameter was always smaller than the aortic anulus diameter. Peak-to-peak aortic valve gradient decreased from 76 +/- 32 mmHg to 30 +/- 19 (P less than .05), and the aortic valve area, calculated by Gorlin formula, increased from 0.40 +/- 0.17 cm2 to 0.57 +/- 0.17 (P less than .05). The second group was treated with a trefoil 25 mm balloon, always larger than the aortic anulus diameter. In this second group, peak-to-peak aortic valve gradient decreased from 73 +/- 34 mmHg to 23 +/- 15 (P less than .05), and aortic valve area increased from 0.47 +/- 0.14 cm2 to 0.88 +/- 0.36 (P less than .05), increasing thus more than in group I (P less than .05). Clinical tolerance to balloon inflation was not the same according to individual patients but was similar between the two groups; complications were comparable in the two groups. These results suggest that aortic valvuloplasty by trefoil balloon larger than aortic anulus can provide wider aortic valve area without increasing complication rate.

A General Method of Four-Bar Linkage Mobility Analysis

The problem of mobility associated with four-bar linkages is addressed in this paper. The mobility analysis is reduced to finding the global extrema of a quadratic function on a cylinder, which then leads to the geometric problem of finding the intersections of a circle and a hyperbola. The method proposed here produces an efficient mobility analysis that can be readily integrated into any suitable optimization algorithm.

Opening snap and isovolumic relaxation period in relation to mitral valve flow in patients with mitral stenosis. Significance of A2--OS interval

In 15 patients with pure or predominant mitral stenosis and in a control group of 11 patients without mitral stenosis the blood flow velocity through the mitral valve orifice was recorded by means of a directional Doppler ultrasound velocity catheter introduced transeptally and positioned in the orifice of the mitral valve. A simultaneous surface phonocardiogram was obtained. The timing of the mitral opening snap in relation to the blood velocity record of the flow through the valve supported the hypothesis that the opening snap is due to a sudden tensing of the valve leaflets by the chordae tendineae. Determination of the exact time of mitral valve opening, made possible by the blood velocity record, led to the division of the classical A2-0S interval (aortic valve closure to opening snap) into two components representing respectively the diastolic isovolumic relaxation period and the time of excursion of the mitral valve cusps. The durations of the isovolumic relaxation period were compared with those in the control patients and were found to correlate with the severity of the mitral stenosis, whereas those of the excursion time of the mitral cusps were influenced by the presence or absence of mitral valve calcification.

Diagnosis and evaluation of mitral valve disease using transseptal Doppler ultrasound catheterization

In 33 patients with confirmed mitral valve disease, the mitral valve flow velocity traces were recorded by means of a directional Doppler ultrasonic velocimeter using the transseptal route, and correlated with the clinical and haemodynamic data. In all cases, characteristic anomalies of the mitral flow velocity patterns were noted and could be related to the type of lesion, stenosis, regurgitation, or a combination of these. Furthermore, specific patterns of the flow velocity traces were shown to correlate satisfactorily with the degree of severity of the disease. The authors propose a pathophysiological interpretation of the anomalies of the velocity patterns, based on turbulence for stenosis and backward flow wave for regurgitation. They conclude that the transseptal directional Doppler catheterization provides a new reliable method for establishing the diagnosis and grading the severity of mitral valve disease using pattern recognition, and, moreover, offers a new approach to the understanding of mitral haemodynamic disturbances on a beat-to-beat basis.

Normal pattern and physiological significance of mitral valve flow velocity recorded using transseptal directional Doppler ultrasound catheterization

In 10 cardiac patients in whom an organic lesion of the mitral valve was exluded by standard investigation procedures during which a diagnostic transseptal catheterization for pressure measurements in the left heart was performed, the authors placed a directional Doppler ultrasonic catheter tip velocimeter at the site of the mitral ring and recorded the mitral flow velocity traces. The pattern of these normal curves is presented and a physiological interpretation proposed. The relation between the mitral flow velocity and low volume curves is discussed in the light of present experimental data on mitral valve flow velocity profiles and variations in size of the mitral orifice. The authors concluded that the flow velocity curves obtained by the Doppler technique constitute a valid physiological reference system for the study of the mitral valve flow velocity tracings that can be recorded in the various forms of mitral valve disease.