COVID19 : quel impact sur le suivi des patients vivant avec le VIH à l'hôpital ?

Introduction

La pandémie Covid-19 a gravement perturbé l'accès aux systèmes de santé. Cette étude a pour objectif d'évaluer l'impact de la crise de la Covid-19 sur le suivi ambulatoire hospitalier des personnes vivant avec le VIH (PVVIH) et de remettre dans le parcours de soins « les perdus de vue de la Covid-19 » une fois identifiés.

Matériels et méthodes

Grâce à une requête informatique du logiciel utilisé en ambulatoire (Diamm/G, Micro6) dans un service de maladies infectieuses, une liste de patients, venus consulter entre Mars 2019 et Mars 2020 puis sans nouveau RDV de consultation après Mars 2020, a été remise à chaque médecin pour qu'il y notifie une raison de non venue de chaque patient. A défaut, une recherche sur le logiciel Orbis et un courrier au médecin correspondant ont été fait. En dernier recours les patients étaient contactés par téléphone ou mail. Et si malgré cela, aucune réponse n'était apportée, le fichier INSEE était consulté afin de rechercher un éventuel décès. Les perdus de vue (PDV) ont été ainsi identifiés : les patients n'ayant pas de nouvelle consultation après Mars 2020 sans raison retrouvée.

Résultats

Sur les 2802 patients vivant avec le VIH (PVVIH) suivis jusqu'en Mars 2020, 544 (19 %) pts ne sont pas venus consulter après cette date : 235 (43 %) sont suivis en ville, 53 (10 %) sont suivis dans un autre hôpital, 34 (6 %) ont déménagé, 26 (5 %) sont décédés, 116 (21 %) sont revenus consulter en 2021 après avoir été contactés et 67 (12 %) sont des PDV. Les caractéristiques de ces PDV sont : 49 (73 %) hommes, âge médian 45.7 ans [25-80], 36 (54 %) étrangers dont 22 (33 %) originaires d'Afrique Subsaharienne, avec un mode de transmission hétérosexuelle chez 32 (48 %), homosexuelle chez 27 (40 %), par usage de drogue intraveineuse chez 3 (4 %), inconnue chez 5 (7 %), une médiane d'ancienneté VIH de 10.7 ans [1-33], une médiane de CD4 à 474/mm3 [23-1293], 17 (25 %) avaient une CV VIH > 50 cp/ml, un stade CDC A chez 55 (82 %) et C chez 12 (18 %). Des particularités ont été notées parmi ces PDV : 12 (14 %) avaient des problèmes d'observance, 17 (20 %) étaient en situation de précarité (logement, travail ou AME), 4 (5 %) présentaient des troubles psychiatriques et 8 (10 %) n'avaient consulté qu'une seule fois (2 arrivées récentes en France, 2 découvertes VIH, 1 sortie de prison, 2 patients suivis ailleurs avant). Les causes des 26 décès sont les suivantes : 11 cancers non classant SIDA, 3 décès liés à la COVID19, 2 pathologies cardio-vasculaires, 1 décès lié à une cirrhose décompensée, 1 décès lié à un SDRA et 8 décès sans cause retrouvée.

Conclusion

Les PDV représentent seulement 2 % (67/2802) de la file active des PVVIH avec une population représentative très hétérogène rendant complexe l'identification d'éventuels facteurs de risque telles que dysobservance et précarité. La pandémie COVID19 a surtout eu un impact sur la redistribution du suivi ville/hôpital et l'exode vers la Province. Cette enquête a reçu un accueil favorable des patients contactés qui se sentaient rassurés et a permis de remettre 4 % de patients de la file active dans le parcours de soin.

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HCV cure: an appropriate moment to reduce cannabis use in people living with HIV? (ANRS CO13 HEPAVIH data)

BACKGROUND

Thanks to direct-acting antivirals, hepatitis C virus (HCV) infection can be cured, with similar rates in HCV-infected and HIV-HCV co-infected patients. HCV cure is likely to foster behavioral changes in psychoactive substance use, which is highly prevalent in people living with HIV (PLWH). Cannabis is one substance that is very commonly used by PLWH, sometimes for therapeutic purposes. We aimed to identify correlates of cannabis use reduction following HCV cure in HIV-HCV co-infected cannabis users and to characterize persons who reduced their use.

METHODS

We used data collected on HCV-cured cannabis users in a cross-sectional survey nested in the ANRS CO13 HEPAVIH cohort of HIV-HCV co-infected patients, to perform logistic regression, with post-HCV cure cannabis reduction as the outcome, and socio-behavioral characteristics as potential correlates. We also characterized the study sample by comparing post-cure substance use behaviors between those who reduced their cannabis use and those who did not.

RESULTS

Among 140 HIV-infected cannabis users, 50 and 5 had reduced and increased their use, respectively, while 85 had not changed their use since HCV cure. Cannabis use reduction was significantly associated with tobacco use reduction, a decrease in fatigue level, paying more attention to one's dietary habits since HCV cure, and pre-HCV cure alcohol abstinence (p = 0.063 for alcohol use reduction).

CONCLUSIONS

Among PLWH using cannabis, post-HCV cure cannabis reduction was associated with tobacco use reduction, improved well-being, and adoption of healthy behaviors. The management of addictive behaviors should therefore be encouraged during HCV treatment.

Why are people still dying of drug-susceptible TB in Paris in the 21st century?

BACKGROUND: Although the burden of TB is lower in France than in low-income countries, patients continue to die from TB in Paris. Our goal was to describe TB-related deaths and to identify associated risk factors.METHODS: We conducted a retrospective cohort study in two hospitals in Paris between 2013 and 2018. All patients with drug-susceptible TB were included and followed until end of treatment. The primary outcome was death. We performed univariate and multivariate analysis using Cox proportional hazard model.RESULTS: Of the 523 patients included, 362 were men (median age 37 years), of whom 24 patients died (4.5%). The final survival model concluded that age (HR 1.1 for each additional year), not living in one´s own accommodation (HR 5.9), being born in France (HR 8.0), being alcoholic (HR 4.2), having a history of cancer (HR 7.1) or meningeal or miliary TB (HR 8.2) were associated with a higher risk of death.CONCLUSION: The rate of TB-associated death is unacceptably high for a curable disease. To note, patients born in France were much more at risk of death than immigrants. We believe raising awareness among healthcare professionals is a potentially easy and efficient lever for improving care.

High performance of a novel antigen detection test on nasopharyngeal specimens for diagnosing SARS-CoV-2 infection

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has become a major public health issue worldwide. Developing and evaluating rapid and easy-to-perform diagnostic tests is a high priority. The current study was designed to assess the diagnostic performance of an antigen-based rapid detection test (COVID-VIRO®) in a real-life setting. Two nasopharyngeal specimens of symptomatic or asymptomatic adult patients hospitalized in the Infectious Diseases Department or voluntarily accessing the COVID-19 Screening Department of the Regional Hospital of Orléans, France, were concurrently collected. The diagnostic specificity and sensitivity of COVID VIRO® results were compared to those of real-time reverse-transcriptase quantitative polymerase chain reaction (RT-qPCR) results. A subset of patients underwent an additional oropharyngeal and/or saliva swab for rapid testing. A total of 121 patients confirmed to be infected and 127 patients having no evidence of recent or ongoing infection were enrolled for a total of 248 nasopharyngeal swab specimens. Overall, the COVID-VIRO® sensitivity was 96.7% (CI, 93.5%-99.9%). In asymptomatic patients, symptomatic patients having symptoms for more than 4 days and those with an RT-qPCR cycle threshold value ≥ 32, the sensitivities were 100%, 95.8%, and 91.9%, respectively. The concordance between RT-qPCR and COVID VIRO® rapid test results was 100% for the 127 patients with no SARS-CoV-2 infection. The COVID-VIRO® test had 100% specificity and sensitivity greater than 95%, which are better than the recommendations set forth by the WHO (specificity ≥ 97%-100%, sensitivity ≥ 80%). These rapid tests may be particularly useful for large-scale screening in emergency departments, low-resource settings, and airports.

First year of pre-exposure prophylaxis implementation in France with daily or on-demand tenofovir disoproxil fumarate/emtricitabine

BACKGROUND

In January 2016, the French Medicine Agency initiated a Temporary Recommendation for Use (TRU) to allow the use of oral intake of tenofovir disoproxil fumarate and emtricitabine for pre-exposure prophylaxis (PrEP) in adults at high risk of HIV. We report the results of the first year of PrEP implementation in France.

METHODS

Data were collected by physicians using a secured web subject-monitoring interface, with two forms: an initiation form, with patients' baseline characteristics, and an HIV seroconversion form. Univariate and adjusted multivariate analysis using a logistic regression model were performed to identify baseline factors associated with on-demand PrEP regimen prescription.

RESULTS

From 4 January 2016 to 28 February 2017, 3405 subjects were enrolled, with 2774 initiation forms completed; 98.1% were male and 96.9% were MSM. An on-demand regimen was prescribed to 57% of subjects. Older age (OR for participants older than 50 years = 1.76, 95% CI 1.35-2.3, P < 0.001) and site of prescription (OR of former IPERGAY sites = 2.28, 95% CI 1.84-2.83, P < 0.001) were associated with on-demand prescription. Those reporting sexually transmitted infection (STI) and condomless anal sex with at least two different partners were less likely to receive on-demand PrEP (OR = 0.68, 95% CI 0.57-0.82 and 0.75, 95% CI 0.57-0.98, respectively; P < 0.05 for all). Four breakthrough HIV infections were reported during the study, in the context of PrEP interruption or acute infection at the time of PrEP initiation.

CONCLUSIONS

In a real-life setting in France, PrEP was used, either daily or on-demand, mostly by MSM, with breakthrough infections being rare.

Nevirapine Use Is Associated with Higher Bone Mineral Density in HIV-1 Positive Subjects on Long-Term Antiretroviral Therapy

We assessed bone mineral density (BMD) in a cohort of human immunodeficiency virus (HIV)-positive patients after a median of 11 years of combination antiretroviral therapy (cART) and evaluated the respective role of HIV infection and antiretroviral drugs (ARVs). A cross-sectional study of 162 participants (131 male) from the ANRS-C08 cohort was performed with bone dual-energy X-ray absorptiometry (DXA) scans and renal assessment. The window of exposure to ARVs was defined as an exposure of more than six cumulative months during the last 3 years before the DXA evaluation to account for a cumulative exposure that could affect bone remodeling. The association with low BMD (Z-score < -2) was assessed by a multiple logistic regression model. The study population was 50 years (median), hepatitis C virus (HCV) (18%), and hepatitis B virus (HBV) (8%) coinfection with HIV-RNA <50 c/mL in 89%, median CD4 of 619/mm³. Prevalence of low BMD was 18% in males and 6% in females. The factors associated with a Z-score < -2 in males were uric acid renal loss [adjusted odds ratio (aOR): 6.1; 95% confidence interval (CI): 1.2-31.5; p = .03], HCV coinfection (aOR: 4.0; 95% CI: 1.3-12.2; p = .02), and less frequent window of exposure to nevirapine (NVP) (aOR: 0.1; 95% CI: 0.02-0.6; p = .01). For the full study sample, there was a strong positive association between duration of exposure to NVP and lumbar spine Z-score (p = .004). HIV-positive patients exposed to long-term cART have a high incidence of low BMD. Tenofovir disoproxil fumarate and ritonavir-boosted protease inhibitors did not seem to be associated with increased risk of low BMD, whereas NVP exposure appeared to have an independent positive association.

P5338Atherosclerotic cardiovascular events in people living with Human Immunodeficiency Virus

Background

People living with Human Immunodeficiency Virus (PLWHIV) under antiretrovirals have an increased risk of atherosclerotic cardiovascular disease (ASCVD) events. The risk factors associated with ASCVD events in this high risk population are various including traditional vascular risk factors and specific HIV-related factors. However their respective influence is questionable.

Purpose

Our aim was to determine the incidence of ASCVD events in a large cohort of PLWHIV and to identify the risk factors associated.

Methods

We conducted a longitudinal observational cohort study of asymptomatic PLWHIV at high risk of ASCVD addressed to our preventive cardiovascular unit for non-invasive cardiovascular evaluation. The first ASCVD event was censored and included CV death, acute coronary syndromes, coronary and peripheral revascularizations (PCI or CABG or endarterectomy or limb procedures) and ischemic strokes.

Results

From January 2003 to December 2014, 763 consecutive asymptomatic PLWHIV were enrolled (mean age of 51.3±8.3 years, 87% men, 90% were free of known coronary artery disease, mean Left ventricular ejection fraction 60%). At baseline, traditional CV risk factors were as follow: 54% had dyslipidemia, 43% hypertension, 35% were active smokers, 22% had family history of CAD and 11% were diabetics. Statins were prescribed in 38% of the cohort, aspirin in 14%, clopidogrel in 14% betablockers in 14%, RAS blockers in 32%, Calcium channel blockers in 8%. At baseline, median duration of HIV seropositivity was 19.8 years (14.0–23.6), 94% were under ARV predominantly protease inhibitors (68%). Median CD4 cell count was 545/mm3 (404–745) and 92% had undetectable HIV viral load. During a median follow up of 5.8 years (3.7–8.7), 58 (7.3%) subjects had a first ASCVD event (incidence of 12.70 [9.78–16.51] per 1000 persons-years) including 5 cardiovascular deaths, 14 ACS, 20 coronary revascularizations, 13 peripheral vascular procedures and 6 strokes) with a median time of occurrence of 3.1 years (1.5–5.1). CV death (first and second ASCVD events) occurred in 8 patients (22%) after CV death related to malignancies (33%) but before deaths related to unexplained causes (21%), infectious disease (13%), liver disease (8%) and suicides (3%). Coronary events including coronary death, MI, and coronary revascularization occurred in 39 patients (5.2%); Incidence of 8.28 [6.00–11.43] per 1000 persons-years. Conventional multivariate Cox model shows that age and tobacco were the independent risk factors associated with ACSVD events [Hazard ratio (HR) 1.04, 95% CI 0.99–1.09, p=0.05 and HR 2.17, 95% CI 1.07–4.38, p=0.03].

Conclusion

Traditional vascular risk factors (age and active smoking) are associated with the occurrence of ASCVD events predominantly coronary artery disease in our observational cohort of asymptomatic PLWIHV at high risk for ASCVD. Cardiovascular prevention including tobacco cease action is mandatory in the aging HIV population.

Risk of HIV transmission during combined ART initiation for HIV-infected persons with severe immunosuppression

Background

Individuals presenting for care with severe immunosuppression typically have high plasma HIV viral load (pVL) and may transmit HIV before and after initiation of combination antiretroviral therapies (cART).

Patients and methods

Using risk equations and data collected in the IMEA 040 DATA trial on sexual behaviour and pVL level of 84 HIV-infected patients (23 women), we estimated monthly rates of HIV transmission for each virologically unsuppressed participant (pVL >50 copies/mL) who reported sex with HIV-negative or unknown serostatus (HNUS) partners at cART initiation, 24 weeks (W24) and W48 after; rates were considered negligible for other participants.

Results

At cART initiation, median pVL was 5.4 log10 copies/mL. The percentage of virologically unsuppressed patients decreased, from 100% at cART initiation to 27% (95% CI 16%-43%) for heterosexuals and 8% (95% CI 2%-22%) for MSM at W48 (P < 0.001). The percentage of patients reporting sex with HNUS partners increased between cART initiation and W48, from 23% (95% CI 10%-42%) to 42% (95% CI 25%-61%) for heterosexuals (P = 0.042) and from 41% (95% CI 21%-64%) to 73% (95% CI 52%-88%) for MSM (P = 0.004). Median monthly HIV transmission rates were 0.0540 (IQR 0.0339-0.0742) for MSM and 0.0018 (IQR 0.0014-0.0191) for heterosexuals at cART initiation, and were reduced by 95% (95% CI 87%-100%) for heterosexuals and 98% (95% CI 95%-100%) for MSM as early as W24.

Conclusions

Risk of onward transmission for severely immunosuppressed individuals is high before and within the first weeks of cART, and persists, at a substantially reduced level, beyond 24 weeks of cART for some individuals. Earlier cART and protecting HIV-negative partners until full viral suppression is achieved could reduce HIV transmission.

Imported malaria in pregnant women: report from a French University Centre

OBJECTIVE

To describe malaria during pregnancy outside endemic areas.

MATERIALS AND METHODS

We retrospectively reviewed all cases of imported malaria during pregnancy, diagnosed over a 11-year period in a French hospital.

RESULTS AND CONCLUSION

We recovered 18 cases, all from sub-Saharan countries. The infection could appear distantly from arrival in France (up to 36 months), was asymptomatic in 3 cases, with anemia being the most common marker of infection (n = 14). The adverse consequences for the fetus (n = 3) or the newborn (n = 4) were frequent. Physicians should be aware of these atypical presentations in order to anticipate the diagnosis and improve the maternal and fetal prognosis.

Bacterial chondritis complications following ear piercing

BACKGROUND

Body piercing has become widespread and is associated with increased complications. Post-piercing chondritis may lead to severe residual deformity. We aimed to report case patients presenting with post-piercing chondritis in our department and to describe clinical features and treatment.

PATIENTS AND METHODS

We conducted a retrospective study of patients presenting with post-piercing chondritis in the infectious disease department of Tenon Hospital, Paris, France.

RESULTS

We included 21 patients. Fifteen bacteriological cultures were positive (7 Pseudomonas aeruginosa, 5 Staphylococcus aureus, and three other). Dual intravenous antibiotic therapy was administered to 13 patients for a median duration of six days [2-8], replaced by an oral antibiotic therapy for a median duration of 15 days [7-40]. Eight patients received oral antibiotic monotherapy for 10 days [7-30]. Median duration of antibiotic therapy was 16 days. Earring removal was performed for 18 patients. No ear deformity or general complication was reported.

CONCLUSION

Transcartilaginous ear piercing may lead to infectious complications or deformity. In case of chondritis, early administration of an antibiotic therapy active against P. aeruginosa and S. aureus is recommended. Specific guidelines are needed.

Acquisition of carbapenemase-producing Enterobacteriaceae by healthy travellers to India, France, February 2012 to March 2013

Healthy travellers to countries where carbapenemases-producing Enterobacteriaceae (CPE) are endemic might be at risk for their acquisition, even without contact with the local healthcare system. Here, we report the acquisition of CPE (two OXA-181, one New Delhi metallo-beta-lactamase 1 (NDM-1)) in three healthy travellers returning from India. The duration of CPE intestinal carriage was less than one month. The results indicate that healthy travellers recently returning from India might be considered as at risk for CPE carriage.

Peg-IFNα/ribavirin/protease inhibitor combination in hepatitis C virus associated mixed cryoglobulinemia vasculitis: results at week 24

Background

The standard-of-care treatment of patients with hepatitis C virus (HCV)-mixed cryoglobulinemia (MC) vasculitis includes pegylated interferon α (PegIFN)-α plus ribavirin and/or rituximab. About 30–40% of patients are non-responders or relapsers to such combination.

Objective

To analyse the safety and efficacy of Peg-IFNα/ribavirin/protease inhibitor combination in HCV-MC vasculitis.

Patients and methods

Open-label, prospective, cohort study including 23 patients with HCV-MC vasculitis. Peg-IFNα/ribavirin was associated to telaprevir (375 mg three times daily, for 12 weeks, (n=15)) or boceprevir (800 mg three times daily, for 44 weeks, (n=8)) for 48 weeks.

Results

The median age was 59 (52.5–66) years, with 48.8% women. Thirteen patients (56.5%) were complete clinical responders, and 10 (43.5%) were partial responders at week 24. The virological response (ie, HCV RNA negativation) was of 69.6% at week 24 (p=0.005). The cryoglobulin level decreased from 0.44 to 0.06 g/l (p=0.0006) and the C4 level increased from 0.09 to 0.15 g/l (p=0.045). Grades 3 and 4 adverse events (mainly anaemia, neutropenia and thrombocytopenia) were observed in 10 cases (43.5%). Twenty patients (87%) received erythropoietin, 9 (39.1%) had red cell transfusion, and 2 (8.7%) had granulocyte stimulating agents. Antiviral therapy discontinuation was required in 8 (34.7%) patients for virological non-response (n=5), virological relapse (n=2) and depression (n=1).

Conclusions

Peg-IFNα/ribavirin/protease inhibitor combination seems highly effective in HCV-MC. Such therapeutic regimen should be administered cautiously considering the high rate of side effects.

[Malaria among immigrants, experience of a Parisian hospital (2006-2010)]

In recent days immigrants represent the main risk group for imported malaria in northern countries. Most of them are migrants returning to their country of origin to visit friends and relatives (VFR). We retrospectively examined the main clinical, biological, and therapeutic data of all malaria cases in immigrants from 2006 to 2010 in Tenon hospital, Paris. The hospital is situated in a Paris district with an important African community. During the study period 239 imported malaria cases were observed in adults of which 199 were immigrants, 186 VFR, and 13 recently arrived. Most cases were from sub-Saharan Africa and Comoro islands. Chimioprophylaxis was not taken in 81.2% of VFR. It was inadequate in 43.7% and not taken correctly in 84.4%. Plasmodium falciparum was the most frequent species identified: 190/199 (95.5%). Severe P. falciparum malaria was observed in 25 cases (13.2%); two of them were recently arrived. One patient, African VFR, died. In this series two high-risk groups were represented: HIV-infected patients and pregnant women. Six of the HIV patients had severe malaria and all pregnant women had anemia. Our results are similar to those observed recently in other European countries. Mean age of VFR is increasing and the risk for severe P. falciparum malaria became identical to the one observed in non-immune travelers. Protection measures remain still insufficient in this population of travelers.