Sexual behaviour and STIs among MSM living with HIV in the PrEP era: the French ANRS PRIMO cohort study

INTRODUCTION

In a context of declining condom use and high sexually transmitted infection (STI) incidence, the diffusion of "treatment as prevention" (Tasp) and more recently pre-exposure prophylaxis (PrEP) may have changed the sexual behaviour of newly diagnosed men who have sex with men (MSM) with HIV.

METHODS

Six hundred and nine MSM were enrolled and followed annually between 2014 and 2021 in the ANRS PRIMO Cohort (ClinicalTrials.gov:NCT03148964) from the time of HIV seroconversion. We studied changes over calendar time in sexual behaviour before and after HIV diagnosis. Factors associated with inconsistent condom use (ICU) after HIV diagnosis, PrEP use by partner(s) and bacterial STI acquisition were studied in random-effects models.

RESULTS

In the 6 months preceding HIV diagnosis, the number of sexual partners decreased from a median of 10 (IQR: 4-19) in 2014 to 6 (3-11) in 2021. After HIV diagnosis, ICU increased from 57.1% (16/28) of visits in 2014 up to 84.2% (229/272) in 2020-2021. Up to 25% (63/229) of MSM with HIV in recent years reported the use of PrEP by their partner(s) as the reason for ICU; these MSM were less frequently in a stable relationship, had a higher number of sexual partners and higher education level than those who did not report the use of PrEP by their partner(s). STI incidence after HIV diagnosis increased between 2014 and 2016 and remained high afterwards. STI risk was no longer associated with PrEP use by partners after adjustment for the number of partners and calendar period. ICU, age below 35 years, not being in a stable relationship, higher number of sexual partners were independently associated with an increased risk of STI.

CONCLUSIONS

Implementation of TasP and more recently PrEP has led to major changes in the sexual behaviour of MSM with HIV. ICU has become overwhelmingly prevalent, PrEP use by the partner increasingly being the reported reason for ICU, behind TasP, which remains the main reason. Characteristics of MSM at the time of diagnosis of HIV have changed, with fewer number of sexual partners today than in 2014, which must lead to broaden the indications for PrEP prescription. STIs incidence remains high in MSM with HIV and requires improvements in screening and prevention methods such as pre- or post-exposition antibiotics or vaccines.

Assessing complex interventions: a systematic review of outcomes used in randomised controlled trials on STI partner notification in high-income countries

BACKGROUND

Partner notification interventions are complex and assessing their effectiveness is challenging. By reviewing the literature on the effectiveness of partner notification interventions, our aim was to evaluate the choice, collection, and interpretation of outcomes and their impact on study findings.

METHODS

We conducted a systematic review of individual-level randomised controlled trials evaluating the effectiveness of partner notification interventions for bacterial STIs, HIV or sexually transmitted HCV in high-income countries since 2000. Partner notification interventions included assisted patient referral interventions and expedited treatment. The content analysis was carried out through a narrative review.

RESULTS

In the 9 studies that met the inclusion criteria, 16 different outcomes were found. In most studies, one or two outcomes assessing partner notification practices were associated with an outcome reflecting STI circulation through index case reinfections. These outcomes assessed the main expected effects of partner notification interventions. However, partner notification is composed of a succession of actions between the intervention on the index case and the testing and/or treatment of the notified partners. Intermediate outcomes were missing so as to better understand levers and barriers throughout the process. Potential changes in participants' sexual behaviour after partner notification, e.g. condom use, were outcomes reported in only two studies assessing interventions including counselling. Most outcomes were collected through interviews, some weeks after the intervention, which might lead to desirability and attrition biases, respectively. Assessment of the effectiveness of partner notification interventions on partner testing/treatment was limited by the collection of data from index cases. Few data describing index cases and their partners were provided in the studies. Additional data on the number and type of exposed partners and the proportion of partners already aware of their infection before being notified would help to interpret the results.

CONCLUSIONS

These insights would help to understand why and under what conditions the intervention is considered effective and therefore can be replicated or adapted to other populations and contexts.

National medical specialty guidelines of HIV indicator conditions in Europe lack adequate HIV testing recommendations: a systematic guideline review

BackgroundAdequate identification and testing of people at risk for HIV is fundamental for the HIV care continuum. A key strategy to improve timely testing is HIV indicator condition (IC) guided testing.AimTo evaluate the uptake of HIV testing recommendations in HIV IC-specific guidelines in European countries.MethodsBetween 2019 and 2021, European HIV experts reviewed guideline databases to identify all national guidelines of 62 HIV ICs. The proportion of HIV IC guidelines recommending HIV testing was reported, stratified by subgroup (HIV IC, country, eastern/western Europe, achievement of 90-90-90 goals and medical specialty).ResultsOf 30 invited European countries, 15 participated. A total of 791 HIV IC guidelines were identified: median 47 (IQR: 38-68) per country. Association with HIV was reported in 69% (545/791) of the guidelines, and 46% (366/791) recommended HIV testing, while 42% (101/242) of the AIDS-defining conditions recommended HIV testing. HIV testing recommendations were observed more frequently in guidelines in eastern (53%) than western (42%) European countries and in countries yet to achieve the 90-90-90 goals (52%) compared to those that had (38%). The medical specialties internal medicine, neurology/neurosurgery, ophthalmology, pulmonology and gynaecology/obstetrics had an HIV testing recommendation uptake below the 46% average. None of the 62 HIV ICs, countries or medical specialties had 100% accurate testing recommendation coverage in all their available HIV IC guidelines.ConclusionFewer than half the HIV IC guidelines recommended HIV testing. This signals an insufficient adoption of this recommendation in non-HIV specialty guidelines across Europe.

Cost-effectiveness of hepatitis C virus test-and-treat and risk reduction strategies among men who have sex with men living with HIV in France

INTRODUCTION

Studies suggest that hepatitis C virus (HCV) micro-elimination is feasible among men who have sex with men (MSM) living with human immunodeficiency virus (HIV), through treatment-as-prevention and interventions aimed at reducing risk behaviours. However, their economic impact is poorly understood. The aim of this study was to assess the cost-effectiveness of HCV screening and risk reduction strategies in France.

METHODS

A compartmental deterministic mathematical model was developed to describe HCV disease transmission and progression among MSM living with HIV in France. We evaluated different combinations of HCV screening frequency (every 12, 6 or 3 months) and risk reduction strategies (targeting only high-risk or all MSM) from 2021 onwards. The model simulated the number of HCV infections, life-expectancy (LYs), quality-adjusted life-expectancy (QALYs), lifetime costs and incremental cost-effectiveness ratio (ICER) over a lifetime horizon (leading to an end of the simulation in 2065).

RESULTS

All strategies increased QALYs, compared with current practices, that is yearly HCV screening, with no risk reduction. A behavioural intervention resulting in a 20% risk reduction in the high-risk group, together with yearly screening, was the least expensive strategy, and, therefore, cost-saving compared to current practices. The ICER per QALY gained for the strategy combining risk reduction for the high-risk group with 6-month HCV screening, compared to risk reduction with yearly screening, was €61,389. It also prevented 398 new HCV infections between 2021 and 2065, with a cost per infection averted of €37,790. All other strategies were dominated (more expensive and less effective than some other available alternative) or not cost-effective (ICER per QALY gained > €100,000).

CONCLUSIONS

In the French context, current HCV screening practices without risk reduction among MSM living with HIV cannot be justified on economic grounds. Risk reduction interventions targeted to high-risk individuals-alongside screening either once or twice a year-could be cost-effective depending on the policymaker's willingness-to-pay.

Predictors of Uncertainty and Unwillingness to Receive the COVID-19 Vaccine in Men Who Have Sex with Men in France

The development of vaccines against COVID-19 has given hope to populations. Public acceptability of vaccination is a major driver in containing the disease. However, in marginalized and stigmatized populations, uncertainty and unwillingness may be a challenge. This study aimed to analyze the factors associated with uncertainty and unwillingness to vaccinate against COVID-19 in men who have sex with men (MSM) living in France. The data used came from Rapport au Sexe (ERAS) 2021, a voluntary, cross-sectional, anonymous, self-administered, online survey conducted from 26 February to 11 April 2021. Among the 15,426 respondents included in the analysis, 60.5% were willing to vaccinate (these included persons already vaccinated), 17.5% were not, and 22% were uncertain. Factors independently associated with uncertainty and unwillingness were lower education level, low health literacy level, financial hardship, being under 30 years of age, and living in a rural area. HIV-positive MSM were less likely to report vaccination uncertainty and unwillingness than HIV-negative MSM and those with unknown serostatus. Although more impacted by COVID-19, socioeconomically vulnerable MSM were the sub-group most unwilling to vaccinate. To improve acceptability of COVID-19 vaccination in MSM, policy makers and researchers must increase access to and understanding of medical information by considering the general public’s health literacy when developing information sources. Moreover, a dedicated global care approach, which ensures these populations can be reached, is necessary.

Hepatitis C virus (HCV) incidence among men who have sex with men (MSM) living with HIV: results from the French Hospital Database on HIV (ANRS CO4-FHDH) cohort study, 2014 to 2017

BackgroundDespite the availability of highly effective direct-acting antivirals (DAAs) and the expected treatment as prevention (TasP) effect, transmission of hepatitis C virus (HCV) persists in men who have sex with men (MSM) who engage in high-risk sexual behaviours.AimWe aimed to estimate the incidence of primary HCV infection among MSM living with HIV in France when DAA was readily available.MethodsWe used data from a large French hospital cohort of persons living with HIV (ANRS CO4-FHDH) prospectively collected between 2014 and 2017. HCV incidence rates were calculated using person-time methods for HCV-negative MSM at inclusion who had serological follow-up from 1 January 2014 to 31 December 2017. Sensitivity analyses were performed by varying the main assumptions to assess their impact on the results.ResultsOf 14,273 MSM living with HIV who were initially HCV-seronegative, 330 acquired HCV during follow-up over 45,866 person-years (py), resulting in an overall estimated incidence rate of 0.72/100 py (95% CI: 0.65-0.80). HCV incidence significantly decreased from 0.98/100 py (95% CI: 0.81-1.19) in 2014 to 0.45/100 py (95% CI: 0.35-0.59) in 2017 (54% decrease; 95% CI: 36-67). This trend was confirmed by most of the sensitivity analyses.ConclusionThe primary incidence of HCV was halved for MSM living with HIV between 2014 and 2017. This decrease may be related to unrestricted DAA availability in France for individuals living with HIV. Further interventions, including risk reduction, are needed to reach HCV micro-elimination in MSM living with HIV.

Missed opportunities for HIV testing in patients newly diagnosed with HIV in Morocco

Background

In Morocco, of the estimated 29,000 people living with HIV in 2011, only 20% were aware of their HIV status. More than half of diagnoses were at the AIDS stage. We assumed that people who were unaware of their infection had contacts with the healthcare system for HIV indicators that might prompt the healthcare provider to offer a test. The aim was to assess missed opportunities for HIV testing in patients newly diagnosed with HIV who accessed care in Morocco.

Methods

A cross-sectional study was conducted in 2012–2013 in six Moroccan HIV centers. Participants were aged ≥18, and had sought care within 6 months after their HIV diagnosis. A standardized questionnaire administered during a face-to-face interview collected the patient’s characteristics at HIV diagnosis, HIV testing and medical history. Contacts with care and the occurrence of clinical conditions were assessed during the 3 years prior to HIV diagnosis. Over this period, we assessed whether healthcare providers had offered HIV testing to patients with HIV-related clinical or behavioral conditions.

Results

We enrolled 650 newly HIV-diagnosed patients (median age: 35, women: 55%, heterosexuals: 81%, diagnosed with AIDS or CD4 < 200 cells/mm³: 63%). During the 3 years prior to the HIV diagnosis, 71% (n = 463) of participants had ≥1 contact with the healthcare system. Of 323 people with HIV-related clinical conditions, 22% did not seek care for them and 9% sought care and were offered an HIV test by a healthcare provider. The remaining 69% were not offered a test and were considered as missed opportunities for HIV testing. Of men who have sex with men, 83% did not address their sexual behavior with their healthcare provider, 11% were not offered HIV testing, while 6% were offered HIV testing after reporting their sexual behavior to their provider.

Conclusions

Among people who actually sought care during the period of probable infection, many opportunities for HIV testing, based on at-risk behaviors or clinical signs, were missed. This highlights the need to improve the recognition of HIV clinical indicators by physicians, further expand community-based HIV testing by lay providers, and implement self-testing to increase accessibility and privacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05711-2.

[Pharmacists’ and key populations’ points of view on HIV self-test dispensation in pharmacies in France]

OBJECTIVE

The HIV self-test has been on sale in France since September 2015. What is the point of view of pharmacists and key populations with regard to accessing self-tests in community pharmacies&#160;?

METHOD

One year after the HIV self-test came onto the market, the points of view of pharmacists and key populations with regard to HIV were collected during six focus groups: the pharmacists themselves; people who had already used HIV self-tests; potential users from two key populations with regard to HIV: migrants from sub-Saharan Africa and men who have sex with men; potential users from populations with active sex lives but not particularly vulnerable with regard to HIV: young adults (&lt;25 years of age), multi-partner heterosexual adults.

RESULTS

The HIV self-test in community pharmacies is perceived by all participants as a significant step forward for accessing screening for HIV. However, issues around discretion and anonymity were seen to create significant tensions with regard to accessing the test itself, but also the information necessary to use it correctly both at a technical level and above all concerning how to interpret test results.

CONCLUSION

Although the present study underlines the role of the pharmacist as a significant public health actor in the dispensation of the self-test, the sales price and questions of anonymity are seen as major obstacles. Priority actions include renewing communication campaigns concerning the existence and the use of the product for the upcoming generations of young people but also specific campaigns targeting more vulnerable populations.

Improving the evidence for indicator condition guided HIV testing in Europe: Results from the HIDES II Study - 2012 - 2015

Background

It is cost-effective to perform an HIV test in people with specific indicator conditions (IC) with an undiagnosed HIV prevalence of at least 0.1%. Our aim was to determine the HIV prevalence for 14 different conditions across 20 European countries.

Methods

Individuals aged 18–65 years presenting for care with one of 14 ICs between January 2012 and June 2014 were included and routinely offered an HIV test. Logistic regression assessed factors associated with testing HIV positive. Patients presenting with infectious mononucleosis-like syndrome (IMS) were recruited up until September 2015.

Results

Of 10,877 patients presenting with an IC and included in the analysis, 303 tested positive (2.8%; 95% CI 2.5–3.1%). People presenting with an IC in Southern and Eastern Europe were more likely to test HIV positive as were people presenting with IMS, lymphadenopathy and leukocytopenia/ thrombocytopenia. One third of people diagnosed with HIV after presenting with IMS reported a negative HIV test in the preceding 12 months. Of patients newly diagnosed with HIV where data was available, 92.6% were promptly linked to care; of these 10.4% were reported lost to follow up or dead 12 months after diagnosis.

Conclusion

The study showed that 10 conditions had HIV prevalences > 0.1%. These 10 ICs should be adopted into HIV testing and IC specialty guidelines. As IMS presentation can mimic acute HIV sero-conversion and has the highest positivity rate, this IC in particular affords opportunities for earlier diagnosis and public health benefit.

Incidence of and risk factors for medical care interruption in people living with HIV in recent years

Objectives

With HIV treatment as a prevention strategy, retention in care remains a key for sustained viral suppression. We sought to identify HIV-infected patients at risk for medical care interruption (MCI) in a high-income country.

Methods

The HIV-infected patients enrolled had to attend the clinic at least twice between January 2010 and October 2014 and were followed up until May 2016. MCI was defined as patients not seeking care in or outside the clinic for at least 18 months, regardless of whether they returned to care after the interruption. The association between MCI and sociodemographic, clinical, and immuno-virological characteristics at HIV diagnosis and during follow-up was assessed using Cox models.

Results

The incidence rate of MCI was 2.5 per 100 persons-years (95% confidence interval [CI] = 2.3–2.7). MCI was more likely in patients who accessed care >6 months after diagnosis (hazard ratio [HR] = 1.30, 95% CI = 1.10–1.54 vs. ≤6 months) or did not report a primary care physician (HR = 2.40; 95% CI = 2.03–2.84). MCI was less likely in patients born in sub-Saharan Africa (HR = 0.75, 95% CI = 0.62–0.91 vs. born in France). During follow-up, the risk of MCI increased when the last CD4 count was ≤350 (HR = 2.85, 95% CI = 2.02–4.04 vs. >500 cells/mm³) and when the patient was not on antiretroviral therapy (HR = 3.67, 95% CI = 2.90–4.66).

Conclusions

The incidence of MCI is low in this hospital that serves a large proportion of migrants. Low or no recorded CD4 counts for a medical visit could alert of a higher risk of MCI, even more in patients who accessed HIV care late or did not report a primary care physician.

Impact of obesity on antiretroviral pharmacokinetics and immuno-virological response in HIV-infected patients: a case-control study

Background

Obesity has high prevalence among HIV-infected patients. Increased adipose tissue mass affects the pharmacokinetics of numerous drugs, but few data are available for antiretroviral drugs.

Objectives

In this study we aimed to explore the pharmacokinetics of antiretroviral drugs and the immuno-virological response in obese patients with HIV infection.

Patients and methods

We examined data from 2009 to 2012 in our hospital's database for HIV-1-infected patients who received an antiretroviral drug (abacavir, emtricitabine, lamivudine, tenofovir, efavirenz, etravirine, nevirapine, atazanavir/ritonavir, darunavir/ritonavir, lopinavir/ritonavir or raltegravir). Obese patients were defined as those with BMI ≥30 kg/m 2 and normal-weight patients as those with BMI 19-25 kg/m 2 . Plasma concentrations ( C 12/24 ) were compared for each antiretroviral drug using a Mann-Whitney test. Suboptimal dosing and virological outcome were assessed by logistic regression, adjusting on covariates.

Results

We enrolled 291 obese and 196 normal-weight patients. Among the 12 analysed antiretroviral drugs, tenofovir, efavirenz and lopinavir C 12 values were significantly lower in obese than normal-weight patients: 66 versus 86 ng/mL, 1498 versus 2034 ng/mL and 4595 versus 6420 ng/mL, respectively ( P  <   0.001). Antiretroviral drug C 12/24 values were more frequently below efficacy thresholds for obese than for normal-weight patients after adjustment for other covariates ( P  <   0.001). Although obese patients showed a higher CD4 count than normal-weight patients (510 versus 444 cells/mm 3 , P  <   0.001), the groups did not differ in virological failure rate.

Conclusions

This study highlights the impact of obesity on antiretroviral drug plasma exposure, but identifies no consequence of this suboptimal exposure on the immuno-virological control in this population.

Comparing the Information and Support Needs of Different Population Groups in Preparation for 2015 Government Approval for HIV Self-testing in France

CONTEXT

HIV self-tests are currently being introduced in France with the aim of promoting screening both for the general population and for high-risk populations.

OBJECTIVE

The current study aimed to identify and compare the information and support needs of the different target population groups.

METHODS

The Delphi process was used to synthesize expert opinions for each population group. Experts were chosen for their experience and expertise in the area of HIV and HIV screening for each population. Each group developed recommendations for a specific population: six high HIV prevalence populations (men who have sex with men; transgender people; substance users; migrants from sub-Saharan Africa; French West Indies; French Guiana) and two low prevalence populations (the general population; people under 25). Each group included expertise from four areas: research, screening and care, policy-making, and community groups.

RESULTS

A final total of 263 recommendations were grouped into eight main themes: Communicating at both national and community levels about self-test arrival (24% of all recommendations); Providing information adapted to the different community groups' needs (23%); Providing counselling on self-test use and access to care (15%); Making self-tests available to all in terms of accessibility and cost (13%); Preparing community healthcare and screening systems for the arrival of the self-test (11%); Approving only high quality self-tests (6%); Defending self-test users' legal rights (5%); Evaluating self-test use (3%). Although a large number of recommendations were common to several groups of experts, the study highlighted a certain number of recommendations specific to each different population group, particularly with regard to information content and access both to information and to the self-tests themselves.

CONCLUSION

Results from the current study should make a significant contribution to policy decisions concerning catering for the specific access, information and support needs of different potential HIV self-test user groups in France.

Auditing HIV Testing Rates across Europe: Results from the HIDES 2 Study

European guidelines recommend the routine offer of an HIV test in patients with a number of AIDS-defining and non-AIDS conditions believed to share an association with HIV; so called indicator conditions (IC). Adherence with this guidance across Europe is not known. We audited HIV testing behaviour in patients accessing care for a number of ICs. Participating centres reviewed the case notes of either 100 patients or of all consecutive patients in one year, presenting for each of the following ICs: tuberculosis, non-Hodgkins lymphoma, anal and cervical cancer, hepatitis B and C and oesophageal candidiasis. Observed HIV-positive rates were applied by region and IC to estimate the number of HIV diagnoses potentially missed. Outcomes examined were: HIV test rate (% of total patients with IC), HIV test accepted (% of tests performed/% of tests offered) and new HIV diagnosis rate (%). There were 49 audits from 23 centres, representing 7037 patients. The median test rate across audits was 72% (IQR 32–97), lowest in Northern Europe (median 44%, IQR 22–68%) and highest in Eastern Europe (median 99%, IQR 86–100). Uptake of testing was close to 100% in all regions. The median HIV+ rate was 0.9% (IQR 0.0–4.9), with 29 audits (60.4%) having an HIV+ rate >0.1%. After adjustment, there were no differences between regions of Europe in the proportion with >0.1% testing positive (global p = 0.14). A total of 113 patients tested HIV+. Applying the observed rates of testing HIV+ within individual ICs and regions to all persons presenting with an IC suggested that 105 diagnoses were potentially missed. Testing rates in well-established HIV ICs remained low across Europe, despite high prevalence rates, reflecting missed opportunities for earlier HIV diagnosis and care. Significant numbers may have had an opportunity for HIV diagnosis if all persons included in IC audits had been tested.

Missed opportunities for HIV testing in newly-HIV-diagnosed patients, a cross sectional study

BACKGROUND

In France, 1/3 HIV-infected patients is diagnosed at an advanced stage of the disease. We describe missed opportunities for earlier HIV testing in newly-HIV-diagnosed patients.

METHODS

Cross sectional study. Adults living in France for ≥1 year, diagnosed with HIV-infection ≤6 months earlier, were included from 06/2009 to 10/2010. We collected information on patient characteristics at diagnosis, history of HIV testing, contacts with healthcare settings, and occurrence of HIV-related events 3 years prior to HIV diagnosis. During these 3 years, we assessed whether or not HIV testing had been proposed by the healthcare provider upon first contact in patients notifying that they were MSM or had HIV-related conditions.

RESULTS

1,008 newly HIV-diagnosed patients (mean age: 39 years; male: 79%; MSM: 53%; diagnosed with an AIDS-defining event: 16%). During the 3-year period prior to HIV diagnosis, 99% of participants had frequented a healthcare setting and 89% had seen a general practitioner at least once a year. During a contact with a healthcare setting, 91/191 MSM (48%) with no HIV-related conditions, said being MSM; 50 of these (55%) did not have any HIV test proposal. Only 21% (41/191) of overall MSM who visited a healthcare provider received a test proposal. Likewise, 299/364 patients (82%) who sought care for s had a missed opportunity for HIV testing.

CONCLUSIONS

Under current screening policies, missed opportunities for HIV testing remain unacceptably high. This argues in favor of improving risk assessment, and HIV-related conditions recognition in all healthcare facilities.

Predictive value of liver enzymes and inflammatory biomarkers for the severity of liver fibrosis stage in HIV/HCV co-infected patients

OBJECTIVE

The aim of our study was to assess a possible association between plasma inflammatory biomarkers (CRP, IL-6, soluble CD14) and the extent of fibrosis or cirrhosis using a FibroScan® in HIV/HCV co-infected patients.

METHODS

This cross-sectional study assessed 60 HIV/HCV co-infected patients who had paired plasma samples and FibroScan® values available. All included patients were controlled for HIV infection (HIV-1 RNA <50 copies/mL) and had detectable HCV RNA levels. Levels of three biomarkers were measured in all samples using commercial ELISA kits. Multivariate logistic regression models identified factors associated with the METAVIR stages of fibrosis (F0-F2 vs. F3-F4).

RESULTS

In univariate logistic regression analyses, in addition to sCD14 (odds ratio [OR] = 3.23, 95% confidence interval [95%CI] = 1.30-7.97, P = 0.01), aspartate aminotransferase (AST), alanine aminotransferase, platelet counts, and CD4 cell counts were associated with the stage of liver fibrosis and, thus, were introduced into the model. However, only AST (OR = 1.06, 95%CI = 1.02-1.10, P = 0.0009) was independently associated with F3-F4 stage liver fibrosis.

CONCLUSIONS

In our study of HIV/HCV co-infected patients, sCD14 plasma level, a biomarker of monocyte activation, was not independently associated with the F3-F4 stage of liver fibrosis. We hypothesize that the higher levels of inflammation markers observed in HIV/HCV co-infected patients, compared to HCV mono-infected patients, prevent this association being observed within this population.

Impact of Herpes simplex virus load and red blood cells in cerebrospinal fluid upon herpes simplex meningo-encephalitis outcome

BACKGROUND

Herpes simplex encephalitis (HSE) often leads to severe disability or death. Factors usually associated with outcome include Simplified Acute Physiology Score, age and delay of initiation of acyclovir treatment.Our aim was to determine the impact of Herpes simplex virus (HSV) load in cerebrospinal fluid (CSF) upon HSE outcome.

METHODS

We retrospectively determined HSV load in the CSF of 43 patients with confirmed HSE, hospitalized in northern France from 1998 to 2005, using CSF samples collected the day of hospital admission and stored at -20°C. We analyzed the association between HSV load and mortality/morbidity by the Glasgow Outcome Scale. Fisher's exact test and Wilcoxon's test were used for statistical analysis.

RESULTS

The M/F sex ratio was 1.7 and median patient age was 61 years. Median HSV load in CSF was 2.0 log copies/μL (IQR 25-75=1.2-2.6). The mortality rate was 32.6% six months after HSE diagnosis. Higher age was associated with mortality (p=0.03). Longer delay in acyclovir initiation tended to be associated with higher mortality but did not reach statistical significance (p=0.08). Severe disability and death due to HSV were associated with a higher Knaus score (p=0.004), later acyclovir initiation (p=0.006), older age (p=0.04) and presence of red blood cells in CSF (p=0.05). HSV load in CSF was neither associated with mortality (p=1.00) nor with morbidity (p=0.90).

CONCLUSION

In this study, HSV load in CSF was not found to be associated with poor outcome in patients with HSE. These data do not support measurement of HSV load at admission in patients with HSE.

Risk factors for syphilis infection in men who have sex with men: results of a case-control study in Lille, France

BACKGROUND

Substantial increases in syphilis have been reported since the early 2000s in northern countries, particularly among men who have sex with men (MSM). The authors aimed to identify risk factors for early syphilis in MSM in Lille, a large urban area of northern France.

METHODS

A matched case-control study was conducted in MSM aged ≥ 18 years. Cases were diagnosed with primary, secondary or early latent syphilis between April 2008 and June 2010. Controls sought care in STIs clinics or were followed in an HIV clinic. Controls had no history of and no current syphilis. They were matched to cases for age and HIV status. Multivariate conditional logistic regression models were used to identify risk factors for early syphilis.

RESULTS

53 patients with early syphilis were enrolled. Average age was 37 years, and 47% were HIV-infected. For analysis, they were matched to 90 controls. Factors associated with syphilis were: low educational attainment (OR=5.38, 95% CI 1.94 to 14.94; p=0.001), receptive oral sex with casual male partners without a condom (OR=4.86, 95% CI 1.63 to 14.48; p=0.005) and anal sex toy use with casual male partners (OR=2.72, 95% CI 1.01 to 7.32; p=0.05). Seeking of sex partners online (OR=5.17, 95% CI 1.33 to 20.11), use of poppers (OR=2.2, 95% CI 1.1 to 4.3) and erectile dysfunction drugs (OR=1.9, 95% CI 1.0 to 13.2) were associated with syphilis only in the univariate analysis.

CONCLUSIONS

Receptive oral sex without a condom and use of anal sex toys were identified as presenting a major risk of syphilis infection. Although these practices have been shown to present low risk of HIV transmission, the general public is unaware of their impact on transmission of other STIs.

ANRS-COM'TEST: description of a community-based HIV testing intervention in non-medical settings for men who have sex with men

OBJECTIVE

To describe a community-based HIV testing programme.

DESIGN AND SETTING

An intervention of HIV voluntary testing conducted in non-medical settings in four French cities.

PARTICIPANTS

Men who have sex with men (MSM).

INTERVENTION

Counselling and rapid HIV testing staffed by trained personnel from an HIV/AIDS community-based organisation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The population that has taken hold of the intervention and the satisfaction of participants. Data were collected on demographics, HIV testing history, sexual practices and satisfaction with the testing programme.

RESULTS

532 MSM were tested between February 2009 and June 2010, of whom 49 (9%) were tested two or more times. 468 MSM (88%) had casual male partners in the previous 6 months, and 152 (35%) reported having unprotected anal intercourse with risky casual partners (HIV infected or HIV serostatus unknown). 159 men (30%) had not been tested in the previous 2 years, and 50 (31%) of whom had unprotected anal intercourse with risky casual partners. Among the 15 patients who tested positive (2.8%), 12 (80%) received confirmation and were linked to care (median CD4 cell count =550/mm(3)). Satisfaction was high: 92% reported being 'very satisfied' with their experience. Steps of counselling and testing procedure were respected by testers and difficulties in handling tests were rare.

CONCLUSIONS

This community-based HIV testing programme reached high-risk MSM, of whom a substantial proportion had not been tested lately. This novel service supplements pre-existing HIV testing services and increases access to HIV testing in high-risk groups.

Natural polymorphisms in HIV-1 protease: impact on effectiveness of a first-line lopinavir-containing antiretroviral therapy regimen

Mutations on HIV protease lead to resistance to protease inhibitors. However, resistance development may be different according to primary, secondary or polymorphic mutations. The present study was designed to assess the impact of natural protease mutations on the effectiveness of a first-line antiretroviral therapy (ART), and secondarily, their effect on the initial viral load (VL). The study was conducted in 175 HIV-1-infected patients, who initiated a first-line lopinavir/r-containing ART regimen and who had an available genotype resistance testing before initiating therapy. We assessed the association between mutations (prevalence > or = 10%) and the initial VL. We assessed the association between mutations and ART effectiveness using two surrogate markers: the slope of VL decrease at 1 month and the time to VL undetectability. For the 175 patients, the initial median VL was 4.94 log(10) copies/ml [interquartile range: 4.44-5.47] and the initial median CD4 lymphocyte count, 219/microl [129-296]. Eighteen mutations had a prevalence > or = 10%. At 1 month, the median VL decrease was 2.35 log(10) copies/ml [1.76-2.82]. The median time to VL undetectability was 128 days [91-196]. No mutation was associated significantly with the initial VL, the slope of VL decrease at 1 month or the time to VL undetectability. This study of antiretroviral-naive patients showed that protease polymorphisms had no impact on the effectiveness of a lopinavir/r-containing ART regimen. However, polymorphisms may affect ART effectiveness differently in other populations, such as ART-experienced patients and/or patients treated with protease inhibitors other than the one used here.