Microelimination or Not? The Changing Epidemiology of Human Immunodeficiency Virus-Hepatitis C Virus Coinfection in France 2012–2018

Background

The arrival of highly effective, well-tolerated, direct-acting antiviral agents (DAA) led to a dramatic decrease in hepatitis C virus (HCV) prevalence. Human immunodeficiency virus (HIV)-HCV–coinfected patients are deemed a priority population for HCV elimination, while a rise in recently acquired HCV infections in men who have sex with men (MSM) has been described. We describe the variations in HIV-HCV epidemiology in the French Dat’AIDS cohort.

Methods

This was a retrospective analysis of a prospective cohort of persons living with HIV (PLWH) from 2012 to 2018. We determined HCV prevalence, HCV incidence, proportion of viremic patients, treatment uptake, and mortality rate in the full cohort and by HIV risk factors.

Results

From 2012 to 2018, 50 861 PLWH with a known HCV status were followed up. During the period, HCV prevalence decreased from 15.4% to 13.5%. HCV prevalence among new HIV cases increased from 1.9% to 3.5% in MSM but remained stable in other groups. Recently acquired HCV incidence increased from 0.36/100 person-years to 1.25/100 person-years in MSM. The proportion of viremic patients decreased from 67.0% to 8.9%. MSM became the first group of viremic patients in 2018 (37.9%). Recently acquired hepatitis represented 59.2% of viremic MSM in 2018. DAA treatment uptake increased from 11.4% to 61.5%. More treatments were initiated in MSM in 2018 (41.2%) than in intravenous drug users (35.6%). In MSM, treatment at the acute phase represented 30.0% of treatments in 2018.

Conclusions

A major shift in HCV epidemiology was observed in PLWH in France from 2012 to 2018, leading to a unique situation in which the major group of HCV transmission in 2018 was MSM.

Clinical Trials Registration. NCT02898987.

Kaposi sarcoma among people living with HIV in the French DAT'AIDS cohort between 2010 and 2015

Background

Although antiretroviral therapy (ART) has reduced the risk of Kaposi sarcoma (KS), KS cases still occur in HIV‐infected people.

Objective

To describe all KS cases observed between 2010 and 2015 in a country with high ART coverage.

Methods

Retrospective study using longitudinal data from 44 642 patients in the French Dat’AIDS multicenter cohort. Patients’ characteristics were described at KS diagnosis according to ART exposure and to HIV‐plasma viral load (HIV‐pVL) (≤50 or >50) copies/mL.

Results

Among the 209 KS cases diagnosed during the study period, 33.2% occurred in ART naïve patients, 17.3% in ART‐experienced patients and 49.5% in patients on ART, of whom 23% for more than 6 months. Among these patients, 24 (11.5%) had HIV‐pVL ≤50 cp/mL, and 16 (66%) were treated with a boosted‐PI‐based regimen. The distribution of KS localization did not differ by ART status nor by year of diagnosis.

Limitations

Data on human herpesvirus 8, treatment modalities for KS and response rate were not collected.

Conclusion

Half of KS cases observed in the study period occurred in patients not on ART, reflecting the persistence of late HIV diagnosis. Factors associated with KS in patients on ART with HIV‐pVL ≤50 cp/mL remain to be explored.

Missed opportunities of HIV pre-exposure prophylaxis in France: a retrospective analysis in the French DAT'AIDS cohort

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) was implemented in France in November 2015 based on individual-level risk factors for HIV infection. We evaluated the proportion of missed opportunities for PrEP among newly HIV-diagnosed people entering the Dat'AIDS cohort in 2016.

METHODS

Multicenter retrospective analysis in 15 French HIV clinical centers of patients with a new diagnosis of HIV infection. Among them we differentiated patients according to the estimated date of infection: those occurring in the PrEP area (a previous negative HIV test in the last 12 months or those with an incomplete HIV-1 western blot (WB) with no HIV-1 anti-Pol-antibody at time of HIV diagnosis) and those in the pre-PrEP area (older infections). Epidemiological, biological and clinical data at HIV diagnosis were collected. Clinicians retrospectively identified potential eligibility for PrEP based on individual-level risk factors for HIV infection among those infected in the PrEP area.

RESULTS

Among 966 patients with a new HIV diagnosis, 225 (23.3%) were infected in the PrEP area and 121 (53.8%) had complete data allowing evaluation of PrEP eligibility. Among them, 110 (91%) would have been eligible for PrEP, median age 31 years, with 68 (75.6%) born in France and 10 (11.1%) in Central/West Africa, with more than one previous STI in 19 (15.7%). The main eligibility criteria for PrEP were being a man who had sex with men or transgender 91 (82.7%) with at least one of the following criteria: unprotected anal sex with ≥2 partners in the last 6 months: 67 (60.9%); bacterial sexually transmitted infection in the last 12 months: 33 (30%); Use of psychoactive substances in a sexual context (chemsex): 16 (14.5%). PrEP was indicated for other HIV risk factors in 25 (22.7%).

CONCLUSION

With 91% (110/121) of patients infected in the PrEP area eligible for PrEP, this study highlights the high potential of PrEP in avoiding new infection in France but also shows a persistent delay in HIV testing. Thus, an important limit on PrEP implementation in France could be insufficient screening and care access.

Ageing with HIV: do comorbidities and polymedication drive treatment optimization?

OBJECTIVES

The aim of the study was to describe the ageing HIV-infected population (> 50 years old) and their current antiretroviral therapy (ART), comorbidities and coprescriptions in France in 2013 and to compare them to the younger population.

METHODS

A retrospective analysis of a prospectively collected database was performed. The characteristics of patients receiving ART as well as their current ART and their numbers of comorbidities and comedications at the censoring date (1 July 2013) were compared between patients ageing with HIV infection, patients who seroconverted while ageing, and younger patients.

RESULTS

We compared 10 318 ageing patients [median age 56 years; 25% interquartile range (IQR) 53-62 years] with 13 302 younger patients (median age 42 years; 25% IQR 36-47 years). The ageing patients were more frequently male than the younger patients (77 vs. 65%). Among the ageing patients, 7025 were diagnosed with HIV infection before 2000 and represented a distinct group, the 'experienced ageing' group, by comparison with the 'recently diagnosed ageing' group. Triple therapy containing a boosted protease inhibitor was used in 28.2% of the patients (vs. 39% and 36% of the younger and "recently diagnosed ageing" groups, respectively); a nonnucleoside reverse transcriptase inhibitor in 27% (vs. 33% and 38%, respectively), an integrase strand transfer inhibitor (INSTI) in 9% (vs. 7% and 9%, respectively), and another regimen (fewer or more than three drugs) in 35.8% (vs. 21% and 16.5%, respectively). "Experienced ageing" patients typically had one or more comorbidities (62.1%) and were receiving at least one comedication (71%). Central nervous system (CNS) agents (prescribed in 44.6% of the "experienced ageing" patients) and antilipidaemics (in 44.2%) were the most frequently prescribed comedications. INSTIs were used in 23% of the population and were used significantly more often in patients with comorbidities and coprescriptions. For all comparisons, P < 0.0001.

CONCLUSIONS

In ageing HIV-infected patients, especially those with a long history of HIV infection, comorbidities and coprescriptions are highly prevalent.

Comparative risk of failure of ABC/3TC or TDF/FTC based first-line regimens in patients with a high viral load

OBJECTIVES

To compare the efficacy, in current clinical practice, of first regimens containing abacavir with lamivudine (ABC/3TC) or tenofovir with emtricitabine (TDF/FTC) in patients with baseline viral load ≥100,000 HIV-1 RNA copies/mL.

METHODS

Using a prospective cohort, we selected all patients starting a first HIV regimen based either on ABC/3TC or on TDF/FTC. The propensity score (PS) method was used to limit the indication bias due to the observational nature of the data. Adjusting and weighting methods via PS were used to compare the effectiveness of a first regimen containing ABC/3TC or TDF/FTC. The primary outcome was treatment failure by month 12 (M12).

RESULTS

Overall, 2781 patients started an antiretroviral (ARV) regimen with ABC/3TC or TDF/FTC each in combination with efavirenz, boosted atazanavir or boosted darunavir. Among the 2472 uncensored patients before M12, 962 (39%) had a baseline viral load ≥100,000 copies/mL of whom 294 were in treatment failure at or before M12. Our analyses showed no difference between ABC/3TC and TDF/FTC in the risk of treatment failure at M12 in patients starting an ARV regimen with a high viral load (≥100,000 copies/mL).

CONCLUSIONS

Using a large prospectively collected cohort of patients seeking care in France, we found no evidence that ABC/3TC based regimens led to more failures than TDF/FTC based ones in patients with high baseline viral loads.

[Complications of vacuum extractor deliveries]

OBJECTIVES

To describe maternal and neonatal complications following deliveries assisted by vacuum extraction and to compare outcomes with those obtained after spontaneous vaginal delivery. We wanted to know if vacuum extractor was a risk factor by itself.

MATERIALS AND METHODS

We conducted a retrospective study of two years activity involving 4524 deliveries of which 845 (18.7%) were vacuum extractor assisted. We precisely defined maternal and neonatal complications to compare their rates in spontaneous vaginal delivery and vacuum extractor groups.

RESULTS

There were 1333 maternal complications and 114 neonatal complications. The adjusted risks of maternal complications were significantly higher in the vacuum extractor group for simple vaginal tears (OR=3.0; p<0.001), the simple perineal tears (OR=1.8; p<0.001) and third degree perineal tears (OR=2.7; p<0.01). For neonatal complications, the difference was significant for cephalhematomas (OR=10; p<0.001) and scalp abrasions (OR=53; p<0.001). No cases of skull fracture or subgaleal subaponeurotic hemorrhage were recorded.

CONCLUSION

Our rates of maternal and neonatal complications after vacuum extractor were similar to those described in the literature. We have been able to show that vacuum extraction is itself a risk factor for third degree perineal tears and cephalhematoma. However, these complications are so infrequent that the advantages of this method of extraction argue in favor of wide use in obstetrics.

[Laparoscopic promontofixation feasibility study in 44 patients]

OBJECTIVE

To evaluate the feasibility of laparoscopic promontofixation.

MATERIAL

and methods. Forty patients between 1993 and 1999 were scheduled for a laparoscopic promontofixation. Fifteen of these patientes had a previous cure of prolapse with recurrence. Three patients had a "universal jointcervix" syndrome (Masters and Allen).

RESULTS

We observed no recurrence of the prolapse after an average follow-up of 18.6 months. The peroperatoire complication rate is 9%, and the postoperative complication rate is 9% too. 4.5% of the patients had to undergo a laparotomy.

CONCLUSION

Laparoscopic promontofixation is feasible with good results in the cure of genital prolapse. Laparoscopy is performing the same procedure as the open technique with the advantages of the minimal invasive surgery.

[Feasibility of the laparoscopic sub-urethral sling procedure]

OBJECTIVE

To evaluate the feasibility of the laparoscopic sling procedure, 44 patients 26 to 66 years old (average 45) with sphincter incompetence were included in this prospective series between 1993 and 1999.

PATIENTS AND METHODS

Patient selection for a sling procedure was based on urodynamic findings (average closure pressure was 34 cm of water). The operative procedure is described.

RESULTS

The follow up ranged from two to 66 months (average 27.6). Seven conversions into laparotomy had to be performed. 35 slings could be set successfully. Four of these slings had to be removed during the year following the procedure; two because of bladder neck erosion and two because of chronic bladder distension. The success rate of the 35 slings is 88.6%. The overall complication rate is 27% including five bladder injuries, 2 urether injuries and one hemorrhage. Ten of the twelve complications occurred in the 12 first patients and the complication rate decreased to 9% in the 32 last patients. Average hospital stay was 4 days.

CONCLUSION

The laparoscopic sling procedure seems to be promising in the management of refractory urinary incontinence due to sphincter incompetence. But it is an advanced laparoscopic procedure for experienced laparoscopic surgeons, needing a long learning curve.

Comparative interleukin (IL-2)/interferon IFN-gamma and IL-4/IL-10 responses during acute infection of macaques inoculated with attenuated nef-truncated or pathogenic SICmac251 virus

Comparison of immune responses to infection by a pathogenic or a nonpathogenic immunodeficiency virus in macaques may provide insights into pathogenetic events leading to simian AIDS. This work is aimed at exploring cytokine expression during infection by simian immunodeficiency virus (SIV). We used semiquantitative reverse transcription-PCR to monitor interleukin (IL)-2/interferon (IFN)-gamma (Th1-like), and IL-4/IL-10 (Th2-like) expression in unmanipulated peripheral blood mononuclear cells (PBMCs), during the acute phase of infection of eight cynomolgus macaques (Macaca fascicularis) with a pathogenic primary isolate of SIVmac251 (full-length nef), and of four other cynomolgus macaques by an attenuated molecular clone of SIVmac251 (nef-truncated). All the monkeys became infected, as clearly shown by the presence of infected PBMCs and by seroconversion. Nevertheless, PBMC-associated virus loads and p27 antigenemia in monkeys infected by the attenuated virus clone remained lower than those observed in animals infected with the pathogenic SIVmac251 isolate. A rise of IL-10 mRNA expression occurred in both groups of monkeys coincident with the peak of viral replication. In monkeys infected with the pathogenic SIVmac251, IL-2, IL-4, and IFN-gamma mRNAs were either weakly detectable or undetectable. On the contrary, animals infected by the attenuated virus exhibited an overexpression of these cytokine mRNAs during the first weeks after inoculation. The lack of expression of these cytokines in monkeys infected with the pathogenic primary isolate may reflect early immunodeficiency.

Functional consequences of macrophage infection by human immunodeficiency virus: bispecific antibody targeting of HIV-1-infected cells to Fc gamma RI expressing effector cells

Human monocytes/macrophages play a major role in pathogenesis of human immunodeficiency virus (HIV) infection. These cells have been suspected of acting as a reservoir for the virus and are important in viral dissemination and persistence in infected individual. Furthermore, several biologic and clinical features indicate that monocytes/macrophages from HIV-1-seropositive patients have characteristics of an activation status, including the ability to secrete high levels of cytokines. Dysregulation of the cytokine network may influence the level and the consequences of viral replication in infected monocytes/macrophages. Therefore, the development of virus-specific agents that may interfere with viral replication could help to slow down the fatal course of HIV infection. In this article, we try to further quantify the early and late kinetic patterns of the cytokine network during HIV-1 macrophage infection and report the biologic effects of virus-specific bispecific antibody (MDX-240) in HIV-1 macrophage infection.