Phylogeography and genomic epidemiology of SARS-CoV-2 in Italy and Europe with newly characterized Italian genomes between February-June 2020

The aims of this study were to characterize new SARS-CoV-2 genomes sampled all over Italy and to reconstruct the origin and the evolutionary dynamics in Italy and Europe between February and June 2020. The cluster analysis showed only small clusters including < 80 Italian isolates, while most of the Italian strains were intermixed in the whole tree. Pure Italian clusters were observed mainly after the lockdown and distancing measures were adopted. Lineage B and B.1 spread between late January and early February 2020, from China to Veneto and Lombardy, respectively. Lineage B.1.1 (20B) most probably evolved within Italy and spread from central to south Italian regions, and to European countries. The lineage B.1.1.1 (20D) developed most probably in other European countries entering Italy only in the second half of March and remained localized in Piedmont until June 2020. In conclusion, within the limitations of phylogeographical reconstruction, the estimated ancestral scenario suggests an important role of China and Italy in the widespread diffusion of the D614G variant in Europe in the early phase of the pandemic and more dispersed exchanges involving several European countries from the second half of March 2020.

Emerging issue of fluconazole-resistant candidemia in a tertiary care hospital of southern italy: time for antifungal stewardship program

An increased number of patients is at risk of Candida spp. bloodstream infection (CBSI) in modern medicine. Moreover, the rising of antifungal resistance (AR) was recently reported. All consecutive CBSI occurred in our Hospital (consisting of 1,370 beds) between 2015 and 2018, were reviewed. For each case, Candida species, AR pattern, ward involved and demographic data of patients were recorded. Overall, 304 episodes of CBSI occurred, with a median (q1:first-,q3:third quartile) of 77 (71-82) CBSI/year. Over the years, a significant increase of CBSI due to C. albicans compared to non-albicans strains was recorded in medical wards (from 65% to 71%, p=0.030), while this ratio remained stable in others. An increase of resistant strains to multiple antifungals such as C. guillermondii was noticed in recent years (from 0% to 9.8%, p=0.008). Additionally, from 2015 to 2018 an increase in fluconazole-resistance was recorded in our Hospital (from 7.4% to 17.4%, p=0.025) and a slight increase in voriconazole-resistance (from 0% to 7% in 2018, p=0.161) was observed, while resistance to echinocandin and amphotericin B remained firmly below 2%. This study suggests a rapid spread of antifungal resistance in our Hospital; therefore, an appropriate antifungal stewardship programs is urgently warranted.

Incidence of Infections and Predictors of Mortality During Checkpoint Inhibitor Immunotherapy in Patients With Advanced Lung Cancer: A Retrospective Cohort Study

BACKGROUND

Immune checkpoint inhibitors (ICIs) have revolutionized nonsmall cell lung cancer (NSCLC) treatment and significantly increased overall survival of patients. However, the incidence of concurrent infections and their management is still debated.

METHODS

From August 2015 to October 2019, all consecutive patients with NSCLC who received nivolumab or pembrolizumab as first- or second-line therapy were retrospectively evaluated. At the time of analysis all patients had died. Clinical characteristics of patients, type of infections, and predictors of mortality were analyzed.

RESULTS

A total of 118 patients were identified: 74 in the nivolumab group and 44 in the pembrolizumab group. At least 1 infection was recorded in 22% of the nivolumab-group versus 27% of the pembrolizumab-group (P = .178). In both groups, the main infection was pneumonia, followed by skin and soft tissue infections, urinary tract infections, and gastroenteritis. Crude mortality for first infection was 10.7%, followed by 25% and 40% for the second and third recurrence, respectively (p for trend = .146). No opportunistic infections were recorded. It is notable that, by Cox-regression model, the independent predictor of mortality was a higher Eastern Cooperative Oncology Group performance status at baseline (P < .001), whereas the multidisciplinary diagnosis and treatment of concurrent infections was associated with a reduced probability of mortality (adjusted hazard ratio = 0.50; 95% confidence interval = 0.30-0.83; P < .001).

CONCLUSIONS

In patients with NSCLC treated with ICIs, multidisciplinary management of concurrent infections may reduce the risk of mortality. Further studies to investigate risk factors for infections, as well as appropriate management strategies and preventive measures in this setting, are warranted.

Prevalence of resistance-associated substitutions to NS3, NS5A and NS5B inhibitors at DAA-failure in hepatitis C virus in Italy from 2015 to 2019

Despite the high efficacy of direct-acting antivirals (DAAs), the selection of resistance-associated substitutions (RASs) after virological failure of hepatitis C virus (HCV) DAAs can impair the cure of chronic HCV. The aim of the study was to characterize RASs after virological failure of DAAs in Italy over the years. Within the Italian network VIRONET-C, the change in prevalence of NS3/4A-NS5A-NS5B RASs was retrospectively evaluated in patients who failed a DAA regimen over the years 2015-2019. NS3, NS5A and NS5B Sanger sequencing was performed using homemade protocols and the geno2pheno system was used to define HCV-genotype/subtype and predict drug resistance. The changes in the prevalence of RASs over time were evaluated using the chi-square test for trend. Predictors of RASs at failure were analysed by logistic regression. Among 468 HCV-infected patients, HCV genotype 1 was the most prevalent (1b in 154, 33% and 1a in 109, 23%). DAA regimens were: ledipasvir (LDV)/sofosbuvir (SOF) in 131 patients (28%), daclatasvir (DCV)/SOF in 109 (23%), ombitasvir/paritaprevir/ritonavir+dasabuvir (3D) in 89 (19%), elbasvir (EBR)/grazoprevir (GRZ) in 52 (10.5%), velpatasvir (VEL)/SOF in 53 (11%), glecaprevir (GLE)/pibrentasvir (PIB) in 27 (6%) and ombitasvir/paritaprevir/ritonavir (2D) in 7 (1.5%); ribavirin was administered in 133 (28%). The NS5A fasta sequence was available for all patients, NS5B and NS3/4A both for 93%. The prevalence of NS5A and NS3/4A RASs significantly declined from 2015 to 2019; NS5B RAS remained stable. Independent predictors of any RASs included older age and genotype 1a (vs G2 and vs G4). Notably, at least partial susceptibility to all the agents included in the GLE/PIB and VEL/SOF/Voxilaprevir (VOX) combinations was predicted in >95% of cases. As RASs remain common at the failure of DAAs, their identification could play a crucial role in optimizing re-treatment strategies. In Italy RAS prevalence has been decreasing over the years and susceptibility to the latest developed drug combinations is maintained in most cases.

Peculiar clinical presentation of COVID-19 and predictors of mortality in the elderly: A multicentre retrospective cohort study

Background

The spectrum of COVID-19 clinical manifestations is not yet known. In the elderly, mortality and extrapulmonary involvement appears more frequent than expected.

Methods

A multicentre-retrospective-case-series study of COVID-19 patients, aged ≥65 years, hospitalised between March 1 and June 15, 2020. Patients were classified at admission into 3 groups based on their Clinical Frailty Scale (CFS) score: 1–3 (group A), 4–6 (group B) and 7–9 (group C).

Results

Of the 206 patients in the study, 60 (29%) were assigned to group A, 60 (29%) to B and 86 (42%) to C. Significantly more frequent in group C than in B or A were: mental confusion (respectively 65%, 33%, 7%; P < 0.001), kidney failure (39%, 22%, 20%; P = 0.019), dehydration syndrome (55%, 27%, 13%; P < 0.001), electrolyte imbalance (54%, 32%, 25%; P = 0.001), and diabetic decompensation (22%, 12%, 7%; P = 0.026). Crude mortality was 27%. By multivariate logistic regression model independent predictors of death were male sex (adjusted odds ratio (aOR) = 2.87,95%CI = 1.15–7.18), CFS 7–9 (aOR = 9.97,95%CI = 1.82–52.99), dehydration at admission (aOR = 4.27,95%CI = 1.72–10.57) and non-invasive/invasive ventilation (aOR = 4.88,95%CI = 1.94–12.26).

Conclusions

Elderly patients with a high CFS showed frequent extrapulmonary signs at admission, even in the absence of lung involvement. These findings, along with a high CFS, predicted a significant risk of mortality.

Recurrent neurosurgical site infection by extensively drug-resistant P. aeruginosa treated with cefiderocol: a case report and literature review

INTRODUCTION

Cefiderocol is a new siderophore cephalosporin designed to be active against extensively resistant Gram-negative bacteria; however, clinical studies are limited to complicated urinary tract infections, pneumonia, and intra-abdominal infections. To date, no data are available on neurosurgical site infections.

CASE PRESENTATION

We present a case of a patient successfully cured with Cefiderocol for a neurosurgical site infection due to extensively resistant P. aeruginosa, who had failed a previous treatment based on combined antimicrobial therapy and right parietal bone excision.

CONCLUSIONS

Cefiderocol is a promising antibiotic for complicated infections due to multidrug resistant gram-negative bacteria.

Anti-spike S1 receptor-binding domain antibodies against SARS-CoV-2 persist several months after infection regardless of disease severity

Data regarding the immunological memory and long‐time kinetics of immunoglobulin (IgG) against viral nucleoprotein (NP) and spike protein S1 receptor‐binding domain (S1RBD) of Severe Acute Respiratory Syndrome‐associated Coronavirus 2 (SARS‐CoV‐2) are lacking. All consecutive COVID‐19 patients admitted to our Clinic between March 1, 2020, and May 1, 2020, who were tested at hospital admission for anti‐S1RBD and anti‐NP IgG were enrolled. Serum samples were tested for anti‐SARS‐CoV‐2 antibodies with the use of two commercially available enzyme‐linked immunosorbent assays. Results are expressed as optical density measurements at 450 nm (OD₄₅₀). Overall, 111 patients were included; the median (q1–q3) age was 57 (49–73) years, 59 (53%) males. According to disease severity, 31 (28%), 47 (42%), and 33 (30%) patients were considered affected by mild/moderate, severe, and critical SARS‐CoV‐2 infection, respectively. During hospitalization, patients with the critical disease showed a higher peak value of both anti‐NP (median OD₄₅₀: 3.66 vs. 3.06 vs. 3.00 respectively, p = .043) and anti‐S1RBD IgG (median OD₄₅₀: 2.33 vs. 1.6 vs. 0.91, respectively, p < .001). By testing 48 subjects 6 months or above from discharge, a significant decrease of anti‐NP IgG was observed (r: −0.5838; p < .0001), whereas anti‐S1RBD IgG showed only a modest reduction (r: −0.1507; p = .0647). Accordingly, 10 (21%) and 2 (4%) patients had a negative serological status for anti‐NP and anti‐S1RBD IgG, respectively; no association with clinical severity was found. IgGs against SARS‐CoV‐2 persisted several months after discharge, regardless of disease severity, suggesting that vaccination could be a valid strategy to fight the pandemic.

‐Antibodies against SARS‐CoV‐2 persisted several months after the disease.

‐ Infection severity apparently did not affect IgG seroconversion.

‐ SARS‐CoV‐2 vaccination could be a valid strategy to fight the pandemic.

Influence of HIV-1 V2 sequence variability on bacterial translocation in antiretroviral naïve HIV-1 infected patients

HIV-1 V2 domain binds α4β7, which assists lymphocyte homing to gut-associated lymphoid tissue. This triggers bacterial translocation, thus contributing to immune activation. We investigated whether variability of V2 179-181 binding site could influence plasma levels of lipopolysaccharide (LPS) and soluble cluster of differentiation 14 (sCD14), markers of microbial translocation/immune activation. HIV gp120 sequences from antiretroviral naïve patients were analyzed for V2 tripeptide composition, length, net charge, and potential N-linked-glycosylation sites. LPS and sCD14 plasma levels were quantified. Clinical/immuno-virologic data were retrieved. Overall, 174 subjects were enrolled, 8% with acute infection, 71% harboring a subtype B. LDV179-181 was detected in 41% and LDI in 27%. No difference was observed between levels of LPS or sCD14 according to different mimotopes or according to other sequence characteristics. By multivariable analysis, only acute infection was significantly associated with higher sCD14 levels. In conclusion, no association was observed between V2 tripeptide composition and extent of bacterial translocation/immune activation.

Lost to follow-up: a challenge over 10 years

The loss of patients to follow up is a major issue related to HIV management. Our research was aimed to evaluate, in a single Italian centre, the rate of patients lost to follow-up (LFU) over 10 years, to describe their socio-demographic and clinical features, and to identify predictors of disengagement from care. Between 2008 and 2017, 563 subjects were LFU. Over the years, the proportion of LFU on the number of patients followed per year, decreased from 6.5% in 2008 to 4.8% in 2017 (p for trend = 0.255). Four different subgroups were identified among LFU:116 patients resulted untraceable; 192 had died; 144 were re-engaged elsewhere; 111 were subsequently re-engaged in our centre. Old age (OR 1.08, 95%, CI = 1.06-1.11; p < 0.001), AIDS (OR = 1.66, 95% CI = 1.04-2.64; p = 0.031), drug addiction (OR = 1.91, 95% CI = 1.07-3.41; p = 0.027) were predictors of death at multivariable analysis. Main predictors of being untraceable were non-Italian nationality (OR = 4.23, 95% CI = 2.19-8.16; p < 0.001) and a short history of cART (OR = 0.93, 95% CI = 0.88-0.99; p = 0.026). Subjects living far from our Centre were often re-engaged elsewhere (OR = 2.36, 95% CI = 1.34-4.15; p = 0.002). According to our analysis, the problem LFU is still relevant: strategies to empower retention in care are thus necessary.

Long-term maintenance of virologic suppression in native and migrant HIV-1 naïve patients: an Italian cohort study

Little is known about long-term maintenance of virologic suppression in HIV migrants in Italy. The study aims to compare virologic failure rates and associated factors among antiretroviral therapy (ART)-naïve migrants and natives enrolled in the ARCA database since 2007 who achieved virologic suppression within 18 months from the beginning of the ART. Kaplan-Meier method assessed the probability of virologic suppression and failure. Cox regression model was used for multivariate analysis. Of 2515 patients, 2020 (80.3%) were Italian, 286 (10.6%) migrants from low-income countries, of whom 201 (75.0%) from Africa, and 227 (9.0%) from high-income-countries. The median follow-up was 4.5 years (IQR 2.5-7). No difference was observed in the time of achievement of virological suppression in the three groups (log-rank: p = 0.5687). Higher probability of virologic failure was observed in Africans compared to Italians, to patients from high-income-countries and from low-income-countries other than Africans (Log-rank = p < 0.001). In the adjusted analysis, a higher virologic failure risk was found in Africans only compared to Italians. [HR 4.01; 95% CI 2.44-6.56, p < 0.001]. In Italy, African migrants are less likely to maintain virologic suppression compared to natives and other migrants. Targeted interventions could be needed for foreigners, especially for Africans.

Capacity assessment for provision of quality sexual reproductive health and HIV-integrated services in Karamoja, Uganda

INTRODUCTION

Sexual and reproductive health (SRH) and Human Immunodeficiency Virus (HIV) are crucial global health issues. Uganda continues to sustain a huge burden of HIV and AIDS.

METHODS

A cross-sectional health facility-based assessment was performed in November and December 2016 in Karamoja Region, northern Uganda. All the 126 health facilities (HFs) in Karamoja, including 5 hospitals and 121 Health Centers (HCs), covering 51 sub-counties of the 7 districts were assessed. We assessed the capacity of a) leadership and governance, b) human resource, c) service delivery, d) SRH and HIV service integration and e) users satisfaction and perceptions.

RESULTS

64% of the established health staffing positions were filled leaving an absolute gap of 704 units in terms of human resources. As for service delivery capacity, on 5 domains assessed, the best performing was basic hygiene and safety measures in which 33% HCs scored "excellent", followed by the presence of basic equipment. The level of integration of SRH/HIV services was 55.56%.

CONCLUSION

HFs in Karamoja have capacity gaps in a number of health system building blocks. Many of these gaps can be addressed through improved planning. To invest in improvements for these services would have a great gain for Uganda.

Infection caused by Sporothrix schenckii: an autochthonous case in Bari, Southern Italy

An autochthonous case of lymphocutaneous sporotrichosis caused by Sporothrix schenckii is reported. The patient developed skin lesions localized along the lymphatics that appeared after he suffered an injury while collecting wicker canes in marshy water. The fungus was identified as Sporothrix schenckii by MALDI-TOF and sequencing. Phylogenetic analysis was also performed. Low MIC values were detected for all tested echinocandins and azoles except for fluconazole. The patient was treated with itraconazole without significant improvement. A regression of lesions was observed after 3 months of therapy with voriconazole. Few cases of sporotrichosis have been reported in Europe. However, several cases of sporotrichosis have been described in Italy. The incidence of sporotrichosis in Italy may be underestimated and microbiologists, and clinicians must be aware of this fungal infection.

Targeted therapies for autoimmune/idiopathic nonmalignant diseases: risk and management of opportunistic infections

INTRODUCTION

The management of patients affected by autoimmune/idiopathic diseases has been revolutionized by the development of targeted therapies (TT). However, the use of TT is complicated by several adverse events, like opportunistic infections (OIs). The potential of TT to predispose to OIs mainly depends on the site of action; nevertheless, such associations are far from being deterministic, because many factors could increase the infection risk.

AREAS COVERED

The impact on the infective risk of different TT used for autoimmune/idiopathic diseases is far from being completely understood. Indeed, many post-marketing reports documented severe or unexpected infections in patients treated with TT that did not emerge during registrative trials. In this review, the authors attempt to provide an easy and practical update about the 'infectious' safety of TT and examine the management strategies of OIs and other infections more frequently observed in the course of treatment with TT.

EXPERT OPINION

The authors suggest to precisely schedule the clinical management of these subjects, both to prevent and eventually treat promptly the TT-related infectious complications. A coordinated approach should be implemented from different medical specialties to improve the overall understanding of safety of TT and, in general, the management of opportunistic infections in immune-compromised hosts.

Gp120 substitutions at positions associated with resistance to fostemsavir in treatment-naive HIV-1-positive individuals

Objectives

Fostemsavir, a novel attachment inhibitor targeting the HIV-1 gp120, has demonstrated wide in vitro activity. However, the high rate of HIV gp120 substitutions could jeopardize its efficacy. We investigated envelope (env) substitutions at positions associated with resistance to fostemsavir in patients with a new HIV-1 diagnosis according to HIV subtype and tropism.

Methods

Gp120 sequences from 409 subjects were retrospectively analysed and the presence of the L116P, A204D, S375H/M/T, M426L, M434I and M475I mutations was evaluated. Other amino acid changes at the same positions were also recorded. The variability at each amino acid position was evaluated using Shannon entropy.

Results

The frequency of mutations was: S375T (13.2%); M426L (6.8%); M434I (2.9%); M475I (2.7%); S375H (1.0%)/M (0.8%) and L116P (0.31%). Statistically significant differences were found at positions 375 (R5/non-R5 strains and B/non-B subtypes) and 426 (B/non-B subtypes); post hoc analysis revealed that significance for position 375 was steered by S375T while for position 426 significance was governed by unusual substitutions, in particular M426R (B/non-B, P &lt; 0.00001). The variability of env constant domains appeared to be more relevant in the non-B virus population.

Conclusions

In conclusion, gp120 substitutions were detected in different subtypes and in both R5 and non-R5 variants. Despite the great variability of gp120, the frequency of mutations was low overall and the predominant substitution was S375T, the role of which in reducing fostemsavir efficacy is less substantial.

Efficacy and tolerability of DAAs in HCV-monoinfected and HCV/HIV-coinfected patients with psychiatric disorders

BACKGROUND

Few data are available regarding the use of direct antiviral agents (DAAs) for chronic hepatitis C in psychiatric patients. The aim of the study is to assess safety and outcome of DAAs in patients with psychiatric comorbidities.

METHODS

This retrospective, observational, single-centre study enrolled patients treated with psychiatric drugs who initiated DAAs between 2015 and 2018. Patients were classified into two groups: A (on anxiolitycs/antidepressant) and B (on antipsychotics). Week-12 sustained virological response (SVR-12) and adverse events (AEs) were evaluated.

RESULTS

One hundred forty-four patients were included (A:101; B:43). Patients were 49.3% males, mean age 60 years (SD ± 13.5); 31.9% cirrhotic; 125 (86.8%) HCV-monoinfected and 19 (13.2%) HCV /HIV-coinfected. Twenty patients (13.8%) required a change of psychiatric therapy before initiation of DAA. Overall, SVR-12 was achieved in 88.2% of subjects in intention-to-treat(ITT)-analysis. Lower SVR rates were observed in group B vs A (79% vs 92%, p = 0.045) and in those changing psychiatric drugs vs others (8% vs 30%, p = 0.015). According to per-protocol (PP)-analysis, SVR-12 was achieved in 93/95 (97.9%) in group A versus 34/36 (94.4%) in group B (p = 0.30). At least one AE occurred in 60 patients (41.6%), including 10 severe AEs, leading to 3 discontinuations. AEs were more frequently reported in group A (p = 0.015).

CONCLUSIONS

The study confirms effectiveness and safety of DAA-based treatment also in this special population, even if a careful evaluation of history and drug-drug interactions is warranted.

Pretreatment HIV drug resistance and treatment failure in non-Italian HIV-1-infected patients enrolled in ARCA

BACKGROUND

An increase in pretreatment drug resistance (PDR) to first-line antiretroviral therapy (ART) in low-income countries has been recently described. Herein we analyse the prevalence of PDR and risk of virological failure (VF) over time among migrants to Italy enrolled in ARCA.

METHODS

HIV-1 sequences from ART-naive patients of non-Italian nationality were retrieved from ARCA database from 1998 to 2017. PDR was defined by at least one mutation from the reference 2009 WHO surveillance list.

RESULTS

Protease/reverse transcriptase sequences from 1,155 patients, mainly migrants from sub-Saharan Africa (SSA; 42%), followed by Latin America (LA; 25%) and Western countries (WE; 21%), were included. PDR was detected in 8.6% of sequences (13.1% versus 5.8% for B and non-B strains, respectively; P<0.001). 2.1% of patients carried a PDR for protease inhibitors (PIs; 2.1% versus 2.3%; P=0.893), 3.9% for nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs; 6.8% versus 2.1%; P<0.001) and 4.3% for non-nucleoside/nucleotide reverse transcriptase inhibitors (NNRTIs; 6.3% versus 3.1%; P=0.013). Overall, prevalence of PDR over the years remained stable, while it decreased for PIs in LA (P=0.021) and for NRTIs (P=0.020) among migrants from WE. Having more than one class of PDR (P=0.015 versus absence of PDR), higher viral load at diagnosis (P=0.008) and being migrants from SSA (P=0.001 versus WE) were predictive of VF, while a recent calendar year of diagnosis (P<0.001) was protective for VF.

CONCLUSIONS

PDR appeared to be stable over the years in migrants to Italy enrolled in ARCA; however, it still remains an important cause of VF together with viral load at diagnosis.

HIV rapid test in a community setting as a strategy to improve access to HIV testing: data from a multicentre experience in Italy

4,000 new HIV diagnoses and approximately 800 AIDS cases are still reported annually in Italy. Improving public awareness and bringing out HIV-undiagnosed individuals are keystones to progress towards the control of the HIV epidemic. For this purpose, the Open HIV TEST project was organized and delivered by the Italian NGO Anlaids, together with local infectious diseases specialists, in order to provide free access to HIV testing outside the healthcare setting. Between October 2017 and February 2019 six Open HIV TEST initiatives were delivered in six Italian cities (3 northern cities, 1 central and 2 southern cities). In all, 581 people were tested: the overall prevalence of HIV test reactivity was 0.7%. Participants were also asked about previous screenings and about their satisfaction with the initiative: previous HIV screening due to pregnancy or surgical procedures was reported mainly by participants in northern centres (p<0.001); finally, the initiative was considered useful and noteworthy by 99% of participants. Prevalence of HIV test reactivity in our experience was in line with national data. Our experience suggests that active testing and counselling strategies in community settings should be recommended and institutionalized by local health authorities in line with the 90-90-90 global strategy.

No impact of previous NRTIs resistance in HIV positive patients switched to DTG+2NRTIs under virological control: Time of viral suppression makes the difference

The accumulation of drug-resistance mutations on combined antiretroviral regimens (ART) backbone could affect the virological efficacy of the regimen. Our aim was to assess the impact of previous drug resistance to nucleoside reverse transcriptase inhibitors (NRTIs) on the probability of virological failure (VF) in patients, under virological control, who switched to dolutegravir (DTG)+2NRTIs regimens. All HIV-1 positive drug-experienced patients who started a regimen composed by DTG+2NRTIs [abacavir/lamivudine or tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF)/emtricitabine (FTC)] in the ARCA collaborative group with HIV-RNA <50 cp/mL were included in the analysis. Patients with a previous VF to integrase inhibitors were excluded. The impact of single and combined NRTIs mutations on the probability of VF (defined as 2 consecutive HIV-RNA >50 copies/mL or one HIV-RNA >1000 copies/mL) was assessed by Kaplan Meier curves. A multivariable Cox regression analysis was constructed to assess factors potentially related to VF. Five hundred and eighty-eight patients were included in the analysis with a median time of viral suppression before the switch of 37 months (IQR 12-78), of whom 148 (25.2%) had at least one previous NRTIs resistance mutation. In the multivariable model no association was observed between NRTIs mutations and VF. Conversely, the duration of viral suppression before switch resulted associated with a lower risk of VF (for 1 month increase, adjusted Hazard Ratio 0.98, 95%CI 0.96-0.99; p=0.024). Previous NRTIs mutations appeared to have no impact on the risk of VF in patients switched to DTG+2NRTIs, whereas a longer interval on a controlled viremia decreased significantly the risk of VF.

Subcutaneous Human Dirofilariosis By D. Repens In South Italy: A Case Report

Human dirofilariosis is a zoonosis caused by different Dirofilaria species: D. repens, D. immitis, D. tenuis and D. ursi, thin nematodes belonging to the Onchocercidae family, whose larval stages are generally found in the natural (felines and canids) or accidental (human) definitive host. In Europe, human infection is rare, even in areas considered endemic such as Spain or Italy. In this paper we describe the case of an 82-year-old woman living in Modugno (Bari municipality), who came to our observation for a subcutaneous nodule on her right thigh that had appeared in the previous two weeks and gradually became necrotic. The woman lived in an apartment with a dog. An adult worm, white, thin, about 140 mm long, came out of the necrotic area spontaneously. After microscopic examination, the worm was identified as D. repens. In Apulia, a South-Italy region, human dirofilariosis is a rare disease and since 1885 only 11 cases have been reported. In recent years we have witnessed an increase in the number of diseases transmitted by vectors at all latitudes, and in our region an increase in the Aedes albopticus population has been reported, so it is reasonable to expect an increase in dirofilariosis cases in humans.

Variability OF HIV-1 V2 env domain for integrin binding: Clinical correlates

The HIV V2^179-181 (HXB2 numbering) tripeptide mediates binding to α4β7 integrin, which is responsible for GALT homing. Our study aimed to assess V2 variability in naive HIV-1 infected patients and its association with clinical and viro-immunological features. Gp120 sequences were obtained from 322 subjects; length, potential N-linked glycosylation sites (PNGs), net-charge (NC) and ^179-181tripeptide α4β7-binding-motif of V2 were evaluated. At multivariate analysis, lower V2 length and higher NC correlated with low CD4 cells; no association was found with PNGs. A greater variability pertained positions 162-163, 164-167, 169, 175-179, 187, 194 and 195 in B sequences, and 163 and 177 in X4 tropic viruses. LDV was the most common tripeptide. Asp¹⁸⁰ was highly conserved; Leu¹⁷⁹ was more frequently observed in non-B and in recent infections compared to others, while Val¹⁸¹ was found in recent infections and in MSM. Further studies to deeply explore the clinical significance of these associations are warranted.

Uncommon testicular localization of Disseminated TB: a case report from Mozambique

Tuberculosis (TB) of the testicle is a rarely reported and poorly described disease localization. There are no well-defined clinical features suggestive of testicular TB, which makes the diagnosis difficult to establish, especially in low-income settings like Mozambique, where TB is endemic and often associated with HIV-infection; both considered leading causes of death worldwide. We reported the case of a 45-year-old male, HIV positive, naïve to antiretroviral treatment, admitted to the Department of Medicine of the Central Hospital of Beira to investigate chronic enlargement of the testicles.

Local Epidemics Gone Viral: Evolution and Diffusion of the Italian HIV-1 Recombinant Form CRF60_BC

The molecular epidemiology of HIV-1 in Italy is becoming increasingly complex, mainly due to the spread of non-B subtypes and the emergence of new recombinant forms. We previously characterized the outbreak of the first Italian circulating recombinant form (CRF60_BC), occurring among young MSM living in Apulia between the years 2009 and 2011. Here we show a 5-year follow-up surveillance to trace the evolution of CRF60_BC and to investigate its further spread in Italy. We collected additional sequences and clinical data from patients harboring CRF60_BC, enrolled at the Infectious Diseases Clinic of the University of Bari. In addition to the 24 previously identified sequences, we retrieved 27 CRF60_BC sequences from patients residing in Apulia, whose epidemiological and clinical features did not differ from those of the initial outbreak, i.e., the Italian origin, young age at HIV diagnosis (median: 24 years; range: 18–37), MSM risk factor (23/25, 92%) and recent infection (from 2008 to 2017). Sequence analysis revealed a growing overall nucleotide diversity, with few nucleotide changes that were fixed over time. Twenty-seven additional sequences were detected across Italy, spanning multiple distant regions. Using a BLAST search, we also identified a CRF60_BC sequence isolated in United Kingdom in 2013. Three patients harbored a unique second generation recombinant form in which CRF60_BC was one of the parental strains. Our data show that CRF60_BC gained epidemic importance, spreading among young MSM in multiple Italian regions and increasing its population size in few years, as the number of sequences identified so far has triplicated since our first report. The observed further divergence of CRF60_BC is likely due to evolutionary bottlenecks and host adaptation during transmission chains. Of note, we detected three second-generation recombinants, further supporting a widespread circulation of CRF60_BC and the increasing complexity of the HIV-1 epidemic in Italy.

Focused ultrasound to diagnose HIV-associated tuberculosis (FASH) in the extremely resource-limited setting of South Sudan: a cross-sectional study

OBJECTIVE

Our cross-sectional study aimed at evaluating the diagnostic performance of Focused Assessment with Sonography for HIV-associated tuberculosis (FASH) to detect extrapulmonary tuberculosis in extremely resource-limited settings, with visceral leishmaniasis as a differential diagnosis with overlapping sonographic feature.

DESIGN

Cross-sectional study.

SETTING

Voluntary Counselling and Testing Centre (VCT) of Yirol Hospital, South Sudan.

PARTICIPANTS

From May to November 2017, 252 HIV-positive patients out of 624 newly admitted to VCT Centre were registered for antiretroviral treatment. According to the number of trained doctors available to practise ultrasound (US) scan, a sample of 100 patients were screened using the FASH protocol.

INTERVENTIONS

Following a full clinical examination, each patient was scanned with a portable US scanner in six different positions for pleural, pericardial, ascitic effusion, abdominal lymphadenopathy and hepatic/splenic microabscesses, according to the FASH protocol. A k39 antigen test for visceral leishmaniasis was also performed on patients with lymphadenopathy and/or splenomegaly. All demographic, clinical and HIV data, as well as FASH results and therapy adjustments, were recorded following the examination.

RESULTS

The FASH protocol allowed the detection of pathological US findings suggestive of tuberculosis in 27 out of the 100 patients tested. Overall, FASH results supported tuberculosis treatment indication for 16 of 21 patients, with the treatment being based exclusively on FASH findings in half of them (8 patients). The group of FASH-positive patients had a significantly higher proportion of patients with CD4 count below 0.2 x10⁹/L (n=22, 81%) as compared with FASH-negative patients (n=35, 48%) (p=0.003). Moreover, 48% (n=13) of FASH-positive patients had CD4 below 100 cells/mm³. All patients tested had a negative result on k39 antigen test.

CONCLUSION

FASH was found to be a relevant diagnostic tool to detect signs of tuberculosis. Further research is needed to better define a patient profile suitable for investigation and also considering diagnostic accuracy.

Cerebrospinal fluid compartmentalization of HIV-1 and correlation with plasma viral load and blood-brain barrier damage

PURPOSE

We aimed to evaluate HIV-1 compartmentalization between the cerebrospinal fluid (CSF) and plasma and investigate as to which extent HIV-1 strains in CSF differ from those in blood and whether a correlation with either plasma viral load (pVL) or an altered blood-brain barrier (BBB) does exist.

STUDY DESIGN

We retrospectively evaluated paired CSF/blood samples collected from 86 HIV+ patients. HIV-RNA quantification, pol (PR/RT), and V3 sequencing were performed. HIV coreceptor tropism (CRT) was inferred (g2p, false-positive rate 10%, FPR). Data of standard CSF analysis were also reviewed; an altered CSF/plasma albumin ratio signified BBB damage. Neurological abnormalities (NA) were recorded.

RESULTS

Overall, 32% of patients had a CSF/plasma HIV-RNA ratio > 1 (discordance); 3% of patients had detectable CSF HIV-RNA despite suppressed pVL (escape). Discordance was more frequent in ART-treated patients (p < 0.001) and in patients with NA (p = 0.016), but was independent of BBB damage (p = 0.65) and AIDS diagnosis (p = 0.96). Finally, CSF/plasma discordance was significantly more frequent (p < 0.0001) in patients with lower pVL values (< 10.000 copies/ml). Env divergence > 10% was found in 44% of sequences and was associated with ART (p = 0.008) and NA (p = 0.037). Overall, 24% of patients had a discordant CSF/blood CRT. A 100% nucleotide identity was observed in only 7.3% of pol sequences; notably, 10% of patients had resistance-associated mutations in CSF, but not in blood.

CONCLUSIONS

Our data confirm an independent replication and evolution of HIV within the CSF. A number of factors either hinder or contribute to the compartmentalization of HIV.

Influence of HLA-B18 on liver fibrosis progression in a cohort of HIV/HCV coinfected individuals

Liver fibrosis is accelerated in human immunodeficiency virus/hepatitis C virus (HIV/HCV) coinfected compared with HCV monoinfected patients, due to multiple cofactors. Recently, HLA-B18 haplotype has been associated with short-term liver disease progression in this population. Our aim was to assess the influence of HLA-B18 on the fibrosis process in HIV/HCV coinfected individuals, untreated for HCV, during a long-term follow-up. All consecutive HIV/HCV co-infectedcoinfected patients followed in our center, with positive HCV-RNA and available human leukocyte antigen (HLA) haplotypes (determined by sequence-specific oligonucleotide primed polymerase chain reaction and simple sequence repeats polymerase chain reaction using Luminex Technology) were included. Liver fibrosis progression was assessed by means of fibrosis-4 index for liver fibrosis (FIB-4) and AST to platelet ratio index. The association between FIB-4 score over time and laboratory and clinical parameters, including HLA, was evaluated by univariate and multivariate multilevel generalized linear models. A total of 29 out of 148 screened patients were excluded because of spontaneous HCV clearance (27% were HLA-B18+). Among the remaining 119 individuals (82% males; median age at first visit = 30 years [interquartile range, IQR, 26-35]; median follow-up = 21.5 years [IQR, 15-25]), 26% were HLA-B18+. No baseline differences were evidenced between HLA-B18+ and B18- patients. Fibrosis progression was significantly faster in HLA-B18+ than in HLA-B18- patients ( P < 0.001) (Figure 1). At univariate analysis, age ( P < 0.001), HLA-B18 haplotype ( P = 0.02) and HIV-RNA viral load overtime ( P < 0.001) were associated with liver disease progression. At multivariate analysis, only age ( P < 0.001) remained independently associated with liver fibrosis progression. Our data suggest a possible association between HLA-B18 and an accelerated liver fibrosis in HIV/HCV coinfected with a long-term follow-up.

HIV-RNA decay in paired blood and semen samples of subjects receiving their first dolutegravir-based ART regimen

BACKGROUND AND OBJECTIVES

We aimed to investigate to what extent a first-line DTG-based ART regimen reduces HIV-RNA in semen compared to plasma.

STUDY DESIGN

In this prospective, observational study, ART-naïve, HIV-infected males starting their first ART regimen with DTG plus TDF/FTC or ABC/3TC were enrolled. Paired blood (BP) and seminal plasma (SP) samples were collected at baseline (T0) and at week-2/4/12/24 after ART initiation. Sexually transmitted infections (STI) were ruled out before enrolment.

RESULTS

Median baseline HIV-RNA levels were lower in SP compared to BP (657 versus 38.200 copies/ml, p < 0.001), three subjects had undetectable semen HIV-RNA. After 12 weeks of treatment, HIV-RNA was below the quantification limit in both BP and SP of 11 pts (61.1%). Discordant results were obtained in 6 subjects (33.3%), showing quantifiable HIV-RNA in blood only (2 cases) and in semen only (4 cases). Finally, one subject had a positive HIV-RNA in SP/BP. At W24, only in 2/16 subjects (12.5%) HIV-RNA was detectable in semen, while in the others it was negative on SP/BP. No concurrent STI was found in subjects with detectable VL in semen.

CONCLUSIONS

DTG demonstrated effectiveness in reducing VL with different kinetics in blood and semen, despite seminal viral suppression after 6 months of ART was not obtained in the totality of subjects.

Prevalence and Predictors of Malaria in Human Immunodeficiency Virus Infected Patients in Beira, Mozambique

Co-infection between malaria and HIV has major public health implications. The aims of this study were to assess the malaria prevalence and to identify predictors of positivity to malaria Test in HIV positive patients admitted to the health center São Lucas of Beira, Mozambique. A retrospective cross-sectional study was performed from January 2016 to December 2016. Overall, 701 adult HIV patients were enrolled, positivity to malaria test was found in 232 (33.0%). These patients were found to be more frequently unemployed (76.3%), aged under 40 (72.0%), with a HIV positive partner (22.4%) and with a CD4 cell count <200 (59.9%). The following variables were predictors of malaria: age under 40 (O.R. = 1.56; 95%CI: 1.22–2.08), being unemployed (O.R. = 1.74; 95%CI: 1.24–2.21), irregularity of cotrimoxazole prophylaxis’s (O.R. = 1.42; 95%CI: 1.10–1.78), CD4 cell count <200 (O.R. = 2.01; 95%CI: 1.42–2.32) and tuberculosis comorbidity (O.R. = 1.58; 95%CI: 1.17–2.79). In conclusion, high malaria prevalence was found in HIV patients accessing the out-patients centre of São Lucas of Beira. Our findings allowed us to identify the profile of HIV patients needing more medical attention: young adults, unemployed, with a low CD4 cell count and irregularly accessing to ART and cotrimoxazole prophylaxis.

Teenage pregnancies in Mozambique: the experience of "Servicios Amigos dos Adolescentes" clinics in Beira

The purpose of this article is to provide insights into the demand for pregnancy-related health services by adolescent girls and young women in Mozambique. We analysed the patient registers for the first year of operation (2014) of the Servicios Amigos dos Adolescentes (SAAJ) [Friendly Services for Adolescents] clinics in Beira, Mozambique. These registers provide details of the service demands of, and services provided to the 8 290 adolescent girls and young women who accessed the 6 SAAJ clinics in 2014. Analysis of that record, with disaggregation of the patients according to age (9 years or less; 10-14; 15-19; 20-24; 25 and older), show that 3 021 (36%) were pregnant or had previously been pregnant; most being girls in the 15-19 age band (59%). Being pregnant or having been pregnant previously was associated with dropping out of school. Of all the girls and women, 60% agreed to HIV testing and counselling; the HIV prevalence rate amongst this group was 4-5% amongst adolescents and 25% amongst women 25 years and older. A minority of the girls and women who were pregnant or had been pregnant previously agreed to HIV testing and counselling. Notwithstanding the limitations for analysis, the results were alarming: substantially high HIV prevalence rates were indicated (2% amongst 10-14 year old girls; 8% amongst 15-19 year olds; 10% amongst 20-24 year olds; and 28% amongst >24 year olds). The data from the SAAJ clinics and results pertain only to conditions in Beira. However, as the first empirical assessment of pregnancy-related service demand amongst adolescent girls and young women in the country and involving a relatively large sample, we contend that this study affirms the need for expansion of sexual and reproductive health (SRH) services, including HIV services, for adolescent girls and young women in Mozambique.

Evolution of HIV-1 transmitted drug resistance in Italy in the 2007-2014 period: A weighted analysis

BACKGROUND

Recent studies suggest that transmitted drug resistance (TDR) may be decreasing in latest years, likely because of the reduced frequency of acquired resistance. However, specific risk factors, geographical areas and special HIV-infected populations may be disproportionally affected by TDR.

OBJECTIVES

Correlates of TDR and time trends were evaluated from 2007 to 2014.

STUDY DESIGN

We evaluated the genotypic results of 2155 naïve patients enrolled in the I.Co.N.A cohort at 23 clinical Centers in Italy between 2007 and 2014. A weighted analysis was performed to account for the patients enrolled in the cohort in each clinical Centre at each biennium (total number of patients: 3737).

RESULTS

Overall prevalence of TDR was 10.7%. Independent predictors of TDR were sexual risk factor (OR 2.315, p = 0.020) and non-Italian geographical origin (OR 1.57, p = 0.038). The weighted prevalence of TDR was 10.5% with a stable proportion over calendar years. Generally, TDR prevalence was numerically higher, although not significantly, in clinical Centers of metropolitan areas with more than 3 millions of residents as compared to others (11.3% vs. 9.2%). The difference in TDR prevalence between these Centers decreased in more recent years.

CONCLUSIONS

A stable frequency of TDR was observed during the most recent years in Italy, with opposite and converging trends in large metropolitan areas as compared to the rest of the country, suggesting a more homogeneous spread of TDR across the country in latest years. Concerns remain for sexual route of infection and non-Italian origin, reinforcing the need for specific prevention strategies prioritizing specific populations.

The At Risk Child Clinic (ARCC): 3 Years of Health Activities in Support of the Most Vulnerable Children in Beira, Mozambique

The concept of &ldquo;children at risk&rdquo; changes worldwide according to each specific context. Africa has a large burden of overall risk factors related to childhood health and development, most of which are of an infective or social origin. The aim of this study was to report and analyze the volumes of activities of fifteen At Risk Child Clinics (ARCCs) within the Beira District (Mozambique) over a 3 year-period in order to define the health profile of children accessing such health services. We retrospectively analyzed the data from all of the children accessing one of the 15 Beira ARCCs from January 2015 to December 2017. From this, 17,657 first consultations were registered. The motivations for accessing the services were in order of relevance: HIV exposure (n. 12,300; 69.7%), other risk conditions (n. 2542; 14.4%), Moderate Acute Malnutrition (MAM) (n. 1664; 9.4%), Severe Acute Malnutrition (SAM) (n. 772; 4.4%), and TB exposure (n. 542; 3.1%). During the first consultations, 16,865 children were screened for HIV (95.5%), and 7.89% tested HIV-positive. In our three years of experience, HIV exposure was the main indication for children to access the ARCCs in Mozambique. ARCCs could represent a strategic point to better understand health demands and to monitor the quality of care provided to this vulnerable population group, however significant effort is needed to improve the quality of the data collection.

Evolution of transmitted HIV-1 drug resistance and viral subtypes circulation in Italy from 2006 to 2016

OBJECTIVES

The aim was to evaluate the evolution of transmitted HIV-1 drug resistance (TDR) prevalence in antiretroviral therapy (ART)-naïve patients from 2006 to 2016.

METHODS

HIV-1 sequences were retrieved from the Antiviral Response Cohort Analysis (ARCA) database and TDR was defined as detection of at least one mutation from the World Health Organization (WHO) surveillance list.

RESULTS

We included protease/reverse transcriptase sequences from 3573 patients; 455 had also integrase sequences. Overall, 68.1% of the patients were Italian, the median CD4 count was 348 cells/μL [interquartile range (IQR) 169-521 cells/μL], and the median viral load was 4.7 log₁₀ HIV-1 RNA copies/mL (IQR 4.1-5.3 log₁₀ copies/mL). TDR was detected in 10.3% of patients: 6% carried mutations to nucleos(t)ide reverse transcriptase inhibitors (NRTIs), 4.4% to nonnucleos(t)ide reverse transcriptase inhibitors (NNRTIs), 2.3% to protease inhibitors (PIs), 0.2% to integrase strand transfer inhibitors (INSTIs) and 2.1% to at least two drug classes. TDR declined from 14.5% in 2006 to 7.3% in 2016 (P = 0.003): TDR to NRTIs from 9.9 to 2.9% (P = 0.003) and TDR to NNRTIs from 5.1 to 3.7% (P = 0.028); PI TDR remained stable. The proportion carrying subtype B virus declined from 76.5 to 50% (P < 0.001). The prevalence of TDR was higher in subtype B vs. non-B (12.6 vs. 4.9%, respectively; P < 0.001) and declined significantly in subtype B (from 17.1 to 8.8%; P = 0.04) but not in non-B subtypes (from 6.1 to 5.8%; P = 0.44). Adjusting for country of origin, predictors of TDR were subtype B [adjusted odds ratio (AOR) for subtype B vs. non-B 2.91; 95% confidence interval (CI) 1.93-4.39; P < 0.001], lower viral load (per log₁₀ higher: AOR 0.86; 95% CI 0.75-0.99; P = 0.03), site in northern Italy (AOR for southern Italy/island vs. northern Italy, 0.61; 95% CI 0.40-0.91; P = 0.01), and earlier calendar year (per 1 year more recent: AOR 0.95; 95% CI 0.91-0.99; P = 0.02).

CONCLUSIONS

The prevalence of HIV-1 TDR has declined during the last 10 years in Italy.

Dolutegravir (DTG)-containing regimens after receiving raltegravir (RAL) or elvitegravir (EVG): Durability and virological response in a large Italian HIV drug resistance network (ARCA)

BACKGROUND

Dolutegravir (DTG) is a next-generation HIV integrase inhibitor (INI) with an increased genetic barrier to resistance with respect to raltegravir (RAL) or elvitegravir (EVG). Few data are available on the durability of DTG-containing regimens.

OBJECTIVES

We aimed at investigating the duration of the DTG-containing regimen, the occurrence of an HIV-1 RNA blip, and factors associated with DTG virological response.

STUDY DESIGN

From the Antiviral Response Cohort Analysis database, we selected 89 HIV-1-positive four-class-experienced subjects who started DTG after receiving RAL or EVG. Factors associated with durability and virological response were analysed by logistic regression.

RESULTS

After a median duration of 18.8 [0.4-76.2] months, 79/89 (88.8%) subjects were still on DTG. All subjects remaining on DTG at the end of follow-up had undetectable HIV-1 RNA, compared to 5/10 subjects who discontinued DTG. DTG discontinuation was less frequent in patients who had experienced ≥10 regimens (HR 0.11, p = 0.040). The probability of having an HIV-1 RNA positive value at the last follow-up significantly increased in patients with non-B HIV-1 subtype (HR 5.77, p < .001) and significantly decreased in patients with CD4 nadir >200/μL (HR 0.29, p = 0.038), with more than 10 previous regimens (HR 0.27, p = 0.040), and who harbored virus with IN mutations (HR 0.12, p = 0.023) at DTG start.

CONCLUSIONS

After previous exposure to first-generation INIs, treatment with DTG showed long durability and did not show virological rebound after virological suppression. Subjects infected with a non-B HIV-1 subtype had a greater risk of having detectable HIV-1 RNA at the last observation.

Pathways of care for HIV infected children in Beira, Mozambique: pre-post intervention study to assess impact of task shifting

Background

In 2013, Mozambique implemented task-shifting (TS) from clinical officers to maternal and child nurses to improve care for HIV positive children < 5 years old. A retrospective, pre-post intervention study was designed to evaluate effectiveness of a new pathway of care in a sample of Beira District Local Health Facilities (LHFs), the primary, local, community healthcare services.

Methods

The study was conducted by accessing registries of At Risk Children Clinics (ARCCs) and HIV Health Services. Two time periods, pre- and post-intervention, were compared using a set of endpoints. Variables distribution was explored using descriptive statistics. T-student, Mann Whitney and Chi-square tests were used for comparisons.

Results

Overall, 588 HIV infected children (F = 51.4%) were recruited, 330 belonging to the post intervention period. The mean time from referral to ARCC until initiation of ART decreased from 2.3 (± 4.4) to 1.1 (± 5.0) months after the intervention implementation (p-value: 0.000). A significant increase of Isoniazid prophylaxis (O.R.: 2.69; 95%CI: 1.7–4.15) and a decrease of both regular nutritional assessment (O.R. = 0.45; 95%CI: 0.31–0.64) and CD4 count at the beginning of ART (O.R. = 0.46; 95%CI: 0.32–0.65) were documented after the intervention.

Conclusions

Despite several limitations and controversial results on nutrition assessment and CD4 count at the initiation of ART reported after the intervention, it could be assumed that TS alone may play a role in the improvement of the global effectiveness of care for HIV infected children only if integrated into a wider range of public health measures.

Predictors of therapy failure in newly diagnosed pulmonary tuberculosis cases in Beira, Mozambique

Objective

Tuberculosis (TB) remains a major global health issue, ranking in the top ten causes of death worldwide. A deep understanding of factors influencing poor treatment outcomes may allow the development of additional treatment strategies, focused on the most vulnerable groups. Aims of the study were: (i) to evaluate the treatment outcome among TB subjects followed in an outpatient setting and (ii) to analyze factors associated with treatment failure in newly diagnosed patients with pulmonary TB in Beira, the second largest city of Mozambique.

Results

A total of 301 TB adult patients (32.6% females) were enrolled. Among them, 62 (20.6%) experienced a treatment failure over a 6 months follow-up. On multivariate model, being males (O.R. = 1.73; 95% CI 1.28–2.15), absence of education (O.R. = 1.85; 95% CI 1.02–2.95), monthly income under 50 dollars (O.R. = 1.74; 95% CI 1.24–2.21) and being employed (O.R. = 1.57; 95% CI 1.21–1.70), low body mass index values (O.R. = 1.42; 95% CI 1.18–1.72) and HIV status (O.R. = 1.42; 95% CI 1.10–1.78) increased the likelihood of therapy failure over 6 months of follow-up. In this study, patients who need more medical attention were young males, malnourished, with low income and low educational degree and HIV positive. These subjects were more likely to fail therapy.

HIV-1 co-receptor tropism and liver fibrosis in HIV-infected patients

Background

In vitro, gp120 of both X4 and R5 HIV-1 strains activates human hepatic stellate cells, but if it can promote liver fibrosis in vivo is unknown. We aimed to evaluate if patients carrying X4 or R5 strains have a different liver fibrosis (LF) progression over time.

Methods

A total of 1,137 HIV-infected patients in ICONA cohort (21% females, 7% HCV co-infected) with an available determination of HIV-1 co-receptor tropism (CRT), a Fibrosis-4 Index for Liver Fibrosis (FIB-4) <3.25 and at least one-year follow-up were included. CRT was assessed by gp120 sequencing on plasma RNA and geno2pheno algorithm (10% false positive rate) or by Trofile. LF was assessed by means of FIB-4. LF progression was defined as an absolute score increase or a transition to higher fibrosis stratum and/or occurrence of liver-related clinical events.

Results

A total of 249 (22%) patients carried X4 strains, which were associated with older age, lower CD4 count, lower nadir CD4, and intravenous drug use. Overall, X4 and R5 patients had similar baseline FIB-4 scores and similar mean FIB-4 slope after a median follow-up of 35 months. There was no difference between X4 and R5 for time to LF progression (p = 0.925). Estimated risk of LF at 24 months (95% CI) after baseline in X4 and R5 was 10.6% (8.3–12.9) and 9.9% (5.9–14.0), respectively. Age, HCV co-infection, diabetes, HIV-duration, HIV-RNA>100.000 cp/mL, antiretroviral therapy exposure were associated with LF progression at multivariate analysis.

Conclusions

A slight LF progression over time was observed in HIV-infected patients. No difference was demonstrated for X4 and R5 HIV-1 strains in accelerating LF evolution.

Prevalence of diabetes mellitus in newly diagnosed pulmonary tuberculosis in Beira, Mozambique

Introduction

Data regarding the association between diabetes mellitus (DM) and tuberculosis (TB) in Africa are scarce. DM screening among TB patients in Mozambique was carried out.

Methods

The study was implemented from January to August 2016 in three Urban Health Centers in Beira, Mozambique and recruited adult (>18 years) patients newly diagnosed with pulmonary TB.

Results

Three hundred and one patients were enrolled (67.4%, males mean age 31.7(SD 11 years). Diabetes was diagnosed in only 3 patients (1%) and impaired glucose tolerance (IGT) in an additional 6 subjects (2%).

Conclusion

A lower than expected prevalence of DM was observed, which could be explained by the lack of traditional risk factors for DM (overweight, age over 45 years, hypertension and smoking) in Mozambique.

The elderly and direct antiviral agents: Constraint or challenge?

BACKGROUND

Direct antiviral agents (DAAs) for chronic hepatitis C showed great effectiveness and good safety profile. So far, few data are available about their use in elderly subjects.

AIM

To assess management, safety and outcome of DAAs treatments in the elderly.

METHODS

This retrospective, single-centre study enrolled all patients aged ≥65 years, compared by age (group A: 65-74 years, group B: ≥75 years), who completed DAAs between February 2015-November 2016. Variables potentially associated to adverse events (AEs) were analyzed. Sustained virological response (SVR) was evaluated at 12-weeks follow-up.

RESULTS

DAAs were administered to 221 patients aged ≥65 years (males: 112; group A: 130, group B: 91). Prescribed regimens were: sofosbuvir-based: 44 patients (19.9%), simeprevir-based: 25 (15%), ledipasvir-based: 49 (22.2%), daclatasvir-based: 12 (5.4%), paritaprevir/ritonavir+ombitasvir±dasabuvir: 91 (41.2%). Ribavirin was used in 121 patients. In 58 subjects co-medications were adjusted due to drug interactions. At least one AE occurred in 130 patients, including 13 SAEs, mainly in older subjects (p=0.04). Female sex (p=0.04), liver stiffness (p=0.023), use of simeprevir (p=0.03) and ribavirin (p=0.009) were associated with AEs. SVR-12 was achieved in 96,9% of subjects.

CONCLUSIONS

A careful baseline evaluation and a strict monitoring allow to optimise management and outcome of DAAs in elderly.

HCV mono-infected and HIV/HCV co-infected individuals treated with direct-acting antivirals: to what extent do they differ?

BACKGROUND

Direct-acting antiviral (DAA)-based treatment of hepatitis C virus (HCV) has been associated with high sustained virological response (SVR) rates and good tolerability in randomized clinical trials. This study was performed to assess the safety and effectiveness of DAAs in both HCV mono-infected and HIV/HCV co-infected patients.

METHODS

All consecutive HCV-infected patients, including HIV/HCV co-infected patients, receiving DAA-based treatment from February 2015 to September 2016 at the study clinic were included. Clinical, virological, and biochemical data were retrieved. The primary end-point was the SVR12 (HCV RNA undetectable 12 weeks after the end of treatment) is commonly used worldwide. The secondary end-point was the safety profile of DAAs during the treatment period.

RESULTS

A total of 382 patients were included; 62 were HIV/HCV co-infected. Cirrhosis was found in 256 patients (67.4%). SVR12 was achieved in 365/382 (95.5%) individuals (58/62 HIV/HCV co-infected, 93.5%) in the intention-to-treat (ITT) analysis. A platelet count <90×10⁹/l (odds ratio (OR) 4.12, 95% confidence interval (CI) 1.5-11.3, p=0.006), HCV genotype 3 infection (OR 5.49, 95% CI 1.9-15.7, p=0.002), liver stiffness >20kPa (OR 3.05, 95% CI 1.03-8.96, p=0.04), and Model for End-Stage Liver Disease (MELD) score >10 (OR 5.27, 95% CI 1.16-23.8, p=0.03) were associated with lower SVR rates. On multivariate analysis, only genotype 3 infection remained a negative predictor of SVR (OR 21.6, 95% CI 3.81-123, p=0.001). Treatment discontinuation was observed in 10 subjects. Severe adverse events (SAEs) occurred in 17 patients (4.5%).

CONCLUSIONS

High SVR12 rates were observed in both HCV mono-infected and HIV/HCV co-infected individuals. Overall, DAA-based treatment was safe and there were no differences in terms of SAEs and treatment discontinuation between the two groups.

Reduced community viral load does not coincide with a reduction in the rate of new HIV diagnoses and recent infections: data from a region of southern Italy

OBJECTIVES

We assessed whether changes in community viral load (CVL) over time were associated with the rate of new HIV diagnoses (NDs).

METHODS

HIV-1-positive individuals referred to our institute and permanently residing in our province were considered for inclusion in the study. A total of 861 HIV-infected adults with at least one HIV RNA measurement (12 530 measurements in total) between 2008 and 2014 were included. Viraemia copy-years were calculated from all HIV RNA values for each patient using the trapezoidal rule; multiple CVL indicators were considered. Total NDs and recent infections (< 1 year) were analysed separately. The association between NDs and CVL was tested by means of mixed Poisson models, with CVL as a fixed effect and year as a random effect.

RESULTS

The incidence of NDs was 2.28 per 100 000 residents in 2008 and 2.52 per 100 000 residents in 2014. Total numbers of NDs and recent infections did not vary significantly over time (P for trend 0.879 and 0.39, respectively). Mean HIV RNA decreased from 31 095.8 HIV-1 RNA copies/mL in 2008 to 21 231.5 copies/mL in 2014 (P < 0.001); a downward trend was always observed regardless of the CVL indicator considered. Depending on the indicator, there were some differences in CVL by patient characteristics. The most substantial contributors to CVL appeared to be male individuals, men who have sex with men (MSM), non-Italians, and untreated subjects (all P < 0.05). The relative risk of ND increased among Italians and MSM with an increasing proportion of subjects having an undetectable HIV RNA, and decreased in the same population with increasing levels of CVL.

CONCLUSIONS

In our setting, CVL represented a good marker of access to care and treatment; however, reduced CVL did not coincide with a reduction in the rate of NDs.

An intricate case of multidrug resistant Plasmodium falciparum isolate imported from Cambodia

Background

Imported cases of multidrug resistant Plasmodium falciparum and treatment failure with artemisinin-based regimens, although rare, have been described also in Western countries and their management is often challenging. This is also due to an inadequate knowledge and implementation of health prevention measures.

Case report

A complex case of imported malaria caused by Plasmodium vivax/P. falciparum isolates in a patient who was not taking chemoprophylaxis while he was travelling in Cambodia is reported in this article. After failures of artemisinin-based and both oral and intravenous quinine-based regimens, a multidrug resistant P. falciparum was detected. The patient was successfully treated with atovaquone–proguanil.

Conclusions

This experience highlights the importance of a careful management that should be based not only on the most up-to-date guidelines, but also on the awareness of a rapidly evolving scenario.

The Revival of an "Old" Marker: CD4/CD8 Ratio

The effectiveness of modern antiretroviral therapies (ART) transformed HIV infection into a chronic disease characterized by a persistent condition of inflammation and immune activation. For this reason, even thought AIDS-related mortality has been reduced with an increased life expectancy, patients living with HIV infection are more likely to develop non-AIDS events despite the achievement of a complete suppression of HIV replication. Hence, the scientific community feels the need to find new biomarkers which would be suitable in clinical practice for identifying patients who require a close monitoring because of an increased risk of developing comorbidities. A renewed interest has emerged about the usefulness of CD4/CD8 ratio as a strong marker of immune activation and immune senescence. Recently, many studies have underlined that CD4/CD8 ratio might represent a good predictor of AIDS and non-AIDS events. Herein, the potential role of the CD4/CD8 ratio for the monitoring of HIV patients in different clinical settings is reviewed.

Switch of predicted HIV-1 tropism in treated subjects and its association with disease progression

Dynamics of human immunodeficiency virus type 1 (HIV-1) tropism after antiretroviral therapy (ART) initiation and their association with disease progression are poorly investigated.This was a cohort study on subjects from the ICONA cohort receiving ART with persistently detectable (PD) or persistently undetectable (PU) viral load (VL) and with stored plasma or peripheral blood mononuclear cell (PBMC) samples at 2 time-points (T1, T2) after ART initiation. HIV-1 co-receptor tropism was determined by V3-loop sequencing and the geno2pheno algorithm. A switch in viral tropism was defined if the tropism classification at T2 differed from that observed at T1. Time to disease progression, defined as the occurrence of a new acquired immune deficiency syndrome (AIDS)-defining event/death from T2, was also evaluated.One hundred ninety-five patients were analyzed (124 PD, 71 PU). Over a median follow-up of 22.6 (19.8-28.1) months, PD and PU patients showed similar rates (95% confidence interval) of switch to a non-R5 virus [PD: 6.9 (3.7-11.2)/100-person-years of follow-up (PYFU); PU: 8.0 (3.4-14.5)/100-PYFU; P = 0.63] and of switch to a R5 virus [PD: 15.4 (7.3-26.4)/100-PYFU; PU: 8.1 (2.5-16.7)/100-PYFU; P = 0.38]. Switch to non-R5 virus was predicted by nadir CD4+ before T1.Twenty-two (18%) PD and 4 (6%) PU subjects experienced disease progression (P = 0.02). The risk of disease progression was independently associated with a switch in co-receptor tropism (adjusted hazard ratio = 4.06, 95% CI: 1.20-13.80, P = 0.03) as well as age, AIDS diagnosis, nadir CD4+ before T2, current CD4+, and VL.Switch of HIV-1 tropism under ART occurs in both directions, with similar rates in subjects with PD or PU VL and it might be predictive of future unfavorable clinical outcome.

Late presentation and loss to follow-up of immigrants newly diagnosed with HIV in the HAART era

To compare clinical characteristics and therapeutic management of newly HIV-diagnosed immigrants to natives. Patients with a first HIV diagnosis from 1996 to 2010 were included. Of 716 new diagnoses, 85 (12 %) were immigrants. Migrants were younger, more frequently females and sexually infected, less likely to voluntarily request testing, and less HCV-coinfected. Late presenters (CD4 <350 or AIDS) were 76 % among migrants versus 56 % in natives (p = 0.006) with an increasing trend over time. HAART was initiated in 76.5 % of natives and 72.4 % of immigrants; the number/type of adverse events and treatment discontinuation were similar. Immigrants received more NNRTIs-based regimens. A similar proportion of patients reached virological suppression at month 1-3-6 after HAART initiation, but 43 % of immigrants versus 27 % of natives resulted lost to follow-up (p < 0.001). Diagnosis of HIV was often delayed among migrants, who also presented a higher rate of lost to follow-up.