Infection par le VIH et parcours de soin : des recommandations à la pratique clinique

International audienceOBJECTIVES:To quantify within a cohort of HIV-infected individuals the number of medical visits and procedures to be carried out according to comorbidities and risk factors to implement a personalized care pathway.PATIENTS AND METHODS:Retrospective study of 915 patients consulting from January 1 to December 31, 2016 at an outpatient unit of multidisciplinary consultations, using an electronic patient record. We built an algorithm using parameters required for the application of the national guidelines for the management of HIV-infected individuals. The frequency of comorbidities was measured according to gender, transmission risk group, and nadir CD4 (200/mm3).RESULTS:Patients were mostly men (median age: 52 years), of whom 16% were aged≥60 years. Viral load was<40 copies/mL in 93.5% of treated patients and CD4 cell count≥500/mm3 for 73%. Overall, 74.5% of patients had at least one comorbidity. The number of comorbidities was similar in men and women but was significantly higher in patients with a nadir CD4 <200/mm3 and increased with age (irrespective of gender). The minimum number of consultations to be scheduled per year was 8123: 70% for the management of comorbidities with an average of six consultations/year/patient. Overall, 53% of patients should attend a proctology consultation. The minimum number of paramedical procedures to be performed was 5115.CONCLUSION:The implementation of a personalized multidisciplinary management within a single facility seems to be a suitable care model to address the needs of HIV-infected individuals.Objectifs. – Quantifier le nombre de consultations et d’actes à réaliser selon les comorbidités et facteurs de risque pour organiser un parcours de soins coordonné et personnalisé d’une file active de personnes vivant avec le VIH (PVVIH).Patients et méthodes. – Étude rétrospective sur 915 PVVIH, suivis du 1erjanvier au 31 décembre 2016 dans une unité ambulatoire pluridisciplinaire avec dossiers patient informatisés. Un algorithme a été construit à partir des caractéristiques sur lesquelles s’appuie le calendrier de suivi des recommandations nationales. La fréquence des comorbidités a été étudiée selon le sexe et le nadir CD4.Résultats. – La file active était composée majoritairement d’hommes (âge médian 52 ans), dont 16 % étaient âgés de ≥ 60 ans, avec un taux deCD4 ≥ 500/mm3chez 73 % et une charge virale < 40 copies/mL chez 93,5 % des patients traités. Au moins, une comorbidité était observée chez74,5 % des patients.Le nombre de comorbidités ne différait pas entre les hommes et les femmes, mais était significativement plus élevé en cas de nadirCD4 < 200/mm3et augmentait avec l’âge, indifféremment du sexe. Le nombre minimal de consultations annuelles à programmer est de 8123 consul-tations, dont 70 % pour la prise en charge des comorbidités avec en moyenne 6 consultations/an/patient. Le nombre minimal de prestationsparacliniques à réaliser était de 5115 actes.Conclusions. – L’organisation d’une gestion en pluridisciplinarité centrée autour du patient au sein d’une même structure apparaît comme unmodèle de prise en charge nécessaire aux besoins des PVVIH

A Case of Undiagnosed HIV Infection in a 57-Year-Old Woman with Multiple Myeloma: Consequences on Chemotherapy Efficiency and Safety

Background. Non-AIDS-defining cancers represent a rising health issue among HIV-infected patients. Nevertheless, HIV testing is not systematic during the initial cancer staging. Here, we report a case of HIV infection diagnosed three years after chemotherapy initiation for multiple myeloma. Results. A 57-year-old woman diagnosed with multiple myeloma underwent a first round of chemotherapy by bortezomib/lenalidomide and then with bortezomib/liposomal-doxorubicine/dexamethasone, with partial remission, poor hematological tolerance, and multiple episodes of pneumococcal infection. Allogenic stem cell transplantation was proposed leading to HIV testing, which revealed seropositivity, with an HIV viral load of 5.5 Log10/mL and severe CD4 T cell depletion (24 cells/mm3). Chemotherapy by bendamustin was initiated. Multidisciplinary staff decided the initiation of antiretroviral therapy with tenofovir/emtricitabin/efavirenz and prophylaxis against opportunistic infections. After 34 months, patient achieved complete remission, sustained HIV suppression, and significant CD4 recovery (450 cells/mm3), allowing effective pneumococcal immunization without relapse. Conclusion. Our case illustrates the drawback that ignored HIV infection is still causing to cancer patients receiving chemotherapy and highlights the importance of early HIV testing in oncology. A multidisciplinary approach including oncologists/hematologists, virologists, and pharmacists is recommended in order to avoid drug interactions between chemotherapy and antiretroviral drugs. Moreover, prophylactic medication is recommended in these patients regardless of CD4+ cell count at the initiation of chemotherapy

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

Abstract 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

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

International audienceBackground: 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

Integrase strand transfer inhibitors and neuropsychiatric adverse events in a large prospective cohort

To analyse the frequency and causes of treatment discontinuation in patients who were treated with an integrase strand transfer inhibitor (INSTI), with a focus on neuropsychiatric adverse events (NPAEs)