Optimization strategies for HIV, syphilis and hepatitis testings in infectious disease and dermatology clinics: preliminary results of Modena collaboration experience

Background: HIV and sexually transmitted diseases (STDs) screening tests are usually offered in many Italian health institutions. These tests are very important for detection of HIV and STDs, for treating them at an early stage and for prevention of diffusion inside communities. Generally, HIV test is the only screening exam performed in Infectious Disease Clinic (IDC). Increased collaboration between IDC and STDs Centre using the same approach to test sexually transmitted infections could implement the number of new diagnoses. In the Azienda Ospedaliero-Universitaria (AOU) of Modena, the IDC and STDs Centre of Dermatology Clinic began a strict collaboration and adopted a common diagnostic profile including HIV, syphilis, HBV and HCV screening tests since 2013. The aim of the study was to observe the results of a seven-years collaboration in term of number of new HIV and STDs diagnoses. Material & Methods: Consecutive patients who underwent at least 1 screening test for HIV, syphilis, HBV and HCV from January 2010 to September 2016 in IDC or STDs Centre were included. Demographical data were electronically recorded in clinical databases. “Linkage to care” was obtained through a capture and recapture method using Modena HIV surveillance System and Modena HIV clinic databases. Results: During the study period 10675 admittances related to 8623 patients, who carried out at least 1 screening test, were registered in the centres. They were mainly male (68.2%). Median age was 33 years-old (IQR 26-43). Foreigners represented 26.5% of tested people. Since 2013 an increasing number of admittances was observed (1343 accesses in 2010 and 1901 in 2015). HBV, HCV and syphilis tests increased in IDC after 2013 as well as HIV tests in STDs Centre (Figure 1). A total of 700 people were positive for at least 1 screening test: 71 with HIV infection (2016 incidence rate 1.4%), 314 with syphilis (2016 incidence rate 1.3%), 182 with HCV infection (2016 incidence rate 1.64%) and 161 with HBV infection (2016 incidence rate 3.8%). The number of HIV and HBV positive tests increased in the last 2 years but the trend was statistically significant only for HIV (p<0.001). 57% of HIV new infections were observed in Italian men, while 82% of new HBV infections were detected in young foreigners. During the study period the number of new syphilis infections showed a reduction (p<0.001) while HCV positive tests were changeless (p=0.245). 87.6% of new infections were found be linked in care in AOU of Modena. Conclusion: The agreement between IDC and STDs Centre has proven to work well increasing the diagnosis over the time and obtaining a good results in “linkage to care”, which allows to patients with positive screening test to be sent to the pertinent Clinic for further investigations and therapeutical management

Collaboration experience between Dermatology Unit and Infectious Disease Clinic in Modena: optimization strategies for HIV, hepatitis and syphilis screening tests

Introduction Screening tests for HIV, HBV, HCV and syphilis are very important to detect and treat these infections at an early stage and prevent their diffusion inside communities. Sexually Transmitted Diseases Ambulatory of Dermatology Unit (STDs-DU) and “Test & Counselling” Ambulatory of Infectious Disease Clinic (T&C-IDC) in Modena began collaboration in 2010 and adopted a common diagnostic serological profile since 2013. Objective The main aim of the study was to analyse the results of screening tests performed in the STDs-DU and T&C-IDC, comparing the results obtained after the adoption of the shared protocol with the previous period. The secondary objective was to evaluate the efficacy of our collaboration in term of number of new diagnoses and linkage to care. Materials and Methods Consecutive patients referred to the STDs-DU and T&C-IDC from January 2010 to December 2016, with at least one performed screening test for HIV, HBV, HCV and syphilis were enrolled. Referral of patients with a new infection was obtained by capture-recapture methods in hospital databases. Results During the seven-years observation we collected 13117 admittances for 9154 patients. We observed a significant increase in the number of screening tests (p<0.001) and ratio between tests and admissions (p=0.002). 644 (7.0%) people with at least one infection were diagnosed. Among these, the most common was syphilis (41.9%), followed by HBV (25.7%), HCV (21.4%) and HIV (10.9%). Syphilis and HCV occurred predominantly in Italians (72.5% and 81.1%) and males (75.7% and 75.5%), while foreign-born (85.5%) mainly harboured HBV infection. HIV diagnosis was detected more frequently among males (67.1%) with a similar proportion between Italians and foreign-born. 543 out of 644 (84.3%) patients were linked to care. Conclusions The cooperation between STDs-DU and T&C-IDC has proven to work well increasing the diagnosis over the time and obtaining good results in linkage to care

Optimization strategies for HIV, hepatitis and syphilis testing in Infectious Disease Clinic and Dermatology Unit of Modena: seven-years results of collaboration experience

Introduction: Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and syphilis infections modify the epidemiology and presentation of each other. Screening tests are very important for detection of sexually transmitted infections (STIs), for treating them at an early stage and prevent the diffusion inside communities. “Test & Counselling” Ambulatory of Infectious Disease Clinic (T&C-IDC) and Sexually Transmitted Diseases Ambulatory of Dermatology Unit (STDs-DU) of the Azienda Ospedaliero-Universitaria Policlinico of Modena began collaboration in 2010 and adopted a common diagnostic profile since 2013. The main objective was to analyse the results of screening tests performed in the T&C-IDC and STDs-DU during the study period in order to identify early HIV, HBV, HCV and syphilis infections. The secondary objective was to evaluate the efficacy of our collaboration in term of number of new STIs diagnoses and linkage to care. Material and Methods: Consecutive patients referred to the T&C-IDC and STDs-DU from January 2010 to December 2016, with at least one performed screening test for HIV, HBV, HCV and syphilis were enrolled. Demographic and laboratory data were acquired from each patient. Linkage to care of positive patients was obtained through a join of different outpatient clinical databases. Results: During the seven-years observation we collected 13117 admittances for 9154 patients. Median age was 35.1 years ± 12.6 and foreign-born population represents 29% of the tested people. People who resulted positive for at least one screening test increased during the study period. A total of 668 infections were detected in 644 patients. Discussion: The agreement between T&C-IDC and STDs-DU has proven to work well increasing the diagnosis over the time and obtaining a good results in linkage to care, which allows to patients with positive screening test to be sent to the pertinent Clinic for further investigations and therapeutic management

Reliable and Accurate CD4+ T Cell Count and Percent by the Portable Flow Cytometer CyFlow MiniPOC and \u201cCD4 Easy Count Kit-Dry\u201d, as Revealed by the Comparison with the Gold Standard Dual Platform Technology

An accurate and affordable CD4+ T cells count is an essential tool in the fight against HIV/AIDS. Flow cytometry (FCM) is the "gold standard" for counting such cells, but this technique is expensive and requires sophisticated equipment, temperature-sensitive monoclonal antibodies (mAbs) and trained personnel. The lack of access to technical support and quality assurance programs thus limits the use of FCM in resource-constrained countries. We have tested the accuracy, the precision and the carry-over contamination of Partec CyFlow MiniPOC, a portable and economically affordable flow cytometer designed for CD4+ count and percentage, used along with the "CD4% Count Kit-Dry"

Th1 and Th17 pro-inflammatory profile characterizes iNKT cells in virologically suppressed HIV+ patients with low CD4/CD8 ratio

INTRODUCTION:: Scanty data exist on the phenotype and functionality of invariant natural killer T (iNKT) cells in HIV+ patients (pts). METHODS:: By flow cytometry, we studied iNKT cells from 54 HIV+ pts who started combined antiretroviral therapy (cART) and had undetectable viral load for >1 year. Twenty-five maintained a CD4/CD8 ratio <0.4, while 29 reached a ratio >1.1; 32 age- and sex-matched subjects were healthy controls (CTR). RESULTS:: Pts with low ratio had lower percentage of CD4+ iNKT cells compared to pts with high ratio, and higher CD8+ iNKT cell percentage; double negative (DN) iNKT cells were lower in HIV+ pts compared to CTR. Pts with low ratio had higher percentage of CD4+ and DN iNKT cells expressing CD38 and HLA-DR compared to pts with high ratio. CD4+ iNKT cells expressing PD-1 were higher in pts with CD4/CD8 ratio <0.4, while DN iNKT cells expressing PD-1 were lower compared to pts with ratio >1.1. Pts with low ratio had higher CD4+ iNKT cells producing IL-17, CD8+ iNKT cells producing IFN-γ, TNF-α or IFN-γ plus TNF-α, and DN iNKT cells producing IL-17 or IL-17 plus IFN-γ compared to CTR. Activated CD4+ (or CD8+) T cells correlated with activated CD4+ (or CD8+) iNKT cells, as well as the percentages of CD4+ (or CD8+) T cells expressing PD-1 was correlated to that of CD4+ (or CD8+) iNKT cells expressing PD-1. CONCLUSIONS:: Low CD4/CD8 ratio despite effective cART is associated with altered iNKT cell subsets, enhanced activation and prominent Th1/Th17 pro-inflammatory profile

Analysis of inflammasomes and antiviral sensing components reveals decreased expression of NLRX1 in HIV-positive patients assuming efficient antiretroviral therapy

Objective: Few studies have investigated the importance of different components of the inflammasome system and of innate mitochondrial sensing (IMS) pathways in HIV infection and its treatment. We analysed the expression of several components of the inflammasome and of the IMS in HIV-positive patients taking successful combination antiretroviral therapy (cART). Methods: We enrolled 20 HIV-positive patients under cART, who achieved viral suppression since at least 10 months and 20 age and sex-matched healthy donors. By RT-PCR, using peripheral blood mononuclear cells (PBMCs), we quantified the mRNA expression of 16 genes involved in inflammasome activation and regulation (AIM2, NAIP, PYCARD, CASP1, CASP5, NLRP6, NLRP1, NLRP3, TXNIP, BCL2, NLRC4, PANX1, P2RX7, IL-18, IL-1\u3b2, SUGT1) and eight genes involved in IMS (MFN2, MFN1, cGAS, RIG-I, MAVS, NLRX1, RAB32, STING). Results: Compared with controls, HIV-positive patients showed significantly lower mRNA levels of the mitochondrial protein NLRX1, which plays a key role in regulating apoptotic cell death; main PBMC subpopulations behave in a similar manner. No differences were observed in the expression of inflammasome components, which however showed complex correlations. Conclusion: The decreased level of NLRX1 in HIV infection could suggest that the virus is able to downregulate mechanisms linked to triggering of cell death in several immune cell types. The fact that HIV-positive patients did not show altered expression of inflammasome components, nor of most genes involved in IMS, suggests that the infection and/or the chronic immune activation does not influence the transcriptional machinery of innate mechanisms able to trigger inflammation at different levels

Virological response and resistance profile in highly treatment-experienced HIV-1-infected patients switching to dolutegravir plus boosted darunavir in clinical practice

Objectives: We evaluated the virological response and resistance profile in combined antiretroviral therapy (cART)-experienced HIV-1-infected patients starting a dual therapy with dolutegravir (DTG) and boosted darunavir (bDRV) for the first time. Methods: Survival analyses were used to evaluate virological success (VS) and virological rebound (VR) in viraemic and virologically suppressed patients, respectively. Major resistance mutations (MRMs) and genotypic susceptibility score (GSS) were evaluated at baseline and after switch. Results: Overall, 130 patients [62 (47.7%) viraemic; 68 (52.3%) virologically suppressed] were retrospectively analysed. At the moment of switch, 81.5% accumulated one or more MRM [protease inhibitor (PI), 35.7%; nucleoside(t)ide reverse transcriptase inhibitor (NRTI), 77.5%; non-NRTI, 69.0%; integrase inhibitor (INI), 10.1%), but 77.7% harboured strains fully susceptible to DTG + bDRV. In viraemic patients, the overall probability of VS by 12 months of treatment was 91.7%. In virologically suppressed patients, the overall probability of VR was 10.5% by 24 months after therapy start. Patients with previous time under virological suppression ≤ 6 months showed a higher VR probability compared with others (37.5% vs. 6.7%, P < 0.002). Among 13 non-responding patients for whom a genotypic resistance test result at failure was available, only two (15.4%) accumulated further resistance in integrase (Y143C/H/R; S147G and N155H) and protease (V32I, L33F, I54L). Conclusions: In highly treatment-experienced patients, the use of dual therapy based on DTG + bDRV appears to be a very good regimen for switch therapy, with a high rate of virological control in both viraemic and virologically suppressed patients. Among non-responding patients, the selection of further resistance is a rare event

Survival outcomes and effect of early vs. deferred cART among HIV-infected patients diagnosed at the time of an AIDS-defining event: a cohort analysis.

Objectives: We analyzed clinical progression among persons diagnosed with HIV at the time of an AIDS-defining event, and assessed the impact on outcome of timing of combined antiretroviral treatment (cART). Methods: Retrospective, European and Canadian multicohort study.. Patients were diagnosed with HIV from 1997-2004 and had clinical AIDS from 30 days before to 14 days after diagnosis. Clinical progression (new AIDS event, death) was described using Kaplan-Meier analysis stratifying by type of AIDS event. Factors associated with progression were identified with multivariable Cox regression. Progression rates were compared between those starting early (< 30 days after AIDS event) or deferred (30-270 days after AIDS event) cART. Results: The median (interquartile range) CD4 count and viral load (VL) at diagnosis of the 584 patients were 42 (16, 119) cells/ mL and 5.2 (4.5, 5.7) log 10 copies/mL. Clinical progression was observed in 165 (28.3%) patients. Older age, a higher VL at diagnosis, and a diagnosis of non-Hodgkin lymphoma (NHL) (vs. other AIDS events) were independently associated with disease progression. Of 366 patients with an opportunistic infection, 178 (48.6%) received early cART. There was no significant difference in clinical progression between those initiating cART early and those deferring treatment (adjusted hazard ratio 1.32 [95% confidence interval 0.87, 2.00], p=0.20). Conclusions: Older patients and patients with high VL or NHL at diagnosis had a worse outcome. Our data suggest that earlier initiation of cART may be beneficial among HIV-infected patients diagnosed with clinical AIDS in our setting

Differential course of HIV-1 infection and apolipoprotein E polymorphism

Abstract We studied the course of infection with human immunodeficiency virus type 1 (HIV-1) in relation to apolipoprotein E (APOE) polymorphism found for 209 Italians treated at Infectious Disease Clinics in Rome and Modena. Clinically, patients were classified into four groups according to the yearly rate of decline in CD4+ cell count (LTNP: long-term non-progression; SLOW, 'NORMAL' or RAPID). Patients at both extremes of the clinical spectrum, i.e. those who rapidly progressed to AIDS and those with stable high CD4 cell counts, had few APOE ɛ4 and ɛ2 alleles (P = 0.04). Detailed clinical information was then used to construct four model-based clinical profiles using grade-of-membership analysis (GoM), predictive of APOE genotypic frequencies: 1. The clinical profile associated with good long-term prognosis lacked ɛ2 (P=0.01); 2. Disease progression to AIDS was associated with ɛ4 and ɛ2, most evident for zidovudine-lamivudine regimens without a protease inhibitor (P = 0.03); and, 3. AIDS patients had low ɛ4 and ɛ2 frequencies, consistent with a high mortality rate among ɛ4+ and ɛ2+ AIDS patients. These findings suggest allele-specific immunomodulatory effects involving inherited APOE isoform important enough to alter the clinical course of HIV infection and, possibly, drug efficacy. They imply a connection between lipid metabolism and immunity potentially relevant to common disorders

Evaluation of HIV-1 integrase resistance emergence and evolution in patients treated with integrase inhibitors.

Abstract Objectives We evaluated the emergence of mutations associated to integrase strand transfer inhibitors (INSTI) resistance (INSTI-RMs) and the integrase evolution in HIV-1 infected patients treated with this drug class. Methods Emergence of INSTI-RMs and integrase evolution (estimated as genetic distance between integrase sequences under-INSTI and before-INSTI treatment) were evaluated in 107 INSTI-naive patients (19 drug-naive and 88 drug-experienced) with two plasma genotypic resistance tests available: one before and one under INSTI treatment. A logistic regression analysis was performed to evaluate factors associated with the integrase evolution under INSTI treatment. Results Patients were mainly infected by B subtype (72.0%). 87 patients were treated with raltegravir, 13 with dolutegravir and 7 with elvitegravir. Before INSTI treatment, one patient harboured the major INSTI-RM R263 K, and three patients the accessory INSTI-RMs T97A. Under INSTI treatment, the emergence of ≥1 INSTI-RM was found in 39 (36.4%) patients. The major INSTI-RMs which emerged more frequently were: N155H (17.8%), G140S (8.4%), Y143R (7.5%), Q148H (6.5%), Y143C (4.7%). Concerning integrase evolution, a higher genetic distance was found in patients with ≥1 INSTI-RM compared to those without emergence of resistance (0.024 [0.012-0.036] vs. 0.015 [0.009-0.024], p = 0.018). This higher integrase evolution was significantly associated with a longer duration of HIV-1 infection, a higher number of past regimens and non-B subtypes. Conclusions Our findings confirmed that in INSTI-naive patients, major INSTI-RMs occur very rarely. Under INSTI treatment, selection of drug-resistance follows the typical drug-resistance pathways; a higher evolution characterizes integrase sequences developing drug-resistance compared to those without any resistance