Suchergebnisse

Purpose of the studyAntiretroviral therapy reduces mortality and morbidity in HIV‐infected individuals, most markedly when initiated early, before advanced immunodeficiency has developed. All international guidelines (IAS 2010, EACS 2011, DHHS 2012) tend to recommend starting ART in patients with high CD4 cell count. Some challenges need to be met before reaching this goal, particularly HIV‐infected patients with late presentation‐diagnosis. The objective of this study was to determine the frequency of and demographic features associated with delayed presentation to care in our centre.MethodsAll patients, newly diagnosed with HIV between January 2007 and December 2011 and on follow‐up in our AIDS Reference Centre, were included. 'Late presenter patient' was defined as patient with CD4 count<350/mm3 at the time of diagnosis. Demographic (age, sex, ethnicity, migration) and clinical characteristics (transmission, CD4 cell count, viral load, CDC stage) were collected. We then compared these features with those identified in our centre between 1997‐2006.Summary of resultsOf the 601 patients diagnosed between 1997–2006, 57.1% were late presenters for HIV diagnosis. Among the 359 patients included between 2007–2011, 42.9% patients were late presenters. Demographic characteristic are summarized in Table 1. In the univariate analysis, patient age >50 years, female sex, immigrant status and heterosexual contact were associated with late presentation for HIV diagnosis. In the multivariate analysis, patients aged >50 and migrant women were the only independent risk factors for late presentation. Except gender, other risk factors remain identical to those that were identified in our centre between 1997–2006 [1].

Characteristics of patients with late presentation (CD4 < 350/mm3) for HIV diagnosis between 2007–2011










Total
n total 359
n (%) 154 (42.9)
p value
OR (95% CI)
Adjusted OR (95% CI)




Age, years


< 30
64
21 (32.8)

1.00
1.00


30–39
135
52 (38.5)

1.28 (0.68–2.40)
1.27 (0.66–2.44)


40–49
95
41 (43.1)

1.55 (0.80–3.01)
1.66 (0.83–3.32)


> 50
65
40 (61.5)
< 0,001
3.27 (1.59–6.74)
2.84 (1.25–6.41)


Sex


Female
103
54 (52.4)

1.00
1.00


Male
256
100 (39)
0,021
0.58 (0.36–0.92)
0.92 (0.48–1.75)


Origine


non‐migrant
141
45 (31.9)

1.00
1.00


Migrant
218
109 (50)
< 0,001
2.13 (1.37–3.32)
1.70 (1.02–2.83)


HIV transmission


MSM
164
49 (29.8)

1.00
1.00


Heterosexual
191
102 (53.4)
< 0,001
2.68 (1.73–4.17)
1.84 (0.99–3.41)




ConclusionA considerable proportion of patients continue to be diagnosed with advanced HIV disease, despite the fact that risk factors for late presentation have been identified clearly. In order to be able to treat all patient at high CD4 cell counts as recommended in all guidelines, we need to develop policies focused directly to categories of people at high risk of late presentation.Conflict of interestNone. All co‐authors have participated in, and agree with the content and conclusions. This work is original and does not infringe any copyright.AcknowledgementA. Sasse, Institut de Santé Publique, Belgium

Purpose of the studyCo‐infection with HIV / hepatitis C virus (HCV) occurs commonly due to similar routes of transmission, mainly in MSM and IVDU patients. In 2009, EACS guidelines introduced the notion of systematic annual HCV screening among HIV‐infected patients. This study evaluated staff knowledge, adherence to HCV screening recommendations and seroconversion rates for HCV in our HIV Reference Centre.MethodsEight physicians (HIV specialists) were interviewed on recommendations and perceived adherence to EACS clinical guidelines on HCV screening [1]. We then reviewed medical records of our cohort of HIV‐infected patients on regular follow‐up in our centre each year, from 2008 to 2011. We considered a patient to be on regular follow‐up when records showed at least two clinical reviews and one HIV viral load testing during the year. Demographic features and HCV serology tests were collected from the operating software of our institution (Medical Explorer v3r9, 2008). Diagnosis of HCV was retained when serology became positive and HCV RNA was detected.










Year
Patients on regular f/un
MSM‐Bisexual patients on regular f/un (%)
HCV serology tests n (%)
HCV tests among MSM‐Bisexual patients n (%)




2008
818
258 (31)
292 (35)
118 (45)


2009
869
290 (33)
314 (28)
132 (45)


2010
938
308 (33)
389 (41)
198 (56)


2011
963
335 (35)
425 (44)
193 (57)




Summary of resultsThough knowledge of current guidelines was excellent (100%), staff claimed a 87.5% adherence rate to these recommendations. Rate of screening rose gradually between 2008 and 2011, especially after introduction of EACS guidelines in 2009 (Table 1 and Fig. 1). The maximal screening rate was in 2011, with 44% of patients tested among the general HIV population and 57% among MSM bisexual patients. This trend was statistically significant in both populations (p<0.01). The year 2011 displayed a marked increase in diagnosis of HCV infection, with 8 new patients diagnosed in a 963‐patient‐large cohort (all were MSM).ConclusionIn our centre, knowledge of EACS guidelines on screening for HCV was good but adherence to these recommendations is poor, though it improves over time. It is consistent with published rates of compliance to clinical guidelines on screening policies for HCV among STD/HIV specialists (47–54%) [2]. However, it remains low compared to expected rates of 70–100%. Education of clinicians is warranted to increase awareness and further improve adherence to guidelines. Peer review and computer‐based algorithms / reminders could be used in order to increase systematic screening.Evolution of HCV Screening & Acute HCV Hepatitis Diagnosis (2008–2011).image

Purpose of the studyObservational studies have noted very high rates of low serum 25‐hydroxyvitamin D [25(OH)D3] levels in both general and HIV‐infected populations. In HIV‐infected patients, low 25(OH)D3 levels are secondary to a combination of usual risk factors and HIV‐specific risk factors, like antiretroviral therapy [1]. The objective of our study is to analyse the magnitude of vitamin D deficiency or insufficiency and the role of various factors such as age, sex, ethnicity, season, and antiretroviral medications in our cohort of HIV‐infected patients.MethodsWe prospectively collected data on 25‐hydroxyvitamin D levels sampled between January 2009 and June 2011 from our cohort of 930 HIV‐infected patients. Vitamin D dosage was performed using immunoassay ('Diasorin' ‐ Saluggia, Italy). We divided vitamin D levels into 3 categories: 25‐hydroxyvitamin D levels <20 mg/nl were considered deficient, insufficient between 20 and 29 ng/ml. Levels ≥30 ng/ml were defined as normal [2]. Data on demographic features (age, ethnicity, season, heterosexuality vs homosexuality), clinical features and laboratory findings (CD4 cell count, viral load, HAART, BMI) were collected from patients' medical records using our institutional database 'Medical explorer v3r9, 2009'.Summary of resultsOverall, 848 patients were included in our study (Table 1).










VitD<20 ng/mL N=590
VitD 20–29 ng/mL N=168
VitD d30 ng/mL N=90≥




Sex (male/female)
340/250 (58/42)*†
109/59 (65/35)*
73/17 (81/19)


BMI (kg/m2)
25.7±5.1*†
24.7±4.1
23.8±3.7


Homo‐ (and bi‐) sexuality vs heterosexuality
169/421 (29/71)*†
68/100 (40/60)*
48/42 (53/47)


Ethnicity (Black/Others)
289/301 (49/51)*†
58/110 (35/65)
21/69 (23/77)


Month of dosage


Dec, Jan, Feb
197 (33)*†
25 (15)
18 (20)


Mar, Apr, May
223 (38)
67 (40)
33 (37)


Jun, Jul, Aug
102 (17)*
60 (36)
29 (32)


Sep, Oct, Nov
68 (10)
16 (10)
10 (11)


HIV viral load


Undetectable
162/428 (27/73)*
56/112 (33/67)*
45/45 (50/50)


Detectable
52 112±160 671
337 871±2 294 712
94 547±234 335


Treatment


EFV
85 (14)*
23 (14)
5 (6)


TDF (alone or in combination)
300/290 (51/49)*
80/88 (48/52)
35/55 (39/61)


HAART (naïve/treated)
116/469 (20/80)*
41/124 (24/74)*
38/52 (42/58)




Low levels of serum 25(OH)D3 were seen in 89.3% of the study population, from which 69.5% were deficient and 19.8% were insufficient. On univariate analysis, female sex, high BMI, black African, heterosexuality, undetectable viral load and antiretroviral treatment were all predictors of vitamin D deficiency and insufficiency. Treatment with efavirenz and tenofovir were the most associated with low vitamin D levels. On multivariate analysis (multiple linear regression model) only female sex (OR=1.14; 95% CI 0.84–0.96; p<0.001), dosage during winter months (OR=1.14; 95% CI 1–1.15; p<0.05) and HAART (OR=1.12; 95% CI 1.04–1.19; p=0.002) were identified as independent risk factors of low 25(OH)D3 levels.ConclusionVitamin D deficiency is frequent in HIV‐infected populations (69.5%). Patients on antiretroviral therapy are at higher risk of vitamin D deficiency. In our cohort, black women and dosage during winter were also independent risk factors for low vitamin D levels.

Purpose of the studyIntroduction of highly active antiretroviral therapy (HAART) has led to an improvement of life expectancy and quality of life in patients living with HIV. Concomitantly, concerns are arising about long‐term side effects of chronic use of antiretroviral therapy. Avascular necrosis of the femoral head (ANFH) and other epiphyses is increasingly reported as one of these debilitating complications. The objective of this study is to analyse clinical characteristics and outcome of patients with avascular necrosis (AN) followed in our centre.Patients and methodsWe analysed retrospectively the charts of 1020 HIV‐1 infected patients followed in our centre and focused on symptomatic patients with radiologicaly proven AN. We analysed risk factors, demographic and clinical characteristics, treatment and outcome in these patients.Summary of resultsTen patients with AN were identified (prevalence of 0.98%). The average interval between HIV diagnosis and diagnosis of AN was 89.1 months (1–254). Four patients had no evidence of risk factors (40%) whereas 6 (60%) had at least one risk factor. One patient had three cumulated risk factors and for him the onset time for AN was shorter (36 months). All patients had been treated by antiretroviral therapy when AN was diagnosed, but one of the patients developed symptoms prior to start of antiretroviral treatment. All classes of antiretroviral drugs have been used: protease inhibitors (mean use duration of 34.7 months before the ONFH onset), non‐nucleoside reverse transcriptase inhibitors (12 months), and nucleoside reverse transcriptase inhibitors (40.5 months). ANFH was unilateral in 4 patients and bilateral in 6 patients. In one of these 6 cases, multiple AN locations were present (table). In eight patients, total hip arthroplasty (THA) (88.8%) was the definitive treatment. Diagnosis of ANFH in the two patients who were not operated is very recent (5 and 13 months) but surgery is already indicated. The average interval between ANFH diagnosis and the first THA was 10.5 months.







Median age
Years (min–max)




Age
46.2 (24–84)


Age at AN diagnosis
40.8 (22–69)


Men
6 (60%)


Caucasian
7 (70%)


Median CD4 count (/µl)
CD4/µl (range)


Nadir
65 (4–242)


At diagnosis of AN
405 (13–957)


Viral load at AN diagnosis
N (%)


Undetectable
5 (50%)


Detectable
5 (50%)


Lipid Profile
mg/dl (range)


TC
234 (145–335)


LDL
134 (65–230)


TG
214 (78–512)


Haemoglobin electrophoresis:
N (%)


Normal
8 (80%)


Abnormal (heterozygote)
1 (10%)


Risk factors:
N (%)


Cortisone
1 (10%)


Alcohol
4 (40%)


Chemotherapy
2 (20%)


Smoking
1 (10%)


Radiotherapy
1 (10%)


Average duration of HAART use
Month (range)


PI
34.2


NNRTI
12


NRTI
40.5


Average time between HIV diagnosis and AN (months)
89.1 (1–254)


Average time between onset of symptoms and first arthroplasty (months)
10.5 (2–20)




ConclusionAN, and particularly ANFH, is a rare but debilitating complication in HIV‐1 infected patients. The role of ARV in the pathogenesis of AN remains unclear. However, classical risk factors play an essential role and accumulation of several risk factors could shorten the time before onset of AN. In the presence of advanced disease (stage III–IV) the final treatment remains arthroplasty.