One quarter of HIV-1 positive individuals in Sweden present for care with HIV or AIDS associated conditions without an HIV test (missed presentations) and 16% report neglect of such symptoms. The ...objective of this study was to identify risk factors for these missed opportunities of HIV-1 diagnosis.
A national study, recruiting 409 newly diagnosed HIV-1 infected adults over a 2.5-year period, was performed. Logistic regression models tested the relationship between missed presentation and patient's neglect versus socio-demographic and behavioural risk factors. Additionally the initiator of the HIV test was assessed.
The odds for a missed presentation was lower for migrants (from East Europe, Asia, and Pacific (East): OR 0.4 (0.2-0.8); Sub-Saharan Africa (SSA): 0.3 (0.2-0.6); other: 0.5 (0.2-1.0)), compared to patients born in Sweden, just as symptoms neglected by the patient (East (0.3 (0.1-1.0); SSA (0.4 (0.2-0.8)). The latter was also lower for men who have sex with men (0.5 (0.2-1.0)), compared to patients infected heterosexually. Patients infected in the East, with present/previous substance use or a previous negative HIV test were more likely to take the initiative to test on their own, whereas those >50 years and with a previously missed presentation had significantly reduced odds, p<0.05.
Individuals without epidemiological indicators of HIV are more likely to have a history of missed presentations, to neglect symptoms and are less prone to take an initiative to test for HIV themselves. It is important to further implement testing to include all patients with symptoms and conditions indicative of HIV.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
A variant of Chlamydia trachomatis that had escaped detection by commonly used systems was discovered in Sweden in 2006. In a nationwide study, we found that it is now prevalent across Sweden, ...irrespective of the detection system used. Genetic analysis by multilocus sequence typing identified a predominant variant, suggesting recent emergence.
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DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The level of evidence for HIV transmission risk through condomless sex in serodifferent gay couples with the HIV-positive partner taking virally suppressive antiretroviral therapy (ART) is limited ...compared with the evidence available for transmission risk in heterosexual couples. The aim of the second phase of the PARTNER study (PARTNER2) was to provide precise estimates of transmission risk in gay serodifferent partnerships.
The PARTNER study was a prospective observational study done at 75 sites in 14 European countries. The first phase of the study (PARTNER1; Sept 15, 2010, to May 31, 2014) recruited and followed up both heterosexual and gay serodifferent couples (HIV-positive partner taking suppressive ART) who reported condomless sex, whereas the PARTNER2 extension (to April 30, 2018) recruited and followed up gay couples only. At study visits, data collection included sexual behaviour questionnaires, HIV testing (HIV-negative partner), and HIV-1 viral load testing (HIV-positive partner). If a seroconversion occurred in the HIV-negative partner, anonymised phylogenetic analysis was done to compare HIV-1 pol and env sequences in both partners to identify linked transmissions. Couple-years of follow-up were eligible for inclusion if condomless sex was reported, use of pre-exposure prophylaxis or post-exposure prophylaxis was not reported by the HIV-negative partner, and the HIV-positive partner was virally suppressed (plasma HIV-1 RNA <200 copies per mL) at the most recent visit (within the past year). Incidence rate of HIV transmission was calculated as the number of phylogenetically linked HIV infections that occurred during eligible couple-years of follow-up divided by eligible couple-years of follow-up. Two-sided 95% CIs for the incidence rate of transmission were calculated using exact Poisson methods.
Between Sept 15, 2010, and July 31, 2017, 972 gay couples were enrolled, of which 782 provided 1593 eligible couple-years of follow-up with a median follow-up of 2·0 years (IQR 1·1–3·5). At baseline, median age for HIV-positive partners was 40 years (IQR 33–46) and couples reported condomless sex for a median of 1·0 years (IQR 0·4–2·9). During eligible couple-years of follow-up, couples reported condomless anal sex a total of 76 088 times. 288 (37%) of 777 HIV-negative men reported condomless sex with other partners. 15 new HIV infections occurred during eligible couple-years of follow-up, but none were phylogenetically linked within-couple transmissions, resulting in an HIV transmission rate of zero (upper 95% CI 0·23 per 100 couple-years of follow-up).
Our results provide a similar level of evidence on viral suppression and HIV transmission risk for gay men to that previously generated for heterosexual couples and suggest that the risk of HIV transmission in gay couples through condomless sex when HIV viral load is suppressed is effectively zero. Our findings support the message of the U=U (undetectable equals untransmittable) campaign, and the benefits of early testing and treatment for HIV.
National Institute for Health Research.
The risk of clinical progression for human immunodeficiency virus (HIV)–infected persons receiving treatment with highly active antiretroviral therapy (HAART) is poorly defined. From an inception ...cohort of 8457 HIV-infected persons, 2027 patients who started HAART during prospective follow-up were examined. Results were validated in another 2 groups of patients (n=1946 and n=1442). In total, 200 patients (9.9%) experienced clinical progression during 5177 person-years (incidence, 3.9/100 years). The most recently measured CD4 cell count, virus load, and hemoglobin level all were independently related to the risk of clinical progression, as was a diagnosis of severe AIDS before the start of HAART. On the basis of these findings, a scoring system was derived (range, 0–17). A single unit increase in the score was associated with a 38% increased risk of clinical progression (relative hazard, 1.38; 95% confidence interval, 1.33–1.43; P<.0001). The scoring system was validated with remarkably good agreement in the 2 other cohorts. This system can be used in patient and resource management
Many HIV-1-infected patients on suppressive antiretroviral therapy (ART) have transiently elevated HIV RNA levels. The clinical significance of these viral blips is uncertain. We have determined the ...incidence of blips and investigated important associations in the Swedish HIV-cohort.
HIV-1-infected ART naïve adults who commenced ART 2007-2013 were retrospectively included. Viral blips were defined as a transient viral load between 50 and 500 copies/mL Subjects not suppressed after six months on ART were excluded.
Viral blips were found in 76/735 included subjects (10.3 %) and in 90/4449 samples (2.0 %). Median blip viral load was 76 copies/mL (range 56-138). Median follow-up time was 170 weeks (range 97-240). Baseline viral load was higher in subjects with viral blips (median log10 4.85 copies/mL) compared with subjects without blips (median log10 4.55 copies/mL) (p < 0.01). There was a significant association between viral blips and risk for subsequent virological failure (p < 0.001).
The Swedish national HIV-cohort has a low incidence of viral blips (10 %). Blips were associated with high baseline viral load and an increased risk of subsequent virological failure.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background. Low 25-hydroxyvitamin D (25(OH)D) has been associated with inflammation, human immunodeficiency virus (HIV) disease progression, and death. We aimed to identify the prognostic value of ...25(OH) D for AIDS, non-AIDS-defining events and death, and its association with immunological/inflammatory markers. Methods. Prospective 1-1 case-control study nested within the EuroSIDA cohort. Matched cases and controls for AIDS (n = 50 matched pairs), non-AIDS-defining (n = 63) events and death (n = 41), with plasma samples during follow-up were selected. Conditional logistic regression models investigated associations between 25(OH)D levels and annual 25(OH)D change and the probability of events. Mixed models investigated relationships between 25(OH) D levels and immunological/inflammatory markers. Results. In sum, 250 patients were included. Median time between first and last sample and last sample and event was 44.6(interquartile range IQR: 22.7-72.3) and 3.1(IQR: 1.4-6.4) months. Odds of death decreased by 46.0%(95% confidence interval CI, 2.0-70.0, P= .04) for a 2-fold increase in latest 25(OH) D level. There was no association between 25(OH) D and the occurrence of AIDS or non-AIDS-defining events (P >.05). In patients with current 25(OH) D < 10 ng/mL, hsIL-6 concentration increased by 4.7%(95% CI, .2,9.4, P =.04) annually after adjustment for immunological/inflammatory markers, and no change in hsCRP rate was observed (P =.76). Conclusions. Low Vitamin D predicts short term mortality in HIV-positive persons. Effectiveness of vitamin D supplementation on inflammation and patient outcomes should be investigated.
People living with HIV have an increased risk of comorbidities with non-communicable diseases such as cardiovascular disease, chronic kidney disease and osteoporotic fractures, compared to the ...general population. The burden of these comorbidities is expected to rise as the HIV-infected population ages. This development may require additional health care resources and it is relevant to ascertain the costs associated with these comorbidities. The population attributed risk approach was applied to estimate excess costs associated with the higher rates of comorbidities among HIV patients in Denmark and Sweden compared to their respective general populations. Excess direct and indirect costs for one year were calculated for myocardial infarction, stroke, osteoporotic fractures and chronic kidney disease. Cost estimates were presented in age and sex subgroups. In the course of one year the excess costs for myocardial infarction, stroke, osteoporotic fractures and chronic kidney disease attributable to HIV was estimated to €3.4 million for Denmark and €2.6 million for Sweden. Chronic kidney disease accounted for the majority of the total excess costs, followed by osteoporotic fractures, myocardial infarction and stroke. The high prevalence of comorbidities in the HIV-infected population is associated with substantial excess costs. Focus on primary and secondary prophylactic interventions is warranted. Additional studies, preferably large-scale case-control studies, may give further insights on the extent and the predictors of these excess costs.
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DOBA, IJS, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
The Swedish Medical Products Agency and the Swedish Reference Group for Antiviral Therapy (RAV) have jointly published recommendations for the treatment of HIV infection on seven previous occasions ...(2002, 2003, 2005, 2007, 2009, 2011 and 2014). In February 2016, an expert group under the guidance of RAV once more revised the guidelines. The most important updates in the present guidelines are as follows:
Tenofovir alafenamide (TAF) has recently been registered. TAF has several advantages over tenofovir disoproxilfumarate (TDF) and is recommended instead of TDF in most cases.
First-line treatment for previously untreated individuals includes dolutegravir, boosted darunavir or efavirenz with either abacavir/lamivudine or tenofovir (TDF/TAF)/emtricitabine.
Pre-exposure prophylaxis (PrEP) is recommended for high-risk individuals.
As in the case of the previous publication, recommendations are evidence-graded in accordance with the Oxford Centre for Evidence Based Medicine (
http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/
) (
Table 1
). This document does not cover treatment of opportunistic infections and tumours.
Table 1.
Levels of evidence and recommendation (
http://www.Cebm.Net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/
).
Quality grading of evidence base
1a Systematic review (with homogeneity) of randomized controlled trials
1b Individual randomized controlled trials with narrow confidence intervals
1c 'All or none' all patients died before the treatment became available, but some now survive on it; or when some patients died before the treatment became available, but none now die on it.
2a Systematic review (with homogeneity) of cohort studies
2b Individual cohort study (including low quality RCT; e.g., <80% follow-up)
2c 'Outcomes' Research; Ecological studies
3a Systematic review (with homogeneity) of case-control studies
3b Individual case-control study
4 Case series (and poor quality cohort and case-control studies)
5 Expert opinion without explicit critical appraisal, or based on physiology, bench research or 'first principles'
Grading of recommendations
A. Based on evidence level 1a, b or c.
B. Based on evidence level 2a, b or c, 3a or b.
C. Based on evidence level 4 D Based on evidence level 5.
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DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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