Hepatitis C diagnosis and treatment in people who use drugs: mind the gap in the linkage to care.

OBJECTIVE: The objective of this study is to identify a simplified rapid screening and linkage-to-care model for HCV among PWUD. PATIENTS AND METHODS: The study stems from a collaborative project bringing together two local Italian Centers for Drug Addiction and the Hepatology-Infectious Diseases Department of Lazzaro Spallanzani. A research physician analyzed the available medical records seeking to identify HCV and HIV infected patients in care in the addiction centers. Between March 2018 and January 2020 subjects were selected from among a cohort of 720 PWUD in the two Centers' care. The study comprises three steps: first, screening for HCVAb; second, the linkage to care; third, clinical assessment to treatment. The research physician recruited patients for the first two steps directly in their local addiction center. The third step was conducted in the Spallanzani. The characteristics of those subjects who adhered to the three-step study program were then compared to those of the non-adhering PWUD. RESULTS: 194 were known HCVAb positive patients. Of the 505 PWUD in the care of the two Centers eligible for screening, 364 were enrolled in the study. 144 resulted HCVAb positive. 269 were tested for HCVRNA. 101 underwent a full assessment. 96 patients started antiviral therapy with DAA. Patients who refused first step screening were older patients and mainly heroin users; in the second step, almost all the HIV/HCV co-infected patients agreed to a viremia test; in the third step all the HIV/HCV co-infected patients refused HCV treatment. CONCLUSIONS: The study suggests an on-site specialist approach conducted directly in the addiction centers themselves starting from screening; it can bring the goal of HCV PWUD microelimination closer.

Intrahepatic Vγ9Vδ2 T-cells from HCV-infected patients show an exhausted phenotype but can inhibit HCV replication.

Hepatitis C virus (HCV) persistence results from inefficiencies of both innate and adaptive immune responses to eradicate the infection. A functional impairment of circulating Vγ9Vδ2 T-cells was described but few data are available on Vγ9Vδ2 T-cells in the liver that, however, represents the battlefield in the HCV/host interaction. Aim of this work was to compare circulating and intrahepatic Vγ9Vδ2 T-cells in chronic HCV-infected patients (HCVpos) and in HCV-negative (HCVneg) subjects. Phenotypic and functional analysis was performed by flow cytometry. Anti-HCV activity was analyzed by using an in vitro autologous liver culture system. Independently from HCV infection, the liver was enriched of Vγ9Vδ2 T-cells expressing an effector/activated phenotype. In contrast, an enrichment of PD-1 expressing Vγ9Vδ2 T-cells was observed both in the peripheral blood and in the liver of HCVpos patients, probably due to a persistent antigenic stimulation. Moreover, a lower frequency of IFN-γ producing Vγ9Vδ2 T-cells was observed in the liver of HCVpos patients, suggesting a functional impairment in the cytokine production in HCVpos liver. Despite this hypo-responsiveness, intrahepatic Vγ9Vδ2 T-cells are able to exert an anti-HCV activity after specific stimulation. Altogether, our data show that HCV infection induced a dysregulation of intrahepatic Vγ9Vδ2 T cells that maintain their anti-HCV activity after specific stimulation. A study aimed to evaluate the mechanisms of the antiviral activity may be useful to identify new pathways able to improve Vγ9Vδ2 T-cells intrahepatic function during HCV infection.

Long-term effects of antiretroviral combination therapy on HIV type 1 DNA levels.

HIV-1 RNA and DNA levels were measured in 58 patients, of whom 37 and 11, respectively, received triple or double combination therapy. At baseline, strong correlations were found between the number of HIV-1 DNA copies per 106 CD4+ cells, the plasma HIV-1 RNA levels, and the isolation rate of HIV-1 from blood cells. In comparison with HIV-1 RNA, a much slower decline in HIV-1 DNA levels was seen, which probably represents a long lifetime of provirus-bearing CD4+ cells. In 10 untreated patients, the proviral load was stable. In patients receiving triple therapy, a significant decline in HIV-1 DNA was seen independent of whether the proviral load was expressed as copies per 106 CD4+ cells or as copies per milliliter of blood. In contrast, a decline was seen only when the proviral load was expressed as copies per 10(6) CD4+ cells in patients given two drugs. The difference between the two patient categories is likely to be due to a more frequent infection of CD4+ cells during therapy in the patients with double therapy. Interpretation of changes in HIV-1 DNA levels is thus dependent on how the proviral burden is expressed. Further studies should evaluate whether changes in HIV-1 DNA load can be used as markers of viral replication during efficient antiretroviral combination therapy.

No association of HIV type 1 long terminal repeat sequence pattern with long-term nonprogression and in vivo viral replication levels in European subjects.

The HIV-1 long terminal repeat (LTR) promotes and modulates proviral transcription in the infected cell. It has been suggested that truncations and even point mutations in functional sites of the LTR are associated with low viral replication and attenuated pathogenesis in HIV-1-infected long-term nonprogressors (LTNPs). We performed a detailed analysis of LTR sequences from proviral DNA of 21 Italian and Swedish, well-characterized LTNPs and of 15 progressor patients. No truncation was found and no correlation was identified between specific LTR mutations and disease progression. We also failed to find a significant correlation between phylogenetic distance and clinical status. Although HIV-1 LTR interpatient heterogeneity among LTNPs and subjects with HIV-1 RNA levels <500 copies/ml tended to be lower, no sequence mutation was correlated with in vivo viral loads. Our results suggest that HIV-1 LTR defects are rare among Italian and Swedish LTNPs.

Human immunodeficiency virus type 1 variability and long-term non-progression.

A high heterogeneity is found in the HIV-1 genome in vivo, not only between individuals, but also within a single individual. Different types of genetic heterogeneity of HIV-1 can be analyzed: the extension and the evolution of the viral quasispecies in blood, the variation between the virus obtained from different body compartment, the differences between isolates from diverse individuals and between HIV-1 subtypes. The virus population during primary HIV-1 infection is generally homogeneous and the intrahost viral evolution is thought to be forced (in absence of antiviral therapy) by the immune system pressure and is generally related to the length of the immunocompetent period. A group of 12 Italian and Swedish well characterized HIV-1 infected long-term nonprogressors (LNTP) have been analyzed for the viral heterogeneity, calculated in the nef gene and in the long terminal repeat (LTR). The intra-sample variations in LTNP were found comparable with those from 8 progressor patients, while a lower inter-individual diversity was observed in the former. In one LTNP the viral evolution during a four-years period was extremely low suggesting that other factors than the host immune pressure may be involved in modulating the intra- and inter-sample HIV-1 diversity.

High-level aminoglycoside resistance among enterococci: evaluation of an agar screen susceptibility test.

Seventy-five enterococci from infected (63 isolates) and colonized (12 isolates) patients hospitalized in various divisions of the Policlinico Umberto I, University of Rome, were in vitro studied for high-level resistance (HLR) to gentamicin (HLRG) and streptomycin (HLRS) with adoption of a standard broth dilution and an agar screen test. The employed procedures provided equal results for 100% of the 75 isolates. Of these, 21 (28%) showed HLRG and 43 (57%) HLRS. Combined HLRG and HLRS were found in 18 (24%) isolates, whereas HLRS or HLRG alone were found in 25 (33%) and 3 (4%) isolates respectively. It is concluded that HLR to aminoglycosides may represent a major problem in Italian institutions. Along with other established procedures, the agar screen test employed in the study may be used to detect this antibiotic resistance in enterococci.

Plasmids as epidemiologic markers in nosocomial gram-negative bacilli: experience in an intensive care unit.

The authors have compared the antimicrobial resistance patterns and plasmid profiles of Gram-negative isolates in an intensive care unit over a 7-month period in order to identify epidemiologically related isolates. Bacterial plasmids were found to be valuable markers for the comparison of strains of nosocomial Gram-negative bacilli. Thirty-nine mechanically ventilated patients in an ICU were included. From bronchoaspiratus, the authors isolated 58 strains of Gram-negative bacilli (24 Ps. aeruginosa and 34 Enterobacteria). Common plasmids were found in most Enterobacteria. The interspecies plasmid exchange suggests that interstate spread of these strains may have occurred. Twenty-six Enterobacteria carried plasmids, 11 of which proved transmissible. The R-factors were transferred to other genera that were isolated in the hospital, thereby adding to the pool of multiresistant nosocomial isolates. Larger plasmids transferred ampicillin and carbenicillin resistance, while gentamycin and cephalotin resistance was carried by smaller plasmids. Only 4 Ps. aeruginosa carried plasmids, one of which was transmissible. Pseudomonas plasmid DNA is extracted with difficulty by the simple lysis method, due to the roughness of the colonies. All Pseudomonas isolates belonged to the same biotype which can be regarded as an epidemiological marker. Therefore, plasmid profiling is a useful tool for epidemiological surveillance of Enterobacteria and is a good method for determining the relatedness of isolates in a nosocomial environment.

[Guidelines for the management of HCV infection in HIV-infected patients. Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani]. / Linee-guida per la gestione clinica della infezione/malattia da HCV nei pazienti con infezione da HIV.

It is crucial to ensure an optimal clinical management of HCV infection in HIV-co-infected persons. The reasons for the development of guidelines on HCV-infection treatment in HIV-infected persons arise from the need for a standardised management of HIV/HCV coinfection in our Institute. The aim of these guidelines are: to clarify principles of clinical management of HCV infection in HIV-infected patients to care-providers; to improve the awareness of HIV-infected patients cared for our Institute on current management of HCV infection; to improve the quality of care on this topic. These guidelines, based on Evidence based Medicine principles, have been developed by a panel of experts, who conducted a systematic review of the literature, mainly taking into account current international recommendations. In the present document, the most frequent clinical presentation occurring in the management of HIV/HCV co-infected patients at our Institution are discussed. The adherence to present guidelines and their effectiveness at our Institution, outcome indicators will be evaluated. The present guidelines cannot entirely substitute the judgement of an expert clinician. However, adherence to these guidelines will contribute to the improvement of the standard of care of HIV/HCV-co-infected persons.

Long-term maintenance of sustained virological response in liver transplant recipients treated for recurrent hepatitis C.

BACKGROUND: The recurrence of hepatitis C viral infection is common after liver transplant, and achieving a sustained virological response to antiviral treatment is desirable for reducing the risk of graft loss and improving patients' survival. AIM: To investigate the long-term maintenance of sustained virological response in liver transplant recipients with hepatitis C recurrence. METHODS: 436 Liver transplant recipients (74.1% genotype 1) who underwent combined antiviral therapy for hepatitis C recurrence were retrospectively evaluated. RESULTS: The overall sustained virological response rate was 40% (173/436 patients), and the mean follow-up after liver transplantation was 11±3.5 years (range, 5-24). Patients with a sustained virological response demonstrated a 5-year survival rate of 97% and a 10-year survival rate of 93%; all but 6 (3%) patients remained hepatitis C virus RNA-negative during follow-up. Genotype non-1 (p=0.007), treatment duration >80% of the scheduled period (p=0.027), and early virological response (p=0.002), were associated with the maintenance of sustained virological response as indicated by univariate analysis. Early virological response was the only independent predictor of sustained virological response maintenance (p=0.008). CONCLUSIONS: Sustained virological response achieved after combined antiviral treatment is maintained in liver transplant patients with recurrent hepatitis C and is associated with an excellent 5-year survival.

Evidence of dual sexual transmission of multi-resistant HIV with two years persistence of resistance to NRTI and NNRTI: a case report.

A case report of dual sexual transmission, with secondary transmission from naïve to naïve patient, of HIV harbouring K103N and L100I mutations, conferring full non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance, plus 2 nucleoside analogous reverse transcriptase inhibitor (NRTI) mutations is described. The secondary transmission of the resistant virus was confirmed by phylogenetic analysis. Data also suggest that mutations related to NRTI and NNRTI resistance may persist for a long time in naive patients, over 2 years in the present case report.

Proviral HIV-1 dynamics and evolution in patients receiving efficient long-term antiretroviral combination therapy.

OBJECTIVES: Different experimental approaches have shown that, despite plasma viral loads under the threshold of detection, HIV-1 frequently continues to replicate in patients receiving potent antiretroviral therapy. However, whether this low-grade viral replication is sufficient for the generation of new major quasispecies has not been studied. Thus, in order to evaluate the extent of variation in the major proviral HIV-1 population, we monitored proviral DNA sequences in such patients over a time period of up to 30 months. METHODS: DNA was extracted from peripheral blood mononuclear cells (PBMC) and the V3 region was amplified by nested polymerase chain reaction (PCR) and directly sequenced. Additionally, both HIV-1 RNA and DNA levels and CD4+ T-lymphocyte counts were monitored. RESULTS: Analysing the V3 gene sequences of 17 patients, we observed a sequence evolution in nine patients. Interestingly, the majority of these changes (77%) occurred in the first interval following the initiation of therapy and despite signs of ongoing replication the proviral DNA levels continued to decrease in all patients. CONCLUSIONS: Our data suggest that, although available data report that HIV-1 continues to replicate in patients with undetectable viraemia, the extent of viral replication in many of these patients is not sufficient to result in changes in the major viral population.

Longitudinal quantification of human immunodeficiency virus type 1 DNA and RNA in long-term nonprogressors.

Twenty patients with human immunodeficiency virus type 1 (HIV-1) infection for >7 years, no HIV-1-related symptoms, no treatment, and CD4+ cell counts >500/microL were included in a prospective study in 1993. Four years later, 12 patients had progressed (SPs), while 8 had not (long-term nonprogressors [LTNPs]). At inclusion, HIV-1 RNA, but not DNA, levels were higher in SPs. During follow-up, a consistent increase in HIV-1 RNA was seen in only 1 LTNP. In 2 LTNPs, plasma viremia was persistently undetectable or <110 copies/mL. Infectious virus was isolated from only 1 LTNP and from 11 SPs. In 4 LTNPs, HIV-1 DNA levels decreased spontaneously with time. The restricted viral replication and the declining HIV-1 DNA levels suggest that the HIV-1 infection can be controlled efficiently in a few LTNPs, leading to a decrease in the total virus burden with time.

Human immunodeficiency virus type 1 disease progression, CCR5 genotype, and specific immune responses.

The correlation among the presence of a 32-bp deletion in the CC-chemokine receptor 5 (CCR5) gene, disease progression, and human immunodeficiency virus type 1 (HIV-1)-specific immune responses was analyzed for a cohort of 79 Caucasian HIV-1-infected patients. The CCR5 genotype (CCR5/CCR5 = wild type/wild type or delta32CCR5/CCR5 = 32-bp deletion/wild type) in peripheral blood mononuclear cells was determined by PCR, followed by sequencing of both wild-type and delta32CCR5 gene fragments. HIV-1-specific humoral responses to gp41 and V3MN peptides were determined by enzyme immunoassays. The prevalence of the delta32CCR5 allele was lower among 37 patients with rapid progression (progression to AIDS or to a CD4 cell count of <200 x 10(6)/liter in less than 9 years; P < 0.01) compared to that for 42 patients with slow progression (no AIDS and CD4 cell count of >200 x 10(6)/liter after at least 9 years from infection) or to that for 25 non-HIV-1-infected Swedish blood donors (P < 0.05). No differences were observed in the wild-type CCR5 sequences between the different groups of patients. For three analyzed patients, the 32-bp delta32CCR5 gene deletions were identical. The antibody titers against gp41 and a V3MN peptide in patients with the delta32CCR5/CCR5 genotype were not significantly different from those in pair-matched CCR5/CCR5 controls. However, in 13 analyzed patients, a stronger serum neutralizing activity was associated with the delta32CCR5/CCR5 genotype. Thus, a CCR5/CCR5 genotype correlates with a shortened AIDS-free HIV-1 infection period and possibly with a worse neutralizing activity, without an evident influence on the antibody response to two major antigenic regions of HIV-1 envelope.

HIV-1 nef mutations and clinical long-term nonprogression. A molecular epidemiology study.

OBJECTIVES: To analyze HIV-1 nef gene mutations in a cohort of Italian and Swedish long-term nonprogressors (LTNP) and to investigate whether particular amino acid substitutions are associated with LTNP. STUDY DESIGN/METHODS: nef alleles from 21 LTNP and 8 progressor controls were amplified by polymerase chain reaction (PCR) and sequenced. The amino acid sequences were compared with the previously reported sequences of 16 North American LTNP and of 28 patients with progressive infection. RESULTS: An untruncated intact open reading frame was observed as major sequence in all LTNP and controls. None of the amino acid substitutions in known biologically functional sites was linked to LTNP. A valine/isoleucine at the variable position 11 was associated with both European (P = .0001) and American (P = .001) LTNP. The interpatient nef variation was lower among European LTNP (P = .002) than in European progressor controls. CONCLUSIONS: Nef amino acid heterogeneity is lower among LTNP, probably reflecting the lower HIV-1 replication rate. Nef gene defects appear uncommon in both Swedish and Italian LTNP, although the presence of a valine/isoleucine at position 11 is statistically associated with a lower probability to progress to disease.

Hemoperfusion and liver disease.

After first adventurous attempts to apply perfusion techniques to the treatment of liver diseases, more extensive experiences have been acquired in the last twenty years, not only in acute hepatic failure but also in some chronic liver diseases (mainly in CAH:chronic active hepatitis, and in primary biliary cirrhosis) and in a severe complication of them, that is cryoglobulinemia. Some experiences on this field that are found in literature, using both plasma exchange and hemoperfusion, are reviewed and some personal data are reported: 15 patients with acute viral liver failure (survival rate: 33%) and 5 patients with a CAH-linked (3 viral and 2 autoimmune) cryoglobulinemia, in whom a good control of the disease parameters was obtained.

Enterococcal septicemia in patients with hematological malignancies.

Thirty-six cases of enterococcal septicemia in patients with hematological malignancies were reviewed retrospectively and categorized according to their clinical significance using strict previously described definitions. Overall, most of the infected patients were males (77%), had acute leukemia (64%), had recently received cytotoxic drug therapy (86%), were granulocytopenic at the onset of septicemia (77%), and acquired the infection during hospitalization (77%). The source of septicemia was unknown in 18 (50%) patients, intestinal in 15 (42%) and intravascular in three (8%). Mortality was 19% among 21 inpatients who had clinically significant septicemia and 30% among patients with septicemia of uncertain clinical significance. The fatal outcome could be definitively attributed to enterococcal septicemia in only one of the nine inpatients who died. Clinically significant septicemia appeared somewhat more frequently to be polymicrobial (p = 0.06), whereas septicemia of unknown significance presented more frequently as breakthrough septicemia (p = 0.013). Unless associated with intravascular infection, enterococcal septicemia in patients with hematological malignancies seems to represent a marker of cytotoxic drug damage of the intestinal mucosa rather than a truly invasive infection.