Acceptability of on-site rapid HIV/HBV/HCV testing and HBV vaccination among three at-risk populations in distinct community-healthcare outreach centres: the ANRS-SHS 154 CUBE study.

BACKGROUND: HIV, HBV and HCV infections continue to represent major health concerns, especially among key at-risk populations such as men who have sex with men (MSM), people who inject drugs (PWIDs), transgender women (TGW) and sex workers (SW). The objective of the ANRS-CUBE study was to evaluate the acceptability of a healthcare, community-based strategy offering a triple rapid HIV-HBV-HCV testing, and HBV vaccination, targeted at three priority groups (MSM, PWIDs and TGW/SWs), in three community centers, in the Paris area. METHODS: This longitudinal multicentric non-randomized study included all adult volunteers attending one of the three specialized community centers in Paris, between July 2014 and December 2015. HIV, HBV and HCV status and acceptability of HBV vaccination were evaluated. RESULTS: A total of 3662, MSM, 80 PWIDs and 72 TGW/SW were recruited in the three centers respectively. Acceptability of rapid tests was 98.5% in MSM and 14.9% in TGW/SWs, but could not be estimated in PWIDs since the number of users attending and the number of proposals were not recorded. User acceptability of HBV vaccination was weak, only 17.9% of the eligible MSM (neither vaccinated, nor infected) agreed to receive the first dose, 12.2% two doses, 5.9% had a complete vaccination. User acceptability of HBV vaccination was greater in PWIDs and TGW/SWs, but decreased for the last doses (66.7 and 53.3% respectively received a first dose, 24.4 and 26.7% a second dose and 6.7 and 0% a third dose). Fifty-three participants (49 MSM and 4 PWIDs) were discovered HIV positive, more than half with a recent infection. All but two HIV positive participants were linked to appropriate care in less than one month. CONCLUSIONS: Rapid HIV-HCV-HBV screening showed a very high level of acceptability among MSM. Efforts need to be made to improve immediate acceptability for HBV vaccination, especially among MSM, and follow-up doses compliance. Our results show the important role of community centers in reaching targets, often fragile, populations, while also suggesting the need to reinforce on-site human support in terms of testing and vaccination, especially when addressing PWIDs.

Which adults in the Paris metropolitan area have never been tested for HIV? A 2010 multilevel, cross-sectional, population-based study.

BACKGROUND: Despite the widespread offer of free HIV testing in France, the proportion of people who have never been tested remains high. The objective of this study was to identify, in men and women separately, the various factors independently associated with no lifetime HIV testing. METHODS: We used multilevel logistic regression models on data from the SIRS cohort, which included 3006 French-speaking adults as a representative sample of the adult population in the Paris metropolitan area in 2010. The lifetime absence of any HIV testing was studied in relation to individual demographic and socioeconomic factors, psychosocial characteristics, sexual biographies, HIV prevention behaviors, attitudes towards people living with HIV/AIDS (PLWHA), and certain neighborhood characteristics. RESULTS: In 2010, in the Paris area, men were less likely to have been tested for HIV at least once during their lifetime than women. In multivariate analysis, in both sexes, never having been tested was significantly associated with an age younger or older than the middle-age group (30-44 years), a low education level, a low self-perception of HIV risk, not knowing any PLWHA, a low lifetime number of couple relationships, and the absence of any history of STIs. In women, other associated factors were not having a child < 20 years of age, not having additional health insurance, having had no or only one sexual partner in the previous 5 years, living in a cohabiting couple or having no relationship at the time of the survey, and a feeling of belonging to a community. Men with specific health insurance for low-income individuals were less likely to have never been tested, and those with a high stigma score towards PLWHA were more likely to be never-testers. Our study also found neighborhood differences in the likelihood of men never having been tested, which was, at least partially, explained by the neighborhood proportion of immigrants. In contrast, in women, no contextual variable was significantly associated with never-testing for HIV after adjustment for individual characteristics. CONCLUSIONS: Studies such as this one can help target people who have never been tested in the context of recommendations for universal HIV screening in primary care.

X ray screening at entry and systematic screening for the control of tuberculosis in a highly endemic prison.

BACKGROUND: Tuberculosis (TB) is a major issue in prisons of low and middle income countries where TB incidence rates are much higher in prison populations as compared with the general population. In the Rio de Janeiro (RJ) State prison system, the TB control program is limited to passive case-finding and supervised short duration treatment. The aim of this study was to measure the impact of X-ray screening at entry associated with systematic screening on the prevalence and incidence of active TB. METHODS: We followed up for 2 years a RJ State prison for adult males (1429 inmates at the beginning of the study) and performed, in addition to passive case-finding, 1) two "cross-sectional" X-ray systematic screenings: the first at the beginning of the study period and the second 13 months later; 2) X-ray screening of inmates entering the prison during the 2 year study period. Bacteriological examinations were performed in inmates presenting any pulmonary, pleural or mediastinal X-ray abnormality or spontaneously attending the prison clinic for symptoms suggestive of TB. RESULTS: Overall, 4326 X-rays were performed and 246 TB cases were identified. Prevalence among entering inmates remained similar during 1st and the 2nd year of the study: 2.8% (21/754) and 2.9% (28/954) respectively, whereas prevalence decreased from 6.0% (83/1374) to 2.8% (35/1244) between 1st and 2nd systematic screenings (p < 0.0001). Incidence rates of cases identified by passive case-finding decreased from 42 to 19 per 1000 person-years between the 1st and the 2nd year (p < 0.0001). Cases identified by screenings were less likely to be bacteriologically confirmed as compared with cases identified by passive-case finding. CONCLUSIONS: The strategy investigated, which seems highly effective, should be considered in highly endemic confined settings such as prisons.

Differences in recourse to HIV testing according to migration origin in the Paris metropolitan area in 2010.

In France, HIV prevention within Maghrebi or French of Maghrebi origin has been seldom studied. The purpose of this study is to compare the recourse to HIV test according to nationality and origin. Data were from the 2010 SIRS cohort, which included 3,006 households representative of the Paris metropolitan area. Results of the study show comparatively low HIV testing rate among Maghrebi and French of Maghrebi origin compared to French with French parents.

Gender, socio-economic status, migration origin and neighbourhood of residence are barriers to HIV testing in the Paris metropolitan area.

In France, numerous HIV patients still discover their HIV status as a result of AIDS-related symptoms. We investigated factors related to the absence of any HIV testing in men and women separately, using the data from the SIRS cohort, which includes 3023 households representative of the Paris metropolitan area in 2005. The failure to use HIV testing services was studied in relation to individual socio-economic and demographic factors as well as some psychosocial characteristics. The effect of the characteristics of the residential neighbourhood was also analysed using multilevel models. In multivariate analysis, the factors associated with no history of HIV testing in women were an age >44 years, the absence of any pregnancy during the previous 15 years, a low education level, unemployment, to have had no or only one steady relationship in one's lifetime, to have a religious affiliation and to live in a poor neighbourhood. In men, factors were age <30 or >44 years, to have had no or only one steady relationship during one's lifetime, to have a religious affiliation and to perceive oneself as being at low risk of HIV infection. An association according to the "migration origin" was observed among men: foreigners and French men born to (at least) one foreign parent were more likely not to have been tested than French men born to two French parents. We conclude that gender, social and territorial differences exist in HIV testing among people living in the Paris area. More systematic proposals of HIV test in primary care would be an effective policy to overcome these persistent social stratifications.

Not all missed doses are the same: sustained NNRTI treatment interruptions predict HIV rebound at low-to-moderate adherence levels.

BACKGROUND: While the relationship between average adherence to HIV potent antiretroviral therapy is well defined, the relationship between patterns of adherence within adherence strata has not been investigated. We examined medication event monitoring system (MEMS) defined adherence patterns and their relation to subsequent virologic rebound. METHODS AND RESULTS: We selected subjects with at least 3-months of previous virologic suppression on a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen from two prospective cohorts in France and North America. We assessed the risk of virologic rebound, defined as HIV RNA of >400 copies/mL according to several MEMS adherence measurements. Seventy two subjects were studied, five of them experienced virologic rebound. Subjects with and without virologic rebound had similar baseline characteristics including treatment durations, regimen (efavirenz vs nevirapine), and dosing schedule. Each 10% increase in average adherence decreased the risk of virologic rebound (OR = 0.56; 95% confidence interval (CI) [0.37, 0.81], P<0.002). Each additional consecutive day off therapy for the longest treatment interruption (OR = 1.34; 95%CI [1.15, 1.68], P<0.0001) and each additional treatment interruption for more than 2 days (OR = 1.38; 95%CI [1.13, 1.77], P<0.002) increased the risk of virologic rebound. In those with low-to-moderate adherence (i.e. <80%), treatment interruption duration (16.2 days versus 6.1 days in the control group, P<0.02), but not average adherence (53.1% vs 55.9%, respectively, P = 0.65) was significantly associated with virologic rebound. CONCLUSIONS: Sustained treatment interruption may pose a greater risk of virologic rebound on NNRTI therapy than the same number of interspersed missed doses at low-to-moderate adherence.

Acute hepatitis A virus infection in Turkey.

Anti-HAV IgM positive serum samples from acute phase hepatitis A patients from various areas in Turkey were tested for viral RNA by RT-PCR (reverse transcriptase polymerase chain reaction), using primer pairs from two different regions of the HAV genome. The PCR products amplified from both genomic regions underwent phylogenetic analyses. A comparison of the regions showed the same genotyping results, and the RT-PCR-2 in the 5'NCR demonstrated greater sensitivity compared to RT-PCR-1 in the VP1-P2A region. The majority of the isolates belonged to genotype IB and are related closely to each other; however, two isolates related even more strongly to the HAV HM175 strain. Two (n = 37) RT-PCR positive sera were classified under genotype IA. A surprising finding emerged for the mean levels of serum transaminases AST and ALT: higher levels were found in patients under 10 years of age compared to older patients. Anti-HAV IgM levels were determined quantitatively and, in addition, the HAV-RNA genome equivalents were ascertained by real time RT-PCR. No evidence was found for an association between viral load and the higher transaminase levels in the younger group.

A tuberculose nas prisões do Rio de Janeiro, Brasil: uma urgência de saúde pública / Tuberculosis in Rio de Janeiro prisons, Brazil: an urgent public health problem

Em 2004, a taxa de incidência da tuberculose nas prisões do Estado do Rio de Janeiro, Brasil, foi trinta vezes superior à da população geral do Estado. Essa taxa provavelmente é subestimada, especialmente pela dificuldade de acesso ao serviço de saúde nesse ambiente. Com o objetivo de melhor avaliar a situação, um primeiro inquérito radiológico sistemático foi realizado e mostrou taxa de prevalência de 4,6 por cento (prisão A, n = 1.052). Dois inquéritos adicionais revelaram, nas unidades B (n = 590) e C (n = 1.372), taxas maiores (6,3 por cento e 8,6 por cento, respectivamente). A comparação das características sócio-demográficas das prisões A, B e C mostrou que a população encarcerada não é homogênea. Em comparação com prisão A, os indivíduos encarcerados nas prisões B e C são oriundos de comunidades mais desfavorecidas e têm mais freqüentemente história de encarceramento anterior e de tuberculose. Essas diferenças, coerentes com os dados de prevalência, implicam a adaptação das medidas de controle da tuberculose ao perfil epidemiológico e sócio-demográfico de cada unidade prisional.

The tuberculosis incidence rate in prisons in Rio de Janeiro State, Brazil, was 30 times higher in 2004 than in the general population and is probably underestimated, particularly given the difficult access to care in the prison setting. To obtain a better estimate, a survey used systematic X-ray screening and showed a prevalence rate of 4.6 percent in one such detention facility, A (n = 1,052). Two additional surveys, in facilities B (n = 590) and C (n = 1,372), showed even higher prevalence rates (6.3 percent and 8.6 percent respectively). A comparison of socio-demographic characteristics between A, B, and C showed a heterogeneous prison population. As compared to facility A, inmates in B and C come from poorer urban communities and have more frequent histories of incarceration and tuberculosis. These differences, consistent with the prevalence data, imply the necessary adaptation of tuberculosis control programs to each detention facility's epidemiological and socio-demographic profile.

Decline in HCV testing and compliance with guidelines in patients of Sentinelles general practitioners, 1996-2002.

Between 1996 and 2002, the French Sentinelles Network observed a more than 2-fold decline in the annual rate of hepatitis C virus (HCV) screening tests prescribed by general practitioners. During this period it droped from 1080 to 450 per 100,000 inhabitants. The proportion of HCV-positives increased from 9.7% to 12.9% between 1996 and 1998 but declined steadily afterwards, reaching 7% in 2002. The majority of HCV-positive patients were men (57%), 38% were aged 30-39 years and 45% were injecting drug users. Two French guidelines for HCV screening were issued in 1997 and 2001. Of the 3462 patients with a known HCV test result, 27.4% were offered following the 1997 guidelines, among which 23.7% were HCV-positive. Of the same 3462 patients, 36.8% were offered following the extended definition of the risk group in the 2001 guidelines, among which 19.9% were positive. The percentage of subjects tested with no biological sign or clinical symptom and no HCV risk factor varies from 11% to 26% showing that SGPs carry out a targeted screening even if they deviate from the strict recommendations. Of the HCV-positive patients, 14% did not meet any criteria of the guidelines suggesting a lack of sensitivity in the current definition of patients recommended for testing.

Major role of hepatitis B genotypes in liver fibrosis during coinfection with HIV.

BACKGROUND: Little is know about the determinants of liver fibrosis progression and genomic variability in hepatitis B virus (HBV) in HIV/HBV-coinfected patients. METHODS: A cross-sectional analysis examined common characteristics of HBV infection in an ongoing cohort study of 308 patients with both HIV-1-positive Western blot and plasma HBV surface antigen (HBsAg) seropositivity. Risk factors for liver fibrosis were studied in a subset of 104 patients for whom liver biopsy and complete HBV genomic analysis were available. Analysis was performed by exact multiple regression analysis. RESULTS: Mean age of the study population was 40.3 years, with a ratio male to female of 5.3 and a mean duration of HIV infection of 9.3 years. In the subset of 104 patients, plasma HBV e antigen (HBeAg) in HBV-replicative patients could not be detected in 28.4% and lamivudine-resistant mutants were detected in 67.8%. HBV genotype A was the most frequent genotype (73/104) and 25 patients were infected by the usually rare genotype G. METAVIR fibrosis score was rated F2-F4 in 70 patients. After adjustment for the most common known determinants of liver fibrosis, HBV genotype G [odds ratio (OR), 12.60; 95% confidence interval (CI), 1.72-infinite; P < 0.009], efavirenz exposure (OR, 3.55; 95% CI, 1.14-12.14; P < 0.03), and the duration of HIV infection (3.86; 95% CI, 1.27-12.64; P < 0.01) were strongly associated with the risk of grade F2-F4 fibrosis. CONCLUSION: HBV genotype G is a determinant of liver fibrosis in HIV/HBV-coinfected patients and HBV genotyping should be considered as part of the management of patients with multiple risk factors for rapid progression of liver fibrosis.

Predictors of virologic failure and resistance in HIV-infected patients treated with nevirapine- or efavirenz-based antiretroviral therapy.

Resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs) increases with the wider use of this class of antiretroviral therapy. The association between adherence and resistance to NNRTI-based regimens is poorly understood. Predictors of virologic failure and resistance according to a baseline evaluation of nonadherence risk factors were determined in a cohort of 71 human immunodeficiency virus (HIV)-infected patients with early virologic response who received an NNRTI-based regimen. During the median follow-up of 29 months, 20 (28%) of 71 patients experienced virologic failure with an NNRTI-based regimen. Virologic failure was associated with repeated drug holidays (> or =48 h of unplanned drug cessation), depression, younger age, and low adherence to therapy during baseline evaluation. Moreover, repeated drug holidays was the only risk factor for developing a major mutation conferring cross-resistance to the NNRTI class (hazard ratio, 22.5; 95% confidence interval, 2.8-180.3; P<.0001). Patients' previous adherence to therapy and drugs genetic barriers, not only the number of pills or doses involved, should be taken into consideration in the decision to simplify highly active antiretroviral therapy.