Characteristics of the Genetic Spread of Carbapenem-Resistant Acinetobacter baumannii in a Tertiary Greek Hospital.

Acinetobacter baumannii (Ab) has increasingly been identified as a cause of hospital-acquired infections and epidemics. The rise of carbapenem-resistant Acinetobacter baumannii (CRAB) poses significant challenges in treatment. Nosocomial outbreaks linked to CRAΒ A. baumannii strains have been reported worldwide, including in Greece. This study aimed to analyze the molecular epidemiology trends of multidrug-resistant A. baumannii isolates in a tertiary hospital in Athens, Greece. A total of 43 clinical isolates of extensively drug-resistant (XDRAB), pan-drug-resistant (PDRAB), and CRAB were collected from patients suffering from blood infection, hospitalized between 2016 and 2020 at the internal medicine clinics and the ICU. A.baumannii isolates underwent testing for Ambler class B and D carbapenemases and the detection of ISAba1, and were typed, initially, using pulsed-field gel electrophoresis, and, subsequently, using sequence-based typing and multiplex PCR to determine European Clone lineages. The blaOXA-23 gene accompanied by ISAba1 was prevalent in nearly all A. baumannii isolates, except for one carrying blaOXA-58. The intrinsic blaOXA-51-like gene was found in all isolates. No Ambler class B carbapenemases (VIM, NDM) were detected. Isolates were grouped into four PF-clusters and no one-cluster spread was documented, consistent with the absence of outbreak. The study indicated that XDR/PDR-CRAB isolates predominantly produce OXA-23 carbapenemase and belong to European Clone II. Further research is needed to understand the distribution of resistant bacteria and develop effective prevention and control strategies.

HIV RNA/DNA Levels at Diagnosis Can Predict Immune Reconstitution: A Longitudinal Analysis.

BACKGROUND: HIV DNA mirrors the number of infected cells and the size of the HIV viral reservoir. The aim of this study was to evaluate the effect of pre-cART HIV DNA levels as a predictive marker of immune reconstitution and on the post-cART CD4 counts trends. METHODS: HIV DNA was isolated from PBMCs and quantified by real-time PCR. Immune reconstitution was assessed up to four years. Piecewise-linear mixed models were used to describe CD4 count changes. RESULTS: 148 people living with HIV (PLWH) were included. The highest rate of immune reconstitution was observed during the first trimester. There was a trend showing that high HIV RNA level resulted in greater increase in CD4 count, especially during the first trimester of cART (difference above vs. below median 15.1 cells/µL/month; 95% CI -1.4-31.5; p = 0.073). Likewise, higher HIV DNA level would predict greater CD4 increases, especially after the first trimester (difference above vs. below median 1.2 cells/µL/month; 95% CI -0.1-2.6; p = 0.071). Higher DNA and RNA levels combined were significantly associated with greater CD4 increase past the first trimester (difference high/high vs. low/low 2.1 cells/µL/month; 95% CI 0.3-4.0; p = 0.024). In multivariable analysis, lower baseline CD4 counts predicted a greater CD4 rise. CONCLUSIONS: In successfully treated PLWH, pre-cART HIV DNA and HIV RNA levels are predictors of immune reconstitution.

A Network Approach to Determine Optimization of PrEP Uptake in Athens, Greece.

Although the HIV epidemic in Athens, Greece has reemerged and spread in men who have sex with men (MSM), state-supported PrEP programs have not been instituted. A PrEP intervention was implemented building upon an existing network cohort of MSM (308 participants; 1212 network members). A PrEP intervention cohort of 106 participants was selected based upon sex behaviors. Individual, partner, and network characteristics were compared between the cohorts. The PrEP cohort members were more highly connected and in more influential positions in the network than their peers. Further, their sexual network connections' behaviors increased their vulnerability to HIV infection relative to the rest of the network's sex partners. This included greater stimulant use (24.2% vs 7.0%; χ2 = 28.2; p < 0.001), greater rates of at least weekly condomless sex (OR = 2.7; 95% CI 2.1-3.5; χ2 = 59.2; p < 0.001) and at least weekly use of drugs or alcohol during sex (OR = 3.4; 95% CI 2.6-4.3; χ2 = 89.7; p < 0.001). Finally the PrEP cohort's social networks showed similarly increased vulnerability to seroconversion, including greater rates of injection drug use (4.1% vs 0.5%; χ2 = 3.9; p = 0.04), greater stimulant use (33.6% vs 14.6%; χ2 = 16.9, p < 0.001), and higher rates of recent STIs (21.6% vs 13.1%; χ2 = 4.4; p = 0.04). Thus, this PrEP intervention engaged individuals in vulnerable positions with vulnerable connections within an MSM community.

Ongoing HIV transmission following a large outbreak among people who inject drugs in Athens, Greece (2014-20).

BACKGROUND AND AIMS: The human immunodeficiency virus (HIV) outbreak among people who inject drugs (PWID) in Athens, Greece in 2011-13 was the largest recent epidemic in Europe and North America. We aimed to assess trends in HIV prevalence, drug use and access to prevention among PWID in Athens to estimate HIV incidence and identify risk factors and to explore HIV-1 dispersal using molecular methods during 2014-20. METHODS: Two community-based HIV/hepatitis C programmes on PWID were implemented in 2012-13 (n = 3320) and 2018-20 (n = 1635) through consecutive respondent-driven sampling (RDS) rounds. PWID were uniquely identified among rounds/programmes. We obtained RDS-weighted HIV prevalence estimates per round for 2018-20 and compared them to 2012-13. We assessed changes in HIV status, behaviours and access to prevention in PWID participating in both periods. We estimated HIV incidence in a cohort of seronegative PWID as the number of HIV seroconversions/100 person-years during 2014-20 and used Cox regression to identify associated risk factors. Molecular sequencing and phylogenetic analysis were performed in HIV seroconverters. RESULTS: HIV prevalence per round ranged between 12.0 and 16.2% in 2012-13 and 10.7 and 11.3% in 2018-20 with overlapping 95% confidence intervals (95% CI). Among PWID participating in both programmes, HIV prevalence (95% CI) increased from 14.2% (11.7-17.1%) in 2012-13 to 22.0% (19.0-25.3%) in 2018-20 (P < 0.001). There was a deterioration in socio-economic characteristics such as homelessness [from 16.2% (95% CI = 13.5-19.2%) to 25.6% (22.3-29.0%)], a shift in cocaine use [16.6% (13.9-19.6%) versus 28.1% (24.7-31.7%], reduced access to free syringes [51.8% (48.0-55.7%) versus 44.5% (40.7-48.3%)] and a decrease in daily injecting [36.2% (32.6-39.9%) versus 28.5% (25.2-32.1%)]. HIV incidence (95% CI) in 2014-20 was 1.94 (1.50-2.52) new cases/100 person-years and younger age, lower educational level, larger injection network and daily injecting were risk factors. Almost 9% of HIV seroconversions occurred within a newly expanding phylogenetic cluster. CONCLUSIONS: In Athens, Greece, compared with the period 2012-13, in the period 2018-20 there was a deterioration in socio-economic conditions among people who inject drugs, an increase in the use of cocaine, reduced access to needle and syringe programmes and stable low levels of human immunodeficiency virus testing. Ongoing human immunodeficiency virus transmission was documented during 2014-20 in existing as well as new transmission clusters.

Pre-exposure Prophylaxis Persistence Among Greek Sexual Minority Men: Results from PrEP for Greece (P4G) Study.

Nearly half the new HIV infections in Greece occur in sexual minority men, yet pre-exposure prophylaxis is not currently supported in the national HIV program. We examined factors associated with PrEP persistence among Greek SMM in PrEP for Greece, the first PrEP study in Greece. Participants (n = 100) were recruited from 2016 to 2018 through respondent-driven sampling among SMM in Athens, receiving supplies for daily PrEP at interval visits over 12-months. PrEP persistence, operationalized as Total PrEP Time, was high, 74% of participants achieving perfect persistence. Higher alcohol risk scores (OR 1.27, 95% CI 1.08-1.49) and adherence to HIV testing guidelines (OR 1.23, 95% CI 1.00-1.51) were associated with persistence. Housing impermanence (OR 0.14, 95% CI 0.04-0.48) and serostatus disclosure concerns (OR 0.77, 95% CI 0.60-0.97) were associated with limited PrEP persistence. While PrEP persistence among Greek SMM is high, socioeconomic factors and societal attitudes may challenge prevention efforts.

Sexualized Drug Use and Chemsex: Their Association with Sexual Health Among Men who have Sex with Men Living in Greece.

Objectives: The study aims to investigate rates of sexualized drug use (SDU) and chemsex, a type of SDU involving specifically the use of crystal methamphetamine, mephedrone, or GHB/GBL and their association with the rates of negative sexual health outcomes among men who have sex with men (MSM) in Greece. Methods: Survey of 485 MSM in internal disease departments and community testing centers. Results: Twenty-eight percent of participants were involved in SDU and 20.4% in chemsex. HIV positive status and recent STI diagnoses were associated with SDU involvement. Conclusion: SDU and chemsex rates and their impact on health reveal the need for informed community-based services.

Sexual Mixing and HIV Transmission Potential Among Greek Men Who have Sex with Men: Results from SOPHOCLES.

HIV incidence among men who have sex with men (MSM) in Greece remains unchanged despite effective response to a recent outbreak among people who inject drugs (PWID). Network factors are increasingly understood to drive transmission in epidemics. The primary objective of the study was to characterize MSM in Greece, their sexual behaviors, and sexual network mixing patterns. We investigated the relationship between serostatus, sexual behaviors, and self-reported sex networks in a sample of MSM in Athens, Greece, generated using respondent driven sampling. We estimated mixing coefficients (r) based on survey-generated egonets. Additionally, multiple logistic regression was used to estimate adjusted odds ratios (AOR) and to assess relationships between serostatus, sexual behaviors, and sociodemographic indicators. A sample of 1,520 MSM participants included study respondents (n = 308) and their network members (n = 1,212). Mixing based on serostatus (r = 0.12, σr = 0.09-0.15) and condomless sex (r = 0.11, σr = 0.07-0.14) was random. However, mixing based on sex-drug use was highly assortative (r = 0.37, σr = 0.32-0.42). This study represents the first analysis of Greek MSM sexual networks. Our findings highlight protective behavior in two distinct network typologies. The first typology mixed assortatively based on serostatus and sex-drug use and was less likely to engage in condomless sex. The second typology mixed randomly based on condomless sex but was less likely to engage in sex-drug use. These findings support the potential benefit of HIV prevention program scale-up for this population including but not limited to PrEP.

Progression of Subclinical Vascular Damage in People Living With HIV Is Not Predicted by Current Cardiovascular Risk Scores: A Prospective 3-Year Study.

BACKGROUND: People living with HIV (PLWH) are at high cardiovascular disease (CVD) risk. Traditional CVD risk scores do not accurately reflect their CVD risk. Noninvasive subclinical vascular damage (SVD) biomarkers are valid surrogates of CVD and able to stratify CVD risk. SETTING: We tested whether 4 widely applied CVD risk scores [Framingham (FRS), Atherosclerotic CVD, Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D), and Greek-specific European Society of Cardiology (ESC) risk scores] are associated with or detect the presence, incidence, and progression of arteriosclerosis, atheromatosis, and arterial hypertrophy in PLWH and uninfected individuals. METHODS: We prospectively examined (at baseline and 3-year follow-up) 10 different arterial sites applying 5 different noninvasive vascular biomarkers and measured all 4 CVD risk scores at baseline. RESULTS: In both PLWH (n = 138) and uninfected (n = 664) individuals, the CVD risk scores (except the ESC) performed differently but reasonably well in identifying the presence of SVD, but all scores failed to predict the incidence/progression of overall SVD. The most clinically useful biomarkers (carotid plaque/atheromatosis) revealed that in PLWH, only the FRS was able to stratify the progression (11% of the low-risk, 33.3% of the medium-risk, and 0% of the high-risk group). CONCLUSIONS: This extensive vascular phenotyping study demonstrated the clear need to incorporate vascular imaging in CVD risk stratification, in addition to designing more accurate HIV-specific CVD risk models. The use of FRS would further enable treatment optimization and CVD prevention strategies in PLWH at medium CVD risk because one-third of carotid atheromatosis progresses within 3 years.

Identifying, linking, and treating people who inject drugs and were recently infected with HIV in the context of a network-based intervention.

Identifying and linking people to care soon after HIV infection could limit viral transmission and protect their health. This work aims at describing the continuum of care among recently HIV-infected people who inject drugs (PWID) and participated in an intervention in the context of an HIV outbreak in Athens, Greece. The Transmission Reduction Intervention Project (TRIP) conducted risk network-based contact tracing and screened people for recent HIV infection. A comprehensive approach with a case management component that aimed to remove barriers to accessing care was adopted. Follow-up data on antiretroviral treatment (ART) and HIV-RNA levels were obtained from HIV clinics. TRIP enrolled 45 recently HIV-infected PWID (80% male) with a median viral load at recruitment of 5.43 log10 copies/mL. Of the recently infected persons in TRIP, 87% were linked to care; of these, 77% started ART; and of those on ART, 89% achieved viral load <200 copies/mL. TRIP and its public health allies managed to get most of the recently HIV-infected PWID who were identified by the program into care and many of them onto ART. This resulted in very low HIV-RNA levels. Treatment as prevention can work if individuals are aided in overcoming difficulties in entry to, or attrition from care.

Prevalence, Incidence, and Contributors of Subclinical Atheromatosis, Arteriosclerosis, and Arterial Hypertrophy in HIV-Infected Individuals: A Single-Center, 3-Year Prospective Study.

Cardiovascular disease (CVD) is an important comorbidity for people living with HIV infection (PLWH) in the combined antiretroviral therapy era. We prospectively examined the presence of subclinical arterial disease in 138 consecutive CVD-free, HIV-infected individuals compared to 664 HIV-negative individuals. We studied 10 arterial sites in 4 beds using 5 distinct biomarkers of subclinical atheromatosis, arteriosclerosis, and hypertrophy and evaluated the association of subclinical arterial damage with CVD-related and HIV-related factors at baseline and at 3-year follow-up. Atheromatosis, arteriosclerosis, and arterial hypertrophy were present in 36.1%, 59.7%, and 34.3% of HIV-infected individuals, respectively, at baseline. HIV infection was independently associated with carotid atheromatosis and hypertrophy. The presence of carotid atheromatosis was independently associated with age, years of smoking, and exposure to nonnucleoside reverse transcriptase inhibitors (NNRTIs). The annual incidence of atheromatosis, arteriosclerosis, and arterial hypertrophy was 5.5, 18.6, and 12.5 cases/100 patients, respectively. Carotid atheromatosis progression was significantly associated with NNRTI exposure. People living with HIV infection exhibited high prevalence and incidence of subclinical arterial damage and site-specific predilection for the carotids. These investigations may help optimize HIV-specific CVD prediction models. The NNRTIs may contribute to atheromatosis, emphasizing the need to consider the atherogenic potential of antiretroviral drugs in management strategies.

Joseph Strnad (1889-1962): handmaker of surgical tools.

Joseph Strnad was a charismatic person who lived in Vienna and Zurich in the first half of the 20th century. He created surgical instruments that are still famous for their functionality and quality. His life story and his contribution to surgery were told by his daughter on the occasion of the donation of her father's tools to the Museum of History of Medicine at the University of Ioannina, as well as in thank you letters to Strnad from famous surgeons.