Resumen ejecutivo del documento de consenso sobre el manejo compartido del paciente con infección por VIH entre Atención Primaria y Hospitalaria / Executive summary of the consensus document on the shared care of patients with HIV infection between Primary and Hospital Care

La realidad actual del diagnóstico y tratamiento de la infección por virus de la inmunodeficiencia humana (VIH) justifica un abordaje multidisciplinar y coordinado entre Atención Primaria y Atención Hospitalaria, contemplando la bidireccionalidad y la comunicación entre los dos escenarios asistenciales. El presente documento de consenso, coordinado entre el Grupo de Estudio del SIDA de la Sociedad Española de Enfermedades Infecciosas (SEIMC-GeSIDA) y la Sociedad Española de Medicina de Familia y Comunitaria (semFYC), nace de esta necesidad. Aquí se resumen las recomendaciones de los cuatro bloques que lo componen: el primero trata aspectos de prevención y diagnóstico de la infección por el VIH; en el segundo se contempla la atención y el manejo clínico de las personas que viven con VIH; el tercero trata aspectos sociales, incluyendo temas legales y de confidencialidad, la calidad de vida y el papel de las ONG; por último, el cuarto bloque aborda la formación/docencia y la investigación bidireccional y compartida.(AU)

The current reality of the diagnosis and treatment of HIV infection justifies a multidisciplinary and coordinated approach between primary care and hospital care. This entails a two-way relationship and communication between the two care settings. This consensus document, coordinated by the AIDS Study Group of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC-GeSIDA) and the Spanish Society of Family and Community Medicine (semFYC), arose because of this need. Here, the recommendations of the four blocks that comprise it are summarized: the first tackles aspects of prevention and diagnosis of HIV infection; the second contemplates the clinical care and management of people living with HIV; the third deals with social aspects, including legal and confidentiality issues, quality of life, and the role of NGOs; finally, the fourth block addresses two-way and shared training/teaching and research.(AU)

Executive summary of the consensus document on the shared care of patients with HIV infection between primary and hospital care.

The current reality of the diagnosis and treatment of HIV infection justifies a multidisciplinary and coordinated approach between Primary Care and Hospital Care, contemplating bidirectionality and communication between the two care settings. The consensus document, coordinated by the AIDS Study Group of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC-GeSIDA) and the Spanish Society of Family and Community Medicine (semFYC), was born out of this need. Here, the recommendations of the four sections that comprise it are summarized: the first deals with aspects of prevention and diagnosis of HIV infection; the second contemplates the clinical care of people living with HIV; the third deals with social factors, including legal and confidentiality issues, quality of life, and the role of NGOs; finally, the fourth block addresses bidirectional and shared training/teaching and research.

Executive summary of the consensus document on the shared care of patients with HIV infection between primary and hospital care / Resumen ejecutivo del documento de consenso sobre el manejo compartido del paciente con infección por VIH entre Atención Primaria y Hospitalaria

The current reality of the diagnosis and treatment of HIV infection justifies a multidisciplinary and coordinated approach between Primary Care and Hospital Care, contemplating bidirectionality and communication between the two care settings. The consensus document, coordinated by the AIDS Study Group of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC-GeSIDA) and the Spanish Society of Family and Community Medicine (semFYC), was born out of this need. Here, the recommendations of the four sections that comprise it are summarized: the first deals with aspects of prevention and diagnosis of HIV infection; the second contemplates the clinical care of people living with HIV; the third deals with social factors, including legal and confidentiality issues, quality of life, and the role of NGOs; finally, the fourth block addresses bidirectional and shared training/teaching and research.(AU)

La realidad actual del diagnóstico y tratamiento de la infección por VIH justifica un abordaje multidisciplinar y coordinado entre atención primaria y atención hospitalaria, contemplando la bidireccionalidad y la comunicación entre los dos escenarios asistenciales. El presente documento de consenso, coordinado entre el Grupo de Estudio del Sida de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC-GeSIDA) y la Sociedad Española de Medicina de Familia y Comunitaria (semFYC), nace de esta necesidad. Aquí se resumen las recomendaciones de los cuatro bloques que lo componen: el primero trata aspectos de prevención y diagnóstico de la infección por el VIH; en el segundo se contempla la atención y el manejo clínico de las personas que viven con VIH; el tercero trata aspectos sociales, incluyendo temas legales y de confidencialidad, la calidad de vida y el papel de las ONG; por último, el cuarto bloque aborda la formación/docencia y la investigación bidireccional y compartida.(A)

The molecular epidemiology of HIV-1 in the Comunidad Valenciana (Spain): analysis of transmission clusters.

HIV infections are still a very serious concern for public heath worldwide. We have applied molecular evolution methods to study the HIV-1 epidemics in the Comunidad Valenciana (CV, Spain) from a public health surveillance perspective. For this, we analysed 1804 HIV-1 sequences comprising protease and reverse transcriptase (PR/RT) coding regions, sampled between 2004 and 2014. These sequences were subtyped and subjected to phylogenetic analyses in order to detect transmission clusters. In addition, univariate and multinomial comparisons were performed to detect epidemiological differences between HIV-1 subtypes, and risk groups. The HIV epidemic in the CV is dominated by subtype B infections among local men who have sex with men (MSM). 270 transmission clusters were identified (>57% of the dataset), 12 of which included ≥10 patients; 11 of subtype B (9 affecting MSMs) and one (n = 21) of CRF14, affecting predominately intravenous drug users (IDUs). Dated phylogenies revealed these large clusters to have originated from the mid-80s to the early 00 s. Subtype B is more likely to form transmission clusters than non-B variants and MSMs to cluster than other risk groups. Multinomial analyses revealed an association between non-B variants, which are not established in the local population yet, and different foreign groups.

Identification of a large, fast-expanding HIV-1 subtype B transmission cluster among MSM in Valencia, Spain.

We describe and characterize an exceptionally large HIV-1 subtype B transmission cluster occurring in the Comunidad Valenciana (CV, Spain). A total of 1806 HIV-1 protease-reverse transcriptase (PR/RT) sequences from different patients were obtained in the CV between 2004 and 2014. After subtyping and generating a phylogenetic tree with additional HIV-1 subtype B sequences, a very large transmission cluster which included almost exclusively sequences from the CV was detected (n = 143 patients). This cluster was then validated and characterized with further maximum-likelihood phylogenetic analyses and Bayesian coalescent reconstructions. With these analyses, the CV cluster was delimited to 113 patients, predominately men who have sex with men (MSM). Although it was significantly located in the city of Valencia (n = 105), phylogenetic analyses suggested this cluster derives from a larger HIV lineage affecting other Spanish localities (n = 194). Coalescent analyses estimated its expansion in Valencia to have started between 1998 and 2004. From 2004 to 2009, members of this cluster represented only 1.46% of the HIV-1 subtype B samples studied in Valencia (n = 5/143), whereas from 2010 onwards its prevalence raised to 12.64% (n = 100/791). In conclusion, we have detected a very large transmission cluster in the CV where it has experienced a very fast growth in the recent years in the city of Valencia, thus contributing significantly to the HIV epidemic in this locality. Its transmission efficiency evidences shortcomings in HIV control measures in Spain and particularly in Valencia.

Increased syphilis trend among patients in an AIDS information and prevention center

Objective A rebound of syphilis cases has recently been observed. This study describes the trend in syphilis infection among persons attending the AIDS information and prevention center of Valencia, Spain. Methods We performed a cohort study of all persons attended from 2000 to 2006. The calendar effect was assessed by a logistic regression model adjusted by sexual and sociodemographic variables. Results A total of 71% were heterosexuals (HT) and 19% were men who had sex with men (MSM). Among the 10,850 users of the center, the prevalence of syphilis was 0.7%. Among MSM, the prevalence of syphilis was 2.4% for the whole period and was 4.6% for 2006. Multivariate analysis showed that the risk of infection was lower in persons with a university education (OR=0.10; 95%CI: 0.03-0.59) than in those without. The risk was higher in persons who took drugs (OR=5.49; 95%CI: 1.55-19.43) or who practiced prostitution (OR=6.83; 95%CI: 2.52-18.53). In 2006, the risk of having syphilis was greater (OR=5.05; 95%CI: 1.12-22.72).Conclusions Syphilis infection increased substantially among MSM. In this collective, the prevalence of infection is related to educational level, prostitution and the use of non-injected recreational drugs (AU)

Objetivo En los últimos años se ha observado un repunte en los casos de sífilis. Este estudio describe la evolución de la infección por sífilis entre las personas que asistieron a un centro de información y prevención del sida de Valencia, España. Métodos Se realizó un estudio de cohorte de todas las personas atendidas entre 2000 y 2006. El efecto calendario se evaluó mediante un modelo de regresión logística ajustando por variables sociodemográficas y sexuales. Resultados El 71% de los que acudieron al centro eran heterosexuales y el 19% eran hombres que tenían sexo con hombres (HSH). Entre los 10.850 individuos, la prevalencia de la sífilis fue del 0,7%. Entre los HSH, la prevalencia de la sífilis fue del 2,4% para todo el período y del 4,6% para 2006. El análisis multivariado mostró que el riesgo de infección fue menor en las personas que tenían estudios universitarios (OR=0,10, IC95%: 0,03-0,59) que entre los que no. El riesgo fue mayor entre las personas que consumieron drogas (OR=5,49, IC95%: 1,55-19,43) y entre los que practican la prostitución (OR=6,83, IC95%: 2,52-18,53). En 2006, el riesgo de tener sífilis fue mayor (OR=5,05, IC95%: 1,12-22,72).Conclusiones La infección por sífilis aumentó sustancialmente entre los HSH. En este grupo, la prevalencia de la infección está relacionada con el nivel educativo, la prostitución y el uso de drogas recreativas no inyectada (AU)

Increased syphilis trend among patients in an AIDS information and prevention center.

OBJECTIVE: A rebound of syphilis cases has recently been observed. This study describes the trend in syphilis infection among persons attending the AIDS information and prevention center of Valencia, Spain. METHODS: We performed a cohort study of all persons attended from 2000 to 2006. The calendar effect was assessed by a logistic regression model adjusted by sexual and sociodemographic variables. RESULTS: A total of 71% were heterosexuals (HT) and 19% were men who had sex with men (MSM). Among the 10,850 users of the center, the prevalence of syphilis was 0.7%. Among MSM, the prevalence of syphilis was 2.4% for the whole period and was 4.6% for 2006. Multivariate analysis showed that the risk of infection was lower in persons with a university education (OR=0.10; 95%CI: 0.03-0.59) than in those without. The risk was higher in persons who took drugs (OR=5.49; 95%CI: 1.55-19.43) or who practiced prostitution (OR=6.83; 95%CI: 2.52-18.53). In 2006, the risk of having syphilis was greater (OR=5.05; 95%CI: 1.12-22.72). CONCLUSIONS: Syphilis infection increased substantially among MSM. In this collective, the prevalence of infection is related to educational level, prostitution and the use of non-injected recreational drugs.

Efectividad del tratamiento antirretroviral combinado de gran actividad en eventos recurrentes de sida en una cohorte de seroconvertores al virus de la inmunodeficiencia humana / Effectiveness of combined antiretroviral therapy on multiple aids-defining illnesses in an hiv seroconverter cohort

Introducción La efectividad del tratamiento antirretroviral de gran actividad (TARGA) en la reducción del tiempo al primer evento definitorio de sida ha sido demostrada por diversos estudios observacionales, pero el efecto en eventos recurrentes de sida no es tan evidente. Material y métodos Se dispone de 1.938 sujetos seroconvertores al VIH de la cohorte GEMES. Se ha utilizado una extensión del modelo de Cox para analizar el tiempo desde la seroconversión a cada evento sida, que tiene en cuenta el tiempo entre sucesivos eventos y que permite que el riesgo de referencia cambie con el número de paciente con sida previos. El calendario se dividió en tres períodos coincidiendo con la disponibilidad de diferentes regímenes de terapia antirretroviral. Resultados Durante el seguimiento 1.524 (78,6%), 259(13,4%), 83 (4,3%) y 72 (3,7%) sujetos desarrollaron 0, 1, 2 y 3 o más eventos definitorios de sida, respectivamente. Después de ajustar por sexo, edad a la seroconversión y categoría de exposición, el riesgo de sida para el período TARGA fue RR=0,38 (IC del 95%, 0,30-0,48) en comparación con el período 1992–1995.Teniendo en cuenta el número de sujetos con sida previos, se observó un RR de 0,40 (IC del95%, 0,32-0,50) para el primer evento sida, RR=0,27 (IC del 95%, 0,15-0,50) para el segundo y 0,41 (IC del 95%, 0,18-0,96) para el tercero. Considerando todos los eventos de sida, se obtiene un riesgo RR=0,32 (IC del 95%, 0,125-0,40). Los usuarios de drogas por vía parenteral tienen un riesgo mayor de desarrollar un primer episodio de sida que los homosexuales, RR=2,14 (IC del 95%, 1,48-3,10).Conclusiones Los resultados obtenidos muestran un efecto protector de la terapia al primer sida, manteniéndose el efecto para posteriores eventos. La inclusión en el análisis de todos los eventos recurrentes de sida permite obtener estimaciones del riesgo más precisas (AU)

Introduction: Several observational studies support the protective effect of combined antiretroviral therapy (cART) on time to first AIDS-defining event, but the effect on multiple AIDS defining illnesses remains unclear. The aim of this study is to analyse whether the protective effect of cART persists beyond the first AIDS-defining illness. Material and methods: A total of 1938 subjects from GEMES seroconverter cohort have been included. Toanalyse cART effectiveness, calendar time has been divided into three periods according to antiretroviral availability. A population-averaged proportional hazard model with staggered entries that counted the gap time, and had event-specific baseline risks, was fitted. Results: During follow-up, 1524 (78.6%), 259 (13.4%), 83 (4.3%) and 72 (3.7%) subjects incurred 0, 1, 2,and 3 or more AIDS-defining illnesses, respectively. After adjustment for sex, age at seroconversion and exposure category, the Relative Risk (RR) of AIDS in the cART period was 0.38 (95%CI 0.30-0.48) compared with the 1992-95 period. The RR of the first, second and third AIDS-defining illness in the cART period were0.40 (95% CI: 0.32-0.50), 0.27 (95% CI: 0.15-0.50) and 0.41 (95% CI: 0.18-0.96) respectively, relative to the reference calendar period when we allowed the odds ratios to vary by the number of prior AIDS-defining events. The relative risk of AIDS, taking all events into account, was 0.32 (95% CI: 0.25-0.40). Intravenous drug users have a higher risk of developing a first episode of AIDS than homosexuals, RR: 2.14 (95% CI:1.48-3.10).Conclusions: Results indicate that the relative effect of cART appears to be both protective and stable over multiple AIDS-defining illnesses. Analysis of multiple AIDS-defining illnesses improves the precision of the estimated relative risk (AU)

[Effectiveness of combined antiretroviral therapy on multiple AIDS-defining illnesses in an HIV seroconverter cohort]. / Efectividad del tratamiento antirretroviral combinado de gran actividad en eventos recurrentes de sida en una cohorte de seroconvertores al virus de la inmunodeficiencia humana.

INTRODUCTION: Several observational studies support the protective effect of combined antiretroviral therapy (cART) on time to first AIDS-defining event, but the effect on multiple AIDS defining illnesses remains unclear.The aim of this study is to analyse whether the protective effect of cART persists beyond the first AIDS-defining illness. MATERIAL AND METHODS: A total of 1938 subjects from GEMES seroconverter cohort have been included. To analyse cART effectiveness, calendar time has been divided into three periods according to antiretroviral availability. A population-averaged proportional hazard model with staggered entries that counted the gap time, and had event-specific baseline risks, was fitted. RESULTS: During follow-up, 1524 (78.6%), 259 (13.4%), 83 (4.3%) and 72 (3.7%) subjects incurred 0, 1, 2, and 3 or more AIDS-defining illnesses, respectively. After adjustment for sex, age at seroconversion and exposure category, the Relative Risk (RR) of AIDS in the cART period was 0.38 (95%CI 0.30-0.48) compared with the 1992-95 period. The RR of the first, second and third AIDS-defining illness in the cART period were 0.40 (95% CI: 0.32-0.50), 0.27 (95% CI: 0.15-0.50) and 0.41 (95% CI: 0.18-0.96) respectively, relative to the reference calendar period when we allowed the odds ratios to vary by the number of prior AIDS-defining events. The relative risk of AIDS, taking all events into account, was 0.32 (95% CI: 0.25-0.40). Intravenous drug users have a higher risk of developing a first episode of AIDS than homosexuals, RR: 2.14 (95% CI: 1.48-3.10). CONCLUSIONS: Results indicate that the relative effect of cART appears to be both protective and stable over multiple AIDS-defining illnesses. Analysis of multiple AIDS-defining illnesses improves the precision of the estimated relative risk.

Intervención preventiva en lugares de interacción social de hombres que mantienen relaciones sexuales con otros hombres / Preventive intervention in venues for interaction used by men who have sex with men

Se realizó una intervención en saunas y pisos para contactos sexuales entre hombres que mantienen relaciones sexuales con hombres de Valencia, cuyo objetivo era prevenir la infección por el virus de la inmunodeficiencia humana (VIH) o, en su caso, evitar el retraso en el diagnóstico y facilitar el contacto con los circuitos sanitarios. Se proporcionó información sobre prevención y se efectuó la prueba rápida para el VIH y la sífilis. Se habló con 500 hombres y se realizó la intervención en 171. El 37% de los sujetos en las saunas y de cada en los pisos nunca se había realizado una prueba. La prevalencia del VIH fue del 1,6% (n=2) en las saunas y del 11% en los pisos (n=5); para la sífilis estos porcentajes fueron del 5 y el 2,3%, respectivamente. La intervención permitió detectar la existencia de bolsas de población poco atendidas y muy expuestas, y facilitó el acceso de estos sujetos al sistema sanitario (AU)

We contacted 500 men and the intervention was performed in 171; 37% of the subjects in saunas and one in four of those in prostitution apartments had never been tested. The prevalence of HIV was 1.6% (n=2) in the saunas, and 11% (n=5) in the apartments (n=5). For syphilis, these percentages were 5% and 2.3% respectively. The intervention revealed the existence of highly exposed population groups with low compliance and facilitated access to the health system in these groups (AU)

[Preventive intervention in venues for interaction used by men who have sex with men]. / Intervención preventiva en lugares de interacción social de hombres que mantienen relaciones sexuales con otros hombres.

An intervention in venues for interaction used by men who have sex with men in Valencia (Spain) was performed to prevent human immunodeficiency virus (HIV) infection or avoid delay in diagnosis and to facilitate contact with the health circuit. Information was provided on prevention and a rapid test for HIV and syphilis was performed. We contacted 500 men and the intervention was performed in 171; 37% of the subjects in saunas and one in four of those in prostitution apartments had never been tested. The prevalence of HIV was 1.6% (n=2) in the saunas, and 11% (n=5) in the apartments (n=5). For syphilis, these percentages were 5% and 2.3% respectively. The intervention revealed the existence of highly exposed population groups with low compliance and facilitated access to the health system in these groups.

Changes in the incidence of tuberculosis in a cohort of HIV-seroconverters before and after the introduction of HAART.

OBJECTIVE: To analyse incidence and determinants of tuberculosis in HIV-seroconverters before and after the introduction of HAART. METHODS: Data from a multicenter cohort study of 2238 HIV-seroconverters between the 1980s and 2004 were analysed and censored by December 2004. Calendar year at risk intervals were pre-1992, 1992-1996 and 1997-2004. Incident tuberculosis was calculated as cases per 1000 person-years (p-y). Survival analyses using Kaplan-Meier and multivariate Cox regression allowing for late-entry were used. Proportional hazards assumptions were checked with tests based on Schoenfeld residuals. RESULTS: Overall, 173 (7.7%) patients developed tuberculosis over 23 698 p-y at a rate of 7.3 cases per 1000 p-y [95% confidence interval (CI), 6.3-8.5]. Incident tuberculosis was higher in intravenous drug-users (IDUs), 12.3 per 1000 p-y compared with persons infected sexually, 3.8 per 1000 p-y (P < 0.001), and persons with clotting disorders (PCD), 2.7 per 1000 p-y (P < 0.001). A decreasing tuberculosis incidence trend was observed from 1995 in all categories. Highest tuberculosis rates, 44 per 1000 p-y, were observed prior to 1997 in IDUs infected with HIV for 11 years. In multivariable analyses women were less likely to develop tuberculosis [relative hazard (RH), 0.62; 95% CI, 0.41-0.96; P < 0.05) and IDUs were more likely to develop tuberculosis (RH, 3.0; 95% CI, 1.72-5.26, P < 0.001). In the HAART era, the hazard of developing tuberculosis was 70% lower (RH, 0.31; 95% CI, 0.17-0.54; P < 0.001). Before 1997, the risk of tuberculosis increased with time since HIV seroconversion, whereas it remained nearly constant in the HAART era. CONCLUSIONS: Since the mid-1990s important decreases in tuberculosis have been observed in HIV-seroconverters that probably reflect the impact of both HAART and tuberculosis control programmes.