"A journey towards acceptance": The process of adapting to life with HIV in Greece. A Qualitative study.

Aim To identify the experiences related to adaptation for people living with HIV in Greece and to explore different adaptation stages as well as their individual reactions. BACKGROUND: Receiving an HIV positive diagnosis leads to major changes in an individual's life and it can trigger an array of emotions including fear, despair and loss of control. As the profile of the disease has changed due to its transition into a chronic disease and extended life expectancy, adaptation to life and coping with uncertain events is of paramount importance. METHOD: Interpretative phenomenological research design was used to guide data collection and analysis. A purposive sampling technique was used. Ethical procedures were taken into account and nine individuals who were diagnosed with HIV took part in the study using semi-structured interviews. RESULTS: Data analysis revealed the different stages of adaptation that the participants experienced after an HIV positive diagnosis. A superordinate theme identified as 'a journey towards acceptance' while five subthemes were formed, namely, 'Communicating the bad news, Conscious loneliness, Getting information, Receiving Support, and Moving on with hope'. CONCLUSION: An HIV positive diagnosis can affect the very core of the individual as the essence of -self- is targeted and in need of reform. Education, empathy, family and social support can help the individual make small steps towards a greater journey, that of acceptance.

HCV Cascade of Care in HIV/HCV Co-Infected Individuals: Missed Opportunities for Micro-Elimination.

People living with HIV-HCV co-infection comprise a target group for HCV-micro-elimination. We conducted an HCV cascade of care (CoC) for HIV-HCV co-infected individuals living in Greece and investigated factors associated with different HCV-CoC stages. We analyzed data from 1213 participants from the Athens Multicenter AIDS Cohort Study. A seven-stage CoC, overall and by subgroup (people who inject drugs (PWID), men having sex with men (MSM), men having sex with women (MSW), and migrants], was constructed, spanning from HCV diagnosis to sustained virologic response (SVR). Logistic/Cox regression models were employed to identify factors associated with passing through each CoC step. Among 1213 anti-HCV-positive individuals, 9.2% died before direct-acting antiviral (DAA) availability. PWID exhibited higher mortality rates than MSM. Of 1101 survivors, 72.2% remained in care and underwent HCV-RNA testing. Migrants and PWID showed the lowest retention rates. HCV-RNA was available for 79.2% of those in care, with 77.8% diagnosed with chronic HCV. Subsequently, 71% initiated DAAs, with individuals with very low CD4 counts (<100 cells/µL) exhibiting lower odds of DAA initiation. SVR testing was available for 203 individuals, with 85.7% achieving SVR. The SVR rates did not differ across risk groups. In 2023, significant gaps and between-group differences persisted in HCV-CoC among HIV-HCV co-infected individuals in Greece.

Simultaneous Multiple-Stages Mpox Genital Lesions on the Same Site in a Traveler to Greece: A Case Report.

A 47-year-old Caucasian traveller from an mpox (formerly monkeypox and also best suited abbreviated MPX)-endemic country was referred for a skin rash, of recent onset, confined to the genital area. The rash consisted of erythematous umbilicated papules, vesicles and pustules with a characteristic white ring. The lesions were observed simultaneously at different stages of progression on the same anatomical site, a clinical presentation that is not encountered frequently. The patient was febrile, fatigued and had blood-tinged cough. The clinical suspicion of mpox was raised, and the initial real-time PCR identified a non-variola orthopox virus, which was confirmed at the National Reference Laboratory to belong to the West African clade.

Low pre-ART CD4 count is associated with increased risk of clinical progression or death even after reaching 500 CD4 cells/µL on ART.

INTRODUCTION: Clinical disadvantages of initiating ART at low CD4 counts have been clearly demonstrated but whether any excess risk remains even after reaching relatively high/safe CD4 levels remains unclear. We explore whether individuals starting ART with <500 CD4 cells/µL who increased their CD4 count above this level, have, from this point onwards, similar risk of clinical progression to serious AIDS/non-AIDS events or death with individuals starting ART with ≥500 CD4 cells/µL. METHODS: Data were derived from a multicenter cohort (AMACS). Adults, starting PI, NNRTI or INSTI based ART, in or after 2000 were eligible, provided they started ART with ≥500 ("High CD4") or started with CD4 <500 cells/µL but surpassed this threshold while on ART ("Low CD4"). Baseline was the date of ART initiation ("High CD4") or of first reaching 500 CD4 cells/µL ("Low CD4"). Survival analysis, allowing for competing risks, was used to explore the risk of progression to study's endpoints. RESULTS: The study included 694 persons in the "High CD4" and 3,306 in the "Low CD4" group. Median (IQR) follow-up was 66 (36, 106) months. In total, 257 events (40 AIDS related, 217 SNAEs) were observed. Rates of progression did not differ significantly between the two groups but the subgroup of those initiating ART with <200 CD4 cells/µL had significantly higher risk of progression after baseline, compared to those in the "High CD4" group. CONCLUSIONS: Individuals starting ART with <200 cells/µL remain on increased risk even after reaching 500 CD4 cells/µL. These patients should be closely followed.

HIV continuum of care: bridging cross-sectional and longitudinal analyses.

OBJECTIVE: The aim of this study was to propose a unified continuum-of-care (CoC) analysis combining cross-sectional and longitudinal elements, incorporating time spent between stages. DESIGN: The established 90-90-90 target follows a cross-sectional four-stage CoC analysis, lacking information on timing of diagnosis, antiretroviral therapy (ART) initiation, and viral suppression durability. METHODS: Data were derived from the Athens Multicenter AIDS Cohort Study (AMACS). In the cross-sectional CoC, we added stratification of diagnosed people with HIV (PWH) by estimated time from infection to diagnosis; of those who ever initiated ART or achieved viral suppression by corresponding current status (in 2018); and cumulative incidence function (CIF) of ART initiation and viral suppression, treating loss-to-follow-up (LTFU) as competing event. Viral suppression was defined as viral load less than 500 copies/ml. Viral suppression durability was assessed by the CIF of viral load rebound. FINDINGS: About 89.1% of PWH in 2018 were diagnosed (range of diagnoses: 1980-2018). Median time to diagnosis was 3.5 years (IQR: 1.1-7.0). Among diagnosed, 89.1% were ever treated, of whom 86.7% remained on ART. CIF of ART initiation and LTFU before ART initiation were 80.9 and 6.0% at 5 years since diagnosis, respectively. Among treated, 89.4% achieved viral suppression, of whom 87.4% were currently virally suppressed. The CIF of viral load rebound was 24.2% at 5 years since first viral suppression but substantially reduced in more recent years. INTERPRETATION: The proposed analysis highlights time gaps in CoC not evident by the standard cross-sectional approach. Our analysis highlights the need for early diagnosis and identifies late presenters as a key population for interventions that could decrease gaps in the CoC.

Changes in Body Mass Index after Initiation of Antiretroviral Treatment: Differences by Class of Core Drug.

Recent research on antiretroviral treatment (ART) for HIV suggests that integrase strand transfer inhibitors (INSTIs) cause faster weight gain compared to other drug classes. Here, we investigated changes in body mass index (BMI) and obesity prevalence after treatment initiation and corresponding differences between drug classes. Data were derived from a large collaborative cohort in Greece. Included individuals were adults who started ART, in or after 2010, while previously ART naïve and achieved virologic response within the first year of ART. Data were analysed using mixed fractional polynomial models. INSTI regimens led to the more pronounced BMI increases, followed by boosted PI and NNRTI based regimens. Individuals with normal initial BMI are expected to gain 6 kg with an INSTI regimen compared to 4 kg with a boosted PI and less than 3 kg with a NNRTI regimen after four years of treatment. Prevalence of obesity was 5.7% at ART initiation and 12.2%, 14.2% and 18.1% after four years of treatment with NNRTIs, PIs, and INSTIs, respectively. Dolutegravir or Raltegravir were associated with marginally faster BMI increase compared to Elvitegravir. INSTIs are associated with faster weight gain. INSTIs' increased risk of treatment emergent obesity and, possibly, weight-related co-morbidities should be judged against their improved efficacy and tolerability but increased clinical attention is required.

Duration of anti-treponemal immunoglobulin M seroreversion after successful syphilis treatment in HIV-positive and -negative patients.

Treponemal immunoglobulin M (IgM) antibody detection is currently among serologic tests used for syphilis diagnosis. However, the exact role of these antibodies is unclear. In this retrospective study of 326 (198 HIV positive and 128 negative) patients with early syphilis and positive IgM serology, data were analysed to investigate the time of IgM seroreversion after treatment and correlation with covariate factors. Median time of IgM seroreversion in the study population was 9 months (range 3-84, interquartile range 5-12). No statistically significant difference was observed between HIV-positive and -negative patients. At 12 months, 80.1% of the patients had a negative IgM test. At 6 months, 100% of HIV-positive patients had a fourfold decrease or greater in Venereal Disease Research Laboratory titres, but only 35.4% had a negative treponemal IgM. Secondary and early latent stage patients had a slower seroreversion of IgM (Hazard Ratio (HR) = 0.73, p = 0.064 and HR = 0.60, p = 0.023, respectively) than those with primary syphilis. A very strong association was observed of time to seroreversion of treponemal IgM with baseline VDRL titre (p < 0.001). Treponemal IgM antibody detection often cannot distinguish between active and successfully treated syphilis. Treponemal IgM may only be useful in the cases recommended in the guidelines, and in cases of untreated syphilis, it could support but not confirm the diagnosis.

Cardiovascular risk factors in HIV infected individuals: Comparison with general adult control population in Greece.

BACKGROUND: Although combined antiretroviral therapy has substantially improved the prognosis of people living with HIV (PLHIV), mortality remains higher compared to the general population, mainly due to higher prevalence of non-HIV-related comorbidities, including cardiovascular diseases (CVD). We assessed the prevalence of CVD risk and its contributing factors in adult PLHIV versus general population controls in Greece. SETTINGS: Cross-sectional comparison of PLHIV (Athens-Multicenter-AIDS-Cohort-Study; AMACS) versus general population controls (National health examination survey; EMENO). METHODS: All HIV-infected adults with ≥1 measurement of interest (blood pressure, lipids, glucose, weight, height) between 2012-2014 and all EMENO participants (2014-2016) were included. Ten-year total CVD risk was estimated using the Framingham (FRS) or the Systematic Coronary Risk Evaluation (SCORE) equations. RESULTS: 5839 PLHIV (median age:41.6 years, 85.4% males) and 4820 controls (median age:48 years, 48.4% males) were included. Adjusting for age, sex and origin, PLHIV were more likely to be current smokers (adjusted OR:1.53 [95% CI:1.35-1.74]) and dyslipidemic (aOR:1.18; [1.04-1.34]), less likely to be obese (aOR:0.44 [0.38-0.52], with no differences in hypertension, diabetes or high (≥20%) FRS but with greater odds of high (≥5%) SCORE (aOR:1.55 [1.05-2.30]). Further adjustment for educational level, anti-HCV positivity and BMI showed higher prevalence of hypertension in PLHIV. CONCLUSIONS: Despite the relative absence of obesity, PLHIV have higher prevalence of traditional CVD risk factors and higher risk of fatal CVD compared to general population. Regular screening and early management of CVD risk factors in PLHIV should be of high priority for CVD prevention.

Long-term evolution of CD4+ cell count in patients under combined antiretroviral therapy.

OBJECTIVE: Combined antiretroviral treatment (cART) results in profound immunologic improvement, but it is unclear whether CD4 cell counts return to levels similar to those of HIV-negative individuals. We explore long-term CD4 cell count evolution post-cART and its association with baseline levels, virologic suppression, pre-cART cumulative viremia and other factors. DESIGN: Data were derived from the AMACS. Included individuals were adults who started cART, at least 2003, while previously ART-naive. METHODS: Changes in CD4 cell counts were modeled through piecewise linear mixed models. RESULTS: A total of 3405 individuals were included. The majority was male (86.0%), homosexual (58.8%) with median (IQR) age at cART initiation 36 (31-44) years and a median (IQR) follow-up of 3.9 (2.0-6.9) years. Most persons (57%) starting cART with less than 200 cells/µl did not reach 600 cells/µl after 7 years of treatment. Those starting cART with 200-349 CD4 cells/µl could reach 600 cells/µl within less than 2 years of fully suppressive treatment. Probability of CD4 normalization (i.e. >800 cells/µl) after 7 years of suppressive treatment was 24 and 46% for those starting treatment with less than 200 or 200-349 CD4 cells/µl, respectively. Lower pre-cART cumulative viremia was associated with faster CD4 recovery. CD4 cell count increases after 4 years were either insignificant or very slow, irrespectively of baseline levels. CONCLUSION: cART initiation before CD4 cell count drops below 350 cells/µl is crucial for achieving normal CD4 levels. These findings underline the importance of timely diagnosis and cART initiation as the risk of both AIDS and non-AIDS-related morbidity/mortality remains increased in patients with incomplete CD4 recovery.

Prevalence of genotypic resistance to nucleoside analogues, nonnucleoside analogues, and protease inhibitors in HIV-infected persons in Athens, Greece.

The objective was to study the prevalence of genotypic resistance to nucleoside analogues (NRTIs), nonnucleoside analogues (NNRTIs), and protease inhibitors among HIV-1-infected persons in Athens, Greece. Patients followed at two HIV units were examined for prevalence of emergence of antiretroviral resistance mutations (ARMs) in this observational study where complete therapy history was available. All mutations were recorded according to the October/November 2005 IAS-USA Drug Resistance Mutations Figures. A total of 234 patients underwent genotypic testing of 2069 followed (1987-2004). The most frequent ARMs of each drug category were to NRTIs at codons M184V [present in 149 tests (63.6%)], M41L [79 (33.8%)], K70R [66 (28.2%)], M184VI [58 (24.8%)], T215YF [53 (22.7%)], D67N [82 (35.0%)], T215Y [72 (30.8%)], K219Q [47 (20.1%)], K219E/Q [54 (23.1%)], and L210W [49 (20.9%)], respectively. The most prevalent mutations related to NNRTIs were K103N [present in 59 tests (25.2%)], G190A [50 (21.4%)], and Y181C [48 (20.5%]. Mutations in the protease gene showed that the ARM at residue L63P was the most prevalent present in 119 samples (50.9%). L90M (26.5%) was among the most frequently observed single key protease mutations in our series, although variables of V82 and I54 amino acid substitutions were more frequent. M184V (63.6%) and K103N (25.2%) were the most frequent mutations related to NRTIs and NNRTIs, respectively.

HIV cascade of care in Greece: Useful insights from additional stages.

BACKGROUND: Aiming to eliminate HIV infection, UNAIDS has set a global "90-90-90" target by 2020. We sought to construct a 6-stages HIV Cascade of Care (CoC) in Greece, overall and by risk group, to assess risk-group and stage-specific progress in achieving the UNAIDS target. PATIENTS AND METHODS: Combining data from the HIV/AIDS surveillance system and a population-based HIV cohort study, the CoC included: i) number of people living with HIV (PLHIV) by end of 2013; ii) proportion of PLHIV ever diagnosed; iii) proportion of diagnosed linked-to-care iv) proportion of linked-to-care ever initiating antiretroviral therapy (ART); v) proportion of treated who retained-in-care vi) proportion of those retained-in-care who were virally suppressed (≤200 copies/mL) at their last visit (01/07/2012-31/12/2013). RESULTS: In 2013, 14147 PLHIV were in Greece. Overall, proportions of each stage in the cascade were: 78.4% diagnosed; 86% linked-to-care; 78.5% initiated ART; 86.4% retained-in-care, and 87.1% virally suppressed. Totally, 42.6% of all PLHIV were virally suppressed. The percentage diagnosed was lower among heterosexual men and women (heterosexuals) than in MSM (men who have sex with men) or PWID (people who inject drugs). Most MSM were linked to care (97.2% of diagnosed) while a substantial proportion of PWID were not (80.8% of diagnosed). Once treated, PWID remained in care in similar proportions to MSM. Unlike PWID, a high proportion of the retained in care MSM and heterosexuals achieved viral suppression. CONCLUSIONS: At the end of 2013, we identified gaps in the HIV CoC in Greece, which differed across risk groups. Targeted interventions are critical in optimizing early diagnosis and timely linkage. A 6-stage CoC, stratified by risk group, can inform strategic public health planning in improving HIV treatment outcomes.