TERT single nucleotide polymorphism rs2736098 but not rs2736100 is associated with telomere length in HIV-infected patients on cART

BACKGROUND

Continuous application of "combination antiretroviral therapy" (cART) has transformed Human immunodeficiency virus (HIV) infection into a manageable chronic disease; however, due to lasting inflammation and cumulative toxicity, progressive pathophysiological changes do occur and potentially lead to accelerated aging, among others, contributing to telomere shortening. The single nucleotide polymorphisms (SNP) rs2736100 and rs2736098 are particularly important for human telomerase (TERT) gene expression. The objective of this study was to evaluate the effects of clinical parameters and single nucleotide polymorphisms in TERT (rs2736100 and rs2736098) on telomere length in HIV-infected patients.

METHODS AND RESULTS

This cross-sectional study included 176 patients diagnosed with HIV infection. Relative telomere length (RTL) was determined by real-time polymerase chain reaction (qPCR), whereas genotyping was performed by polymerase chain reaction, followed by restriction fragment length polymorphism analysis (PCR-RFLP). The mean age of the patients (p = .904), time since HIV diagnosis (p = .220), therapy-related variables such as the cART regimen (0.761), and total cART duration (p = .096) did not significantly affect RTL. TERT rs2736100 genotype showed no association with RTL. However, TERT rs2736098 heterozygotes (GA) had significantly longer telomeres (P = .049) than both homozygotes (GG and AA).

CONCLUSIONS

Our findings support the fact that cellular aging in HIV-infected patients is influenced by the TERT rs2736098 polymorphism.

Association between Combination Antiretroviral Therapy and Telomere Length in People Living with Human Immunodeficiency Virus

Long-term exposure to combination antiretroviral therapy (cART) may be associated with accelerated ageing. Telomere length is considered to be reliable aging biomarker. The aim of this study was to compare patients' relative telomere length (RTL) between and within different cART classes and to estimate the impact of certain HIV-related variables on RTL. The study was conducted in 176 HIV-infected male patients receiving cART, with ≤50 copies HIV RNA/mL plasma. RTL was determined from mononuclear cells by quantitative polymerase chain reaction. Standard statistical tests and unsupervised machine learning were performed. The mean RTL was 2.50 ± 1.87. There was no difference (p = 0.761) in RTL between therapeutic groups: two nucleoside reverse transcriptase inhibitors as the backbone treatment, combined with either integrase inhibitor, protease inhibitor, or non-nucleoside reverse transcriptase inhibitor (NNRTI). Machine learning results suggested duration of HIV infection, CD4+ T-cell count, and cART, including NNRTI, as potentially significant variables impacting RTL. Kendall's correlation test excluded duration of HIV infection (p = 0.220) and CD4+ T-cell count (p = 0.536) as significant. The Mann-Whitney test confirmed that cART containing NNRTI impacted RTL (p = 0.018). This was the first study to show that patients using efavirenz within cART had significantly shorter telomeres than patients using nevirapine.

Chronic Kidney Disease and Nephrology Care in People Living with HIV in Central/Eastern Europe and Neighbouring Countries-Cross-Sectional Analysis from the ECEE Network

Chronic kidney disease (CKD) is a significant cause of morbidity and mortality among patients infected with human immunodeficiency virus (HIV). The Central and East Europe (CEE) region consists of countries with highly diversified HIV epidemics, health care systems and socioeconomic status. The aim of the present study was to describe variations in CKD burden and care between countries. The Euroguidelines in the CEE Network Group includes 19 countries and was initiated to improve the standard of care for HIV infection in the region. Information on kidney care in HIV-positive patients was collected through online surveys sent to all members of the Network Group. Almost all centres use regular screening for CKD in all HIV (+) patients. Basic diagnostic tests for kidney function are available in the majority of centres. The most commonly used method for eGFR calculation is the Cockcroft-Gault equation. Nephrology consultation is available in all centres. The median frequency of CKD was 5% and the main cause was comorbidity. Haemodialysis was the only modality of treatment for kidney failure available in all ECEE countries. Only 39% of centres declared that all treatment options are available for HIV+ patients. The most commonly indicated barrier in kidney care was patients' noncompliance. In the CEE region, people living with HIV have full access to screening for kidney disease but there are important limitations in treatment. The choice of dialysis modality and access to kidney transplantation are limited. The main burden of kidney disease is unrelated to HIV infection. Patient care can be significantly improved by addressing noncompliance.

Helicobacter pylori infection rates in dyspeptic Serbian HIV-infected patients compared to HIV-negative controls

Helicobacter pylori infection does not belong to the spectrum of opportunistic infections in people living with HIV (PLHIV). To evaluate the Helicobacter pylori infection prevalence rate trends in HIV co-infected individuals in comparison to the HIV-negative population, we compared histopathological findings of H. pylori positive gastritis (gastritis topography and histopathology) between 303 PLHIV and 2642 HIV-negative patients who underwent esophagogastroduodenoscopy (EGD) between 1993 and 2014 due to dyspeptic symptoms. The prevalence of H. pylori infection was significantly higher in HIV-negative controls than in PLHIV (50.2% vs. 28.1%). A significantly positive linear trend of H. pylori co-infection in PLHIV was revealed in the observed period (b = 0.030, SE = 0.011, p = 0.013), while this trend was significantly negative in HIV-negative patients (b = - 0.027, SE = 0.003, p < 0.001). Patients with HIV/H. pylori co-infection had significantly higher CD4⁺ T cell counts and more often had undetectable HIV viremia, due to successful anti-retroviral therapy (ART). Stomach histopathological findings differed between HIV co-infected and H. pylori mono-infected patients. Our findings confirm that the ART has changed the progression of HIV infection, leading to a significant increase in the prevalence of H. pylori infection in dyspeptic PLHIV over time. Our data also suggests that a functional immune system may be needed for H. pylori-induced human gastric mucosa inflammation.

Clinical Outcomes in Persons Coinfected With Human Immunodeficiency Virus and Hepatitis C Virus: Impact of Hepatitis C Virus Treatment

BACKGROUND

A hepatitis C (HCV) cure is associated with changes in lipids and inflammatory biomarkers, but its impact on clinical endpoints among treated human immunodeficiency virus (HIV)/HCV coinfected persons is unclear.

METHODS

People living with HIV from EuroSIDA with a known HCV status after January 2001 were classified into strata based on time-updated HCV RNA measurements and HCV treatment, as either HCV antibody-negative; spontaneously resolved HCV; chronic, untreated HCV; cured HCV (HCV RNA-negative); or HCV treatment failures (HCV RNA-positive). Poisson regression was used to compare incidence rates between HCV groups for end-stage liver disease (ESLD; including hepatocellular carcinoma [HCC]), non-acquired immunodeficiency virus defining malignancy (NADM; excluding HCC), and cardiovascular disease (CVD).

RESULTS

There were 16 618 persons included (median follow-up 8.3 years, interquartile range 3.1-13.7). There were 887 CVD, 902 NADM, and 436 ESLD events; crude incidence rates/1000 person-years follow-up were 6.4 (95% confidence interval [CI] 6.0-6.9) for CVD, 6.5 (95% CI 6.1-6.9) for NADM, and 3.1 (95% CI 2.8-3.4) for ESLD. After adjustment, there were no differences in incidence rates of NADM or CVD across the 5 groups. HCV-negative individuals (adjusted incidence rate ratio [aIRR] 0.22, 95% CI 0.14-0.34) and those with spontaneous clearance (aIRR 0.61, 95% CI 0.36-1.02) had reduced rates of ESLD compared to cured individuals. Persons with chronic, untreated HCV infections (aIRR 1.47, 95% CI 1.02-2.13) or treatment failure (aIRR 1.80, 95% CI 1.22-2.66) had significantly raised rates of ESLD, compared to those who were cured.

CONCLUSIONS

Incidences of NADM or CVD were independent of HCV group, whereas those cured had substantially lower incidences of ESLD, underlining the importance of successful HCV treatment for reducing ESLD.

Where are we with pre-exposure prophylaxis use in Central and Eastern Europe? Data from the Euroguidelines in Central and Eastern Europe (ECEE) Network Group

OBJECTIVES

Pre-exposure prophylaxis (PrEP) for HIV infection is an important intervention for control of the HIV epidemic. The incidence of HIV infection is increasing in the countries of Central and Eastern Europe (CEE). Therefore, we investigated the change in PrEP use in CEE over time.

METHODS

The Euroguidelines in Central and Eastern Europe (ECEE) Network Group was initiated in February 2016 to compare standards of care for HIV and viral hepatitis infections in CEE. Data on access to PrEP were collected from 23 countries through online surveys in May-June 2017 (76 respondents) and in November 2018-May 2019 (28 respondents).

RESULTS

About 34.2% of respondents stated that tenofovir/emtricitabine (TDF/FTC) was licensed for use in their country in 2017, and 66.7% that it was licensed for use in 2018 (P = 0.02). PrEP was recommended in national guidelines in 39.5% of responses in 2017 and 40.7% in 2018 (P = 0.378). About 70.7% of respondents were aware of "informal" PrEP use in 2017, while 66.6% were aware of this in 2018 (P = 0.698). In 2018, there were 53 centres offering PreP (the highest numbers in Poland and Romania), whereas six countries had no centres offering PreP. The estimated number of HIV-negative people on PreP in the region was 4500 in 2018. Generic TDF/FTC costs (in Euros) ranged from €10 (Romania) to €256.92 (Slovakia), while brand TDF/FTC costs ranged from €60 (Albania) to €853 (Finland).

CONCLUSIONS

Although the process of licensing TDF/FTC use for PrEP has improved, this is not yet reflected in the guidelines, nor has there been a reduction in the "informal" use of PrEP. PrEP remains a rarely used preventive method in CEE countries.

Severe hepatotoxicity induced by efavirenz in a treatment-naïve, low body mass index HIV-infected, female patient with no hepatitis and other virus co-infections

Combined antiretroviral therapy (cART) consisting of two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI), such as efavirenz, is still the first-line treatment in resource-limited settings. However, efavirenz has shown strong prominence of disadvantages with variance in plasma concentration and central nervous side effects. Our study presents HIV infected, drug naïve, female patient with relatively low BMI, CYP2B6 516G>T (rs3745274) genotype with high efavirenz plasma concentration. In this case report, the patient was admitted at the hospital 6 months after cART initiation with drug-induced severe hepatotoxicity. Furthermore, pathophysiological findings proved confluent parenchymal necrosis after aspiration liver biopsy, with mild to moderate inflammation in portal tracts with focal interface hepatitis. All other possible causes were excluded. Thus, we conclude that efavirenz has a potential harmful effect in patients with low BMI, specific genotyping and interindividual pharmacokinetics affecting high plasma concentration.

Uptake of tenofovir-based antiretroviral therapy among HIV-HBV-coinfected patients in the EuroSIDA study

BACKGROUND

According to guidelines all HIV-HBV-coinfected patients should receive tenofovir-based combination antiretroviral therapy (cART). We aimed to investigate uptake and outcomes of tenofovir-based cART among HIV-HBV patients in the EuroSIDA study.

METHODS

All hepatitis B surface antigen (HBsAg)+ patients followed up after 1 March 2002 were included. Changes in the proportion taking tenofovir-based cART over time were described. Poisson regression was used to investigate the relationship between tenofovir use and clinical events.

RESULTS

953 HIV-HBV patients were included. Median age was 41 years and patients were predominantly male (85%), White (82%) and ART-experienced (88%). 697 and 256 were from Western and Eastern Europe, respectively. 55 started cART during follow-up, the proportion starting with CD4⁺ T-cell count <350 cells/mm³ decreased from 85% to 52% in the periods 2002-2006 to 2007-2015. Tenofovir use, among those taking cART, increased from 4% in 2002 to 73% in 2015. Compared to West, tenofovir use was lower in East in 2005 (7% versus 42%), and remained lower in 2015 (63% versus 76%). Among 602 patients taking tenofovir-based cART during follow-up, 155 (26%) discontinued tenofovir. 27 of all discontinuations were due to adverse effects. Only 14 started entecavir and/or adefovir after tenofovir discontinuation, whereas 10 started pegylated interferon. Tenofovir use was not significantly associated with lower risk of liver-related clinical events (n=51), adjusted incidence rate ratio (IRR) 0.64 (95% CI 0.35, 1.18) for comparing patients on tenofovir with those off tenofovir.

CONCLUSIONS

Although use of tenofovir-based cART among HIV-HBV patients has increased across Europe, a substantial proportion are still starting cART late and are receiving suboptimal HBV therapy.

Comparison of Demographic, Epidemiological, Immunological, and Clinical Characteristics of Patients with HIV Mono-infection Versus Patients Co-infected with HCV or/and HBV: A Serbian Cohort Study

OBJECTIVE

The study aimed to correlate the status of hepatitis C (HCV) and hepatitis B virus (HBV) co-infection in patients with human immunodeficiency virus (HIV) infection with clinical and demographic data prior to starting highly active antiretroviral therapy (HAART) and assess the impact of HCV and HBV co-infection on the natural history of HIV infection.

PATIENTS AND METHODS

The study involved a total of 836 treatment-naive patients with available serological status for HBV and HCV at the point of therapy initiation. Patients were stratified into four groups: HIV mono-infection, HIV/HCV, HIV/HBV, and HIV/HCV/HBV co-infection. Demographic, epidemiological, immunological and clinical characteristics were analyzed in order to assess the possible impact of HCV and HBV co-infection on HIV - related immunodeficiency and progression to AIDS.

RESULTS

The prevalence of HCV and HBV co-infection in our cohort was 25.7% and 6.3%, respectively. Triple HIV/HCV/HBV infection was recorded in 1.7% of the patients. In comparison with those co-infected with HCV, patients with HIV mono-infection had lower levels of serum liver enzymes activity and higher CD4 cell counts, and were less likely to have CD4 cell counts below100 cells/µL and clinical AIDS, with OR 0.556 and 0.561, respectively. No difference in the development of advanced immunodeficiency and/or AIDS was recorded between patients with HIV monoinfection and those co-infected with HBV, or both HCV/HBV.

CONCLUSION

HIV/HCV co-infection was found to be more prevalent than HIV/HBV co-infection in a Serbian cohort. Co-infection with HCV was related to more profound immunodeficiency prior to therapy initiation, reflecting a possible unfavorable impact of HCV on the natural history of HIV infection.

Influenza A H1N1 virus infection among pregnant women in a tertiary hospital in Belgrade, Serbia

INTRODUCTION

Pregnant women are at higher risk of developing severe influenza. Our aim was to analyze clinical course and risk factors for fatal outcome in pregnant women with influenza (H1N1) infection.

METHODOLOGY

This retrospective study enrolled eleven pregnant women with confirmed Influenza A (H1N1) infection treated in the Clinic for Infectious and Tropical Diseases, Belgrade, Serbia in a 6-years period.

RESULTS

The mean age of pregnant women was 28.9 ± 5.2 years, and mean gestational age was 23.1 ± 7.0 weeks. Nine (81.8%) pregnant women had pneumonia (six had interstitial and three had bacterial pneumonia). Pregnant women developed pneumonia more often than other women in the reproductive period, but without statistical significance (81.8% vs. 65.7%, p = 0.330, OR (95% CI) 2.35 (0.47-11.80)). Nine (81.8%) pregnant women recovered. None of them experienced preterm delivery or abortion. Two women (18.2%) died due to acute respiratory distress syndrome. In one of them fetal death occurred one day before she died. The other one was performed caesarean section three days before death. Her newborn and children of all recovered women were healthy at birth. Prolonged time to initiation of oseltamivir and higher body mass index were statistically significantly associated with fatal outcome (p = 0.002, and p = 0.007, respectively). Gestational week of pregnancy, the etiology of pneumonia and comorbidity were not found to be risk factors for death (p = 0.128, p = 0.499 and p = 1.000, respectively).

CONCLUSION

Pregnant women with H1N1 infection are at higher risk of pneumonia and death than other women in the reproductive period. Early antiviral therapy reduces the risk of unfavorable outcome.

Analysis of variability of urinary excreted JC virus strains in patients infected with HIV and healthy donors

In immunocompromised individuals, especially in patients with T cell immunodeficiency, reactivation of JCPyV can cause serious life-threatening diseases. Nowadays, HIV infection is one of the most important factor for reactivation of JCPyV and the development of of the progressive multifocal leukoencephalopathy (PML). Mutations in the outer loops of the VP1 region can lead to the selection of the viral variants with changed tropism and increased pathological potential. The aims of this study were to determine sequence variation and amino acid changes within VP1 loops and the structure of non-coding control region (NCCR) of urinary excreted JCPyV isolates among HIV-infected patients and healthy donors. Single urine samples from 114 HIV-infected patients and 120 healthy donors were collected. PCR was performed for amplification of VP1 and NCCR. Amplified fragments were directly sequenced and analyzed by using bioinformatics tools. Nucleotide substitutions were detected within DE and EF loops and in the β-sheets of both studied groups. In HIV-infected patients group, 70% of mutations were detected within receptor domains. Among healthy donors, one mutation was identified within β-sheets while the remaining were located within receptor domains. The most prevalent mutation was L157V in both groups. Analysis of NCCR revealed that all isolates had archetype structure with some minor changes. Since single point mutations at specific place within outer loop of VP1 region can cause formation of variants with changed receptor specificity, identification of these mutations in HIV-infected patients can help to single out those with higher risk for development of polyomavirus-associated diseases.

High Frequency of Human Leukocyte Antigen-B*57:01 Allele Carriers among HIV-Infected Patients in Serbia

Abacavir is an effective antiretroviral drug and one of the most commonly used nucleoside reverse transcriptase inhibitors in Serbia. А percentage of the treated patients experience a potentially life-threatening hypersensitivity reaction, which was shown to be associated with the presence of the class I MHC allele, HLA-B*57:01; hence genotyping for HLA-B*57:01 prior to starting abacavir is nowadays recommended in international HIV treatment guidelines. In Serbia, this testing became available in 2013. This study was designed to estimate the prevalence of the HLA-B*57:01 allele in Serbian HIV-1-infected patients. The presence of the HLA-B*57:01 allele was analyzed in 273 HIV-1-infected patients aged 18 years or more, who were abacavir naïve. Buccal swab samples were obtained from all participants and assayed for the presence of HLA-B*57:01 using a commercially available HLA-B*57:01 real-time PCR kit. The presence of the HLA-B*57:01 allele was found in 22 of 273 tested individuals (8%; 95% CI 5.4-11.9%). This is the first study that estimated the HLA-B*57:01 prevalence among HIV-infected patients in Serbia. The very high prevalence of HLA-B*57:01 found in our study strongly supports HLA-B*57:01 genotyping, which should be implemented prior to the initiation of an abacavir-containing therapy to reduce the risk of potentially life-threatening hypersensitivity reactions.

Intravenous drug use - an independent predictor for HCV genotypes 3 and 4 infection among HIV/HCV co-infected patients

INTRODUCTION

About one quarter of human immunodeficiency virus (HIV) infected persons in Serbia have also been found to be hepatitis C virus (HCV) co-infected. In the general population, HCV genotype 1 has been shown to be the most prevalent one. Here, we present the first study on the distribution of HCV genotypes among HIV/HCV co-infected patients in Serbia, in relation to epidemiological and clinical features.

MATERIAL AND METHODS

The study included HIV/HCV co-infected and a group of HCV mono-infected patients in the period 1998-2012, with collection of epidemiological, clinical, and behavioral data using a standardized questionnaire. The HCV genotyping to the level of pure genotype was performed by reverse hybridization.

RESULTS

Intravenous drug use (IDU) was found to be significantly more prevalent among the co-infected patients (p < 0.01). HCV genotype 1 was detected in 87% of patients with mono-infection, compared to 46.3% of patients with co-infection (p < 0.01); genotypes 3 and 4 were significantly more common among co-infected patients (6% and 5%, vs. 27% and 25%, respectively). Multivariate logistic regression confirmed IDU, infection with non-1 HCV genotype and HCV viral load over 5 log to be predictors of HIV co-infection.

CONCLUSIONS

The HCV genotypes 3 and 4 were found to be significantly more prevalent among HIV/HCV co-infected patients in Serbia, compared to HCV mono-infected patients, but also more prevalent compared to the European HIV/HCV co-infected cohort. History of IDU represents an independent predictor of HCV genotypes 3 and 4 infection, with important implications for treatment.

Correlation of Leptin, Adiponectin, and Resistin Levels in Different Types of Lipodystrophy in HIV/AIDS Patients

BACKGROUND

Leptin, adiponectin, and resistin may play an important role in the development of lipodystrophy (LD) in HIV/AIDS patients. The aim of this study was to correlate levels of leptin, adiponectin, and resistin between HIV/AIDS patients with LD and without lipodystrophy (non-LD), as well as between subgroups of LD [lipoatrophy (LA), lipohypertrophy (LH), and mixed fat redistribution (MFR)] and non-LD patients.

METHODS

Cross-sectional study of 66 HIV/AIDS patients. Serum levels of leptin, adiponectin, and resistin were measured. The associations between adipocytokine levels and metabolic variables were estimated by Spearman correlation. Analysis of covariance with bootstrapping method was used to examine the relationship between adiponectin and leptin and lipodystrophy categories.

RESULTS

The LD was observed in 29 (44%) patients, while 15 (52%) of them had LA, 4 (14%) had LH, and 10 (34%) patients had MFR. No significant differences regarding leptin, adiponectin, and resistin levels, between LD and non-LD patients, were observed. LH patients had significantly higher levels of leptin and adiponectin in comparison with non-LD patients (P = 0.039, P = 0.011, respectively). Within the LD group, LA patients had significantly lower levels of leptin (LA vs. LH, P = 0.020; LA vs. MFR, P = 0.027), while LH patients had significantly higher levels of adiponectin (LH vs. LA, P = 0.027; LH vs. MFR, P = 0.028). Correlation of adiponectin with LD remains significant in the LH subgroup after adjustment for age, body mass index, cystatin-C, plasminogen activator inhibitor-1 (PAI-1), and interferon gamma (IFN-γ) (P = 0.001).

CONCLUSIONS

Adiponectin and leptin levels differ significantly between LH patients and non-LD patients, as well as between the LD subgroups. Adiponectin may be a more useful marker of LD in HIV/AIDS patients.

Forensic application of phylogenetic analyses - Exploration of suspected HIV-1 transmission case

Transmission of human immunodeficiency virus (HIV) between individuals may have important legal implications and therefore may come to require forensic investigation based upon phylogenetic analysis. In criminal trials results of phylogenetic analyses have been used as evidence of responsibility for HIV transmission. In Serbia, as in many countries worldwide, exposure and deliberate transmission of HIV are criminalized. We present the results of applying state of the art phylogenetic analyses, based on pol and env genetic sequences, in exploration of suspected HIV transmission among three subjects: a man and two women, with presumed assumption of transmission direction from one woman to a man. Phylogenetic methods included relevant neighbor-joining (NJ), maximum likelihood (ML) and Bayesian methods of phylogenetic trees reconstruction and hypothesis testing, that has been shown to be the most sensitive for the reconstruction of epidemiological links mostly from sexually infected individuals. End-point limiting-dilution PCR (EPLD-PCR) assay, generating the minimum of 10 sequences per genetic region per subject, was performed to assess HIV quasispecies distribution and to explore the direction of HIV transmission between three subjects. Phylogenetic analysis revealed that the viral sequences from the three subjects were more genetically related to each other than to other strains circulating in the same area with the similar epidemiological profile, forming strongly supported transmission chain, which could be in favour of a priori hypothesis of one of the women infecting the man. However, in the EPLD based phylogenetic trees for both pol and env genetic region, viral sequences of one subject (man) were paraphyletic to those of two other subjects (women), implying the direction of transmission opposite to the a priori assumption. The dated tree in our analysis confirmed the clustering pattern of query sequences. Still, in the context of unsampled sequences and inherent limitations of the applied methods, we cannot unambiguously prove that HIV-1 transmission occurred directly between two individuals. Further exploration of the known and suspected transmission cases is needed in order to define methodologies and establish their reliability.

Rubella immune status of neonates - a window towards seroprevalence among childbearing women

BACKGROUND

When contracted in pregnancy, rubella may cause serious chronic infection of the fetus and development of Congenital Rubella Syndrome. Despite widespread application of rubella vaccination, periodical outbreaks are still being reported worldwide. The aim of this study was to determine rubella seroprevalence and antibody levels in neonates in Serbia as a proxy of maternal serostatus.

METHODS

ELISA based serological testing for rubella was done in 599 neonates treated at the Institute of Neonatology in Belgrade, from January 2010 to December 2011. All individuals with rubella IgG concentration ≥10 IU/ml were considered seropositive for rubella.

RESULTS

The mean age of enrolled neonates was 18 ± 6 days. The overall seroprevalence of rubella IgG antibodies among the tested neonates was 540/599(90.2 %, 95 % CI: 87.5-92.3). Seropositivity rate among sera of the neonates enrolled in 2010 was significantly higher than those collected in 2011 (p < 0.0001). There was no difference in average maternal age, gestational age or frequency of receiving blood products among the two study years. Significant high seropositivity rate was observed among neonates from mother aged >30 as compared to those from mothers aged <20 years (p = 0.02). Significant difference was also found between average IgG titers in the two study years (79 IU/mL in 2010 vs. 46 IU/mL in 2011, p < 0.0001).

CONCLUSION

We report on high rubella seroprevalence among newborns in Serbia, as a proxy of rubella serostatus of childbearing aged women. Notably, declining trend of rubella antibodies toward diminishing titers suggest the importance of sustained rubella serosurvey and antenatal screening at the national level.

Proceedings of The 8th Romanian National HIV/AIDS Congress and The 3rd Central European HIV Forum : Sibiu, Romania. 5-7 May 2016

O1 HIV-1 diversity in Bulgaria (current molecular epidemiological picture)

Ivailo Alexiev, Reneta Dimitrova, Anna Gancheva, Asya Kostadinova, Mariyana Stoycheva, Daniela Nikolova, Ivaylo Elenkov

O2 Knowledge, attitudes and practices of the general population on HIV/AIDS, hepatitis B and C in Romania

Cătălin Tilișcan, Mioara Predescu, Bogdan Păunescu, Anca Streinu-Cercel, Oana Săndulescu, Claudiu Mihai Șchiopu, Mădălina Hristache, Lăcrămioara Aurelia Brîndușe, Adrian Streinu-Cercel

O3 The prevalence of human leukocyte antigen-B*57:01 allele carriers and CXCR4 tropism among newly diagnosed HIV infected patients in Serbia

Marija Todorovic, Marina Siljic, Dubravka Salemovic, Valentina Nikolic, Ivana Pesic-Pavlovic, Jovan Ranin, Djordje Jevtovic, Maja Stanojevic

O4 HIV transmission among stable serodiscordant couples from the former Pediatric Cohort follow up in the National Institute of Infectious Diseases

Ana Maria Tudor, Delia Vlad, Mariana Mărdărescu, Sorin Petrea, Cristina Petre, Ruxandra Neagu-Drăghicenoiu, Rodica Ungurianu, Alina Cibea, Odette Chirilă, Cristian Anghelina, Ileana Coserea

O5 Unemployment is associated with syringe sharing among people who inject drugs in Greece

Pantelia-Amalia Krikelli, Eirini Pavlitina, Mina Psichogiou, Demetris Lamnisos, Leslie Williams, Anya Korobchuk, Britt Skaathun, Pavlo Smyrnov, John Schneider, Vana Sypsa, Dimitrios Paraskevis, Angelos Hatzakis, Samuel R. Friedman, Georgios K. Nikolopoulos

O6 Correlation of adipocytokine levels in different types of lipodystrophy in HIV/AIDS patients

Gordana Dragović, Danica Srdić, Al Musalhi Khawla, Ivan Soldatović, Jelena Nikolić, Djordje Jevtović, Devaki Nair

O7 IP10 – a possible biomarker for the progression of HIV infection

Aura Temereanca, Adelina Rosca, Luminita Ene, Benchawa Soontornniyomkij, Carmen Diaconu, Claudia Dita, Cristian Achim, Simona Ruta

O8 A permanent challenge: persistent low viremia in HIV positive patients on ART

Șerban Benea, Ruxandra Moroti, Raluca Jipa, Eliza Manea, Andrada Stan, Elisabeta Benea, Dan Oțelea, Adriana Hristea

O9 Infections in IDUs according to their HIV status

Adriana Hristea, Irina Lăpădat, Raluca Jipa, Ruxandra Moroti, Șerban Benea, Doina Antonică, Irina Panait, Roxana Petre

O10 Trends in combined antiretroviral therapy used in methadone program integrated with HIV care - 20 years of experience

Justyna D. Kowalska, Ewa Pietraszkiewicz, Ewa Grycner, Ewa Firlag-Burkacka, Andrzej Horban

O11 Extracellular cyclophilin A – inflammatory mediator in HIV infected patients

Ovidiu Vlaicu, Leontina Bănică, Simona Paraschiv, Ana-Maria Tudor, Ruxandra Moroti, Dan Oțelea

O12 High cardiovascular disease risk in Serbian population, an issue of concern

Bojana Dimitrijević, Ivan Soldatović, Đorđe Jevtović, Jovana Kusić, Dubravka Salemović, Jovan Ranin, Gordana Dragović

O13 Genotypic rifampicin resistance in HIV/ tuberculosis coinfected patients from a tertiary level infectious diseases hospital

Dragoș Florea, Ioana Bădicuț, Alexandru Rafila, Cornel Camburu, Adriana Histrea, Mihaela Frățilă, Dan Oțelea

O14 Occurrence of residual HCV RNA in liver and peripheral blood mononuclear cells among patients with chronic hepatitis C infection and/or HCV/HIV coinfection after IFN-based therapy

Ivana Gmizic, Dubravka Salemovic, Ivana Pesic-Pavlovic, Marina Siljic, Valentina Nikolic, Miljana Djonin-Nenezic, Ivana Milosevic, Branko Brmbolic, Maja Stanojevic

O15 Romanian nationwide screening for infection with HIV and hepatitis B and C viruses

Anca Streinu-Cercel, Oana Săndulescu, Alina Cristina Neguț, Mioara Predescu, Alexandra Mărdărescu, Mihai Săndulescu, Adrian Streinu-Cercel

O16 Treatment emergent variants to combined direct antiviral agents therapy against hepatitis C virus

Ana Belen Pérez, Natalia Chueca, Marta Álvarez, Juan Carlos Alados, Antonio Rivero, Francisco Vera, Marcial Delgado, Javier Salmeron, Miguel Jiménez, Maria José Blanco, Moises Diago, Miguel Garcia-deltoro, Marta Alvarez, Francisco Téllez, Federico García

O17 Clinical and epidemiological aspects in tuberculosis/HIV coinfected patients

Diana Tănase, Eliza Manea, Rodica Bacruban, Dragoș Florea, Dan Oțelea, Alexandru Rafila, Mariana Mărdărescu, Adriana Hristea

O18 Resistance to NS3 protease inhibitors in persons with chronic hepatitis C infected with hepatitis C virus subtype 1a from Croatia

Ivana Grgic, Ana Planinic, Maja Santak, Lana Gorenec, Snjezana Zidovec Lepej, Adriana Vince

O19 Analysis of a simplified diagnostic score for tuberculous meningitis in HIV-infected adults with meningitis

Eliza Manea, Adriana Hristea, Șerban Benea, Ruxandra Moroti, Diana Tănase, Cristian M. Niculae, Simona Merisor, Raluca Jipa

O20 Molecular tracing of the origin of HIV-1 infection among persons who inject drugs in Athens: a phyloethnic study

Dimitrios Paraskevis, Evangelia Kostaki, Georgios K. Nikolopoulos, Vana Sypsa, Mina Psichogiou, Dimitra Paraskeva, Athanassios Skoutelis, Meni Malliori, Samuel R. Friedman, Angelos Hatzakis

O21 The dynamics of virological response to HIV-1 infection and antiretroviral therapy initiation in patients with and without HLA-B*5701 Allele

Malgorzata Hackiewicz, Piotr Zabek, Ewa Firlag-Burkacka, Andrzej Horban, Justyna Dominika Kowalska

O22 Increase in the numbers of non-B subtypes and potential recombinant forms circulating among Slovenian MSM in the recent years

Maja M. Lunar, Jana Mlakar, Mario Poljak

O23 Genotyping intrahost polymorphisms in hepatitis C virus E2 protein associated with resistance to antibody neutralization

Leontina Bănică, Eliza Martin, Valeriu Gheorghiță, Andrei Petrescu, Dan Oțelea, Costin-Ioan Popescu, Simona Paraschiv

O24 Genotyping of HCV NS3 protease inhibitors resistance and phenotyping of rare double resistance mutations in HCV cell culture system

Emil Neaga, Vlaicu Ovidiu, Andrei Juncu, Leontina Bănică, Simona Paraschiv, Dan Oțelea, Costin-Ioan Popescu

O25 Employment status controls the relationship between neurocognitive impairment and depression in a cohort of young HIV-infected adults since childhood

Adrian Luca, Florin Lazăr, Anca Elena Luca, Luminița Ene, Cristian Achim

O26 Predictors of survival in parenterally-infected HIV positive children and youth diagnosed with progressive multifocal leukoencephalopathy

Cosmina Gingăraş, Ștefan Adrian Anton, Roxana Rădoi, Simona Tetradov, Grațiela Țârdei, Maria Nica, Razvan Alexandru Capşa, Cristian L. Achim, Cristiana Oprea, Luminița Ene

O27 Neurocognitive and brain functioning in HIV-infected young MSM treated with cART

Bogna Szymańska, Natalia Gawron, Agnieszka Pluta, Emilia Łojek, Ewa Firląg – Burkacka, Andrzej Horban, Robert Bornstein, et HARMONIA3 Study Group

O28 Clinical value of RT-PCR detection of Toxoplasma gondii DNA in cerebrospinal fluid

Olivia Burcoș, Simona Manuela Erscoiu, Filofteia Bănicioiu Cojanu, Andreea Toderan, Maria Nica, Ionuț Cristian Popa, Emanoil Ceaușu, Petre Iacob Calistru

O29 Characteristics of sleep disorders in Romanian adults infected with human immunodeficiency virus

Manuela Arbune, Mirela Alexandrache, Anca-Adriana Arbune, Doina-Carina Voinescu

O30 Diagnosing neuroHIV: the rift between clinicians and pathologists

Ioan-Alexandru Diaconu, Laurențiu Stratan, Victoria Aramă, Luciana Nichita, Alexandra Diaconu, Anca Negru, Alina Orfanu, Anca Leuștean, Daniela Adriana Ion

O31 A challenging neurological complication in a HIV-infected young woman with multiple opportunistic infections

Irina Ianache, Cristiana Oprea

O32 Brain abscess with uncertain etiology in a late-presenter HIV infected patient

Anca Leuștean, Cristina Popescu, Alina Orfanu, Anca Negru, Remulus Catana, Cristina Murariu, Ioan-Alexandru Diaconu, Mihaela Rădulescu, Cătălin Tilișcan, Victoria Aramă

O33 Cerebral toxoplasmosis and left crural monoparesis with fatal evolution in a noncompliant patient with AIDS C3

Iosif Marincu, Patricia Poptelecan, Valeria Bică, Florin Lazăr, Livius Tirnea

O34 Opportunistic infections still a problem in HIV-infected patients in cART era: a Romanian single center experience

Irina Ianache, Roxana Rădoi, Manuela Nica, Grațiela Țârdei, Luminița Ene, Emanoil Ceaușu, Petre Calistru, Cristiana Oprea

P1: Epidemiological aspects of co-infection of HIV/TB in Moldova

Iurie Osoianu, Ala Halacu

P2 Perinatal exposure at HIV infection in Oltenia region

Andreea Cristina Stoian, Florentina Dumitrescu, Iulian Diaconescu, Augustin Cupșa, Lucian Giubelan, Loredana Ionescu, Irina Niculescu

P3 Women living with HIV in Mureș county

Carmen Chiriac, Nina Șincu, Iringo Zaharia Kezdi, Anca Georgescu, Brândușa Țilea, Cristina Girbovan, Andrea Incze, Andrea Fodor

P4 Late diagnosis of HIV infection in children - a challenge for Romania

Alina Cibea, Mariana Mărdărescu, Cristina Petre, Ruxandra Drăghicenoiu, Rodica Ungurianu, Ana Maria Tudor, Delia Vlad, Carina Matei

P5 Cirrhosis Assessment in Patients Co-infected HIV-Hepatitis B Virus

Elena Dumea, Lucian Cristian Petcu, Simona Claudia Cambrea

P6 HIV late presenters in Craiova Regional Center, Romania

Florentina Dumitrescu, Augustin Cupsa, Andreea Cristina Stoian, Lucian Giubelan, Irina Niculescu, Iulian Diaconescu, Dan Hurezeanu, Livia Dragonu, Mioara Cotulbea

P7 Some aspects of malignancies in patients HIV / AIDS

Simona Manuela Erscoiu, Ionuț Cristian Popa, Denisa Stroie, Petronela Ionescu, Nedeea Duță, Camelia Dobrea, Irina Voican, Emanoil Ceaușu, Petre Iacob Calistru

P8 Factors associated with resilience among people living with HIV in Romania

Florin Lazăr

P9 Fever in HIV-infected patients: a thorny problem to be solved by the clinicians

Lucian Giubelan, Augustin Cupșa, Iulian Diaconescu, Florentina Dumitrescu, Dan Hurezeanu, Livia Dragonu, Irina Niculescu, Andreea Cristina Stoian, Oana Obretin, Mariana Stănescu, Mihai Jianu

P10 Th1, Th2, Th9, Th17 and Th22 cytokines in acute and chronic HIV-1 infection

Lana Gorenec, Snjezana Zidovec Lepej, Ivana Grgic, Ana Planinic, Janja Iscic Bes, Adriana Vince, Josip Begovac

P11 Dyslipidemia in HIV-infected patients treated with protease inhibitors – case report

Luminița Elena Horga

P12 Why use less treatment for the metabolic abnormalities in HIV patients-too many drugs?

Corina Itu, Luminița Elena Horga, Laura Augusta David-Aldea, Anca Ciorogar, Cristian Jianu, Mihaela Lupșe

P13 Sacral Herpes Zoster, with hyperalgesic form, in a patient with C3 stage HIV infection

Iuliana Caramangiu, Ovidiu Roșca, Monica Cialma, Andreea Ardeleanu, Iosif Marincu

P14 Factors associated with in-hospital mortality in tuberculous and cryptococcal meningitis

Raluca Jipa, Eliza Manea, Șerban Benea, Irina Lăpădat, Nicoleta Irimescu, Irina Panait, Cristian Niculae, Adriana Hristea

P15 Lipodystrophy: still present adverse event in resource-limited settings

Jovana Kusic, Djordje Jevtovic, Dubravka Salemovic, Jovan Ranin, Bozana Dimitrijevic, Gordana Dragovic

P16 TB and HIV coinfected patient, an emergent challenge - case report

Laura-Augusta Aldea-David

P17 Efficacy of prophylactic antiretroviral treatment in new-born infants from HIV-positive mothers in 2012-2014, for the North-Eastern part of Romania

Carmen Manciuc, Cristina Nicolau, Liviu Prisăcariu, Alexandra Largu

P18 Surveillance of mother to child transmission of HIV in Romania – 31 December 2015

Mariana Mărdărescu, Adrian Streinu-Cercel, Cristina Petre, Marieta Iancu, Sanda Vintilă, Daniela Vitelaru, Iosif Ionel, Claudiu Mihai Șchiopu, Alexandra-Henriette Mărdărescu

P19 The antiretroviral therapy failure and the need to select the effective treatment in the Republic of Moldova

Pavel Micsanschi, Tiberiu Holban, Ina Bîstrițchi, Lucia Pârțână, Angela Nagîț, Svetlana Popovici, Maria Talmaci, Irina Cucerova

P20 Disseminated cryptococcosis in a patient with C3 HIV stage and multiresistant to antiretroviral therapy with lethal evolution

Sorina Georgiana Mitrescu, Dana Mihalcea, Iulia Caramangiu, Ovidiu Roșca, Iosif Maricu

P21 Aspects of tuberculosis infection in HIV-positive patients from Romania – our experience

Anca Negru, Daniela Munteanu, Victoria Aramă, Raluca Mihăilescu, Ioan Diaconu, Remulus Catana, Cristina Popescu, Alina Orfanu, Anca Leuștean, Mihaela Rădulescu, Cătălin Tilișcan, Raluca Năstase, Violeta Molagic, Irina Duport, Cristina Dragomirescu, Ștefan Sorin Aramă

P22 Dyslipidemia in HIV-infected patients

Nicoleta M Negruț

P23 Challenges in the management of an HIV seropositive patient with psoriasis undergoing immunomodulator therapy

Violeta Elena Niță, Daniela Ioana Munteanu, Raluca Mihăilescu, Ioan Diaconu, Anca Negru, Cristina Popescu, Victoria Aramă

P24 Acute peritonitis as a sign of IRIS in an HIV-infected patient with MAC latent infection

Alina Orfanu, Cristina Popescu, Anca Leuștean, Anca Negru, Remulus Catana, Ioan Diaconu, Cătălin Tilișcan, Victoria Aramă, Sorin Ștefan Aramă

P25 The virologic outcome of the treatment of chronic hepatitis B among HIV co-infected patients on HAART

Ivana Pesic Pavlovia, Dubravka Salemovic, Jovan Ranin, Djordje Jevtovic

P26 A case of HIV encephalopathy with aphasia, agnosia, apraxia and right homonymous hemianopsia

Ovidiu Roșca, Andreea Ardeleanu, Iulia Caramangiu, Daniela Desaga, Valerica Bică, Sorina Mitrescu, Iosif Marincu

P27 Molecular footprints on human immunodeficiency virus -1 genome and association with phylogenetic clustering among subtype B infected patients in Serbia

Marina Siljic, Dubravka Salemovic, Valentina Nikolic, Djordje Jevtovic, Ivana Pesic-Pavlovic, Jovan Ranin, Marija Todorovic , Maja Stanojevic

P28 Neurosyphilis and human immunodeficiency virus infection: double challenge

Nina-Ioana Șincu, Anca Georgescu, Brândușa Țilea, Iringo Zaharia Kezdi, Andrea Incze, Cristina Gârbovan, Carmen Lucia Chiriac

P29 Differences between HIV-infected adults since childhood and non HIV-infected persons on managing everyday life

Anca Elena Luca, Florin Lazăr, Adrian Luca, Luminița Ene, Roxana Rădoi, Adina Talnariu, Silvia Suciu, Cristian Achim

P30 Molecular detection of Bartonella quintana in a HIV immunodepressed patient with fever and isolated lymphadenopathy - Case report

Diana Gabriela Iacob, Dragoș Florea, Simona Iacob

P31 Present epidemiological characteristics of HIV/AIDS newly diagnosed cases in South-Eastern Romania

Manuela Arbune, Miruna Drăgănescu, Alina Iancu

P32 The gender’s preferences among opportunists?

Ruxandra Moroti, Cristian M Niculae, Simona Merisor, Eliza Manea, Serban Benea, Andrada Stan, Raluca Hrisca, Raluca Jipa, Diana Tanase, Adriana Hristea

P33 Polymorphism of interleukin-28B gene in persons with chronic hepatitis C from Croatia

Ivana Grgic, Ana Planinic, Lana Gorenec, Snjezana Zidovec Lepej, Adriana Vince

Nucleoside Reverse Transcriptase Inhibitor Usage and the Incidence of Peripheral Neuropathy in HIV/AIDS Patients

Peripheral neuropathy (PN) is a well-known adverse effect of treatment with nucleoside reverse transcriptase inhibitors (NRTIs). We performed a prospective follow-up study in HIV-infected patients on antiretroviral therapy containing NRTIs. The objective of this study was to examine the incidence of PN among patients using NRTI drugs. Data were obtained using medical records of patients continuously monitored for the efficacy and toxicity of antiretroviral therapy. The incident cases of PN were examined. Incidence rates of PN were calculated for each antiretroviral regimen that included zidovudine, zalcitabine, lamivudine, didanosine (ddI), stavudine (d4T) or didanosine+ stavudine. Poisson regression was used to compare the relative risk of PN for each regimen. A total of 112 HIV-infected patients were treated with at least one NRTI-containing regimen. Thirty-two cases of PN were recorded. The lowest incidence rate (IR) of 0.13 per 100 person-years occurred in patients treated with didanosine. The highest IR for PN occurred with the didanosine+stavudine combination (IR=0.18 per 100 person-years). Compared to didanosine alone, the relative risk of PN was 1.77 (95%CI, 0.52–2.12) for stavudine, and 1.76 (95%CI, 0.95–2.49) for didanosine+stavudine. Other risk factors for PN included a low CD4 cell count and female sex. Our data show that the risk of PN is almost twice as high when stavudine is used alone or in combination with didanosine. The use of stavudine alone or in combination with didanosine should probably not be routinely recommended if other treatment options are available.

Choice of first-line antiretroviral therapy regimen and treatment outcomes for HIV in a middle income compared to a high income country: a cohort study

Background

The range of combination antiretroviral therapy (cART) regimens available in many middle-income countries differs from those suggested in international HIV treatment guidelines. We compared first-line cART regimens, timing of initiation and treatment outcomes in a middle income setting (HIV Centre, Belgrade, Serbia - HCB) with a high-income country (Royal Free London Hospital, UK - RFH).

Methods

All antiretroviral-naïve HIV-positive individuals from HCB and RFH starting cART between 2003 and 2012 were included. 12-month viral load and CD4 count responses were compared, considering the first available measurement 12-24 months post-cART. The percentage that had made an antiretroviral switch for any reason, or for toxicity and the percentage that had died by 36 months (the latest time at which sufficient numbers remained under follow-up) were investigated using standard survival methods.

Results

361/597 (61 %) of individuals initiating cART at HCB had a prior AIDS diagnosis, compared to 337/1763 (19 %) at RFH. Median pre-ART CD4 counts were 177 and 238 cells/mm³ respectively (p < 0.0001). The most frequently prescribed antiretrovirals were zidovudine with lamivudine (149; 25 %) and efavirenz [329, 55 %] at HCB and emtricitabine with tenofovir (899; 51 %) and efavirenz [681, 39 %] at RFH. At HCB, a median of 2 CD4 count measurements in the first year of cART were taken, compared to 5 at RFH (p < 0.0001). Median (IQR) CD4 cell increase after 12 months was +211 (+86, +359) and +212 (+105, +318) respectively. 287 (48 %) individuals from HCB and 1452 (82 %) from RFH had an available viral load measurement, of which 271 (94 %) and 1280 (88 %) were <400 copies/mL (p < 0.0001). After 36 months, comparable percentages had made at least one antiretroviral switch (77 % HCB vs. 78 % RFH; p = 0.23). However, switches for toxicity/patient choice were more common at RFH. After 12 and 36 months of cART 3 % and 8 % of individuals died at HCB, versus 2 % and 4 % at RFH (p < 0.0001).

Conclusion

In middle-income countries, cART is usually started at an advanced stage of HIV disease, resulting in higher mortality rates than in high income countries, supporting improved testing campaigns for early detection of HIV infection and early introduction of newer cART regimens.

Oral teicoplanin for successful treatment of severe refractory Clostridium difficile infection

INTRODUCTION

Clostridium difficile is the leading cause of hospital-acquired diarrhoea. There is no defined protocol for treating severe Clostridium difficile infection (CDI) refractory to vancomycin or vancomycin and metronidazole combination therapy. The aim of this study was to evaluate the rate of clinical cure, time to resolution of diarrhoea and recurrence rate in patients with severe refractory CDI treated with oral teicoplanin.

METHODOLOGY

A one-year prospective study was carried out in the Clinic for Infectious and Tropical Diseases, Clinical Center Serbia. Patients with severe and complicated CDI who failed to respond to oral vancomycin and intravenous metronidazole combination therapy were enrolled. They were given oral teicoplanin 100 mg bi-daily. Patients were followed for recurrence for eight weeks.

RESULTS

Nine patients with a mean age of 70.8±9.4 years were analyzed. All patients had pseudomembranous colitis, and five had complicated disease. In four patients intracolonic delivery of vancomycin was also performed in addition to oral vancomycin and intravenous metronidazole prior to initiating teicoplanin, but without improvement. After teicoplanin initiation all patients achieved clinical cure. The mean time to resolution of diarrhoea after teicoplanin introduction was 6.3±4.5 days. There was no statistically significant difference in time to resolution of diarrhoea according to initial leucocyte count, age over 65 years, the presence of ileus, complicated disease and the use of concomitant antibiotic therapy (p = 0.652, 0,652, 0.374, 0.374, and 0,548, respectively). None of the patients experienced recurrence.

CONCLUSIONS

Oral teicoplanin might be a potential treatment for severe and complicated refractory CDI, but further studies are required.

Molecular characterization of BK virus in patients infected with human immunodeficiency virus

Immunosuppression seems to be the most important cause of BKPyV reactivation. Recently, a spectrum of diseases associated with BKPyV infection has been reported in HIV-infected patients. BKPyV isolates can be classified into four subtypes based on nucleotide polymorphisms within VP1 coding region. Mutations within the BC loop of the VP1 may be associated with an increase in the viral pathogenicity. The aims of this study were to determine prevalence and distribution of BKPyV subtypes, sequence variation and mutations within VP1 among HIV-infected patients and healthy donors. Urine samples from 114 HIV-infected patients and 120 healthy donors were collected. PCR followed by sequence analysis was carried out using primers specific for VP1 and NCRR of the virus genome. The predominant BKPyV subtype was I, followed by IV. In isolates from HIV-infected patients, the majority of non-synonymous alterations were located within the BC loop. BKV sequences from healthy donors showed non-synonymous alterations outside of the receptor loops in the β-sheets. The higher frequency of mutations in the BC loop of VP1 protein was detected among HIV-infected patients. The most frequent mutation was E82D. All HIV-infected patients who harbored mutations had CD4(+) cell counts less than 200 cell/mm(3). It seems that immunosuppression is a very important factor for BKPyV reactivation that can increase viral replication rate and leads to higher frequency of mutations in the BC loop of the VP1. These mutations may change receptor specificity, and further studies are needed to determine the effect of these mutations on the biological properties of the BKPyV.

Clostridium difficile infection: a Serbian single-center experience

INTRODUCTION

Clostridium difficile infection (CDI) is the most common cause of hospital-acquired diarrhea. Severity of CDI is associated with advanced age and co-morbidities. The clinical spectrum varies from mild watery diarrhea to severe fulminant pseudomembranous colitis with complications.

METHODOLOGY

This study conducted over a six-year period (2008 to 2013) included 510 patients treated at the University Hospital for Infectious and Tropical Diseases in Belgrade, Serbia. In patients with a history of previous hospitalization and/or treatment with antimicrobial agents who developed diarrhea, the diagnosis was established with rapid tests for C. difficile toxin A and B and by stool culture for C. difficile (454 patients) or by endoscopic examination and histological analyses of the biopsy samples taken from the colonic mucosa (56 patients).

RESULTS

The mean age of patients was 67.71±13.34 years. A total of 67.8% patients were older than 65 years. Over half (58.7%) of the patients were female. 93% had been previously hospitalized and/or had surgical interventions, during which they had been treated with antibiotics. In the clinical presentation spectrum, pseudomembranous colitis occurred in 51.0%. The mean duration of illness after the introduction of specific antibiotic therapy was 7.10 ± 4.88 days. Complications developed in 14 patients. The disease relapsed in 43 (8.4%). Thirty-two (6.3%) patients died, mostly due to co-morbidities.

CONCLUSIONS

CDI is the most important cause of hospital-acquired diarrhea in Serbia. The disease mainly affects elderly patients with co-morbidities. The incidence of complications is low and prognosis is age dependent and related to pre-existing diseases.

Ten years survey of primary HIV-1 resistance in Serbia: the occurrence of multiclass resistance

In Serbia, the first cases of HIV infection were reported in 1985, whereas antiretroviral (ARV) therapy has been in use since 1987. With this study we aimed to assess the occurrence and pattern of HIV resistance mutations among newly diagnosed patients in the period 2002-2011. The study prospectively included 181 adult patients. Genotypic HIV-1 drug resistance testing was performed and drug resistance was scored according to the 2009 WHO list for surveillance of drug resistance mutations (SDRMs). A bioinformatic approach was used to estimate the duration of infection by calculating the percentage of ambiguous basecalls per sequence, with a cutoff of 0.47% as the delimiter for recent infection. The overall prevalence of transmitted drug resistance (TDR) found in the study was 8.8% (16/181, 95% CI=5.5-13.8). Thirty-one percent of resistant samples contained multiple SDRMs. In particular, 5/16 patients with resistance carried viral strains with SDRMs to multiple ARV classes, hence one-third of resistant strains were multiclass resistant, including non-B strains. A total of 51.9% of samples (94/181) were classified as recent infection, with a significant increase in the second part of the study period. However, the prevalence of TDR in recent infection was 6.4% (6/94, 95% CI=2.9-13.2), not statistically different from that found in nonrecent infection. We showed a changing pattern of TDR mutations over the study period, with a substantial occurrence of multiclass resistance, across different HIV subtypes. Our results highlight the need for continued surveillance of primary resistance.

Immuno-virological discordance and the risk of non-AIDS and AIDS events in a large observational cohort of HIV-patients in Europe

BACKGROUND

The impact of immunosuppression despite virological suppression (immuno-virological discordance, ID) on the risk of developing fatal and non-fatal AIDS/non-AIDS events is unclear and remains to be elucidated.

METHODS

Patients in EuroSIDA starting at least 1 new antiretroviral drug with CD4<350 cells/µl and viral load (VL)>500 copies/mL were followed-up from the first day of VL< = 50 copies/ml until a new fatal/non-fatal non-AIDS/AIDS event. Considered non-AIDS events included non-AIDS malignancies, pancreatitis, severe liver disease with hepatic encephalopathy (>grade 3), cardio- and cerebrovascular events, and end-stage renal disease. Patients were classified over time according to whether current CD4 count was above (non-ID) or below (ID) baseline level. Relative rates (RR) of events were calculated for ID vs. non-ID using adjusted Poisson regression models.

RESULTS

2,913 patients contributed 11,491 person-years for the analysis of non-AIDS. 241 pre-specified non-AIDS events (including 84 deaths) and 89 AIDS events (including 10 deaths) occurred. The RR of developing pre-specified non-AIDS events for ID vs. non-ID was 1.96 (95% CI 1.37-2.81, p<0.001) in unadjusted analysis and 1.43 (0.94-2.17, p = 0.095) after controlling for current CD4 count. ID was not associated with the risk of AIDS events (aRR 0.76, 95% CI 0.41-1.38, p = 0.361).

CONCLUSION

Compared to CD4 responders, patients with immuno-virological discordance may be at increased risk of developing non-AIDS events. Further studies are warranted to establish whether in patients with ID, strategies to directly modify CD4 count response may be needed besides the use of ART.

Temporal changes and regional differences in treatment uptake of hepatitis C therapy in EuroSIDA

OBJECTIVES

All HIV/hepatitis C virus (HCV)-coinfected patients with chronic HCV infection and ≥ F2 fibrosis should be considered for HCV therapy. This study aimed to determine the rate of HCV treatment uptake among coinfected patients in Europe.

METHODS

EuroSIDA patients with viraemic HCV infection were included in the study. Poisson regression was used to identify temporal changes and regional differences in HCV treatment uptake.

RESULTS

A total of 1984 patients were included in the study, with a median follow-up time of 168 months [interquartile range (IQR) 121-204 months]. To date, 501 (25.3%) HIV/HCV-coinfected patients have received HCV therapy. Treatment incidence rose from 0.33 [95% confidence interval (CI) 0.16-0.50] per 100 person-years of follow-up (PYFU) in 1998 to 5.93 (95% CI 4.49-7.38) in 2007, falling to 3.78 (95% CI 2.50-5.07) in 2009. After adjustment, CD4 cell count > 350 cells/μL [incidence rate ratio (IRR) 1.33 (95% CI 1.06-1.67) vs. CD4 count 200-350 cells/μL] and ≥F2 liver fibrosis [IRR 1.60 (95% CI 1.14-2.25; P = 0.0065) vs. < F2 fibrosis] were predictors of anti-HCV treatment initiation. However, 22% of patients who remain untreated for HCV, with fibrosis data available, had ≥F2 fibrosis and should have been considered for treatment, while only 36% of treated patients had ≥F2 fibrosis.

CONCLUSIONS

Although treatment incidence for HCV has increased, there remain a large proportion of patients indicated for treatment who have yet to be treated.

The significance of hepatitis B virus (HBV) genotypes for the disease and treatment outcome among patients with chronic hepatitis B in Serbia

BACKGROUND

Hepatitis B virus (HBV) genotypes influence disease progression and treatment outcome.

OBJECTIVES

To determine natural history and treatment outcome in patient chronically infected with HBV.

STUDY DESIGN

A cohort study included 162 treatment naive patients with chronic HBV infection in order to analyze factors influencing natural history of infection and survival.

RESULTS

Genotype A was far less prevalent, detected in 14.2%. The prevalence of HbeAg+ serology of 60.8% among patients infected with genotype A was significantly higher then 30.9% recorded among those with genotype D (P=0.02). Even though patients from two genotypes subgroups had significantly different prevalence of HBeAg serology, their viral loads were similar at the time of diagnosis (2.90 log10 and 3.31 log10 HBV DNK IU/μl plasma, for genotypes A and D, respectively). The analyses of viral loads across three serologic patterns of chronic HBV infection were: for HBeAg+/HBeAb-, HbeAg-/HBAb+, and both "e" antigen and antibodies negative: 4.24, 2.67 and 2.69 log10 IU/ml of HBV DNA IU/μl, respectively (P=0.01). Mean time to liver cirrhosis was 23.2±3.4 years and 15.1±8.4 years, for genotypes A and D, respectively (P=0.02). The overall estimated mean survival of patients with chronic HBV infection was 28.4 years, and was influenced by the stage of liver disease, but not by gender, age above 40, viral genotype and lamivudine therapy.

CONCLUSIONS

Patients infected with genotype D had more rapid progression to ESLD regardless of levels of viral replication. All clinical and laboratory differences between genotypes did not affect survival of patients with chronic hepatitis B, regardless of lamivudine therapy.

Molecular typing of the local HIV-1 epidemic in Serbia

Worldwide HIV-1 pandemic is becoming increasingly complex, with growing heterogeneity of subtypes and recombinant viruses. Previous studies have documented HIV-1 subtype B as the predominant one in Serbia, with limited presence and genetic diversity of non B subtypes. In recent years, MSM transmission has become the most frequently reported risk for HIV infection among newly diagnosed patients in Serbia, but very little is known of the network structure and dynamics of viral transmission in this and other risk groups. To gain insight about the HIV-1 subtypes distribution pattern as well as characteristics of HIV-1 transmission clusters in Serbia, we analyzed the genetic diversity of the pol gene segment in 221 HIV-1-infected patients sampled during 2002-2011. Subtype B was found to still be the most prevalent one in Serbia, accounting for over 90% of samples, while greater diversity of other subtypes was found than previously reported, including subtypes G, C, A, F, CRF01 and CRF02. In total, 41.3% of analyzed subtype B sequences were found associated in transmission clusters/network, that are highly related with MSM transmission route.

Non-specific inflammatory parameters in patients with pandemic H1N1 influenza

The measurement of non-specific inflammation parameters, such as erythrocyte sedimentation rate (ESR), fibrinogen, C-reactive protein (CRP) and procalctinon (PCT) are very important tools for diagnosis of infections, as well as for monitoring of treatment response. The aim of this study was to determine the significance of non-specific inflammatory parameters in patients with influenza H1N1 infection. ESR, fibrinogen, CRP and PCT were analyzed in patients with influenza H1N1 infection. The diagnosis of influenza H1N1 was established from the nasopharyngeal swabs using Real Time Polymerase Chain Reaction - (RT PCR) method. Chest X-ray was performed to diagnose pneumonia Sixty-three out of 340 hospitalized patients with influenza had pandemic influenza. Their mean age was 34.60±13.82 years. They were referred to hospital 1 to 7 (4.06±2.0) days after onset of symptoms. Of these, 46 had pneumonia, while the majority (41 patients) had interstitial pneumonia, and only five had lobar or segmental pneumonia. Patients with pneumonia had significantly higher levels of CRP and PCT in comparison with those without pneumonia. Patients with lobar pneumonia had significantly higher CRP than those with interstitial pneumonia. However, mean values of PCT between interstitial and lobar pneumonia cases did not differ significantly. Interstitial pneumonia was the most common complication of H1N1 infection among our patients. Non-specific parameters of inflammation, especially CRP and PCT were increased in all pneumonia cases, regardless of the etiology. Monitoring of non-specific inflammatory parameters in patients with H1N1 infection allows recognition of patients with complications, their prompt hospitalization and early initiation of antimicrobial therapy.

The role of nucleoside reverse transcriptase inhibitors usage in the incidence of hyperlactatemia and lactic acidosis in HIV/AIDS patients

Hyperlactatemia and lactic acidosis (LA) are among the most dangerous and life-threatening side effect that occurs during therapy with some nucleoside reverse transcriptase inhibitors (NRTIs), mainly didanosine (ddI) and stavudine (d4T), also known as d-drugs. Therefore, we performed a prospective, follow-up study and aimed to examine the incidence rates (IR) and rate ratios (RR) of hyperlactatemia and LA for each NRTI. Three hundred and ninety-six HIV-patients were included in final analysis comprising 783.8 person-years of follow-up. Between 1st January 2000 and 1st January 2008, 19 cases of hyperlactatemia and 15 cases of LA were recorded. Between regimens with the significant impact for developing hyperlactatemia and LA the lowest IR was for didanosine (IR=2.87 per 100 person-years, 95%CI=0.45-9.25 and IR=4.31 per 100 person-years, 95%CI=1.07-13.91, respectively), and the highest for didanosine+stavudine (IR=10.17 per 100 person-years, 95%CI=1.02-19.76 and IR=7.39 per 100 person-years, 95%CI=1.02-13.05, respectively). Compared to didanosine alone the RR of hyperlactatemia was 2.67 (95%CI=1.11-12.52) for stavudine, and 4.06 (95%CI=1.31-15.48) for didanosine+stavudine. The RR of LA was 3.12 (95%CI=1.13-10.65) for stavudine, and 5.13 (95%CI=1.54-13.37) for didanosine+stavudine in comparison with didanosine alone. Other risk factors for AP were CD4 cell count less than 200 cells/mm³ and female sex. Our results suggest that the use of stavudine alone or in combination with didanosine should not be used as first-line therapy, especially in patients with CD4 cell count less than 200 cells/mm³ and females if other treatment options are available.

Alveolar granulocytic sarcoma of the mandible in a patient with HIV

BACKGROUND

Granulocytic sarcoma (chloroma) occurs primarily in patients with acute myelogenous leukemia although it can also appear in connection with other myeloproliferative disorders.

CASE REPORT

We present the case of a 52-year-old human immunodeficiency virus (HIV)-positive female patient with a CD4+ count of 321 cells/ml, who developed an alveolar granulocytic sarcoma of the mandible. Pathological analysis of the tumor mass showed an infiltrate of immature cells which were positive for CD13, CD33, CD15, CD11b, and CD64, and negative for CD34, CD117, and HLA-DR. The patient achieved complete remission following a 1-week course of chemotherapy, however, 7 months later she developed a second granulocytic sarcoma in the left soleus muscle. The absolute CD4+ count had now reduced to 3 cells/ml with an inversion in the Th/Ts index (0.01), and she died of gram-negative sepsis 1 month later.

CONCLUSIONS

Granulocytic sarcoma is extremely rare in patients with HIV. The case is discussed with reference to the literature.

Older age at the time of liver biopsy is the important risk factor for advanced fibrosis in patients with chronic hepatitis C

BACKGROUND/AIMS

Progression of chronic hepatitis C depends on the host and viral characteristics, duration of infection, co-infection with other viruses, etc. In this study, some of demographic, epidemiological and viral data as risk factors for a degree of liver fibrosis were evaluated.

METHODOLOGY

A total of 144 patients was investigated (89 males, ages from 16-65 years) classified into two groups, with fibrosis scores 0-3 and 4-6, using the Ishak scoring system. Significant variables were entered into univariate logistic regression model and further multivariate analysis was performed.

RESULTS

There were 64% and 36% of patients with fibrosis scores 0-3 and 4-6, respectively. Gender, moderate to heavy alcohol abuse and high viral RNA were equally distributed between both groups. In univariate analysis, the age older than 40, history of intravenous drug abuse, and the genotype 1b were independently associated with different fibrosis scores. Multivariate regression analysis revealed ages older than 40 as the positive (p < 0.001), and younger than 40 as the negative predictive factors for fibrosis scores 4-6 and 0-3 (p < 0.001), respectively.

CONCLUSIONS

Our results indicate the age over 40 at the time of liver biopsy as the important risk factor for advanced liver disease in chronic hepatitis C according to fibrosis scores.

Hepatitis C virus genotypes in Serbia and Montenegro: The prevalence and clinical significance

AIM: To investigate the prevalence of hepatitis C virus (HCV) genotypes in Serbia and Montenegro and their influence on some clinical characteristics in patients with chronic HCV infection.

METHODS: A total of 164 patients was investigated. Complete history, route of infection, assessment of alcohol consumption, an abdominal ultrasound, standard biochemical tests and liver biopsy were done. Gene sequencing of 5’ NTR type-specific PCR or commercial kits was performed for HCV genotyping and subtyping. The SPSS for Windows (version 10.0) was used for univariate regression analysis with further multivariate analysis.

RESULTS: The genotypes 1, 2, 3, 4, 1b3a and 1b4 were present in 57.9%, 3.7%, 23.2%, 6.7%, 6.7% and 1.8% of the patients, respectively. The genotype 1 (mainly the subtype 1b) was found to be independent of age in subjects older than 40 years, high viral load, more severe necro-inflammatory activity, advanced stage of fibrosis, and absence of intravenous drug abuse. The genotype 3a was associated with intravenous drug abuse and the age below 40. Multivariate analysis demonstrated age over 40 and intravenous drug abuse as the positive predictive factors for the genotypes 1b and 3a, respectively.

CONCLUSION: In Serbia and Montenegro, the genotypes 1b and 3a predominate in patients with chronic HCV infection. The subtype 1b is characteristic of older patients, while the genotype 3a is common in drug abusers. Association of the subtype 1b with advanced liver disease, higher viral load and histological activity suggests earlier infection with this genotype and eventually its increased pathogenicity.

Are Specific Antiretrovirals associated with an Increased Risk of Discontinuation due to Toxicities or Patient/Physician Choice in patients with Hepatitis C Virus Coinfection?

Background

Liver damage associated with hepatitis C (HCV) may influence the likelihood of experiencing discontinuation due to toxicities or patient/physician choice (TOXPC) in patients taking combination antiretroviral therapy (cART). Little information to address this concern is available from clinical trials as patients with HCV are often excluded.

Aims

To compare incidence rates of discontinuation due to TOXPC associated with specific antiretrovial drugs in patients with or without HCV.

Patients/methods

A total of 4929 patients from EuroSIDA under follow-up from January 1999 on a specific nucleoside pair (zidovudine/lamivudine, didanosine/stavudine, stavudine/lamivudine, or other) with a third drug (abacavir, nelfinavir, indinavir, nevirapine, efavirenz, lopinavir/ ritonavir or other boosted-protease inhibitor (PI)-containing regimen) and with known HCV serostatus were studied for the incidence of discontinuation of any nucleoside pair or third drug due to TOXPC. Incidence rate ratios were derived from Poisson regression models.

Results

In total 1358 patients had HCV (27.5%). During 12 799 person-years of follow-up there were 2141 discontinuations due to TOXPC for nucleoside pairs and 2501 for third drugs. The incidence of discontinuation due to TOXPC was consistently higher in patients with HCV after stratification by nucleoside pair or third drug. After adjustment for CD4+ count, gender, exposure group, time on HAART, region and treatment regimen, there were few differences in the rate of discontinuation due to TOXPC in those with HCV compared with those without for any nucleoside pairs or third drugs. Similar results were seen when concentrating on discontinuation due to toxicities alone.

Conclusions

Although patients with HCV generally had higher rates of discontinuation due to TOXPC compared with patients without HCV, there was little evidence to suggest that this was associated with any specific nucleoside pair or third drug used as part of cART. Our results do not suggest that any specific component of cART is more poorly tolerated in patients with HCV or that the presence of HCV should influence the choice between antiretrovirals used as part of a cART regimen.

HIV-1 subtypes in Yugoslavia

To gain insight concerning the genetic diversity of HIV-1 viruses associated with the HIV-1 epidemic in Yugoslavia, 45 specimens from HIV-1-infected individuals were classified into subtypes by sequence-based phylogenetic analysis of the polymerase (pol) region of the viral genome. Forty-one of 45 specimens (91.2%) were identified as pol subtype B, 2 of 45 as subtype C (4.4%), 1 of 45 as CRF01_AE (2.2%), and 1 as CRF02_AG recombinant (2.2%). Nucleotide divergence among subtype B sequences was 4.8%. Results of this study show that among HIV-1-infected patients in Yugoslavia subtype B predominates (91.5%), whereas non-B subtypes are present at a low percentage, mostly related to travel abroad.

CMV DNA in blood and CSF of HIV infected patients

Cytomegalovirus (CMV) infection frequently affects the central nervous system in HIV infected patients. Varied clinical manifestations of CMV disease make virological detection of CMV essential for proper diagnosis and treatment. Thus, in patients in different stages of HIV-induced disease, we attempted to detect cell associated and free, non cell associated CMV DNA in cerebrospinal fluid (CSF) and in peripheral blood mononuclear cells (PBMCs). Twenty-six blood samples were collected from 22 patients included in the study. Nine of these blood samples were tested in pair with the concomitant CSF sample for the presence of CMV DNA by a commercial hybridization test. CMV serostatus and avidity of IgG antibodies were detected by a commercial ELISA test. CMV DNA was present in the cells found in CSF in all but one of the AIDS patients, independently of the presence of neurological symptoms, suggesting that it represented a marker of advanced immunodeficiency, rather than of the specific CMV-related disease. Cell-associated CMV DNA in CSF tested positive even in the samples negative for cell-free CMV DNA in the CSF, and with no detectable CMV DNA in the PBMCs of concomitant blood sample. We believe that searching for CMV DNA in different compartments of CSF merits further attention.

The role of passive immunization in hiv-positive patients : a case report

An HIV-positive patient presented with pulmonary tuberculosis as her AIDS-defining diagnosis in 1993 and was effectively treated with 12 months of standard antituberculosis medications (isoniazide, rifampin, and pyrazinamide for 2 months). She received zidovudine for 6 weeks at the time of her diagnosis; however, because of patient preference, she has not received subsequent standard HIV medications (7 years). Her CD4 count at the time of diagnosis (1993) was 297/microL. Monthly passive immunotherapy was administered (fresh frozen plasma from HIV-negative blood donors with a significant titer for the anti-vasoactive intestinal peptide [VIP]/NTM antibody) from December 1993 to June 1994. Her CD4 count increased to > 400/microL during the passive immunotherapy and has remained stable for the past 6 years. The rational for the use of anti-VIP/NTM antibodies preparations in HIV, the possible mode of action of anti-VIP/NTM antibodies, the use of Ig preparations, and the role of exercise as a natural source of anti-VIP/NTM antibodies are discussed. This case report supports the potential therapeutic use of anti-VIP antibodies for treatment of HIV disease.

Antigen/antibody content of circulating immune complexes in HIV-infected patients

Dual infection with HIV and hepatitis B virus (HBV) is not an uncommon feature. Immunity impairment due to HIV infection can be the cause of a higher rate of HBV replication with less intensive liver damage and less effective immune response to HBV. Many HIV-infected patients have an elevated level of circulating immune complexes (CIC) in serum, throughout all stages of illness evolution. The aim of our study was to estimate p24 and HBsAg content of CIC in dually infected patients, and the prevalence of major classes of complexed antibodies (IgM and IgG). We examined 146 samples of sera from 105 HIV positive patients of the Institute for Infectious and Tropical Diseases during 1992 and 1993. On those sera we performed p24Ag and HbsAg detection, with and without prior dissociation of CIC, we determined serum level of CIC and immunoglobulin classes IgM and IgG level in sera and in polyethilenglycol (PEG) precipitates of sera. Acid dissociation of immune complexes revealed a high proportion of HIV antigen positive sera in all stages of HIV disease progression. HbsAg in serum of HIV positive patients was also found coupled in immune complexes much more frequently than in the HIV negative control group. In many instances both antigens were simultaneously found coupled in CIC. Immune complexes detected have been shown to contain both IgM and IgG immunoglobulins, while IgM antibodies were associated to immune complexes in higher proportion than IgG, compared to total serum immunoglobulins.