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.

HIV health care providers are ready to introduce pre-exposure prophylaxis in Central and Eastern Europe and neighbouring countries: data from the Euroguidelines in Central and Eastern Europe (ECEE) Network Group

OBJECTIVES

Pre-exposure prophylaxis (PrEP) for HIV infection has been introduced in only a few European countries. We investigated the potential to provide PrEP in the Central and Eastern European region, and in neighbouring countries.

METHODS

The Euroguidelines in Central and Eastern Europe (ECEE) Network Group was formed in February 2016 to review standards of care for HIV infection in the region. Information related to PrEP was collected through on-line surveys. Respondents were recruited by ECEE members based on their involvement in HIV care.

RESULTS

Seventy-six respondents from 23 countries participated in the survey. Twenty-six (34.2%) respondents reported that PrEP [tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC)] was registered by the drug registration authority in their country. Fifty-three (70.7%) respondents reported being aware of 'informal' PrEP use in their country. If they had access to PrEP, 56 (74.7%) would advise its use in their practice. Forty-five (59.2%) respondents had concerns regarding PrEP use, and 10 (13.3%) expressed the need for more training. Most of the respondents (88.2%) would provide PrEP to people with high-risk behaviours.

CONCLUSIONS

PrEP is already used informally in some countries in the region. Physicians are keen to use PrEP if and when it is accessible. Obstacles towards implementing PrEP in those countries were mostly related to lack of national guidelines, drug registration and governmental strategy.

The extent of B-cell activation and dysfunction preceding lymphoma development in HIV-positive people

OBJECTIVES

B-cell dysfunction and activation are thought to contribute to lymphoma development in HIV-positive people; however, the mechanisms are not well understood. We investigated levels of several markers of B-cell dysfunction [free light chain (FLC)-κ, FLC-λ, immunoglobulin G (IgG), IgA, IgM and IgD] prior to lymphoma diagnosis in HIV-positive people.

METHODS

A nested matched case-control study was carried out within the EuroSIDA cohort, including 73 HIV-positive people with lymphoma and 143 HIV-positive lymphoma-free controls. Markers of B-cell dysfunction were measured in prospectively stored serial plasma samples collected before the diagnosis of lymphoma (or selection date in controls). Marker levels ≤ 2 and > 2 years prior to diagnosis were investigated.

RESULTS

Two-fold higher levels of FLC-κ [odds ratio (OR) 1.84; 95% confidence interval (CI) 1.19, 2.84], FLC-λ (OR 2.15; 95% CI 1.34, 3.46), IgG (OR 3.05; 95% CI 1.41, 6.59) and IgM (OR 1.46; 95% CI 1.01, 2.11) were associated with increased risk of lymphoma > 2 years prior to diagnosis, but not ≤ 2 years prior. Despite significant associations > 2 years prior to diagnosis, the predictive accuracy of each marker was poor, with FLC-λ emerging as the strongest candidate with a c-statistic of 0.67 (95% CI 0.58, 0.76).

CONCLUSIONS

FLC-κ, FLC-λ and IgG levels were higher > 2 years before lymphoma diagnosis, suggesting that B-cell dysfunction occurs many years prior to lymphoma development. However, the predictive value of each marker was low and they are unlikely candidates for risk assessment for targeted intervention.

Infection-related and -unrelated malignancies, HIV and the aging population

OBJECTIVES

HIV-positive people have increased risk of infection-related malignancies (IRMs) and infection-unrelated malignancies (IURMs). The aim of the study was to determine the impact of aging on future IRM and IURM incidence.

METHODS

People enrolled in EuroSIDA and followed from the latest of the first visit or 1 January 2001 until the last visit or death were included in the study. Poisson regression was used to investigate the impact of aging on the incidence of IRMs and IURMs, adjusting for demographic, clinical and laboratory confounders. Linear exponential smoothing models forecasted future incidence.

RESULTS

A total of 15 648 people contributed 95 033 person-years of follow-up, of whom 610 developed 643 malignancies [IRMs: 388 (60%); IURMs: 255 (40%)]. After adjustment, a higher IRM incidence was associated with a lower CD4 count [adjusted incidence rate ratio (aIRR) CD4 count < 200 cells/μL: 3.77; 95% confidence interval (CI) 2.59, 5.51; compared with ≥ 500 cells/μL], independent of age, while a CD4 count < 200 cells/μL was associated with IURMs in people aged < 50 years only (aIRR: 2.51; 95% CI 1.40-4.54). Smoking was associated with IURMs (aIRR: 1.75; 95% CI 1.23, 2.49) compared with never smokers in people aged ≥ 50 years only, and not with IRMs. The incidences of both IURMs and IRMs increased with older age. It was projected that the incidence of IRMs would decrease by 29% over a 5-year period from 3.1 (95% CI 1.5-5.9) per 1000 person-years in 2011, whereas the IURM incidence would increase by 44% from 4.1 (95% CI 2.2-7.2) per 1000 person-years over the same period.

CONCLUSIONS

Demographic and HIV-related risk factors for IURMs (aging and smoking) and IRMs (immunodeficiency and ongoing viral replication) differ markedly and the contribution from IURMs relative to IRMs will continue to increase as a result of aging of the HIV-infected population, high smoking and lung cancer prevalence and a low prevalence of untreated HIV infection. These findings suggest the need for targeted preventive measures and evaluation of the cost-benefit of screening for IURMs in HIV-infected populations.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Spotlight on measles 2010: a cluster of measles in a hospital setting in Slovenia, March 2010

After ten years of being measles free, Slovenia experienced a cluster with secondary transmission in a hospital setting in March 2010. The index case, a resident of Ireland, was hospitalised on the day after his arrival to Slovenia and diagnosed with measles two days later. After his discharge, two cases of measles were notified, a hospital staff member and a visitor to the clinic, suggesting transmission in a hospital setting.

Low prevalence of hepatitis C virus infection among human immunodeficiency virus type 1-infected individuals from Slovenia and Croatia

The prevalence of hepatitis C virus (HCV) infection in the population of human immunodeficiency virus 1 (HIV-1)-infected individuals from Slovenia and Croatia was determined. One hundred and sixty-six out of a total of 188 Slovenian HIV-1-infected individuals and 120 subjects who were randomly chosen out of a total 342 Croatian HIV-1 antibodies-positive individuals were tested for HCV infection. Detection of HCV antibodies was carried out by a third generation enzyme-linked immunoassay (ELISA) and the positive samples were additionally tested by a third generation immuno-blot assay. Additionally, the presence of HCV RNA was determined in all serum samples by a qualitative polymerase chain reaction (PCR). Twenty-four (14.5%) out of 166 Slovenian and 18 (15.0%) out of 120 Croatian HIV-1-infected individuals were HCV antibodies-positive. Nineteen out of 24 (79.2%) Slovenian and 13 out of 18 (72.2%) Croatian anti-HCV positive individuals were also viremic. HCV RNA was not detected in any of 244 HCV antibodies-negative/HIV-1-infected individual from both countries. A significant difference in the prevalence of HCV infection between blood (77.8% in Slovenia and 66.7% in Croatia) and sexual exposure risk groups (1.6% in Slovenia and 6.6% in Croatia) was found in both countries. In a study carried out on the highest proportion of entire population of HIV-1-infected individuals from a certain country or geographic region, Slovenia and Croatia were identified as countries with the second and third lowest prevalence of HCV infection among HIV-1/HIV-2 infected individuals worldwide.

Influenza vaccination of human immunodeficiency virus 1-infected patients receiving antiretroviral therapy

In 13 human immunodeficiency virus 1 (HIV-1) infected patients receiving a highly active antiretroviral therapy (HAART) annual influenza vaccination was conducted. It was hoped that HAART would prevent a post-vaccination increase in HIV-1 load and potential adverse effects. Only two patients had an increased viral load on day 14 post vaccination (p.v.). At 6 months p.v., the majority of the patients had a significantly increased CD4 cell count and a significantly decreased viral load. This indicates that HAART can protect patients from adverse consequences of influenza vaccination. The production of antibodies to the influenza A and B viruses in the HIV-infected patients was substantially lower than that in healthy persons. We propose that HIV-positive patients receiving HAART should be subjected to annual influenza vaccination.

Proviral HIV-1 DNA in gingival crevicular fluid of HIV-1-infected patients in various stages of HIV disease

The oral cavity is rarely reported to be a site of human immunodeficiency virus (HIV) transmission, despite detectable virus in saliva and relatively frequent prevalence of periodontal disease in HIV-infected persons yielding increased excretion of mononuclear-cell-enriched gingival fluid. To search for possible sources of HIV in saliva, and using the polymerase chain-reaction technique, we sought the presence and shedding patterns of proviral HIV-1 DNA in gingival crevicular fluid in a group of patients previously determined as HIV-1-seropositive. Periodontal status at the collection sites was monitored by several clinical parameters, including Plaque Index, Gingival Index, probing depth, and clinical attachment loss. Gingival crevicular fluid samples were collected by means of paper points. Proviral HIV-1 DNA was detected in the gingival fluid of 17 out of 35 HIV-1-infected patients. Its detection correlated significantly with higher plasma HIV-1 RNA viral load (p = 0.03) and not with peripheral blood CD4+ cell count, the presence of blood in gingival fluid, or oral lesions. There was a significant correlation between clinical attachment loss at the sites of fluid collection and plasma HIV-1 RNA viral load (p = 0.002), and borderline correlation between the latter and probing depth (p = 0.54) in the group of patients harboring proviral HIV-1 DNA in gingival crevicular fluid. The results of our study suggest that mononuclear cells present in gingival crevicular fluid and harboring proviral HIV-1 DNA could represent a potential source of HIV-1 in the presence or absence of local bleeding, especially in persons with advanced HIV infection and increased loss of clinical attachment.

Seroprevalence of HIV-1 subtypes A-E among HIV-1 infected individuals from Slovenia

To investigate the prevalence of HIV-1 subtypes A-E in Slovenia, 82 HIV-1 infected individuals were tested for the presence of HIV-1 subtype specific antibodies using a research competitive peptide enzyme immuno assay supplied by Boehringer Mannheim. In 74 individuals unambiguous results were obtained. As in other European countries, the majority of Slovenian HIV-1 infected individuals (86.5%) were infected with subtype B. Infections with subtypes C, A, D and E were detected in 8.1%, 2.7%, 1.3% and 1.3% individuals, respectively.

Prevalence of mutant CCR5 allele in Slovenian HIV-1-infected and non-infected individuals

A 32 bp deletion in the CCR5 gene designated CCR5 delta 32 has been identified recently as the cellular basis for resistance to human immunodeficiency virus type 1 (HIV-1) in some individuals which remained non-infected despite a repeated exposure to this virus. The prevalence of this deletion was examined by polymerase chain reaction (PCR) on 51 HIV-1-infected and 385 non-infected individuals from all parts of Slovenia. 84.4% of the the HIV-1-infected and 83.2% of the non-infected individuals were homozygous for wild type CCR5, and 19.6% and 16.3%, respectively, were heterozygous. No homozygous mutant genotype was observed among the HIV-1-infected patients. Of the non-infected individuals, 2 women (0.5%) were found to harbour the CCR5 delta 32/CCR5 delta 32 genotype only, which is, to the best of our knowledge, the lowest prevalence of this particular genotype found among Caucasians to date.

Immunological differentiation between tickborne encephalitis with and without concomitant neuroborreliosis

Cerebrospinal fluid lymphocyte subsets in patients with tickborne encephalitis (TBE) and in patients with TBE with concomitant neuroborreliosis (double infection) were analysed by flow cytometry. In the TBE group, higher percentages of CD4+DR+ T cells (p = 0.02) and CD25+ T cells (p = 0.0002) were observed, while in the group with double infection, higher percentages of CD19+ cells (p = 0.007), CD8+DR- T cells (p = 0.04), and CD3+CD71 + T cells (p = 0.0002) were found. It was concluded that several differences in immune cell parameters are present between the two groups of patients. Three variables (CD19+ cells, CD3+CD25+ T cells, CD3+CD71+ T cells) were included in the logistic regression model for calculation of probability for double infection. Flow cytometric characterisation of lymphocyte subsets in CSF can further substantiate the diagnosis of concomitant neuroborreliosis in patients with TBE.

Tick-borne encephalitis: possibly a fatal disease in its acute stage. PCR amplification of TBE RNA from postmortem brain tissue

Tick-borne encephalitis has occurred regularly in Europe since it was first diagnosed in 1931 by Schneider. The mortality rate of patients with this disease is 1-2%. Death usually occurs in the acute stage of illness. A case report of a 28-year-old patient from Slovenia, who died shortly after the onset of tick-borne encephalitis, is described. The clinical course of disease, results of serological tests, neuropathological findings and polymerase chain reaction amplification of parts of viral genome from postmortem brain tissues are presented.

Flow cytometric analysis of lymphocytes in cerebrospinal fluid in patients with tick-borne encephalitis

INTRODUCTION

Cerebrospinal fluid (CSF) lymphocyte subsets were examined by flow cytometry in 33 patients with tick-borne encephalitis (TBE) in order to determine their values.

PATIENTS AND METHODS

Lymphocytes were isolated from CSF and lymphocyte subsets were determined: lymphocytes T (CD3+), lymphocytes B (CD19+), NK cells (CD3-CD56+), helper T cells (CD3+CD4+) and cytotoxic T cells (CD3+CD8+). The expression of IL-2 receptors (CD25+) and transferrin receptors (CD71+) on T cells and HLA-DR molecules on T cell subsets was examined. Furthermore, possible relationships among different TBE patient population variables (gender, age, severity of disease, duration of meningitis) were considered.

RESULTS

The analyses of the CSF lymphocyte population subsets are presented. Lymphocytes T (CD3+) were significantly higher in the CSF than in the peripheral blood as was the case with the T cells that expressed transferrin receptors (CD71). Lymphocytes B (CD19+) and NK cells (CD3-CD56+) prevailed in the peripheral blood. In the early course of the disease, a higher expression of HLA-DR molecules on T lymphocytes was observed, while later a higher expression of IL-2 receptors (CD25+) was observed.

DISCUSSION

Significant differences in lymphocyte subsets between the CSF and the peripheral blood were found. Significant time-dependent changes of CSF lymphocyte subsets during course of infection were observed. The results of the present study give us deeper insight into CNS cellular immunopathogenic mechanisms in patients with TBE.

In vivo administration of azithromycin affects lymphocyte activity in vitro

A therapeutic dose of azithromycin was administered to test subjects and then the following lymphocyte functions were examined in vitro: proliferative lymphocyte response to stimulation with pokeweed mitogen, levels of immunoglobulins G, A, and M in serum, and the amount of the soluble interleukin 2 receptors in supernatants of mononuclear cell cultures stimulated with phytohemagglutinin and phorbol myristate acetate. The study was performed as a controlled clinical trial comparing an azithromycin-treated group (n = 21) and a placebo-treated control group (n = 10). Healthy female volunteers were placed into one of the two groups, and the study was performed as a double-blind trial. Although the findings of the present study showed that azithromycin significantly increased the proliferative lymphocyte response to pokeweed mitogen, the results could have been due to experimental variation. However, impairment of the lymphocyte function was not observed, which could represent valuable information. Likewise, no effect of azithromycin on levels of the immunoglobulins in serum was observed. The most marked effect of azithromycin on the lymphocyte function was demonstrated by an elevation in the amount of soluble interleukin 2 receptor production in mononuclear cell cultures. The lack of impairment or, perhaps, even a beneficial influence on the immunodefense system may be an important property of azithromycin, especially in immunocompromised individuals.