• No results found

Prevalence and characteristics of HIV/HBV and HIV/HCV coinfections in Tuscany

N/A
N/A
Protected

Academic year: 2021

Share "Prevalence and characteristics of HIV/HBV and HIV/HCV coinfections in Tuscany"

Copied!
5
0
0

Loading.... (view fulltext now)

Full text

(1)

w w w . e l s e v ie r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

Prevalence

and

characteristics

of

HIV/HBV

and

HIV/HCV

coinfections

in

Tuscany

Monia

Puglia

a

,

Cristina

Stasi

a,b,∗

,

Monica

Da

Frè

a

,

Fabio

Voller

a

aRegionalHealthAgencyofTuscany,Florence,Italy

bUniversityofFlorence,DepartmentofExperimentalandClinicalMedicine,Florence,Italy

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received22July2015 Accepted17November2015 Availableonline31December2015

Keywords: HIV HBV HCV Coinfections

a

b

s

t

r

a

c

t

Introduction:Worldwideabout30%ofHIV-infectedpatientsarecoinfectedwithHCVorHBV. TheHIV/HCVcoinfectionismorecommoninindividualswhohaveahistoryofdrug addic-tion.TheaimsofthisstudyweretoassesstheHCVandHBVprevalenceinHIV-infected patientsandanalyzetheircharacteristics.

Methods:We considered the new HIV diagnoses notified by the regional surveillance systemofTuscanyfrom2009to2013.Descriptiveanalyseswereconductedonthe socio-demographiccharacteristics,routesoftransmission,andreasontoperformthetest.In coinfectedpatientsweassessedtheriskforbeinglatepresenter(LP)ortheriskofhaving AIDS.

Results:In5yearsofsurveillancea totalof1354newHIVdiagnoseswerenotified:1188 (87.7%)wereHIValone,106(7.8%)HIV/HCV,56(4.1%)HIV/HBV,and4(0.33%)HIV/HCV/HBV. Themainriskfactorwasinjectiondrugusein52.8%ofHCV/HIVcases,whileinHIV/HBV patientsthemainriskfactorwassexualexposure.HIV/HBVcoinfectedpatientsshowed worseclinicalandimmunologicalfeaturesthanHIVandHIV/HCVpatients:78.6%hadCD4 countlessthan350mm−3(vs.54.6%and62.1%,respectively)and39.4%hadAIDS(vs20.7% and7.6%).TheriskforbeingLPtriplesforHIV/HBV(OR2.98;95%IC:1.56–5.70)thanpatients withHIValone.

Conclusions:WehaveobservedlessadvanceddiseaseinHIVandHCV-HIVpatients com-paredwithHBV–HIVcoinfectedpatients.Moreover,ourresultsshowahigherprevalenceof HIV/HCVamongdrugaddictsandintheage-group35–59,correspondingtothosebornin yearsconsideredmostatriskforaddiction.Thisstudyalsoconfirmsthefindingofaless advancedHIVdiseaseinHIV/HCVcoinfectedpatients.

©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

TheAcquiredImmuneDeficiencySyndrome(AIDS),reported forthe first time inliterature in1981, representsthe final

Correspondingauthor.

E-mailaddress:cristina.stasi@gmail.com(C.Stasi).

clinical stageofinfectionbythe humanimmunodeficiency virus(HIV).1

The advent of Highly Active Anti-Retroviral Therapy (HAART)haschangedthenaturalhistoryandepidemiologyof HIVinfection.Inparticular,themortalityratehasdecreased

http://dx.doi.org/10.1016/j.bjid.2015.11.007

1413-8670/©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

(2)

asaconsequenceofthereductioninthenumberofpeople whodeveloptheconditionofAIDS.In2012,peoplelivingwith HIVinfection orAIDSwere35 millionworldwide,whilethe newdiagnoseswereabout2.3million,withadecreaseof33% comparedto2001,whennewinfectionswereapproximately 3.4million.2

Sub-SaharanAfricaisthemostaffectedregion.Recently,1 millionnewdiagnoseswerereported.SouthandSouth-East Asia reported270thousand newdiagnoses.InEurope,HIV infection remainsaproblemofmajorpublic health impor-tance. Italy, in 2012, reported 3853 new diagnoses of HIV infectionand715casesofAIDS,amountingtoanincidence rateof6.5and1.7casesper100,000inhabitants,respectively. Theserates,althoughlowerthantheEuropeanaverage,are higherthantheaverageofotherEuropeanUnionand Euro-peanEconomicArea(EU/EEA)countries.3

Worldwide,about1milliondeathsperyearareattributed tohepatitisBorCviralinfections(HBVorHCV).This repre-sents2.7%ofallcausemortality.Themostcommoncauses includehepatocellularcarcinoma.Moreover,57%ofcasesof livercirrhosisand78%oflivercancerarecausedbyHBVand HCV.4HBV,HCV,andHIVsharethesametransmissionroutes. Ithasbeenestimatedthatworldwideabout30%ofpeoplewith HIVarecoinfectedwithHCVorHBV.5Usually,theHIV/HCV co-infectionismorecommoninindividualswhohaveahistory ofdrugaddiction.6 Severalstudies havealsodemonstrated thatsuchcoinfectionspresentamajorriskforliverfibrosis progressionandsubsequentevolutiontocirrhosis.7

Basedonthesepremises,theobjectivesofthisstudywere toevaluatetheprevalenceofHIV/HCVandHIV/HBV coinfec-tionsinTuscanyandtoanalyzetheircharacteristics.

Methods

InItaly,AIDSwasdeclaredanationallynotifiableinfectious diseasebyMinisterialDecreeNo.288ofNovember28,1986and wassubsequentlysubjectedtospecialnotificationbyfillingin aspecialform.In2008,newdiagnosesofHIVinfectionswere alsosubjectedtomandatorynotification.

InTuscany,themanagementoftheHIVregional surveil-lance system hasbeen improvedsince 2009and requiring notificationofnewHIVdiagnoses.

Inthisstudy,weconsideredthecasesofnewHIVdiagnoses notifiedinTuscanyfrom2009to2013totheRegional Surveil-lance System. This dataset contained information about patientgender,age, nationality,modeoftransmission, rea-sonforbeingtested,CD4lymphocytescount,HIVviralload, andAIDSdiagnosis.Weanalyzedtheprevalenceof coinfec-tion with HBV (based on the presence of antigen surface – HBsAg), HCV (based on the presence of anti-HCV anti-body,which identifiespeople whohavebeen infectedwith thevirus),orboth.Weconsideredthefollowingclinicaland immunologicalconditions:(1)latepresentation(LP):persons presentingforcarewithaCD4countbelow350cells/␮Lorwith anAIDS-definingevent(suchasbacterialinfections, candidia-sis,cryptococcosis,cytomegalovirusretinitis,Kaposisarcoma, lymphoma),irrespective ofCD4cell count;(2) presentation withadvancedHIVdisease(AHD):personspresentingforcare withaCD4countbelow200cells/␮LorwithanAIDS-defining

event,regardlessoftheCD4cellcount8;and(3)AIDS condi-tion,definedashavingHIVand anopportunisticinfection, regardlessoftheCD4cellcount.

Socio-demographic characteristics, risk factors, reasons for being HIV tested, and the clinical and immunological features of patients were analyzed in the following four groups of patients: HIV monoinfection, HIV/HBV, HIV/HCV, and HIV/HBV/HCV infectedpatients. A chi-squaretest was performedtoanalyzetheassociationbetweeneachvariable andtheconditionofcoinfection.

Multivariate logistic regression analysis was used to exploreifthecoinfectionconditionswereassociatedwithLP, AHDorAIDS,adjustingforgender,age,nationality,andrisk factors.

StatisticalanalyseswereperformedusingSTATA SE12.0 statisticalsoftware.

Results

Infiveyearsofsurveillance(2009–2013),1402newHIV diag-noseswerenotifiedinTuscany,withanincidencerateof7.6 per 100,000residents. InformationonHBV orHCV coinfec-tionwasavailablefor1354(96.6%ofthetotalnumberofthe newHIVdiagnoses)HIVinfectedpatients:1188(87.7%)were monoinfected, 106(7.8%)werecoinfectedwithHIV/HCV, 56 (4.1%)withHIV/HBV,and4(0.3%)withHIV/HCV/HBV.

IntheHIVmonoinfected,HIV/HBV,and HIV/HCVgroups 20.9%,14.3%,and 18.9%werefemale, respectively(Table1). Italiannationalitywassignificantlydifferentinthreegroups of patients: 91.5% ofHIV/HCV patients, 60.7% ofHIV/HBV, and74.8%ofHIVmonoinfection.Most(73.6%)oftheHIV/HCV patientswerediagnosedinthe35–59agegroup(medianage 43),comparedto50.0%ofHIV/HBVpatients(medianage38) and55.6%ofHIVmonoinfectedpatients(medianage39).

AmongHIV/HCVcases52.8%had beeninfectedthrough injection drug use. In HIV/HBV and HIV monoinfected patients,themainriskfactorforviraltransmissionwassexual exposure(Fig.1).

HIV testingwas mainly donedue tosuspicionofa dis-easeorHIV-relatedclinicalsignsofacuteinfection,especially inHIV/HBVpatients(62.5%).Thetestwasperformed sponta-neouslyduetotheperceptionoftheriskofinfectionby14.3% ofHIV/HBV,26.7%ofHIVmonoinfected,and21.7%ofHIV/HCV patients.Moreover,amongHIV/HCVpatients,7.6%and12.3% ofthepatientsperformedthetestinprisonorbecauseitwas offeredbytheServiceforDrugAddiction(Table2).

HIV/HBVpatientspresentedaworseclinicaland immuno-logicalpicturecomparedwithHIVmonoinfectedandHIV/HCV patients.HIVviralloadofHIV/HBVandHIV/HCVcoinfected patientswasnotsignificantlydifferent.InHIV/HBVpatients the proportionsofLP(78.6%)andAHD (64.3%)were higher compared toHIV/HCV (61.3%and 41.5%) and HIV monoin-fected patients (55.2% and 39.6%). AIDS was diagnosed in 39.3%,20.7%, and 7.6%ofHIV/HBV,HIV monoinfected and HIV/HCVpatients,respectively.

Adjustingforgender,age,nationality,andriskfactors,the HIV/HBV patientsshowed ahigherrisk tobeLPcompared to HIV monoinfected patients (OR3.04; 95% CI:1.55–5.95). TheriskofhavingAHDwasalsohigherinHIV/HBVpatients (OR2.84;95%CI:1.57–5.14) comparedtoHIVmonoinfected

(3)

Table1–Socio-demographiccharacteristicsofHIV,HIV/HBV,HIV/HCV,HIV/HCV/HBVpatientsnotifiedinTuscany (2009–2013).

Socio-demographiccharacteristics HIV HIV/HBV HIV/HCV HIV/HCV/HBV p-value

n % n % n % n % Gender Male 940 79.1 48 85.7 86 81.1 3 75.0 0.647 Female 248 20.9 8 14.3 20 18.9 1 25.0 Agegroup 0–16 4 0.3 0 – 0 – 0 – 0.050 17–34 427 35.9 21 37.5 20 18.9 1 25.0 35–59 660 55.6 28 50.0 78 73.6 3 75.0 ≥60 97 8.2 7 12.5 8 7.6 0 – Nationality Italian 889 74.8 34 60.7 97 91.5 4 100.0 0.000 Foreign 299 25.2 22 39.3 9 8.5 0 –

Table2–ReasonsforgettinganHIVtestinHIV,HIV/HBV,HIV/HCV,HIV/HCV/HBVadultpatientsnotifiedinTuscany (2009–2013).

ReasonsforgettinganHIVtesta HIV HIV/HBV HIV/HCV

HypothesisofanHIV-relatedpathology 38.2 46.4 31.1

Hypothesisofasexuallytransmitteddisease 9.0 12.5 4.7

Situationofacuteinfection 7.9 3.6 8.5

Totalnumbertestedforacuteinfection/STD/HIVrelateddisease 55.2 62.5 44.3

Spontaneously 26.7 14.3 21.7

Gynecologicalconsultationduringpregnancy 4.1 3.6 2.8

Offeredafterinformativecampaign 1.9 1.8 0.9

OfferedbytheServiceforDrugAddiction 0.9 1.8 12.3

Carriedoutbeforesurgery 1.4 3.6 –

Offeredinprison 0.6 1.8 7.6

Offeredbeforeblood/organ/tissue/spermdonation 1.9 1.8 –

Offeredbyfamilyconsultant/gynecologist(ifnotpregnant) 0.7 – –

Noriskfactor 0.4 – –

Other 6.0 7.1 10.4

a Multipleresponses.

patients. No statistically significant difference was found betweenHIV/HCV andHIVmonoinfectedpatients(Table3). ComparedtoHIVmonoinfectedpatients,HIV/HBVpatients hadahigherriskofAIDS(OR2.44;95%CI:1.35–4.43)while theriskofHIV/HCVpatientsseemedlower(OR0.23;95%CI: 0.10–0.52).

Discussion

Toourknowledge,thisstudyshowsforthefirsttimethatthe clinical andimmunological featuresofHIV/HBVcoinfected

patientsaremoreseverecomparedtothoseco-infectedwith HIV/HCVandHIVmonoinfectedpatientsatthetimeofHIV diagnosis.HIVwasdiagnosedeitherinprisonorbythe Ser-viceforDrugAddictioninalmost20%ofHCV/HIVcoinfected patients, whichmayhavecontributedtothe lessadvanced HIVdiseaseinthispopulation.Infact,druguseisthemain riskfactorfortransmissioninthisgroupofpatients.Moreover, about15–45%positiveforanti-HCVantibodiesspontaneously clearthevirus.

TheHIV/HBVco-infectionwascommoninforeignersand they had both age and risk factors similar to those who

Table3–Multivariatelogisticregressionanalysis.EstimateofrelativeriskforHIV,HIV/HBV,HIV/HCVtobeLP,AHDor AIDS.AdultpatientsnotifiedinTuscany.2009–2013.

Latepresenter AdvancedHIVdisease AIDS

%a OR IC95% % OR IC95% % OR IC95%

HIV 55.2 1.00 – 39.6 1.00 – 20.7 1.00 –

HIV/HBV 78.6 3.04 1.55–5.95 64.3 2.84 1.57–5.14 39.3 2.44 1.35–4.43

HIV/HCV 61.3 1.24 0.75–2.05 41.5 0.81 0.49–1.34 7.6 0.23 0.10–0.52

Oddsratioandconfidenceintervalsat95%adjustedbygender,age,nationality,modeoftransmission. a Thetotalamountofthethreeconditionsisnot100%,becauseeachgroupmaybeinsideothergroups.

(4)

100% 80% 60% 40% 20% 0%

HIV HIV/HBV HIV/HCV

Unknown Other Transfusion IDU MSM Heterosexual

Fig.1–HIVtransmissionrouteinHIV,HIV/HBV,HIV/HCV,

HIV/HCV/HBVinfectedadultpatientsnotifiedinTuscany

(2009–2013).

wereHIVmonoinfected.However,thesepatientshadaworse immunologicalpictureatthetimeofHIVdiagnosiscompared toHIV/HCVco-infectedpatients,probablybecausethesexual transmissionwasthemainriskfactorinHIV/HBVcoinfected patients, with subsequent less perception of the infection transmissionrisk,thereforetheyonlyperformedthetestafter experiencingHIV-relatedsymptoms.Moreover,theywereat higherriskofhavingLP,AHD,orAIDScomparedtoHCV coin-fectedpatients.Accordingwiththesefindings,recentstudies pointedoutthatHBVinfectioncomplicatesthemanagement ofHIVinfection.Infact,patientswithchronicHBVatthetime ofHIVdiagnosishadanimpairedCD4recovery,an acceler-atedimmunologicdeterioration,andasignificantlyhigherrisk ofanAIDSordeathevent.9,10 ThisissimilartoHIVinduced impairmentofHBV,whichinturninfluencesnegativelythe courseandprogressionofHIVdisease.

WealsofoundahighprevalenceofHBV–HIVcoinfection inforeigners.In1991,ItalyinitiateduniversalHBV vaccina-tionforallnewbornsand12-year-oldadolescents.Sincethe vaccinationprogramshadadifferentpaceindeveloping coun-tries,thehighprevalenceamongforeignerscouldbedueto non-compliancewithItaly’svaccinationprogram.11

Theintroductionofblood-screeningforHCVintheearly 1990s strongly decreased HCV transmission from blood transfusions. Our data also confirm the results of several studiesthatshowedahighprevalenceofHCVcoinfectionin HIV-infectedintravenousdrugusers.6,12,13Moreover,this co-infection wasmoreprevalent inpatientsaged35–59years, correspondingtothosebornintheyearsatmajorriskfordrug abuse.Babyboomersarepeoplebornduringthepost-World WarII,approximatelybetweentheyearsof1946and1964.HCV infectionandfattyliverdiseasearemorecommonintheBaby Boomersandmayplayamoredominantroleastheyage,14 probablybecauseagingofthebabyboomercohortwillsoon

comprisealargeproportionofpersonswhohaveusedillicit drugsintheirlifetimes.Arecentcross-sectionalstudy con-ductedinBrazilshowedthattheprevalencerateofHIV-HCV coinfectionwas6.9%among848HIV-infectedpatients receiv-ingcareatreferencecentersintheMidwestRegionofBrazil.15 Thisalsoconfirmsthelessadvanceddiseaseinthesepatients, probablyduetoahigherperceivedriskofdisease,whichcould leadthemtotestearlier.Evenafteradjustingforgender,age, nationality,andtransmissionroute,wewereabletoshowthat HIV/HCVhadalowerriskofhavingAIDSdiagnosisatthetime ofdetectionofHIVinfectioncomparedtoHIVmonoinfected patients.

HCV screeninginHIV-infectedpatientsishighly recom-mended inorder to treatHCV infection whenappropriate. Currently, interferon-free treatment regimens are available and they require shorterperiods of treatment (3 months). These regimens are freeof the associatedsubstantial side effects, and preliminary results suggest that these treat-mentsarealsoeffectiveinpatientswithcirrhosis(somefor 6months).16

Inconclusion,ourdatashowthatbothageandrisk fac-torsforHIV/HBVcoinfectedpatientsaresimilartothatofHIV monoinfectedpatients.Moreover,theprevalenceofHBVwas higher inHIV-infectedforeignerscomparedtoHIV-infected Italian patients.Future pathogenesisstudies are neededto confirmthehigherriskforLP,AHD,andAIDSinHBV coin-fected patients. Our dataalso confirma higherprevalence ofHIV/HCVinfectionsamongdrugaddicts,especiallyinthe 35–59agegroup,correspondingtothosebornintheyears con-sideredmostatriskfordrugabuse.Thisalsosuggeststhatthe higherperceived riskofdiseaseleadstoearlierHIVtesting comparedtoHIV/HBVpatients.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1.EPICENTRO.InfezionedaHIVeAIDS;2014.Availablefrom:

http://www.epicentro.iss.it/problemi/aids/storia.asp

2.WorldHealthOrganization.Globalreport:UNAIDSreporton theglobalAIDSepidemic2013;2013.Availablefrom:http:// www.unaids.org/en/media/unaids/contentassets/documents/

epidemiology/2013/gr2013/unaidsglobalreport2013en.pdf

3.CentroOperativoAIDS.Aggiornamentodellenuovediagnosi

diinfezionedaHIVedeicasidiAIDSinItaliaal31Dicembre

2012.Notiziariodell’IstitutoSuperiorediSanità26(9);2013.

4.WorldHealthOrganization.Hepatitis:frequentlyasked questions;2014.Availablefrom:http://www.who.int/csr/

disease/hepatitis/worldhepatitisday/questionanswer/en/

5.LacombeK,RockstrohJ.HIVandviralhepatitiscoinfections:

advancesandchallenges.Gut.2012;61:i47–58.

6.AlterMJ.EpidemiologyofviralhepatitisandHIVco-infection.

JHepatol.2006;44:S6–9.

7.ChenJY,FeeneyER,ChungRT.HCVandHIVco-infection:

mechanismsandmanagement.NatRevGastroenterol

Hepatol.2014;11:362–71.

8.AntinoriA,CoenT,CostagiolaD,etal.Latepresentationof

(5)

9. ChunHM,RoedigerMP,HullsiekKH,etal.HepatitisBvirus

coinfectionnegativelyimpactsHIVoutcomesinHIV

seroconverters.JInfectDis.2012;205:

185–93.

10.TsaiMS,ChangSY,LoYC,etal.HepatitisBvirus(HBV)

coinfectionacceleratesimmunologicprogressioninpatients

withprimaryHIVinfectioninanareaofhyperendemicityfor

HBVinfection.JInfectDis.2013;208:1184–6.

11.StasiC,SilvestriC,BraviS,etal.HepatitisBandC

epidemiologyinanurbancohortinTuscany(Italy).ClinRes

HepatolGastroenterol.2015;39:e13–5.

12.AmonJJ,GarfeinRS,Ahdieh-GrantL,etal.Prevalenceof

hepatitisCvirusinfectionamonginjectiondrugusersinthe

UnitedStates,1994–2004.ClinInfectDis.2008;46:

1852–8.

13.BurtonMJ,ReillyKH,PenmanA.Incarcerationasariskfactor

forhepatitisCvirus(HCV)andhumanimmunodeficiency

virus(HIV)co-infectioninMississippi.JHealthCarePoor

Underserved.2010;21:1194–202.

14.DavisGL,RobertsWL.Thehealthcareburdenimposedby

liverdiseaseinagingBabyBoomers.CurrGastroenterolRep.

2010;12:1–6.

15.FreitasSZ,TelesSA,LorenzoPC,etal.HIVandHCV

coinfection:prevalence,associatedfactorsandgenotype

characterizationinthemidwestregionofBrazil.RevInstMed

TropSaoPaulo.2014;56:517–24.

16.StasiC,SilvestriC,VollerF,CiprianiF.Theepidemiological

changesofHCVandHBVinfectionsintheeraofnewantiviral

therapiesandtheanti-HBVvaccine.JInfectPublicHealth.

w w w . e l s e v i (http://creativecommons.org/licenses/by-nc-nd/4.0/ http://www.epicentro.iss.it/problemi/aids/storia.asp 2013 2013. http://www.who.int/csr/disease/hepatitis/world 2012;61:i47–58. 2006;44:S6–9. 2014;11:362–71. 2011;12:61–4. 2012;205:185–93. 2013;208:1184–6. 2015;39:e13–5. 2008;46:1852–8. 2010;21:1194–202. Davis 2014;56:517–24. Stasi

References

Related documents

Fusion of different motifs of chikankari embroidery was done for the development of new designs for sofa backs and cushion covers.. Five designs were sketched for each

CRF acting through the CRF1R has been implicated in both stress sensitization of the anxiety during CIA exposure (Breese et al, 2011; Huang et al., 2010; Knapp et al., 2011) and

In this regard, promising preliminary support for targeting fear-avoidance behaviour is found in two re- cent studies successfully treating PTSD [17] and fear of movement in relation

A data is extracted from the information document which is called as Information Extraction (IE) and is based on the rule model. The algorithm used is based on the

Telomerase extracts from three tumor cell lines (human lung cancer cell line, A549; human breast cancer cell line, MCF7; and human liver cancer line, HepG2) were added to

They argue that the merger exercised of the domestic banking system in the year 2000 has no significant impact on the ownership structure of the domestic banking industry;

Wklv sdshu vshflhv d jhqhudo vhw ri frqglwlrqv xqghu zklfk wkh lpsdfwv ri d srolf| fdq eh lghqwlhg xvlqj gdwd jhqhudwhg xqghu d glhuhqw srolf| uhjlph1 Zh vkrz wkdw vrph ri wkh

a Follow-up positron emission tomography/computed tomography image at the local hospital; the arrow indicate the cardiophrenic angle lymph node metastasis.. 2 Intraoperative images