Four years of surveillance of recent HIV infections at country level, France, mid 2003 - 2006: experience and perspectives.

New systems of surveillance to better monitor the dynamics of HIV are needed. A national surveillance of new HIV diagnoses which included the collection of dried serum spots (DSS) to identify recent infections (<6 months) using an EIA-RI assay was implemented in 2003 in France. The collection of DSS is based on the voluntary participation by both patients and microbiologists. Multivariate analysis was used to identify factors associated with recent infection (RI). Between July 2003 and December 2006, 14,155 cases newly diagnosed for HIV were reported. A minority of patients refused the collection of DSS (3.3%) and the rate of participation of laboratories was 80%. The test was performed for 10,855 newly diagnosed HIV cases, the overall proportion of RI was 23.1% (95% CI, 22.3%-23.9%). The proportion of RI was higher among men who have sex with men (MSM) (42.8%) than among heterosexuals (16.3%). Among heterosexuals, it varied by current nationality: 27% among French versus 8.4% among Africans. The risk of RI was greater for MSM (aOR=1.8), those of French nationality (aOR=3.9), those with high-economic status (aOR=1.2), those tested after a risk exposure (aOR=1.4), those tested for HIV three or more times during their lifetime (aOR=2.5). The risk of RI decreased with age. A nation-wide implementation of RI monitoring is feasible. The information on RI is very useful for renewing prevention messages, particularly among population in which HIV transmission is on going, such as MSM.

Differential improvement in survival among patients with AIDS after the introduction of HAART.

We explored changes in the survival of patients with AIDS (PWA) according to the availability of antiretroviral drugs (1994-2002). We tested whether changes in the hazard ratio of progression to death (HR) have been homogeneous among various groups of PWA. We included 4158 PWA diagnosed in Paris, notified to the French National Surveillance Institute by 2002. Four calendar periods were defined: monotherapy (1994-95), bitherapy-HAART transition (1996), early HAART (1997-99), late HAART (2000-October 2002). HR were calculated with Cox models, including the calendar period, modelled as a time dependent covariate. Models were stratified by age, transmission category, CD4 cell count, and AIDS-defining illnesses (ADI) group. Cumulative survival at 60 months increased from 44.0% (before July 1996) to 75.6% (after July 1996) and median survival increased from 31.9 months to >76 months. Adjusted HR reached a minimum in the late HAART period (HR 0.22, 95% CI: 0.19-0.26). No difference in the decrease of the HR has been found by age. HR decreased and was marked during the late HAART period across all HIV transmission categories, including intravenous drug use. HR decreased significantly for all ADIs groups, including tumours. Among PWA diagnosed with tuberculosis, the HR decreased significantly only in the late HAART period. HR decrease was stronger for PWA with a CD4 cell count < or =200/mm(3). Substantial improvements in survival after the introduction of HAART were found for all PWA but varied by specific ADIs and the degree of immunosuppression.

Preliminary results from the new HIV surveillance system in France.

In addition to AIDS surveillance, data on HIV infection are necessary to better follow the dynamics of the epidemic. We report the first results of France's mandatory anonymous HIV notification system, which is linked to a virological surveillance of recent HIV infections and of circulating HIV types, groups and subtypes. HIV notifications are initiated by microbiologists who create an anonymous code of patient's identity. Clinicians complete the notification form with epidemiological and clinical data. Notifications are sent to the local health authorities and passed to the Institut de Veille Sanitaire (InVS). Laboratories voluntarily send sera from newly diagnosed HIV infected persons on dried blood spots to the national HIV reference laboratory where an immunoassay for recent infection (< or = 6 months) and a serotyping assay for the determination of group and subtype are done. The virological results are then merged at the InVS with the information from the mandatory reporting. Of the first 1301 new HIV diagnoses reported in 2003, 43% were in women, and overall, 53% were in heterosexuals, of whom 47% were of sub-Saharan African origin. MSM accounted for 36% of male notifications. A dried blood spot was available for 64% of new HIV diagnoses. Evidence of recent infection was found for 38%, ranging from 22% in IDUs to 58% in MSM. Twenty-six percent of infections in sub-Saharan migrants were recent infections. HIV-1 accounted for 98% of all notifications: 48% of these were non-B subtypes. The first results of the HIV notification system indicate that heterosexual transmission is the predominant mode of transmission and that persons originating from sub-Saharan Africa are particularly affected. Over half of infections shown to be recently acquired were in MSM; this may indicate an increased HIV incidence in this population.

Preliminary results from the new HIV surveillance system in France.

In addition to AIDS surveillance, data on HIV infection are necessary to better follow the dynamics of the epidemic. We report the first results of France's mandatory anonymous HIV notification system, which is linked to a virological surveillance of recent HIV infections and of circulating HIV types, groups and subtypes. HIV notifications are initiated by microbiologists who create an anonymous code of patient's identity. Clinicians complete the notification form with epidemiological and clinical data. Notifications are sent to the local health authorities and passed to the Institut de Veille Sanitaire (InVS).

[Prevalence of HBV, HCV, HIV and HTLV in autologous blood donors in France between 1993 and 2000]. / Prévalence des virus des hépatites B et C, du VIH et de l'HTLV chez les candidats à une transfusion autologue programmée en France, 1993-2000.

The epidemiological surveillance of autologous blood donors has been carried out in France since 1993. The number of autologous donors increased regularly from 1993 to 1997 but has decreased during the last three years to become less than 50,000 in 2000. The sex-ratio was stable over time (0.85 male for 1 female). The population of autologous donors grew older between 1993 and 2000: the proportion of those aged under 50 years old decreased from 29% in 1993 to 18% in 2000 while the proportion of those over 69 increased from 22 to 34%. Between 1993 and 2000, HbsAg prevalence decreased by a factor of 2.5 and HCV prevalence by a factor of 5. For HIV, a slight decrease was observed and the prevalence of HTLV was stable over time. In 2000, HCV prevalence (0.23%) was two times higher than HBsAg prevalence (0.12%), fifteen times higher than HTLV prevalence in Continental France (0.015%) and one hundred times higher than HIV prevalence (0.002%). The prevalence was similar in men and women for HCV, about two times higher in men than in women for HBsAg and three times higher for HIV. On the contrary, HTLV prevalence was about two times higher in women than in men. HBsAg and HCV prevalence rates were also calculated by age group. The prevalence rates for HBsAg increased up to the 30-39 age group among women and the 40-49 age group among men; then the rates decreased but were higher in men than in women. For HCV, while the prevalence increased continuously with age among women, a peak was reached for men in the 30-39 age group followed by a decrease up to the 50-59 age group and the prevalence was stable afterwards. The very low level of the current risk of transmitting viral infections by homologous transfusion and technical changes in autologous transfusion seem to be the two main factors that contributed to the recent decline in the number of autologous donors. The decrease in HBsAg and anti-HCV prevalence between 1993 and 2000 is multifactorial, but the drop observed for HCV is probably linked to a decrease in HCV prevalence of the general population over the last ten years.

Factors associated with tuberculosis at AIDS diagnosis in France.

OBJECTIVE: To identify factors associated with tuberculosis (TB) at AIDS diagnosis in France. DESIGN: Analysis of surveillance data. METHODS: Among all adult AIDS cases diagnosed since January 1988 and reported by December 1993 in France, the proportion diagnosed with AIDS-defining TB (extrapulmonary TB among cases diagnosed between 1988 and 1992, all forms of TB among cases diagnosed in 1993) was analysed by year of diagnosis, sex, age, nationality, profession, HIV transmission group and region of residence by multiple logistic regression. RESULTS: Between 1988 and 1992, 5.7% (1134 out of 19,968) of AIDS patients were diagnosed with AIDS-defining extrapulmonary TB. Presence of extrapulmonary TB was associated with male sex [adjusted odds ratio (AOR), 1.7], nationality from a sub-Saharan country (AOR, 4.8), heterosexual contact or injecting drug use (AOR, 2.4 and 2.7, respectively), residence in the Paris area (AOR, 1.7), and unemployment or factory work (AOR, 2.5 and 2.4, respectively). In 1993, 10.6% (393 out of 3721) of AIDS patients were diagnosed with TB (all forms). In multivariate analysis, three factors were independently associated with the risk of presenting TB at AIDS diagnosis: transmission category, nationality, and region of residence. CONCLUSIONS: Some factors associated with TB at AIDS diagnosis in France are known to be related to a high incidence of TB in industrialized countries (nationality, from a developing country, male sex, low socioeconomic status). The independent association with injecting drug use or residence in Paris suggests a contribution of recent TB infection in specific groups of HIV-infected persons. This contribution should be evaluated to implement appropriate preventive measures.