High-grade anal intraepithelial neoplasia is associated with HIV-1 RNA rectal shedding in virologically suppressed MSM.

OBJECTIVE: The protective effect of ART has not yet been definitively established in MSM. We aimed to characterize the factors associated with persistent HIV-1 RNA rectal shedding. METHODS: Prospective study including virologically suppressed MSM from an HIV cohort. High-resolution anoscopy (HRA) was performed for screening of anal dysplasia, and rectal sampling for HIV-1 RNA quantification and sexually transmitted infections (STIs) investigation through multiplex PCR. Both generalized linear mixed (GLM) and zero-altered negative binomial (ZANB) models were performed. RESULTS: One hundred and fifty-five rectal swab samples from 132 virologically suppressed MSM were included. HIV-1 RNA was detectable in 61 (39.3%) samples, with median (IQR) rectal viral load (rVL) of 295.8 (158.8-522) copies/swab. Multivariable GLM showed that the presence of high-grade anal intraepithelial neoplasia (HG-AIN; OR 2.85 [95% CI 1.10-7.38]) and a protease inhibitor-based regimen (OR 2.49 [0.98-6.34]) resulted in increased risk for rectal HIV-1 shedding, whereas higher nadir CD4+/CD8+ T-cell ratio (OR 0.18 [0.04-0.93]) was negatively associated with rectal shedding. ZANB analyses showed that the best predictors of having detectable rVL were lower nadir CD4+/CD8+ T-cell ratio (OR 0.98 [0.96-0.99]) and PI-based regimens (OR 4.85 [1.29-18.24]); the presence of HG-AIN (RR 2.50 [1.41-4.45]), and a higher burden of STIs (RR 1.39 [1.03-1.85]) were predictors of rectal HIV-1 shedding intensity. CONCLUSION: The prevalence of HIV-1 RNA rectal shedding is high in virologically suppressed MSM. In addition to ART and the immune system integrity, local factors, including the co-existence of HG-AIN and the burden of STIs, may account for the persistence of HIV-1 RNA shedding in rectal mucosa.

HIV infection early diagnosis experience in primary care.

INTRODUCTION: Traditional screening system focus on classic risk factors "lost" a substantial proportion of HIV-infected patients. Several organizations such as CDC or USPS Task Force favour universal screening for HIV infection for good cost-effectiveness profile. In a previous study prevalence of HIV infection in patients attending our infectious diseases department was high (5.4%). OBJECTIVE: To determine prevalence of HIV infection in patients aged 20-55 years in primary care (PC). MATERIAL AND METHODS: A propsective observational study was undertaken between February and June 2013. We performed a screening of HIV infection type "Opt-out" (offering voluntary rejection) in 4 PC centers (32 Physicians) in San Juan-Alicante. Sample size (n=318) for a prevalence of 1% and a confidence level of 97% was calculated. Nevertheless, other PC physician not recruiting patients performed HIV testing according clinical risk factors. RESULTS: HIV testing was offered to 508 patients. Mean age 38.9±10 years (58.5% female). Overall, 430 (83.8%) agreed to participate. Finally, 368 patients (71.7% of total) were tested for HIV. No patient had a positive result (100% ELISA HIV negative). However, following clinical practice, 3 patients were diagnosed of HIV in the same period by non-recruiting physicians. In 2 cases, serology was performed at the patient's request and in one case by constitutional syndrome. The 3 patients were MSM. CONCLUSIONS: 1) In our study, we detected no new cases of HIV infection through universal screening. 2) Our screened population could be lower-risk because of high percentage of women included (58.5%). 3) Performing HIV opt-in screening (clinical practice), we detected 3 cases in the same period, all having HIV risk factors (MSM). 4) These results suggest that opt-out screening should be developed in high-risk populations. It is still to be determined what is the best screening strategy in low-risk populations such as ours.

Comparison of combined nose-throat swabs with nasopharyngeal aspirates for detection of pandemic influenza A/H1N1 2009 virus by real-time reverse transcriptase PCR.

Data assessing the diagnostic accuracies of use of different respiratory samples for the detection of the novel influenza A/H1N1 2009 virus by molecular methods are lacking. The objective of this study was to compare the sensitivity of combined nose and throat swabs (CNTS) with that of nasopharyngeal aspirates (NPA). This was a prospective study of adults and children with suspected influenza. Real-time reverse transcriptase PCR testing was used for the virological diagnosis. Of the 2,473 patients included, 264 with paired CNTS and NPA were randomly selected. Novel influenza A/H1N1 virus was identified in at least one sample for 115 (43.6%) patients, the majority of them young adults. In 109 patients (94.8%) the virus was identified in the CNTS, and in 98 (85.2%) it was identified in the NPA (P = 0.02). In 93 patients (80.1%), the virus was identified in both specimens. Spearman's rho correlation coefficient between the two methods was 0.82 (P < 0.001). There were no significant differences in accuracy between the specimens when patients were stratified according to demographic or clinical characteristics except in the case of women, in whom the sensitivity of CNTS was higher (P = 0.01). The combination of CNTS and NPA had a significantly higher sensitivity in identifying the virus than did each method alone (P = 0.02 for the comparison of the combination of both sampling methods with CNTS, and P < 0.001 for the comparison with NPA). We conclude that in patients with the novel influenza A/H1N1 virus, the diagnostic yield of CNTS is higher than that of NPA. The combination of both sampling methods increases the likelihood of diagnosing the virus.

A comparative study of bacteremic and non-bacteremic pneumococcal pneumonia.

BACKGROUND: Few attempts have been made to compare bacteremic and non-bacteremic pneumococcal pneumonia, mainly because it is difficult to gain agreement on which cases represent non-bacteremic pneumococcal pneumonia. Recently, an immunochromatographic assay for the detection of Streptococcus pneumoniae urinary antigen has been successfully evaluated for the diagnosis of pneumococcal pneumonia. The aim of our study was to examine and compare clinical and radiological features, risk factors, and outcome associated with bacteremic and non-bacteremic groups. METHODS: A retrospective study (1995-2003) analyzing the clinical records of patients diagnosed with pneumococcal pneumonia in our institution was performed. S. pneumoniae were identified by blood cultures (bacteremic group) and detection of urinary antigen (non-bacteremic group). RESULTS: There were 82 patients (57 bacteremic and 25 non-bacteremic). In seven non-bacteremic cases, another etiology was detected, i.e., Legionella (n=1) and Chlamydia pneumoniae (n=6). Bacteremic patients were significantly younger (p=<0.001), more likely to have liver disease (p=0.028), current smokers (p=0.024), alcohol and intravenous drug abusers (p=0.014 and p<0.001, respectively), and infected with HIV (p<0.001). Non-bacteremic patients were more likely to have congestive heart failure (p=0.004), chronic obstructive pulmonary disease (p=0.033) and to be former smokers (p=0.004). Bacteremic cases needed more prolonged intravenous antibiotic treatment (6 days vs. 4.5 days; p=0.006) than non-bacteremic cases and their length of stay was also longer. CONCLUSION: In our study, smoking was the leading risk factor for pneumococcal pneumonia. However, current smokers have an increased risk of bacteremic forms and former smokers and patients with COPD developed non-bacteremic forms more frequently. Bacteremic patients need more prolonged intravenous antibiotic treatment than non-bacteremic patients.