CONHIV14 - HIV-related Infections, Co-infections and Cancers, etc. – Part three - page 4

1. INTRODUCTION
3. RESULTS
2. PATIENTS & METHODS
*Community oriented Study Group of ICONA
C. Balotta, A. Cingolani, GM Corbelli, M. Errico, E. Girardi, G. Guaraldi,
S. Lo Caputo, F. Maggiolo, A. D’Arminio Monforte and S. Marcotullio
Statisticians: S. Zona,P. Lorenzini, A. Cozzi-Lepri
ICONA Foundation Study Group
BOARD OF DIRECTORS
M Moroni (Chair), M Andreoni, G Angarano, AAntinori, A d
Arminio Monforte, F Castelli, R Cauda, G
Di Perri, M Galli, R Iardino, G Ippolito, A Lazzarin, CF Perno, F von Schloesser, P Viale
SCIENTIFIC SECRETARY
A d
Arminio Monforte, AAntinori, A Castagna, F Ceccherini-Silberstein, A Cozzi-Lepri, E Girardi, S Lo
Caputo, C Mussini, M Puoti
STEERING COMMITTEE
M Andreoni, AAmmassari, AAntinori, A d
Arminio Monforte, C Balotta, P Bonfanti, S Bonora, M
Borderi, MR Capobianchi, A Castagna, F Ceccherini-Silberstein, A Cingolani, P Cinque, A Cozzi-
Lepri, A d
Arminio Monforte, A De Luca, A Di Biagio, E Girardi, N Gianotti, A Gori, G Guaraldi, G
Lapadula, M Lichtner, S Lo Caputo, G Madeddu, F Maggiolo, G Marchetti, S Marcotullio, L Monno, C
Mussini, M Puoti, E Quiros Roldan, S Rusconi
STATISTICAL AND MONITORING TEAM
A.Cozzi-Lepri, P. Cicconi, I. Fanti, T. Formenti, L. Galli, P. Lorenzini
PARTICIPATING PHYSICIANS AND CENTERS
Italy A Giacometti, A Costantini, S Mazzoccato (Ancona); G Angarano, L Monno, C Santoro (Bari); F
Maggiolo, C Suardi (Bergamo); P Viale, E Vanino, G Verucchi (Bologna); F Castelli, E Quiros
Roldan, C Minardi (Brescia); T Quirino, C Abeli (Busto Arsizio); PE Manconi, P Piano (Cagliari); J
Vecchiet, K Falasca (Chieti); L Sighinolfi, D Segala (Ferrara); F Mazzotta, S Lo Caputo (Firenze); G
Cassola, C Viscoli, AAlessandrini, R Piscopo, G Mazzarello (Genova); C Mastroianni, V Belvisi
(Latina); P Bonfanti, I Caramma (Lecco); A Chiodera, AP Castelli (Macerata); M Galli, A Lazzarin, G
Rizzardini, M Puoti, A d
Arminio Monforte, AL Ridolfo, R Piolini, A Castagna, S Salpietro, L Carenzi,
MC Moioli, C Tincati, G. Marchetti (Milano); C Mussini, C Puzzolante (Modena); A Gori, G. Lapadula
(Monza); N Abrescia, A Chirianni, MG Guida, M Gargiulo (Napoli); F Baldelli, D Francisci (Perugia); G
Parruti, T Ursini (Pescara); G Magnani, MA Ursitti (Reggio Emilia); R Cauda, M. Andreoni, AAntinori,
V Vullo, A. Cingolani, A d
Avino, L Gallo, E Nicastri, R Acinapura, M Capozzi, R Libertone, G Tebano
(Roma); A Cattelan, L Sasset (Rovigo); MS Mura, G Madeddu (Sassari); A De Luca, B Rossetti
(Siena); P Caramello, G Di Perri, GC Orofino, S Bonora, M Sciandra (Torino); M Bassetti, A Londero
(Udine); G Pellizzer, V Manfrin (Vicenza).
4. DISCUSSION
REFERENCES
Increased incidence of Sexually Transmitted Diseases (STD) in the recent years: data from the
ICONA cohort.
A Cingolani
1*
, S Zona
2
, E Girardi
3
, A Cozzi-Lepri
4
, L Monno
5
, E Quiros Roldan
6
, G Guaraldi
2
, A Antinori
7
, A d’Arminio Monforte
8
, S Marcotullio
9
for
the Community Oriented Study
Group
of The Icona Foundation Study Group
The role of fully suppressive cART in reducing the transmission of
HIV infection to HIV-negative partner has been well established
(1). Nevertheless, some local genital factors such as bacterial or
viral infections, namely Sexually Transmitted Diseases (STDs), can
increase the shedding of HIV in semen, leading to an increase of
HIV transmission (2).
This aspect has been well demonstrated in people not assuming
cART, whereas little is known whether the same increase risk is
applicable to people on fully-suppressive cART. It has been
recently demonstrated that effective cART does not completely
reduce the risk of HIV transmission in sexually active men who
have sex with other men (MSM) with concomitant STD (3). Thus it
has been recently hipothesized that the persistent risky behaviours
may reduce the beneficial effect of cART on the incidence of HIV
infection (4), to study the incidence and determinants of STD may
help to increase knowledgment regarding risky behaviours.
A previous analysis whithin ICONA cohort demonstrated that the
use of highly active antiretroviral therapy (cART) was not
associated with a higher risk of newly acquired HBV and syphilis,
and that suppressive cART was associated with a lower risk of
HBsAg seroconversion (5). Nevertheless, a comprehensive
approach considering all STI has never been assessed.
Specific objectives were to analyze temporal trend of any incident
STI, according with plasma HIV-RNA level in the entire period of
cohort observation, to evaluate factors associated with a new
diagnosis of STI in patients according with level of HIV-RNA and to
analyze the role of ART on the onset of STI during time.
All HIV-infected patients enrolled in the Icona Foundation
Cohort Study from 1997 were included in the present
analysis.
STD is defined at the occurrence of any of the following
conditions: any-stage syphilis (primary, secondary, latent,
tertiary, and unspecified), HPV-related diseases, urethritis
(gonococcal, non-gonococcal), HSV-related genital ulcers,
any genital ulcer disease not otherwise specified, vaginitis
(trichomonas, bacteric, not specified), HBV, HCV, HAV (see
statistical methods for details regarding inclusion of hepatitis).
Data on STD are available at enrolment and they are updated
at the occurrence of any clinical event or, in their absence, at
least every 6 months.
STDs incidence rate (IR) were calculated according to current
plasma viral load level (HIV-RNA<50 c/ml, HIR-RNA> 50 c/ml)
and calendar period (1998-2002, 2003-2007, 2008-2012).
Predictors of STD occurrence were estimated using Poisson
regression. Sandwich estimates were used when people had
more than one event.
Two different regression analyses were done: 1) Excluding
acute hepatits in IVDU. 2) Excluding all cases of acute
hepatitis.
As covariates will be used demographical, epidemiological
and clinically relevant variables recorded in the database,
namely: age (strafied as 18-30 year old, 31-40, 41-50, 51-60
and >60 year old), gender, risk behaviour for HIV transmission
(heterosexual, MSM, intravenous drug users, other risks),
educational level (primary, secondary school, college, and
university), ethnicity; current CD4 cell count (<100, 101-350,
351-500, and >500 cells/uL), ART status (ART-naïve, on ART,
on treatment interruption at STD diagnosis).
Data of 9,168 pts were analysed. 2355 were women (25.7%). Over 46,736 PYFU, 996 episodes of STD were observed (crude IR 21.3/1,000 PYFU)
Mean age at first visit 37.3 (SD 9.3)
74% were male. 31% were MSM, 39% heterosexuals, 25% IDU, 6% other risk.
3327 pts were enrolled in 1998-2002, 1273 in 2003-2007, 4568 in 2008-2012.
Median (IQR) CD4/mmc and HIV-RNA/ml at STD: 433 (251-600) and 10,900 (200-63,000). 400 (40%) episodes occurred while people were on ART (IR
12.8/31297 PYFU ), 534 (53%) in naive patients (IR 44.6/11961 PYFU).
48 pts (0.5%) presented more than 1 episode of incident STD.
Figure 2
Multivariable Poisson regression analysis for factors associated with incident STDs (analysis performed excluding new
onset of hepatitis in IVDU; similar results were observed excluding all cases of hepatitis )
Figure 2
Incidence of specific STDs
.
1.
Cohen MS, Chen YQ, McCauley M. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011 Aug
11;365(6):493-505.
2.
Johnson LF, Lewis DA. The effect of genital tract infections on HIV-1 shedding in the genital tract: a systematic review and
meta-analysis.Sex Transm Dis. 2008 Nov;35(11):946-59
3.
Politch JA, Mayer KH, Welles SL, et al. Highly active antiretroviral therapy does not completely suppress HIV in semen of
sexually active HIV-infected men who have sex with men. AIDS 2012; 26:1535-1543.
4.
Phillips AN, Cambiano V, Nakagawa F, et al. Increased HIV incidence in men who have sex with men despite high levels
of ART-induced viral suppression: analysis of an extensively documented epidemic.Plos One 2013; 8:55312
5.
P. Cicconi, A. Cozzi-lepri, G. Orlando, et al. . Recent Acquired STD and the Use of HAART in the Italian Cohort of Naive
for Antiretrovirals (I.Co.N.A): Analysis of the Incidence of Newly Acquired Hepatitis B Infection and Syphilis. Infection 2008:
36:46-53
Risk of acquiring a new STD has been increasing over the years of
observation whitin the ICONA cohort
The use of ART reduce the risk of acquiring STD (as a proxy of whether a
person is regularly seen for care)
Highly tailored interventions (focused on young people, MSM, people with
low CD4+ cell count, those with low schooling and those recently diagnosed
with HIV ) - involving Community groups and/or specific experts for
every field - to prevent STDs and potential further spread of HIV infection
should be considered.
The biological role of virological suppression in reducing the risk of STD
could not be derived from our results
Table 1
Incident rates (IR) according to population characteristics.
1
Dep of Public Health, Infectious Diseases, Catholic University, Roma, Italy;
2
Clinic Infectious Diseases, Univeristy of Modena and Reggio Emilia, Modena, Italy;
3
Dep of Epidemiology and
7
Clinical Department, National Institute for Infectious Diseases “L.Spallanzani”, Roma, Italy;
4
Department of Infection and Population Health, Division of Population Health, UCLMedical School, Royal
Free Campus, London, United Kingdom;
5
Insitute of Infectious Diseases, Univeristy of Bari, Bari, Italy;
6
Insitute of Infectious Diseases, University of Brescia, Brescia, Italy;
8
Clinic of Infectious and Tropical Diseases, Dept. of Medicine, Surgery and Dentistry, San Paolo University Hospital Milan, Milano, Italy, 9 Nadir Foundation Onlus, Roma, Italy
>
<
*
Interna'onal Congress on Drug Therapy in HIV Infec'on.
2014 – Glasgow UK
Poster P 121
Figure 1
Distribution of incident STDs
STD
Incidence rate/1000 PYFU
95%CI
Any stage syphilis
3.95
3.59-4.35
HPV
1.96
1.71-2.24
Acute viral hepatitis
HAV
HBV
HCV
1.72
0.19
6.54
3.74
1.49-1.99
0.09-0.36
5.83-7.32
3.21-4.34
HSV
0.81
0.65-0.99
Gonococcal uretritis
0.46
0.35-0.61
Non gonococcal uretritis
0.47
0.36-0.62
Other genital ulcers
0.11
0.06-0.19
Background
: Aims of this analysis were to identify temporal trends in the
incidence of sexually transmitted diseases (STDs) in a cohort of HIV+
people and to evaluate factors associated with the risk of a new STD
diagnosis.
Methods
: All HIV-infected patients in the Icona Foundation Study cohort
enrolled after 1998 were included. STD incidence rates (IR) were calculated
and stratified by calendar periods. Predictors of STDs were identified by
Poisson regression model with sandwich estimates for standard errors.
Results
: Data from 9,168 participants were analyzed (median age 37.3
(range: 18-81), 74% male, 30% MSM). Over 46,736 PYFU, 996 episodes of
STDs were observed (crude IR = 21.3/1,000 PYFU, 95% CI: 20.0-22.6). By
multivariable Poisson regression analysis, MSM (rate ratio (RR) 3.03,
95%CI 2.52–3.64 vs. heterosexuals), calendar period (RR 1.67, 95% C.I.
1.42–1.97, in 2008-2012 vs. 1998-2002), HIV-RNA>50 c/ml (RR 1.44 ,
95%CI 1.19–1.74 vs. HIV-RNA ≤50c/ml) and a current CD4+ cell
count<100/mmc (RR 4.66, 95%CI 3.69–5.89, p<0.001 vs. CD4+ cell
count>500) were associated with increased risk of STDs. In contrast, older
age (RR=0.82 per 10 years older, 95%CI 0.77–0.89) and to be currently on
ART ( RR 0.38, 95%CI 0.33–0.45) compared to be ART-naïve people and
on treatment interruption were associated with a lower risk of developing
STDs.
Conclusions
: An increase in the incidence of STDs was observed in more
recent years. Interventions to prevent STDs and potential spread of HIV
should target young population, MSM and people currently not receiving
ART
1,2,3 5,6,7,8,9,10,11,12
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