Dan Oțelea

Postpartum evolution of newborns to mothers addicted to “new drugs” and recently diagnosed with HIV infection

Background In 2011 and 2012 Romania registered a significant increase in the number of intravenous drug users (IVDUs) along with a change in the use pattern, namely the replacement of heroin with the so called “new drugs”. These are mostly synthetic cannabinoids and cathiones. Within this context, the share of new IVDU-HIV cases expanded from 3% in 2010 to 29% in 2012. Our objective was to observe the evolution of 30 newborns to mothers recently diagnosed with HIV infection, who were also “new drugs” consumers.

Clinical utility of the GeneXpert assay for the diagnosis of Clostridium difficile infections

Background Since 2011 a rapid increase of cases with Clostridium difficile infection (CDI) was observed in the National Institute for Infectious Diseases (NIID), the largest tertiary level infectious diseases hospital in Romania. The need of a fast and accurate diagnosis of CDI and the low sensitivity of the available rapid immunoassays supported the introduction of a molecular assay as a part of the CDI diagnostic strategy. The present study aimed to evaluate the clinical utility of the GeneXpert Clostridium difficile (Cepheid, Sunnyvale, CA) assay in the diagnosis of CDI cases in NIID.

Baseline HIV-1 tropism prediction in advanced immune suppressed patients: evidence of CXCR4 viruses in IDUs infected with recombinant forms

Until 2011, the main risk factor for the spread of HIV-1 in Romanian adult population was heterosexual contact. More recently, the number of HIV-1 new cases among IDUs significantly increased. This new subepidemic is characterized by circulation of particular forms of infective strains (CRF14_BG), high prevalence of HCV co-infections and infective endocarditis. Genotypic methods are currently used for testing viral tropism in HIV infected patients. Deep sequencing proved to have much higher sensitivity than population sequencing in detecting minority - CXCR4 tropic viruses. Previous studies suggested that the presence of CXCR4 phenotype at baseline is frequently associated with a faster disease progression. The aim of the study was to evaluate the viral tropism at the moment of HIV diagnostic in IDU patients. We have analyzed sequences from 19 IDUs that presented low CD4 counts (<200 cells/cmm) and/or CDC stage C when HIV-1 infection was diagnosed. They were compared with strains from 24 heterosexuals diagnosed at the same time with the IDUs were included in the study. RT PCR was performed to amplify the V3 loop. Population sequencing was done using BigDye chemistry and 3500 Genetic Analyzer. Deep-sequencing was performed on the GS Junior 454 sequencing platform and AVA software was used to analyze the output sequences. The tropism prediction was assessed by geno2pheno[coreceptor] bioinformatic algorithm and subtyping with REGA tool version 2.0. The IDU group was mainly infected with recombinant forms: CRF14_BG and recombinants between F1 and CRF14_BG (68.4%, 13/19); the heterosexuals had F1 subtype viruses (95.8%, 23/24). CXCR4 tropism was associated with IDUs and in particular with CRF14_BG (p=0.0027). All the CRF14_BG were X4 by population sequencing. Furthermore, when tested with deep sequencing the viral populations of CRF14_BG samples were exclusively X4 (no minority R5 populations). Dual tropic (CCR5 and CXCR4) populations were more frequent in F1 samples isolated from heterosexuals and predicted as X4 by population sequencing. We found concordance between the predictions of the two methods. In the heterosexual group both techniques predicted mainly CCR5 viruses. CXCR4 tropic CRF14_BG viruses were very common in IDUs at baseline. This may contribute to faster disease progression in this population than in heterosexuals infected with the F1 CCR5 tropic strains.

The dynamics of HIV trends of transmission in the Romanian cohort

Since the early 1990s Romania has made important progresses in the HIV/AIDS area, also recognised by the international community. These steps forward concern treatment and care for people living with HIV/AIDS (PLWHA) and prevention of HIV transmission among young people and vulnerable groups. However, the global economic crisis has generated a behavioural change especially among the young population, with an increase of incidence at 2.54/100,000 (31 December 2013). At the end of 2013 we performed the annual statistical evaluation of the HIV epidemic. The National Database registered 19,261 cases of HIV and AIDS (cumulative total 1985-2013), of which 12,273 were PLWHA. Most cases (65%) were diagnosed when they were children (<14) at the beginning of the 1990s and since then have experienced multiple ART regimens and reached a fertile age. Most of the new registered cases (797) represent young PLWHA (20-24, 25-29) who suffered changes in their behavioural patterns. Hence, the former intravenous drug users (IDUs) shifted to daily use of new drugs (ethnobotanicals) while young women acquired HIV through unprotected sex and i.v. drug use. Another area of concern was mother to child transmission of HIV that we assessed in the context of prenatal and postnatal cares. Since 2011, the national response to HIV has weakened as a consequence of the economy. Hence, the new IDU-HIV cases boosted from 14 cases (3%) in 2010 to 233 (29.23%) in 2013. At the same time we detected a growth in the share of children born from women using drugs, including women living with HIV/AIDS (WLHA). For the same category we identified 76.83% HCV co-infections, 11% HBV-HCV co-infections. The assessment evinced that late presenters account for more than 50% from the new cases, with CD4<350 cells/cmm. In addition, 32% of patients in treatment have low CD4 counts <350 cells/cmm (end 2013). The rising number of pregnant women addicted to drugs is directly proportional to the expanding figures of drugs and new drugs users. Cares provided to newborns from mothers who use i.v drugs and new drugs, perinatally exposed to HIV are usually associated with hepatitis B, C and with syphilis. Romania needs an upgrade of its national HIV/AIDS policies: broaden access to treatment and integrated services, using ART as prevention measure to avoid HIV transmission among the general population and a strengthened partnership between the medical networks, in order to respond to the emergent HIV trends.

Variation in CD4 cell count among IDUs versus sexually-infected HIV-positive naïve patients in Romania

Since 2011 Romania is experiencing a dramatic increase of newly diagnosed HIV infections among injecting drug users (IDUs), mainly linked to the introduction of new psychoactive substances (NPS) on the Romanian market, their use being related to higher levels of risk behavior compared to opioid abuse. There is no sufficient data showing the natural course of HIV in subjects infected through IDU – the majority are ART-naive due to recently acquired infection (many are asymptomatic and have a CD4 cell count over 350 cells/cmm) and poor adherence. Our objective was to determine if IDUs have a faster decline in CD4 cells than sexually-infected patients. We performed a retrospective study, including ART-naive HIV-positive patients diagnosed between January 2011 and June 2013 at the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, who had 2 subsequent CD4 cell count determinations over a timespan of 6-24 months and a baseline CD4 count higher than 350 cells/cmm. Among 1,248 newly diagnosed patients, 234 met these inclusion criteria. The data were statistically analyzed using SPSS version 17 (independent sample t-test, Mann-Whitney test, linear regression; the significance level was set at 0.05). The majority (80%, 187/234) were men and the median age was 29 years (15-76). More than half of the patients (138; 59%) were former or active IDUs, with low socioeconomic status, most of them injecting both opioids and NPS and 55 (40%) of them were in detention at the moment of HIV diagnosis. Among them, 98% were coinfected with HCV, as opposed to only 21% of the sexually-infected patients. Subtype analysis was performed for 64 patients and revealed the following subtypes and circulating recombinant forms (CRF): 50 F1, 3 B, 10 CRF14_BG and 1 CRF14_F. There was no significant difference of CD4 cell count between the two groups at baseline (p=0.55). The median variation of CD4 cells in IDUs was 150 and 42 in the non IDUs group. IDUs had a statistically significant CD4 cell decline (p=0.01). HCV coinfection was also correlated with a faster decline in CD4 cells (p <0.001). The more rapid decline of CD4 cells among IDUs could be explained by direct effect of drugs, differences in the virulence of the HIV strains circulating among IDUs and HCV coinfection. These data highlight the importance of carefully monitoring IDUs with HIV infection and of initiating ART earlier in this risk group.

Antiviral resistance in HCV strains isolated from Romanian patients with limited treatment options for chronic HCV infection

Results We assessed data from 12 patients (gender ratio 1:1), of which 10 had HCV monoinfection and 2 had HCV+HIV coinfection. The mean age was 43.8 ± 16.5 years (range 19-71 years). Eleven patients were infected with HCV genotype 1b, and one patient had been coinfected with genotype 2a/2c but had spontaneously cleared 2a infection and was now monoinfected with HCV 2c. Only one patient had IL28-B genotype CC, 4 patients CT and 5 patients TT (in two cases data on IL28-B were not available). Seven of the patients had received prior anti-HCV therapy: 2 with peg-interferon+ribavirin, 2 with faldaprevir-based regimens and 3 with telaprevir-based regimens. Of them, 3 had been non-responders and 4 had been relapsers. The mean plasma HCV-RNA was 6.1±0.7 log10 IU/ mL. Patients were distributed over the whole range of fibrosis values on FibroMax, with a slight predominance of advanced fibrosis: F3 (2 patients) and F4 (3 patients). Resistance to boceprevir or simeprevir was identified in 3/12 cases (fold-change range: 4-24) and 2/12 cases (fold-change range: 32-38), respectively, although none of the patients had received prior therapy with these antivirals. Resistance to telaprevir was identified in 3/12 cases (surprisingly, none of the cases with telaprevir therapy). Possible resistance was identified in another 6 cases (including cases treated with telaprevir and faldaprevir). The overall fold-change range was 1.8-22.4. Resistance to faldaprevir was identified in 3/12 cases (surprisingly, none of the cases with faldaprevir therapy), with a fold-change range of 1.2-360.0.

Antiretroviral treatment and association with prematurity in perinatal HIV-exposed children

Results From 206 children with complete 18 months follow up, 21% (43 cases) were diagnosed with HIV infection and more than 33% had at least one congenital condition. We found birth defects in various organs in studied children: heart (130 cases), musculoskeletal system (47 cases), kidney (20 cases), nervous system (20 cases), digestive tract (10 cases) and metabolic and genetic disorders (2 cases each). 26 from the 163 HIV-exposed children and 6 from the 43 HIV-infected cases were born before 37 weeks of gestation, 4 HIV-exposed and 4 HIV-infected children were small for gestational age. We found low birth weight (<2500 g) in 18 HIV-exposed children and 3 HIV infected children and extremely low birth weight (1000) in one HIV-exposed child. We found congenital malformation in 11 preterm HIV-exposed children and 2 preterm HIV-infected children, but also in 38 HIV-exposed children and 19 HIV-infected babies with normal gestation period. The difference between the rate of congenital malformation and prematurity was not statistically significant (p=0.08) in any of studied groups and HIV diagnosis was not associated with a higher risk of preterm birth (p=0.93). Mother being part of the Romanian cohort was not statistically associated with higher risk of prematurity. We found a significant association between antiretroviral treatment during pregnancy and prematurity (p=0.003). The most used drugs to treat mothers were boosted protease inhibitors (99% cases).

Low level viraemia and the risk of virological failure in HIV infected patients

Objective: to estimate the rate and the significance of low level viraemia in HIV positive patients registered in the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, Bucharest, Romania. We retrospectively analysed the rate of HIV viral loads (VL) 200 and >1000 copies/mL) over a 12 months period. A low level VL was detected in 16.2% of the 3,916 evaluated patients, the rate of HIV RNA of 51-200 copies/mL being two times higher than the rate of a VL <50 copies/mL. A number of 84 patients had a VL<200 copies/mL after being HIV RNA undetectable. In these patients the risk of virological failure over a 12 months period was not correlated with the HIV VL group or the used antiretroviral treatment (protease inhibitors PI vs. non-PI containing regimen). A low level viraemia is a rather common event in the studied HIV patients. In previously undetectable patients a HIV RNA <200 copies/mL is not associated with an increased risk of virological failure in the next year.

Short-term evaluation of immediately-treated patients with acute HIV infection, recently diagnosed in the National Institute for Infectious Diseases "Prof. Dr. Matei Balş", Bucharest, Romania

Methods All newly-diagnosed HIV-infected adults (>18 yo) in the last 18 months (01.2013-06.2014) in an infectious diseases hospital were considered. The including criteria for AHI group were: detectable HIV-RNA or positive antigen/antibody combination assays in the setting of a negative/indeterminate HIV Western blot. AHI group was classified accordingly to Fiebig stages and was further evaluated regarding CD4 count and viral load (VL) at diagnosis, at 3 and 6 months. ART initiation and the regimen were also registered.

Tuberculosis in children perinatally exposed to HIV in the current epidemiological TB context

Method During 01.01.2011 -01.07.2014 in the Immunocompromised Children Department from the National Institute for Infectious Diseases “Prof. Dr. Matei Bals” we analyzed the dynamical evolution of 214 perinatally HIV exposed children, aged 0-4 years. Lack of vaccination due to prematurity and the degree of immunosuppression in maternity contributed considerably to the increased incidence of TB in the family’s epidemiological context (at least one family member is diagnosed with tuberculosis). A troubling aspect is that these children come from families with resistant forms of tuberculosis (TB MDR) due to their parents’ poor adherence to treatment, mainly those pertaining to the 1989-1993 HIV cohort in Romania.