Pietro Colletti

Prospective evaluation of hepatic steatosis in HIV-infected patients with or without hepatitis C virus co-infection

BACKGROUND Limited data are available on hepatic steatosis (HS) in HIV patients who are not infected with hepatitis C virus (HCV). The aims of this study were to assess the prevalence of HS and its risk factors in HIV patients with and without HCV infection, and to evaluate whether HS correlates with advanced liver fibrosis and/or cardiovascular disease risk. METHODS Fifty-seven HIV mono-infected and 61 HIV/HCV co-infected patients were enrolled consecutively. All patients underwent liver ultrasound and transient elastography. The main parameters of liver function, HIV and HCV viral loads, CD4+ cell counts, and data on highly active antiretroviral therapy (HAART) were recorded. Cardiovascular disease risk was evaluated using the 10-year Framingham risk score. RESULTS HS prevalence in the whole HIV population was 53% (54% in mono-infected patients and 51% in co-infected patients). HS was associated with lipodystrophy and triglyceride values (p<0.0001), metabolic syndrome (p<0.0004), and total cholesterol levels (p<0.001) in both HIV groups. In HIV mono-infected patients, HS was linked with HAART exposure of >1 year (p<0.01). By multivariate analysis, only triglyceride levels (p<0.02) and Framingham risk score (p<0.05) were independently associated with HS in both HIV groups. No correlation was observed between HS and advanced liver fibrosis, measured by transient elastography. CONCLUSIONS HS was common in HIV patients, occurring in about half of the population. HS was found to be linked with the Framingham risk score, but was not correlated with advanced liver fibrosis. We suggest that in our HIV population with HS, the burden of cardiovascular disease risk is greater than that of liver disease progression.

Associated Factors and Liver Disease Severity for Decreased Bone Mineral Density in HIV Mono- and HIV/HCV Co-infected Patients

Objective: We assessed the prevalence and risk factors of decreased bone mineral density (BMD) in patients mono-infected with human immunodeficiency virus (HIV) or co-infected with hepatitis C virus (HIV/HCV). We also evaluated whether bone loss was linked to lipid asset in both groups and to severity of liver fibrosis in the co-infected group. Methods: We consecutively enrolled 194 HIV-patients (129 mono-infected and 65 co-infected). All HIV-patients underwent dual-energy X-ray absorptiometry (DXA), while co-infected patients underwent transient elastography. Advanced liver fibrosis was defined as a median liver stiffness ≥ 9.5 kPa. Fibrosis was also assessed in all the HIVpatients using FIB-4. Results: The overall prevalence of low BMD and osteoporosis was 26.8% and 26.0%, respectively. It was significantly higher among HIV/HCV co-infected than mono-infected patients in lumbar/femoral sites (P<0.04 and P<0.05, respectively). HDL-cholesterol levels correlated independently with lumbar DXA Z-score (P<0.03) in HIV mono-infected subjects. Liver stiffness correlated negatively and independently with femoral Z- and T-scores among co-infected patients (P<0.003; P<0.01, respectively). Stratifying co-infected subjects by sex, liver stiffness and lumbar/ femoral Z-scores (P<0.04) or T-scores (P<0.05; P<0.04, respectively) correlated negatively only in the females. Longer PI exposure was negatively and independently correlated with BMD. Conclusion: Our HIV-infected patients appeared at high risk for low BMD and osteoporosis. Severity of liver fibrosis was an independent predictor of bone loss in co-infection, although other factors could affect the skeletal system in HIV/HCV co-infection. Further research into the impact of liver fibrosis and lipid asset on bone disease in HIV-infection is necessary

Determinants of HIV outpatient service utilization according to HIV parameters.

The increased life expectancy of HIV patients in the era of highly active antiretroviral therapy has had profound consequences for the healthcare systems that provide their care. It is useful to assess whether healthcare resources need to be adapted to the different stages of HIV infection or to patient characteristics [1]. To study how patient features influence utilization of out patient services, we retrospectively analyzed the electronic health record of HIV‐positive patients who had followed day‐care programs at the AIDS Center of the University of Palermo, Italy.

Behavioral and clinical characteristics of people receiving medical care for HIV infection in an outpatient facility in Sicily, Italy

Aim The authors examined a cohort of HIV-positive outpatients at the AIDS Center of Palermo University in Italy in order to identify factors related to the frequency of their visits to the outpatient facility for health care services. Methods Two hundred and twenty-four HIV-infected subjects were enrolled in the study. Demographic and HIV disease characteristics were recorded and assessed with the number of days accessed to our outpatients unit in univariate and multivariate analyses. The potential relationship with immunological status was also analyzed stratifying the patients into groups according to their CD4+ T-cell counts (≥500 vs <500/mm3, and ≥200 vs <200/mm3). Results Both univariate and multivariate analyses showed that duration of antiretroviral therapy <5 years and hypertension were significantly associated with a CD4+ T-cell count of <500/mm3, whereas geographic origin (Africa) was associated with a CD4+ T-cell count of <200/mm3. Mean number of days the patients sought access to day-care services for laboratory tests was negatively associated with CD4+ T-cell count. Conclusion Patients with low CD4+ T-cell counts showed higher use of health care services, demonstrating how early HIV diagnosis can help to reduce health care costs. The CD4+ T-cell cut-off of 200 cells emphasizes the importance of identifying and managing HIV infection among hard-to-reach groups like vulnerable migrants. In our sample, the illegal status of immigrants does not influence the management of their HIV/AIDS condition, but the lack of European health card that documents the current antiretroviral status, could interfere with the efforts to eradicate AIDS. A better understanding of the major determinants of HIV treatment costs has led to appropriate large-scale actions, which in turn has increased resources and expanded intervention programs. Further guidance should be offered to hard-to-reach groups in order to improve early AIDS diagnosis, and procedures for identifying and managing these vulnerable subjects should be made available to care commissioners and service providers.

PrEP in Italy: The time may be ripe but who’s paying the bill? A nationwide survey on physicians’ attitudes towards using antiretrovirals to prevent HIV infection

Several studies have demonstrated the efficacy of the oral pre-exposure prophylaxis (PrEP) with tenofovir (with or without emtricitabine) on preventing HIV-negative partners of HIV infected patients to become infected through sexual contacts. PrEP is already available in the United States and now is approved by European Medicine Agency. In this setting we would like to gauge physicians’ knowledge, acquaintance with and attitude to include PrEP in their clinical practice. A cross sectional survey was conducted among Italian physicians expert on antiretroviral therapy. Out of 146 physicians, 35% of participants declared to be familiar with PrEP but only 46% of them believed that, currently, there are not enough reasons to make it available in Italy. 51% of physicians have already been attracted to prescribe it and 63.4% have been openly asked about PrEP. The main concerns noticed were: the risk of acquire other sexual transmitted diseases (STDs) (70% of physicians feared that PrEP could favor STDs spread), the potential harmful of PrEP if not adequately implemented and, especially the risk of possible side effects if not properly used. Nevertheless, 55.9% of participants believed that Health Authorities face an ethical obligation to make PrEP available as part of the strategies to protect from HIV transmission and half of the respondents asked for further researches to better define the role for PrEP. Attitudes regarding PrEP impact on Italian National Health Organization were also very interesting: 57.5% of participants did not believe that investing in PrEP would be an appropriate use of healthcare resources, while 70.6% affirmed that PrEP’s financial coverage should not be funded by the Italian National System of Health (SSN). This survey showed a high awareness of PrEP potential among Italian physicians coupled with a great deal of skepticism about how and if implementing it in clinical practice.

1303 PREVALENCE OF HEPATIC STEATOSIS AND ITS RELATIONSHIP WITH CARDIOVASCULAR RISK IN HIV-PATIENTS WITH OR WITHOUT HCV CO-INFECTION

Background and Aims: Limited data are available on hepatic steatosis (HS) among human immunodeficiency virus (HIV) patients uninfected with hepatitis C virus (HCV). Little is known about the relationship between cardiovascular (CVD) risk and HS in HIV monoand HIV/HCV co-infected patients. Aims of the study were to assess prevalence of HS and its risk factors in HIV-patients and to evaluate whether HS correlated with advanced liver fibrosis (ALF) and/or CVD risk. Methods: Fifty seven HIV monoand 61 HIV/HCV co-infected patients were consecutively enrolled. The “bright liver echopattern” (BL) was used for HS diagnosis. ALF was defined as “liver stiffness” ≥ 9.5 kPa by transient elastography (TE). Main parameters of liver function, glycaemia, total cholesterol (T-Chol), triglycerides (TG), HDL-C, HIV and HCV viral load, duration of highly active antiretroviral therapy (HAART) and CD4+ cell count were recorded. CVD risk was appreciated using the 10-year Framingham risk score (FRS) and the diagnosis of metabolic syndrome (MS) performed according to ATP III criteria. Results: In the whole HIV-population HS prevalence was 52.5% (54.4% in HIV monoand 50.8% in co-infected patients (P = not significant). HS was associated with lipodistrophy, TG values (P < 0.0001), MS (P < 0.0004) and T-Chol levels (P < 0.001) in both HIV-groups (table). In HIV mono-infected patients HS was linked with HAART exposure >1 year (P < 0.01). By multivariate analysis only TG levels (P < 0.02) and FRS (P < 0.05) were indipendently associated with HS in both HIV groups. No correlation was observed between HS and ALF, measured by TE.