Suchergebnisse

AbstractIntroductionStudies suggest that hepatitis C virus (HCV) micro‐elimination is feasible among men who have sex with men (MSM) living with human immunodeficiency virus (HIV), through treatment‐as‐prevention and interventions aimed at reducing risk behaviours. However, their economic impact is poorly understood. The aim of this study was to assess the cost‐effectiveness of HCV screening and risk reduction strategies in France.MethodsA compartmental deterministic mathematical model was developed to describe HCV disease transmission and progression among MSM living with HIV in France. We evaluated different combinations of HCV screening frequency (every 12, 6 or 3 months) and risk reduction strategies (targeting only high‐risk or all MSM) from 2021 onwards. The model simulated the number of HCV infections, life‐expectancy (LYs), quality‐adjusted life‐expectancy (QALYs), lifetime costs and incremental cost‐effectiveness ratio (ICER) over a lifetime horizon (leading to an end of the simulation in 2065).ResultsAll strategies increased QALYs, compared with current practices, that is yearly HCV screening, with no risk reduction. A behavioural intervention resulting in a 20% risk reduction in the high‐risk group, together with yearly screening, was the least expensive strategy, and, therefore, cost‐saving compared to current practices. The ICER per QALY gained for the strategy combining risk reduction for the high‐risk group with 6‐month HCV screening, compared to risk reduction with yearly screening, was €61,389. It also prevented 398 new HCV infections between 2021 and 2065, with a cost per infection averted of €37,790. All other strategies were dominated (more expensive and less effective than some other available alternative) or not cost‐effective (ICER per QALY gained > €100,000).ConclusionsIn the French context, current HCV screening practices without risk reduction among MSM living with HIV cannot be justified on economic grounds. Risk reduction interventions targeted to high‐risk individuals—alongside screening either once or twice a year—could be cost‐effective depending on the policymaker's willingness‐to‐pay.

BACKGROUND: The risk/benefit of initiating ART in primary HIV infection (PHI) is unclear. The benefits are more likely to outweigh the risks in patients with severe PHI. An accepted definition of severe PHI is, however, lacking. METHODS: CASCADE patients with HIV test interval <6 months were classified as severe and non-severe PHI based on whether the following traits were recorded in the first 6 months following seroconversion: severe specific pre-defined symptoms, central nervous system-implicated illness, and ≥1, ≥2 CD4<350 (and <500) cells/mm(3). For each definition, we used Kaplan-Meier curves and Cox survival models to compare time to AIDS/death, censoring at the earlier of last clinic visit or 1/1/1997, when combination antiretroviral therapy (cART) became available. RESULTS: Among 1108 included patients mostly males (85%) infected through sex between men (71%), 366 were diagnosed with AIDS/died. The risk of AIDS/death was significantly higher for individuals with severe symptoms, those with ≥1 CD4<350 cells/mm(3) or ≥2 CD4 <500 cells/mm(3) in the first 6 months [aHR (95% confidence interval) 2.1 (1.4,3.2), 2.0 (1.5,2.7), and 2.3, (1.5-3.5) respectively]. Median [interquantile range] survival for patients with ≥2, ≥1 and no CD4<350 cells/mm(3) within 6 months of seroconversion was 3.9 [2.7,6.5], 5.4 [4.5,8.4] and 8.1 [4.3,10.3] years, respectively. The diagnosis of CNS-implicated symptoms was rare and did not appear to be prognostic. CONCLUSION: One CD4 count <350 or two <500 cells/mm(3) within 6 months of seroconversion and/or severe illness in PHI may be useful early indicators of individuals at high risk of disease progression. ; The research leading to these results has received funding from the European Union Seventh Framework Programme (FP7/2007-2013) under EuroCoord grant agreement no. 260694. Sara Lodi is holder of a Juan de la Cierva Fellowship (grant number JCI 2010-08151). There are no current external funding sources for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ; Sí

IntroductionA key objective of combined antiretroviral therapy (cART) is to reach and maintain high CD4 cell counts to provide long‐term protection against AIDS‐defining opportunistic infections and malignancies, as well as other comorbidities. However, a high proportion of patients present late for care. Our objective was to assess CD4 cell count recovery up to seven years in naïve patients initiating cART with at least three drugs in usual clinical care.MethodsFrom the French Hospital Database on HIV, we selected naïve individuals initiating cART from 2000 with at least two years of follow‐up. Participants were further required to have achieved viral load suppression by six months after initiating cART and were censored in case of virological failure. We calculated the proportion of patients (Kaplan‐Meier estimates) who achieved CD4 recovery to >500/mm3 according to baseline CD4 cell count.ResultsA total of 15,025 patients were analyzed with a median follow‐up on ART of 65.5 months (IQR: 42.3–96.0). At cART initiation, the median age was 38.6 years (IQR: 32.2–46.0), 9734 (64.8%) were men, median CD4 cell count was 239 (IQR: 130–336) and 2668 (17.8%) had a prior AIDS event. Results are presented in the Table 1.
KM estimates of achieving a CD4 cell count >500/mm3 over time according to baseline CD4 cell count at cART initiation












Baseline CD4+cell count, Median (IQR)
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7




CD4<200 (n=5909), 100 [39–156]
8% (7–9)
21% (20–22)
33% (31–34)
43% (42–45)
52% (50–54)
60% (58–61)
61% (59–62)


200≤CD4<350 (n=5751), 269 [235–305]
40% (39–42)
61% (60–62)
73% (72–74)
81% (580–82)
85% (84–86)
88% (87–89)
90% (89–91)


350≤CD4<500 (n=2252), 404 [374–443]
74% (72–76)
87% (85–88)
91% (90–92)
94% (93–95)
95% (93–96)
96% (95–98)
97% (95–98)




ConclusionsThis study shows that CD4 cell counts continue to increase seven years after cART initiation, whatever the baseline CD4 cell count. Failing to achieve CD4 recovery with continuous viral load suppression is rare for naïve patients initiating cART in routine clinical practice, but takes substantially longer in patients who initiate antiretroviral therapy at low CD4 cell counts.

AbstractIntroductionSince the beginning of the HIV epidemic in resource‐rich countries, Pneumocystis jirovecii pneumonia (PjP) is one of the most frequent opportunistic AIDS‐defining infections. The Collaboration of Observational HIV Epidemiological Research Europe (COHERE) has shown that primary Pneumocystis jirovecii Pneumonia (PjP) prophylaxis can be safely withdrawn in patients with CD4 counts of 100 to 200 cells/µL if plasma HIV‐RNA is suppressed on combination antiretroviral therapy. Whether this holds true for secondary prophylaxis is not known, and this has proved difficult to determine due to the much lower population at risk.MethodsWe estimated the incidence of secondary PjP by including patient data collected from 1998 to 2015 from the COHERE cohort collaboration according to time‐updated CD4 counts, HIV‐RNA and use of PjP prophylaxis in persons >16 years of age. We fitted a Poisson generalized additive model in which the smoothed effect of CD4 was modelled by a restricted cubic spline, and HIV‐RNA was stratified as low (<400), medium (400 to 10,000) or high (>10,000copies/mL).ResultsThere were 373 recurrences of PjP during 74,295 person‐years (py) in 10,476 patients. The PjP incidence in the different plasma HIV‐RNA strata differed significantly and was lowest in the low stratum. For patients off prophylaxis with CD4 counts between 100 and 200 cells/µL and HIV‐RNA below 400 copies/mL, the incidence of recurrent PjP was 3.9 (95% CI: 2.0 to 5.8) per 1000 py, not significantly different from patients on prophylaxis in the same stratum (1.9, 95% CI: 0.1 to 3.7).ConclusionsHIV viraemia importantly affects the risk of recurrent PjP. In virologically suppressed patients on ART with CD4 counts of 100 to 200/µL, the incidence of PjP off prophylaxis is below 10/1000 py. Secondary PjP prophylaxis may be safely withheld in such patients. While European guidelines recommend discontinuing secondary PjP prophylaxis only if CD4 counts rise above 200 cells/mL, the latest US Guidelines consider secondary prophylaxis discontinuation even in patients with a CD4 count above 100 cells/µL and suppressed viral load. Our results strengthen and support this US recommendation.