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Objective: To evaluate frailty, falls and perceptions of ageing among clinically stable individuals with HIV, engaged with remote healthcare delivered via a novel smartphone application. Methods: This was a multi-centre European cross-sectional, questionnaire-based sub-study of EmERGE participants. Frailty was assessed using the five-item FRAIL scale. Present criteria were summed and categorized as follows: 0, robust; 1-2, pre-frail; 3-5, frail. Falls history and EQ-5D-5L quality of life measure were completed. Participants were asked their felt age and personal satisfaction with ageing. Results: A total of 1373 participated, with a mean age of 45 (± 9.8) years. Frailty was uncommon at 2%; 12.4% fell in the previous year, 58.8% of these recurrently. Mood symptoms and pain were prevalent, at 43.3% and 31.8%, respectively. Ageing satisfaction was high at 76.4%, with 74.6% feeling younger than their chronological age; the mean felt age was 39.3 years. In multivariable analysis, mood symptoms and pain were positively associated with frailty, falls and ageing dissatisfaction. An increase in pain severity and mood symptoms were respectively associated with 34% and 63% increased odds of pre-frailty/frailty. An increment in pain symptoms was associated with a 71% increase in odds of falling. Pain was associated with ageing poorly, as were mood symptoms, with odds of dissatisfaction increasing by 34% per increment in severity. Conclusions: Although uncommon, frailty, falls and ageing dissatisfaction were seen in a younger cohort with medically stable HIV infection using a remote care model, promoting screening as advocated by European guidelines. These were more common in those with pain or mood symptoms, which should be proactively managed in clinical care and explored further in future research. info:eu-repo/semantics/publishedVersion

We aimed to calculate the efficiency of the EmERGE Pathway of Care in five European HIV clinics, developed and implemented for medically stable people living with HIV.Participants were followed up for 1 year before and after implementation of EmERGE, between April 2016 and October 2019. Micro-costing studies were performed in the outpatient services of the clinics. Unit costs for outpatient services were calculated in national currencies and converted to US$ 2018 OECD purchasing parity prices to enable between clinic comparisons in terms of outcomes and costs. Unit costs were linked to the mean use of services for medically stable people living with HIV, before and after implementation of EmERGE. Primary outcome measures were CD4 count and viral load; secondary outcomes were patient activation (PAM13) and quality of life (PROQOL-HIV). Out-of-pocket expenditure data were collected.There were 2251 participants: 87-93% were male, mean age at entry was 41-47 years. Medically stable people living with HIV had outpatient visits in four sites which decreased by 9-31% and costs by 5-33%; visits and costs increased by 8% in one site, which had to revert back to face-to-face visits. Antiretroviral drugs comprised 83-91% of annual costs: the Portuguese site had the highest antiretroviral drug costs in US$ purchasing parity prices. Primary and secondary outcome measures of participants did not change during the study.EmERGE is acceptable and provided cost savings in different socio-economic settings. Antiretroviral drug costs remain the main cost drivers in medically stable people living with HIV. While antiretroviral drug prices in local currencies did not differ that much between countries, conversion to US$ purchasing parity prices revealed antiretroviral drugs were more expensive in the least wealthy countries. This needs to be taken into consideration when countries negotiate drug prices with pharmaceutical vendors. Greater efficiencies can be anticipated by extending the use of the EmERGE Pathway to people with complex HIV infection or other chronic diseases. Extending such use should be systematically monitored, implementation should be evaluated and funding should be provided to monitor and evaluate future changes in service provision.

Herpes zoster (HZ) is an acute, cutaneous viral infection caused by the reactivation of varicella-zoster virus (VZV) (1). It is a frequent medical condition with an incidence rate of 2-3 cases per 1000 person/years in the general population and 7-10 cases per 1000 person/years after the age of 50 (1,2). Risk factors and triggers for reactivation of HZV have not yet been determined precisely, but are likely to include malignancies, immune deficiencies, solid organ and bone marrow transplant recipients, autoimmune diseases, psychological conditions, emotional stress, human immunodeficiency virus (HIV) infection, and other patients receiving immunosuppressive therapies (1,3). A 24-year-old IV drug user presented with grouped clusters of vesicles and erosions on an erythematous, edematous base distributed on the left side of the penile shaft and the left infraumbilical region (Figure 1, a and b), with regional lymphadenopathy. He had prodromal symptoms of pain, dysesthesia and burning a few days prior to the appearance of the skin lesion. The patient reported unprotected sexual contacts a few months before the eruptions. The unilateral distribution was highly suggestive of herpes zoster. A Tzanck smear was performed by obtaining scrapings from the base of a fresh vesicular lesion after it had been unroofed; it showed the characteristic presence of multinucleated giant cells that suggested herpes infection. Polymerase chain reaction (PCR) analysis of vesicular fluid yielded positive results for VZV. A 7-day course of acyclovir (800 mg 5 times a day) was initiated. The patient reported marked improvement on the second day of antiviral therapy. The course was uncomplicated, and the lesions healed without postherpetic neuralgia. Serologic tests for syphilis (VDRL/RPR and TPHA) and hepatitis C and B serologic tests were negative, but HIV test (enzyme immunoassays (EIA) for HIV-1 and HIV-2 antibodies were positive, which was later confirmed with Western blot (WB) tests. Because of the positive HIV test, the patient was referred to the Clinic for Infectious Diseases for further treatment. Herpes zoster is painful vesicular skin eruption with unilateral dermatomal involvement, usually with a severe impact on the quality of life in affected patients (1). The risk for developing HZ during a lifetime in patients exposed to VZV infection is 10-30% (4). However, the risk is higher in immunocompromised patients, particularly in cancer patients and HIV-positive patients (1,5,6). HZ is seen approximately 7 times more frequent in patients with HIV infection (5). Reactivated VZV infection may occur at any stage of HIV infection and may be the first clinical evidence of HIV infection. The development of HZ in immunocompromised individuals can be explain by decline in cell-mediated immunity and CD4 count (6). HZ predominantly affects the thoracic region, followed by the head, cervical, and lumbar regions (1). Sacral dermatomes are involved in only up to 2% of cases (1). HZ involving the penis is rarely reported, with only few case reports in the literature (3,7-9). Birch et al. compared VZV and herpes simplex virus (HSV) in specimens obtained from the genital lesions of adults presenting with presumed genital herpes infection (10). They found VZV in nearly 3% of virus-positive genital specimens, which demonstrates that this virus needs to be considered in the differential diagnosis of genital herpetic lesions (10) and that it is possible that genital HZ infection is underdiagnosed. Tzanck smear is a rapid and inexpensive method, but it cannot differentiate VZV from HSV. Genital HZ could be mistaken for zosteriform HSV infection, so a PCR test should be performed to confirm the underlying diagnosis (1). Genital forms of HZ are rare and sometimes clinically difficult to diagnose, especially when the typical zosteriform distribution is lacking; PCR testing is therefore suggested. HZ is considered a possible HIV indicator; an HIV test should therefore be performed. According to our knowledge and literature search, this is the first case report of penile HZ in an HIV-positive patient.

A total of 835 patients with symptoms of chronic prostatitis syndrome and no evidence of structural or functional lower genitourinary tract abnormalities were examined in a three year period at the Outpatient Department for Urogenital Infections, University Hospital for Infectious Diseases "Dr. Fran Mihaljević" Zagreb, Croatia. Disease etiology was determined in 482 (57.72%) patients. Chlamydia trachomatis was proved to be the causative pathogen in 161 patients, Trichomonas vaginalis in 85, Escherichia coli in 68, Enterococcus in 51, Proteus mirabilis in 20, Klebsiella pneumoniae in 9, Streptococcus agalactiae in 15, Ureaplasma urealyticum in 49 patients with chronic prostatitis. Other patients had mixed infection. In 257 (53.32%) of 482 patients, the inflammatory finding (10 WBCs/hpf) was found in EPS or VB3. Normal WBCs/hpf (10) was found in 103 (63.98%) of 161 patients with symptoms of chronic prostatitis in whom C. trachomatis was detected in EPS or VB3, in 50 (58.82%) of 85 patients in whom Trichomonas vaginalis was isolated, and in 23 (46.94%) of 49 patients in whom Ureaplasma urealyticum was isolated.