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To determine the value contribution of cabotegravir + rilpivirine, the first injectable every two months long-acting antiretroviral regimen, using multi-criteria decision analysis.The study was developed in two phases. After a small pilot, a field ork study with a larger number of multidisciplinary experts was carried out. Seven single-tablet regimens, currently recommended by the GeSIDA guidelines, were selected as comparators. EVIDEM methodology was followed, with a framework composed by 12 quantitative and 5 contextual criteria. Mean and standard deviations were calculated for quantitative criteria (1 to 5 scale; comparative criteria -5 to +5), whereas qualitative criteria were analyzed as percentages of experts that considered a positive, neutral or negative impact for the National Health System.35 experts participated in the study. Human immunodeficiency virus- 1 infection was considered severe (mean ± standard deviation: 3.0 ± 1.0), with moderate size of affected population (2.7 ± 1.2) and unmet needs (2.8 ± 1.0). Minimal differences were found in comparative efficacy/effectiveness (0.1 ± 0.5), safety/tolerability (-0.5 ± 0.7), and cost criteria: cost of the intervention (0.5 ± 2.0), other medical costs (0.2 ± 1.8) and non- medical/indirect costs (0.5 ± 1.6). Experts perceived an improvement with cabotegravir + rilpivirine long-acting, compared to current daily oral single-tablet regimens, in patient-reported outcomes (2.7 ± 1.4). Therapeutic benefit of the long-acting regimen was considered moderate-to-high (3.5 ± 1.2). Experts considered the evidence provided by cabotegravir + rilpivirine long- actingrobust (4.3 ± 0.8), with elevated consensus on its future recommendation in guidelines (3.2 ± 1.0). In contextual criteria, most experts considered positive the impact on population priorities and access (91%), common goal and specific interests (63%) and political, historical, and cultural context criteria (60%). Impact was neutral in system capacity and appropriate use (40%), and opportunity costs and affordability criteria (51%). Result of the weighted global value contribution of cabotegravir + rilpivirine long-acting was 0.34 (-1 to +1 scale), with Patient Reported Outcomes comparative criterion bringing the highest added value.Cabotegravir + rilpivirine long-acting provides added value contribution to human immunodeficiency virus-1 management in Spain compared to daily oral single-tablet regimens. Patient Reported Outcomes and therapeutic benefit of cabotegravir + rilpivirine long-acting were highly valued by experts, as the expected benefit in adherence and stigma-related issues would improve overall quality of life for people living with human immunodeficiency virus-1.Determinar la contribución de valor de cabotegravir + rilpivirina, el primer tratamiento antirretroviral inyectable de acción prolongada, utilizando metodología de análisis de decisión multicriterio.Método: El estudio se desarrolló en dos fases: una prueba piloto y una fase de extensión, con un grupo multidisciplinar más grande. Se seleccionaron siete regímenes de comprimido único orales diarios recomendados en las guías GeSIDA como comparadores. Se utilizó el marco EVIDEM, compuesto por 12 criterios cuantitativos y 5 contextuales. Los criterios cuantitativos se analizaron calculando la media y desviación estándar, y los cualitativos se analizaron mediante el porcentaje de expertos que consideraron el impacto positivo, neutro o negativo para el Sistema Nacional de Salud.Un total de 35 expertos participaron en el estudio. La infección por virus de la inmunodeficiencia humana 1 se consideró grave (media ± desviación estándar: 3,0 ± 1,0), con un tamaño de población afectada (2,7 ± 1,2) y unas necesidades no cubiertas (2,8 ± 1,0) moderadas. Las diferencias fueron mínimas en los criterios comparativos de eficacia/efectividad (0,1 ± 0,5), seguridad/tolerabilidad (–0,5 ± 0,7) y coste: coste del tratamiento (0,5 ± 2,0), otros costes médicos (0,2 ± 1,8) y costes no-médicos/indirectos (0,5 ± 1,6). Los expertos observaron una emtrimejora con cabotegravir + rilpivirina de acción prolongada en los resultados reportados por los pacientes (2,7 ± 1,4). El beneficio terapéutico (3,5 ± 1,2) se consideró moderado-alto. La evidencia de cabotegravir + rilpivirina de acción prolongada fue considerada robusta (4,3 ± 0,8), con elevado consenso sobre su futura recomendación en las guías (3,2 ± 1,0). En los criterios contextuales, el impacto fue positivo en los criterios de prioridades de acceso (91%), objetivo común (63%) y contexto político (60%). El impacto fue neutro en la capacidad del sistema (40%) y los costes de oportunidad (51%). El resultado promedio de la contribución del valor global de cabotegravir + rilpivirina de acción prolongada fue de 0,34 (escala de –1 a +1), siendo el criterio de resultados reportados por el paciente el que proporcionó la mayor contribución de valor (0,04).Cabotegravir + rilpivirina de acción prolongada aporta un valor añadido en el manejo del virus de la inmunodeficiencia humana 1 en España en comparación con los regímenes de comprimido único utilizados actualmente. Los expertos valoraron positivamente los resultados reportados por los pacientes y el beneficio terapéutico de cabotegravir + rilpivirina de acción prolongada, considerando que el beneficio esperado en la adherencia y los problemas relacionados con el estigma produciría una mejora en la calidad de vida de las personas con virus de la inmunodeficiencia humana 1.

Human immunodeficiency virus (HIV) remains incurable due to latent viral reservoirs established in non-activated CD4 T cells that cannot be eliminated via antiretroviral therapy. Current efforts to cure HIV are focused on identifying drugs that will induce viral gene expression in latently infected cells, commonly known as latency reversing agents (LRAs). Some drugs have been shown to reactivate latent HIV but do not cause a reduction in reservoir size. Therefore, finding new LRAs or new combinations or increasing the round of stimulations is needed to cure HIV. However, the effects of these drugs on viral rebound after prolonged treatment have not been evaluated. In a previous clinical trial, antiretroviral therapy intensification with maraviroc for 48 weeks caused an increase in residual viremia and episomal two LTR-DNA circles suggesting that maraviroc could reactivate latent HIV. We amended the initial clinical trial to explore additional virologic parameters in stored samples and to evaluate the time to viral rebound during analytical treatment interruption in three patients. Maraviroc induced an increase in cell-associated HIV RNA during the administration of the drug. However, there was a rapid rebound of viremia after antiretroviral therapy discontinuation. HIV-specific T cell response was slightly enhanced. These results show that maraviroc can reactivate latent HIV in vivo but further studies are required to efficiently reduce the reservoir size.

Resumen Introduccion El objetivo de este estudio es estimar el impacto economico en Espana de la optimizacion del tratamiento antirretroviral (TAR) triple en pacientes con carga viral suprimida segun las recomendaciones GeSIDA/PNS (2015) y su aplicabilidad en la practica clinica. Metodos A partir de los datos de prescripcion del TAR de la encuesta hospitalaria 2014, siguiendo las recomendaciones de GeSIDA/PNS de optimizacion de TAR con grado de evidencia A- I , se desarrollo un modelo farmacoeconomico. Las pautas de optimizacion, la voluntad de optimizacion y demas asunciones y resultados del modelo fueron validados por un panel de expertos en la infeccion por VIH (infectologos y farmaceuticos hospitalarios). El analisis se realizo desde la perspectiva del SNS, considerando el coste farmacologico anual, precio de venta del laboratorio notificado, deduccion RD-Ley-8/2010 e IVA. Resultados El panel selecciono 6 estrategias de optimizacion y estimo que en Espana de los 80.859 pacientes actualmente en TAR triple, 10.863 (13,4%) serian candidatos a optimizar su TAR segun estas estrategias, generando ahorros de 15,9 M €/ano (2,4% del coste farmacologico del TAR triple). Las estrategias mas factibles (> 40% del total de pacientes candidatos a optimizar, n = 4.556) y asociadas a mayores reducciones del gasto (ahorro entre 653 y 4.797 €/paciente-ano segun el TAR triple de partida) serian las optimizaciones a ATV/r + 3TC. Conclusion La aplicacion a la practica clinica espanola de las principales estrategias de optimizacion recomendadas en el documento GeSIDA/PNS (2015) generaria ahorros sustanciales, especialmente aquellas basadas en biterapia con ATV + 3TC, contribuyendo asi al control del gasto farmaceutico y a la sostenibilidad del SNS.

In this study, we have characterized quasispecies dynamics and the evolution of viral tropism in naive HIV-1-infected patients treated with a short course of maraviroc monotherapy (ClinicalTrials.gov registration no. NCT01060618) independently of the tropism of the infecting virus. We randomly selected 20 patients infected with viruses displaying different basal tropisms-10 carrying R5 and 10 carrying dual/mixed X4 (DM/X4) viruses-at recruitment as determined by phenotypic assay (Trofile). Evolution of viral quasiespecies at the end of treatment was determined by ultradeep sequencing of the V3 region using a 454 Life Sciences Platform and geno2pheno (g2p) algorithm for viral tropism prediction. The false-positive rate (FPR) that defines the probability of classifying an R5 virus falsely as X4 was set at 10%. X4-specific HIV-1 viral load (VL) was calculated from sequences with an FPR of 1-log10 copies/ml reduction in VL was detected in 70% of patients independently of the basal tropism of the infecting virus. Viral tropism remained stable, and nonsignificant differences in FPR values before and after treatment were found for the majority of patients in both tropism groups. Only three patients (one with R5 and two with DM/X4 viruses) showed an increased (>1 log) X4 VL, and one patient harboring a DM/X4-tropic virus displayed a significant reduction in FPR values at the end of treatment. Fast changes in the composition of viral populations were observed in all patients after 10 days of maraviroc (MVC) monotherapy treatment, and a complete replacement of viral quasiespecies was found in 3/10 patients carrying R5-using viruses and 4/10 patients carrying DM/X4-using viruses.IMPORTANCE Initiation of treatment with maraviroc requires previous determination of viral tropism by genotypic or phenotypic methods because of the risk of treatment failure and selection of DM/X4-tropic variants. In this study, we confirm previous work showing that the virologic response to maraviroc is independent of basal tropism. By deep-sequencing analysis, we determined that fast changes in viral populations were due to the emergence of minority variants in some patients whereas in others generation of new strains was detected. The risk of DM/X4 selection was very low as FPR values remained stable, and only one patient showed a detrimental switch to DM/X4 variants. Our data show that some DM/X4 viruses are sensitive to maraviroc treatment probably because only a low proportion of DM/X4 viruses use preferentially the X4 receptor and contain authentically maraviroc-resistant viruses that are not accurately detected by current assays. We thank Olga Palao (AIDS Immunopathogenesis Unit) and A. Zaballos (Genomics Unit, Instituto de Salud Carlos III) for their secretarial and technical assistance, respectively. We also greatly appreciate our patients for their willingness to participate. Sí

Maraviroc is a CCR5 antagonist used in the treatment of HIV-1 infection. We and others have suggested that maraviroc could reactivate latent HIV-1. To test the latency-reversing potential of maraviroc and the mechanisms involved, we performed a phase II, single-center, open-label study in which maraviroc was administered for 10 days to 20 HIV-1-infected individuals on suppressive antiretroviral therapy (EudraCT registration no. 2012-003215-66). All patients completed full maraviroc dosing and follow-up. The primary endpoint was to study whether maraviroc may reactivate HIV-1 latency, eliciting signaling pathways involved in the viral reactivation. An increase in HIV-1 transcription in resting CD4 + T cells, estimated by levels of HIV-1 unspliced RNA, was observed. Moreover, activation of the NF-κB transcription factor was observed in these cells. To elucidate the mechanism of NF-κB activation by maraviroc, we have evaluated in HeLa P4 C5 cells, which stably express CCR5, whether maraviroc could be acting as a partial CCR5 agonist, with no other mechanisms or pathways involved. Our results show that maraviroc can induce NF-κB activity and that NF-κB targets gene expression by CCR5 binding, since the use of TAK779, a CCR5 inhibitor, blocked NF-κB activation and functionality. Taking the results together, we show that maraviroc may have a role in the activation of latent virus transcription through the activation of NF-κB as a result of binding CCR5. Our results strongly support a novel use of maraviroc as a potential latency reversal agent in HIV-1-infected patients. IMPORTANCE HIV-1 persistence in a small pool of long-lived latently infected resting CD4 + T cells is a major barrier to viral eradication in HIV-1-infected patients on antiretroviral therapy. A potential strategy to cure HIV-1-infection is the use of latency-reversing agents to eliminate the reservoirs established in resting CD4 + T cells. As no drug has been shown to be completely effective so far, the search for new drugs and combinations remains a priority for HIV cure. We examined the ability of maraviroc, a CCR5 antagonist used as an antiretroviral drug, to activate latent HIV-1 in infected individuals on antiretroviral therapy. The study showed that maraviroc can activate NF-κB and, subsequently, induce latent HIV-1-transcription in resting CD4 + T cells from HIV-1-infected individuals on suppressive antiretroviral therapy. Additional interventions will be needed to eliminate latent HIV-1 infection. Our results suggest that maraviroc may be a new latency-reversing agent to interfere with HIV-1 persistence during antiretroviral therapy.

Objectives In view of the fact that mucosal damage associated with HIV-1 infection leads to microbial translocation despite successful antiretroviral treatment, we analysed microbial translocation and expression of the gut-homing β7 receptor on peripheral T cells in HIV-1-infected individuals. Methods Fifteen long-term suppressed HIV-1-infected patients, of whom seven had their treatment intensified with maraviroc and eight with raltegravir, were included in the study. Samples at baseline, at week 48 of intensification, and at weeks 12 and 24 after deintensification were analysed for soluble CD14, lipopolysaccharide (LPS), LPS-binding protein, gut-homing β7 receptor and T-cell subsets. Results The increases in both microbial translocation and expression of the gut-homing β7 receptor on activated CD8 T cells found during maraviroc intensification were reduced after deintensification. Moreover, the correlations between activated β7+ T cells and LPS levels found during intensification with maraviroc (P = 0.036 and P = 0.010, respectively) were lost during deintensification. In contrast, microbial translocation was stable during raltegravir intensification, with the exception of decreased LPS levels and activated CD4 β7+ T cells, which reverted to baseline values after deintensification. Conclusions Microbial translocation is an important factor in gut immune activation and mucosa inflammation, as evidenced by the association between the dynamics of microbial translocation and activated T cells expressing the gut-homing β7 receptor. The recruitment of activated β7+ T cells to the gut tract when alteration of microbial translocation is maximum may be the major mechanism for recovery of mucosal integrity.

Objectives We compared reasons for the choice of regimen, time to and reasons for third drug modification, virological response and change in CD4 T-cell counts in patients started on atazanavir/ritonavir (ATV/r)- vs. efavirenz (EFV)-based first-line regimens. Methods We included patients from the Cohort of the Spanish HIV Research Network (CoRIS), a multicentre cohort of HIV-positive treatment-naive subjects, in the study. We used logistic regression to assess factors associated with choosing ATV/r vs. EFV, proportional hazards models on the subdistribution hazard to estimate subdistribution hazard ratios (sHRs) for third drug modification, logistic regression to estimate odds ratios (ORs) for virological response and linear regression to assess mean differences in CD4 T-cell count increase from baseline. Results Of 2167 patients, 10.7% started on ATV/r. ATV/r was more likely than EFV to be prescribed in injecting drug users [adjusted OR 1.85; 95% confidence interval (CI) 1.03–3.33], in 2009–2010 (adjusted OR 1.63; 95% CI 1.08–2.47) and combined with abacavir plus lamivudine (adjusted OR 1.53; 95% CI 0.98–2.43). Multivariate analyses showed no differences, comparing ATV/r vs. EFV, in the risk of third drug modification (sHR 1.04; 95% CI 0.74–1.46) or in virological response (OR 0.81; 95% CI 0.46–1.41); differences in mean CD4 T-cell count increase from baseline were at the limit of statistical significance (mean difference 29.8 cells/μL; 95% CI −4.1 to 63.6 cells/μL). In patients changing from EFV, 48% of changes were attributable to toxicity/adverse events, 16% to treatment failure/resistance, 3% to simplification, and 8 and 12%, respectively, to patients' and physicians' decisions; these percentages were 24, 6, 12, 14 and 24%, respectively, in those changing from ATV/r. Conclusions ATV/r- and EFV-based regimens meet the requirements of both efficacy and safety for initial combination antiretroviral regimen, which relate to better durability.

Knowledge of human papillomavirus (HPV) type distribution in populations at risk for anal cancer is needed. Here, we describe the anal HPV genotype distribution in a large Spanish cohort (Cohort of the Spanish HIV Research Network HPV [CoRIS-HPV]) of HIV-positive men who have sex with men (MSM) according to geographical origin, age, and cytological status. A cross-sectional analysis of baseline data from 1,439 HIV-infected MSM (2007 to 2012) was performed. Anal HPV genotyping was performed using the Linear Array HPV genotyping test. Descriptive analyses of subject characteristics, prevalences, and 95% confidence intervals (CI) were performed. The global prevalences of HPV, high-risk HPV (HR-HPV), and low-risk HPV (LR-HPV) types were 95.8%, 83.0%, and 72.7%, respectively. Among the HR-HPV types, HPV16 was the most common, followed by HPV59, -39, -51, -18, and -52. The prevalence of multiple HR-HPV infections was 58.5%. There were no differences in the crude analyses between Spanish and Latin-American MSM for most HPV types, and a peak in prevalence for most HPV types was seen in patients in their late thirties. Globally and by specific HPV groups, men with abnormal anal cytologies had a higher prevalence of infection than those with normal cytologies. This study has the largest number of HIV-positive MSM with HPV genotype data analyzed according to cytological status as far as we know. The information gained from this study can help with the design of anal cancer prevention strategies in HIV-positive patients.

OBJECTIVES To describe raltegravir pharmacokinetics at steady-state in HIV/hepatitis C virus (HCV)-coinfected patients under antiretroviral (ARV) treatment with (n = 5) and without (n = 5) advanced liver cirrhosis (Child-Pugh C). METHODS This was a non-randomized, Phase I, parallel-assignment, open-label pharmacokinetic study in HIV/HCV-coinfected patients with Child-Pugh grade C hepatic cirrhosis. We recruited clinically stable HIV/HCV-coinfected adult patients with controlled HIV viraemia (

Objective: Antiretroviral therapy (ART) intensification has been shown to reduce the reservoir of latently infected CD4 þ T cells. However, it is currently unknown whether this effect is maintained after discontinuation of the intensifying drug. Design: The effect of ART intensification during 48 weeks with maraviroc or raltegravir inchronicallyHIV-1-infectedpatientswasassessedintwopreviousclinicaltrials.Inthis study, we analysed this effect at week 24 after discontinuation of the intensifying drugs, at baseline and 48 weeks of intensification. Methods: We measured the latently infected memory CD4 þ T cells carrying replication-competent virus, 2-long terminal repeat (2-LTR) circles and CD4 þ /CD8 þ T cells activation. Results: Fifteen patients were evaluated. After 48 weeks of intensification, HIV-1 reservoir size significantly decreased from 1.1 to 0.0 infectious units per million (IUPM) (P ¼0.004). After 24 weeks of drugdiscontinuation, the median size of the reservoir was still significantly lower than at baseline (P ¼0.008). 2-LTRs were undetectable in all individuals at baseline and after 48 weeks of intensification, continuing undetectable in all patients except two at week 24 after discontinuation (P ¼0.1). CD4 þ and CD8 þ T-cell activation significantly decreased at 48 weeks after intensification, without further increase after discontinuation. Conclusion: The effects of ART intensification with maraviroc or raltegravir persist at least 24 weeks after discontinuation of the drug. In a global strategy, ART intensification should be considered as part of a combination approach to achieve a functional cure or HIV eradication. 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2013, 27:2081‐2088

The aim of our study was to determine the baseline prevalence of anal squamous intraepithelial lesions (SIL) and associated risk factors in HIV-infected men who have sex with men (MSM) in a Spanish ongoing multicenter cohort. CoRIS-HPV started in 2007, nested in the Spanish AIDS Research Network Cohort (CoRIS). Anal liquid cytology testing was performed. High-risk human papillomavirus (HR-HPV) infection was determined, and positive samples were genotyped. We analyzed all subjects up to April 2011. Multivariate logistic regression analyses were performed. A total of 551 subjects with baseline anal liquid cytologies were analyzed; 37.0% negative for intraepithelial lesion, 9.0% atypical squamous cells of uncertain significance (ASCUS), 41.0% low-grade SIL, 4.0% high-grade SIL and 9.0% inadequate. Prevalence of anal SIL (excluding ASCUS) in valid samples (n = 450) was 54.7% (95% confidence interval [CI] = 49.9–59.3). Globally HR-HPV prevalence was 81.7% (95% CI = 78.0–85.2). Multiple infections (≥2 HR-HPV genotypes) were documented in 77.7% (95% CI = 73.1–82.0). The only risk factor associated with anal SIL was the number of HR-HPV types; MSM with five or more HR-HPV genotypes had an odds ratio (OR) of anal SIL seven times greater (OR = 7.4; 95% CI = 2.8–19.6) than those with one HR-HPV genotype. No associations were found for age, educational level, smoking, geographical origin, CD4 T-cell count, antiretroviral treatment or number of sexual partners. The prevalence of anal SIL in young HIV-positive MSM is high, and the main risk factor is multiple infections with HR-HPV types.

Summary Objectives HIV-infected subjects on antiretroviral therapy often fail to normalize the CD4/CD8 ratio despite CD4 count normalization. We aimed to analyze the biological significance of this finding. Methods Cross-sectional analysis in 20 HIV-infected subjects on stable triple-ART, plasma HIV RNA 350 cells/mm 3 . Laboratory measurements included T-cell activation (HLADR + , CD38 + ) and senescence (CD57 + ), lipopolysaccharide (LPS), sCD14 and the HIV latent reservoir (number of latently infected memory CD4 cells carrying replication-competent virus). Results CD4/CD8 ratio was positively correlated with CD4 nadir ( r = 0.468, p = 0.038) and accumulated ART exposure ( r = 0.554, p = 0.0011), and negatively with viral load before ART initiation ( r = −0.547, p = 0.013), CD4 + HLADR + CD38 + T-cells ( r = −0.428, p = 0.086) and CD8 + CD57 + T-cells ( r = −0.431, p = 0.084). No associations with LPS, sCD14 or HIV latent reservoir were found. After the multivariate analyses, the CD4/CD8 ratio remained independently associated with CD4 + HLADR + CD38 + T-cells and CD8 + HLADR + T-cells. Conclusions In our study in subjects on suppressive ART the CD4/CD8 ratio was independently associated with T-cell activation. Our results must be confirmed in larger studies, as this parameter might be a useful clinical tool to identify subjects with ongoing immune activation despite long-term viral suppression.

OBJECTIVES The stability of the reservoir of latently infected memory CD4 T-cells may be associated with continuous replenishment from residual HIV-1, not completely eliminated by otherwise successful antiretroviral therapy (ART). Treatment intensification could help to control residual virus and to modify the latent reservoir. The objective of this work is to assess the effect of intensifying therapy with raltegravir on the HIV-1 cell reservoir. DESIGN A pilot open-label phase-II clinical trial was performed to analyze ART intensification with raltegravir after 48 weeks in chronically HIV-1-infected patients on stable ART. METHODS We measured the number of latently infected memory CD4 T cells, residual viremia, 2-long terminal repeat circles, CD4/CD8 T-cell activation, lymphocyte subpopulations, gut homing receptor, and bacterial translocation. RESULTS A significant decay of HIV-1 latent reservoir was observed after intensification in the nine patients included (P = 0.021). No variation was found in either residual viremia or 2-long terminal repeat circles, whereas CD8 T-cell activation decreased at week 36 (P = 0.028). No differences were found in naive T-cell or effector memory cell counts, and the frequencies of gut homing receptor on activated or effector memory CD8 T cells. Bacterial translocation was stable, with the exception of a late decrease in lipopolysaccharide levels. CONCLUSIONS In this pilot noncomparative trial, treatment intensification with raltegravir significantly decreased the latent cellular HIV-1 reservoir and CD8 T-cell activation. Despite the limitations inherent to trial design, our results suggest that ART intensification should be considered as an adjuvant strategy to eradicate HIV-1 infection.

Although atazanavir is widely used in hepatitis C virus (HCV)-HIV-1 patients, little is known about its safety in advanced liver disease. We studied 34 HCV-HIV-1 patients with cirrhosis receiving atazanavir. After 551.2 patient-months of follow-up, there were no cases of serious liver toxicity or cirrhosis decompensation, and only 18.5% discontinued the drug. Despite median bilirubin level at inclusion was 1.5 mg/ml, increases in bilirubin level were mild. Model for end-stage liver disease score (MELD) increased to 1.35 points (95% confidence interval 0.13-2.6), but no patient changed their pretreatment situation after atazanavir introduction. Atazanavir is a well tolerated option in cirrhosis, and significant alterations in bilirubin or MELD were not observed.

Background Screening of anal cancer in HIV-infected MSM with anal cytology results in high rates of false positive results and elevated burden of high-resolution anoscopies. High-risk HPV up-regulates p16 and Ki67 expression in epithelial cells. We assessed the usefulness of P16/Ki-67 immunostaining cytology for the diagnosis of precancerous anal lesions. Methodology Cross-sectional multicenter study. Concomitant anal liquid cytology with p16/Ki-67 immunostaining and HRA with biopsy of acetowhite lugol-negative lesions was performed in HIV-infected MSM. We compared the diagnostic performance of an abnormal anal cytology and p16/Ki-67 immunostaining relative to HRA-guided biopsy by logistic regression and comparison of ROC areas. Results We included 328 HIV-infected MSM. HSIL was histologically diagnosed in 72 subjects (25.1%), and 2 (0.6%) were diagnosed with anal cancer. An abnormal cytology showed a sensitivity of 95.6% and a specificity of 58.8% for the diagnosis of biopsy-proven HSIL. P16/Ki67 positivity was associated with the presence of biopsy-proven HSIL (P trend = 0.004) but with low sensitivity (41.2%) and specificity (71%). The combination of standard cytology with P16/Ki67 immunostaining did not increment the predictive value of standard cytology alone (AUC 0.685 vs. 0.673, respectively, P = 0.688). Conclusion In HIV-infected MSM P16/Ki67 immunostaining does not improve the diagnostic accuracy of anal cytology, which shows a high sensitivity yet poor specificity. Other approaches aimed at improving the diagnostic accuracy of current techniques for the diagnostic of precancerous HSIL are warranted.

We aimed to evaluate whether virological response to a short course of maraviroc monotherapy could predict HIV-1 tropism.A clinical trial was performed in HIV-1 treatment-naive patients infected with R5- or non-R5-tropic virus determined using the Trofile(®) assay, with1000 HIV-1 RNA copies/mL. Maraviroc was administered for 10 days. Viral load was measured at baseline and days 4, 7, 10 and 28. The main outcome measurement was the decline in HIV-1 RNA at day 10. The trial was registered in the ClinicalTrials.gov database (NCT01060618; TROPISMVC).Forty patients [30 R5 and 10 dual/mixed (D/M)] were recruited. There was a significant decrease in HIV-1 RNA after 10 days of maraviroc treatment in patients with R5-tropic virus (median 1.52 log10 RNA copies/mL; 95% CI 1.23-1.63; P 0.0001), but also in patients with D/M-tropic virus (median 1.62 log(10) RNA copies/mL; 95% CI 0.33-1.88; P = 0.00024). The difference in the HIV-1 RNA decrease (-0.16 log(10) RNA copies/mL; 95% CI -0.53 to 0.22) was not significant (P = 0.410). A decrease0.5 log(10) RNA copies/mL was found in 96.3% of patients with R5-tropic virus and in 70% of patients with D/M-tropic virus (P = 0.052). The differences were not significant when a decline of 1 log(10) RNA copies/mL was considered (92.6% versus 70%; P = 0.11).Treatment-naive patients infected with R5- or D/M-tropic virus have similar virological responses to a short course of maraviroc monotherapy. This clinical test thus cannot be used as a surrogate marker of viral tropism in this population.

Fundamento La tularemia era una enfermedad practicamente inexistente en Espana hasta finalesde 1997, cuando se declaro un brote epidemico en nuestra comunidad. El objetivo denuestro trabajo ha sido estudiar los datos existentes sobre el diagnostico microbiologico de 55pacientes que sufrieron tularemia. Pacientes Y Metodos Se obtuvieron 32 muestras para cultivo pertenecientes a 19 pacientes y151 sueros correspondientes a 55 pacientes. El diagnostico serologico se realizo mediante seroaglutinacionen tubo y microaglutinacion. En todos los sueros se realizo una seroaglutinacionde Wright (SAW) y un test de Coombs frente a Brucella y seroaglutinaciones frente a Yersiniaenterocolitica O:9, Yersinia enterocolitica O:3 y Proteus OX 19. Resultados Se aislo F. tularensis en dos muestras (6,25%) de las 32 estudiadas. Se obtuvierontitulos mayores o iguales a 1/160 en el 78,2% y en el 74,5% de los sueros iniciales por seroaglutinacionen tubo y microaglutinacion, respectivamente. La correlacion entre las dos pruebasfue de 0,80 (p Conclusiones El cultivo de F. tularensis es poco sensible. La correlacion obtenida entre la seroaglutinacionen tubo y microaglutinacion es buena. Ambas tecnicas son utiles en el diagnosticode la tularemia, con algunas ventajas de la microaglutinacion sobre la aglutinacion. Background Tularemia was practically unknown in Spain until the end of 1997, when an epidemicoutbreak was declared. This paper presents the data on microbiological diagnosis of 55patients who suffered from tularemia. Patients and Methods Thirty-two samples from 19 patients and 151 serum samples from 55 patientswere obtained for culture. Serologic diagnosis was performed by tube seroagglutinationand microagglutination. Three types of tests were performed on all sera: Wright seroagglutination(WSA), Coombs test against Brucella spp. and seroagglutination against Yersinia enterocoliticaO:3, Yersinia enterocolitica O:3, and Proteus OX 19. Results F. tularensis was found in two samples (6.25%) of the 32 received. Titers. 1/160were obtained in 78.2% and 74.5% of the initial sera by tube seroagglutination and microagglutination,respectively. Correlation between the two tests was 0.80 (p Conclusions Culture of F. tularensis has low sensitivity. The correlation obtained between tubeseroagglutination and microagglutination is good. Both techniques are useful in routine diagnosisof tularemia, although microagglutination has some advantages over tube agglutination.

INTRODUCTION Microbial translocation (MT) has been proposed as one of the triggering mechanisms of persistent immune activation associated to HIV-1 infection. Our objectives were to determine the correlation between different measurements of MT in suppressed HIV-1-infected individuals and to evaluate its correlation with immune activation. METHODS Eighteen suppressed HIV-1-infected patients with CD4+ T-cell count above 350 cells per cubic millimeter and undetectable plasma viral load, included in antiretroviral treatment intensification clinical trials, were evaluated. Samples obtained at baseline and at established time points during the trials were analyzed. Lipopolysaccharide (LPS), lipopolysaccharide binding protein (LBP), soluble CD14 (sCD14), and bacterial 16S ribosomal DNA (16S rDNA), and markers of immune activation were determined. RESULTS We analyzed 126 plasma samples from the 18 patients. LPS significantly correlated with sCD14 (P < 0.001, r = 0.407) and LBP (P = 0.042, r = 0.260). Also, a significant correlation was found between sCD14 and LBP (P = 0.009, r = 0.325) but not between bacterial 16S rDNA and LPS, sCD14, or LBP (P = 0.346, P = 0.405, and P = 0.644). On the other hand, no significant correlation was found between LPS, sCD14, or LBP and CD4 (P = 0.418, P = 0.619, and P = 0.728) or CD8 T-cell activation (P = 0.352, P = 0.275, and P = 0.124). Bacterial 16S rDNA correlated with activated CD4 T cells (P = 0.005, r = 0.104) but not with activated CD8 T cells (P = 0.171). CONCLUSIONS There is a good correlation in the quantification of LPS, sCD14, and LBP levels, but not with bacterial 16S rDNA, as measurements of MT. We are unable to ensure that MT directly triggers T-cell immune activation at least among these patients with relatively good immune recovery and under treatment intensification.

Raltegravir (RAL) constitutes the first available integrase strand transfer inhibitor (INSTI) available in clinical practice. Three independent pathways have been described to confer resistance to RAL. Secondary mutations with little effect on INSTI susceptibility and additional substitutions with an uncertain role have also been described especially in HIV-1 non-B variants.We evaluated the prevalence of primary, secondary, and additional resistance mutations to INSTIs in patients naïve to RAL or elvitegravir (EGV) carrying different HIV-1 variants.A total of 83 patients infected by B HIV-1 subtype (64%) or non-B HIV-1 variants (36%) were evaluated. No primary mutations to RAL or EGV were found in the inte-grase sequences analyzed. Secondary mutations were detected in only 5 patients. Additional mutations were found in both in B and non-B variants. According to the geno2pheno algorithm, some of the secondary mutations detected (L74V, E138K, G163RS, and V151I) have been associated with a reduced estimated susceptibility to RAL and only the E138K mutation has been associated with a decreased estimated susceptibility to EGV. No virological failure was observed after RAL was administrated in 17 patients carrying 1 or more additional substitutions in the absence of primary or secondary mutations.No primary resistance mutations to INSTI were found in treatment-naïve or -experienced patients infected with B or non-B HIV-1 variants. The vast majority had some polymorphic and non-polymorphic substitutions; however response to RAL was excellent in patients who harbored one or more of these mutations. We could not identify any clinical factors associated with the presence of any of these mutations.

We estimated the effect of sexual behavior, age, and immunodeficiency on the number of high-risk human papillomavirus (HR-HPV) types in the anal canal among human immunodeficiency virus-positive men who have sex with men (MSM). Anal samples were genotyped with the Linear Array HPV Genotyping Test, and risk factors were investigated with Poisson regression. Of 586 MSM, 69% were Spanish, and 25.6% were Latin American; the median age was 34.9 years (interquartile range [IQR], 30.1-40.8). The median number of recent sex partners was 6 (IQR, 2-24 sex partners), and the median CD4(+) T-cell count was 531.5 cells/mm(3) (IQR, 403-701 cells/mm(3)). The prevalence of any and multiple HR-HPV infections was 83.4% and 60.5%, respectively. The most common types were HPV-16 (42%), HPV-51 (24%), HPV-39 (23.7%), and HPV-59 (23.5%). Age had a statistically significant, nonlinear association with the number of types, with the highest number detected around 35 years of age (P

The aim of our study was to determine the baseline prevalence of anal squamous intraepithelial lesions (SIL) and associated risk factors in HIV-infected men who have sex with men (MSM) in a Spanish ongoing multicenter cohort. CoRIS-HPV started in 2007, nested in the Spanish AIDS Research Network Cohort (CoRIS). Anal liquid cytology testing was performed. High-risk human papillomavirus (HR-HPV) infection was determined, and positive samples were genotyped. We analyzed all subjects up to April 2011. Multivariate logistic regression analyses were performed. A total of 551 subjects with baseline anal liquid cytologies were analyzed; 37.0% negative for intraepithelial lesion, 9.0% atypical squamous cells of uncertain significance (ASCUS), 41.0% low-grade SIL, 4.0% high-grade SIL and 9.0% inadequate. Prevalence of anal SIL (excluding ASCUS) in valid samples (n = 450) was 54.7% (95% confidence interval [CI] = 49.9-59.3). Globally HR-HPV prevalence was 81.7% (95% CI = 78.0-85.2). Multiple infections (≥2 HR-HPV genotypes) were documented in 77.7% (95% CI = 73.1-82.0). The only risk factor associated with anal SIL was the number of HR-HPV types; MSM with five or more HR-HPV genotypes had an odds ratio (OR) of anal SIL seven times greater (OR = 7.4; 95% CI = 2.8-19.6) than those with one HR-HPV genotype. No associations were found for age, educational level, smoking, geographical origin, CD4 T-cell count, antiretroviral treatment or number of sexual partners. The prevalence of anal SIL in young HIV-positive MSM is high, and the main risk factor is multiple infections with HR-HPV types.

Objective: The primary objective was to assess the effect of MVC intensification on latently infected CD4 + T cells in chronically HIV-1-infected patients receiving antiretroviral therapy. Methods: We performed an open-label pilot phase II clinical trial involving chronically HIV-1-infected patients receiving stable antiretroviral therapy whose regimen was intensified with 48 weeks of maraviroc therapy. We analyzed the latent reservoir, the residual viremia and episomal 2LTR DNA to examine the relationship between these measures and the HIV-1 latent reservoir, immune activation, lymphocyte subsets (including effector and central memory T cells), and markers associated with bacterial translocation. Results: Overall a non significant reduction in the size of the latent reservoir was found (p = 0.068). A mean reduction of 1.82 IUPM was observed in 4 patients with detectable latent reservoir at baseline after 48 weeks of intensification. No effect on plasma residual viremia was observed. Unexpectedly, all the patients had detectable 2LTR DNA circles at week 24, while none of them showed those circles at the end of the study. No changes were detected in CD4 + or CD8 + counts, although a significant decrease was found in the proportion of HLA-DR + /CD38 + CD4 + and CD8 + T-cells. LPS and sCD14 levels increased. Conclusions: Intensification with MVC was associated with a trend to a decrease in the size of the latent HIV-1 reservoir in memory T cells. No impact on residual viremia was detected. Additional studies with larger samples are needed to confirm the results. Trial Registration: ClinicalTrials.gov NCT00795444

We aimed to evaluate immunological, virological and clinical response to HAART, as well as all-cause mortality, in treatment-naive patients with a diagnosis of tuberculosis (TB) in the prior 6 months, compared to subjects with another AIDS-defining illness (ADI) or event-free individuals in an open, prospective and multicenter hospital-based cohort of HIV-infected naive adults (2004-2008). All cause mortality rates were calculated by Cox regression models. Among 4407 patients, 2400 (54.5%) started HAART: 110 (4.6%) had had previous TB and 414 (17.3%) another ADI. Median time from TB diagnosis to inititation of HAART was 53 days (IQR: 25.75-83.25), and for other ADI was 22 days (IQR: 8-42). Overall, 151 (6.3%) patients developed a new ADI during follow-up; 63% reached virological suppression and 69.4% had increases of ≥50 CD4+/µl, at 6 months. No statistically significant differences were found according to a previous history of TB or another ADI. Overall, 85 subjects died in 4031 person-years of follow-up with a mortality rate of 2.1 (95%CI: 1.7-2.6). When compared to subjects who started HAART in the absence of a previous ADI (HR 1), a prior diagnosis of an ADI other than TB was significantly associated with an increased risk of death. (HR 1.6; 95%CI: 1.1-2.3), but not a diagnosis of TB (HR 1.15; 95%CI: 0.5-2.5). In conclusion, a previous diagnosis of TB or another ADI before HAART did not compromise short-term virological and immunological response to treatment. A prior diagnosis of an ADI different to TB significantly increased all cause mortality.

Objectives To determine the effect of food on the antiviral activity of enteric-coated (EC) capsules of didanosine (ddI). Methods We conducted a pilot, randomized, open-label study of 28-day ddI-EC capsules monotherapy-administered in a fasted state (group 1, n=11) or with food (group 2, n=10) to treatment-naive chronically HIV-1-infected individuals. To assess the antiviral efficacy, HIV-1 RNA was determined at baseline, day 3, day 7 and weekly thereafter. The area under the HIV-1 RNA curve minus baseline weighted by time (AUCMB/day) was calculated. Results Mean baseline HIV-1 RNA was 4.2 log10 copies/mL in group 1 and 3.8 log10 copies/mL in group 2. After 28 days, the mean HIV-1 RNA reduction was 0.99 log10 copies/mL [95% confidence interval (CI) 0.45–1.53] for group 1 and 0.89 log10 copies/mL (95% CI 0.38–1.40) for group 2. AUCMB/day values were 0.775 log10 copies/mL (95% CI 0.33–1.22) and 0.774 log10 copies/mL (95% CI 0.48–1.07), respectively, showing no difference in the rate of decrease of HIV-1 RNA (P=0.995). Mean ddI plasma levels at day 28 were 0.0234 mg/L for group 1 and 0.0227 mg/L for group 2 (P=0.96). Conclusions In this pilot study, the administration of food did not have any significant effect on the antiviral activity of ddI-EC capsules.

Background Evaluation of the diagnostic value of anal cytology versus HRA in detecting anal intraepithelial neoplasia (AIN) and the added value of molecular markers in a multicenter cohort of HIV positive MSM (CoRIS-HRA). Methods: Concomitant anal liquid cytology and HRA with biopsy of acetowhite lugol-negative lesions if observed. Concordance was evaluated by the Kappa index. Dual staining for p16INK4a and Ki-67 (CINtec® PLUS, Roche) was done in cytology samples. Taking biopsy as the ‘gold standard’ for AIN diagnosis, the sensitivity and specificity of anal cytology and p16INK4/Ki-67 dual positivity was calculated. Results: Since November 2012, 172 patients were recruited in five Spanish hospitals. In 56 patients, no biopsies were performed as no lesions were observed. In the remaining 116 patients, 142 biopsies were obtained. Among 172 cytologies, 10.5% were inadequate, 27.9% negative, 1.1% ASCUS, 45.3% LSIL and 15.2% HSIL. Histology showed inadequacy in 3.5% of cases, negativity in 25.3%, LG-AIN in 35.2% and HG-AIN in 35.9%. In 116 patients, cytology and biopsy results were available (the highest lesion grade was used if multiple biopsies existed); the strength of agreement was fair (Kappa 0.351; 95% CI 0.232–0.470). Sensitivity and specificity of anal cytology versus HRA guided biopsy was 88.3% and 66.7%, respectively. In 67 cases, results from dual staining for p16INK4a/Ki-67 were available, rendering a sensitivity of 47.3% and a specificity of 66.7% compared with histology results. Conclusions: Although preliminary, our results show that in our setting dual staining for p16INK4a/Ki-67 did not improve the operational characteristics of anal liquid cytology.

Background: It has been suggested that the stability of the CD4 cell reservoir could be related to the continuous replenishment from plasma-residual HIV-1. Intensification with an entry inhibitor could help eliminate the detectable levels of ongoing viral replication and accelerate the decay of the reservoir by inhibiting the entry of the virus into the cells. Methods: The intensification study with an entry inhibitor (maraviroc-MVC) included patients with stable antiretroviral therapy (ART) with three or more drugs, viral load (VL) of 350 cells/mm3 and CCR5-tropism. Latently infected resting CD4 cells were determined at baseline, week 12 and week 24, with further analyses planned at week 36 and week 48. Highly purified resting CD4 cells were isolated using magnetic beads rendering ~20 million and plated in replicate dilutions and stimulated in a limiting dilution culture assay, with irradiated PBMCs from a seronegative donor. Cells containing HIV-replication-competent were quantified by HIV-1 p24 Antigen Assay (results in infective units per million). Results: Nine patients have been included. Median time of HIV-1 diagnosis was 103 months [IQR 58-240], ART was administered for a median of 75 months [IQR 38-144], and the median baseline CD4 count was 711 cells/mm3 [IQR 547-793]. At baseline, the reservoir could be quantified in six out of nine patients. One patient has left the study, and the other eight patients continue with VL of