The Perilous Road from HIV Diagnosis in the Hospital to Viral Suppression in the Outpatient Clinic

The HIV care continuum has received considerable attention in recent years, however few care continua focus on the population of patients who are diagnosed during an inpatient hospital admission. We aimed to describe the HIV care continuum for patients newly diagnosed during hospitalization through 24-month follow-up. 

A retrospective chart review of HIV patients diagnosed at Grady Memorial Hospital from 2011 - 2012 was performed and records were matched to Georgia Department of Public Health HIV/AIDS surveillance data. Descriptive statistics and statistical tests of independence were utilized. 

Ninety-four new diagnoses were confirmed during the two-year study period. Median age was 43 years old (IQR 30 - 51), 77% were male, 72% were non-Hispanic Black, 31% were men who have sex with men (MSM) and 77% were uninsured. Median CD4 count at diagnosis was 134 cells/µL (IQR 30 - 307). Eighty-four percent received their diagnosis prior to hospital discharge, 68% linked to care by 90 days, 73% were retained for 12 months, 48% were virologically suppressed by 12 months, 58% were retained for 24 continuous months and 38% achieved continuous VS during the initial 24 months after diagnosis. 

Late diagnosis is a persistent problem in hospitalized patients. Despite relative success with linkage to care and 12-month retention in care, a minority of patients maintained retention and VS for 24 continuous months.

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By:  Colasanti J1, Goswami ND2, Khoubian JJ3, Pennisi E4, Root C5, Ziemer D6, Armstrong W7, Del Rio C8.

• 1Emory University, Medicine , 49 Jesse Hill Jr Drive , Division of Infectious Diseases , Atlanta, Georgia, United States , 30303 ; jcolasa@emory.edu.
• 2Atlanta, United States ; neela.goswami@emory.edu.
• 3Los Angeles, United States ; jacob.khoubian@gmail.com.
• 4Atlanta, United States ; alpennisi@dhr.state.ga.us.
• 5Atlanta, United States ; cmroot@emory.edu.
• 6Atlanta, United States ; dziemer@GMH.EDU.
• 7Emory University, Infectious Disease, Atlanta, Georgia, United States ; wsarmst@emory.edu.
• 8Emory University, Hubert Department of Global Health , 1518 Clifton Rd. NE , CNR Building , Room 7011 , Atlanta, Georgia, United States , 30322 ; cdelrio@emory.edu. 
• AIDS Res Hum Retroviruses. 2016 Mar 22.

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Trends in CD4 Count Testing, Retention in Pre-ART Care, and ART Initiation Rates over the First Decade of Expansion of HIV Services in Haiti

BACKGROUND:

High attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is widely reported. Though treatment guidelines have changed to broaden ART eligibility and services have been widely expanded over the past decade, data on the temporal trends in pre-ART outcomes are limited; such data would be useful to guide future policy decisions.

METHODS:

We evaluated temporal trends and predictors of retention for each step from HIV testing to ART initiation over the past decade at the GHESKIO clinic in Port-au-Prince Haiti. The 24,925 patients >17 years of age who received a positive HIV test at GHESKIO from March 1, 2003 to February 28, 2013 were included. Patients were followed until they remained in pre-ART care for one year or initiated ART.

RESULTS:

24,925 patients (61% female, median age 35 years) were included, and 15,008 (60%) had blood drawn for CD4 count within 12 months of HIV testing; the trend increased over time from 36% in Year 1 to 78% in Year 10 (p<0.0001). Excluding transfers, the proportion of patients who were retained in pre-ART care or initiated ART within the first year after HIV testing was 84%, 82%, 64%, and 64%, for CD4 count strata ≤200, 201 to 350, 351 to 500, and >500 cells/mm3, respectively. The trend increased over time for each CD4 strata, and in Year 10, 94%, 95%, 79%, and 74% were retained in pre-ART care or initiated ART for each CD4 strata. Predictors of pre-ART attrition included male gender, low income, and low educational status. Older age and tuberculosis (TB) at HIV testing were associated with retention in care.

CONCLUSIONS:

The proportion of patients completing assessments for ART eligibility, remaining in pre-ART care, and initiating ART have increased over the last decade across all CD4 count strata, particularly among patients with CD4 count ≤350 cells/mm3. However, additional retention efforts are needed for patients with higher CD4 counts.

Below:  A: Proportion of Patients with Timely, Late, or No Blood Draw for CD4 Count by Year; B: Number and Proportion of Patients Returning for CD4 Count Results by Year

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By:  Koenig SP1,2, Bernard D1, Dévieux JG3, Atwood S2, McNairy ML4, Severe P1, Marcelin A1, Julma P1, Apollon A1, Pape JW1,4.

• 1Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti.
• 2Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America.
• 3AIDS Prevention Program, Florida International University, Miami, FL, United States of America.
• 4Center for Global Health, Weill Cornell Medical College, New York, NY, United States of America
• PLoS One. 2016 Feb 22;11(2):e0146903. doi: 10.1371/journal.pone.0146903. eCollection 2016. 

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The Impact of Comprehensive Case Management on HIV Client Outcomes

In 1990, New York State instituted Comprehensive Medicaid Case Management, also known as Target Case Management (TCM), for people dealing with multiple comorbid conditions, including HIV. 

The goal of TCM is to assist clients in navigating the health care system to increase care engagement and treatment adherence for individuals with complex needs. HIV-positive individuals engaged in care are more likely to be virally suppressed, improving clinical outcomes and decreasing chances of HIV transmission. 

The purpose of this study was to understand the impact of TCM management on outcomes for people with HIV. Data were obtained from Amida Care, which operates not-for-profit managed care Medicaid and Medicare Special Needs Plans (SNPs) for HIV clients. Changes in clinical, cost, as well as medical and pharmacy utilization data among TCM clients were examined between January 2011 through September 2012 from the start of case management enrollment through the end of the study period (i.e., up to 6 months after disenrollment). Additionally, CD4 counts were compared between Amida Care TCM clients and non-TCM clients. 

Notable findings include increased CD4 counts for TCM clients over the one-year study period, achieving parity with non-TCM clients (i.e., Mean CD4 count > 500). When looking exclusively at TCM clients, there were increases in medication costs over time, which were concomitant with increased care engagement. Current findings demonstrate that TCM is able to achieve its goals of improving care engagement and treatment adherence. 

Subsequent policy changes resulting from the Affordable Care Act and the New York State Medicaid Redesign have made the Health Home the administrator of TCM services. Government entities charged with securing and managing TCM and care coordination for people with HIV should provide thoughtful and reasonable guidance and oversight in order to maintain optimal clinical outcomes for TCM clients and reduce the transmission of HIV.

Full article at:   http://goo.gl/Lz1c6Z

By:  Brennan-Ing M1,2, Seidel L1,3, Rodgers L4, Ernst J1,5, Wirth D5, Tietz D6, Morretti A7, Karpiak SE1,2.

• 1Center on HIV and Aging, ACRIA, New York, New York, United States of America.
• 2College of Nursing, New York University, New York, New York, United States of America.
• 3Graduate School of Social Service, Fordham University, New York, New York, United States of America.
• 4BOOM! Health, Bronx, New York, United States of America.
• 5Amida Care, Inc., New York, New York, United States of America.
• 6Human Resources Administration, City of New York, New York, New York, United States of America.
• 7Columbia University, New York, New York, United States of America. 
• PLoS One. 2016 Feb 5;11(2):e0148865. doi: 10.1371/journal.pone.0148865.

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The HIV Care Continuum among Female Sex Workers: A Key Population in Lilongwe, Malawi

OBJECTIVE:

The HIV care continuum among female sex workers (FSW), a key population, has not been well characterized, especially within the generalized epidemics of sub-Saharan Africa. This was the first study to characterize the HIV care continuum among FSW in Lilongwe, Malawi.

METHODS:

From July through September 2014, we used venue-based sampling to enroll 200 adult FSW in Lilongwe, Malawi into a cross-sectional evaluation assessing HIV care continuum outcomes. Seropositive FSW, identified using HIV rapid testing, received rapid CD4 counts in addition to viral loads using dried blood spots. We calculated proportions of HIV-infected FSW who had history of care, were on ART, and had suppressed viral load and we used Poisson regression to estimate the associations of demographic characteristics and transmission risk behaviors with each outcome.

RESULTS:

HIV seroprevalence was 69% (n = 138). Among all FSW the median age was 24 years (IQR: 22-28). Among the 20% who were newly diagnosed and reported previously testing negative, the median time since last HIV test was 11 months (interquartile range: 3-17). The majority (69%) of HIV-infected FSW had a history of HIV care, 52% reported current ART use, and 45% were virally suppressed. Of the FSW who reported current ART use, 86% were virally suppressed. Transmission risk behaviors were not associated with continuum outcomes.

CONCLUSIONS:

FSW in Lilongwe were predominately young and have a high HIV prevalence. Only half of HIV-infected FSW reported current ART use, but the majority of those on ART were virally suppressed. To reduce ongoing transmission and improve health outcomes, increased HIV testing, care engagement, and ART coverage is urgently needed among FSW. Universal testing and treatment strategies for all FSW in Malawi must be strongly considered.

Below:  HIV Care Continuum among HIV-infected female sex workers, Lilongwe, Malawi

Full article at:   http://goo.gl/tszQCR

By:  Lancaster KE1,2, Powers KA1, Lungu T3, Mmodzi P3, Hosseinipour MC3,2, Chadwick K4, Go VF5, Pence BW1, Hoffman IF3,2, Miller WC1,2.

• 1Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
• 2Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
• 3UNC Project Malawi, University of North Carolina at Chapel Hill, Lilongwe, Malawi.
• 4Theatre for a Change, Lilongwe, Malawi.
• 5Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
• PLoS One. 2016 Jan 25;11(1):e0147662. doi: 10.1371/journal.pone.0147662. eCollection 2016. 

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Improvements in the Continuum of HIV Care in an Inner-City Emergency Department

Objective: The Johns Hopkins Hospital Emergency Department has served as a window on the HIV epidemic for 25 years, and as a pioneer in emergency department-based screening/linkage-to-care (LTC) programs. We document changes in the burden of HIV and HIV care metrics to the evolving HIV epidemic in inner-city Baltimore.

Design/methods: We analyzed seven serosurveys conducted on 18 144 adult Johns Hopkins Hospital Emergency Department patients between 1987 and 2013 as well as our HIV-screening/LTC program (2007, 2013) for trends in HIV prevalence, cross-sectional annual incidence estimates, undiagnosed HIV, LTC, antiretrovirals treatment, and viral suppression.

Results: HIV prevalence in 1987 was 5.2%, peaked at more than 11% from 1992 to 2003 and declined to 5.6% in 2013. Seroprevalence was highest for black men (initial 8.0%, peak 20.0%, last 9.9%) and lowest for white women. Among HIV-positive individuals, proportion of undiagnosed infection was 77% in 1987, 28% in 1992, and 12% by 2013 (P < 0.001). Cross-sectional annual HIV incidence estimates declined from 2.28% in 2001 to 0.16% in 2013. Thirty-day LTC improved from 32% (2007) to 72% (2013). In 2013, 80% of HIV-positive individuals had antiretrovirals ARVs detected in sera, markedly increased from 2007 (27%) (P < 0.001). Proportion of HIV-positive individuals with viral suppression (<400 copies/ml) increased from 23% (2001) to 59% (2013) (P < 0.001).

Conclusion: Emergency department-based HIV testing has evolved from describing the local epidemic to a strategic interventional role, serving as a model for early HIV detection and LTC. Our contribution to community-based HIV-screening and LTC program parallels declines in undiagnosed HIV infection and incidence, and increases in antiretroviral use with associated viral suppression in the community.

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By:  Kelen, Gabor D.^a; Hsieh, Yu-Hsiang^a; Rothman, Richard E.^a; Patel, Eshan U.^b; Laeyendecker, Oliver B.^b; Marzinke, Mark A.^c,d; Clarke, William^c; Parsons, Teresa^d; Manucci, Jordyn L.^d; Quinn, Thomas C.^b,d

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The Continuum of HIV Care in Catalonia

The objective was to produce a cascade of care for Catalonia to gain a public health perspective on the overall quality of HIV services and allow comparison with other countries. It was constructed using the Integrated Epidemiological Surveillance System of HIV in Catalonia and data from the PISCIS Cohort. 

Estimates of the number of people living with HIV in Catalonia are modelled using Spectrum Projection Package 2011 (UNAIDS/WHO). Totals for each stage in the cascade are obtained by applying to the preceding stage a proportion estimated from available surveillance and cohort data. Undiagnosed HIV was estimated from the European literature. The proportions retained in care, on ART and virally suppressed were derived from the PISCIS cohort. Programmatic data on ART consumption was used to validate estimates. 

By the end of 2011 there were about 33,000 people living with HIV in Catalonia, 71% of which had been both diagnosed and linked to care. We estimate that 61% of all HIV infected persons were retained in care, 56% were on ART and 48% were virally suppressed. These figures data are comparable, although slightly lower, than that of France or the UK. 

The Cascade of HIV Care in Catalonia is similar to other western European countries such as France and the UK. Direct estimates of the undiagnosed HIV population and linkage to care are desirable but the contribution of cohort data to the cascade highlights their continued importance in HIV surveillance and design of evidence-based health strategies.

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By:  Campbell CN1,2,3, Ambrosioni J4, Miro JM4, Esteve A1,2,3,5, Casabona J1,2,3,5, Navarro G5,6, García I7, Ferrer E8, Force L9, Tural C10.

• 1 Centre d'Estudis Epidemiològics sobre les Infeccions de Transmissió Sexual i Sida de Catalunya (CEEISCAT) - ASPC , Badalona , Spain.
• 2 CIBER Epidemiologia y Salud Publica (CIBERESP) , Madrid , Spain.
• 3 Institut d'Investigació Germans Trias i Pujol (IGTP) , Badalona , Spain.
• 4 Infectious Diseases Service, Hospital Clínic - IDIBAPS , University of Barcelona , Barcelona , Spain.
• 5 Departament de Pediatria, d'Obstetricia i Ginecologia i de Medicina Preventiva i de Salut Publica , Universitat Autònoma de Barcelona , Bellaterra, Barcelona , Spain.
• 6 Corporació Sanitària i Universitària Parc Taulí , Sabadell , Spain.
• 7 Hospital General de L'Hospitalet, L'Hospitalet del Llobregat , Barcelona , Spain.
• 8 Hospital Universitari de Bellvitge, L'Hospitalet del Llobregat , Barcelona , Spain.
• 9 Hospital de Mataró , Mataró , Spain.
• 10 Hospital Universitari Germans Trias i Pujol , Badalona , Spain.

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HIV Care Continuum among Men Who Have Sex With Men and Persons Who Inject Drugs in India: Barriers to Successful Engagement

BACKGROUND:

We characterize the human immunodeficiency virus (HIV) care continuum for men who have sex with men (MSM) and persons who inject drugs (PWID) across India.

METHODS:

We recruited 12 022 MSM and 14 481 PWID across 26 Indian cities, using respondent-driven sampling (September 2012 to December 2013). Participants were aged ≥18 years and either self-identified as male and reported sex with a man in the prior year (MSM) or reported injection drug use in the prior 2 years (PWID). Correlates of awareness of HIV-positive status were characterized using multilevel logistic regression.

RESULTS:

A total of 1146 MSM were HIV infected, of whom a median of 30% were aware of their HIV-positive status, 23% were linked to care, 22% were retained before antiretroviral therapy (ART), 16% had started ART, 16% were currently receiving ART, and 10% had suppressed viral loads. There was site variability (awareness range, 0%-90%; suppressed viral load range, 0%-58%). A total of 2906 PWID were HIV infected, of whom a median of 41% were aware, 36% were linked to care, 31% were retained before ART, 20% had started ART, 18% were currently receiving ART, and 15% had suppressed viral loads. Similar site variability was observed (awareness range: 2%-93%; suppressed viral load range: 0%-47%). Factors significantly associated with awareness were region, older age, being married (MSM) or female (PWID), use of other services (PWID), more lifetime sexual partners (MSM), and needle sharing (PWID). Ongoing injection drug use (PWID) and alcohol use (MSM) were associated with lower awareness.

CONCLUSIONS:

In this large sample, the major barrier to HIV care engagement was awareness of HIV-positive status. Efforts should focus on linking HIV testing to other essential services.

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By:  Mehta SH1, Lucas GM2, Solomon S3, Srikrishnan AK3, McFall AM1, Dhingra N4, Nandagopal P3, Kumar MS3, Celentano DD1, Solomon SS5.

• 1Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health.
• 2Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
• 3Y.R. Gaitonde Centre for AIDS Research and Education, Chennai, Tamil Nadu.
• 4National AIDS Control Organisation, New Delhi, India.
• 5Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland Y.R. Gaitonde Centre for AIDS Research and Education, Chennai, Tamil Nadu. 

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The HIV Care Continuum among Men Who Have Sex with Men in Moscow, Russia: A Cross-Sectional Study of Infection Awareness & Engagement In Care

OBJECTIVES:

Early diagnosis and treatment of HIV infection is critical to improving clinical outcomes for HIV-infected individuals. We sought to characterise the HIV care continuum and identify correlates of being unaware of one's HIV infection among men who have sex with men (MSM) in Moscow, Russia.

METHODS:

Participants (N=1376) were recruited via respondent-driven sampling and completed a sociobehavioural survey and HIV testing from 2010 to 2013. Sample and population estimates were calculated for key steps along the HIV care continuum for HIV-infected MSM and logistic regression methods were used to examine correlates of being unaware of one's HIV infection.

RESULTS:

15.6% of participants were HIV infected. Of these, only 23.4% were previously aware of their infection, 8.7% were on antiretroviral therapy (ART), and 4.4% reported an undetectable viral load. Bisexual identity (reference: homosexual; adjusted odds ratio, having ≥5 sexual partners in the last 6 months, and employer HIV testing requirements were associated with being unaware of one's HIV infection. HIV testing in a specialised facility and testing ≥2 times in the last 12 months were inversely associated with being unaware of HIV infection.

CONCLUSIONS:

There is a steep gradient along the HIV care continuum for Moscow-based MSM beginning with low awareness of HIV infection. Efforts that improve access to acceptable HIV testing strategies, such as alternative testing facilities, and linkage to care are needed for key populations.

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By:  Wirtz AL1, Zelaya CE2, Latkin C3, Peryshkina A4, Galai N5, Mogilniy V4, Dzhigun P4, Kostetskaya I4, Mehta SH6, Beyrer C2.

• 1Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA Department of Emergency Medicine, Johns Hopkins Medical Institute, Baltimore, Maryland, USA.
• 2Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
• 3Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
• 4AIDS Infoshare, Moscow, Russian Federation.
• 5Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA Department of Statistics, University of Haifa, Israel.
• 6Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. 

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Adaptation of the HIV Care Continuum as a Method for Evaluating Syphilis and Gonorrhea Disease Control Activities in Los Angeles County

Treatment verification and contact elicitation are core approaches used to control the spread of sexually transmitted diseases (STDs). Methodology adapted from the HIV care continuum is presented as an evaluation and communication tool for STD control activities.

Sexually transmitted disease surveillance and program data for Los Angeles County in 2013 were used to construct a 2-part continuum to examine syphilis (all stages) and gonorrhea outcomes among index patients and elicited contacts. The Index Case Continuum (Part 1) assesses the proportion of patients who were treated, assigned for interview, interviewed, and provided name and locating information for at least 1 contact. The Elicited Contact Continuum (Part 2) assesses the proportion of contacts who were located, interviewed, and treated.

Among 3668 patients with syphilis, 97% (n = 3556) were treated, 72% (n = 2633) were interviewed, and 25% (n = 920) provided name and locating information for at least 1 contact. The corresponding numbers for 12,541 gonorrhea cases were 95% (n = 11,936), 45% (n = 5633), and 16% (1944), respectively. Among the 1392 contacts elicited from syphilis cases, 53% (n = 735) were either interviewed or determined to not need an interview and 43% (n = 595) were treated. The corresponding numbers for the 2323 contacts elicited from gonorrhea cases were 53% (n = 1221) and 46% (n = 1075), respectively.

Adaptation of the HIV continuum is a useful tool for evaluating treatment verification and contact elicitation activities. In Los Angeles County, this approach revealed significant drop-offs in the proportion of index cases naming contacts and in the proportion of contacts who are interviewed and treated.

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By:  Murphy RD1, Wohl AR, Ma Y, Kobeissi L, Oduyemi O, Pérez MJ.

• 1From the Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles CA. 

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Good Continuum of HIV Care in Belgium Despite Weaknesses in Retention & Linkage to Care among Migrants

The Belgian HIV epidemic is largely concentrated among men who have sex with men and Sub-Saharan Africans. We studied the continuum of HIV care of those diagnosed with HIV living in Belgium and its associated factors.

Data on new HIV diagnoses 2007–2010 and HIV-infected patients in care in 2010–2011 were analysed. Proportions were estimated for each sequential stage of the continuum of HIV care and factors associated with attrition at each stage were studied.

Of all HIV diagnosed patients living in Belgium in 2011, an estimated 98.2 % were linked to HIV care, 90.8 % were retained in care, 83.3 % received antiretroviral therapy and 69.5 % had an undetectable viral load (<50 copies/ml). After adjustment for sex, age at diagnosis, nationality and mode of transmission, we found lower entry into care in non-Belgians and after preoperative HIV diagnoses; lower retention in non-Belgians and injecting drug users; higher retention in men who have sex with men and among those on ART. Younger patients had lower antiretroviral therapy uptake and less viral suppression; those with longer time from diagnosis had higher ART uptake and more viral suppression; Sub-Saharan Africans on ART had slightly less viral suppression.

The continuum of HIV care in Belgium presents low attrition rates over all stages. The undiagnosed HIV-infected population, although not precisely estimated, but probably close to 20 % based on available survey and surveillance results, could be the weakest stage of the continuum of HIV care. Its identification is a priority along with improving the HIV care continuum of migrants.

Below:  Diagram representing the distribution of the HIV diagnosed population within the continuum of HIV care

Below:  Distribution of delay between HIV diagnosis and first medical contact in HIV care (recorded CD4 or VL) among patients entered in care

Below: Estimated percentage of diagnosed HIV individuals living in Belgium by stage of the continuum of HIV care, 2011  

Full article at: http://goo.gl/QQABPb

By: D. Van Beckhoven^1*, E. Florence², J. Ruelle³, J. Deblonde¹, C. Verhofstede⁴, S. Callens⁵,E. Vancutsem⁶, P. Lacor⁷, R. Demeester⁸, J.-C. Goffard⁹, A. Sasse¹ and For the BREACH (Belgian Research on AIDS and HIV Consortium)

¹Epidemiology of Infectious Diseases Unit, Scientific Institute of Public Health, Rue J. Wytsman 14, Brussels, 1050, Belgium

²Department of Clinical Sciences, Instituut Tropische Geneeskunde, Antwerp, Belgium

³Institute of Experimental and Clinical Research (IREC), Unit of Medical Microbiology (MBLG), Université Catholique de Louvain, Brussels, Belgium

⁴AIDS Reference Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University, Ghent, Belgium

⁵Department of Internal Medicine, Universitair Ziekenhuis Gent, Ghent, Belgium

⁶Department of Microbiology and Infection Control, Universitair Ziekenhuis Brussel, Brussels, Belgium

⁷Department of Internal Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium

⁸Department of Internal Medicine and Infectious Diseases, CHU de Charleroi, Charleroi, Belgium

⁹Service of Internal Medicine, Hôpital Erasme, Brussels, Belgium

  

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