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Introduction Although bacterial co- and superinfections are rarely present in patients with COVID-19, overall antibiotic prescribing in admitted patients is high. In order to counter antibiotic overprescribing, antibiotic stewardship teams need reliable data concerning antibiotic prescribing in admitted patients with COVID-19. Methods In this prospective observational cohort study, we performed a quantitative and qualitative evaluation of antibiotic prescriptions in patients admitted to the COVID-19 ward of a 721-bed Belgian university hospital between 1 May and 2 November 2020. Data on demographics, clinical and microbiological parameters and antibiotic consumption were collected. Defined daily doses (DDD) were calculated for antibiotics prescribed in the context of a (presumed) bacterial respiratory tract infection and converted into two indicators: DDD/admission and DDD/100 hospital bed days. A team of infectious disease specialists performed an appropriateness evaluation for every prescription. A driver analysis was performed to identify factors increasing the odds of an antibiotic prescription in patients with a confirmed COVID-19 diagnosis. Results Of 403 eligible participants with a suspected COVID-19 infection, 281 were included. In 13.8% of the 203 admissions with a COVID-19 confirmed diagnosis, antibiotics were initiated for a (presumed) bacterial respiratory tract co-/superinfection (0.86 DDD/admission; 8.92 DDD/100 bed days; 39.4% were scored as ‘appropriate’). Five drivers of antibiotic prescribing were identified: history of cerebrovascular disease, high neutrophil/lymphocyte ratio in male patients, age, elevated ferritin levels and the collection of respiratory samples for bacteriological analysis. Conclusion In the studied population, the antibiotic consumption for a (presumed) bacterial respiratory tract co-/superinfection was low. In particular, the small total number of DDDs in patients with confirmed COVID-19 diagnosis suggests thoughtful antibiotic use. However, antibiotic stewardship programmes remain crucial to counter unnecessary and inappropriate antibiotic use in hospitalized patients with COVID-19. Trial Registration The study is registered at ClinicalTrials.gov (NCT04544072). Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00535-2.

Background HIV patients face considerable acute and chronic healthcare needs and battling the HIV epidemic remains of the utmost importance. By focusing on health outcomes in relation to the cost of care, value-based healthcare (VBHC) proposes a strategy to optimize quality of care and cost-efficiency. Its implementation may provide an answer to the increasing pressure to optimize spending in healthcare while improving patient outcomes. This paper describes a pragmatic value-based healthcare framework for HIV care. Methods A value-based HIV healthcare framework was developed during a series of roundtable discussions bringing together 16 clinical stakeholder representatives from the Belgian HIV reference centers and 2 VBHC specialists. Each round of discussions was focused on a central question translating a concept or idea to the next level of practical implementation: 1) how can VBHC principles be translated into value-based HIV care drivers; 2) how can these value-based HIV care divers be translated into value-based care objectives and activities; and 3) how can value-based HIV care objectives and activities be translated into value-based care indicators. Value drivers were linked to concrete objectives and activities using a logical framework approach. Finally, specific, measurable, and acceptable structure, process and outcomes indicators were defined to complement the framework. Results Our framework identifies 4 core value areas where HIV care would benefit most from improvements: Prevention, improvement of the cascade of care, providing patient-centered HIV care and sustaining a state-of-the-art HIV disease management context. These 4 core value areas were translated into 12 actionable core value objectives. For each objective, example activities were proposed. Indicators are suggested for each level of the framework (outcome indicators for value areas and objectives, process indicators for suggested activities). Conclusions This framework approach outlines how to define a patient- and public health centered value-based HIV care paradigm. It proposes how to translate core value drivers to practical objectives and activities and suggests defining indicators that can be used to track and improve the framework’s implementation in practice.

Between 19 May and 12 June 2020, employees of the UZ Brussel were recruited in this study aiming to document the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence, to investigate the potential work-related risk factors for SARS-CoV-2 infection and to estimate the proportion of asymptomatic infections. In total, 2662 participants were included of whom 7.4% had immunoglobulin G antibodies against SARS-CoV-2. Of the participants reporting a positive polymerase chain reaction for SARS-CoV-2, 89% had antibodies at the time of blood sampling. Eleven per cent of the antibody positive participants reported no recent symptoms suggestive of coronavirus disease 2019 (COVID-19). Participants reporting fever, chest pain and/or anosmia/ageusia were significantly more frequently associated with the presence of antibodies against SARS-CoV-2. The presence of antibodies was highest in the group that had had contact with COVID-19-infected individuals outside the hospital with or without using appropriate personnel protective equipment (PPE) (P < 0.001). Inside the hospital, a statistically significant difference was observed for the employees considered as low-risk exposure compared to the intermediate-risk exposure group (P = 0.005) as well as the high-risk exposure group compared to the intermediate exposure risk group (P < 0.001). These findings highlight the importance of using correct PPE.

This study aims to quantify antibiotic consumption for suspected respiratory tract superinfections in COVID-19 patients, while investigating the associated drivers of antibiotic prescribing in light of the current signs of antibiotic overuse. Adult patients with a positive COVID-19 diagnosis admitted to a Belgian 721-bed university hospital were analyzed retrospectively (March 11th–May 4th, 2020), excluding short-term admissions (

BACKGROUNDSeasonal influenza-like illness (ILI) affects millions of people yearly. Severe acute respiratory infections (SARI), mainly caused by influenza, are a leading cause of hospitalisation and mortality. Increasing evidence indicates that non-influenza respiratory viruses (NIRVs) also contribute to the burden of SARI. In Belgium, SARI surveillance by a network of sentinel hospitals is ongoing since 2011.AIMHere, we report the results of using in-house multiplex PCRs for the detection of a flexible panel of viruses in respiratory ILI and SARI samples and the estimated incidence rates of SARI associated to each virus.METHODSILI was defined as an infection with onset of fever and cough or dyspnoea. SARI was defined as an infection requiring hospitalization with onset of fever and cough or dyspnoea within the previous 10 days. Samples were collected during four winter seasons and tested by multiplex RT-qPCRs for influenza virus and NIRVs. Using catchment population estimates, incidence rates of SARI associated to each virus were calculated.RESULTSOne third of the SARI cases were positive for NIRVs, reaching 49.4% among children under fifteen. In children under five, incidence rates of NIRV-associated SARI were double that of influenza (103.4 versus 57.6 per 100000 person-months), with NIRV co-infections, respiratory syncytial viruses, human metapneumoviruses and picornaviruses contributing the most (33.1, 13.6, 15.8 and 18.2 per 100000 person-months, respectively).CONCLUSIONEarly testing for NIRVs could be beneficial to clinical management of SARI patients, especially in children under five, for whom the burden of NIRV-associated disease exceeds that of influenza.

Background Seasonal human coronaviruses (hCoVs) broadly circulate in humans. Their epidemiology and effect on the spread of emerging coronaviruses has been neglected thus far. We aimed to elucidate the epidemiology and burden of disease of seasonal hCoVs OC43, NL63, and 229E in patients in primary care and hospitals in Belgium between 2015 and 2020.Methods We retrospectively analysed data from the national influenza surveillance networks in Belgium during the winter seasons of 2015-20. Respiratory specimens were collected through the severe acute respiratory infection (SARI) and the influenza-like illness networks from patients with acute respiratory illness with onset within the previous 10 days, with measured or reported fever of 38 degrees C or greater, cough, or dyspnoea; and for patients admitted to hospital for at least one night. Potential risk factors were recorded and patients who were admitted to hospital were followed up for the occurrence of complications or death for the length of their hospital stay. All samples were analysed by multiplex quantitative RT-PCRs for respiratory viruses, including seasonal hCoVs OC43, NL63, and 229E. We estimated the prevalence and incidence of seasonal hCoV infection, with or without co-infection with other respiratory viruses. We evaluated the association between co-infections and potential risk factors with complications or death in patients admitted to hospital with seasonal hCoV infections by age group. Samples received from week 8, 2020, were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).Findings 2573 primary care and 6494 hospital samples were included in the study. 161 (6.3%) of 2573 patients in primary care and 371 (5.7%) of 6494 patients admitted to hospital were infected with a seasonal hCoV. OC43 was the seasonal hCoV with the highest prevalence across age groups and highest incidence in children admitted to hospital who were younger than 5 years (incidence 9.0 [95% CI 7.2-11.2] per 100 000 person-months) and adults older than 65 years (2.6 [2.1-3.2] per 100 000 person-months). Among 262 patients admitted to hospital with seasonal hCoV infection and with complete information on potential risk factors, 66 (73.3%) of 90 patients who had complications or died also had at least one potential risk factor (p=0.0064). Complications in children younger than 5 years were associated with co-infection (24 [36.4%] of 66; p=0.017), and in teenagers and adults (>= 15 years), more complications arose in patients with a single hCoV infection (49 [45.0%] of 109; p=0.0097). In early 2020, the Belgian SARI surveillance detected the first SARS-CoV-2-positive sample concomitantly with the first confirmed COVID-19 case with no travel history to China.Interpretation The main burden of severe seasonal hCoV infection lies with children younger than 5 years with co-infections and adults aged 65 years and older with pre-existing comorbidities. These age and patient groups should be targeted for enhanced observation when in medical care and in possible future vaccination strategies, and co-infections in children younger than 5 years should be considered during diagnosis and treatment. Our findings support the use of national influenza surveillance systems for seasonal hCoV monitoring and early detection, and monitoring of emerging coronaviruses such as SARS-CoV-2. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Belgian Federal Public Service Health, Food Chain Safety, and Environment; Belgian National Insurance Health Care (Institut national d'assurance maladie-invalidite/Rijksinstituut voor ziekte-en invaliditeitsverzekering); and Regional Health Authorities (Flanders Agentschap zorg en gezondheid, Brussels Commission communautaire commune, Wallonia Agence pour une vie de qualite).

International audience; Background: Infective endocarditis (IE) is a life-threatening disease. Despite advancements in diagnostic methods, the initial clinical presentation of IE remains a valuable asset. Therefore, the impact of clinical presentation on outcomes and its association with microorganisms and IE localization were assessed herein. Methods: This retrospective study included 183 patients (age 68.9 ± 14.2 years old, 68.9% men) with definite IE at two tertiary care hospitals in Belgium. Demographic data, medical history, clinical presentation, blood cultures, imaging data and outcomes were recorded. Results: In-hospital mortality rate was 22.4%. Sixty (32.8%) of the patients developed embolism, 42 (23%) shock, and 103 (56.3%) underwent surgery during hospitalization. Shock at admission predicted embolism during hospitalization (odds ratio [OR] 2.631, 95% confidence interval [CI] 1.119-6.184, p = 0.027). A new cardiac murmur at admission predicted cardiac surgery (OR 1.949, 95% CI 1.007-3.774, p = 0.048). Methicillin resistant Staphylococcus aureus predicted in-hospital mortality and shock (p = 0.005, OR 6.945, 95% CI 1.774-27.192 and p = 0.015, OR 4.691, 95% CI 1.348-16.322, respectively). Mitral valve and aortic valve IE respectively predicted in-hospital death (p = 0.039, OR 2.258, 95% CI 1.043-4.888) and embolism (p = 0.017, OR 2.328, 95% CI 1.163-4.659). Conclusions: In this retrospective study, shock at admission independently predicted embolism during hospitalization in IE patients. Moreover, a new cardiac murmur at admission predicted the need for cardiac surgery. This emphasizes the importance of a comprehensive initial clinical evaluation in combination with imaging and microbiological data, in order to identify high-risk IE patients early.

Background Despite improvements in medical and surgical therapy, infective endocarditis (IE) remains a deadly disease. Echocardiography is the first-line diagnostic tool. However, data regarding its role in the prognostic assessment of in-hospital clinical outcome of IE are scarce. Purpose We sought to assess the role of echocardiography to predict the in-hospital outcome in a large cohort of patients diagnosed with definite IE and its association with clinical presentation and microorganisms. Methods We retrospectively included patients from two centers between 2006 and 2018. Transthoracic and transesophageal echocardiography were performed in all patients. The clinical endpoints were in-hospital death, embolic events (cerebrovascular and non-cerebrovascular), shock (septic shock and cardiogenic shock) and cardiac surgery. Results 183 patients with definite IE (age 68.9 ± 14.2 years old, 68.9% male) were evaluated. Ninety three (50.8%) patients had aortic valve IE and 81 (44.3%) patients presented with mitral valve IE. Twenty three patients had multivalvular IE. The in-hospital mortality rate was 22.4%. Sixty patients (32.8%) had embolic events and 42 (23%) patients developed shock during hospitalization. Surgery was performed in 103 (56.3%) patients. Mitral valve IE on echocardiography was an independent predictor of in-hospital mortality (p = 0.038, OR 0.38, 95% CI 0.15 – 0.94) and aortic valve IE on echocardiography was an independent predictor of embolic events (p = 0.018, OR 0.36, 95% 0.16-0.84). The presence of a new cardiac murmur upon admission was predictive for the need of cardiac surgery (p = 0.042, OR 0.51, 95% CI 0.22- 1.09) and correlated with the severity of valvular regurgitation identified by echocardiography (p = 0.024). Methicillin resistant Staphylococcus aureus (MRSA) as the causative microorganism was an independent predictor for in - hospital mortality and for the development of shock during hospitalization (p = 0.010, OR 0.13 95% CI 0.30 - 0.62 and p = 0.027, OR 6.11, 95% CI 1.22 – 30.37, respectively). No correlation was found between MRSA and echocardiographic parameters. Conclusion Mitral valve IE was an independent predictor of in - hospital mortality. Furthermore, aortic valve IE was an independent predictor of embolic events. The presence of a new cardiac murmur was predictive for the need of cardiac surgery and correlated with the severity of valvular regurgitation by echocardiography. Our findings suggest that a thorough physical examination upon admission is required in combination with a comprehensive echocardiographic exam for early identification of patients with IE at high - risk for in-hospital death and complications.

Objectives: This 5-year follow-up study aimed to assess clinical outcomes of HIV-1 infected adults treated with atazanavir (ATV) in clinical practice in Belgium, to describe patient profiles and characteristics, as well as treatment safety. Methods: A multicenter, non-interventional, non-comparative, retrospective cohort study was performed in HIV-1 positive adult patients treated with ATV between 2006 and 2012. Data were collected from 8 AIDS reference centers’ databases. All analyses were on-treatment. Sub-analyses were carried out in unboosted ATV treated patients and in females. The primary endpoint was defined as the time-to-treatment-discontinuation. Furthermore, virological suppression, immunological response, time to loss of virological response, reasons for ATV initiation, and discontinuation were also assessed. Results: 2264 ARV-naive and ARV-experienced patients (median age: 41 years) were included. Females and non-Caucasians were broadly represented (40 and 45%, respectively). The probability to remain on treatment was 0.78 (CI: 0.76; 0.78) for the first and 0.69 (CI: 0.66; 0.71) for the second year and was similar between males and females. Overall, 771 patients (34.1%) discontinued ATV over time, the median (Q1-Q3) time to discontinuation being 0.8 (0.3–1.5) year. In unboosted ATV-treated patients, results were comparable to the overall ATV population, except for a higher rate of discontinuation-over-time (45.1%). Conclusions: Clinical and safety data from this 5 year-cohort study show that the vast majority of patients remained on ATV treatment for the first and second years, overall as well as patients treated with unboosted ATV and females.

Book of the 18th Conference in Internal Medicine

Summary Background Effective two-drug regimens could decrease long-term drug exposure and toxicity with HIV-1 antiretroviral therapy (ART). We therefore aimed to evaluate the efficacy and safety of a two-drug regimen compared with a three-drug regimen for the treatment of HIV-1 infection in ART-naive adults. Methods We conducted two identically designed, multicentre, double-blind, randomised, non-inferiority, phase 3 trials: GEMINI-1 and GEMINI-2. Both studies were done at 192 centres in 21 countries. We included participants (≥18 years) with HIV-1 infection and a screening HIV-1 RNA of 500 000 copies per mL or less, and who were naive to ART. We randomly assigned participants (1:1) to receive a once-daily two-drug regimen of dolutegravir (50 mg) plus lamivudine (300 mg) or a once-daily three-drug regimen of dolutegravir (50 mg) plus tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg). Both drug regimens were administered orally. We masked participants and investigators to treatment assignment: dolutegravir was administered as single-entity tablets (similar to its commercial formulation, except with a different film colour), and lamivudine tablets and tenofovir disoproxil fumarate and emtricitabine tablets were over-encapsulated to visually match each other. Primary endpoint was the proportion of participants with HIV-1 RNA of less than 50 copies per mL at week 48 in the intention-to-treat-exposed population, using the Snapshot algorithm and a non-inferiority margin of −10%. Safety analyses were done on the safety population. GEMINI-1 and GEMINI-2 are registered with ClinicalTrials.gov, numbers NCT02831673 and NCT02831764, respectively. Findings Between July 18, 2016, and March 31, 2017, 1441 participants across both studies were randomly assigned to receive either the two-drug regimen (n=719) or three-drug regimen (n=722). At week 48 in the GEMINI-1 intention-to-treat-exposed population, 320 (90%) of 356 participants receiving the two-drug regimen and 332 (93%) of 358 receiving the three-drug regimen achieved plasma HIV-1 RNA of less than 50 copies per mL (adjusted treatment difference −2·6%, 95% CI −6·7 to 1·5); in GEMINI-2, 335 (93%) of 360 in the two-drug regimen and 337 (94%) of 359 in the three-drug regimen achieved HIV-1 RNA of less than 50 copies per mL (adjusted treatment difference −0·7%, 95% CI −4·3 to 2·9), showing non-inferiority at a −10% margin in both studies (pooled analysis: 655 [91%] of 716 in the two-drug regimen vs 669 [93%] of 717 in the three-drug regimen; adjusted treatment difference −1·7%, 95% CI −4·4 to 1·1). Numerically, more drug-related adverse events occurred with the three-drug regimen than with the two-drug regimen (169 [24%] of 717 vs 126 [18%] of 716); few participants discontinued because of adverse events (16 [2%] in the three-drug regimen and 15 [2%] in the two-drug regimen). Two deaths were reported in the two-drug regimen group of GEMINI-2, but neither was considered to be related to the study medication. Interpretation The non-inferior efficacy and similar tolerability profile of dolutegravir plus lamivudine to a guideline-recommended three-drug regimen at 48 weeks in ART-naive adults supports its use as initial therapy for patients with HIV-1 infection. Funding ViiV Healthcare.

SummaryStigma and discrimination within health care settings remain a public health challenge across diverse cultural environments and may have deleterious effects on mental and physical health. This study explores the causes, forms and consequences of HIV-related stigma and discrimination among migrant sub-Saharan African women living with HIV in Belgium. A qualitative study was conducted with 44 HIV-positive sub-Saharan African migrant women between April 2013 and December 2014 in health care settings in Belgium. Data were analysed using thematic content analysis. Twenty-five of the women reported overt stigma and discrimination and fifteen reported witnessing behaviours that they perceived to be stigmatizing and discriminatory in health care settings. The themes that emerged as to the causes of stigma and discrimination were: public perceptions of migrants and HIV, fear of contamination and institutional policies on HIV management. Reported forms of stigma and discrimination included: delayed or denied care, excessive precautions, blame and humiliation. The consequences of stigma and discrimination were: emotional stress, inconsistent health-care-seeking behaviour and non-disclosure to non-HIV treating personnel. Stigma and discrimination in health care settings towards people with HIV, and more specifically towards HIV-positive sub-Saharan African migrant women, impedes sustainable preventive measures. Specialized education and training programmes for non-HIV health care providers require in-depth investigation.

Background: Although previous research that considered a variety of chronic diseases have shown that quality of provider-patient relationship is related to health outcomes, key issues defining HIV care provider-patient relationship has not been well studied in Belgium. It is important to understand the key elements that define HIV care team-patient relationship and how they deal with psychosocial issues facing sub-Saharan African (SSA) migrant women with HIV/AIDS in Belgium. Methods: Face to face in-depth semi-structured interviews with 8 HIV experts at an AIDS Reference Centre in Brussels were conducted between December 2013 and March 2014. Observations during patient–doctor consultations were also conducted. Experts were asked to describe their experiences in the treatment and care of SSA migrant women with HIV/AIDS. Thematic analysis approach was used in the analysis of the transcripts. Results: HIV care team viewed their role as encompassing both biomedical and psychosocial aspects of care, reported a bottom-up communication about HIV care and the ability to positively influence patients’ acceptance and coping with HIV/AIDS as a long-term illness. The team described communication as a process, individualized approaches to recommendations and viewed their provision of care as satisfying. Some participants described their frustration at not being able to get some patients adhere to their treatment. Conclusion: HIV care team reported increased job satisfaction in their interaction with patients. Further research is necessary to determine if educational interventions to improve non-HIV healthcare providers’ interaction skills could improve patient-healthcare providers’ relationship and reduce stigma and discrimination in healthcare settings.

In this review of the current challenges in the fight against HIV, we describe the state of the HIV epidemic and the framework put in place using the 90-90-90 objectives to try and curb the epidemic worldwide. There are numerous effective and evidence-based prevention measures against the spread of HIV, but the biggest challenges lie in the lack of political commitment, reluctance to address issues of sexuality and reproduction, and criminalization of key populations that are at the highest risk of HIV. Access to HIV treatment and continued care without stigmatization should be as easy and cheap as possible for those who are tested and diagnosed with HIV to achieve the best results worldwide. Regarding the treatment of HIV, the last decades have been very successful in dramatically improving the quality of life of people living with HIV, reducing the transmission rate and decreasing HIV-associated morbidity and mortality. It could even be argued that the next milestone will be a strategy that allows individuals to stop com- bination antiretroviral therapy safely before a cure is discovered. Despite great progress, people with HIV have shorter life expectancy than those without the virus, and the underlying causes are probably multifactorial, including premature aging, drug toxicities, and comorbidities. Even if challenges remain, hope should too, with the ultimate goal to end the HIV epidemic.

Summary: RegaDB is a free and open source data management and analysis environment for infectious diseases. RegaDB allows clinicians to store, manage and analyze patient data, including viral genetic sequences. Moreover, RegaDB provides researchers with a mechanism to collect data in a uniform format and offers them a canvas to make newly developed bioinformatics tools available to clinicians and virologists through a user friendly interface. Availability and implementation: Source code, binaries and documentation are available on http://regaweb.med.kuleuven.be/software/regadb/ RegaDB is written in the Java programming language, using a web-service oriented architecture. Contact: pieter.libin@rega.kuleuven.be Supplementary information: Supplementary material demonstrating the functionalities of the system is available at Bioinformatics online. Published version

Spirituality/religion serves important roles in coping, survival and maintaining overall wellbeing within African cultures and communities, especially when diagnosed with a chronic disease like HIV/AIDS that can have a profound effect on physical and mental health. However, spirituality/religion can be problematic to some patients and cause caregiving difficulties. The objective of this paper was to examine the role of spirituality/religion as a source of strength, resilience and wellbeing among sub-Saharan African (SSA) migrant women with HIV/AIDS. A qualitative study of SSA migrant women was conducted between April 2013 and December 2014. Participants were recruited through purposive sampling and snowball techniques from AIDS Reference Centres and AIDS workshops in Belgium, if they were 18 years and older, French or English speaking, and diagnosed HIV positive more than 3 months beforehand. We conducted semi-structured interviews with patients and did observations during consultations and support groups attendances. Thematic analysis was used to analyse the data. 44 women were interviewed, of whom 42 were Christians and 2 Muslims. None reported religious/spiritual alienation, though at some point in time many had felt the need to question their relationship with God by asking "why me?" A majority reported being more spiritual/religious since being diagnosed HIV positive. Participants believed that prayer, meditation, regular church services and religious activities were the main spiritual/religious resources for achieving connectedness with God. They strongly believed in the power of God in their HIV/AIDS treatment and wellbeing. Spiritual/religious resources including prayer, meditation, church services, religious activities and believing in the power of God helped them cope with HIV/AIDS. These findings highlight the importance of spirituality in physical and mental health and wellbeing among SSA women with HIV/AIDS that should be taken into consideration in providing a caring and healthy environment.

Patients with HIV not only have to deal with the challenges of living with an incurable disease but also with the dilemma of whether or not to disclose their status to their partners, families and friends. This study explores the extent to which sub-Saharan African (SSA) migrant women in Belgium disclose their HIV positive status, reasons for disclosure/non-disclosure and how they deal with HIV disclosure. A qualitative study consisting of interviews with twenty-eight SSA women with HIV/AIDS was conducted. Thematic content analysis was employed to identify themes as they emerged. Our study reveals that these women usually only disclose their status to healthcare professionals because of the treatment and care they need. This selective disclosure is mainly due to the taboo of HIV disease in SSA culture. Stigma, notably self-stigma, greatly impedes HIV disclosure. Techniques to systematically incorporate HIV disclosure into post-test counseling and primary care services are highly recommended.

Objectives : Infectious agents triggering haemophagocytic lymphohistiocytosis (HLH) primarily involve the herpes virus group. We report a case of HLH precipitated by Plasmodium falciparum . Materials and methods : Clinical and laboratory findings in a patient presenting with fever were collected. After confirmation of acute malaria, anti-malarial treatment was administered. Results : Despite initial favourable evolution, the patient developed fever again together with a worsening of the haematological parameters and increased ferritin levels. A bone marrow biopsy confirmed the diagnosis of HLH. Conclusion : This case illustrates that HLH should be considered in the differential diagnosis of acute malaria in patients with persisting fever and pancytopenia.

Introduction : We studied factors associated with the continuum of HIV care in Belgium. Methods : Data of the national registration of new HIV diagnosis and of the national cohort of HIV-infected patients in care were combined to obtain estimates of and factors related with proportions of HIV-infected patients in each step of the continuum of care from diagnosis to suppressed viral load (VL). Factors associated with ignorance of HIV seropositivity were analyzed among patients co-infected with HIV and STI in the Belgian STI sentinel surveillance network. Associated factors were identified by multivariate logistic regression. Results : Among 4038 individuals diagnosed with HIV between 2007 and 2010, 90.3% were linked to care. Of 11684 patients in care in 2010, 90.8% were retained in care up to the following year, 88.3% of those were on ART, of whom 95.3% had suppressed VL (

Corrigendum to ‘A phase I/IIa immunotherapy trial of HIV-1-infected patients with Tat, Rev and Nef expressing dendritic cells followed by treatment interruption’ [Clin. Immunol. 142 (2012) 252–268] Sabine D. Allard⁎, Brenda De Keersmaecker, Anna L. de Goede, Esther J. Verschuren, Jeanette Koetsveld , Mariska L. Reedijk , Carolien Wylock, Annelies V. De Bel , Judith Vandeloo, Frank Pistoor , Carlo Heirman, Walter E.P. Beyer , Paul H.C. Eilers , Jurgen Corthals , Iman Padmos, Kris Thielemans, Albert D.M.E. Osterhaus , Patrick Lacor, Marchina E. van der Ende, Joeri L. Aerts , Carel A. van Baalen, Rob A. Gruters c,2

SummaryGranulocytic sarcoma or chloroma is defined as an extramedullar solid tumor, composed of granulocytic precursor cells at various levels of differentiation. Granulocytic sarcoma is mostly associated with acute and chronic leukemia, rarely with polycythemia vera and myelofibrosis. The use of special immunohistochemical stains is mandatory, because this tumor is often misdiagnosed as malignant lymphoma.We report two cases of granulocytic sarcoma (tonsil and ovary) associated with chronic myelogenous leukemia. We describe the first reported association of atypical CML and granulocytic sarcoma.

HIV treatment may be less effective as a prevention option when HIV patients especially migrants encounter difficulties in accessing treatment and care even in resource-rich settings. This paper explores perspectives of HIV-infected Sub-Saharan African (SSA) migrant women and their caregivers on HIV treatment/care in Belgium. We conducted a qualitative study between April 2013 and December 2014. We included HIV-infected SSA migrant women and their caregivers providing treatment and care in a university teaching hospital in Belgium. Data was analyzed using thematic analysis. A total of 44 patients and eight HIV healthcare providers were included in the study. All participants acknowledged the availability and accessibility to free treatment that contributes to long-term survival if treatment is adhered to. Women with uncertain immigration status and unstable housing reported difficulties in obtaining treatment/care and the fear of discontinuity if deported to their country of origin. Free, available and accessible healthcare remains paramount and makes living with HIV/AIDS tolerable despite the chronic nature and seriousness of the disease. HIV/AIDS SSA women believe that adhering to antiretroviral therapy increases longevity; greatly improve quality of health and restores self-esteem. Barriers to obtain care for the undocumented may have dire consequences on public health.

Recent studies have shown that in selected conditions antiretroviral drugs can be used to protect HIV seronegative persons from becoming infected, when exposed to the risk of sexual HIV transmission. This concept of 'pre-exposure prophylaxis' or 'PrEP' has raised many questions that concern cost, safety and ethical issues. In this article, different aspects of PrEP are analysed with a view to trying to answer the question whether today's society is already prepared to accept PrEP as one of the tools to prevent transmission of HIV by high-risk sexual contacts.

Communication from the brain to the immune system is influenced by hemispheric lateralisation (HL). Left-HL is immunopotentiating, right-HL is immunosuppressive. Only one study has examined the effects of HL on the progression of HIV (Gruzelier et al., 1996). That study included a small sample with very little control over third variables. The present study tested whether left HL predicted higher CD4 and CD8 levels, statistically controlling for confounders.

In a phase I/IIa clinical trial, 17 HIV-1 infected patients, stable on cART, received 4 vaccinations with autologous dendritic cells etectroporated with mRNA encoding Tat, Rev and Nef, after which cART was interrupted. Vaccination was safe and feasible. During the analytical treatment interruption (All), no serious adverse events were observed. Ninety-six weeks following ATI, 6/17 patients remained off therapy. Although induced and/or enhanced CD4(+) and CD8(+) T-cell responses specific for the immunogens were observed in most of the patients, we found no correlation with the number of weeks off cART. Moreover, CD4(+) T-cell counts, plasma viral load and the time remaining off cART following ATI did not differ from historical control data. To conclude, the vaccine was safe, well tolerated and resulted in vaccine-specific immune responses. Since no correlation with clinical parameters could be found, these results warrant further research in order to optimize the efficacy of vaccine-induced T-cell responses. (C) 2011 Elsevier Inc. All rights reserved.

We describe a case of reactive arthritis followingShigellainfection after a trip to Egypt. The diagnostic challenge and treatment of this acute medical condition are discussed.

We describe a case of an HIV-seropositive patient presenting with a severe stomatitis that initially improved with anti-infective agents. Only 13 days after the onset of the stomatitis, the patient developed rapidly progressive constitutional symptoms and a cutaneous eruption. He was diagnosed with a Stevens-Johnson syndrome (SJS) caused by the antiretroviral drug nevirapine (NVP). Despite meticulous supportive care and withdrawal of all drugs, his situation worsened and developed into a toxic epidermal necrolysis (TEN), or Lyell's syndrome, complicated by a toxic hepatitis. Treatment with a novel combination of intravenous immunoglobulins (IVIG) and N-acetylcysteine (NAC) resulted in an exceptionally fast recovery. A literature research revealed no other cases of patients treated with both NAC and IVIG for the combination of TEN and toxic hepatitis. Because of the rapid clinical recovery, this approach merits further investigation. This case report also illustrates the importance of early suspicion of SJS when an HIV-infected patient treated with nevirapine presents with stomatitis.

A healthy 38-year-old man presented with a short history of a viral syndrome, accompanied by purpura and gingival bleeding. Examination of the blood showed a profound thrombocytopenia. Cytomegalovirus infection was diagnosed and a causal relationship between CMV infection and thrombocytopenia was assumed on clinical grounds. We successfully treated the patient with oral prednisone. In the discussion, we briefly mention the different hypothetical mechanisms leading to autoimmune thrombocytopenia.

Routinely processed bone marrow biopsies of 59 patients with untreated multiple myeloma (MM) and of 41 patients with monoclonal gammopathies of undetermined significance (MGUS) were immunocytochemically studied with the MB2 monoclonal antibody. In 54 of 59 biopsies of patients with MM, most neoplastic plasma cells showed strong cytoplasmic positivity to MB2. In contrast, only three biopsies of patients with MGUS contained highly MB2-positive plasma cells, whereas the plasma cells in the remaining biopsies were either negative (18 of 41) or revealed a weak dot-like staining of the cytoplasm (20 of 41). Plasma cells in tonsillar tissue, gastric and duodenal mucosae, and bone marrow with reactive plasmacytosis were not stained with MB2. These findings suggest that MB2 helps to distinguish between MM and MGUS. Because the five MB2-negative patients with MM were all in stage III and had very short survival time, neoplastic plasma cell staining with MB2 could also have a prognostic significance.

This study is the first prospective study to assess the prevalence, epidemiology, and risk factors of HIV-1 drug resistance in newly diagnosed HIV-infected patients in Belgium. In January 2003 it was initiated as part of the pan-European SPREAD program, and continued thereafter for four inclusion rounds until December 2006. Epidemiological, clinical, and behavioral data were collected using a standardized questionnaire and genotypic resistance testing was done on a sample taken within 6 months of diagnosis. Two hundred and eighty-five patients were included. The overall prevalence of transmitted HIV-1 drug resistance in Belgium was 9.5% (27/285, 95% CI: 6.6-13.4). Being infected in Belgium, which largely coincided with harboring a subtype B virus, was found to be significantly associated with transmission of drug resistance. The relatively high rate of baseline resistance might jeopardize the success of first line treatment as more than 1 out of 10 (30/285, 10.5%) viruses did not score as fully susceptible to one of the recommended first-line regimens, i.e., zidovudine, lamivudine, and efavirenz. Our results support the implementation of genotypic resistance testing as a standard of care in all treatment-naive patients in Belgium.

Multidrug-resistant (MDR) Acinetobacter baumannii are emerging as important nosocomial pathogens. These organisms have a capacity for long-term survival in the hospital environment. The purpose of this study was to describe the course and control of an outbreak with MDR A. baumannii in a Belgian university hospital after transfer of two trauma patients from Greece. Wounds in both patients were colonised with MDR A. baumannii. Over an 11 month period from September 2004 to July 2005, carbapenem-non-susceptible A. baumannii (producing carbapenem-hydrolysing oxacillinase OXA-58) were isolated from 28 patients, despite early implementation of contact precautions. MDR A. baumannii was detected in routine clinical diagnostic samples from 26 patients and in screening specimens from an additional two patients. Twenty patients (71.4%) were colonised or infected during their stay in intensive care. Twenty-four (85.7%) respiratory samples were positive for MDR A. baumannii. Careful review of all procedures related to the respiratory tract did not identify a common route of transmission. Outbreak control required multiple interventions, including contact isolation of colonised and infected patients, monitoring the practice of personnel, screening of asymptomatic patients, use of isolation rooms and enhanced environmental disinfection. Introduction of single-use ventilator circuits was considered but the outbreak was controlled before implementation.

Progressive multifocal leukoencephalopathy (PML) is a demyelinating neurologic disorder caused by a polyomavirus, called JC virus. PML affects mainly immunocompromised hosts. We report a case of PML as first manifestation of sarcoidosis in a previously healthy man. Treatment with cidofovir, resulted in a neurological and radiological stabilization. To our knowledge the association of PML and sarcoidosis without previous immunosuppressive treatment has only been described in a few cases, none of them were treated with cidofovir. (C) 2007 Elsevier B.V. All rights reserved.