These data highlight the need for tailored public health interventions in immigrants to avoid spreading in Italy of HIV genetic forms and ART-resistant variants, as well as HIV co-morbidities. Of note, for Finally, a wide study in a cohort of over 27, socially marginalized immigrants in Piedmont estimated a prevalence of 2.
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These genetic forms can be transmitted with different efficiency 9 , 10 and have different sensitivity to ART Thus, public health interventions are needed to limit the spreading of new HIV clades and molecular variants in the population. Indeed, several studies reported that non-B HIV-1 subtypes are now circulating in several previously subtype B-restricted areas of the world, including Italy 13 , In particular, the estimated prevalence of infection with non-B subtypes in the Italian population has increased from 2.
A few studies, mainly conducted at a local level, have investigated the heterogeneity of HIV genetic forms in the Italian general population, which also includes migrant communities 15 , 16 , Our study specifically investigated the distribution of HIV subtypes and CRFs and the presence of their variants carrying mutations of resistance to antiretroviral therapy ART in the population of immigrants resident in Italy.
In addition, in order to provide more information for health police in these communities, we also described the clinical, virological and immunological characteristics of this population, as well as the presence of HBV and HCV co-infections and TB. The number of females exceeded that of males Females were significantly younger than males: One hundred and seven patients out of There was no association between the presence of co-infections and gender.
Three hundred-fifty-four people were HIV aviremic Patients on ART were Among those on ART, Many statistically supported clusters were found, indicating the presence of different pure subtypes and CRFs. These results are in line with those obtained using the REGA subtyping tool.
The different subtypes and CRFs are shown in colour, according to the legends present on the top left for panel a, and top right for panel b, respectively. The scale bar indicates 0. Frequency of each pure subtype and CRF is shown at the bottom of panel a and b, respectively.
Overall, the patients were infected by a wide diversity of subtypes and recombinant forms. Subtype B represented The remaining non-B subtypes were detected in CRFs accounted for Prevalence of HIV-1 subtypes and recombinant forms in immigrants resident in Italy. The prevalence of the genetic forms is expressed as the percentage of the total number.
The distribution of the HIV-1 genetic forms according to the geographical origin of immigrants is shown in Fig. Distribution of HIV-1 subtypes and recombinant forms by geographical area of origin of immigrants resident in Italy. Each subtype and CRF is identified by a colour according to the legend reported at the bottom of the figure. The prevalence of each genetic form is reported as the percentage of the total number for each region. Behaviours at-risk for HIV infection were known for immigrants. In order to study the transmission between imported and local HIV variants, sequences from the immigrants and the Italians were analysed by subtype and according to the HIV risk behaviour and demographic data Figs.
ML trees are shown. Roman numbers indicate clusters. Names include the city one-letter code, and an internal patient code. Italian natives are indicated in red, immigrants in black. Names in the cluster include the city one-letter code and an internal patient code. The risk factor HET: Heterosexual is reported only for patients included in a cluster. Three patients two drug users from different countries and the heterosexual Italian native were resident in the same city. Seven clusters were identified.
Cluster I includes C subtype sequences and is composed of three heterosexual patients, living in the same city, two autochthonous and one from Colombia. Cluster II is composed of two sequences from Romanian heterosexual patients, one male and one female resident in the same city, whereas cluster III consists of three sequences from patients living in the same city, two male Romanian homosexual patients and one male autochthonous drug abuser.
Clusters IV and V include subtype A1 infected patients. Cluster IV is composed of two heterosexual patients, one male and one female from Pakistan and Eritrea, respectively, and a male autochthonous homosexual patient, all living in the same city. Cluster V consists of two sequences isolated from two drug abusers from the same city, one autochthonous and one from Tunisia.
Clusters VI is composed of a heterosexual patient from Cameroon and an autochthonous drug abuser, whereas cluster VII of two heterosexual patients from Nigeria, one male and one female, resident in the same city. Four statistically supported clusters were found. Only cluster III shows an intermixing between immigrant and autochthonous sequences and includes two sequences from heterosexual patients, an autochthon and a patient from Ukraine.
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The remaining clusters are all sequences from immigrants. Cluster I consists of a heterosexual patient and a patient reporting having been poly-transfused in the country of origin. Overall, 45 out of Thirteen mutations were also present for PIs, which included drugs with a high genetic barrier such as darunavir and lopinavir. Therefore, due to the low number, the D and F1 subtypes were not included in the analysis and all the CRFs were merged together to increase the statistical power of the analysis.
When considering each mutation singularly, CRFs and subtype B showed the highest number of different mutations, but due to the low frequency of each mutation, a statistical treatment was not carried out. Relative frequency of patients with DRMs according to the genotype. The number of sequences included in the analysis is indicated in brackets at the top of each clade. Previous studies were conducted in a few areas providing only a partial picture of the dynamics of the HIV genetic forms circulating in the country 13 , 15 , The present study also describes the immunological and virological characteristics of the study subjects and related co-infections, with the aim of providing more clinical information on the immigrants resident in Italy.
However, being a retrospective study some information is missing, such as, for example, the possibility of determining where the patient acquired the infection in the country of origin, in Italy or elsewhere. In our study, females were more numerous and significantly younger than males. Women had better immune-virological parameters than males. Only This is in agreement with previous data in ART-treated migrants in Italy showing that only This difference could be explained by a greater difficulty of migrants to access health care and, consequently, by a lower compliance to therapy, and it is in line with data confirming an increased risk of virological failure to the first antiretroviral regimen in HIV-infected migrants as compared to Italian natives However, the role of the infecting clade cannot be ruled out.
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In our study, In particular, 9. The prevalence data from our study are slightly different, possibly due to a different composition of the migrant communities present in our study. Phylogenetic analysis of HIV genetic forms revealed that These data are remarkably different from those found in the general population in Italy, which indicate an In our study, the recombinant forms were present in Although, the CRFs distribution varies according to the different geographical regions, the prevalence of CRFs has been described to increase overtime, both globally and regionally, including in Italy 18 , In our study, the Cuban patient was a year old woman.
No information on risk behavior for HIV infection and the year of entry in Italy was reported for this patient.
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Thus, based on the available information, we cannot rule out the possibility that the patient acquired this HIV genetic form outside of her country of origin, in Italy, or elsewhere. The genetic forms isolated from immigrants were, overall, in agreement with their presence in the countries of origin, although the prevalence of each genetic form by geographical area often does not reflect what is reported in the literature 27 , This may depend on the distribution of the communities of immigrants in our country and in our study group.
Clustering analysis of pure non-B and CRF isolates showed the presence of clusters between immigrants and Italian natives. No clusters were present among HIV-1 B subtype-infected immigrants and only a cluster between immigrants and autochthonous sequences were found. This is consistent with the higher prevalence of pure B subtype in the Italian autochthonous individuals, as compared to the immigrant population Finally, the clustering analysis of non-B pure subtype and CRF sequences indicated that the unprotected heterosexual contacts are a main route of transmission both among immigrants and between immigrants and Italian natives.
We detected DRMs in Among ART-treated people, The most common mutations were KN The MV mutation has been suggested to be a marker of noncompliance to therapy This suggests that drug resistance affects to a similar extent all HIV-1 clades, as recently described The most represented mutations in all clades were those of the NNRTI drug class, in agreement with data reported in the literature 39 , 40 , 41 , indicating that mutations to NNRTIs tend to increase overtime.
However, the limited number of subtype A-infected patients in our study does not allow drawing any firm conclusions on the possible relation between subtype A and mutations to NRTI drug class. This indicates that a continuous surveillance of HIV genetic forms is needed in Italy, and that this should be accompanied by specific public health interventions targeting the immigrant community in order to limit spreading of different HIV genetic forms both in the immigrant community and in the general population in Italy.
Demographic, behavioural, clinical, immunological and virological data were obtained from the clinical centres.
Plasma samples were collected in 1 patient , 8 , 90 , 50 , 56 , , 31 , 54 , 25 and 1. Being a retrospective study, the Ethics committee has authorized its conduct without the need to obtain a specific informed consent from the participants, because the study falls under the conditions foreseen in the authorization no. Data were processed using unique identifiers to ensure confidentiality. HIV subtyping from plasma was successful in patients with detectable viremia.
Plasma samples from these patients were collected in 4 patients , 43 , 23 , 24 , 17 , , 29 , 36 , 15 , 1. Sequences are registered in Genbank Genbank accession no. The 39 reference sequences included: subtype A 6 sequences , B 4 sequences , C 4 sequences , D 4 sequences , F 8 sequences , G 4 sequences , H 4 sequences , J 3 sequences and K 2 sequences.
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These two datasets were used for HIV subtyping. In order to infer the phylogenetic relationship among strains based on the risk factors, HIV clade and demographic data, other three datasets third, fourth and fifth dataset were built, including only sequences from patients for whom demographic and epidemiological and behavioural information was available.
Italian patients were enrolled in the period — in the clinical centres of Brescia, Genoa, Sassari, Naples and Bari. The third dataset was composed of 25 PR-RT sequences from immigrant patients, and from Italian natives, all infected by subtype-B. The fourth dataset was composed of 75 PR-RT sequences from immigrant patients and 12 from Italian natives, all infected by pure non-B subtypes.
All sequences were aligned using MAFFT 43 and manually edited with Bioedit 44 , removing gaps and cutting to identical sequence lengths. Only major resistance mutations were considered in the analysis. Accessory mutations were excluded. Descriptive statistics summarizing quantitative variables included mean, standard deviation, standard error, median, 25 th and 75 th percentiles. Frequency distributions were presented for categorical variables. Comparisons of continuous variables among different groups was performed by using nonparametric tests Kruskal-Wallis test, Mann-Whitney test.
Statistical analyses were carried out at two-sided with a 0. Thematic report: Migrants. HIV and migrants. Lai, A. What is changed in HBV molecular epidemiology in Italy? Coppola, N. Hepatitis B virus, hepatitis C virus and human immunodeficiency virus infection in undocumented migrants and refugees in Southern Italy, January to June Euro Surveill.
Cuomo, G. Public Health.
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Baussano, I. High rates of Mycobacterium tuberculosis among socially marginalized immigrants in low-incidence area, , Italy. Magiorkinis, G. The global spread of HIV-1 subtype B epidemic. Kiwanuka, N. Venner, C. Lessells, R. Are subtype differences important in HIV drug resistance? Chudy, M.
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