To enable an up-to-date molecular analysis of human immunodeficiency virus (HIV) genotypes circulating in Germany we have established a surveillance system based on recently acquired HIV infections. New HIV infections are reported to the Robert Koch Institute as a statutory duty for anonymous notification. In 2013 and 2014, a dried serum spot (DSS) sample was received from 6,371 newly diagnosed HIV-cases; their analysis suggested that 1,797 samples originated from a recent infection. Of these, 809 were successfully genotyped in the pol region to identify transmitted drug resistance (TDR) mutations and to determine the HIV-1 subtype. Total TDR was 10.8%, comprising 4.3% with mono-resistance to nucleoside reverse transcriptase inhibitors (NRTIs), 2.6% to non-NRTIs, 3.0% to protease inhibitors and 0.6% and 0.2%, respectively, with dual-and triple-class resistances. HIV-1 subtype B was most prevalent with 77.0%. Non-B infections were identified more often in men and women with heterosexual transmission compared with intravenous drug users or men who have sex with men (79% and 76%, 33%, 12%; all p < 0.05). Non-B subtypes were also more frequently found in patients originating from countries other than Germany (46% vs 14%; p < 0.05) and in patients infected outside of Germany (63% vs 14%; p < 0.05).

Die Zahl der Menschen, die mit einer HIV-Infektion leben, nimmt seit Mitte der 1990er-Jahre zu. Die frühe Testung und Therapie allein reicht nicht aus, um das Infektionsgeschehen wirksam einzuschränken. Eine nachhaltige Eindämmung der HIV-Neuinfektionen muss mit einer zeitgleichen Eindämmung von sexuell übertragbaren Erkrankungen wie Syphillis, Chlamydia trachomatis und Gonorrhö einhergehen. Häufigere Untersuchungen, optimiertes Therapiemanagement und Kondomgebrauch sind dafür notwendige Strategien.

The number of people living with HIV infection has been increasing since the mid 1990s and is expected to rise further in the coming years. The HIV epidemic in Germany is still most affected by developments in the group of men who have sex with men (MSM). In this group, the number of newly diagnosed HIV infections has increased in recent years especially in large cities. Despite increased efforts to motivate HIV-infected people, who were not previously diagnosed, to be tested as early as possible and to seek medical treatment, the number of undiagnosed HIV-infected persons has increased. There are more people infected with HIV than those who have been tested positive for HIV and subsequently receive antiretroviral treatment. However, early testing and treatment alone are not sufficient to effectively contain the infection. Increased efforts are required to more effectively prevent new HIV infections by combining all the available options. In Germany as in all other developed countries, a stronger increase in the number of syphilis infections among MSM is reported, which is primarily due to a higher willingness to risk unprotected contacts, whereby the risk of HIV infection is also increased. The public prevention messages available for HIV are only partially effective against syphilis. More frequent examinations and optimized therapy management are necessary in addition to the use of condoms to prevent the spread of syphilis, gonorrhea, and Chlamydia trachomatis. Sustainable containment of new HIV infections must, therefore, be accompanied by both containment of sexually transmitted infections (STI) and use of public prevention messages for HIV/STI.

BACKGROUND Few studies consider the incidence of individual AIDS-defining illnesses (ADIs) at higher CD4 counts, relevant on a population level for monitoring and resource allocation. METHODS Individuals from the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) aged ≥14 years with ≥1 CD4 count of ≥200 µL between 1998 and 2010 were included. Incidence rates (per 1000 person-years of follow-up [PYFU]) were calculated for each ADI within different CD4 strata; Poisson regression, using generalized estimating equations and robust standard errors, was used to model rates of ADIs with current CD4 ≥500/µL. RESULTS A total of 12 135 ADIs occurred at a CD4 count of ≥200 cells/µL among 207 539 persons with 1 154 803 PYFU. Incidence rates declined from 20.5 per 1000 PYFU (95% confidence interval [CI], 20.0-21.1 per 1000 PYFU) with current CD4 200-349 cells/µL to 4.1 per 1000 PYFU (95% CI, 3.6-4.6 per 1000 PYFU) with current CD4 ≥ 1000 cells/µL. Persons with a current CD4 of 500-749 cells/µL had a significantly higher rate of ADIs (adjusted incidence rate ratio [aIRR], 1.20; 95% CI, 1.10-1.32), whereas those with a current CD4 of ≥1000 cells/µL had a similar rate (aIRR, 0.92; 95% CI, .79-1.07), compared to a current CD4 of 750-999 cells/µL. Results were consistent in persons with high or low viral load. Findings were stronger for malignant ADIs (aIRR, 1.52; 95% CI, 1.25-1.86) than for nonmalignant ADIs (aIRR, 1.12; 95% CI, 1.01-1.25), comparing persons with a current CD4 of 500-749 cells/µL to 750-999 cells/µL. DISCUSSION The incidence of ADIs was higher in individuals with a current CD4 count of 500-749 cells/µL compared to those with a CD4 count of 750-999 cells/µL, but did not decrease further at higher CD4 counts. Results were similar in patients virologically suppressed on combination antiretroviral therapy, suggesting that immune reconstitution is not complete until the CD4 increases to >750 cells/µL.

Die Zahl der Menschen, die mit einer HIV-Infektion leben, nimmt seit Mitte der 1990er-Jahre zu und wird voraussichtlich in den nächsten Jahren weiter ansteigen. Die HIV-Epidemie in Deutschland wird nach wie vor am stärksten geprägt durch die Entwicklung in der Gruppe der Männer, die Sex mit Männern haben (MSM). Bei ihnen hat insbesondere in den Großstädten die Zahl der neu diagnostizierten HIV-Infektionen in den letzten Jahren zugenommen. Trotz der verstärkten Bemühungen, bislang nicht diagnostizierte HIV-Infizierte möglichst früh zum Test zu motivieren und sich in medizinische Behandlung zu begeben, ist die Zahl der nicht diagnostizierten HIV-infizierten Personen gestiegen. Es infizieren sich mehr Menschen mit HIV, als positiv auf HIV getestet und anschließend antiretroviral behandelt werden. Die frühe Testung und Behandlung allein reicht aber nicht aus, um das Infektionsgeschehen wirksam einzudämmen. Dazu bedarf es verstärkter Anstrengungen, die Zahl der Neuinfektionen mit HIV durch die Kombination aller zur Verfügung stehenden Möglichkeiten, noch wirksamer als bisher zu verhindern. In Deutschland wird ebenso wie in allen anderen Industrienationen ein verstärkter Anstieg der Zahl an Syphilisinfektionen bei MSM berichtet, die vornehmlich auf eine höhere Risikobereitschaft, ungeschützte Kontakte einzugehen, zurückzuführen ist, wodurch auch das Risiko für eine HIV-Infektion erhöht ist. Die für HIV verfügbaren Präventionsbotschaften sind nur bedingt gegenüber der Syphilis wirksam. Häufigere Untersuchungen und optimiertes Therapiemanagement sind neben dem Kondomgebrauch notwendig, um die Verbreitung der Syphilis, von Chlamydia trachomatis und Gonorrhö einzudämmen. Eine nachhaltige Eindämmung der HIV-Neuinfektionen muss daher mit einer zeitgleichen Eindämmung von STI einhergehen und Eingang in die Präventionsbotschaften von HIV/STI finden.

Aim To estimate the prevalence of HIV-TDR and ADR in one resistance study of the German ClinSurv-HIV cohort. Method The ClinSurv study is a national open multi-centre long term observational cohort with 15 participating clinical centres (n = 16,750 patients; 31.12.2011). In a resistance study all ClinSurv patients in five centres were identified. Sequences were processed through the Stanford University Genotypic Resistance Interpretation Algorithm ( www. hivdb.stanford.edu; HIVdb version 6.1.1F; 2012 webService version beta-1.0.1) to identify mutations and to determine drug susceptibility. Sequences were analysed by using different lists of mutations (Bennett D. 2009; Johnson V. 2011). Trends in the prevalence of drug resistance mutations were calculated by logistic regression. Results A total of 9,528 patients from five study centres were included into analysis. 4,989 viral sequences were collected from 34% (3,267/9,528) of these patients. 47% (2,365/4,989) of sequences were produced from patients being treatment naïve and 50% (2,495/4,989) from patients under treatment. TDR was identified in 10% (203/1,950) of viral strains. The prevalence of TDR over time was stable at 10.4% (95% CI 9.1–11.8; OR: 0.98; 95% CI 0.92–1.04; p for trend = 0.6; 2001–2011). NRTI-resistance was determined in 7% (128/1,950), followed by 3% NNRTI- and PI-resistance, respectively (NNRTI: 61/1,950; PI: 56/1,950). Prevalence of ADR in treated patients was high (61%; 1,500/2,453 of sequences) but declined significantly over time (OR: 0.8; 95% CI 0.77–0.83; p for trend < 0.001; 2001–2011). Within drug classes NNRTI-resistance was predominant (56%; 834/1503), followed by NRTI-resistance in 52% (1,139/2,194) of sequences of patients with ADR exposed to these drug classes. PI-resistance was identified in 30% (543/1778). Integrase-resistance was determined in 8% (13/161) of integrase-sequences. Discussion Prevalence of TDR is highly stable in this unselected study population, whereas ADR declined significantly over the time, indicating that this decline was presumably influenced by ART related effects, broader resistance testing and resistance test guided therapy.