Human immunodeficiency virus type 1 (HIV-1) infection became a chronic disease in patients under long-term antiretroviral therapy (ART) to control viral replication. Because of the existence of viral reservoirs, most people living with HIV-1 (PWH) experience viral rebound following antiretroviral treatment interruption (TI), whether they have been treated since the primary infection (primary HIV infection patient [PHI]) or the chronic stage (chronic HIV infection patient [CHI]), with rates of 87% and 96%, respectively, at 6 months after TI (1
). Nevertheless, in rare cases, viral replication remains controlled for several years after ceasing ART. Most of these individuals, known as posttreatment controllers (PTCs), have been treated since primary infection, such as in the French ANRS-VISCONTI cohort (2
). They differ from the rare individuals, known as natural HIV infection controllers (HICs), who maintain low or undetectable viral loads without treatment (<1%) (3
). In this context, current research on HIV remission aims at finding therapeutic alternatives that do not require the lifelong intake of ART. As PTCs constitute models of HIV infection control without ART, a better understanding of the viral and host parameters responsible for this control may help with the development of therapeutic strategies benefiting all PWH.
In HICs, an overrepresentation of protective HLA alleles, such as HLA-B*27 and B*57, has been observed, as well as a high cytotoxic CD8 T cell response (3
). This has not been observed in PTCs, who instead present high expression of HLA-B*35, an allele associated with a faster progression toward AIDS in the absence of ART (2
). Contrary to HICs, PTCs also often exhibit symptomatic primary infection (1
), and these differences suggest that different mechanisms might occur in PTCs (4
). Viral characteristics might also contribute to the mechanism of control of HIV infection in these two groups. For example, both PTCs and HICs have a small viral reservoir, as reflected by their particularly low levels of blood HIV DNA (2
) or cell-associated HIV RNA (7
). However, although necessary, a small reservoir size does not appear to be sufficient to induce viral control, as most individuals treated since the primary infection display low levels of total HIV DNA (8
) but less than 10% of them might become PTCs after TI (1
). The quality of the total HIV DNA, determined by considering the proportions of intact versus defective genomes within the proviral pool in these persons, could be important. Indeed, previous studies have shown that during ART-controlled infection, most of the HIV DNA corresponds to defective genomes containing large deletions, frameshifts, or apolipoprotein B mRNA-editing catalytic polypeptide-like (APOBEC)-induced hypermutations (10–13
). Regarding HICs and PTCs, data on their proviral landscape is very limited, but one hypothesis is that a lower proportion and/or level of intact genomes might contribute to the control of infection. Genetic diversity is another viral factor that might contribute to the control of infection: a low diversity might facilitate the control by the immune system, while a higher one might help in escaping it. Regarding HICs, Jiang et al. recently showed that they were characterized by low levels of intact HIV DNA in specific integration sites (14
). In HICs, viral genetic diversity appears correlated to the level of viral replication (15
). Information concerning PTCs is limited to a study by Sharaf et al. that included PTCs with a generally shorter period of control than those of the ANRS-VISCONTI cohort. These PTCs displayed lower intact proviral loads than noncontrollers (NCs), although with similar overall proportions (17
). Their proviral landscape had not evolved at a median of 1.4 years after TI. It is currently unclear whether PTCs maintain a low diversity several years after treatment interruption, similar to PHIs (18
), or whether this diversity increases after several years, similar to most untreated individuals.
In the present study, we aimed to investigate the proviral genome landscape in a group of PTCs with durable control of infection. To this end, we determined (i) the viral genetic diversity and (ii) the presence and proportions of intact and defective archived HIV genomes in blood samples from PTCs several years after TI, in comparison with those of HICs and of two groups of patients receiving efficient ART (since primary infection [PHIs] and since chronic infection [CHIs]).
In the hope of inducing remission of HIV infection without the necessity for lifelong intake of antiretroviral therapy, a better understanding of the factors associated with the control of infection in PTCs, who represent models of remission, is needed. A characteristic of PTCs is a small reservoir size, which appears to be a necessary but insufficient criterion. Indeed, only a minority of individuals with a small reservoir size keep the control of infection in the case of TI (3
). We describe here for the first time the viral diversity and the proportions of intact and defective proviruses in PTCs almost a decade after TI, with ultradeep sequencing technologies providing an in-depth characterization of archived genomes constituting the HIV reservoir.
One hypothesis was that low viral diversity could contribute to, and be the result of, the control of HIV infection. In our study, the PTC, PHI, and HIC-a groups presented similarly low genetic diversities, whereas those of the HIC-b and CHI groups were higher, consistent with the past viral replication. Concordantly, De Azevedo et al. showed that proviral diversity was higher in viremic controllers (with persistent viremia at 80 to 2,000 copies/mL) than in elite controllers (persistent undetectable viral loads) (16
). The link between viral diversity and history of viremia is also reinforced by the significant correlation in our study between the diversity indexes and the total HIV DNA load: previous studies showed that when measured in situations of controlled infection, this biomarker of persistence reflects the history of HIV infection and cumulative viremia (5
). Based on this correlation, our data indicate that no or very little viral replication occurred in the HIC-a group or in the PTCs for all the years since TI. This low viral diversity reflects the sustained control of viral replication since early infection. Of note, our study also reveals substantial variability in the genetic proviral diversity among PTCs, as previously observed for other groups of PWH.
The similar results between PTCs and PHIs call into question the predictive value of viral genetic diversity for virologic control or breakthroughs. Previous studies are discordant concerning this potential predictive value. Pernas et al. showed no significant difference in gag
gene diversity but a higher diversity of the env
gene in cases of loss of natural control than in persistent control (27
). In contrast, De Azevedo et al. found no predictive value of env
diversity for virologic breakthroughs (28
). In our study, RT
gene) viral diversity was not predictive of a breakthrough in the four following years in HICs or in PTCs (data not shown). Unfortunately, we did not have enough biological material to study the viral diversity of the env
gene, which might have been more informative. In contrast, viral blips were previously shown to be predictive for the loss of control in PTCs and HICs (29
) and for the time before rebound after TI in early-treated individuals (9
). Plasma viral loads thus appear to be better predictors of future breakthroughs than viral diversity of HIV DNA, which takes longer to be archived.
Our study also explored the proportions of intact and defective proviruses among the proviral pool during different contexts of controlled HIV infection and provided the first complete genome analysis of HIV DNA in both PTCs and HICs. Of note, the HICs for whom we obtained viral genome sequences in this study had a higher median HIV DNA level than the 202 HICs analyzed in the national ANRS-CODEX cohort (6
). A peculiarity of the HIC group was the presence of a partial nef
deletion in every proviral sequence of two HICs, which could be associated with a decrease in viral infectivity (23
). Our finding of nef
defects in all sequenced proviruses suggests that either the founder virus might have been an attenuated strain in these cases or the cells harboring nonattenuated proviruses were progressively eliminated by the immune response and these proviruses with defects in nef
became largely predominant. Concordantly, previous reports showed that several cases of spontaneous control of HIV infection were linked to the presence of attenuated viral strains harboring a truncated or deficient protein, in particular Env, Vif, or Nef (32–34
). This characteristic for only two of the seven HICs, as well as the high interindividual heterogeneity of results observed within this group, highlight the plethora of mechanisms that could contribute to HIV control. No nef
deletion was observed in PTCs in our results, suggesting that posttreatment and natural control may rely upon distinct mechanisms, although both groups have a small blood HIV reservoir (35
). The lack of Nef-deficient proviruses in the PTC group should be confirmed in more individuals.
When studying the complete HIV DNA genome of PTCs, we showed that they had low proportions of intact genomes in samples taken at a median of 9.4 years after TI, not different from the proportions observed in other groups. These data suggest that other factors play a role in the viral control. High heterogeneity of the proportions of intact proviruses was observed among PTCs (0% to 36%), as observed in other groups of PWH. In their study, Sharaf et al. used single-genome amplification and next-generation sequencing (NGS) to analyze samples from before TI from 10 PTCs and 16 NCs who experienced viral rebound after TI (17
). The proportions of intact genomes before TI were similar in both groups (median [range], 1.4% [0 to 42%] and 4.1 [0 to 32%] in the future PTCs and NCs, respectively, out of a median [range] of 27 [3 to 73] proviral sequences per individual for PTCs and 50 [12 to 120] for NCs). Our results show that this status is maintained for several years after TI. Sharaf’s study also revealed that PTCs have a genetically intact proviral reservoir 7-fold lower than that of NCs in absolute values before TI. This smaller number of intact viral genomes resulted from lower total HIV DNA loads in PTCs than in NCs. In our study, several years after TI, the quantity of intact proviruses was not different than that observed in aviremic PWH on ART or in HICs. Only the number of defective proviruses was lower in PTCs than in CHIs, similar to PHIs. As PTCs had been treated since the primary infection and well controlled afterwards, there was no opportunity for viral evolution and accumulation of proviruses with defects. Defective proviruses can contribute to HIV pathogenesis (5
) by the production of viral RNAs and proteins/antigens that continuously stimulate the immune system (36
) or to infectious viruses after complementation, even if this process is probably less efficient than production by intact proviral genomes (38
). This could partly explain the facts that the total HIV DNA load, which is correlated to a high level of defective proviruses, is a clinically relevant marker (5
) and that a reduced number of defective proviruses could be beneficial.
Based on the presence of some proviral sequences with strict identity, assumed to be clones with identical integration sites (24
), we showed that clonal cell expansion contributed to the persistence of both intact and defective proviruses, as previously described (11
Interestingly, the comparison of samples taken 4 to 6 years later (i.e., 11.8 to 15.2 years after TI) from the three PTCs in our study showed no or little evolution of the proviral landscape, either in the proportions of intact and defective genomes or in the viral sequences themselves, as shown by the intermingled sequences on the phylogenetic tree. These results suggested that the stability of the proviral landscape in PTCs between the period before TI and 1.4 years after TI that was previously described (17
) is prolonged for more than 10 years after TI. These data suggest that the blood proviral landscape in PTCs is preserved early by ART and does not seem to evolve after TI due to effective control of HIV. Nevertheless, as all PHIs do not become PTCs in the case of TI (4
), despite their similar proviral characteristics, host factors most probably predominate in the control of infection in cases of HIV remission. One recently suggested hypothesis is the control of viral replication by particularly efficient natural killer (NK) cells in association with HLA-Bw4 and HLA-C2 killer immunoglobulin-like receptor (KIR) ligands (40
). In ART-treated PWH, Einkauf et al. recently showed that proviruses integrated in nongenic chromosomal regions were transcribed less that those in genic regions and that transcriptionally active proviruses underwent a negative selection over time, except in the case of clonal expansion (41
). Such a study of integration sites of intact and defective proviruses in PTCs could provide further information on their reservoirs. We can hypothesize that the NK immune response in PTCs could have contributed to the selection of cells harboring either intact proviruses integrated in nongenic regions or defective proviruses. Control in PTCs could then be associated with a “block and lock” mechanism, which could be effective in the presence of small quantities of intact proviruses. The noticeable interindividual heterogeneity shown for the first time among PTCs for all the biomarkers we studied points out that several mechanisms of control could exist and that a single strategy for cure might not fit all PWH.
One limitation of this study is the relatively small number of sequences analyzed because of the low HIV DNA loads. The complexity of TI and the rarity of posttreatment control limit large studies on PTCs. Very few cohorts include PTCs with such a long period of time after TI, making the data from the ANRS-VISCONTI cohort very valuable. Recent data have indicated that the proportions of defective proviruses could differ between blood and tissues and that viruses that rebounded after TI could have come from diverse anatomical compartments (42
). Further studies on lymphoid tissues and on animal models could be informative of the global proviral landscape in remission, including integration sites, and help in approaching the complexity of viral control.
To conclude, the present study provides for the first time an in-depth characterization of the proviral landscape in PTCs nearly a decade after TI and compares it to that of HICs. Our results show that the PTC group presents similarly small proportions and quantities of intact proviruses as the other groups examined in the study. Although host/immune factors most probably play a role in posttreatment control, the particularly small blood HIV reservoirs and the low frequencies of intact proviruses in PTCs could facilitate the control of infection in these patients. Furthermore, the low viral diversity and the absence of evolution in the landscape of the HIV DNA quasispecies after TI confirm the slow dynamics of HIV infection in PTCs. This and other studies in PTCs should help in designing strategies to achieve sustained viral remission in the absence of ART.
We thank the participants and clinicians who participated in this study and the RHIVIERA consortium for helpful discussions.
The ANRS-CODEX/VISCONTI cohort is sponsored by the French National Agency for Research on AIDS and Viral Hepatitis (ANRS). This work was supported by the ANRS (grant to V.A.-F.) and a National Institutes of Health grant (NIH grant no. P01-AI131365-01 to A.S.-C.). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
The members of the ANRS-VISCONTI study group are as follows: Faroudy Boufassa and Sylvie Orr (CMG, Hôpital Bicêtre, Le Kremlin Bicêtre); Firouzé Bani-Sadr, Maxime Hentzien, Jean-Luc Berger, and Isabelle Kmiec (Maladies Infectieuses, CHU—Hôpital Robert Debré, Reims); Gilles Pichancourt and Safa Nasri (Hémato-Oncologie, Centre Hospitalier Henri Duffaut, Avignon); Gilles Hittinger, Véronique Lambry, and Anne-Cécile Beaudrey (Maladies Infectieuses, CHITS Hôpital Sainte Musse, Toulon); Gilles Pialoux, Julie Chas, Christia Palacios, and Anne Adda (Maladies Infectieuses, Hôpital Tenon, Paris); Jean Paul Viard and Marie-Josée Dulucq (Centre de Diagnostic et Thérapeutique, Hôtel Dieu, Paris); Laurence Weiss, Marina Karmochkine, and Mohamed Meghadecha (Service d’Immunologie Clinique, Hôpitaux Universitaires Paris Centre—Hôtel Dieu, Paris); Dominique Salmon-Ceron and Marie-Pierre Piétri (Unité Fonctionnelle de Pathologie Infectieuse, Hôtel Dieu, Paris); Philippe Blanche (Médecine Interne, Hôpital Cochin, Paris); Jean-Michel Molina, Olivier Taulera, Diane Ponscarme, and Jeannine Delgado Bertaut (Maladies Infectieuses, Saint-Louis, Paris); Djamila Makhloufi, Matthieu Godinot, and Valérie Artizzu (Immunologie Clinique, Hôpital Edouard Herriot, Lyon); Patrick Miailhes, Laurent Cotte, Sophie Pailhes, Anne Conrad, Ludovic Karkowski, and Stanislas Ogoudjobi (Maladies Infectieuses et Tropicales, Hôpital de la Croix Rousse, Lyon); Yazdan Yazdanpanah, Sophie Matheron, and Cindy Godard (Maladies Infectieuses, Bichat, Paris); Louis Bernard, Frédéric Bastides, and Olivier Bourgault (Maladies Infectieuses, Hôpital Bretonneau, Tours); Christine Jacomet and Emilie Goncalves (Maladies Infectieuses, Hôpital Gabriel-Montpied, Clermont-Ferrand); Pascal Chavanet, Lionel Piroth, and Sandrine Gohier (Infectiologie, CHU François Mitterrand, Dijon); Agnès Meybeck, Thomas Huleux, and Pauline Cornavin (Maladies Infectieuses, Hôpital Gustave Dron, Tourcoing); Yasmine Debab and David Théron (Maladies Infectieuses et Tropicales, Hôpital Charles Nicolle, Rouen); and Thierry Prazuck, Laurent Hocqueloux, and Barbara De Dieuleveult (Maladies Infectieuses, Hôpital de La Source, Orléans). The members of the ANRS-CODEX Study Group are as follows: Jean-Pierre Faller and Patricia Eglinger (Service des Maladies Infectieuses, CH de Belfort-Montbéliard, Belfort); Pascal Roblot and David Plainchamp (Service de Médecine Interne, CHU Poitiers-La Milétrie, Poitiers); Hugues Aumaître and Martine Malet (Service des Maladies Infectieuse et Tropicales, CH de Perpignan, Perpignan); Christine Rouger, Gérard Rémy, and Isabelle Kmiec (Service des Maladies Infectieuses, CHU Reims-Hôpital Robert Debré, Reims); Jean-Luc Delassus (Service de Médecine Interne, CHI Ballanger, Aulnay Sous-Bois); Alain Devidas (Service d’Hématologie, CH Sud-Francilien—Hôpital Gilles de Corbeil, Corbeil-Evry); Eric Froguel and Sylvie Tassi (Service de Médecine Interne-Maladies Infectieuses, CH de Marne la Vallée, Jossigny); Philippe Genet and Juliette Gerbe (Service Hématologie-Immunologie, Centre Hospitalier Victor Dupouy, Argenteuil); Olivier Patey and Richier Laurent (Service des Maladies Infectieuses et Tropicales, CHI Villeneuve Saint Georges, Villeneuve Saint Georges); Marie-Christine Drobacheff and Aurélie Proust (Service de Dermatologie, Hôpital Saint-Jacques, Besançon); Helder Gil (Service de Médecine Interne, CHU de Besançon, Besançon); Laurence Gérard and Eric Oksenhendler (Service d’Immunopathologie Clinique, Hôpital Saint Louis, Paris); Jean-Michel Molina, Caroline Lascoux, and Sylvie Parlier (Service de Maladies Infectieuses et Tropicales, Hôpital Saint Louis, Paris); Frédéric Lucht and Véronique Ronat (Service de Maladie Infectieuse, Hôpital Bellevue, Saint Etienne); Michel Dupon, Hervé Dutronc, Séverine Le Puil, and Didier Neau (Service des Maladies Infectieuses, CHU—Hôpital Pellegrin, Bordeaux); Patrick Mercié (Service Tropicales, CHU—Hôpital Saint André, Bordeaux); Philippe Morlat, Sabrina Caldato, Jean-Luc Schmit, and Nathalie Decaux (Service de Médecine Interne et Maladies Tropicales, CHU—Hôpital Saint André, Bordeaux); Jean-Pierre Bru and Gaëlle Clavere (Service des Maladies Infectieuses, Centre Hospitalier Annecy, Annecy); Olivier Lambotte, Jean-François Delfraissy, Cécile Goujard, and Katia Bourdic (Service de Médecine Interne AP-HP—CHU de Bicêtre, Le Kremlin Bicêtre); Daniel Vittecoq and Claudine Bolliot (Service des Maladies Infectieuses AP-HP—CHU de Bicêtre, Le Kremlin Bicêtre); Thierry Lambert (Consultation d’Hématologie, AP-HP—CHU de Bicêtre, Le Kremlin Bicêtre); Jean-François Bergmann and Maguy Parrinello (Service de Médecine Interne A, Hôpital Lariboisière, Paris); Gilles Pichancourt (Service Hématologie, Hôpital Henri Duffaut, Avignon); Yves Welker (Service de Maladies Infectieuses, CHI de Poissy—Saint Germain en Laye, Saint Germain en Lay); Alain Lafeuillade and Gisèle Philip (Service d’Infectiologie, CHITS Hopital Sainte Musse, Toulon); Christophe Rapp and Melle Lerondel (Service des Maladies Infectieuses, Hôpital d’Instruction des Armées Bégin, Saint Mandé); Pierre de Truchis and Berthe Huguette (Département de Médecine Aigue Spécialisée, Hôpital Raymond Poincaré, Garches); Vincent Jeantils and Fatouma Mchangama (Unité de Maladies Infectieuses, Hôpital Jean Verdier, Bondy); Paul Henri Consigny and Fatima Touam (Consultation de Maladies Infectieuses, Centre Médical de l’Institut Pasteur, Paris); Gilles Pialoux and Sophie le Nagat (Service des Maladies Infectieuses, Hôpital Tenon, Paris); Olivier Bouchaud and Patricia Honoré (Service de Médecine Interne et Endocrinologie, Hôpital Avicenne, Bobigny); François Boué and Mariem Raho-Moussa (Service de Médecine Interne, Hôpital Antoine Béclère, Clamart); Jean-Paul Viard, Agnès Cros, Dominique Salmon-Céron, Marie-Pierre Pietri, Laurence Weiss, and Lio Collias (Consultation d’Immunologie Clinique et Infectiologie, Hôpital Hôtel Dieu, Paris); David Zucman, Olivier Blétry, and Dominique Bornarel (Service de Médecine Interne, Hôpital Foch, Suresnes); Emmanuel Mortier and Zeng Feng (Service de Médecine Interne, Hôpital Louis Mourier, Colombes); Jean-Daniel Lelièvre (Service d’Immunologie Clinique, Hôpital Henri Mondor, Créteil); Christine Katlama, Yasmine Dudoit, Anne Simon, and Catherine Lupin (Service des Maladies Infectieuses, Hôpital Pitié-Salpêtrière, Paris); Pierre-Marie Girard and Michèle Pauchard (Service des Maladies Infectieuses, Hôpital Saint Antoine, Paris); Sylvie Abel and André Cabié (Service de Maladies Infectieuses et Tropicales, Hôpital Pierre Zobda-Quitman, Fort de France, Martinique); Pascale Fialaire, Jean-Marie Chennebault, and Sami Rehaiem (Service des Maladies Infectieuses et Tropicales, CHU Angers, Angers); Luc de Saint Martin, Pascale Perfezou, and Jean-Charles Duthe (Service de Pneumologie, CHU de Brest, Brest); Pierre Weinbreck and Claire Genet (Service des Maladies Infectieuses, CHU de Limoges, Limoges); Djamila Makhloufi and Florence Garnier (Service d’Immunologie Clinique, HCL—Hôpital Edouard Herriot, Lyon); Patrick Miailhes and Stanislas Ogoudjobi (Service de Maladies Infectieuses et Tropicales, HCL—Hôpital Edouard Herriot, Lyon); Isabelle Poizot-Martin, Olivia Fauche, and Alena Ivanova (Service Hématologie-CISIH, Hôpital Sainte Marguerite, Marseille); Patrick Philibert and Mame Penda Sow (Consultation de Médecine Interne, Hôpital Européen Marseille, Marseille); Patrick Yeni, Sophie Matheron, and Cyndi Godard (Service des Maladies Infectieuses, Hôpital Bichat Claude Bernard, Paris); François Raffi and Hervé Hüe (Service de Médecine Interne, Hôpital de l’Hôtel Dieu, Nantes); Philippe Perré (Service de Médecine Interne Post-Urgence, Centre Hospitalier Départemental, La Roche sur Yon); Pierre Marie Roger and Aline Joulie (Service des Maladies Infectieuses, CHU—Hôpital l’Archet, Nice); Éric Rosenthal (Service Médecine Interne, CHU—Hôpital l’Archet, Nice); Christian Michelet, Faouzi Souala, and Maja Ratajczak (Service des Maladies Infectieuses, CHU—Hôpital Pontchaillou, Rennes); Marialuisa Partisani and Patricia Fischer (HUS—Hôpital Civil, Strasbourg); Louis Bernard and Pascale Nau (Service des Maladies Infectieuses, CHRU—Hôpital Bretonneau, Tours); Pierre Delobel and Florence Balsarin (Service des Maladies Infectieuses, CHU—Hôpital Purpan, Toulouse); Marc De Lavaissiere (Service Médecine Interne, CHG de Montauban, Montauban); Renaud Verdon and Philippe Feret (Service des Maladies Infectieuses, CHU—Hôpital de la Côte de Nacre, Caen); Christine Jacomet (Service des Maladies Infectieuse, CHU Gabriel Montpied, Clermont Ferrand); Lionel Piroth and Sandrine Gohier (Service de Maladies Infectieuses et Tropicales, CHU—Hôpital du Bocage, Dijon); Pascale Leclercq and Sylvie Gerberon (Service Médecine Aigue Spécialisée, CHU—Hôpital Albert Michallon, Grenoble); Agnés Meybeck and Raphaël Biekre (Service des Maladies Infectieuses, CH—Hôpital Gustave Dron, Tourcoing); Thierry May and Marie-Pierre Bouillon (Service de Maladies Infectieuses et Tropicales, CHU Nancy, Nancy); François Caron, Yasmine Debab, and David Theron (Service de Maladies Infectieuses et Tropicales, CHU—Hôpital Charles Nicolle, Rouen); Marc Gatfosse (Service de Médecine Interne, CH René Arbeltier, Coulommiers); Martin Martinot and Anne Pachart (Service de Maladies Infectieuses-Médecine Interne, Hôpitaux Civils de Colmar, Colmar); Patrice Poubeau (Service de Pneumo-Phtisiologie, Centre Hospitalier Sud Réunion—Hôpital de St Pierre, Saint Pierre, La Réunion); Catherine Gaud (Service Immunologie Clinique, Centre Hospitalier Félix Guyon, Ile de la Réunion); Agnès Uludag (Service de Médecine Interne, Hôpital Beaujon, Clichy); Philippe Arsac and Lydia Bouaraba (Service de Médecine Interne, CHR Orléans—Hôpital Porte Madeleine, Orléans); Laurent Hocqueloux and Barbara de Dieulevault (Service de Maladies Infectieuses et Tropicales, Hôpital Orléans la Source, Orléans); Isabelle De Lacroix Szmania and Laurent Richier (Service des Médecine Interne, Centre Hospitalier Intercommunal, Créteil); Vincent Daneluzzi (Service de Médecine A, CASH—Hôpital Max Fourestier, Nanterre); Elisabeth Rouveix (Service de Médecine Interne 2, Hôpital Ambroise Paré, Boulogne); Geneviève Beck-Wirth (Service d’Hématologie Clinique VIH, Centre Hospitalier de Mulhouse, Mulhouse); Philippe Romand (Service de Pneumologie, CHI Les Hôpitaux du Léman, Thonon les Bains); Laurent Blum and Martine Deschaud (Service Médecine-Gastroentérologie, Centre Hospitalier René Dubos, Pontoise); Christophe Michau (Service de Médecine Interne, Centre Hospitalier de Saint Nazaire, Saint Nazaire); Christian Bernard and Florence Salaun (Service de Médecine Interne, CHR Metz Thionville—Hôpital Notre Dame de Bon Secours, Metz); Philippe Muller (Service de Dermatologie, Hôpital Beauregard, Thionville); Yves Poinsignon (Service de Médecine Interne, Hôpital Prosper Chubert, CHBA, Vannes); Annie Lepretre and Martine Deschaud (Service de Médecine Interne, Hôpital Simone Veil, Eaubonne); Albert Sotto and Régine Doncesco (Service des Maladies Infectieuses et Tropicales, CHU Caremeau, Nîmes); Pascale Perfezou and Jean Charles Duthe (Service de Pneumologie, CH de Cornouaille—Hôpital Laennec, Quimper); Mathilde Aurore Niault and Virginie Mouton-Rioux (Service d’Hématologie, Maladie Infectieuses, CH Bretagne Sud, Lorient); Jean-Philippe Talarmin and Jean Charles Duthé (Service Médecine Interne, CH de Cornouaille—Hôpital Laennec, Quimper); Mathilde Dupont and Stéphane Natur (Service des Maladies Infectieuses et Tropicales, CH Saint Malo, Saint Malo); and Hikombo Hitoto and Ali Mahamadou Ibrahim (Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Le Mans, Le Mans).