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Le Infezioni in Medicina, n. 3, 147-151, 2005
Lavori
originali
Original
articles
Prevalence of HIV infections
in hospitalised immigrants in
Clinics of Infectious Diseases
in Italy: a multicentric survey
Prevalenza delle infezioni da HIV in soggetti
extracomunitari afferenti ai reparti di Malattie Infettive
in Italia: studio multicentrico
1,2
Gaetano Scotto, 1,2Annalisa Saracino, 1Roberto Pempinello,
Issa El-Hamad, 1Salvatore Geraci, 2Emilio Palumbo,
2
Donatella Concetta Cibelli, 2Gioacchino Angarano
1
1
SIMIT (Italian Society of Infectious and Tropical Diseases) Committee for Immigrants
Infectious Diseases Study;
2
Infectious Diseases O.U., University of Foggia, Italy
■ INTRODUCTION
the diagnosis of the infection. However, it is difficult to ascertain whether infected subjects
contracted the infection abroad, that is in the
host country [5].
In Italy too, a steep increase was estimated in
HIV cases among immigrants, from 2.7% between 1982-1992, to 14.8% between 2000-2001,
which is disproportionate in comparison with
the number of immigrants in Italy in the same
period [6].
The aim of this retrospective study is to determine the prevalence of HIV infection in a population of immigrants hospitalised in Italian
Clinics of Infectious Diseases during 2002 and
all tested for anti-HIV, irrespective of the cause
of hospitalisation and, only for HIV-positive
patients, to evaluate some demographic (age,
sex, origin) and clinical features (only HIV positivity or AIDS, new diagnosis or not, diagnosis
of opportunistic infections).
S
ince 1981, when HIV infection was first defined, the epidemic has shown a varying
trend and its spread has been observed in
many areas of the world, particularly in developing countries. An excessive number of HIV cases (80% of 45 million affected subjects during
2002) and deaths (95% of 3 million estimated
deaths) are concentrated in developing countries, where 1/14 of these patients takes antiretroviral treatment and only 1/5 of the population at risk participates in appropriate prevention programmes [1].
Two thirds of them live in Sub-Saharan Africa,
but they may also come from Eastern European
countries and above all from Asian regions. The
epidemic is thus increasing alarmingly [2-4]. In
the light of these data we note that in industrialized countries, the prevalence of HIV is
higher among immigrants than among the natives, probably because of the heterogeneous
distribution of HIV infection in the Northern
and Southern areas of the World. This epidemic
situation might cause the spread of the infection to affluent Northern countries.
In Western European countries we observed an
increase in HIV cases involving immigrants
from endemic areas, probably due to many factors such as the high immigration rate, the risk
of interethnic sexual transmission, or a delay in
■ PATIENTS AND METHODS
Our study included 46 Italian Wards of Infectious Diseases; 2255 immigrants were tested for
anti-HIV during 2002: 1571 were hospitalised in
ordinary admission and 684 were attended in
Day-hospital. All patients, after informed written consent, were tested for anti-HIV independently of the cause of hospitalisation. Epidemi-
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ological and clinical data were collected from
each subject resulting HIV-positive; the diagnosis of HIV infection was tested by HIV-Ab research (Cobas System Molecular Roche,
Switzerland); HIV viral load was determined
by means of commercial kits: HIV-RNA (Assay
DNA versant Bayer, Germany); the presence of
any opportunistic infections (OI) was also evaluated.
Descriptive statistics were calculated for demographic, clinical and viro-immunological features of all cases; mean and standard deviation
are presented for normally distributed variables.
tients came from South America (5.1% of all
South Americans tested) and 6 (2.8%) were affected by AIDS. Of the 356 Eastern Europeans,
15 (4.2%) were HIV-positive, and there were 6
(1.6%) cases of AIDS (Table 1).
Distribution by sex and age differed among all
patients: HIV infected subjects were predominantly male (52.1 %), while females were prevalent (50.5% versus 49.5%) among AIDS cases.
The mean age of all patients was 34.5 years
(range: 2-72 yrs), with no significant difference
between males and females (34.7 yrs and 34.3
yrs, respectively). Moreover, we observed that
179/378 subjects (47.5%) fell in the 31 to 40 age
class, 120 (31.8%) were between 21 and 30 yrs
old, 41 (10.9%) from 41 to 50 yrs, 30 (7.9%) were
over fifty, while only 8 were paediatric patients.
Distribution by sex and age related to HIV infection was as follows: 101 male HIV-positive
patients had a mean age from 31 to 40 yrs
(51.2%), 26.3% (52 patients) belonged to the
range from 21 to 30 yrs, and 21 (10.6%) fell in
the 41-50 age class. Overall, among female HIVpositive subjects, we found a mean age between
21 to 40 years (80%), with 78 patients (43.1%) in
the range from 31 to 40 yrs, and 68 in the range
from 21 to 30 yrs (Table 2).
Among all HIV+ Africans, males only slightly
outnumbered females (M/F: 1.24). The most
represented African country was Nigeria
(21.3%), followed by Senegal (20%), Ivory Coast
(9.8%) and Ghana (9.45 %).
Females were prevalent among HIV-positive
■ RESULTS
Of the 2255 patients tested for anti-HIV, 378
were HIV-positive (16.8%) and 93/378 were
cases of AIDS (24%). Most patients were unaware of their positivity for anti-HIV (254/378,
67.1% of all HIV-positive patients and 57/93, or
61.2%, of AIDS patients). Most of the subjects
tested came from Africa (1285/2255, 56.9%),
while 402 (17.8%) subjects come from Asia, 356
(15.7%) from Eastern Europe and 212 (9.4%)
from South America. Most of the HIV-positive
patients came from Africa (234, 18.2% of all
Africans tested) and 73 (5.6%) African patients
showed AIDS symptoms; of the 402 Asians, 25
(6.2%) were only HIV-infected and 8 (1.9%)
were affected by AIDS; 11 HIV-positive pa-
Table 1 - Prevalence of HIV patients and AIDS cases in relation to origin of subjects tested.
Area of origin
Africa
Asia
South America
Eastern Europe
Total
Tested subjects
1285 (56.9)*
402 (17.8%)*
212 (9.4%)*
356 (15.7%)*
2255
HIV +
234 (18.2%)°
25 (6.8%)º
11 (5.1%)°
15 (4.2%)°
285
AIDS
73 (5.6%)°
8 (1.9%)°
6 (2.8%)°
6 (1.6%)°
93
*rate calculated on 2255; °rate calculated on number of subjects tested come from Africa, Asia, South America and Eastern Europe,
respectively
Table 2 - Correlation between age and sex of patients infected by HIV.
Age (years)
Number of patients
Male/female
8 (2.1%)
8/0
21-30
120 (31.8%)
52/68
31-40
179 (47.3%)
101/78
41-50
41 (10.9%)
21/20
>50
30 (7.9%)
15/15
<20
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Table 3 - Correlation between sex and origin of patients with HIV infection.
Area of origin
Male/female (ratio)
Africa
Asia
South America
Eastern Europe
170/137 (1.24)
9/24 (0.37)
6/11 (0.5)
12/9 (1.339
trend already observed by other industrialized
countries with a high immigration rate [6-8].
Most of the patients tested in Italy came from
African countries (61.9%), probably due to the
widespread occurrence of HIV infection in the
African continent (mainly Sub-Saharan Africa),
where the HIV pandemia accounts for 70% of
all HIV-positive subjects in the world and for
80% of deaths caused by AIDS [9, 10]. Our results showed that HIV infection among immigrants is particularly dangerous for female subjects. Indeed, while the statistics for all the infected subjects living in Italy in 2002 showed
that women with HIV infection amounted to
22.1% (11/125) of all infected subjects, about
50% of infected immigrants were female.
These data reflect that, as reported by the
WHO, about 50% of the 38 million adult people
infected with HIV, living in 2002, and of the 5
million new cases in the same year, were female
[1]. We think that sexual transmission of HIV is
the first cause of its spread in many developing
countries (>80%). The prevalence of HIV-positive females is due to many factors, such as a
high risk of sexual transmission of HIV from
male to female, an easier transmissibility of its
diffused genotypes in such regions.
Thus the high prevalence of infected women
may reflect the epidemic trend in their countries of origin, but it may also continue in the
host country [11, 12].
In our study female HIV+ patients outnumbered males among Asian and South American
populations (M/F: 0.37 and 0.5, respectively);
we observed no significant difference between
African and Eastern Europe subjects (M/F:1.24,
M/F: 1.33, respectively).
The most represented average age class of all
HIV+ examined patients was that from 21 to 40
years (70% of male, >80% of female patients).
These results probably were due to the fact that
many immigrants were young and moved in
search of jobs to maintain their families (the
number of students and refugees is very low).
Moreover, we recorded a very low prevalence
(2%) of paediatric cases, perhaps due to the
small number of HIV infections during pregnancy (10 cases) and to the many voluntary
abortions (87 cases).
Among the 93 cases of AIDS, the most frequent
patients from South America (M/F: 0.5); they
were mainly Brazilian (40.8%), Ecuadorian
(15.4 %), Colombian and Dominican (9.8%). Females were also prevalent among Asian HIV+
patients (M/F: 0.37); they mainly came from
Thailand (30.3%), China and India (18.1%),
Bangladesh and Sri-Lanka (12.1%). By contrast,
HIV+ Eastern Europeans were predominantly
male (M/F: 1.33), coming from Poland (30%),
Croatia (20%), Romania (12.5%) and Russia
(10%) (Table 3).
In our study we estimated 93 cases of AIDS, affected by several opportunistic infections. Indeed, we observed 38 cases of tuberculosis
(TBC), 21 cases of venereal diseases, 13 subjects
affected by Toxoplasmosis, 8 cases of pneumonia by Pneumocystis carinii (PCP), 11 co-infected
patients (HIV/HCV), 7 cases of Non-HodgkinLymphoma (NHL), 6 subjects with Kaposi Sarcoma (KS) and, finally, 10 cases of fungal infection.
As for the TBC clinical variants, the most observed form was lung tuberculosis (29 cases),
followed by the lymphoglandular form (6 subjects, all from African countries). We also found
3 cases of meningeal tuberculosis (tubercular
meningitis).
Venereal diseases were very frequent among
female HIV positive patients: we evaluated 18
cases of syphilis; all cases of Toxoplasmosis
were cerebral variants and 10/13 patients arrived from Eastern Europe. All co-infected
(HIV/HCV) subjects came from Eastern European areas, who were drug abusers.
In our study we found 8 paediatric patients,
three of whom (37.5%) also showed AIDS
symptoms (2 cases of tuberculosis and 1 case of
pneumonia by PC).
■ DISCUSSION
In our retrospective multicentric survey we
tested for anti-HIV 2255 immigrants hospitalised in 46 Infectious Disease Wards all over
Italy during 2002. Our data show that HIV infection represents an important problem with a
prevalence, in our experience, of 16.8%. This
percentage is confirmed by the 2001 AIDS Italian Health Institute which noted an increasing
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opportunistic infections were TBC (38 cases)
and venereal diseases (21 cases).The prevalence
of TBC was 10.5% among HIV+ patients and
40.8% of those affected by AIDS.
As for the TBC clinical variants the most frequent form was lung tuberculosis (29 cases). In
our epidemiological survey, HIV and TBC
proved strictly associated and both were endemic diseases in many developing countries.
Malnutrition and the lack of medical and therapeutic approaches lead to increased immunodeficiency and the spread of many infections like
HIV and tuberculosis. Our data suggest either
reactivation of latent infection by Mycobacterium tuberculosis (MT) in HIV-positive subjects or a new infection by MT in HIV-infected
patients; both pathogenic mechanisms are
probably connected with malnutrition, poor
hygiene and living conditions, over-crowding,
hard work and inadequate health services.
WHO recorded that 1/3 of HIV-positive patients or AIDS cases are affected by tuberculosis, mainly coming from African countries
(26/38 co-infected patients) [13, 14).
Venereal diseases were prevalent among very
young (average age: 21.7 years) female immigrants (20/21 cases); all the patients came from
African regions and syphilis was the most frequent (18/21 cases) [9, 10).
These results confirm the connection between
HIV and venereal infections in the cohort of female immigrants. This is due to many factors,
such as early sexual activity or the sexual
promiscuity and violence to which they are
subjected (physical and psychological violence,
prostitution, etc.) [10, 11].
In conclusion, HIV can be defined a frequent infectious disease among all immigrants, especially among African female subjects. In our
survey, we wish to support the absolute necessity of a better Health Service System related to
suitable prophylaxis, diagnosis and treatment
for all such patients.
Key words: HIV, immigration, hospitalisation,
AIDS, health
Italian Group for Immigrant Infectious Diseases study:
L. Sacco Hospital, Milan (MD T. Quirino), San Salvatore
Hospital, Pesaro (MD M. Calducci), Spedali Civili Hospital
Brescia (MD G. Cadeo), University Hospital, Brescia (MD I.
EL-Hamad), Civile Hospital Ascoli Piceno (MD N. Vitucci),
Misericordia Hospital Grosseto (MD M.P. Allegri), S. Carlo
Hospital Potenza (MD B. Piretti), Umberto I Policlinic II
Hospital Division, Rome (MD A. Paffetti), Hospital
Risceglie (MD R. Losappio), Hospital Perugia (MD C.
Sfara), Universitari Clinic Foggia (MD G. Scotto), S. Maria
Goretti Hospital Latina (MD G. Salome), Universitari Clinic
Bari (MD P. Maggi), C. Poma Hospital Mantova (MD S.
Miccolis), Umberto I Policlinic I Hospital Division Roma
(MD A. Brogi), Bambino Gesù Hospital Roma (MD L. Lancella), S. Maria Annunziata Hospital Firenze (MD A. Gabbati), Civile Hospital Legnano (MD M. Villa), Hospital
Biella (MD A. Salatino), University Hospital, Ancona (MD
D. Drenaggi), II University Hospital, La Sapienza Roma
(Prof. M. Ciardi), Umberto I Hospital Frosinone (MD M.
Limodio), Umberto I Policlinic III Hospital Division Roma
(Prof. S. Delia), University Hospital, Catania (MD E.
Caltabiano, MD G. Cosentino), Hospital Catania (MD M.
Raspaglieli), Hospital Avezzano (MD R. Mariani), Universitary Clinic Bologna (MD S. Sabbatani), Hospital Asti (MD
A. Casabianca), Hospital Cremona (MD D. Galloni), S.
Anna Hospital, Ferrara (MD M. Pantaleoni), Hospital
Formia (MD F. Purificato), S. Antonio Hospital Trapani
(MD V. Portelli), Hospital Aosta (MD R. Chasseur),
Basilotta Hospital Nicosia (MD B. Benenat), Hospital Campobasso (MD P. Sabatini), Hospital Ravenna (MD G. Bellardini), Hospital Trieste (MD A. Valencic), Hospital Macerata
(MD P. Milini), Hospital Modica (MD F. Sebbia), University
Hospital, Chieti (Prof. E. Pizzigallo), Pugliese-Ciaccio Hospital Catanzaro (MD P. Scerbo), Hospital Pescara (MD A.
Consorte), Hospital Varese (MD M. Gioia), Hospital
Caserta (MD G. Coviello), University Hospital, Verona (MD
A. Azzimi) Papardo Hospital, Messina (MD M. Allegra),
Gaslini Hospital, Genova (MD G. Losurdo), Galliera Hospital, Genova (MD P. Cristalli).
SUMMARY
Our aim was to evaluate the prevalence of HIV infection in immigrants hospitalised in infectious
disease settings in Italy during 2002. Each participating centre filled in a CRF which regarded the
number of immigrants hospitalised in ordinary
regime or in day-hospital during 2002 and, for
HIV-positive patients only, some demographic
(age, sex, origin) and clinical features (only HIV
positivity or AIDS, new diagnosis or not, diagnosis
of opportunistic infections).
A total of 46 Infectious Diseases Units participated
in the study and a total number of 2255 patients
were tested for anti-HIV, irrespective of the cause
of hospitalization, with 378 (16%) cases of positivity. Women accounted for 47.9%; the mean age of
the population was 34.5 years. African patients
showed a higher prevalence of HIV infections than
subjects from other geographical areas (61.9% of
all cases). Most HIV-infected patients were unaware of their positivity. In conclusion, HIV infection represents one of the main health problems
among immigrants, particularly of African origin.
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RIASSUNTO
Obiettivi: Scopo del presente studio è stato quello di valutare la prevalenza dell’infezione da HIV in pazienti
immigrati ricoverati in Reparti di Malattie Infettive in
Italia nel corso dell’anno 2002.
Pazienti e metodi: Ciascun centro partecipante ha
compilato un CRF riportando il numero di pazienti immigrati ricoverati in regime di ospedalizzazione ordinaria o di day hospital nel corso del 2002 e, esclusivamente
per i pazienti HIV-positivi, alcune caratteristiche demografiche (età, sesso, paese di origine) e cliniche (positività per HIV o AIDS, nuova diagnosi, diagnosi di infezioni opportunistiche).
Risultati: Complessivamente, hanno partecipato allo
studio 46 Unità di Malattie Infettive, per un numero totale di 2255 pazienti sottoposti a test per anti-HIV, indipendentemente dalla causa dell’ospedalizzazione, di
cui 378 (16%) positivi. Il 47.9% di tale popolazione era
di sesso femminile; l’età media era pari a 34,5 anni. In
confronto ai pazienti provenienti da altre aree geografiche, quelli africani evidenziavano una più elevata prevalenza di infezione da HIV (61,9% di tutti i casi). La
maggior parte dei pazienti affetti da HIV non ne era
consapevole.
Conclusioni: L’infezione da HIV rappresenta uno dei
maggiori problemi sanitari tra gli immigrati, particolarmente per quelli di origine Africana.
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