Suicidality among nonadherent patients living with HIV in Buenos Aires, Argentina: prevalence and correlates.

Of those in the general population hospitalized for suicidal ideation and suicide attempts in Argentina, many reattempt suicide and are readmitted. However, few studies in Argentina have examined suicidal ideation and suicide-related behaviors among people living with HIV (PLHIV) and none have examined these factors among nonadherent PLHIV, though the prevalence of suicidal ideation in this group may be higher than in the general population and also than in other groups of PLHIV. This study of PLHIV in Buenos Aires, Argentina, examined the correlates of suicidal ideation in nonadherent PLHIV. Nonadherent patients with HIV (N = 118) were recruited from two clinics providing outpatient healthcare services to PLHIV in Buenos Aires, Argentina. Participants completed assessments on demographic characteristics, depression and suicidality, stigma, and self-efficacy. Participants were HIV-infected men (51%) and women (49%) with a median age of 40 years (IQR = 11). About half had completed high school or more, two-thirds were employed, and had a mean monthly income of 4196.79 (SD = 3179.64) Argentine pesos (USD$221). Thirty-three (28% [95% CI 20.3, 37.3]) participants reported suicidal ideation in the past two weeks, and one-third (35.6% [27.1, 44.9]) reported lifetime suicidal ideation. In bivariate analyses, attending a public clinic, being female, younger, unemployed, and experiencing greater stigma and depression were associated with suicidal ideation. In multivariable logistic regression, stigma interacted with the number of years since HIV diagnosis to predict suicidal ideation. The impact of stigma on suicidal ideation decreased with time since HIV diagnosis, suggesting that suicidal ideation may arise following HIV diagnosis due to perception of HIV-related stigma. Interventions to reduce perceived stigma during the period following HIV diagnosis may reduce suicidal ideation in this population. Organizational initiatives that explore HIV stigma microagressions in the healthcare setting may be needed to optimize health outcomes.

Improving Adherence to Care Among "Hard to Reach" HIV-Infected Patients in Argentina.

Many HIV-infected patients fail to achieve undetectable viral load and are not retained in care. This pilot study examined patients lost to care in public and private clinics in Buenos Aires, Argentina. The impact of patient and provider interventions was compared separately and collectively. In Phase 1, participants prescribed antiretrovirals and non-adherent to treatment in the prior 3-6 months (n = 60) were randomized to patient intervention or standard of care (SOC) and assessed over 12 months. In Phase 2, providers were trained in interviewing techniques and 60 additional patients were randomized to patient intervention or SOC condition. Averaged across patient intervention status, Phase 2 provider intervention patients reported the most improved adherence and viral suppression at 6 and 12 months. Adherence in "patient intervention only" improved at midpoint and returned to baseline at 12 months. Results suggest provider training sustained patient adherence and viral suppression among "hard to reach" patients.

Implementation and uptake of the Conexiones y Opciones en la Argentina intervention: feasibility and acceptability.

Challenging HIV-infected patients, those neither adherent nor actively engaged in care, represent an important opportunity for intervention if the HIV epidemic is to be contained. This pilot study assessed the feasibility and acceptability of an adapted patient adherence intervention and a motivational interview-based provider intervention in urban Buenos Aires, Argentina, in order to optimize health benefits in challenging HIV-infected patients. To maximize implementation and uptake of both strategies, interventions were adapted to the local setting. Qualitative data and a short quantitative assessment from patients, staff, fellows, residents and physicians (n = 84) were examined to establish the feasibility and acceptability of offering patient and provider evidence-based interventions in both public and private health-care settings. Results identified key themes on provision of information, use of specialized communication techniques and group support in the utilization of the interventions. Both providers (n = 12) and patients (n = 120) endorsed the acceptability and value of the interventions, and the feasibility of their delivery. Findings support the use of both intervention modalities with challenging patients in diverse urban health-care settings.

Examining Adherence Among Challenging Patients in Public and Private HIV Care in Argentina.

Treatment engagement, retention and adherence to care are required for optimal HIV outcomes. Yet, patients may fall below the treatment recommendations for achieving undetectable viral load or not be retained in care. This study examined the most challenging patients in Buenos Aires, Argentina, those non-adherent to HIV care. Men (n = 61) and women (n = 59) prescribed antiretrovirals (ARVs) and non-adherent to treatment in the prior 3-6 months were enrolled and assessed regarding adherence, knowledge, motivation and attitudes regarding treatment. Private clinic patients had lower viral load and higher self-reported adherence than public clinic patients. Motivations to be adherent and positive beliefs regarding ARVs were associated with increased adherence in public clinic participants. Increased self-efficacy was associated with increased adherence among participants from both clinics. Results support patient and provider interventions that strengthen the characteristics supporting adherence, engagement and retention in public and private clinic settings.

Patient-provider perceptions on engagement in HIV care in Argentina.

Approximately 30% of patients participating in the national antiretroviral therapy (ART) program in Argentina fail to achieve an undetectable viral load, and approximately 25% are not retained in care. This qualitative study was designed to explore and identify factors associated with engagement and retention in public and private health care in Buenos Aires, Argentina. Qualitative data from key informants (n = 12) and focus groups (n = 4 groups) of patients and providers from private and public HIV treatment facilities were recorded and transcribed. Predetermined and arising themes related to adherence, engagement, and retention in care were coded and analyzed using qualitative data analysis software. Reasons identified for patients' lack of adherence or engagement in care differed between patients and providers, and patients attributed limitations to low self-efficacy, fear and concerns about HIV, and lack of provider involvement in treatment. In contrast, providers viewed themselves as decision-makers in patient care and patients as responsible for their own nonadherence due to lack of commitment to their own health or due to medication side effects. Patients reported health care system limitations and HIV concerns contributed to a lack of engagement, and providers identified limited HIV literacy and stigma as additional problems. Both agreed that chronic illness and substance addiction impacted adherence and retention, and agreed on the importance of trust, honesty, and communication in the patient-provider relationship. Results support the incorporation of system-, provider-, and patient-focused components into interventions to facilitate patient engagement, adherence, and retention in public and private settings in Argentina.

Demographic and psychosocial factors associated with appointment attendance among HIV-positive outpatients.

Non-adherence to medical regimens is a critical threat to HIV-infected individuals. Persons living with HIV/AIDS must adhere to their outpatient medical appointments to benefit from continually improving HIV care regimens. The primary purpose of the present study was to identify individual and psychosocial characteristics associated with HIV-related medical appointment non-attendance. One hundred seventy eight adult participants attending the Outpatient Adult HIV/AIDS Immunology Clinic at Jackson Memorial Hospital (JMH) in Miami, Florida participated in the study. Scheduled and missed appointments obtained retrospectively over a 12-month period indicated that medical appointment non-attendance was a significant problem. Overall, 27.9% of scheduled appointments were missed during the study period. Young age and limited family support were predictors of non-attendance. These findings support those of others and highlight targeted intervention efforts to reduce appointment non-attendance among persons living with HIV/AIDS.

Congenital Chagas' disease transmission in the United States: Diagnosis in adulthood.

Two brothers with congenitally-acquired Chagas' disease (CD) diagnosed during adulthood are reported. The patients were born in the USA to a mother from Bolivia who on subsequent assessment was found to be serologically positive for Trypanosoma cruzi. Serologic screening of all pregnant women who migrated from countries with endemic CD is strongly recommended.

Motivational Interviewing among HIV Health Care Providers: Challenges and Opportunities to Enhance Engagement and Retention in Care in Buenos Aires, Argentina.

In Argentina, providers' response to motivational interviewing (MI) to improve engagement and retention in care among challenging patients with HIV was evaluated. Twelve HIV care physicians participated, and their video recordings pre- and post-MI training were also obtained. One week post-training, 11 of the 12 participants were committed to using MI strategies during consult session. Of the 12 participants, 9 demonstrated appropriate utilization of MI techniques and change in HIV education provided during consultation (Z = -2.375, P = .018). Motivational interviewing appears to be a viable strategy to enhance engagement and retention in challenging HIV-positive patients.

[Barriers to adherence and retention in public and private healthcare according to patients and health workers]. / Obstáculos a la adherencia y retención en los sistemas de salud público y privado según pacientes y personal de salud.

INTRODUCTION: The National Program of AIDS guarantees universal access to antiretroviral medication, yet people receiving treatment through the public healthcare system do not achieve an undetectable viral load in the same rate than patients in the private system. This qualitative study aims to identify factors associated with adherence and retention in the HIV-cascade of care at public and private setting from Buenos Aires, based on patients and healthcare workers' perceptions. METHODS: Qualitative data from 12 semi-structured interviews with key informants and 4 focus groups of patients and healthcare workers from the public and private systems were recorded. Transcripts were coded and analyzed, using the QRS Nvivo9® software for qualitative data analysis, into set themes on adherence. RESULTS: Patients and healthcare workers of both systems agree on the importance of HIV-related stigma, professional-patient relationship and communication, and the division of treatment-related responsibilities as fundamental aspects for adherence and retention in the HIV-cascade of care. Differences in the manner these factors interact were observed between healthcare systems. Structural barriers are presented as the main adherence barrier in the public system. DISCUSSION: The need for interventions focused on the doctor-patient dyad considering the features of each healthcare is highlighted in order to facilitate patient engagement in adherence.

Sex risk practices among HIV-positive individuals in Buenos Aires, Argentina.

We have limited information regarding the sexual risk behaviors of HIV-positive individuals in Argentina. It is important to understand these behaviors in order to develop strategies oriented at decreasing unsafe sex practices. A random sample of 140 HIV-positive individuals was recruited from an HIV primary care clinic in Buenos Aires, Argentina, between August and September 2005. Participants responded survey questions regarding their sexual behaviors in the previous three months. Logistic regression analysis was used to determine factors associated with inconsistent condom use during vaginal, anal, and oral sex. Of the 140 participants surveyed, 69% were male, the mean age was 38 years old, 29% reported having less than a high school education, and 84% reported having engaged in vaginal, anal, and/or oral sex in the past 3 months. Of 53 participants who reported engaging in anal sex, 60% were men who have sex with men, and 40% were heterosexuals. Inconsistent condom use was reported by 31% of participants engaging in anal sex, 39% of participants engaging in vaginal sex, and 71% of participants engaging in oral sex. When adjusting for other factors, participants reporting symptoms of depression were 5.2 times more likely to use condoms inconsistently during vaginal sex, and 4.3 times more likely to use condoms inconsistently during anal sex compared to participants reporting no depression symptoms. Providers should assess sexual risk practices of HIV-positive individuals reporting symptoms of depression, and provide counseling regarding the importance of consistent condom use to those patients who are engaging in unsafe sex practices.

Obstáculos a la adherencia y retención en los sistemas de salud público y privado según pacientes y personal de salud / Barriers to adherence and retention in public and private healthcare according to patients and health workers

Introducción: el Programa Nacional de Sida garantiza el acce-so universal a los antirretrovirales, aun así las personas que reciben me-dicamentos a través del sistema público no logran obtener una carga vi-ral indetectable en la misma proporción que los pacientes del sistema privado. Este estudio cualitativo tiene como objeto identificar los facto-res asociados a la adherencia y retención en la cascada de atención de VIH de los sistemas de salud público y privado de Buenos Aires, según las percepciones de pacientes y del personal de salud.Métodos: se registraron datos cualitativos de 12 entrevistas semi-es-tructuradas a informantes clave y 4 grupos focales de pacientes y per-sonal de salud tanto del sistema público como privado. Se codificaron y analizaron temas predeterminados sobre adherencia, utilizando el soft-ware QRS Nvivo9® de análisis de datos cualitativos.Resultados: pacientes y personal de salud de ambos sistemas coinci-den en la importancia del estigma asociado al VIH, la relación médico-paciente, la comunicación entre ambos y la división de responsabilida-des en relación al tratamiento como aspectos fundamentales para la adherencia y retención en la cascada de atención. Se observan diferen-cias entre los sistemas en la forma en que algunos de estos aspectos ac-túan. Las barreras estructurales se presentan como principales obstácu-los del sistema público.Discusión: se resalta la necesidad de intervenciones focalizadas en la díada médico-paciente que consi-dere las particularidades de cada sistema de aten-ción para facilitar el compromiso del paciente en la adherencia

Introduction: The National Program of AIDS guarantees universal access to antiretroviral medication, yet people receiving treatment through the public healthcare system do not achieve an undetectable viral load in the same rate than patients in the private system. This qualitative study aims to identify factors associated with adherence and retention in the HIV-cascade of care at public and private setting from Buenos Aires, based on patients and healthcare workers' perceptions.Methods: Qualitative data from 12 semi-structured interviews with key informants and 4 focus groups of patients and healthcare workers from the public and private systems were recorded. Transcripts were coded and analyzed, using the QRS Nvivo9® software for qualitative data analysis, into set themes on adherence.Results: Patients and healthcare workers of both systems agree on the importance of HIV-related stigma, professional-patient relationship and communication, and the division of treatment-related responsibilities as fundamental aspects for adherence and retention in the HIV-cascade of care. Differences in the manner these factors interact were observed between healthcare systems. Structural barriers are presented as the main adherence barrier in the public system.Discussion: The need for interventions focused on the doctor-patient dyad considering the features of each healthcare is highlighted in order to facilitate patient engagement in adherence

Neumonías extrahospitalarias: revisión 109 casos entre 1985-1989 / Extrahospitalary neumonies: review of 109 cases between 1985-1989

Se revisaron un total de 109 historias clínicas de pacientes ingresados en el Servicio de Medicina 3 del Hospital Vargas en un período de 5 años (1985-1989) con el diagnóstico de Neumonía Extrahospitalaria. Encontramos 48 hombres y 61 mujeres con una edad promedio de 37 años. El tiempo promedio de hospitalizacion fue de 17,6 días. Se hizo el diagnóstico definitivo o presuntivo en un 10% de los casos, siendo Streptococcus pneumoniae el agente etiológico más frecuentemente aislado (45%). Se realizó además un análisis de los factores de riesgo, manifestaciones clínicas, diagnóstico microbiológico y radiológico, y modalidades terapéuticas

Absceso esplénico: presentación de un caso en un paciente inmunocompetente / Splenic absces: presentation of the a case in an immunocompetent patient

El absceso esplénico es una entidad poco común que se presenta en pacientes con factores predisponentes o con alguna condición de inmunosupresión. Durante las últimas décadas se han mejorado los procedimientos diagnósticos que han permitido una conducta terapéutica precoz a través de la esplenectomía o el drenaje percutáneo en combinación con la antibioticoterapia sistémica. Los autores presentan un caso de absceso esplénico único por enterococcus spp, en un paciente inmunocompetente, tratado mediante drenaje percutáneo dirigido por tomografía computarizada y seis semanas de antibioticoterapia

Presentación de dos casos y revisión de la literatura: nocardiosis asociada a inmunosupresión / Report of two cases and review of literature: nocardiosis associated with immunosuppression

Se presentan dos casos de infección por Nocardia asteroides identificados en el Hospital Vargas de Caracas en 1991. Ambos presentan estados de inmunosupresión caracterizados, en el primero por uso prolongado de esteroides y el segundo por infección por VIH. Los sitios de infección por Nocardia incluyeron: pulmón y ganglios linfáticos. Fueron tratados con sulfonamida y TMP-SMX respectivamente, falleciendo uno de ellos por retardo en la identificación bacteriana. Se revisa la literatura referente a infección por Nocardia sp. Debido al incremento en la incidencia de estados de inmunosupresión, adquiridos como en el SIDA o inducidos por drogas (esteroides y antineoplásicos) se está presentando un aumento notable de infecciones oportunistas que obliga a los médicos a mantener un alto índice de sospecha para el diagnóstico precoz y manejo terapético.

Tratamiento de las infecciones causadas por bacilos Gram negativos: experiencia con cefoperazona / Treatment of infections due to gram negative bacilli: experience with cefoperazone

Se trataron 19 pacientes con diversas infecciones causadas por bacilos Gram negativos, todos ellos sensibles a la cefoperazona. El régimen utilizado fue de 4 grms. diarios por vía endovenosa, repartidos en dos dosis, por un minimo de 5 días. Se diagnosticaron: infección de herida operatoria 6, osteomielitis 4, sepsis de origen intra-abdominal 2, infección de piel y tejidos blandos 1, sepsis de origen en el tracto urinario 1, neumonía nosocomial 1, peritonitis en diálisis peritoneal ambulatoria continua (D.P.A.C.) 1, úlcera crónica de miembro inferior 1, bacteriemia 1, sepsis en anemia drepanocítica 1. Todos los micro-organismos aislados fueron sensibles in vitro a la cefoperaza: Pseudomonas aeruginosa 9, Enterobacter spp 6, Klebsiella pneumoniae 5, Escherichia coli 3, Proteus mirabilis 1 Acinetobacter calcoaceticus variedad anitratus 1, Salmonella enteritidis 1, Providencia rettgeri 1. Hubo respuesta clínica favorable (cura) en el 84% y bacteriológica en el 74% de los casos. Tres pacientes (12%) presentaron como único efecto colateral reacción tipo disulfiram con la ingesta concomitante de alcohol durante el tratamiento; 4 pacientes presentaron dolor local durante la administración endovenosa en ausencia de flebitis. La cefoperazona es una droga potencialmente útil en el tratamiento de infecciones causadas por bacilos Gram negativos incluyendo a la Pseudomonas aeruginosa

Paracoccidioidomicosis diseminada con invasión al sistema nervioso central y manifestaciones de tipo convulsivo / Disseminated paracoccidioidomycoses with invasion to central nervous system and manifestations of convulsive type

Presentamos un caso de Paracoccidiodomicosis diseminada con manifestaciones neurológicas caracterizadas por convulsiones tónico-clónicas generalizadas y demostración de lesiones de ocupación de espacios cerebrales a través de la tomografía computarizada de cráneo (TC). Recibió tratamiento con trimetropin sulfametoxasol (TMO-SMX) y anticonvulsionantes con la desaparición de los síntomas. La TC de control realizada 6 meses después de tratamiento continuo demostró desaparición completa de las lesiones cerebrales. Se mantuvo el tratamiento con TMP-SMX durante 3 años con excelente tolerancia. En la forma visceral diseminada de la enfermedad existe invasión al sistema nervioso central (SNC) e un porcentaje apreciable de pacientes (12 por ciento), muchos de ellos asintomáticos. Sugerimos la exploración neurorradiológica de todos los casos de infección con signos clínicos sugestivos de invasión al SNC a fin de poder escoger una modalidad de tratamiento con penetración adecuada al líquido cefalorraquídeo.

Endocarditis infecciosa en el Hospital Vargas de Caracas / Indective endocarditis diagnosis in the Hospital Vargas of Caracas

Se estudiaron en forma retrospectiva las historias clínicas de 64 pacientes que cunplían con los criterios diagnósticos de endocarditis infecciosa (EI) en el Hospital Vargas de Caracas entre enero de 1990 y diciembre de 1995. Se analizó la casuística en base a diagnóstico definitivo o probable de EI, sexo, edad, signos y síntomas más frecuentes, factores predisponentes, hallazgos microbiológicos, ecocardiográficos, evolución clínica, complicaciones y mortalidad durante su hospitalización. De acuerdo al análisis de los resultados, la endocarditis infecciosa no es una patología despreciable en nuestro medio, presentándose la mayoría de los casos entre la segunda y cuarta década de vida en pacientes en su mayoría con valvulopatias subyacentes, con un predominio de Gram positivos como agente causal y una mortalidad superior a la reportada en otras series internacionales, principalmente por complicaciones cardíacas

Bacteriemias nosocomiales por acinetobacter calcoaceticus: experiencia en cinco años / Endemic nosocomial acinetobacter calcoaceticos bacteremias: experience in five years

Se revisaron en forma retrospectiva, las historias de 21 pacientes con hemocultivos positivos para Acinetobacter calcoaceticus sp (A.c) entre diciembre de 1980 y enero de 1986, en el Hospital Privado Centro Médico de Caracas. 15 de los episodio fueron bacteriemias verdaderas. La mayoría de los pacientes (12) se encontraron en la Unidad de Cuidados Intensivos, siendo el acceso vascular, la principal fuente de infección debido a la contaminación de las líneas vasculares. Se apreció una alta resistensia a los antibioticos utilizados. Fallecieron únicamente aquellos pacientes que presentaron shock séptico que no recibieron antibióticos activos sobre el microorganismo. El resto de los pacientes evolucionaron satisfactoriamente. El pronóstico de las bacteriemias por A.c. es favorable si son tratadas adecuadamente, de acuerdo a nuestra experiencia

Peritonitis durante la diálisis peritoneal ambulatoria continuada (D.P.A.C) / Peritonitis during continuos ambulatory peritoneal dialysis (C.A.P.D)

En Junio de 1983 se inició en el Centro Médico de Caracas el Programa de D.P.A.C. Un total de 37 pacientes entraron en el estudio hasta Octubre de 1986. Desde Junio de 1983 hasta Febrero de 1986 (período A) el líquido peritoneal (L.P) fue sembrado en medio líquido en volumen menor de 2 ml; a partir de Marzo de 1986 (período B) se usó en forma rutinaria un volumen de 3 ml. De 21 episodios de peritonitis observados durante el período A, 16 (76%) de los cultivos de L.P. fueron positivos, mientras que en el período B, 26 (100%) fueron positivos. Más del 50% de las infecciones fueron causadas por microorganismos Gram positivos, los más frecuentes fueron el Staphylococcus coag. negativo (13) y coag. positivo (8). Entre los microorganismos Gram negativos, se aislaron con más frecuencia la Escherichia coli (5) y Pseudomonas spp, (3). Hubo 7 infecciones por hongos, 4 por Candidas spp, y 3 por hongos filamentosos. El examen directo del L.P. con la coloración de Gram no fue de utilidad diagnóstica. En la siembra del L.P., el uso de un volumen de 3 ml se asoció con el aislamiento de microorganismos en todos los casos y constituye la explicación de la diferencia en los resultados obtenidos en los dos períodos mencionados