HIV treatment cascade in regions of Peru with the highest HIV prevalence.

OBJECTIVES: To describe the HIV treatment cascade and care continuum in regions of highest HIV prevalence in Peru. METHODS: An observational longitudinal study was carried out in 14 tertiary hospitals in Peru. These are the main hospitals that administer antiretroviral treatment (ART) in the regions that represent approximately 95% of reports of HIV/AIDS cases in Peru in 2013. We included individuals older than 18 years newly diagnosed with HIV from 1 January 2011 to 31 December 2012. Medical records were reviewed until 2015. RESULTS: A total of 2119 people living with HIV (PLHIV) were identified in the selected health facilities (mean age = 35.26 years, 78% male). 97.25% [1845/1897; 95% confidence interval (CI): 96.4-97.9%] of the patients attended the consultation at least once during the follow-up, but only 64.84% (885/1365; 95% CI: 62.2-67.4%) attended within a month after the diagnosis. After starting ART, 74.63% (95% CI: 71.9-77.2%) of PLHIV remained in healthcare. Regardless of the time after diagnosis, 88.40% (1837/2078; 95% CI: 86.9-89.7%) of PLHIV started ART during the observation time. However, 78.68% (95% CI: 76.8-80.4%) did so during the first post-treatment year and only 28.88% (95% CI: 27.9-31.9%) after 1 month. After starting treatment, it was observed that 51.60% (95% CI: 49.2-54%) of PLHIV reached viral suppression during the follow-up period. CONCLUSIONS: Further analysis and improvements in the definition of indicators are required to achieve conclusive results; however, these data will give us a general understanding of the progress of Peruvian health policies in achieving the goal established by the WHO.

Glycated hemoglobin as a surrogate for evaluating the effectiveness of drugs in diabetes mellitus trials: a systematic review and trial-level meta-analysis.

OBJECTIVE: The objective of this study was to investigate whether glycated hemoglobin (HbA1c) is a valid surrogate for evaluating the effectiveness of antihyperglycemic drugs in diabetes mellitus (DM) trials. METHODS: We conducted a systematic review of placebo-controlled randomized clinical trials (RCTs) evaluating the effect of a treatment on HbA1c (mean difference between groups) and clinical outcomes (relative risk of mortality, myocardial infarction, stroke, heart failure, and/or kidney injury) in patients with DM. Then, we investigated the association between treatment effects on HbA1c and clinical outcomes using regression analysis at the trial level. Lastly, we interpreted the correlation coefficients (R) using the cut-off points suggested by the Institute for Quality and Efficiency in Healthcare (IQWiG). HbA1c was considered a valid surrogate if it demonstrated a strong association: lower limit of the 95 percent confidence interval (95 percent CI) of R greater than or equal to .85. RESULTS: Nineteen RCTs were identified. All studies included adults with type 2 DM. None of the associations evaluated was strong enough to validate HbA1c as a surrogate for any clinical outcome: mortality (R = .34; 95 percent CI -.14 to .69), myocardial infarction (R = .20; -.30 to .61), heart failure (R = .08; -.40 to .53), kidney injury (R = -.04; -.52 to .47), and stroke (R = .81; .54 to .93). CONCLUSIONS: The evidence from multiple placebo-controlled RCTs does not support the use of HbA1c as a surrogate to measure the effectiveness of antihyperglycemic drugs in DM studies.

Impact of COVID-19 induced lockdown on physical activity and sedentary behavior among university students: A systematic review.

BACKGROUND: The COVID-19 pandemic has entailed a significant socio-economic impact on various layers of the population. In many countries, attempts to control viral dissemination involved lockdown measures that limited citizens' overall mobility and professional and leisure activities. OBJECTIVE: This systematic review investigates the impact of COVID-19-induced lockdowns on university student physical activity and sedentary behav-ior, as these relate to physical and mental well-being. METHODS: Data was collected through PubMed/MEDLINE, Embase, SCOPUS, and APA PsycInfo databases until January 2021. RESULTS: Seven studies conducted in five different countries (United States, Spain, Italy, China, and United Kingdom) were included in the final review. Overall, most studies reported a significant decrease in mild physical activity (i.e., walking) among undergraduate students but not among graduate students. Consistently, most studies reported a significant increase in sedentary time (i.e., sitting time on weekdays) in undergraduate students but not in graduate students. We observed that students who were more sedentary previous to lockdown, increased or did not change their moderate and/or vigorous physical activity. In contrast, those who were less sedentary previous to lockdown decreased their moderate and/or vigorous physical activity. CONCLUSIONS: COVID 19 induced lockdowns appear to have negatively affected walking and sedentary behavior among undergraduate students but not among graduate students. Our results highlight the importance of promoting the World Health Organization recommendations for physical activity and sedentary behavior among university students to improve health outcomes.

Dióxido de cloro y derivados del cloro para prevenir o tratar la COVID-19: revisión sistemática / Chlorine dioxide and chlorine derivatives for the prevention or treatment of COVID-19: a systematic review

RESUMEN Objetivos: Realizar una revisión sistemática acerca de la efectividad y seguridad del uso de dióxido de cloro y derivados del cloro, en la prevención o el tratamiento de la COVID-19. Materiales y métodos: Se siguieron las pautas internacionales de elaboración de revisiones sistemáticas de PRISMA y el Manual Cochrane para revisiones sistemáticas de intervenciones. La estrategia de búsqueda la desarrolló un bibliotecario y la revisaron dos de los autores. Se complementó la búsqueda electrónica con una búsqueda manual. Se incluyeron ensayos clínicos aleatorizados, estudios cuasiexperimentales, estudios de cohorte, estudios de casos y controles, estudios de corte transversal y reportes de casos; y se excluyeron estudios in vitro o realizados en animales. Dos revisores, de forma independiente, seleccionaron los estudios según los criterios de elegibilidad definidos, usando el aplicativo web Rayyan, en caso de discordancia se hizo partícipe a un tercer revisor. El protocolo de la revisión sistemática se registró en PROSPERO (CRD42020200641). Resultados: No se identificó ningún estudio publicado ni en proceso de publicación que haya evaluado el uso del dióxido de cloro o derivados del cloro, administrado por vía inhalatoria, oral o parenteral en humanos, como agente preventivo o terapéutico de la COVID-19 o en infecciones por otros coronavirus. Solo se identificó el registro de un único estudio catalogado como observacional que hasta ahora no tiene resultados. Conclusiones: A la fecha, no existe evidencia científica que apoye el uso del dióxido de cloro o derivados del cloro para prevenir o tratar la COVID-19.

ABSTRACT Objectives: To systematically review the effectiveness and safety of chlorine dioxide solution and chlorine derivatives used in the prevention or treatment of COVID-19. Methods: This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and follows the guidelines provided in the Cochrane Handbook for Systematic Reviews of Interventions. A librarian developed and executed the search strategy; it was further reviewed by two of the authors and complemented by manual search. Randomized clinical trials, quasi-experimental studies, cohort studies, case-control studies, cross-sectional studies, and case reports were included; in vitro or animal studies were excluded. Abstract and full-text screening according to pre-defined eligibility criteria were performed by two reviewers independently using web application Rayyan QCRI. Disagreements on study selection were resolved by a third reviewer. The systematic review protocol was registered in PROSPERO (CRD42020200641). Results: Neither published nor pre-print studies evaluating the use of chlorine dioxide or derivatives on SARS-CoV-2 infection were identified. The only finding was an unpublished observational study registry which has no results released yet. Conclusions: To date, there are no scientific evidence to uphold the use of chlorine dioxide or derivatives as preventive or therapeutic agents against COVID-19.

Agentes potencialmente terapéuticos contra el SARS-CoV-2: revisión rápida de la evidencia.

The Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) of the Seguro Social de Salud (EsSalud) has completed seven brief reports by means of rapid reviews of evidence regarding the potentially effective therapies against SARS-CoV-2 in order to provide current and relevant information for decision makers, clinicians, researchers and the academic community in Peru. The therapeutic agents evaluated were chloroquine/hydroxychloroquine, lopinavir/ritonavir, tocilizumab, oseltamivir, interferon, atazanavir and anti SARS-CoV-2 serum. Evidence identification included the review of PubMed and Cochrane Library electronic databases. Additionally, manual search was carried out on websites from groups dedicated to research and education on health, as well as in the main specialized societies or institutions, such as, the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC). Furthermore, in order to reduce publication bias, the websites: www.clinicaltrials.gov and http://apps.who.int/trialsearch were searched to identify in-progress or unpublished clinical trials. Finally, a "snowball" strategy was performed by reviewing the reference lists of the systematic reviews, primary studies and selected narrative reviews to identify relevant information. The latest review (March 27, 2020) showed that there is no evidence to recommend any medication for patients´ treatment with COVID-19. More evidence, preferably high-quality randomized clinical trials, is needed for decision-making against SARS-CoV-2.

El Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) del Seguro Social de Salud (EsSalud) ha desarrollado siete informes breves mediante revisiones rápidas de evidencia sobre los agentes potencialmente terapéuticos contra el SARS-CoV-2 con la finalidad de brindar información actual y relevante para los decisores, clínicos, investigadores y la comunidad académica en el Perú. Los agentes terapéuticos evaluados incluyeron cloroquina/hidroxicloroquina, lopinavir/ritonavir, tocilizumab, oseltamivir, interferón, atazanavir y plasma anti-SARS-CoV-2. La identificación de evidencia incluyó la revisión de las bases electrónicas PubMed y Cochrane Library. Adicionalmente, se realizó una búsqueda manual en las páginas web de grupos dedicados a la investigación y educación en salud, así como, en las principales sociedades o instituciones especializadas, como la Organización Mundial de la Salud (OMS) y los Centros para el Control y la Prevención de Enfermedades (CDC, por sus siglas en inglés). Asimismo, para disminuir el sesgo de publicación, se buscó en las páginas web www.clinicaltrials.gov y http://apps.who.int/trialsearch, para identificar ensayos clínicos en desarrollo o que no hayan sido publicados aún. Finalmente, se consideró extraer información con una estrategia de «bola de nieve¼ mediante la revisión de las listas de referencias de las revisiones sistemáticas, estudios primarios y revisiones narrativas que sean de relevancia. A la fecha de la última revisión (27 de marzo de 2020), no se dispone de evidencia para recomendar un medicamento específico para el tratamiento de pacientes con COVID-19. Se necesita de mayor evidencia, preferentemente ensayos clínicos de buena calidad, para la toma de decisiones terapéuticas contra el SARS-CoV-2.

Agentes potencialmente terapéuticos contra el SARS-CoV-2: revisión rápida de la evidencia

RESUMEN El Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) del Seguro Social de Salud (EsSalud) ha desarrollado siete informes breves mediante revisiones rápidas de evidencia sobre los agentes potencialmente terapéuticos contra el SARS-CoV-2 con la finalidad de brindar información actual y relevante para los decisores, clínicos, investigadores y la comunidad académica en el Perú. Los agentes terapéuticos evaluados incluyeron cloroquina/hidroxicloroquina, lopinavir/ritonavir, tocilizumab, oseltamivir, interferón, atazanavir y plasma anti-SARS-CoV-2. La identificación de evidencia incluyó la revisión de las bases electrónicas PubMed y Cochrane Library. Adicionalmente, se realizó una búsqueda manual en las páginas web de grupos dedicados a la investigación y educación en salud, así como, en las principales sociedades o instituciones especializadas, como la Organización Mundial de la Salud (OMS) y los Centros para el Control y la Prevención de Enfermedades (CDC, por sus siglas en inglés). Asimismo, para disminuir el sesgo de publicación, se buscó en las páginas web www.clinicaltrials.gov y http://apps.who.int/trialsearch, para identificar ensayos clínicos en desarrollo o que no hayan sido publicados aún. Finalmente, se consideró extraer información con una estrategia de «bola de nieve¼ mediante la revisión de las listas de referencias de las revisiones sistemáticas, estudios primarios y revisiones narrativas que sean de relevancia. A la fecha de la última revisión (27 de marzo de 2020), no se dispone de evidencia para recomendar un medicamento específico para el tratamiento de pacientes con COVID-19. Se necesita de mayor evidencia, preferentemente ensayos clínicos de buena calidad, para la toma de decisiones terapéuticas contra el SARS-CoV-2.

ABSTRACT The Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) of the Seguro Social de Salud (EsSalud) has completed seven brief reports by means of rapid reviews of evidence regarding the potentially effective therapies against SARS-CoV-2 in order to provide current and relevant information for decision makers, clinicians, researchers and the academic community in Peru. The therapeutic agents evaluated were chloroquine/hydroxychloroquine, lopinavir/ritonavir, tocilizumab, oseltamivir, interferon, atazanavir and anti SARS-CoV-2 serum. Evidence identification included the review of PubMed and Cochrane Library electronic databases. Additionally, manual search was carried out on websites from groups dedicated to research and education on health, as well as in the main specialized societies or institutions, such as, the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC). Furthermore, in order to reduce publication bias, the websites: www.clinicaltrials.gov and http://apps.who.int/trialsearch were searched to identify in-progress or unpublished clinical trials. Finally, a "snowball" strategy was performed by reviewing the reference lists of the systematic reviews, primary studies and selected narrative reviews to identify relevant information. The latest review (March 27, 2020) showed that there is no evidence to recommend any medication for patients´ treatment with COVID-19. More evidence, preferably high-quality randomized clinical trials, is needed for decision-making against SARS-CoV-2.

Chlorine dioxide and chlorine derivatives for the prevention or treatment of COVID-19: a systematic review. / Dióxido de cloro y derivados del cloro para prevenir o tratar la COVID-19: revisión sistemática.

OBJECTIVES: To systematically review the effectiveness and safety of chlorine dioxide solution and chlorine derivatives used in the prevention or treatment of COVID-19. METHODS: This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and follows the guidelines provided in the Cochrane Handbook for Systematic Reviews of Interventions. A librarian developed and executed the search strategy; it was further reviewed by two of the authors and complemented by manual search. Randomized clinical trials, quasi-experimental studies, cohort studies, case-control studies, cross-sectional studies, and case reports were included; in vitro or animal studies were excluded. Abstract and full-text screening according to pre-defined eligibility criteria were performed by two reviewers independently using web application Rayyan QCRI. Disagreements on study selection were resolved by a third reviewer. The systematic review protocol was registered in PROSPERO (CRD42020200641). RESULTS: Neither published nor pre-print studies evaluating the use of chlorine dioxide or derivatives on SARS-CoV-2 infection were identified. The only finding was an unpublished observational study registry which has no results released yet. CONCLUSIONS: To date, there are no scientific evidence to uphold the use of chlorine dioxide or derivatives as preventive or therapeutic agents against COVID-19.

OBJETIVOS: Realizar una revisión sistemática acerca de la efectividad y seguridad del uso de dióxido de cloro y derivados del cloro, en la prevención o el tratamiento de la COVID-19. MATERIALES Y MÉTODOS: Se siguieron las pautas internacionales de elaboración de revisiones sistemáticas de PRISMA y el Manual Cochrane para revisiones sistemáticas de intervenciones. La estrategia de búsqueda la desarrolló un bibliotecario y la revisaron dos de los autores. Se complementó la búsqueda electrónica con una búsqueda manual. Se incluyeron ensayos clínicos aleatorizados, estudios cuasiexperimentales, estudios de cohorte, estudios de casos y controles, estudios de corte transversal y reportes de casos; y se excluyeron estudios in vitro o realizados en animales. Dos revisores, de forma independiente, seleccionaron los estudios según los criterios de elegibilidad definidos, usando el aplicativo web Rayyan, en caso de discordancia se hizo partícipe a un tercer revisor. El protocolo de la revisión sistemática se registró en PROSPERO (CRD42020200641). RESULTADOS: No se identificó ningún estudio publicado ni en proceso de publicación que haya evaluado el uso del dióxido de cloro o derivados del cloro, administrado por vía inhalatoria, oral o parenteral en humanos, como agente preventivo o terapéutico de la COVID-19 o en infecciones por otros coronavirus. Solo se identificó el registro de un único estudio catalogado como observacional que hasta ahora no tiene resultados. CONCLUSIONES: A la fecha, no existe evidencia científica que apoye el uso del dióxido de cloro o derivados del cloro para prevenir o tratar la COVID-19.

Efficacy and Safety in the Continued Treatment With a Biosimilar Drug in Patients Receiving Infliximab: A Systematic Review in the Context of Decision-Making From a Latin-American Country.

Introduction: Biological products, including infliximab (INF), are a therapeutic option for various medical conditions. In the Peruvian Social Security (EsSalud), infliximab is approved for the treatment of rheumatoid arthritis, psoriasis, psoriatic arthropathy, ankylosing spondylitis, ulcerative colitis and Crohn's disease (in cases refractory to conventional treatment). Biosimilars are a safe and effective alternative approved for these diseases in patients who start treatment with infliximab. Nevertheless, there are people in treatment with the biological reference product (BRP), in whom the continuing therapy with a biosimilar biological product (BBP) must be evaluated. Objectives: To synthesize the best available evidence, calculate a preliminary financial impact and conduct technical discussions about the interchangeability into biosimilar in patients receiving treatment with original infliximab for medical conditions approved in EsSalud. Methodology: We carried out a systematic review of controlled clinical trials. Primary search was performed in Pubmed- MEDLINE, SCOPUS, WOS, EMBASE, TRIPDATABASE, DARE, Cochrane Library, NICE, AHRQ, SMC, McMaster-PLUS, CADTH, and HSE until June-2018. We used the Cochrane Collaboration tool to assess the risk of bias. Also, we implemented a preliminary financial analysis about the impact of biosimilar introduction on institutional purchasing budget. Moreover, technical meetings with medical doctors specialized in rheumatology, gastroenterology and dermatology were held for discussing findings. Results: In primary search, 1136 records were identified, and 357 duplicates were removed. From 799 records, we excluded 765 after title and abstract evaluation. From 14 full-text appraised documents, we included five clinical trials in the risk of bias assessment: four studies evaluated CTP-13 and one tested SB2. Two double-blind clinical trials reported no differences in efficacy and safety profiles between maintenance group (INF/INF) and interchangeability group in all diseases included (INF/CTP-13) and rheumatoid arthritis (CTP13 and SB2). In the other three studies, open-label extension of primary clinical trials, no differences were founded in efficacy and safety profiles between CTP-13/CTP-13 and INF/CTP-13 groups. In financial analysis, the inclusion of biosimilars implied savings around S/7´642,780.00 (1USD=S/3.30) on purchasing budget of EsSalud. In technical meetings, beyond certain concerns, specialists agreed with the findings. Conclusions: Evidence from clinical trials support that there are no differences in efficacy or safety of continuing the treatment with Infliximab BRP or exchanging into its biosimilar in patients with medical conditions approved in EsSalud. Financial analysis shows that the biosimilar introduction produce savings in purchasing institutional budget. Therefore, based on cost-opportunity principle, exchanging into biosimilar in patients receiving the original Infliximab, is a valid therapeutic alternative in the Peruvian Social Security.

[Barriers to implementing screening, brief intervention and referral to treatment for substance use in HIV/AIDS health services in Peru]. / Barreras para implementar el despistaje, intervenciones breves y referencia al tratamiento por problemas de consumo de alcohol y otras drogas en hospitales que atienden personas que viven con el VIH/SIDA en el Perú.

OBJECTIVES.: Screening and treatment for substance use among people living with HIV/AIDS (PLWHA) is highly recommended. Nevertheless, in Peru healthcare for PLWHA does not include a standardized or systematic assessment to identify substance use. The aim of this study was to assess the feasibility of implementing screening, brief intervention and referral to treatment (SBIRT) in healthcare settings attending people living with PLWHA. MATERIALS AND METHODS.: After providing training in SBIRT for PLWHA's healthcare personnel (including nurses and physicians) focus groups were conducted to explore knowledge, beliefs and perceived barriers to implementation and interviews were conducted to assess the barriers and facilitators of two tertiary hospitals in Lima, Peru. RESULTS.: focus groups and interviews' thematic coding revealed three dimensions: 1) the unknown extent of substance use within PLWHA, 2) space and time limitations hinder completion of brief interventions during routine visits, and 3) insufficient access to substance use treatment appropriate for HIV patients. CONCLUSIONS.: Multiple barriers, including lack of awareness of substance use problems, limited space and time of providers, and lack of specialized services to refer patients for treatment make it difficult to implement SBIRT in the Peruvian healthcare system.

Tratamiento anti-retroviral conteniendo raltegravir en mujeres gestantes con infección por VIH: revisión sistemática / Antiretroviral therapy containing raltegravir in HIV-infected pregnant women: systematic review

Introduction: The risk of mother to child transmission (MTCT) of HIV increases in pregnant women diagnosed late in pregnancy. Some experts suggest that the use of raltegravir (RAL), as part of the antiretroviral treatment in these pregnant women, could reduce the risk of MTCT, since RAL can quickly decrease the viral load. Objective: To evaluate the available scientific information on the efficacy and safety of RAL, during the third trimester of pregnancy, in reducing MTCT of HIV. Methods: We conducted a systematic review of the literature. The following databases were consulted: MEDLINE, Tripdatabase, Cochrane, Lilacs and Web of Science. We included systematic reviews, clinical trials, observational studies or case reports. The search was not filtered by language. Results: Fourteen studies met the inclusion criteria. Selected studies were case reports or case series. We included, in total, 44 pregnancies (with 45 live births). A case of TMI of HIV was reported. Eight studies reported adverse events, of which four cases can be attributed to the use of RAL. Conclusion: There is insufficient evidence on the efficacy and safety of RAL to decrease the risk of MTCT in HIV pregnant women who present in the last trimester of pregnancy.

Introducción: El riesgo de transmisión materno-infantil (TMI) del VIH incrementa en mujeres gestantes diagnosticadas tardíamente en el embarazo. Algunos expertos sugieren que el uso de raltegravir (RAL), como parte del esquema de tratamiento anti-retroviral en estas pacientes, puede reducir el riesgo de TMI al disminuir rápidamente la carga viral. Objetivo: Evaluar la información científica existente sobre la eficacia y seguridad de RAL durante el tercer trimestre de gestación en la reducción de la TMI del VIH. Materiales y Métodos: Revisión sistemática de la literatura. Las bases de datos consultadas fueron: MED-LINE, Tripdatabase, Cochrane, Lilacs y Web of Science. En la búsqueda se incluyeron revisiones sistemáticas, ensayos clínicos, estudios observacionales o reportes de caso. La búsqueda no se filtró por idioma. Resultados: Catorce estudios cumplieron los criterios de inclusión. Los estudios seleccionados fueron reportes o series de caso. Se incluyeron 44 embarazos (con 45 nacidos vivos), se reportó un caso de TMI del VIH y ocho estudios reportaron eventos adversos, cuatro de ellos atribuibles al uso de RAL. Conclusión: No se encontró evidencia suficiente sobre la eficacia y seguridad RAL en mujeres gestantes con infección por VIH que se presentan en el último trimestre del embarazo, para disminuir el riesgo de TMI.

Barreras para implementar el despistaje, intervenciones breves y referencia al tratamiento por problemas de consumo de alcohol y otras drogas en hospitales que atienden personas que viven con el VIH/SIDA en el Perú / Barriers to implementing screening, brief intervention and referral to treatment for substance use in HIV/AIDS health services in Peru

RESUMEN Objetivos. Evaluar la factibilidad de implementar la detección, intervención breve y referencia a tratamiento (SBIRT, por sus siglas en inglés) en los servicios de atención para personas viviendo con el virus de inmunodeficiencia humana/ síndrome de inmunodeficiencia adquirido (PVVS). Materiales y métodos. Se realizó un estudio de tipo cualitativo, luego de capacitar profesionales de salud (incluyendo, enfermeras y médicos) que proveen atención de salud a PVVS en la aplicación del SBIRT, se realizaron grupos focales para explorar las barreras percibidas para su implementación y se realizaron entrevistas para evaluar las barreras y facilitadores en dos hospitales de tercer nivel de Lima, Perú. Resultados. La codificación temática de los grupos focales y las entrevistas revelaron tres dimensiones principales de barreras: 1) el desconocimiento acerca del consumo de sustancias en las PVVS; 2) limitaciones de espacio y tiempo que dificultan las intervenciones breves durante las visitas de rutina, y 3) insuficientes servicios con capacidades para el tratamiento el uso de sustancias apropiadas donde puedan ser referidos los pacientes con estos problemas. Conclusiones. Múltiples barreras, incluyendo el desconocimiento por los problemas de consumo de sustancias, limitaciones de espacio y tiempo de los profesionales, y carencia de servicios especializados a donde referir los pacientes para un cuidado especializado, haría difícil implementar SBIRT en un contexto como el del sistema de salud peruano.

ABSTRACT Objectives. Screening and treatment for substance use among people living with HIV/AIDS (PLWHA) is highly recommended. Nevertheless, in Peru healthcare for PLWHA does not include a standardized or systematic assessment to identify substance use. The aim of this study was to assess the feasibility of implementing screening, brief intervention and referral to treatment (SBIRT) in healthcare settings attending people living with PLWHA. Materials and methods. After providing training in SBIRT for PLWHA's healthcare personnel (including nurses and physicians) focus groups were conducted to explore knowledge, beliefs and perceived barriers to implementation and interviews were conducted to assess the barriers and facilitators of two tertiary hospitals in Lima, Peru. Results. focus groups and interviews' thematic coding revealed three dimensions: 1) the unknown extent of substance use within PLWHA, 2) space and time limitations hinder completion of brief interventions during routine visits, and 3) insufficient access to substance use treatment appropriate for HIV patients. Conclusions. Multiple barriers, including lack of awareness of substance use problems, limited space and time of providers, and lack of specialized services to refer patients for treatment make it difficult to implement SBIRT in the Peruvian healthcare system.

Associations between DSM-IV mental disorders and subsequent onset of arthritis.

OBJECTIVE: We investigated the associations between DSM-IV mental disorders and subsequent arthritis onset, with and without mental disorder comorbidity adjustment. We aimed to determine whether specific types of mental disorders and increasing numbers of mental disorders were associated with the onset of arthritis later in life. METHOD: Data were collected using face-to-face household surveys, conducted in 19 countries from different regions of the world (n=52,095). Lifetime prevalence and age at onset of 16 DSM-IV mental disorders were assessed retrospectively with the World Health Organization (WHO) Composite International Diagnostic Interview (WHO-CIDI). Arthritis was assessed by self-report of lifetime history of arthritis and age at onset. Survival analyses estimated the association of initial onset of mental disorders with subsequent onset of arthritis. RESULTS: After adjusting for comorbidity, the number of mood, anxiety, impulse-control, and substance disorders remained significantly associated with arthritis onset showing odds ratios (ORs) ranging from 1.2 to 1.4. Additionally, the risk of developing arthritis increased as the number of mental disorders increased from one to five or more disorders. CONCLUSION: This study suggests links between mental disorders and subsequent arthritis onset using a large, multi-country dataset. These associations lend support to the idea that it may be possible to reduce the severity of mental disorder-arthritis comorbidity through early identification and effective treatment of mental disorders.

[Antiretroviral therapy containing raltegravir in HIV-infected pregnant women: Systematic review]. / Tratamiento anti-retroviral conteniendo raltegravir en mujeres gestantes con infección por VIH: Revisión sistemática.

INTRODUCTION: The risk of mother to child transmission (MTCT) of HIV increases in pregnant women diagnosed late in pregnancy. Some experts suggest that the use of raltegravir (RAL), as part of the antiretroviral treatment in these pregnant women, could reduce the risk of MTCT, since RAL can quickly decrease the viral load. OBJECTIVE: To evaluate the available scientific information on the efficacy and safety of RAL, during the third trimester of pregnancy, in reducing MTCT of HIV. METHODS: We conducted a systematic review of the literature. The following databases were consulted: MEDLINE, Tripdatabase, Cochrane, Lilacs and Web of Science. We included systematic reviews, clinical trials, observational studies or case reports. The search was not filtered by language. RESULTS: Fourteen studies met the inclusion criteria. Selected studies were case reports or case series. We included, in total, 44 pregnancies (with 45 live births). A case of TMI of HIV was reported. Eight studies reported adverse events, of which four cases can be attributed to the use of RAL. CONCLUSION: There is insufficient evidence on the efficacy and safety of RAL to decrease the risk of MTCT in HIV pregnant women who present in the last trimester of pregnancy.

Estudio transversal de uso de servicios de salud mental en cinco ciudades del Perú / Cross sectional study of mental health services use in five cities of Peru

ANTECEDENTES: La primera causa de carga de enfermedad en el Perú son las enfermedades neuropsiquiátricas. OBJETIVO: El objetivo del presente estudio fue generar información acerca del uso de 12 meses de servicios de salud mental en la población adulta urbana de Perú. MÉTODO: El Estudio Mundial de Salud Mental(EMSM)se desarrolló con una muestra probabilística y multietápica de 3930 participantes de 18 a 65 años de edad en Lima, Arequipa, Huancayo, Iquitos y Tacna entre julio del 2004 y diciembre del 2005. Utilizó la Entrevista Diagnóstica Internacional Compuesta, que proporciona diagnósticos de acuerdo con el DSM-IV y el CIE-10. RESULTADOS: Sólo una de cada cinco personas que presentaron algún trastorno durante los últimos 12 meses recibió tratamiento durante ese período. En promedio, durante este tiempo recibieron tres atenciones. Sólo 9.7% de las personas con cualquier trastorno durante los últimos 12 meses recibió un tratamiento adecuado. Las personas con bajo nivel de educación tuvieron menor acceso a tratamiento mínimamente adecuado (OR=0.1; 95% CI=0.0, 0.5). El grupo con trastornos de uso de sustancias presentó menor acceso a tratamiento en los últimos 12 meses (12.7%). DISCUSIÓN Y CONCLUSIÓN: En el Perú existe una brecha de atención de salud mental. Las personas de menor educación y las personas con trastorno de abuso de sustancias son el grupo de menor acceso a cualquier tipo de tratamiento adecuado. La brecha de atención pone en evidencia la urgente necesidad de dirigir atención y recursos hacia la detección y tratamiento oportuno de las enfermedades mentales en el Perú.

BACKGROUND: Neuropsichiatric diseases constitute the first cause of burden of disease in Peru. OBJECTIVE: The aim of this study was to describe 12 month mental health services utilization, of the 18 to 65 years old urban population in Peru. METHOD: As part of the World Mental Health Survey Initiative (WMHSI), this research used a multistage, clustered-area probability sample of 3930 18-65 years old household residents in Lima, Arequipa, Huancayo, Iquitos and Tacna between July 2004 and December of 2005. The Instrument used was the Composite International Diagnostic Interview (CIDI) that produces DSM-IV/ICD-9 diagnoses by means of computerized algorithms. RESULTS: In the last 12 months, only one of every 5 people who had a mental disorder during this period received any treatment. The average number of treatment visits per year was only three. 9.7% of those with any mental disorder received appropriate treatment. People with low education had less access to minimally adequate treatment (OR=0.1, 95% CI=0.0, 0.5). The group with substance use disorders had lower access to treatment in the last 12 months (12.7%). DISCUSSION AND CONCLUSION: Peru presents a wide gap in mental health treatment. Mental Health treatment gap in Peru emphasizes the need to direct resources towards screening and treatment of mental disorders.

Associations between DSM-IV mental disorders and subsequent non-fatal, self-reported stroke.

OBJECTIVES: To examine the associations between a wide range of mental disorders and subsequent onset of stroke. Lifecourse timing of stroke was examined using retrospectively reconstructed data from cross-sectional surveys. METHODS: Data from the World Mental Health Surveys were accessed. This data was collected from general population surveys over 17 countries of 87,250 adults. The Composite International Diagnostic Interview retrospectively assessed lifetime prevalence and age at onset of DSM-IV mental disorders. A weighted subsample (n=45,288), was used for analysis in the present study. Survival analyses estimated associations between first onset of mental disorders and subsequent stroke onset. RESULTS: Bivariate models showed that 12/16 mental disorders were associated with subsequent stroke onset (ORs ranging from 1.6 to 3.8). However, after adjustment for mental disorder comorbidity and smoking, only significant relationships between depression and stroke (OR 1.3) and alcohol abuse and stroke (OR 1.5) remained. Among females, having a bipolar disorder was also associated with increased stroke incidence (OR 2.1). Increasing number of mental disorders was associated with stroke onset in a dose-response fashion (OR 3.3 for 5+ disorders). CONCLUSIONS: Depression and alcohol abuse may have specific associations with incidence of non-fatal stroke. General severity of psychopathology may be a more important predictor of non-fatal stroke onset. Mental health treatment should be considered as part of stroke risk prevention. Limitations of retrospectively gathered cross sectional surveys design mean further research on the links between mental health and stroke incidence is warranted.

Pediatric-Onset and Adult-Onset Separation Anxiety Disorder Across Countries in the World Mental Health Survey.

OBJECTIVE: The age-at-onset criterion for separation anxiety disorder was removed in DSM-5, making it timely to examine the epidemiology of separation anxiety disorder as a disorder with onsets spanning the life course, using cross-country data. METHOD: The sample included 38,993 adults in 18 countries in the World Health Organization (WHO) World Mental Health Surveys. The WHO Composite International Diagnostic Interview was used to assess a range of DSM-IV disorders that included an expanded definition of separation anxiety disorder allowing onsets in adulthood. Analyses focused on prevalence, age at onset, comorbidity, predictors of onset and persistence, and separation anxiety-related role impairment. RESULTS: Lifetime separation anxiety disorder prevalence averaged 4.8% across countries (interquartile range [25th-75th percentiles]=1.4%-6.4%), with 43.1% of lifetime onsets occurring after age 18. Significant time-lagged associations were found between earlier separation anxiety disorder and subsequent onset of internalizing and externalizing DSM-IV disorders and conversely between these disorders and subsequent onset of separation anxiety disorder. Other consistently significant predictors of lifetime separation anxiety disorder included female gender, retrospectively reported childhood adversities, and lifetime traumatic events. These predictors were largely comparable for separation anxiety disorder onsets in childhood, adolescence, and adulthood and across country income groups. Twelve-month separation anxiety disorder prevalence was considerably lower than lifetime prevalence (1.0% of the total sample; interquartile range=0.2%-1.2%). Severe separation anxiety-related 12-month role impairment was significantly more common in the presence (42.4%) than absence (18.3%) of 12-month comorbidity. CONCLUSIONS: Separation anxiety disorder is a common and highly comorbid disorder that can have onset across the lifespan. Childhood adversity and lifetime trauma are important antecedents, and adverse effects on role function make it a significant target for treatment.

Cost-effectiveness analysis of 10- and 13-valent pneumococcal conjugate vaccines in Peru.

OBJECTIVE: To evaluate the cost-effectiveness of introducing the 10-valent pneumococcal conjugate vaccine (PCV10) versus the 13-valent PCV (PCV13) to the National Immunization Schedule in Peru for prevention of pneumococcal disease (PD) in children <5 years of age. METHODS: The integrated TRIVAC vaccine cost-effectiveness model from the Pan American Health Organization's ProVac Initiative (version 2.0) was applied from the perspective of the Government of Peru. Twenty successive cohorts of children from birth to 5 years were evaluated. Clinical outcomes were pneumococcal pneumonia (PP), pneumococcal meningitis (PM), pneumococcal sepsis (PS) and acute otitis media from any causes (AOM). Measures included prevention of cases, neurological sequelae (NS), auditory sequelae (AS), deaths and disability adjusted life years (DALYs). A sensitivity analyses was also performed. FINDINGS: For the 20 cohorts, net costs with PCV10 and PCV13 were US$ 363.26 million and US$ 408.26 million, respectively. PCV10 prevented 570,273 AOM; 79,937 PP; 2217 PM; 3049 PS; 282 NS; 173 AS; and 7512 deaths. PCV13 prevented 419,815 AOM; 112,331 PN; 3116 PM; 4285 PS; 404 NS; 248 AS; and 10,386 deaths. Avoided DALYs were 226,370 with PCV10 and 313,119 with PCV13. Saved treatment costs were US$ 37.39 million with PCV10 and US$ 47.22 million with PCV13. Costs per DALY averted were US$ 1605 for PCV10, and US$ 1304 for PCV13. Sensitivity analyses showed similar results. PCV13 has an extended dominance over PCV10. CONCLUSION: Both pneumococcal vaccines are cost effective in the Peruvian context. Although the net cost of vaccination with PCV10 is lower, PCV13 prevented more deaths, pneumococcal complications and sequelae. Costs per each prevented DALY were lower with PCV13. Thus, PCV13 would be the preferred policy; PCV10 would also be reasonable (and cost-saving relative to the status quo) if for some reason 13-valent were not feasible.

Cost-effectiveness analysis of pneumococcal conjugate vaccines in preventing pneumonia in Peruvian children.

INTRODUCTION: Pneumococcal pneumonia (PP) has a high burden of morbimortality in children. Use of pneumococcal conjugate vaccines (PCVs) is an effective preventive measure. After PCV 7-valent (PCV7) withdrawal, PCV 10-valent (PCV10) and PCV 13-valent (PCV13) are the alternatives in Peru. This study aimed to evaluate cost effectiveness of these vaccines in preventing PP in Peruvian children <5 years-old. METHODOLOGY: A cost-effectiveness analysis was developed in three phases: a systematic evidence search for calculating effectiveness; a cost analysis for vaccine strategies and outcome management; and an economic model based on decision tree analysis, including deterministic and probabilistic sensitivity analysis using acceptability curves, tornado diagram, and Monte Carlo simulation. A hypothetic 100 vaccinated children/vaccine cohort was built. An incremental cost-effectiveness ratio (ICER) was calculated. RESULTS: The isolation probability for all serotypes in each vaccine was estimated: 38% for PCV7, 41% PCV10, and 17% PCV13. Avoided hospitalization was found to be the best effectiveness model measure. Estimated costs for PCV7, PCV10, and PCV13 cohorts were USD13,761, 11,895, and 12,499, respectively. Costs per avoided hospitalization were USD718 for PCV7, USD333 for PCV10, and USD 162 for PCV13. At ICER, PCV7 was dominated by the other PCVs. Eliminating PCV7, PCV13 was more cost effective than PCV10 (confirmed in sensitivity analysis). CONCLUSIONS: PCV10 and PCV13 are more cost effective than PCV7 in prevention of pneumonia in children <5 years-old in Peru. PCV13 prevents more hospitalizations and is more cost-effective than PCV10. These results should be considered when making decisions about the Peruvian National Inmunizations Schedule.

Disponibilidad de medicamentos psicotrópicos en establecimientos del Ministerio de Salud del Perú, 2011 / Availability of psychotropic medications in health care facilities of the Ministry of Health of Peru, 2011

Objetivos. Describir la disponibilidad de medicamentos psicotrópicos para el tratamiento de trastornos mentales en el Perú en los establecimientos del Ministerio de Salud. Materiales y métodos. Se analizaron informes mensuales de inventarios de medicamentos disponibles y de consumo en los establecimientos del Ministerio de Salud durante el año 2011. Usando un diseño transversal, se determinó la disponibilidad de siete clases de medicamentos psicotrópicos, distinguiendo el nivel de atención de los establecimientos, y el nivel de autonomía de decisión para la compra de medicamentos. Resultados. Los medicamentos ansiolíticos estuvieron disponibles en los establecimientos de salud de todos los niveles de atención. Los antidepresivos y antipsicóticos se encontraron disponibles en alrededor de dos tercios de los hospitales, y en menos del 20% de centros y puestos de salud. Las otras cuatro clases de medicamentos psicotrópicos (litio, hipnóticos y sedantes, psicoestimulantes/TDAH y drogas antidemencia) solo estuvieron disponibles en hospitales y mas no así en centros y puestos de salud. El 5% de los hospitales contó con suministro suficiente para satisfacer la demanda durante todos los meses del año. Conclusiones. Existe una importante brecha en la disponibilidad de medicamentos psicotrópicos en los establecimientos del Ministerio de Salud del Perú. Se observa esta situación tanto en hospitales como en el nivel primario de atención. Es necesario tomar acciones en la política y gestión de salud, incluyendo más financiamiento y una mayor capacitación en salud mental para el personal de la atención primaria, entre otras iniciativas.

Objectives. Describe the availability of psychotropic medications for the treatment of mental disorders in the health care facilities of the Ministry of Health of Peru. Materials and methods. Monthly inventory reports of the availability and consumption of medications in facilities of the Ministry of Health during 2011 were analyzed. Using a cross sectional design, the availability of seven classes of psychotropic medications was determined. Also, the level of care of the establishments and the level of decisional autonomy to purchase medications were determined. Results. Anti-anxiety medications were available in health facilities of all levels of care. Antidepressants and antipsychotics were available in about two thirds of hospitals and in less than 20% of health centers and small health clinics. The other four classes of psychotropic medications (lithium, hypnotics and sedatives, psychostimulants/ADHD, and anti-dementia drugs) were only available in hospitals and not in health centers and small health clinics. 5% of hospitals had a sufficient supply to meet the demand for the year. Conclusions. There is a significant gap in the availability of psychotropic medications in the health care facilities of the Ministry of Health of Peru. This was observed both in hospitals and in primary care facilities. Actions are needed in health policy and management, including more funding and greater mental health training for staff in primary care, among other initiatives.

Aceptabilidad del castigo físico en la crianza de los niños en personas que fueron víctimas de violencia física en la niñez en Perú / Acceptability of physical punishment in child rearing by people who were victims of physical violence during childhood in Peru

Objetivos. El estudio evaluó la asociación entre haber sido víctima de violencia física en la niñez y la aceptabilidad, en etapas posteriores de vida, hacia el uso del castigo físico en la crianza de los niños. Materiales y métodos. Se realizó un análisis secundario de un estudio sobre violencia en 6399 personas mayores de 14 años residentes de las ciudades de Lima, Callao, Maynas, Arequipa, Cusco, Trujillo y Huamanga. Se usó modelos de regresión logística univariados y multivariados para estimar asociaciones estadísticas. Resultados. La aceptabilidad del uso del castigo físico en la crianza de niños es mayor en personas con el antecedente de ser víctimas de violencia física durante la niñez en comparación con las no victimizadas (OR=1,8; IC 95%: 1,5-2,1; p<0,001) ajustando por potenciales variables de confusión. Conclusiones. Las personas expuestas a violencia física durante la niñez tienen más riesgo de aceptar o justificar la misma durante la adultez, lo que podría contribuir a mantener esta práctica de crianza de una generación a la siguiente. Iniciativas dirigidas a prevenir el uso del castigo físico en la crianza de niños se deben implementar para reducir la tendencia a reproducir el ejercicio de violencia en personas victimizadas.

Objectives. This study evaluated the association between having been a victim of physical violence during childhood and the acceptability, in later life, towards the use of physical punishment in child rearing. Materials and methods. A secondary analysis was conducted of a study on violence in 6,399 people over 14 years of age living in the cities of Lima, Callao, Maynas, Arequipa, Cusco, Trujillo and Huamanga. Univariate and multivariate logistic regression models were used to estimate statistical associations. Results. The acceptability of the use of physical punishment in child rearing is higher in people who were victims of physical abuse during childhood compared with non-victimized people (OR = 1.8; 95% CI: 1.5-2 1; p <0.001) after adjusting for potential confounders. Conclusions. People exposed to physical violence during childhood are more likely to accept or justify violence in adulthood, which could help maintain this child rearing practice from one generation to the next. Initiatives aimed at preventing the use of physical punishment in child rearing should be implemented to reduce the tendency to reproduce the action of violence by victimized people.