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INTRODUCTION: Immune reconstitution following antiretroviral therapy (ART) initiation is crucial to prevent AIDS and non-AIDS-related comorbidities. Patients with suppressed viraemia who fail to restore cellular immunity are exposed to an increased risk of morbidity and mortality during long-term follow-up, although the underlying mechanisms remain poorly understood. We aim to describe clinical outcomes and factors associated with the worse immune recovery and all-cause mortality in people living with HIV (PLWH) from Latin America following ART initiation. METHODS: Retrospective cohort study using the CCASAnet database: PLWH ≥18 years of age at ART initiation using a three drug-based combination therapy and with medical follow-up for ≥24 months after ART initiation and undetectable viral load were included. Patients were divided into four immune recovery groups based on rounded quartiles of increase in CD4 T-cell count at 2 years of treatment (<150, [150, 250), [250, 350] and >350 cells/mm3 ). Primary outcomes included all-cause mortality, AIDS-defining events and non-communicable diseases that occurred >2 years after ART initiation. Factors associated with an increase in CD4 T-cell count at 2 years of treatment were evaluated using a cumulative probability model with a logit link. RESULTS: In our cohort of 4496 Latin American PLWH, we found that patients with the lowest CD4 increase (<150) had the lowest survival probability at 10 years of follow-up. Lower increase in CD4 count following therapy initiation (and remarkably not a lower baseline CD4 T-cell count) and older age were risk factors for all-cause mortality. We also found that older age, male sex and higher baseline CD4 T-cell count were associated with lower CD4 count increase following therapy initiation. CONCLUSIONS: Our study shows that PLWH with lower increases in CD4 count have lower survival probabilities. CD4 increase during follow-up might be a better predictor of mortality in undetectable PLWH than baseline CD4 count. Therefore, it should be included as a routine clinical variable to assess immune recovery and overall survival.
Assuntos
Síndrome da Imunodeficiência Adquirida , Fármacos Anti-HIV , Infecções por HIV , Humanos , Masculino , Estudos Retrospectivos , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Fatores de Risco , Quimioterapia Combinada , Contagem de Linfócito CD4 , Carga Viral , Fármacos Anti-HIV/uso terapêutico , Terapia Antirretroviral de Alta AtividadeRESUMO
BACKGROUND: Case-control studies involving test-negative (TN) and syndrome-negative (SN) controls are reliable for evaluating influenza and rotavirus vaccine effectiveness (VE) during a random vaccination process. However, there is no empirical evidence regarding the impact in real-world mass vaccination campaigns against SARS-CoV-2 using TN and SN controls. OBJECTIVE: To compare in the same population the effectiveness of SARS-CoV-2 vaccination on COVID-19-related hospitalization rates across a cohort design, TN and SN designs. METHOD: We conducted an unmatched population-based cohort, TN and SN case-control designs linking data from four data sources (public primary healthcare system, hospitalization registers, epidemiological surveillance systems and the national immunization program) in a Chilean municipality (Rancagua) between March 1, 2021 and August 31, 2021. The outcome was COVID-19-related hospitalization. To ensure sufficient sample size in the unexposed group, completion of follow-up in the cohort design, and sufficient time between vaccination and hospitalization in the case-control design, VE was estimated comparing 8-week periods for each individual. RESULTS: Among the 191,505 individuals registered in the primary healthcare system of Rancagua in Chile on March 1, 2021; 116,453 met the cohort study's inclusion criteria. Of the 9,471 hospitalizations registered during the study period in the same place, 526 were COVID-19 cases, 108 were TN controls, and 1,628 were SN controls. For any vaccine product, the age- and sex-adjusted vaccine effectiveness comparing fully and nonvaccinated individuals was 67.2 (55.7-76.3) in the cohort design, whereas it was 67.8 (44.1-81.4) and 77.9 (70.2-83.8) in the TN and SN control designs, respectively. CONCLUSION: The VE of a COVID-19 vaccination program based on age and risk groups tended to differ across the three observational study designs. The SN case-control design may be an efficient option for evaluating COVID-19 VE in real-world settings.
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Vacinas contra COVID-19 , COVID-19 , Hospitalização , Vacinação em Massa , SARS-CoV-2 , Eficácia de Vacinas , Humanos , COVID-19/prevenção & controle , COVID-19/epidemiologia , Chile/epidemiologia , Pessoa de Meia-Idade , Hospitalização/estatística & dados numéricos , Masculino , Feminino , Adulto , Idoso , Vacinas contra COVID-19/imunologia , Vacinas contra COVID-19/administração & dosagem , Estudos de Casos e Controles , Adolescente , SARS-CoV-2/imunologia , Vacinação em Massa/métodos , Vacinação em Massa/estatística & dados numéricos , Adulto Jovem , Criança , Pré-Escolar , Lactente , Estudos de Coortes , Programas de Imunização , Idoso de 80 Anos ou maisRESUMO
Objectives: As earthquakes occur frequently in Latin America and can cause significant disruptions in HIV care, we sought to analyze patterns of HIV care for adults at Latin American clinical sites experiencing a significant earthquake within the past two decades. Study design: Retrospective clinical cohort study. Methods: Adults receiving HIV care at sites experiencing at least a "moderate intensity" (Modified Mercalli scale) earthquake in the Caribbean, Central and South America network for HIV epidemiology (CCASAnet) contributed data from 2003 to 2017. Interrupted Time Series models were fit with discontinuities at site-specific earthquake dates (Sept. 16, 2015 in Chile; Apr. 18, 2014 and Sept. 19, 2017 in Mexico; and Aug. 15, 2007 in Peru) to assess clinical visit, CD4 measure, viral load lab, and ART initiation rates 3- and 6-months after versus before earthquakes. Results: Comparing post-to pre-earthquake periods, there was a sharp drop in median visit (incidence rate ratio [IRR] = 0.79, 95% confidence interval [CI]: 0.68-0.91) and viral load lab (IRR = 0.78, 95% CI: 0.62-0.99) rates per week, using a 3-month window. CD4 measurement rates also decreased (IRR = 0.43; 95% CI: 0.37-0.51), though only using a 6-month window. Conclusions: Given that earthquakes occur frequently in Latin America, disaster preparedness plans must be more broadly implemented to avoid disruptions in HIV care and attendant poor outcomes.
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INTRODUCTION: The objective was to characterize real-world outcomes of drug-drug interactions (DDIs) between antiretrovirals (ARVs) and other drugs, including over-the-counter medications (OTC), and treatment outcomes in clinical practice. METHODS: www.clinicalcasesDDIs.com is an open-access website for healthcare providers to consult and briefly describe real-world clinical cases on DDI with ARVs. We reviewed all the clinical cases reported to the website between March 2019 and May 2023. RESULTS: A total of 139 cases were reported, mostly involving ritonavir or cobicistat (boosters; 74 cases), unboosted integrase inhibitors (InSTI; 29 cases), and non-nucleoside reverse transcriptase inhibitors (NNRTI; 23 cases). Central nervous system drugs (29 cases) and cardiovascular drugs (19 cases) were the most frequently described co-medications. Notably, OTC medications were implicated in 27 cases, including mineral supplements (11 cases), herbals (8 cases), weight loss drugs (4 cases), anabolic steroids (3 cases), and recreational drugs (1 case). OTC acted as the perpetrator drug in 21 cases, leading to loss of ARV efficacy in 17 instances (mineral supplements in 10 cases, weight loss drugs in 4 cases, herbals in 3 cases). Additionally, toxicity was reported in 4 out of 6 cases where OTC was considered the victim drug of the DDI (anabolic steroids in 3 cases, MDMA in 1 case). CONCLUSIONS: Frequent unwanted outcomes resulting from DDIs between ARVs and OTC medications underscore the importance of integrating non-prescription drugs into medication reconciliation. The real-world data available through www.clinicalcasesDDIs.com serves as a valuable resource for assessing the clinical relevance of DDIs.
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Infecções por HIV , Pessoas Transgênero , Humanos , Identidade de Gênero , Estudos LongitudinaisRESUMO
INTRODUCCIÓN: En las cuatro décadas de la epidemia por VIH, se han observado avances notables que han contribuido a una disminución progresiva en la incidencia de nuevas infecciones y en la mortalidad a nivel mundial. Sin embargo, no ha ocurrido lo mismo en Latinoamérica y en Chile. OBJETIVO: Esta revisión tiene como objetivo conocer la epidemiología actual a nivel global, latinoamericano y chileno. METODOLOGÍA: Se analizaron los informes epidemiológicos oficiales de infección por VIH emitidos por organismos nacionales e internacionales, más los estudios epidemiológicos nacionales. RESULTADOS: Se estima que 39 millones de personas viven con VIH en el mundo; no obstante, la mortalidad y la incidencia de nuevos casos han disminuido de forma notoria durante las últimas dos décadas, asociado a una expansión en al acceso a terapia antirretroviral en forma global. A diferencia del resto del mundo, América Latina presenta una tendencia de alza en las nuevas infecciones y Chile registra un aumento de 35% en nuevos casos durante los últimos 10 años, coincidiendo con un aumento en los flujos de migrantes que ha afectado a la región. Algunas estrategias preventivas como la profilaxis pre exposición se han implementa-do a un ritmo lento, tanto a nivel mundial, como latinoamericano. CONCLUSIONES: La epidemiología del VIH presenta características propias regionales y nacionales. En particular en Chile, diversos factores incluyendo déficit en políticas públicas de prevención y los recientes flujos migratorios han modelado nuestra actual epidemia. El desafío presente debe contemplar los esfuerzos multisectoriales para lograr los objetivos de ONUSIDA en esta década.
BACKGROUND: Over the course of the last four decades of global HIV epidemic, significant improvements have contributed to gradually reduce the frequency of new infections and global mortality rates. However, in Latin America particularly in Chile, new infections continue increasing. AIM: This review aims to comprehend the_epidemiology today on a worldwide, Latin American, and Chilean scale. METHODS: National epidemiology studies and official HIV reports from international and national organizations were reviewed. RESULTS: It is estimated that 39 million people live with HIV worldwide; however, mortality and the incidence of new cases have decreased markedly over the last two decades, associated with an expansion in access to antiretroviral therapy globally. In contrast to the rest of the world, Latin America shows an upward trend in new infections, with Chile registering a 35% increase in new cases over the last 10 years, coinciding with an increase in migratory flows that has occurred throughout the region. Some preventive strategies, such as pre-exposure prophylaxis, have been implemented at a slow pace, both globally and in Latin America. CONCLUSIONS: The epidemiology of HIV has regional and national characteristics. Specifically in Chile, several factors, including deficits in public prevention policies and recent migratory flows, have shaped our current epidemic. The present challenge must contemplate multisectoral efforts to achieve the UNAIDS objectives during this decade.
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Humanos , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Infecções por HIV/tratamento farmacológico , Infecções por HIV/transmissão , Chile/epidemiologia , Saúde Global , Transmissão Vertical de Doenças Infecciosas/estatística & dados numéricos , Antirretrovirais/uso terapêutico , América Latina/epidemiologiaRESUMO
INTRODUCCIÓN: Se desconoce el grado de supresión viral en pacientes con infección por VIH que inician terapia antirretroviral (TAR) con cargas virales (CV) muy altas. OBJETIVO: Conocer el porcentaje de supresión viral en pacientes con VIH que inician TAR con CV ≥ 500.000 copias/mL a 96 semanas. PACIENTES Y MÉTODO: Estudio retrospectivo. Se incluyeron pacientes que iniciaron TAR con CV ≥ 500.000 copias/mL, entre los años 2008 y 2018, estratificándose en base a escala logarítmica. Se determinó el porcentaje de supresión viral, y las variables asociadas a este desenlace. RESULTADOS: Se incluyeron 221 pacientes. La mediana de edad y CV era de 43 años y 6,0 log, respectivamente, estando la mayoría (37%) en estadio C3 al inicio de TAR. El 48,8 y 87,7% de los pacientes logró la supresión viral al año y dos años de seguimiento, respectivamente. Se observó que, a mayor edad, a mayor inmunosupresión, y a mayor CV, mayor el tiempo para lograr la indetectabilidad. Sólo se demostró fracaso virológico en tres pacientes. DISCUSIÓN: Los pacientes con infección por VIH que inician TAR con CV muy altas demoran más tiempo en lograr la supresión viral, lo cual es proporcional a la magnitud de ésta y al grado de inmunosupresión, sin que esto conlleve mayor riesgo de fracaso virológico.
BACKGROUND: The degree of viral suppression in HIV patients who start antiretroviral therapy (ART) with very high viral loads (CV) is unknown. AIM: To know the percentage of viral suppression in HIV patients who start ART with CV ≥ 500,000 copies/mL at 96 weeks. METHOD: Retrospective study. Patients who started ART with a CV ≥ 500,000 copies/mL between 2008 and 2018 were included, stratifying on the basis of a logarithmic scale. The percentage of viral suppression and the variables associated with this outcome were determined. RESULTS: 221 patients were included. The median age and CV were 43 years and 6.0 log, respectively, with the majority (37%) being in stage C3 at the start of ART. 48.8 and 87.7% of the patients achieved viral suppression at one year and two years of follow-up, respectively. It was observed that the older the immunosuppression, and the higher CV, the longer the time to achieve undetectability. Virological failure was only demonstrated in three patients. DISCUSSION: Patients with HIV infection who start ART with very high CVs take longer to achieve viral suppression, which is proportional to the magnitude of this and the degree of immunosuppression, without this entailing a greater risk of virological failure.
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Humanos , Infecções por HIV/tratamento farmacológico , Fármacos Anti-HIV/uso terapêutico , Testes Sorológicos , Estudos Retrospectivos , Contagem de Linfócito CD4 , Carga Viral , Terapia Antirretroviral de Alta AtividadeRESUMO
Resumen En Chile, la cepa del virus parotídeo utilizada en la vacuna es Leningrad-Zagreb (L-Z). Aunque la relación entre meningitis y la cepa L-Z sigue siendo controvertida, la mayoría de los casos reportados han presentado un cuadro de curso benigno y sin secuelas neurológicas. Presentamos el caso de una paciente que tres semanas post-inmunización con la vacuna tresvírica evolucionó con una meningitis aséptica de predominio mononuclear, con serología para IgM positiva contra el virus parotídeo. En este caso clínico, existió una relación temporal entre la vacunación, el inicio del cuadro parotídeo y posteriormente el meníngeo; la curva de inmunoglobulinas demostró una infección aguda posterior a la vacuna. Si bien no se logró aislar el virus en LCR, es razonable atribuir el cuadro a una infección post-vacunal.
In Chile, the strain of the mumps virus used in the vaccine is Leningrad-Zagreb (L-Z). Although the relationship between meningitis and the L-Z strain remains controversial, most of the reported cases have shown a benign course without permanent neurological sequelae. We present a case of a patient who presented an aseptic meningitis three weeks after immunization with a mumps vaccine; and laboratory confirmation showed positive serum mumps IgM antibody. In this clinical case, there was a temporal relationship between vaccination and the onset of the mumps and subsequently the meningeal involvement; the immunoglobulin curve demonstrates acute infection after vaccination. Although it was not possible to isolate the virus in CSF, it is reasonable to attribute the picture to a post-vaccinal infection.
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Humanos , Meningite , Caxumba , Vacina contra Caxumba/efeitos adversos , Chile , Vírus da CaxumbaRESUMO
Background: The HIV epidemic reached Chile in late 1980s and as an early response, AIDS care centers were organized. Fundación Arriarán (FA) was the first center. Free antiretroviral therapy (ART) was later provided with progressive coverage and complexity over the years. Aim: To quantify evolution of mortality, retention and loss to follow up (LTFU) over 25 years according to different periods of access to ART, from no availability to full coverage with current drugs at FA center. Material and Methods: Retrospective analysis of FA database of 5,080 adults admitted between 1990 and 2014. The sample was distributed in 7 groups: A: no ART (1990-92), B: monotherapy, C: dual therapy, D: dual/triple ART, E: early triple therapy with incomplete coverage, F same as E but with complete coverage and G: contemporary ART (2008-14). Mortality, retention and LTFU were evaluated at 1, 3, 5, 7 and 10 years and at 31/12/2015. Results: Mortality varied from 40% to 2%, and 62% to 7% at 1 and 5 years, for groups A and G respectively; from 71% to 16% at 10 years for groups A and E, respectively. Retention at 5 years were 28%, 23%, 39%, 62%, 75%, 75% and 77% for groups A to G, respectively. LTFU was 10%, 19%, 15%, 17%, 9% 12% and 10% at 5 years for same groups, respectively. At 12/31/2015 22% of patients had died, 11% were LTFU, 60% were retained in care and 6% had been transferred. Conclusions: There is a marked reduction in mortality and increase in retention of HIV patients' concomitant to expanded access to modern therapy, although LTFU remains a problem.