Long-term HIV care outcomes under universal HIV treatment guidelines: A retrospective cohort study in 25 countries.

BACKGROUND: While national adoption of universal HIV treatment guidelines has led to improved, timely uptake of antiretroviral therapy (ART), longer-term care outcomes are understudied. There is little data from real-world service delivery settings on patient attrition, viral load (VL) monitoring, and viral suppression (VS) at 24 and 36 months after HIV treatment initiation. METHODS AND FINDINGS: For this retrospective cohort analysis, we used observational data from 25 countries in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium's Asia-Pacific, Central Africa, East Africa, Central/South America, and North America regions for patients who were ART naïve and aged ≥15 years at care enrollment between 24 months before and 12 months after national adoption of universal treatment guidelines, occurring 2012 to 2018. We estimated crude cumulative incidence of loss-to-clinic (CI-LTC) at 12, 24, and 36 months after enrollment among patients enrolling in care before and after guideline adoption using competing risks regression. Guideline change-associated hazard ratios of LTC at each time point after enrollment were estimated via cause-specific Cox proportional hazards regression models. Modified Poisson regression was used to estimate relative risks of retention, VL monitoring, and VS at 12, 24, and 36 months after ART initiation. There were 66,963 patients enrolling in HIV care at 109 clinics with ≥12 months of follow-up time after enrollment (46,484 [69.4%] enrolling before guideline adoption and 20,479 [30.6%] enrolling afterwards). More than half (54.9%) were females, and median age was 34 years (interquartile range [IQR]: 27 to 43). Mean follow-up time was 51 months (standard deviation: 17 months; range: 12, 110 months). Among patients enrolling before guideline adoption, crude CI-LTC was 23.8% (95% confidence interval [95% CI] 23.4, 24.2) at 12 months, 31.0% (95% CI [30.6, 31.5]) at 24 months, and 37.2% (95% [CI 36.8, 37.7]) at 36 months after enrollment. Adjusting for sex, age group, enrollment CD4, clinic location and type, and country income level, enrolling in care and initiating ART after guideline adoption was associated with increased hazard of LTC at 12 months (adjusted hazard ratio [aHR] 1.25 [95% CI 1.08, 1.44]; p = 0.003); 24 months (aHR 1.38 [95% CI 1.19, 1.59]; p < .001); and 36 months (aHR 1.34 [95% CI 1.18, 1.53], p < .001) compared with enrollment before guideline adoption, with no before-after differences among patients with no record of ART initiation by end of follow-up. Among patients retained after ART initiation, VL monitoring was low, with marginal improvements associated with guideline adoption only at 12 months after ART initiation. Among those with VL monitoring, VS was high at each time point among patients enrolling before guideline adoption (86.0% to 88.8%) and afterwards (86.2% to 90.3%), with no substantive difference associated with guideline adoption. Study limitations include lags in and potential underascertainment of care outcomes in real-world service delivery data and potential lack of generalizability beyond IeDEA sites and regions included in this analysis. CONCLUSIONS: In this study, adoption of universal HIV treatment guidelines was associated with lower retention after ART initiation out to 36 months of follow-up, with little change in VL monitoring or VS among retained patients. Monitoring long-term HIV care outcomes remains critical to identify and address causes of attrition and gaps in HIV care quality.

Sarcoma de Kaposi en personas que viven con VIH-SIDA en un hospital público de referencia en Perú / Kaposi's sarcoma in people living with HIV/aids in a public referral hospital in Peru

RESUMEN El sarcoma de Kaposi (SK) es el cáncer más frecuente en las personas que viven con VIH. Las investigaciones sobre esta condición son escasas en la región, por lo que, el objetivo de este artículo fue describir las características demográficas, clínicas y terapéuticas de los pacientes con VIH que desarrollaron SK en el Hospital Cayetano Heredia entre el 2000 y 2018. Se identificaron 129 casos de SK, con una mediana de edad de 33 años, con predominio en varones con el 92% (119/129), y en su mayoría hombres que tienen sexo con hombres (HSH). La mediana de tiempo desde el diagnóstico de VIH hasta el del SK fue de cinco meses, asociado con un recuento de linfocitos CD4 de 64 células/µL (RIC: 33-185) al momento del diagnóstico de SK. El compromiso cutáneo fue el más común; sin embargo, al menos la mitad de ellos también tuvo la forma visceral.

ABSTRACT Kaposi's sarcoma (KS) is the most frequent cancer in people living with HIV. Research on this condition is scarce in the region, therefore, this article aimed to describe the demographic, clinical and therapeutic characteristics of patients with HIV who developed KS at the Cayetano Heredia Hospital between 2000 and 2018. A total of 129 KS cases were identified, with a median age of 33 years, predominantly males with 92% (119/129), and mostly men who have sex with men (MSM). The median time from HIV diagnosis to KS diagnosis was five months, associated with a CD4 lymphocyte count of 64 cells/μL (IQR: 33-185) at KS diagnosis. Cutaneous involvement was the most common presentation; however, at least half also had the visceral form.

Cáncer en personas que viven con VIH-SIDA en un hospital público de referencia en Perú

El objetivo del estudio fue describir las características demográficas, clínicas y terapéuticas de pacientes con VIH-SIDA que desarrollaron algún tipo de cáncer. Se identificaron 276 casos de cáncer diagnosticados en el Hospital Nacional Cayetano Heredia entre el 2000 y 2018. El 80,8% (223/276) correspondieron a neoplasias definitorias de sida (NDS), siendo el más frecuente el sarcoma de Kaposi; mientras que, entre las neoplasias no definitorias de sida (NNDS), el más frecuente fue el linfoma de Hodgkin. La mediana de edad fue 36,5 años, siendo más alta entre los casos diagnosticados de NNDS. Con respecto al nivel de linfocitos CD4 al diagnóstico de cáncer, la mediana entre las NDS fue mucho menor que las NNDS, 87,5 células/µL y 216 células/µL, respectivamente. Por tanto, las NNDS tuvieron una historia más larga de infección por VIH, y una edad más avanzada al diagnóstico de cáncer, así como niveles de células CD4 más altos.

This study was carried out to describe and compare the demographic, clinical, and therapeutic characteristics of HIV patients who developed some cancer. We identified 276 cancer cases diagnosed at Hospital Cayetano Heredia between 2000 and 2018. 80,8% (223/276) had AIDS-defining-cancers (ADCs), being Kaposi's Sarcoma the most frequent type; meanwhile, among non-AIDS-defining-cancers (NADCs), the most frequent was Hodgkin lymphoma. The median age was 36,5 years, being highest among the cases diagnosed with NADCs. Concerning CD4 lymphocyte counts, the median among ADCs was much lower than NADCs, 87,5 cells/µl and 216 cells/µl, respectively. Therefore, NADCs cases have a longer history of HIV infection, and an older age at cancer diagnosis, as well as higher CD4 cells counts.

Falla hepática aguda fulminante como manifestación de leucemia de células T del adulto en paciente con infección por HTLV-1 / Acute Liver Failure as Presentation of Adult T-cell Leukemia in an HTLV-1 Patient

La falla hepática aguda es el desarrollo de injuria hepática severa con deterioro de la función de síntesis y encefalopatía. Dentro de la variedad de causas, las infiltraciones neoplásicas representan menos del 0,5%. Presentamos el caso de un paciente varón HTLV1 positivo que debuta con una clínica de hepatitis aguda, siendo posteriormente diagnosticado con diseminación de linfoma/leucemia de células T del adulto. Desafortunadamente el paciente presentó deterioro rápido y progresivo de la función hepática, falleciendo a los pocos días de la hospitalización

Acute liver failure is the development of severe hepatic injury with deterioration of liver synthesis function and encephalopathy. Among all the variety of causes, neoplastic infiltration represents less than 0.5%. We present the case of a male patient with a past medical history of HTLV-1 infection, who reports symptoms of acute hepatitis, being diagnosed with Adult T-cell leukemia/ lymphoma. Unfortunately, the patient had a rapid deterioration and passed away a few days after admission

Linfoma duodenal asociado a infección por Strongyloides stercoralis. Dos manifestaciones de la infección por HTLV-1 / Duodenal Lynphoma associated to Strongyloides stercoralis infection. Two types of HTLV-1 infection

La infección por el virus linfotrópico de células T humanas tipo 1 (HTLV-1), es causante de la leucemia/linfoma de células T del Adulto (ATLL), siendo la afectación duodenal poco usual. La coinfección de HTLV-1 con Strongyloides stercolaris es común en los pacientes con HTLV- 1 debido a la inadecuada respuesta TH2 que presentan estos sujetos. Describimos a una paciente mujer de 48 años de edad, natural y procedente de la selva del Perú con historia familiar de infección por HTLV- 1 quien acude con diarrea crónica y baja de peso. Se le diagnosticó infección por HTLV-1 así como ATLL duodenal y estrongiloidiasis. Se inició tratamiento con ivermectina y quimioterapia, siendo estabilizada y dada de alta. Reportamos el presente caso debido a la poca frecuencia de coexistencia en duodeno de ATLL y estrongiloidiasis.

Infection by the Human T- Lymphotropic virus I (HTLV-1) causes Adult T cell Leukemia-lymphoma (ATLL), being the duodenal involvement rare. Commonly, patients co-infected with HTLV-1 and Strongyloides stercoralis are seen due to the lack of TH2 response found on these patients. We describe a 48-year-old woman, from the jungle of Peru, with a family history of HTLV-1 infection, who presented with a History of chronic diarrhea and weight loss. HTLV-1 infection with ATLL and strongyloidiasis were diagnosed. Ivermectin treatment and chemotherapy were initiated, being stabilized, and discharged. We report this case because of the unusual coexistence in the duodenum of ATLL and strongyloidiasis.

Compromiso intestinal por Mycobacterium avium en un paciente con VIH/ SIDA / Intestinal disease due to Mycobacterium avium in a patient with HIV/AIDS

amos el primer caso de colitis por Mycobacterium avium en un paciente peruano con infección por VIH /SIDA.

We report the first case of colitis due to Mycobacterium avium in a Peruvian patient with HIV/AIDS.