[Medical Care of people living with HIV in the Instituto Mexicano del Seguro Social]. / Atención a personas que viven con el VIH en el IMSS.

Infection by the human immunodeficiency virus (HIV) is apublic health problem worldwide, however, the incidence has remained relatively stable. In Mexico, around 10,000 new cases are reported each year. The Instituto Mexicano del Seguro Social (IMSS) has been a pioneer in the care of people living with HIV (PLWHA), gradually incorporating the different antiretroviral drugs (ARV). The first ARV used at the institutional level was zidovudine, in the 1990s, and later other agents were incorporated, such as protease inhibitors, drugs from the group of non-nucleoside analogs, and integrase inhibitors. In 2020, the migration to ARV schemes coformulated in a single tablet based on integrase inhibitors, which constitute a highly effective option and timely supply of drugs has been achieved in 99% of the population. In the aspect of prevention, the IMSS has also been a pioneer by being the first institution to implement HIV pre-exposure prophylaxis in 2021 at the national level and since 2022 universal post-exposure prophylaxis is available. The IMSS continues to be at the forefront incorporating the use of different management tools and instruments for the benefit of the population living with HIV. This document summarizes the history of HIV in the IMSS from the beginning of the epidemic to the present time.

La infección por el virus de la inmunodeficiencia humana (VIH) es un problema de salud pública a nivel mundial, sin embargo, la incidencia ha permanecido relativamente estable. En México se informa de alrededor de 10,000 casos nuevos al año. El Instituto Mexicano del Seguro Social (IMSS) ha sido pionero en la atención a las personas que viven con el VIH (PVV), incorporando paulatinamente los diferentes medicamentos antirretrovirales (ARV). El primer ARV utilizado a nivel institucional fue la zidovudina, en la década de los noventa, y posteriormente fueron incorporados otros agentes como los inhibidores de la proteasa, los medicamentos del grupo de los análogos no nucleósidos y los inhibidores de la integrasa. En el año 2020 ocurrió la migración a esquemas de ARV coformulados en una sola tableta a base de inhibidores de la integrasa, que constituyen una opción de alta eficacia y se ha logrado el surtimiento oportuno de los fármacos en el 99% de la población. En el aspecto de la prevención, el IMSS también ha sido pionero al ser la primera institución en implementar la profilaxis preexposición de VIH en el año 2021 a nivel nacional y desde el año 2022 se dispone de la profilaxis postexposición universal. El IMSS continúa a la vanguardia incorporando el uso de diferentes herramientas e instrumentos de gestión para beneficio de la población que vive con el VIH. En el presente documento se sintetiza la historia del VIH en el IMSS desde los inicios de la epidemia hasta el momento actual.

Effect of highly active antiretroviral therapy on homocysteine plasma concentrations in HIV-1-infected patients.

OBJECTIVE: To analyze the effect of antiretroviral therapy on homocysteine levels in HIV-1-infected patients. DESIGN: Observational, prospective study of patients with AIDS. METHODS: We included patients with HIV-1 infection naive for antiretroviral drugs. Before and after 6 months of treatment, we evaluated fasting and postoral methionine load plasma homocysteine, serum vitamins B6 and B12, and intraerythrocyte folate levels. RESULTS: We studied 69 patients who began therapy for a 6-month period. Fasting and postoral methionine load plasma homocysteine levels increased significantly after 6 months of antiretroviral therapy with respect to basal values (P < 0.001). Fasting hyperhomocysteinemia was present in 7.3% of patients before treatment and in 89.9% after 6 months of therapy (P = 0.0001). Postoral methionine load hyperhomocysteinemia was found in 4.5% of subjects before therapy vs. 98.5% at the end of study period (P = 0.001). These results were not associated with folate or vitamins B6 or B12 levels. CONCLUSIONS: In patients with HIV-1 infection, fasting and postoral methionine load plasma homocysteine levels increased after 6 months of antiretroviral treatment. Nutritional abnormalities were not responsible for hyperhomocysteinemia, suggesting that enzymatic disturbances in the metabolic pathways of homocysteine may occur.

Effect of combined administration of clopidogrel and lysine acetylsalicylate versus clopidogrel and aspirin on platelet aggregation and activated GPIIb/IIIa expression in healthy volunteers.

Platelet activation contributes to thrombotic events in cardiovascular disease. Acetylsalicylic acid (ASA) is used in combination with clopidogrel to reduce cardiovascular events. Lysine acetylsalicylate (L-ASA), also inhibits platelet activation with fewer gastrointestinal side effects than ASA. Dual therapy with L-ASA and clopidogrel may result in an antiplatelet effect with fewer side effects. We compared the antiplatelet effect of combined ASA/clopidogrel versus L-ASA/clopidogrel in healthy subjects. Fourteen volunteers (seven men and seven women, aged 25-45 years) received antiplatelet therapy during 14-day periods in the following sequence: 75 mg ASA; 160 mg L-ASA; 75 mg clopidogrel; 160 mg L-ASA plus 75 mg clopidogrel, and 75 mg ASA plus 75 mg clopidogrel. We evaluated platelet aggregation and glycoprotein IIb/IIIa activation. Our results show that administration of L-ASA/clopidogrel is as effective as ASA/clopidogrel combination.

[Clinical characteristics and follow-up of patients with AIDS and acute abdominal pain]. / Características clínicas y evolución de pacientes con SIDA y dolor abdominal agudo.

Abdominal symptoms frequently affect patients with AIDS. Acute abdominal pain is a diagnostic challenge that may require elective or urgent surgical treatment, although information about the latter is scarce. In this study we analyzed the clinical findings and follow-up of acute abdominal pain complicating patients with AIDS. In a two-year period, we collected several variables from patients with AIDS and acute abdominal pain: demographic, laboratory, clinical symptoms, initial diagnosis, surgical findings, post-surgical and histopathological diagnosis and post-surgical complications. From 232 hospitalized patients, 34 had acute abdominal pain: 32 male and 2 women (median age = 32 years; range 26 to 58 years). Twenty-two patients required surgical treatment. Eight patients had a post-surgical complication; in five of them, six surgical re-interventions were performed. Three deaths occurred in the 30-day period after surgery. Survival for patients conservatively treated was 4 months (1 to 17 months), vs. 6.5 months (1 to 20 months) in the surgically treated group. Physicians should be aware about the several diagnostic possibilities of acute abdominal pain complicating patients with AIDS. Delay of surgery in these patients may be lethal. Surgery has an important role in the integral treatment of patients with AIDS.

Características clínicas y evolución de pacientes con SIDA y dolor abdominal agudo / Clinical characteristics and follow-up of patients with AIDS and acute abdominal pain

Los síntomas abdominales son frecuentes en el SIDA y el dolor abdominal es un reto diagnóstico que puede requerir cirugía electiva o urgente aunque la información acerca de esta última es pobre. En este estudio analizamos los hallazgos clínicos y evolución de pacientes con SIDA y dolor abdominal agudo. En un periodo de dos años, recolectamos variables demográficas y de laboratorio, síntomas clínicos, diagnóstico inicial, hallazgos quirúrgicos, diagnóstico postquirúrgico, hallazgos histopatológicos y complicaciones postoperatorias de pacientes con SIDA y dolor abdominal agudo. De 232 pacientes hospitalizados, 34 tuvieron dolor abdominal agudo: 32 hombres y 2 mujeres (mediana de edad = 32 años; intervalos 26 a 58). Veintidós pacientes requirieron manejo quirúrgico. Ocho pacientes presentaron complicaciones postquirúrgicas; cinco requirieron seis segundas intervenciones. Ocurrieron tres muertes en los 30 días luego de la cirugía inicial. La supervivencia para los pacientes tratados médicamente fue 4 meses (1 a 17), contra 6.5 meses (1 a 20) del grupo quirúrgico. El médico debe estar alerta acerca de las posibilidades diagnósticas del enfermo con SIDA y dolor abdominal agudo. Demorar la cirugía puede ser letal. La cirugía tiene un papel importante en el tratamiento integral del paciente con SIDA.

Abdominal symptoms frequently affect patients with AIDS. Acute abdominal pain is a diagnostic challenge that may require elective or urgent surgical treatment, although information about the latter is scarce. In this study we analyzed the clinical findings and follow up of acute abdominal pain complicating patients with AIDS. In a two-year period, we collected several variables from patients with AIDS and acute abdominal pain: demographic, laboratory, clinical symptoms, initial diagnosis, surgical findings, post surgical and histopathological diagnosis and post surgical complications. From 232 hospitalized patients, 34 had acute abdominal pain: 32 male and 2 women (median age = 32 years; range 26 to 58 years). Twenty-two patients required surgical treatment. Eight patients had a post surgical complication; in five of them, six surgical re interventions were performed. Three deaths occurred in the 30 day period after surgery. Survival for patients conservatively treated was 4 months (1 to 17 months), vs. 6.5 months (1 to 20 months) in the surgically treated group. Physicians should be aware about the several diagnostic possibilities of acute abdominal pain complicating patients with AIDS. Delay of surgery in these patients may be lethal. Surgery has an important role in the integral treatment of patients with AIDS.

Venous thrombosis among patients with AIDS.

Thrombosis has been considered an uncommon complication in patients with AIDS. In a 42-month period, 28 adult male homosexuals with AIDS experienced 34 thrombotic events. All but three received HAART regimen, two a successful round of double nucleoside analog therapy, and one patient received no treatment. Median age of group was 38.5 years (range, 24 to 56 years). Median time from HIV infection to thrombosis was 40.5 months (range, 3 to 108 months). No patient had previous thrombosis, family history of thrombosis, or prothrombotic conditions. There were 31 deep vein thromboses, two pulmonary thromboembolisms, and one renal vein thrombosis. Six patients had two thrombotic events. The rate of thrombosis during the 42-month study period was 1.52% (cumulative incidence = 0.30%/year), while the rate of thrombosis in 600 patients before the era of protease inhibitor therapy was 0.33% (cumulative incidence approximately 0.055%/year) (p < 0.001). Due to high incidence of thrombotic recurrences and hemorrhagic complications while using oral anticoagulants, acetylsalicylic acid was initiated; no thrombotic episodes were recorded while using this drug. Protein C and protein S deficiency were found in nine and two patients, respectively. Two patients had lupus anticoagulant and two activated protein C resistance (APCR) without FV Leiden mutation (APCR test was negative after initial screening). Fifteen patients had no thrombophilic abnormalities. These data suggest that protease inhibitors could be a risk factor for venous thrombosis not due to thrombophilic abnormalities but likely related to abnormalities in platelets or endothelium.

Diarrea crónica y Cryptosporidium en pacientes diabéticos con subpoblación linfocitaria normal: informe de dos casos / Chronic diarrhea and Cryptosporidium in diabetic patients with normal lymphocyte subset counts: report of two cases

Se describen dos casos de pacientes diabéticos con cuentas normales de linfocitos TCD4+, que presentaban diarrea crónica y en los cuales se detectó Cryptosporidium en heces. En ambos casos las pruebas serológicas para VIH resultaron negativas. El hecho de que estos pacientes desarrollaran una patología que se observa comunmente en presencia de cuentas bajas de linfocitos TCD4+, sugiere que una alteración inmunológica distinta de la celular pudiera estar involucrada en la patogénesis de esta infección. Los autores sugieren que la búsqueda intencionada de Cryptosporidium debe considerarse en el estudio de la diarrea crónica del paciente diabético