[Hospitalizations and deaths related to sporotrichosis in Brazil (1992-2015)]. / Hospitalizações e óbitos relacionados à esporotricose no Brasil (1992-2015).

Sporotrichosis is a subcutaneous mycosis with global distribution, and patients generally receive outpatient treatment. Since 1998 there has been an increase in cases in the state of Rio de Janeiro, Brazil, mainly via zoonotic transmission involving cats. Patients coinfected with the human immunodeficiency virus (HIV) often require hospitalization and evolve to death. This study analyzes and describes data from 1992 to 2015 obtained from the database of the Brazilian Unified National Health System (SUS). There were 782 hospitalizations and 65 deaths in Brazil. Six percent of the hospitalizations and 40% of the deaths involved coinfection with HIV. There were 250 hospitalizations and 36 deaths in Rio de Janeiro, with a progressive increase over the course of the period. The states of São Paulo and Goiás also showed high numbers. Men, non-whites, and individuals with low schooling evolved more frequently to death. In conclusion, sporotrichosis is associated with hospitalizations and deaths throughout Brazil, especially in the state of Rio de Janeiro.

A esporotricose é uma micose subcutânea de distribuição global e, em geral, os pacientes são tratados ambulatorialmente. Desde 1998, observa-se aumento dos casos no Estado do Rio de Janeiro, Brasil, especialmente por transmissão zoonótica envolvendo gatos. Os pacientes coinfectados pelo vírus da imunodeficiência humana (HIV), muitas vezes, necessitam de hospitalizações e evoluem a óbito. Este estudo analisa e descreve dados de 1992 a 2015, provenientes de bancos de dados do Sistema Único de Saúde. No Brasil, ocorreram 782 hospitalizações e 65 óbitos. Em 6% das hospitalizações e 40% dos óbitos, havia coinfecção pelo HIV. No Rio de Janeiro, foram 250 hospitalizações e 36 óbitos, com aumento progressivo, ao longo do período. Destacaram-se, ainda, São Paulo e Goiás. Homens, não brancos, com baixa escolaridade evoluíram mais frequentemente a óbito. Conclui-se que a esporotricose está associada a hospitalizações e óbitos em todo o Brasil, com destaque para o Rio de Janeiro.

La esporotricosis es una micosis subcutánea de distribución global y, en general, los pacientes son tratados ambulatoriamente. Desde 1998, se observa un aumento de los casos en el estado de Río de Janeiro, Brasil, principalmente por transmisión zoonótica implicando gatos. Los pacientes coinfectados por el virus de la inmunodeficiencia humana (VIH), muchas veces, necesitan de hospitalizaciones y evolucionan a óbito. Este estudio analiza y describe datos de 1992 a 2015, provenientes de bancos de datos del Sistema Único de Salud (SUS). En Brasil, se produjeron 782 hospitalizaciones y 65 óbitos. En un 6% de las hospitalizaciones y 40% de los óbitos, había coinfección por el VIH. En Río de Janeiro, fueron 250 hospitalizaciones y 36 óbitos, con un aumento progresivo a lo largo del período. Se destacaron, incluso, São Paulo y Goiás. Hombres, no blancos, con baja escolaridad evolucionaron más frecuentemente a óbito. Se concluye que la esporotricosis está asociada a hospitalizaciones y óbitos en todo Brasil, destacando Río de Janeiro.

Hospitalizações e óbitos relacionados à esporotricose no Brasil (1992-2015) / Hospitalizations and deaths related to sporotrichosis in Brazil (1992-2015) / Hospitalizaciones y óbitos relacionados con la esporotricosis en Brasil (1992-2015)

Resumo: A esporotricose é uma micose subcutânea de distribuição global e, em geral, os pacientes são tratados ambulatorialmente. Desde 1998, observa-se aumento dos casos no Estado do Rio de Janeiro, Brasil, especialmente por transmissão zoonótica envolvendo gatos. Os pacientes coinfectados pelo vírus da imunodeficiência humana (HIV), muitas vezes, necessitam de hospitalizações e evoluem a óbito. Este estudo analisa e descreve dados de 1992 a 2015, provenientes de bancos de dados do Sistema Único de Saúde. No Brasil, ocorreram 782 hospitalizações e 65 óbitos. Em 6% das hospitalizações e 40% dos óbitos, havia coinfecção pelo HIV. No Rio de Janeiro, foram 250 hospitalizações e 36 óbitos, com aumento progressivo, ao longo do período. Destacaram-se, ainda, São Paulo e Goiás. Homens, não brancos, com baixa escolaridade evoluíram mais frequentemente a óbito. Conclui-se que a esporotricose está associada a hospitalizações e óbitos em todo o Brasil, com destaque para o Rio de Janeiro.

Abstract: Sporotrichosis is a subcutaneous mycosis with global distribution, and patients generally receive outpatient treatment. Since 1998 there has been an increase in cases in the state of Rio de Janeiro, Brazil, mainly via zoonotic transmission involving cats. Patients coinfected with the human immunodeficiency virus (HIV) often require hospitalization and evolve to death. This study analyzes and describes data from 1992 to 2015 obtained from the database of the Brazilian Unified National Health System (SUS). There were 782 hospitalizations and 65 deaths in Brazil. Six percent of the hospitalizations and 40% of the deaths involved coinfection with HIV. There were 250 hospitalizations and 36 deaths in Rio de Janeiro, with a progressive increase over the course of the period. The states of São Paulo and Goiás also showed high numbers. Men, non-whites, and individuals with low schooling evolved more frequently to death. In conclusion, sporotrichosis is associated with hospitalizations and deaths throughout Brazil, especially in the state of Rio de Janeiro.

Resumen: La esporotricosis es una micosis subcutánea de distribución global y, en general, los pacientes son tratados ambulatoriamente. Desde 1998, se observa un aumento de los casos en el estado de Río de Janeiro, Brasil, principalmente por transmisión zoonótica implicando gatos. Los pacientes coinfectados por el virus de la inmunodeficiencia humana (VIH), muchas veces, necesitan de hospitalizaciones y evolucionan a óbito. Este estudio analiza y describe datos de 1992 a 2015, provenientes de bancos de datos del Sistema Único de Salud (SUS). En Brasil, se produjeron 782 hospitalizaciones y 65 óbitos. En un 6% de las hospitalizaciones y 40% de los óbitos, había coinfección por el VIH. En Río de Janeiro, fueron 250 hospitalizaciones y 36 óbitos, con un aumento progresivo a lo largo del período. Se destacaron, incluso, São Paulo y Goiás. Hombres, no blancos, con baja escolaridad evolucionaron más frecuentemente a óbito. Se concluye que la esporotricosis está asociada a hospitalizaciones y óbitos en todo Brasil, destacando Río de Janeiro.

Effects of antiretroviral treatment and nadir CD4 count in progression to cardiovascular events and related comorbidities in a HIV Brazilian cohort: a multi-stage approach.

The use of highly active antiretroviral therapy has resulted in changes of comorbidity profile in people living with HIV (PLHIV), increasing non-AIDS-related events. The occurrence of cardiovascular events is greater in PLHIV, but the mechanism responsible for it is still controversial. This article aimed to investigate factors associated with the progression to cardiovascular events in PLHIV using HAART. A 15-years cohort study with 1135 PLHIV was conducted in Rio de Janeiro-Brazil. Clinical progression was stratified in five states: No comorbidities (s1), arterial hypertension (s2), lipid abnormalities (s3), hypertension and lipid abnormalities (s4) and major cardiovascular events (stroke, coronary artery disease, thrombosis or death) (s5). Semi-Markov models evaluated the effects of cardiovascular traditional factors, treatment and clinical covariates on transitions between these states. Hazard Ratios (HR) and 95% confidence intervals (CI) were provided. In addition to traditional factors (age, sex, educational level and skin color), the development of one comorbidity (lipid abnormalities or hypertension) increased in patients with low nadir CD4 (<50 cells/mm3), (HR = 1.59, CI 1.11-2.28 and 1.36, CI 1.11-1.66, respectively). The risk to experience a second comorbidity (s3→s4) increased 75% with low nadir CD4. Age was the only factor that increased the risk of major cardiovascular events once having lipid abnormalities with or without hypertension (s3,s4→s5). The prolonged use of certain antiretroviral drugs (abacavir, didanosine, ritonavir, lopinavir, amprenavir and fosamprenavir) increased the risk of direct transition (s1→s5) to major cardiovascular events (HR = 5.29, CI 1.16-24.05). This analysis suggests that prolonged use of certain antiretroviral drugs led directly to major cardiovascular events, while low nadir CD4 only affected the occurrence of lipid abnormalities and hypertension. Management strategies, including rational use of complex exams (such as, computed-tomography angiography), statins and antihypertensives, should be developed based on the distinct roles of antiretroviral use and of HIV infection itself on the progression to cardiovascular events.

Impact of HIV-1 Subtypes on AIDS Progression in a Brazilian Cohort.

Viral and host factors are known to play a role in the different patterns of AIDS progression. The cocirculation of HIV-1 subtypes B, F1, BBR, and BF1; the occasional detection of HIV-1 subtype D; and an increasing prevalence of subtype C and other recombinant forms have been described in Rio de Janeiro, Brazil. The aim of this study was to evaluate the potential association of HIV-1 subtypes circulating among HIV-1+ individuals in Rio de Janeiro with AIDS disease progression. For this purpose, 246 HIV-1 individuals under clinical and laboratory follow-up from 1986 to 2011 were classified according to their progression to AIDS in typical progressors (n = 133), rapid progressors (n = 95), and long-term nonprogressors (n = 18). The env-gp120 region was amplified and sequenced. Neighbor-joining phylogenetic inferences were performed in Mega 6 and bootscan analysis was performed in Simplot 3.5.1. The Kaplan-Meier method and Cox modeling were performed to determine the time until an AIDS-defining event based on the HIV-1 subtypes/variants. Similar AIDS progression rates were observed among individuals infected with HIV-1 subtype B and variant BBR. However, a direct association between more rapid AIDS progression and HIV-1 subtypes, D and BF1, was confirmed in the multivariate analysis, corroborating previous results. Our findings contribute to the investigation of the possible influence of HIV-1 subtypes in AIDS outcome.

Sporotrichosis: an emerging neglected opportunistic infection in HIV-infected patients in Rio de Janeiro, Brazil.

Sporotrichosis associated with zoonotic transmission remains a relevant public health problem in Rio de Janeiro, Brazil, affecting a large at-risk population, which includes HIV-infected individuals. We assessed patients co-infected by Sporothrix spp. and HIV over time in the context of an unabated sporotrichosis epidemic. A retrospective cohort retrieved information from a National reference institute for infectious diseases regarding 48 patients with sporotrichosis-HIV co-infection (group 1) as well as 3,570 patients with sporotrichosis (group 2), from 1987 through March 2013. Most patients from group 1 were male (68.8%), whereas women were predominant in group 2 (69.1%; p<0.0001). Patients from group 1 were younger than those from group 2 (µâ€Š= 38.38±10.17 vs. 46.34±15.85; p<0.001) and differed from group 2 in terms of their race/ethnic background, with 70.8% non-white patients in group 1 vs. 38.6% from group 2 (p<0.0001). Close to half (∼44%) of the patients from group 1 were hospitalized due to sporotrichosis over time, whereas hospitalization was very unlikely in group 2, among whom approximately 1% were hospitalized over time. Dissemination of sporotrichosis was the main cause of hospitalization in both groups, although it was more common among hospitalized patients from group 1 (19/21 [90.5%] vs. 16/37 [43.2%]; p<0.001). Over the period under analysis, eight patients died due to sporotrichosis (3/48 vs. 5/3,570). The diagnosis of sporotrichosis elicited HIV testing and subsequent diagnosis in 19/48 patients, whereas 23/48 patients were simultaneously diagnosed with the two infections. HIV infection aggravates sporotrichosis, with a higher incidence of severe disseminated cases and a higher number of hospitalizations and deaths. Underserved populations, among whom sporotrichosis has been propagated, have been affected by different transmissible (e.g., HIV) and non-transmissible diseases. These populations should be targeted by community development programs and entitled to integrated management and care of their superimposed burdens.

Association of single nucleotide polymorphisms in the lens epithelium-derived growth factor (LEDGF/p75) with HIV-1 infection outcomes in Brazilian HIV-1+ individuals.

The lens epithelium-derived growth factor p75 (LEDGF/p75), coded by the PSIP1 gene, is an important host co-factor that interacts with HIV-1 integrase to target integration of viral cDNA into active genes. The aim of this study was to investigate the association of SNPs in the PSIP1 gene with disease outcome in HIV-1 infected patients. We performed a genetic association study in a cohort of 171 HIV-1 seropositive Brazilian individuals classified as rapid progressors (RP, n = 69), typical progressors (TP, n = 79) and long-term nonprogressors (LTNP, n = 23). The exonic SNP rs61744944 and 9 tag SNPs were genotyped. A group of 192 healthy subjects was analyzed to determine the frequency of SNPs and haplotypes in the general population. Linkage disequilibrium (LD) analyses indicated that the SNPs analyzed were not in high LD (r2<0.8). Logistic regression models suggested that patients carrying the T allele rs61744944 (472L) were more likely to develop a LTNP phenotype (OR = 4.98; p = 0.05) as compared to TP group. The same trend was observed when LTNPs were compared to the RP group (OR = 3.26). Results of haplotype analyses reinforced this association, since the OR values obtained for the haplotype carrying allele T at rs61744944 also reflected an association with LTNP status (OR = 6.05; p = 0.08 and OR = 3.44; p = 0.12 for comparisons to TP and RP, respectively). The rare missense variations Ile436Ser and Thr473Ile were not identified in the patients enrolled in this study. Gene expression analyses showed lower LEDGF/p75 mRNA levels in peripheral blood mononuclear cells obtained from HIV-1 infected individuals. However, these levels were not influenced by any of the SNPs investigated. In spite of the limited number of LTNPs, these data suggest that the PSIP1 gene could be associated with the outcome of HIV-1 infection. Further analyses of this gene may guide the identification of causative variants to help predict disease course.

Trends in AIDS-defining opportunistic illnesses incidence over 25 years in Rio de Janeiro, Brazil.

OBJECTIVES: To assess the temporal trends in incidence of AIDS-defining opportunistic illnesses in an urban cohort of a middle-income country. METHODS: HIV infected patients aged ≥ 18 years at cohort entry were included in this analysis. We calculated incidence rates per 1000 persons-years of observation for the first opportunistic illness presented after cohort enrollment, from 1987 to 2012. Trends for overall and specific opportunistic illnesses were tested and incidence rate ratios for the most recent calendar period were calculated as the ratio between the incidence rate observed in the most recent period of the study (2009-2012) and the incidence rate observed in first period of the study (1987-1990). RESULTS: Overall, 3378 patients were included in this analysis; of which 1119 (33%) patients presented an opportunistic illness during follow up. Incidence rates of all opportunistic illnesses decreased over time, and the overall opportunistic illness incidence rates fell from 295.4/1000 persons-years in 1987-1990 to 34.6/1000 persons-years in 2009-2012. Tuberculosis, esophageal candidiasis, cerebral toxoplasmosis and Pneumocystis jirovecii pneumonia were the most incident opportunistic illnesses in the cohort. Tuberculosis had the highest incidence rate in the study period. The peak in tuberculosis incidence occurred in 1991-1993 (80.8/1000 persons-years). Cerebral toxoplasmosis was the third most incident opportunistic illness in the study, with a peak of incidence of 43.6/1000 persons-year in 1987-1990. CONCLUSIONS: All opportunistic illnesses incidence rates decreased over the years but they still occur in an unacceptable frequency. Tuberculosis co-infection among HIV-infected persists as an important challenge for health care professionals and policy makers in our setting. Impressively high rates of cerebral toxoplasmosis were found suggesting that its incidence among HIV-infected is linked to the high prevalence of Toxoplasma gondii infection in the general population.

Progression of leprosy disability after discharge: is multidrug therapy enough?

OBJECTIVE: To evaluate the risk factors related to worsening of physical disabilities after treatment discharge among patients with leprosy administered 12 consecutive monthly doses of multidrug therapy (MDT/WHO). METHODS: Cohort study was carried out at the Leprosy Laboratory in Rio de Janeiro, Brazil. We evaluated patients with multibacillary leprosy treated (MDT/WHO) between 1997 and 2007. The Cox proportional hazards model was used to estimate the relationship between the onset of physical disabilities after release from treatment and epidemiological and clinical characteristics. RESULTS: The total observation time period for the 368 patients was 1 570 person-years (PY), averaging 4.3 years per patient. The overall incidence rate of worsening of disability was 6.5/100 PY. Among those who began treatment with no disability, the incidence rate of physical disability was 4.5/100 PY. Among those who started treatment with Grade 1 or 2 disabilities, the incidence rate of deterioration was 10.5/100 PY. The survival analysis evidenced that when disability grade was 1, the risk was 1.61 (95% CI: 1.02-2.56), when disability was 2, the risk was 2.37 (95% CI 1.35-4.16), and when the number of skin lesions was 15 or more, an HR = 1.97 (95% CI: 1.07-3.63). Patients with neuritis showed a 65% increased risk of worsening of disability (HR = 1.65 [95% CI: 1.08-2.52]). CONCLUSION: Impairment at diagnosis was the main risk factor for neurological worsening after treatment/MDT. Early diagnosis and prompt treatment of reactional episodes remain the main means of preventing physical disabilities.

Is pregnancy associated with severe dengue? A review of data from the Rio de Janeiro surveillance information system.

BACKGROUND: Dengue is a reportable disease in Brazil; however, pregnancy has been included in the application form of the Brazilian notification information system only after 2006. To estimate the severity of maternal dengue infection, the available data that were compiled from January 2007 to December 2008 by the official surveillance information system of the city of Rio de Janeiro were reviewed. METHODS AND PRINCIPAL FINDINGS: During the study period, 151,604 cases of suspected dengue infection were reported. Five hundred sixty-one women in their reproductive age (15-49 years) presented with dengue infection; 99 (18.1%) pregnant and 447 (81.9%) non-pregnant women were analyzed. Dengue cases were categorized using the 1997 WHO classification system, and DHF/DSS were considered severe disease. The Mann-Whitney test was used to compare maternal age, according to gestational period, and severity of disease. A chi-square test was utilized to evaluate the differences in the proportion of dengue severity between pregnant and non-pregnant women. Univariate analysis was performed to compare outcome variables (severe dengue and non-severe dengue) and explanatory variables (pregnancy, gestational age and trimester) using the Wald test. A multivariate analysis was performed to assess the independence of statistically significant variables in the univariate analysis. A p-value<0.05 was considered statistically significant. A higher percentage of severe dengue infection among pregnant women was found, p = 0.0001. Final analysis demonstrated that pregnant women are 3.4 times more prone to developing severe dengue (OR: 3.38; CI: 2.10-5.42). Mortality among pregnant women was superior to non-pregnant women. CONCLUSION: Pregnant women have an increased risk of developing severe dengue infection and dying of dengue.

Multi-state models for defining degrees of chronicity related to HIV-infected patient therapy adherence.

Few studies on AIDS that evaluate factors associated with treatment failure have considered the slow evolution of the disease and multiple health state transitions following the use of antiretrovirals. In this article we study factors associated with the progression between different stages of the disease, focusing on therapy adherence using a sample of 722 HIV+ patients followed up for 3 years. States were defined using the following classifications of the CD4 cell count: s1 (CD4 ≥ 500); s2 (350 ≤ CD4 < 500); and s3 (CD4 < 350). The transitions between states were modeled using multi-state models. Antiretroviral therapy adherence and disease duration were associated with transitions between immune states during follow-up. Low adherence increased the hazard ratio of a transition between s1 to s2 and intermediate adherence increased the hazard ratio of a transition between s2 to s3. On the other hand, older age and disease duration between two and four years are protective factors for AIDS progression. Multi-state modeling is a powerful approach for studying chronic diseases and estimating factors associated with transitions between each stage of progression, thus enabling the use of more individualized and effective interventions.

Multi-state models for defining degrees of chronicity related to HIV-infected patient therapy adherence / Modelos multiestado para determinação dos graus de cronicidade de acordo com a adesão de paciente infectado pelo HIV / Modelos multi-estado para la determinación de los grados de cronicidad, de acuerdo con la adhesión del paciente infectado por el VIH

Few studies on AIDS that evaluate factors associated with treatment failure have considered the slow evolution of the disease and multiple health state transitions following the use of antiretrovirals. In this article we study factors associated with the progression between different stages of the disease, focusing on therapy adherence using a sample of 722 HIV+ patients followed up for 3 years. States were defined using the following classifications of the CD4 cell count: s1 (CD4 ≥ 500); s2 (350 ≤ CD4 < 500); and s3 (CD4 < 350). The transitions between states were modeled using multi-state models. Antiretroviral therapy adherence and disease duration were associated with transitions between immune states during follow-up. Low adherence increased the hazard ratio of a transition between s1 to s2 and intermediate adherence increased the hazard ratio of a transition between s2 to s3. On the other hand, older age and disease duration between two and four years are protective factors for AIDS progression. Multi-state modeling is a powerful approach for studying chronic diseases and estimating factors associated with transitions between each stage of progression, thus enabling the use of more individualized and effective interventions.

Poucos estudos sobre AIDS que avaliam fatores associados à falha terapêutica consideram sua evolução lenta, com a passagem por múltiplos estados de saúde, consequência do uso de antirretrovirais. Nesse artigo foram estudados fatores associados à progressão entre estados imunes, enfocando adesão, em 722 pacientes HIV+ acompanhados por 3 anos. O desfecho foi a contagem de células CD4 classificada em s1 (CD4 ≥ 500), s2 (350 ≤ CD4 < 500) e s3 (CD4 < 350). As transições entre estados foram modeladas por modelos multiestado. A adesão à terapia antirretroviral e o tempo de doença estão associados diferentemente à mudança do estado imune vivido pelo paciente. Baixa adesão à terapia aumentou o risco de s1→s2 e adesão intermediária aumentou o de s2→s3. Por outro lado, idades elevadas e tempo de doença de 2 a 4 anos se apresentam como fatores de proteção na progressão da AIDS. A modelagem multiestado é uma abordagem poderosa no estudo de doenças crônicas, por estimar os fatores associados a cada etapa da evolução de doenças crônicas, possibilitando a adoção de intervenções mais individualizadas e eficazes.

Existen pocos estudios sobre el SIDA que evalúan factores asociados al fallo terapéutico, consideran su evolución lenta, con el pasaje por múltiples estados de salud, consecuencia del uso de antirretrovirales. En ese artículo se estudiaron factores asociados a la progresión entre estados inmunes, enfocando adhesión, en 722 pacientes VIH+ acompañados durante 3 años. El desenlace fue el cómputo de células CD4, clasificado en s1 (CD4 ≥ 500), s2 (350 ≤ CD4 < 500) y s3 (CD4 < 350). Las transiciones entre estados se modelaron por modelos multi-estado. La adhesión a la terapia antirretroviral y el tiempo de enfermedad están asociados diferentemente al cambio del estado inmune vivido por el paciente. Baja adhesión a la terapia aumentó el riesgo de s1→s2 y una adhesión intermedia aumentó de un s2→s3. Por otro lado, edades elevadas y tiempo de enfermedad de 2 a 4 años se presentan como factores de protección en la progresión del SIDA. El modelo multi-estado es un enfoque poderoso en el estudio de enfermedades crónicas, por estimar los factores asociados a cada etapa de la evolución de enfermedades crónicas, posibilitando la adopción de intervenciones más individualizadas y eficaces.

Análise de sobrevivência: teoria e aplicações em saúde / Survival analysis: theory and applications in health

O objetivo apoiar o desenvolvimento metodológico em análise de dados longitudinais, através da aplicação, teste e disseminação de métodos estatísticos inovadores no contexto da saúde, particularmente os voltados para a análise de sobrevida

Efeito do critério de diagnóstico da AIDS e da Adesão ao tratamento anti-retroviral na progressão clínica em HIV/AIDS / Effect of diagnostic criteria for AIDS and Adherence to antiretroviral treatment on clinical progression in HIV / AIDS

A AIDS, desde o seu surgimento no início dos anos 80, apresentou-se como um relevante problema de saúde pública. Além da prevenção de doenças oportunistas e do tratamento da AIDS foi essencial estabelecer critérios para definir casos da doença. O objetivo do presente estudo foi ressaltar as diferenças observadas nas funções de sobrevida de casos definidos por diferentes critérios e conhecer o efeito da adesão à terapia anti-retroviral (TARV) no prognóstico dos pacientes HIV/AIDS. No primeiro artigo, 1.415 indivíduos HIV+ atendidos no IPEC foram avaliados pelos critérios de definição de caso do Ministério da Saúde (MS/2004) e dos Centers for Disease Control and Prevention (CDC/1993), e a função de sobrevida foi estimada para cada critério, considerando o uso de TARV e co-fatores sócio-demográficos e clínicos. Os resultados desta avaliação mostraram que a sobrevida estimada depende do critério adotado além de apresentar preditores distintos. No segundo artigo, em buscas no Medline e Lilacs, selecionou-se 38 artigos que avaliaram a ocorrência de desfechos relevantes na evolução da AIDS em função da adesão ao tratamento. Na avaliação desses artigos, foi evidenciado que a adesão dos pacientes ao tratamento antiretroviral nos diversos matizes considerados na literatura mostrou-se um preditor importante dos desfechos nas suas múltiplas representações no acompanhamento dos pacientes, independente do estadiamento clínico, uso prévio de tratamento, CD4 e carga viral basais. No terceiro artigo, para 711 pacientes foram considerados os dados de fornecimento de anti-retrovirais (dispensas) disponíveis no Sistema de Controle Logístico de Medicamentos (SICLOM) para avaliar a adesão e estimar o risco de falha terapêutica pelo modelo de Cox...

Since its emergence in the early 1980s, AIDS has appeared as a relevant public health problem. In addition to preventing opportunistic diseases and treating AIDS it was essential to establish disease-defining criteria. The aim of the present study was to highlight the differences in cases survival functions defined by different criteria and to know the effect ofadherence to antiretroviral therapy on the prognosis of patients with HIV/AIDS. In the first article, 1,415 HIV+ subjects seen at IPEC were assessed by two case-defining criteria(MS/2004 and CDC/1993), their survival function was estimated for each standard, considering the use of ARV and socio-demographic and clinical cofactors. The results showed that estimated survival depends on the chosen standard, besides presenting distinct predictors. In the second article, through searches at MEDLINE and LILACS, there were selected 38 articles that evaluated the occurrence of relevant outcomes to the developmentof AIDS in function of adherence to treatment. The analysis of these articles emphasized that the adherence of patients to ARV or HAART in various aspects considered in the literature was an important predictor of outcomes in their multiple representations in themonitoring of patients, independent of their clinical staging, use of prior treatment and baseline CD4 and viral load. In the third article, to 711 patients, there were considereddata from antiretroviral disposal available at SICLOM for adherence assessment and estimation of therapeutic failure risk by the Cox model...

Comparison of clinical response to initial highly active antiretroviral therapy in the patients in clinical care in the United States and Brazil.

BACKGROUND: US and Brazilian studies indicate that highly active antiretroviral therapy (HAART) has been effective in reducing morbidity and mortality from HIV/AIDS. Differences exist in the adoption and patterns of antiretroviral drug use and in the incidence of AIDS-defining illness (ADI) between the 2 countries, however, and there has not been a direct comparison of clinical response between Brazil and the United States. We sought to determine if there have been differences in the clinical response to HAART from HIV clinical practices in the United States and Brazil. METHODS: We compared 2 similarly designed clinical cohorts from Baltimore, Maryland and Rio de Janeiro, Brazil. Patients who started HAART from 1997 to 2004 were compared for HIV-1 RNA suppression and CD4+ T-lymphocyte count change by 1 year of therapy and for development of an ADI up to 6 years of follow-up. A total of 1368 patients from Baltimore and 1045 patients from Rio de Janeiro were studied. RESULTS: There was no difference by location in achieving an HIV-1 RNA level <400 copies/mL (46.9% in Rio de Janeiro, 50.8% in Baltimore), in the log change in HIV-1 RNA level (-1.65 log in Rio de Janeiro, - 1.63 log in Baltimore), or in the change in CD4 count (116 cells/mm3 in Rio de Janeiro, 122 cells/mm3 in Baltimore) by 12 months after starting HAART. By Kaplan-Meier analysis and Cox regression adjusted for demographic and clinical prognostic factors, there was no difference by location in development of the first ADI after starting HAART (relative hazard = 1.02; 95% confidence interval: 0.82 to 1.25 for Rio de Janeiro vs. Baltimore). The most commonly occurring ADI in Rio de Janeiro was tuberculosis (27.7% of patients), and the most commonly occurring ADI in Baltimore was esophageal candidiasis (36.8% of patients). CONCLUSIONS: There were only minor differences in clinical response to the use of HAART comparing Rio de Janeiro with Baltimore, despite differences in patterns of antiretroviral drug use and ADI incidence. This analysis indicates that HAART can be similarly effective in treating HIV/AIDS in countries with different economies.

Survival of AIDS patients using two case definitions, Rio de Janeiro, Brazil, 1986-2003.

BACKGROUND: Recent studies have shown substantial increases in the survival of AIDS patients in developed countries and in Brazil as a result of antiretroviral therapy (ART) and prophylaxis for opportunistic infections. This study compares survival rates using the Brazilian Ministry of Health 2004 and Centers for Disease Control and Prevention (CDC) 1993 case definitions in a large HIV/AIDS referral centre in Rio de Janeiro. METHODS: Survival after AIDS diagnosis was assessed in a clinic-based cohort of 1415 individuals using the Kaplan-Meier method and Cox proportional hazards models. RESULTS: There were 393 (88%) deaths from AIDS-related causes and 52 (12%) from unrelated or unknown causes. A total of 205 patients (14%) were lost to follow-up and 765 patients (55%) remained alive until the end of the study. Three-quarters of patients (75%) were still alive 22 months [95% confidence interval (CI) 19-26] after the AIDS diagnosis according to the CDC case definition and 31 months (95% CI 26-36) according to the Ministry of Health case definition. Independent predictors of survival included AIDS defined by CD4 cell count and any use of highly active antiretroviral therapy, with either case definition, and initial stage of the case, with the Ministry of Health case definition. CONCLUSION: Survival observed in this reference centre is comparable or longer than other international studies, although the choice of case definition criterion influenced findings. Adoption of the Ministry of Health case definition may enhance the ability to track the use of and outcomes from ART among AIDS patients.

Effect of sociodemographic, clinical-prophylactic and therapeutic procedures on survival of AIDS patients assisted in a Brazilian outpatient clinic

The Brazilian AIDS Program offers free and universal access to antiretroviral therapy. This study investigates the influence of sociodemographic, clinical-prophylactic and therapeutic factors on survival, after AIDS diagnosis, in an open cohort of 1,420 patients assisted in a university hospital in the city of Rio de Janeiro (1995 _ 2002). Kaplan-Meier and Cox proportional hazards models were used to estimate the effect of variables in the three dimensions studied. The overall survival time of the upper quartile was 24 months (CI95 percent= 20.5-27.5), increasing from 14 months, in 1995, to 46 months, in 1998. We found a protective effect of heterosexual behavior against death that could be attributed to the increasing female-to-male sex ratio in the cohort, which coincided with the time of therapy introduction. Low schooling, hospital admission and lack of follow-up were identified as risk factors for death; PCP and Toxoplasmosis prophylaxis were protective. The number of attempts required to consolidate the antiretroviral therapy showed no significant effect on survival. The full model, which includes the number of antiretroviral drugs in the regimen, confirmed the triple therapy as the best regimen. This study brings important information for designing guidelines to deal with different aspects related to the practical management of patients and their behavior, thus contributing to the success of the program of free access to antiretroviral therapy implemented in Brazil.

Análise de sobrevida dos pacientes com aids atendidos em um Centro de Pesquisa no Rio de Janeiro: 1986-2000 / Survival analysis of AIDS patients cared for in a Rio de Janeiro Research Center: 1986-2000

Esta tese tem como objetivo determinar o tempo decorrido e fatores relacionados à sobrevida, a partir do diagnóstico da aids dos pacientes atendidos no Centro de Pesquisa Hospital Evandro Chagas (CPqHEC). Comparar a sobrevida segundo os critérios definição de caso de aids estabelecidos pelos Centros de controle de doenças e prevenção dos EUA (CDC) em 1987 e 1983 e pelo Ministério da Saúde Brasil em 1998.