Survival and medical intervention in southern Brazilian AIDS patients

Survival benefits of antiretroviral therapy in Brazil: a model-based analysis

Objective

In Brazil, universal provision of antiretroviral therapy (ART) has been guaranteed free of charge to eligible HIV-positive patients since December 1996. We sought to quantify the survival benefits of ART attributable to this programme.

Methods

We used a previously published microsimulation model of HIV disease and treatment (CEPAC-International) and data from Brazil to estimate life expectancy increase for HIV-positive patients initiating ART in Brazil. We divided the period of 1997 to 2014 into six eras reflecting increased drug regimen efficacy, regimen availability and era-specific mean CD4 count at ART initiation. Patients were simulated first without ART and then with ART. The 2014-censored and lifetime survival benefits attributable to ART in each era were calculated as the product of the number of patients initiating ART in a given era and the increase in life expectancy attributable to ART in that era.

Results

In total, we estimated that 598,741 individuals initiated ART. Projected life expectancy increased from 2.7, 3.3, 4.1, 4.9, 5.5 and 7.1 years without ART to 11.0, 17.5, 20.7, 23.0, 25.3, and 27.0 years with ART in Eras 1 through 6, respectively. Of the total projected lifetime survival benefit of 9.3 million life-years, 16% (or 1.5 million life-years) has been realized as of December 2014.

Conclusions

Provision of ART through a national programme has led to dramatic survival benefits in Brazil, the majority of which are still to be realized. Improvements in initial and subsequent ART regimens and higher CD4 counts at ART initiation have contributed to these increasing benefits.

Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression

Objective

Pneumocystis jirovecii pneumonia (PCP), the commonest opportunistic infection in HIV-infected patients in the developed world, is less commonly described in tropical and low and middle income countries (LMIC). We sought to investigate predictors of PCP in these settings.

Design

Systematic review and meta-regression.

Methods

Meta-regression of predictors of PCP diagnosis (33 studies). Qualitative and quantitative assessment of recorded CD4 counts, receipt of prophylaxis and antiretrovirals, sensitivity and specificity of clinical signs and symptoms for PCP, co-infection with other pathogens, and case fatality (117 studies).

Results

The most significant predictor of PCP was per capita Gross Domestic Product, which showed strong linear association with odds of PCP diagnosis (p<0.0001). This was not explained by study design or diagnostic quality. Geographical area, population age, study setting and year of study also contributed to risk of PCP. Co-infection was common (444 episodes/1425 PCP cases), frequently with virulent organisms. The predictive value of symptoms, signs or simple tests in LMIC settings for diagnosis of PCP was poor. Case fatality was >30%; treatment was largely appropriate. Prophylaxis appeared to reduce the risk for development of PCP, however 24% of children with PCP were receiving prophylaxis. CD4 counts at presentation with PCP were usually <200×10^3/ml.

Conclusions

There is a positive relationship between GDP and risk of PCP diagnosis. Although failure to diagnose infection in poorer countries may contribute to this, we also hypothesise that poverty exposes at-risk patients to a wide range of infections and that the relatively non-pathogenic P. jirovecii is therefore under-represented. As LMIC develop economically they eliminate the conditions underlying transmission of virulent infection: P. jirovecii, ubiquitous in all settings, then becomes a greater relative threat.

The first ten years: achievements and challenges of the Brazilian program of universal access to HIV/AIDS comprehensive management and care, 1996-2006

A review was carried out of papers published between 1996 and 2006, documenting the introduction of highly active anti-retroviral therapy (HAART) in Brazil. Papers indexed in the MEDLINE and SciELO databases were retrieved using different combinations of keywords related to the management and care of AIDS in the post-HAART era: opportunistic diseases and co-infections, adherence to therapy, survival in the pre- and post-HAART eras, adverse events and side-effects, emergence and possible transmission of resistant viral strains, metabolic and cardiovascular disorders, and issues related to access to care and equity. The review documents the dramatic changes in HIV/AIDS disease progression in the post-HAART era, including an increase in survival and quality of life and a pronounced decrease in the episodes of opportunistic diseases. Notwithstanding such major achievements, new challenges have emerged, including slow evolving co-infections (such as hepatitis C, metabolic and cardiovascular disorders), the emergence of viral resistance, with consequences at the individual level (virological failure) and the community level (primary/secondary resistance at the population level), and impacts on the cost of new therapeutic regimens.

Preliminary estimates of human immunodeficiency virus prevalence and incidence among cocaine abusers of Porto Alegre, Brazil

A sample of 193 southern Brazilian inner-city cocaine abusers was studied to assess the prevalence of human immunodeficiency virus (HIV) infection. Following the exclusion of those who were seropositive from the intake sample, a cohort of 138 HIV-negative cocaine abusers was followed for 18 months to assess seroincidence rates and the associated characteristics. HIV status, drug use, sexual risk behaviors, and presence and severity of medical and psychiatric symptoms were collected at intake using a Brazilian version of the Risk Assessment Battery, the Addiction Severity Index (ASI), Symptom Check List-90 (SCL-90), and Beck Depression Inventory (BDI); this was repeated at 6-, 12-, and 18-month intervals. The overall seroprevalence was 28.5%, and the variables associated with HIV seropositivity were age older than 25 years, being single, having less than 8 years of education, and having injected cocaine at least once. Although follow-up procedures were difficult to implement due to sample characteristics, we obtained data from 82.6% of the participants for at least one follow-up and for 57% at all follow-up windows. Most participants showed high scores on the Beck Depression Inventory (mean of 20.6 +/- 13.9) and Symptom Check List-90 (mean of 106.4 +/- 91.9). There were 8 seroconversions in the 18-month period, yielding an incidence rate of 5.03/100 (confidence interval [CI] 2.2-9.7) person-years at risk. None of the seroconverters reported recent cocaine injection, and only 14.5% of the overall sample reported ever injecting cocaine, which suggests that another significant mode of transmission via sexual behavior should be considered as well. Each of these findings has important implications for the design of preventive interventions.

[Limitations and alternatives to the implementation of a program for drug users at risk of HIV infection using the Social Network Approach]

The authors describe the development of a preventive program focused on intravenous drug users at risk of HIV infection, using the Social Network Approach as the intervention model. The authors describe the project's steps in a large university hospital in southern Brazil, emphasizing the unique methods and techniques developed by the treatment staff. Problems encountered during the project development are discussed, aimed at identifying the reasons why the program only achieved partial success. The authors identify critical issues, such as the use of a new technique not previously tried in Brazil, difficulties in maintaining IV drug users in treatment, lack of infrastructure for walk-in treatment, and the challenge of motivating staff and patients to continue treatment. The authors conclude by listing suggestions aimed at facilitating the development of new projects based on the same conceptual model.

Differential trends in mortality from AIDS in men and women in Brazil (1984-1995)

OBJECTIVE

To analyse trends in AIDS mortality in men and women in Brazil, for the period 1984-1995.

DESIGN AND METHODS

National statistics on yearly numbers of reported deaths by cause, in conjunction with census population counts and inter-censory estimates, were used to calculate age- and sex-specific AIDS mortality rates for Brazil as a whole and for São Paulo and Rio de Janeiro, the two largest cities in Brazil, and those most affected by the AIDS epidemic to date.

RESULTS

Numbers of reported deaths from AIDS have increased yearly in Brazil since 1984, to approximately 15,000 in 1995. The data suggest that after a very dramatic rise in mortality rates, the epidemic may have started to slow even before the introduction of freely available highly-active anti-retroviral therapy, although unequally in terms of both geographical and sex distributions. Women also tended to die at relatively younger ages than men in all areas studied, and by 1995 the impact of AIDS on overall mortality was practically the same for men and women aged 25-34 years (21% in São Paulo).

CONCLUSIONS

Trends in mortality from AIDS in Brazil reflect both the geographical expansion of the epidemic outwards from its original epicentres, and the fact that women are becoming increasingly affected by the AIDS epidemic.