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Pires KL, Baranda MSDM, Brum TMA, Pessôa B, Pupe CCB, do Nascimento OJM. HIV-associated painful neuropathy: where are we? ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:607-615. [PMID: 35946704 PMCID: PMC9387191 DOI: 10.1590/0004-282x-anp-2021-0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/27/2021] [Accepted: 10/05/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND After the advent of combination antiretroviral therapy, infection with the human immunodeficiency virus (HIV) ceased to be a devastating disease, but sensory neuropathy resulting from the permanence of the virus and the side effects of treatment have worsened the morbidities of these patients. OBJECTIVE To investigate the quality of life of 64 HIV-positive patients: 24 with painful neuropathy (case group) and 40 without painful neuropathy (control group). The impact of other factors on quality of life was also assessed. METHODS To assess painful neuropathy, the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale, Douleur Neuropathique 4 (DN4) questions and Neuropathy Disability Score (NDS) were used. The Short Form Health Survey (SF-36) scale was used to assess quality of life. Factors related or unrelated to HIV were obtained through the medical history and analysis on medical records. RESULTS The quality of life of patients with neuropathic pain was worse in six of the eight domains of the SF-36 scale. The number of clinical manifestations related to HIV, length of time with detectable viral load since diagnosis, length of time since the diagnosis of HIV infection and length of time of HAART use had a negative impact on quality of life. Higher levels of CD4, education and family income had a positive impact. CONCLUSIONS Painful neuropathy related to HIV is a factor that worsens the quality of life of patients infected with this virus and should be included in the clinical evaluation.
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Affiliation(s)
- Karina Lebeis Pires
- Universidade Federal Fluminense, Departamento de Neurologia, Unidade de Pesquisa Clínica, Niterói RJ, Brazil
- Universidade Federal do Estado do Rio de Janeiro, Departamento de Neurologia, Unidade de Pesquisa Clínica, Niterói RJ, Brazil
| | | | - Talita Mota Almeida Brum
- Universidade Federal do Estado do Rio de Janeiro, Departamento de Neurologia, Unidade de Pesquisa Clínica, Niterói RJ, Brazil
| | - Bruno Pessôa
- Universidade Federal Fluminense, Departamento de Neurocirurgia, Unidade de Pesquisa Clínica, Niterói RJ, Brazil
| | - Camila Castelo Branco Pupe
- Universidade Federal Fluminense, Departamento de Neurologia, Unidade de Pesquisa Clínica, Niterói RJ, Brazil
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Yitbarek GY, Addis WD, Dagnaw FT, Ayehu GW, Melese BD, Amare TJ, Mulu AT, Bayih WA, Ashagrie BK, Zewde EA, Munye T, Chanie ES, Ebabu W, Alemayehu SA, Arage G, Teshome AA. Magnitude of Peripheral Sensory Neuropathy and Associated Factors Among HIV/AIDS Clients Receiving Care at Public Health Institutions, Northwest Ethiopia. Mol Pain 2022; 18:17448069221089593. [PMID: 35266800 PMCID: PMC9016588 DOI: 10.1177/17448069221089593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background: In the mid-1990s, the development of combination antiretroviral
therapy converted HIV infection into a chronic condition, with newly diagnosed
patients now living longer than the general population. HIV affects both the
central and peripheral nerve systems, resulting in a variety of clinical
problems, including peripheral neuropathy, which is a common neurological
consequence. Despite this, there is a scarcity of data on the extent of
peripheral sensory neuropathy and its underlying factors in Ethiopia,
necessitating this study. Objective: The primary goal of this study is to assess
the degree of peripheral sensory neuropathy and its related factors among
HIV/AIDS clients on follow up at public health institutions in Northwest
Ethiopia. Methodology: Institution based cross-sectional study was conducted
from November 1 to 30 December 2020 at selected south Gondar zone public health
institutions ART clinic. Multistage sampling technique was used to select the
study participants. Standardized Questioner adapted from other study was used to
collect the data. Moreover, Brief Peripheral Neuropathy Screening tool (BPNS)
was used to assess peripheral sensory neuropathy. The data were entered with
epi-data manager version 4.4 and analyzed using STATA version 16. Result: A
total of 555 adult PLWHIV agreed to participate in the study, resulting in a
response rate of 96.8%. The prevalence of Peripheral sensory neuropathy was
32.25, 95% CI (28.28, 36.26). The participant’s age, DM comorbidity, viral load
level, and disease clinical stage were all found to have a statistically
significant association with peripheral sensory neuropathy. Conclusion:
Peripheral sensory neuropathy was incredibly common. Accordingly, peripheral
sensory neuropathy was found considerably associated with age, viral load level,
stage of the disease, and DM comorbidity. It is vital to integrate routine
peripheral sensory neuropathy screening strategies for clients who are on ART
follow up for prevention and early identification of the problem.
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Julian T, Rekatsina M, Shafique F, Zis P. Human immunodeficiency virus-related peripheral neuropathy: A systematic review and meta-analysis. Eur J Neurol 2020; 28:1420-1431. [PMID: 33226721 DOI: 10.1111/ene.14656] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/02/2020] [Accepted: 11/17/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Human immunodeficiency virus (HIV)-associated neurological syndromes occur in affected individuals as a consequence of primary HIV infection, opportunistic infections, inflammation and as an adverse effect of some forms of antiretroviral treatment (ART). The aim of this systematic review was to establish the epidemiological characteristics, clinical features, pathogenetic mechanisms and risk factors of HIV-related peripheral neuropathy (PN). METHODS A systematic, computer-based search was conducted using the PubMed database. Data regarding the above parameters were extracted. Ninety-four articles were included in this review. RESULTS The most commonly described clinical presentation of HIV neuropathy is the distal predominantly sensory polyneuropathy. The primary pathology in HIVPN appears to be axonal rather than demyelinating. Age and treatment with medications belonging in the nucleoside analogue reverse transcriptase class are risk factors for developing HIV-related neuropathy. The pooled prevalence of PN in patients naïve to ARTs was established to be 29% (95% CI: 9%-62%) and increased to 38% (95% confidence interval [CI]: 29%-48%) when looking into patients at various stages of their disease. More than half of patients with HIV-related neuropathy are symptomatic (53%, 95% CI: 41%-63%). Management of HIV-related neuropathy is mainly symptomatic, although there is evidence that discontinuation of some types of ART, such as didanosine, can improve or resolve symptoms. CONCLUSIONS Human immunodeficiency virus-related neuropathy is common and represents a significant burden in patients' lives. Our understanding of the disease has grown over the last years, but there are unexplored areas requiring further study.
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Affiliation(s)
- Thomas Julian
- Medical School, The University of Sheffield, Broomhall, Sheffield, UK.,Academic Directorate of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Martina Rekatsina
- Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - Faiza Shafique
- Academic Directorate of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Benevides MLACDSE, Filho SB, Debona R, Bergamaschi ENC, Nunes JC. Prevalence of Peripheral Neuropathy and associated factors in HIV-infected patients. J Neurol Sci 2017; 375:316-320. [PMID: 28320159 DOI: 10.1016/j.jns.2017.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 01/13/2017] [Accepted: 02/06/2017] [Indexed: 10/20/2022]
Abstract
The progress on HIV infection treatment has allowed a longer survival for HIV-infected patients. However, chronic comorbidities are emerging. Peripheral Neuropathy (PN) represents one of the most prevalent neurologic disorders among these patients, and comprehensive studies may contribute to a reduction in the morbidity of this condition. This is a cross-sectional analytic study conducted in a tertiary referral hospital in southern Brazil. This study investigates the prevalence of PN among HIV-infected patients and associated demographic, clinical and laboratory variables. A number of 150 HIV-infected patients admitted between January and May 2016 were interviewed, submitted to physical and neurological examination, and data from their medical records were obtained. The prevalence of PN was 31.3%. It was increased among older patients (p=0.02), patients with higher CD4 lymphocytes levels (p=0.02), and smokers (OR=3.4; 95% CI 1.6-6.9; p<0.01). The research identified a high prevalence of PN in HIV-infected patients. Older age and higher CD4 levels have been associated with PN. To the best of our knowledge, this was one of the first studies reporting an association between tobacco use and PN among HIV-infected patients. Further studies are necessary to elucidate the pathological mechanisms linking PN and tobacco.
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Affiliation(s)
| | - Sérgio Beduschi Filho
- Hospital Nereu Ramos (HNR), Rua Rui Barbosa, Agronômica, Florianópolis, Santa Catarina (SC), Brazil
| | - Rodrigo Debona
- Division of Neurology, UFSC, Rua Professora Maria Flora Pausewang, Trindade, Florianópolis, Brazil
| | | | - Jean Costa Nunes
- Division of Neuropathology, Universidade Federal de Santa Catarina (UFSC), Rua Professora Maria Flora Pausewang, Trindade, Florianópolis, Santa Catarina (SC), Brazil; Neurodiagnostic Brasil-Diagnósticos em Neuropatologia, Rua Santos Saraiva, Estreito, Florianópolis, Santa Catarina (SC), Brazil.
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Tumusiime DK, Venter F, Musenge E, Stewart A. Prevalence of peripheral neuropathy and its associated demographic and health status characteristics, among people on antiretroviral therapy in Rwanda. BMC Public Health 2014; 14:1306. [PMID: 25526665 PMCID: PMC4320525 DOI: 10.1186/1471-2458-14-1306] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 12/16/2014] [Indexed: 11/13/2022] Open
Abstract
Background The introduction of antiretroviral therapy (ART) has dramatically reduced the mortality rate of people living with HIV (PLHIV). However, complications of both HIV and ART, such as peripheral neuropathy currently affect PLHIV. The purpose of this study was to establish the prevalence of peripheral neuropathy of the lower extremity and, its association with demographic and health status, characteristics among people on ART in Rwanda. Methods A cross sectional study was conducted among 507 women and men aged between 18 and 60 years, on ART, randomly selected from eight selected ART clinics in Rwanda. Brief Peripheral Neuropathy Screen was used to assess peripheral neuropathy. Results Peripheral neuropathy prevalence was 59% overall, mean age of the participants was 39.7 (±9.2) and a slightly older age was associated with peripheral neuropathy; [42(±9.2) vs 37 (±8.8) (p < 0.001)]. 78% of participants living in urban settings compared to 40% in rural settings reported peripheral neuropathy, 69% of participants with higher levels of education (secondary level and above) reported lower extremity neuropathy. The three factors were significantly associated with peripheral neuropathy in multivariable model analysis: older age [aOR = 1.1, 95% CI (1.0, 1.2), p < 0.001], primary education level [aOR = 0.6 95% Cl (0.3, 1.0), p = 0.04] and urban setting [aOR = 0.1, 95% CI (0.06, 0.3), p < 0.001], after adjusting for other factors. None of the health status characteristics namely; the level of CD4 cell count, duration of HIV infection and duration on ART, was independently associated with peripheral neuropathy. Conclusions The prevalence of peripheral neuropathy among PLHIV on ART in Rwanda is high. It is unclear why urban setting has an effect on PN levels in this cross sectional study, but does suggest that unidentified social and lifestyles factors may have a role in subjective symptoms and objective signs, of PN.
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Affiliation(s)
- David Kabagema Tumusiime
- Research Centre, College of Medicine and Health Sciences, University of Rwanda, Box 3286, Kigali, Rwanda.
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Tumusiime DK, Musabeyezu E, Mutimurah E, Hoover DR, Shi Q, Rudakemwa E, Ndacyayisenga V, Dusingize JC, Sinayobye JD, Stewart A, Venter FWD, Anastos K. Over-reported peripheral neuropathy symptoms in a cohort of HIV infected and uninfected Rwandan women: the need for validated locally appropriate questionnaires. Afr Health Sci 2014; 14:460-7. [PMID: 25320598 DOI: 10.4314/ahs.v14i2.24] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Peripheral neuropathy symptoms (PNS) are commonly manifested in HIV-infected (HIV+) individuals, although data are limited on the prevalence and predictors of PNS in HIV+ patients from sub-Saharan Africa. OBJECTIVE To determine the prevalence and predictors of PNS in HIV+ and HIV-uninfected (HIV-) Rwandan women. METHODS Data were analysed from 936 (710 HIV+ and 226 HIV-) women from the Rwanda Women Interassociation Study and Assessment (RWISA), an observational prospective cohort study investigating the effectiveness and toxicity of ART in HIV+ women. RESULTS Of 936 enrolled, 920 (98.3%) were included in this analysis with 44% of HIV- and 52% of the HIV+ women reporting PNS (p=0.06). CD4+ count was not associated with PNS, although there was a non-significant trend towards higher prevalence in those with lower CD4+ counts. For the HIV- women, only alcohol and co-trimoxazole use were independently associated with PNS. WHO HIV stage IV illness and albumin ≤ 3.5 were associated with PNS in HIV+ women. CONCLUSIONS The rate of peripheral neuropathy symptoms reported in this cohort of HIV-infected African women seems implausible, and rather suggests that the screening tool for peripheral neuropathy in culturally diverse African settings be locally validated.
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Abstract
Peripheral neuropathies are the most common neurological manifestations occurring in HIV-infected individuals. Distal symmetrical sensory neuropathy is the most common form encountered today and is one of the few that are specific to HIV infection or its treatment. The wide variety of other neuropathies is akin to the neuropathies seen in the general population and should be managed accordingly. In the pre-ART era, neuropathies were categorized according to the CD4 count and HIV viral load. In the early stages of HIV infection when CD4 count is high, the inflammatory demyelinating neuropathies predominate and in the late stages with the decline of CD4 count opportunistic infection-related neuropathies prevail. That scenario has changed with the present almost universal use of ART (antiretroviral therapy). Hence, HIV-associated peripheral neuropathies are better classified according to their clinical presentations: distal symmetrical polyneuropathy, acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), mononeuropathies, mononeuropathies multiplex and cranial neuropathies, autonomic neuropathy, lumbosacral polyradiculomyelopathy, and amyotrophic lateral sclerosis (ALS)-like motor neuropathy. Treated with ART, HIV-infected individuals are living longer and are at a higher risk of metabolic and age-related complications; moreover they are also prone to the potentially neurotoxic effects of ART. There are no epidemiological data regarding the incidence and prevalence of the peripheral neuropathies. In the pre-ART era, most data were from case reports, series of patients, and pooled autopsy data. At that time the histopathological evidence of neuropathies in autopsy series was almost 100%. In large prospective cohorts presently being evaluated, it has been found that 57% of HIV-infected individuals have distal symmetrical sensory neuropathy and 38% have neuropathic pain. It is now clear that distal symmetrical sensory neuropathy is caused predominantly by the ART's neurotoxic effect but may also be caused by the HIV itself. With a sizeable morbidity, the neuropathic pain caused by distal symmetrical sensory neuropathy is very difficult to manage; it is often necessary to change the ART regimen before deciding upon the putative role of HIV infection itself. If the change does not improve the pain, there are few options available; the most common drugs used for neuropathic pain are usually not effective. One is left with cannabis, which cannot be recommended as routine therapy, recombinant human nerve growth factor, which is unavailable, and topical capsaicin with its side-effects. Much has been done to and learned from HIV infection in humans; HIV-infected individuals, treated with ART, are now dying mostly from cardiovascular disease and non-AIDS-related cancers. It hence behooves us to find new approaches to mitigate the residual neurological morbidity that still impacts the quality of life of that population.
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Affiliation(s)
- Alberto Alain Gabbai
- Department of Neurology, UNIFESP-Escola Paulista de Medicina, São Paulo, Brazil.
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Jayakumar P, Shankar EM, Karthikeyan M, Ravikannan P. Lipodystrophy and adrenal insufficiency: potential mediators of peripheral neuropathy in HIV infection? Med Hypotheses 2012; 78:373-6. [PMID: 22244839 DOI: 10.1016/j.mehy.2011.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 10/13/2011] [Accepted: 12/06/2011] [Indexed: 02/02/2023]
Abstract
The mechanisms behind certain co-morbid conditions associated with chronic HIV disease still remain elusive. HIV-associated peripheral neuropathy is one among those rarely studied manifestations in HIV-1 infection. Numerous underlying factors associated with peripheral neuropathy have been described in HIV disease. Herein, we hypothesized certain heretofore undescribed potential mechanisms that lead to HIV associated neuropathy. Being a multifactoral manifestation, HIV-associated neuropathy is presumed to have an association with physiological factors namely, adrenal inadequacy/steroid resistance and lipodystrophy-induced cushion-effect loss in peripheral nerves. Therefore, management of the adrenals with steroids at the time-point of high inflammatory burden thereby preventing lipodystrophy by selecting the optimum treatment regimen could markedly alleviate the severity of HIV-associated neuropathic manifestations.
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Affiliation(s)
- Palanisamy Jayakumar
- Antiretroviral Therapy (ART) Centre, Government Rajaji Hospital, Madurai 625 020, India.
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Ghosh S, Chandran A, Jansen JP. Epidemiology of HIV-related neuropathy: a systematic literature review. AIDS Res Hum Retroviruses 2012; 28:36-48. [PMID: 21902585 DOI: 10.1089/aid.2011.0116] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
We sought to identify and summarize the incidence and prevalence of neuropathy among HIV patients and subgroups. A systematic search of the literature was performed using MEDLINE and EMBASE. The relevant literature was identified based on predefined criteria. Prevalence data were collected from cross-sectional and cohort studies. Incidence data were collected from cohort and case-control studies. Thirty-seven studies were included of which there were 23 cohort studies, 13 cross-sectional studies, and one case-control study. The prevalence of neuropathy among HIV patients derived from 25 studies varied from 1.2% to 69.4%. Regarding the development of neuropathy among HIV-positive patients, standardized by study duration, the rates per 100 person-years ranged from 0.7 to 39.7. Among older patients there is a greater risk of neuropathy. The same seems to be the case for patients with more severe disease. Currently available studies providing information on the incidence and prevalence of neuropathy among HIV patients suggest a significant burden, but there is a great variation in results across studies. There is no definitive explanation for the variation. However, it underscores the fact that complexity of the disease, along with absence of standardized diagnostic criteria, has considerably influenced the methodologies and outcomes of the studies.
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Smith JA. HIV and AIDS in the Adolescent and Adult: An Update for the Oral and Maxillofacial Surgeon. Oral Maxillofac Surg Clin North Am 2008; 20:535-65. [DOI: 10.1016/j.coms.2008.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Hung CF, Gibson SA, Letendre SL, Lonergan JT, Marquie-Beck JA, Vaida F, Ellis RJ. Impact of long-term treatment with neurotoxic dideoxynucleoside antiretrovirals: implications for clinical care in resource-limited settings. HIV Med 2008; 9:731-7. [PMID: 18651859 DOI: 10.1111/j.1468-1293.2008.00615.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES A minority of HIV-infected patients taking an antiretroviral (ARV) regimen containing dideoxynucleosides (d-drugs) such as stavudine (d4T) and didanosine (DDI) experiences dose-limiting neuropathic pain and paraesthesias, usually within weeks of starting these drugs. Because d-drugs are among the few affordable options available in developing countries, continuing d-drug therapy would be a desirable strategy for many HIV-infected individuals. Therefore, we evaluated the safety of continuing d-drug therapy. METHODS In a US cohort, we compared the rates of worsening neuropathic symptoms and signs in HIV-infected individuals on stable ARV regimens that did (n=252) or did not (n=250) include d-drugs. Rates of worsening were compared using proportional hazards model and the log-rank test. RESULTS The risk ratios (RR) were not significantly larger for worsening neuropathy signs [0.94; 95% confidence interval (CI) 0.84-1.07] or symptoms (0.99; 95% CI 0.88-1.14) in patients taking d-drugs continuously compared to those not taking d-drugs. CONCLUSIONS Continued d-drug exposure among patients tolerating an initial trial did not increase the risk of worsening neuropathy compared to non-d-drug-containing regimens. If applicable in developing countries, these findings suggest that in most patients d-drugs can be continued safely in the long term without increasing the risk of worsening neuropathy.
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Affiliation(s)
- C F Hung
- University of California, San Diego, CA, USA
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Silva MTT, Araújo A. Highly active antiretroviral therapy access and neurological complications of human immunodeficiency virus infection: Impact versus resources in Brazil. J Neurovirol 2005; 11 Suppl 3:11-5. [PMID: 16540448 DOI: 10.1080/13550280500511360] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Currently, there are almost 600,000 human immunodeficiency virus (HIV)-infected individuals in Brazil. From 1984 to 2004, 362,364 acquired immunodeficiency virus (AIDS) cases were officially reported and 155,000 patients are under highly active antiretroviral therapy (HAART) treatment. Like in developed countries, universal access to treatment in Brazil has definitively changed both mortality and morbidity of AIDS. Today, the median survival time is 58 months, with a 2-year survival of 63%, versus 18 months before HAART. As expected, the incidence of nervous system opportunistic infectious diseases and tumors has also decreased in Brazil. However, few Brazilian reports about neurological manifestations of HIV infection are available, particularly after the beginning of more effective antiretroviral therapy. Autopsy series report that toxoplasmosis is the most prevalent neurological disease, followed by cryptococcosis and HIV encephalitis. A much lower incidence of progressive multifocal leukoencephalopathy has been described in Brazil than in reports from developed countries. A possibility for this discrepancy could be differences in terms of JC virus (JCV) isolates or even the interactions between JCV and local HIV strains. Some particularities about the involvement of the nervous system in Brazilian patients are worthy of note, such as the occurrence of central nervous system involvement in chronic Chagas' disease in patients with AIDS, and the concomitance of leprosy and HIV infection. National surveillance of neurological manifestations of HIV infection is needed to ascertain the real impact of HAART on nervous system diseases associated with AIDS in Brazil.
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Affiliation(s)
- Marcus Tulius T Silva
- Neurology Service, The Reference Centers for Neuroinfections and HTLV, Instituto de Pesquisa Clínica Evandro Chagas-FIOCRUZ, Rio de Janeiro, Brazil.
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