Diferenças de gênero ao acolhimento de pessoas vivendo com HIV em serviço universitário de referência de São Paulo, Brasil

Clinical profile and mortality in patients with T. cruzi/HIV co-infection from the multicenter data base of the "Network for healthcare and study of Trypanosoma cruzi/HIV co-infection and other immunosuppression conditions"

OBJECTIVE

Chagas disease (CD) globalization facilitated the co-infection with Human Immunodeficiency Virus (HIV) in endemic and non-endemic areas. Considering the underestimation of Trypanosoma cruzi (T. cruzi)-HIV co-infection and the risk of life-threatening Chagas Disease Reactivation (CDR), this study aimed to analyze the major co-infection clinical characteristics and its mortality rates.

METHODS

This is a cross-sectional retrospective multicenter study of patients with CD confirmed by two serological or one parasitological tests, and HIV infection confirmed by immunoblot. CDR was diagnosed by direct microscopy with detection of trypomastigote forms in the blood or other biological fluids and/or amastigote forms in inflammatory lesions.

RESULTS

Out of 241 patients with co-infection, 86.7% were from Brazil, 47.5% had <200 CD4+ T cells/μL and median viral load was 17,000 copies/μL. Sixty CDR cases were observed. Death was more frequent in patients with reactivation and was mainly caused by CDR. Other causes of death unrelated to CDR were the manifestation of opportunistic infections in those with Acquired Immunodeficiency Syndrome. The time between the co-infection diagnosis to death was shorter in patients with CDR. Lower CD4+ cells count at co-infection diagnosis was independently associated with reactivation. Similarly, lower CD4+ cells numbers at co-infection diagnosis and male sex were associated with higher lethality in CDR. Additionally, CD4+ cells were lower in meningoencephalitis than in myocarditis and milder forms.

CONCLUSION

This study showed major features on T. cruzi-HIV co-infection and highlighted the prognostic role of CD4+ cells for reactivation and mortality. Since lethality was high in meningoencephalitis and all untreated patients died shortly after the diagnosis, early diagnosis, immediate antiparasitic treatment, patient follow-up and epidemiological surveillance are essentials in T. cruzi/HIV co-infection and CDR managements.

Hepatitis B viremia in HIV-coinfected individuals under antiretroviral therapy

BACKGROUND

Antiretroviral therapy (ART) has decreased AIDS incidence and mortality, rendering comorbidities, such as hepatitis B more relevant for people living with human immunodeficiency virus (HIV). Since antiretroviral drugs may also inhibit hepatitis B virus (HBV) replication, analyzing the impact of ART on management of hepatitis B in this population is important.

OBJECTIVE

To assess HBV viremia among HIV/HBV coinfected individuals on ART and its associated factors.

METHOD

For this cross-sectional study, HIV/HBV-coinfected individuals, aged over 18 years, who were on ART for over six months and receiving care at an outpatient clinic in São Paulo were recruited. Sociodemographic characteristics, information about viral exposure, clinical and laboratory data, including evaluation of liver fibrosis were obtained. Plasma HBV DNA was measured by polymerase chain reaction. Viral genome sequencing was conducted for genotyping and identification of drug resistance-conferring mutations if viral load exceeded 900 IU/mL.

RESULTS

Out of 2,946 patients who attended the clinic in 2015, 83 were eligible and 56 evaluated. Plasma HBV DNA was detected in 16 (28.6%) (95% CI: 18.0-41.3%), all on lamivudine and tenofovir treatment. HBV DNA detection was associated with lower education (p = 0.015), higher international normalized ratios (p = 0.045), history of an AIDS-defining illness [OR: 3.43 (95% CI: 1.10-11.50)], and HBeAg detection [OR: 6.60 (95% CI: 1.84-23.6)]. In contrast, a last CD4+ count above 500 cells/mm3 in the year prior to inclusion [OR: 0.18 (95% CI: 0.04-0.71)] and detection of anti-HBe [OR: 0.21 (95% CI: 0.04-0.99)] were negatively associated. Patients with HBV DNA above 900 IU/mL were infected with subgenotypes A1 (n = 3) and D2 (n = 1), and exhibited viral mutations associated with total resistance to lamivudine and partial resistance to entecavir.

CONCLUSIONS

Despite being on ART, a significant proportion of HIV/HBV-coinfected individuals present HBV viremia. Characterization of factors that are associated with this finding may help professionals provide better management to these patients.

HIV testing and clinical status upon admission to a specialized health care unit in Pará, Brazil

OBJECTIVE

To analyze the clinical and laboratory characteristics of HIV-infected individuals upon admission to a reference health care center.

METHODS

This cross-sectional study was conducted between 1999 and 2010 on 527 individuals with confirmed serological diagnosis of HIV infection who were enrolled in an outpatient health care service in Santarém, PA, Northern Brazil. Data were collected from medical records and included the reason for HIV testing, clinical status, and count of peripheral CD4+ T lymphocytes upon enrollment. The data were divided into three groups, according to the patient’s year of admission – P1 (1999-2002), P2 (2003-2006), and P3 (2007-2010) – for comparative analysis of the variables of interest.

RESULTS

In the study group, 62.0% of the patients were assigned to the P3 group. The reason for undergoing HIV testing differed between genders. In the male population, most tests were conducted because of the presence of symptoms suggesting infection. Among women, tests were the result of knowledge of the partner’s seropositive status in groups P1 and P2. Higher proportion of women undergoing testing because of symptoms of HIV/AIDS infection abolished the difference between genders in the most recent period. A higher percentage of patients enrolling at a more advanced stage of the disease was observed in P3.

CONCLUSIONS

Despite the increased awareness of the number of HIV/AIDS cases, these patients have identified their serological status late and were admitted to health care units with active disease. The HIV/AIDS epidemic in Pará presents specificities in its progression that indicate the complex characteristics of the epidemic in the Northern region of Brazil and across the country.

Acolhimento em saúde: uma revisão sistemática em periódicos brasileiros

Este estudo apresenta uma revisão sistemática sobre acolhimento em saúde em periódicos brasileiros. As bases de dados pesquisadas foram Bireme, MedLine, PubMed, SciELO e Science Direct. Utilizando como descritor único o termo "acolhimento", a pesquisa resultou na análise quantitativa e qualitativa de 40 artigos publicados entre 1999 e 2011. Os resultados indicaram que: os dois periódicos com maior número de publicações sobre o tema foram Cadernos de Saúde Pública e Ciência & Saúde Coletiva (25,0 e 22,5%, respectivamente); nos anos de 2004 a 2010, foram publicados sete artigos sobre o tema, e, em 2011, seis artigos foram encontrados. As áreas predominantes foram Saúde Pública/Coletiva (57,6%) e Enfermagem (39,4%). A análise qualitativa da variável "objeto de estudo" identificou artigos cuja investigação era os pontos de vista de usuários, profissionais e de ambos. Já a variável "percepções dos profissionais" ressaltou aspectos positivos do acolhimento. São necessários novos estudos que qualifiquem o conhecimento a respeito dessa forma de atendimento à população tanto nos serviços de atenção básica quanto de atenção especializada.

[Access to health services: approaches, concepts, policies and analysis model]

Access to health services is a multifaceted and multidimensional issue involving political, economic, social, organizational, technical and symbolic aspects in establishing access to universal healthcare. This theoretical review paper intends to discuss the different approaches, analyze the context and policies for special groups on access, marking an analysis model delineated by the above aspects, from readings on the topic in question. This analysis reveals a diversity of approaches to access the formulation and implementation of public policies and their potential for changing the organization of the health system. We identified progress in reducing inequalities in health and increased access to the network of the Unified Health System (SUS), especially in primary care. There were also limitations related to accessibility, fragmentation, decentralization and regionalization of the service network, with inadequacies in the process of care and attention to specific groups, and regional disparities. Finally, the analysis model proposed seeks to develop a critical stance to reflect and intervene in health practices and services, with the objective goal being responsible, comprehensive, effective, equitable and quality healthcare.

Cotidiano de mulheres após contágio pelo HIV/AIDS: subsídios norteadores da assistência de enfermagem

A pesquisa trata de compreender o cotidiano de mulheres após contágio do HIV/aids como subsídios norteadores da assistência de enfermagem. Pesquisa qualitativa, com participação de 39 mulheres que estavam em atendimento ambulatorial para HIV em Fortaleza-CE. Os dados foram coletados por meio de entrevistas e analisados por Análise de Conteúdo. Dos resultados, emergiu uma categoria: mudanças no cotidiano das mulheres após contágio pelo HIV, com três subcategorias: mudanças no âmbito afetivo familiar; modificações no contexto social, trabalho, lazer; novos hábitos cotidianos com vistas à qualidade de vida. Ao término do estudo, evidenciamos que a mulher soropositiva vivencia situações de abandono familiar, isolamento social, estagnação das atividades laborais e lazer devido ao estigma da doença. Os depoimentos demonstraram redução ou abandono da bebida, do fumo e das práticas sexuais desprotegidas. Os resultados sinalizam para enfermagem ações assistenciais que contemplem questões biopsicossocioespirituais.

Gender differences in oral manifestations among HIV-infected Brazilian adults

AIM

The purpose of this study was to compare gender differences in the prevalence of oral lesions in HIV-infected Brazilian adults.

METHODOLOGY

A retrospective study was conducted of medical records from HIV/AIDS patients from 1993 to 2004. Oral lesions were only included in this study if definitively diagnosed through microscopic analysis, therapeutic test or according to EC-Clearing house criteria.

RESULTS

A total of 750 men and 237 women were included in the study. Statistically significant differences were observed only for oral hairy leukoplakia, Kaposi sarcoma and lymphadenopathy (P < 0.01). However, a model of logistic regression showed that only oral hairy leukoplakia presented a significant association with gender and males had a significantly likelihood (four times higher than females) of presenting with this oral manifestation [OR 4.3 (95% CI: 1.39-13.36)].

CONCLUSION

These data shows that oral manifestations are less prevalent in females than in males, particularly oral hairy leukoplakia.

The hope of women with HIV/AIDS: evaluation using the Herth Scale

This descriptive cross-sectional study had the objective to evaluate the level of hope in women aged 50 or older suffering from HIV/AIDS, utilizing the Herth Hope Scale. The study involved 200 HIV- positive women, within the age bracket of interest, enrolled in three STI/AIDS specialized healthcare services in the city of São Paulo. The rules of the 196/96 Resolution were met and the study was approved by the Research and Ethics Committee. Data were collected in 2010 using two instruments: subjects' characterization and the Herth Hope Scale. Results demonstrated an average score of 36.75 (±4.52) on the Herth Hope Scale, with an interval of 12 to 48. This score is below the score obtained with the same scale for various pathologies, indicating a reduced perception of hope by the sample. Nurses should provide interventions to improve hope for these people, establishing realistic goals and strengthening social support.

Late entry into HIV care: estimated impact on AIDS mortality rates in Brazil, 2003-2006

BACKGROUND

Worldwide, a high proportion of HIV-infected individuals enter into HIV care late. Here, our objective was to estimate the impact that late entry into HIV care has had on AIDS mortality rates in Brazil.

METHODOLOGY/PRINCIPAL FINDINGS

We analyzed data from information systems regarding HIV-infected adults who sought treatment at public health care facilities in Brazil from 2003 to 2006. We initially estimated the prevalence of late entry into HIV care, as well as the probability of death in the first 12 months, the percentage of the risk of death attributable to late entry, and the number of avoidable deaths. We subsequently adjusted the annual AIDS mortality rate by excluding such deaths. Of the 115,369 patients evaluated, 50,358 (43.6%) had entered HIV care late, and 18,002 died in the first 12 months, representing a 16.5% probability of death in the first 12 months (95% CI: 16.3-16.7). By comparing patients who entered HIV care late with those who gained timely access, we found that the risk ratio for death was 49.5 (95% CI: 45.1-54.2). The percentage of the risk of death attributable to late entry was 95.5%, translating to 17,189 potentially avoidable deaths. Averting those deaths would have lowered the 2003-2006 AIDS mortality rate by 39.5%. Including asymptomatic patients with CD4(+) T cell counts >200 and ≤ 350 cells/mm(3) in the group who entered HIV care late increased this proportion by 1.8%.

CONCLUSIONS/SIGNIFICANCE

In Brazil, antiretroviral drugs reduced AIDS mortality by 43%. Timely entry would reduce that rate by a similar proportion, as well as resulting in a 45.2% increase in the effectiveness of the program for HIV care. The World Health Organization recommendation that asymptomatic patients with CD4(+) T cell counts ≤ 350 cells/mm(3) be treated would not have a significant impact on this scenario.

Gender-related mortality for HIV-infected patients on highly active antiretroviral therapy (HAART) in rural Uganda

The purpose of this study was to examine gender differences in mortality for human immunodeficiency virus (HIV) patients in rural Western Uganda after six months of highly active antiretroviral therapy (HAART). Three hundred eighty five patients were followed up for six months after initiating HAART. Statistical analysis included descriptive, univariate and multivariate methods, using Kaplan-Meier estimates of survival distribution and Cox proportional hazards regression. Mortality in female patients (9.0%) was lower than mortality in males (13.5%), with the difference being almost statistically significant (adjusted hazard ratio for females 0.55; 95% confidence interval [CI]: 0.28-1.07; P = 0.08). At baseline, female patients had a significantly higher CD4+ cell count than male patients (median 147 cells/μL vs 120 cells/μL; P < 0.01). A higher CD4+ cell count and primary level education were strongly associated with better survival. The higher CD4+ cell count in females may indicate that they accessed HAART services at an earlier stage of their disease progression than males. A borderline statistically significant lower mortality rate in females shows that females fare better on treatment in this context than males. The association between lower mortality and higher CD4+ levels suggest that males are not accessing treatment early enough and that more concerted efforts need to be made by HAART programs to reach male HIV patients.

Contextos de vulnerabilidade para o HIV entre mulheres brasileiras

Este artigo tem como objetivo identificar os contextos de vulnerabilidade para o HIV entre mulheres brasileiras. Entre novembro de 2003 a dezembro de 2004 foi realizado um estudo de corte transversal em 13 municípios distribuídos nas cinco regiões do país, incluindo, respectivamente, 1.777 mulheres com diagnóstico positivo para HIV e 2.045 mulheres usuárias de serviços públicos de atenção à saúde da mulher sem diagnóstico conhecido de soropositividade para o HIV. A comparação entre os dois grupos mostrou que as mulheres com diagnóstico de HIV/AIDS não apresentaram um número de parceiros significativamente diferente com relação às mulheres sem diagnóstico de HIV/AIDS. No entanto, as mulheres vivendo com HIV/AIDS apresentaram início da vida sexual mais precoce, menor aderência ao uso de preservativos, e uma maior proporção dessas mulheres relatou uso de drogas, ocorrência de DST e de violência sexual na vida. Tais resultados sugerem a importância de pensar em estratégias de prevenção voltadas para o fortalecimento das mulheres e não apenas focadas em seus comportamentos individuais.