Abstract
INTRODUCTION
: In this study, clinical-laboratory and epidemiological characteristics are described for a group of 700 individuals with HIV (human immunodeficiency virus)/AIDS (acquired immunodeficiency syndrome) in the ART (antiretroviral therapy) era at a teaching hospital that provides a quaternary level of care, with an emphasis on opportunistic infections (OIs), co-infections and immune profile.
METHODS
: A retrospective cross-sectional study of AIDS cases was conducted from 1998 to 2008 by reviewing medical records from the Base Hospital/FUNFARME (Fundação Faculdade Regional de Medicina), São José do Rio Preto, São Paulo, Brazil.
RESULTS:
The individuals were 14 to 75 years of age, and 458 were males. Heterosexuals accounted for 31.1% of all patients. Eighty-three percent were on ART, and 33.8% of those presented difficulties with treatment adherence. OIs were analyzed from medical records, and Pneumocystis jiroveci pneumonia was the most prevalent, regardless of the LTCD4+ (TCD4+ Lymphocytes) levels. Individuals whose viral loads were ≥10,000 showed a 90% greater chance of neurotoxoplasmosis. For P. jiroveci pneumonia, neurotoxoplasmosis, esophageal candidiasis, pulmonary tuberculosis and neurocryptococcosis, the chances of infection were higher among patients with LTCD4+ levels below 200 cells/mm3. HIV/hepatitis C virus (HCV) and HIV/hepatitis B virus (HBV) co-infections were significantly associated with death.
CONCLUSIONS
: OIs remain frequent in the ART era even in populations where the access to medical care is considered satisfactory.
HBV; HCV; HIV; Opportunistic infections
INTRODUCTION
Three decades after the discovery of the human immunodeficiency virus (HIV), it is
estimated that 33.4 million people worldwide are living with the virus. In Brazil,
608,230 cases of AIDS were reported from 1980 to June 2011, and 186,445 of these cases
were reported in the State of São Paulo. In 2012, the observed frequency of the disease
in São José do Rio Preto, a city located in the Northwest region of São Paulo, was
33.2/100,000(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
. The virus can be spread to
individuals of all social levels. In Brazil, social, economic and cultural inequalities
favor the spread of AIDS, with impoverishment of the infected population. Other
characteristics of the epidemic are an increased number of cases among individuals who
have sex with someone of the opposite gender, feminization, aging and an increased
number of infected individuals outside major urban centers, a process also known as
interiorization(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
(2)2 Schiesari Jr A, Galisteu KJ, Cardoso LV, Schiesari VMB, da Cruz Furini
AA, Rossit ARB, et al. Epidemiological patterns of AIDS in a reference center from
Catanduva, São Paulo State, Brazil. Open J Med Microbiol 2012;
2:47-53.
(3)3 Silva LCF, Santos EM, Silva Neto ALS, Miranda AE, Talhari S, Toledo LM.
Pattern of HIV/AIDS infection in Manaus, State of Amazonas, between 1996 and 2000.
Rev Soc Bras Med Trop 2009; 42:543-550.. In Brazil, AIDS is an epidemic with a wide
spectrum of clinical presentations and without a single epidemiological profile, is
concentrated in high risk and vulnerable populations, and has regional subepidemics(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
.
Antiretroviral therapy (ART) has been available since 1996 for individuals diagnosed
with AIDS and has allowed long-term control of the disease with increased survival(4)4 Quinn TC. HIV epidemiology and the effects of antiviral therapy on
long-term consequences. AIDS 2008; 22 (suppl III):7-12.
(5)5 Demarchi IG, Cardoso DM, Aristides SMA, Moliterno RA, Silveira TGV,
Cardoso RF, et al. Activity of antiretroviral drugs in human infections by
opportunistic agents. Braz J Pharm Sci 2012; 48:171-185. and decreased morbidity and mortality
rates(5)5 Demarchi IG, Cardoso DM, Aristides SMA, Moliterno RA, Silveira TGV,
Cardoso RF, et al. Activity of antiretroviral drugs in human infections by
opportunistic agents. Braz J Pharm Sci 2012; 48:171-185.. However, AIDS has become a chronic
and degenerative disease for patients undergoing ART(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
(2)2 Schiesari Jr A, Galisteu KJ, Cardoso LV, Schiesari VMB, da Cruz Furini
AA, Rossit ARB, et al. Epidemiological patterns of AIDS in a reference center from
Catanduva, São Paulo State, Brazil. Open J Med Microbiol 2012;
2:47-53.
(6)6 World Health Organization (WHO). HIV/AIDS. Geneva: WHO; 2014 (accessed
2014 May 15). Available at: http://www.who.int/hiv/en/
http://www.who.int/hiv/en/...
. In 2012, 313,000 individuals were on ART in
Brazil(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
, and 76% of these patients had an
undetectable viral load(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
.
The advances in the arsenal of antiretroviral therapy have reduced the HIV viral load,
the occurrence of opportunistic infections (OIs), and death rates due to AIDS,
especially in patients with increased CD4+ T cell counts(4)4 Quinn TC. HIV epidemiology and the effects of antiviral therapy on
long-term consequences. AIDS 2008; 22 (suppl III):7-12.
(5)5 Demarchi IG, Cardoso DM, Aristides SMA, Moliterno RA, Silveira TGV,
Cardoso RF, et al. Activity of antiretroviral drugs in human infections by
opportunistic agents. Braz J Pharm Sci 2012; 48:171-185.
(6)6 World Health Organization (WHO). HIV/AIDS. Geneva: WHO; 2014 (accessed
2014 May 15). Available at: http://www.who.int/hiv/en/
http://www.who.int/hiv/en/...
(7)7 Brooks JT, Kaplan JE, Masur H. What's new in the 2009 US Guidelines for
prevention and treatment of opportunistic infections among adults and adolescents
with HIV. Top HIV Med 2009; 17:109-114.. However, even in the ART era, HIV-related OIs
are still an important cause of hospitalization and death(3)3 Silva LCF, Santos EM, Silva Neto ALS, Miranda AE, Talhari S, Toledo LM.
Pattern of HIV/AIDS infection in Manaus, State of Amazonas, between 1996 and 2000.
Rev Soc Bras Med Trop 2009; 42:543-550.
(5)5 Demarchi IG, Cardoso DM, Aristides SMA, Moliterno RA, Silveira TGV,
Cardoso RF, et al. Activity of antiretroviral drugs in human infections by
opportunistic agents. Braz J Pharm Sci 2012; 48:171-185.
(7)7 Brooks JT, Kaplan JE, Masur H. What's new in the 2009 US Guidelines for
prevention and treatment of opportunistic infections among adults and adolescents
with HIV. Top HIV Med 2009; 17:109-114.
(8)8 Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de
DST, AIDS - Hepatites Virais;. Brasília: Ministério da Saúde; 2014 (accessed 2014
June 18). Available at: http://www.aids.gov.br/pcdt/
http://www.aids.gov.br/pcdt/...
, which may be the result of late diagnosis and
low levels of CD4+ T cell counts(8)8 Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de
DST, AIDS - Hepatites Virais;. Brasília: Ministério da Saúde; 2014 (accessed 2014
June 18). Available at: http://www.aids.gov.br/pcdt/
http://www.aids.gov.br/pcdt/...
. According to
the Centers for Disease Control and Prevention (CDC) classification(9)9 Centers of Disease Control and Prevention (CDC). Opportunistic
infections and their relationship to HIV/AIDS. Atlanta: CDC; 2014(Accessed 2014 April
10). Available at:
https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
https://www.aids.gov/hiv-aids-basics/sta...
, several diseases are considered OIs for HIV-seropositive
patients. In tropical regions, HIV infection is associated with high prevalences of
tuberculosis, neurotoxoplasmosis, chronic diarrhea and lung diseases(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
(9)9 Centers of Disease Control and Prevention (CDC). Opportunistic
infections and their relationship to HIV/AIDS. Atlanta: CDC; 2014(Accessed 2014 April
10). Available at:
https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
https://www.aids.gov/hiv-aids-basics/sta...
. However, the variability of host-etiological
agent interactions and difficulties in the diagnosis of some OIs contribute to a lack of
data that demonstrate consistent evidence of the effects of OIs(7)7 Brooks JT, Kaplan JE, Masur H. What's new in the 2009 US Guidelines for
prevention and treatment of opportunistic infections among adults and adolescents
with HIV. Top HIV Med 2009; 17:109-114.
(10)10 Karp CL, Auwaerter PG. Coinfection with HIV and tropical infectious
diseases. I. Protozoal pathogens. Clin Infect Dis 2007;
45:1208-1213..
Based on the epidemiological diversity observed in different regions of Brazil, studies about AIDS are very important and contribute to the creation of regional public health policies that include strategies targeted to the particular needs of HIV-positive populations and corresponding health services. In this study, clinical-laboratory and epidemiological characteristics are described in a sample of 700 individuals with HIV/AIDS in the ART era in a teaching hospital that provides a quaternary level of care, with an emphasis on OIs, confections and immune profiles.
METHODS
This investigation was a cross-sectional study with data obtained from January 1998 to
December 2008. During this period, medical records from 1972 living patients and 979
deceased patients were available. The sample size studied represented 23% of the
patients. In total, 700 patients with a diagnosis of HIV/AIDS were evaluated. Five
hundred medical records were from living patients, and 200 were from deceased patients.
These data are part of the archive of the Infectious and Parasitic Diseases Outpatient
Clinic at the Base Hospital/Regional Medical School Foundation [Ambulatório de
Doenças Infecciosas e Parasitárias do Hospital de Base (ADIPHB),
Fundação Faculdade Regional de Medicina (FUNFARME)], São José do Rio
Preto, São Paulo, Brazil. The Base Hospital (BH) is a large quaternary level care
teaching hospital (720 beds) that provides specialized care. It is an important
reference hospital for health care services in the Northwest region of the State of São
Paulo and is linked to the Medical School and Nursing School programs of the São José do
Rio Preto Medical School [Faculdade de Medicina de São José do Rio
Preto (FAMERP)]. The City of São José do Rio Preto has approximately 408,435
inhabitants(11)11 Instituto Brasileiro de Geografia e Estatística (IBGE). Rio de Janeiro:
IGBE; 2014 (accessed 2014 May 2). Available at:
http://cidades.ibge.gov.br/xtras/perfil.php?lang=&ampcodmun=354980&search=sao-paulo|sao-jose-do-rio-preto.
http://cidades.ibge.gov.br/xtras/perfil....
and is located 454km from the
City of São Paulo.
This study was approved by the Research Ethics Committee of the São José do Rio Preto Medical School/FAMERP under protocol no 3361/2008 and was conducted in accordance with the required ethical standards. The inclusion criteria of the study were individuals older than 13 years who were diagnosed with HIV-1/AIDS and on ART. The exclusion criteria were cases where the medical records did not have at least 80% of the information requested by the instrument. Data collection from the medical records (both paper and electronic formats) was performed using a protocol standardized by physicians specializing in infectious diseases, nurses, pharmacists and other health care professionals involved in the study.
The data analyzed included age, gender, educational level, area of residence (rural or
urban), date of diagnosis of HIV-1 infection, categories of exposure to HIV-1
acquisition, identification and frequency of AIDS-defining OIs(6)6 World Health Organization (WHO). HIV/AIDS. Geneva: WHO; 2014 (accessed
2014 May 15). Available at: http://www.who.int/hiv/en/
http://www.who.int/hiv/en/...
(9)9 Centers of Disease Control and Prevention (CDC). Opportunistic
infections and their relationship to HIV/AIDS. Atlanta: CDC; 2014(Accessed 2014 April
10). Available at:
https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
https://www.aids.gov/hiv-aids-basics/sta...
, serum CD4+ T cell counts and HIV viral load
levels at the diagnosis of the OI. In addition, information in the medical records about
the use of ART and patient adherence to treatment (assessed by the receipt of
antiretroviral drugs from the pharmacy) were evaluated. The presence of co-infections
with hepatitis B virus (HBV) and hepatitis C virus (HCV) were also investigated. This
study considered AIDS-defining OIs as those OIs that met the CDC criteria adapted by the
Brazilian Ministry of Health. Statistical analyses were performed using R software,
version 2.4.1 (The R Foundation for Statistical Computing ISBN 3-900051-070 -
http://www.r-project.org, Vienna, Austria). Fisher's exact test was used to analyze
independence among the proportions. The proportion and probability (odds ratio) were
adjusted, and 95% confidence intervals were estimated. The level of significance adopted
for statistical inference was 5%; p-value<0.05 was considered statistically
significant.
RESULTS
The ages of the analyzed patients (700 cases) ranged from 14 to 75 years, with a mean age of 41.8 years. Of these patients, 458 (65.4%) were males. An educational level of less than eight years of education was observed in 51.6% (n=361) of the cases, and 91.4% (n=640) of the individuals resided in urban areas. HIV was diagnosed during hospitalization or medical treatment of other diseases in 317 (45.3%) patients. Thirty (n=211) percent of the individuals were previously diagnosed with HIV-1 ( Table 1 ). Regarding the categories of exposure to HIV-1, 31.1% of the individuals were heterosexual. However, this information was not available in 48.1% of the medical records analyzed in this study ( Table 1 ).
Among the outpatients, 83% were on ART, and problems with treatment adherence were reported in 33.8% of these cases. OIs were observed in 297 individuals, representing 42.5% of the patients, and patients with more than one OI were observed. Table 2 shows the most prevalent OIs observed in patients on ART according to the LTCD4+ levels and viral load. Pneumocystis jiroveci pneumonia was the most prevalent OI, regardless of the LTCD4+ levels or viral load, with 17.7% (p-value <0.01) greater than 200 cells/mm3 and 28% below 200 cells/mm3. This OI had a 55% lower chance (0.37-0.83) of affecting patients with levels of LTCD4+ greater than 200 cells/mm3. However, no association with viral loads was found. The second most prevalent OI was neurotoxoplasmosis, presenting a 0.3 times (0.18-0.49) lower chance of occurrence in patients whose LTCD4+ levels were high (p-value <0.01). Neurotoxoplasmosis preferably affected individuals whose viral loads were ≥10,000 (p-value <0.01), who presented 90% (1.11-3.24) greater chances of developing this OI than those with viral loads below this count. Esophageal candidiasis, pulmonary tuberculosis and neurocryptococcosis also had lower chances of afflicting patients whose LTCD4+ levels were above 200 cells/mm3 (p-value ≤0.01).
Tuberculosis was the most prevalent OI among the deceased patients, with 23.5% (p-value <0.01) and 2.15 times (1.45-3.18) greater chances of occurrence in this group. Cryptococcosis (p-value <0.01) was also associated with a 2.12 (1.27-3.58) times greater chance of a death outcome. Patients whose deaths were not due to OI were not evaluated in this study. For 57/200 death cases investigated, the survival time was, on average, one year and seven months after the diagnosis of HIV-1.
Table 3 presents the frequencies of patients with HIV/HBV or HIV/HCV co-infection. HIV-1/HCV (p-value <0.01) and HIV/HBV (p-value <0.01) co-infections were significantly associated with death in patients on ART.
DISCUSSION
In 2011 in Brazil, HIV was more prevalent in both males and females aged 30 to 44 years
old(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
. The present study revealed a higher
incidence of HIV among young adult males, as previously described by our group at the
municipality of Catanduva, São Paulo(2)2 Schiesari Jr A, Galisteu KJ, Cardoso LV, Schiesari VMB, da Cruz Furini
AA, Rossit ARB, et al. Epidemiological patterns of AIDS in a reference center from
Catanduva, São Paulo State, Brazil. Open J Med Microbiol 2012;
2:47-53.. However,
there was a decrease in the male: female (M:F) ratio among infected individuals in the
ART era (1.89M:1F), which is in agreement with the current trend of the spread of the
HIV/AIDS epidemic among women(12)12 Nunes CLX, Gonçalves LA, Silva PT, Bina JC. Clinical-epidemiological
characteristics of a group of HIV/AIDS infected women in Salvador-Bahia. Rev Soc Bras
Med Trop2004; 37:436-440.. This ratio was
4.5M:1F in São José do Rio Preto in the 1980s and 1990s. In 2009, with the drop in the
number of infected men, this ratio was 2M:1F, which is similar to the national average
observed in 2011 (1.7M:1F)(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
(13)13 Sistema de Informação de Agravos de Notificação (SINAN) - Vigilância
Epidemiológica. Programa Estadual DST/Aids-SP (VE-PE STD/AIDS - SP), 2010. Bepa 2011;
8:14-21..
The increased number of cases among heterosexuals is a critical factor favoring the increased number of HIV infections among females. These data reveal the importance of interrupting the epidemiological chain that is underway in our region(2)2 Schiesari Jr A, Galisteu KJ, Cardoso LV, Schiesari VMB, da Cruz Furini AA, Rossit ARB, et al. Epidemiological patterns of AIDS in a reference center from Catanduva, São Paulo State, Brazil. Open J Med Microbiol 2012; 2:47-53. through preventive policies that focus on the contribution of females to the epidemic. It is undeniable that the present study illustrates a regional profile of the epidemic's course; however, further studies involving all reported AIDS cases and not only outpatients are still needed to obtain a clearer profile of the current extent of the phenomenon. In addition, cultural factors can be an additional risk for the increased number of cases among women, especially in the men having sex with women (MSW) group, who do not demand the use of condoms most of the time.
Homosexuals/bisexuals represent 6.6% of the patients analyzed, and heterosexuals
represent 31.1%. In the United States, the transmission of HIV among men who have sex
with men represented 78% of cases among men aged 13 to 24 years of age(14)14 Sharma A, Stephenson RB, White D, Sullivan PS. Acceptability and
intended usage preferences for six HIV testing options among internet-using men who
have sex with men. Springer Plus 2014; 3:109.. In the Brazilian population, the most
significant increase in HIV-positive cases was observed among young individuals
belonging to the MSM group, whose frequency increased from 0.56% in 2002 to 1.2% in
2007(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
. Information regarding sexuality is
typically rare, which may result from bisexual behavior being hidden due to cultural
issues, leading this group to declare themselves as heterosexuals(2)2 Schiesari Jr A, Galisteu KJ, Cardoso LV, Schiesari VMB, da Cruz Furini
AA, Rossit ARB, et al. Epidemiological patterns of AIDS in a reference center from
Catanduva, São Paulo State, Brazil. Open J Med Microbiol 2012;
2:47-53.
(14)14 Sharma A, Stephenson RB, White D, Sullivan PS. Acceptability and
intended usage preferences for six HIV testing options among internet-using men who
have sex with men. Springer Plus 2014; 3:109.
(15)15 Gabriel R, Barbosa DA, Viana LAC. Perfil epidemiológico dos clientes com
HIV/AIDS da Unidade Ambulatorial de Hospital Escola de Grande Porte - Município de
São Paulo. Rev Latino-Am de Enfermagem 2005; 13:509-513.. Prophylactic intervention is very important
in this group, and experimental models have demonstrated that it can reduce the risk of
HIV transmission in the MSM group by 25%. Diagnostic intervention is recommended at
least once a year in this group and every 3-6 months in MSM/injection drug users(14)14 Sharma A, Stephenson RB, White D, Sullivan PS. Acceptability and
intended usage preferences for six HIV testing options among internet-using men who
have sex with men. Springer Plus 2014; 3:109.
(15)15 Gabriel R, Barbosa DA, Viana LAC. Perfil epidemiológico dos clientes com
HIV/AIDS da Unidade Ambulatorial de Hospital Escola de Grande Porte - Município de
São Paulo. Rev Latino-Am de Enfermagem 2005; 13:509-513..
Human immunodeficiency virus transmission through injection drug use (IDU) was common in
the period before ART; however, the results obtained in the present study showed a
significant decrease in IDU in the ART era (4.6%). The municipality of São José do Rio
Preto was an important drug trafficking route until 1992, and therefore, the use of
injectable drugs and MSM behavior were the main forms of HIV-1 transmission. Starting in
1994, heterosexuals became the predominant category of exposure to HIV, which is still
observed today, with men and especially women in stable relationships being
affected(13)13 Sistema de Informação de Agravos de Notificação (SINAN) - Vigilância
Epidemiológica. Programa Estadual DST/Aids-SP (VE-PE STD/AIDS - SP), 2010. Bepa 2011;
8:14-21.. In fact, among the 13,447
HIV-positive cases with classification of exposure reported in the Notifiable Diseases
Information System [Sistema de Informação de Agravos de Notificação
(SINAN)], 52.7% were heterosexual(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
and therefore
critical for expansion of the epidemic among women.
Individuals with low educational levels have been most affected by the disease in
Brazil(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
(15)15 Gabriel R, Barbosa DA, Viana LAC. Perfil epidemiológico dos clientes com
HIV/AIDS da Unidade Ambulatorial de Hospital Escola de Grande Porte - Município de
São Paulo. Rev Latino-Am de Enfermagem 2005; 13:509-513.
(16)16 Schuelter-Trevisol F, Pucci P, Justino AZ, Pucci N, Silva ACBD.
Epidemiological profile of HIV patients in the southern region of Santa Catarina
state in 2010. Epidemiol Serv Saude 2010; 22:87-94.. Our data reveal an association between
HIV-infected individuals in the ART era and low (51.6%) educational level. The
impoverishment of the epidemic observed in our study is similar to the scenario reported
in a study conducted in the City of São Paulo that demonstrated that low educational
levels (less than eight years of education) and poor professional skills are
predisposing factors to HIV infection and treatment noncompliance(2)2 Schiesari Jr A, Galisteu KJ, Cardoso LV, Schiesari VMB, da Cruz Furini
AA, Rossit ARB, et al. Epidemiological patterns of AIDS in a reference center from
Catanduva, São Paulo State, Brazil. Open J Med Microbiol 2012;
2:47-53.
(15)15 Gabriel R, Barbosa DA, Viana LAC. Perfil epidemiológico dos clientes com
HIV/AIDS da Unidade Ambulatorial de Hospital Escola de Grande Porte - Município de
São Paulo. Rev Latino-Am de Enfermagem 2005; 13:509-513.
(16)16 Schuelter-Trevisol F, Pucci P, Justino AZ, Pucci N, Silva ACBD.
Epidemiological profile of HIV patients in the southern region of Santa Catarina
state in 2010. Epidemiol Serv Saude 2010; 22:87-94.. Additionally, a study conducted in the City
of São Paulo with 1,837 HIV-seropositive individuals revealed that 76.3% had only a
primary education. Recent studies indicate impoverishment among the infected
population(15)15 Gabriel R, Barbosa DA, Viana LAC. Perfil epidemiológico dos clientes com
HIV/AIDS da Unidade Ambulatorial de Hospital Escola de Grande Porte - Município de
São Paulo. Rev Latino-Am de Enfermagem 2005; 13:509-513.. These data contrast with the
epidemiological profile observed at the beginning of the epidemic, where the majority of
the patients had high school education or college degrees(16)16 Schuelter-Trevisol F, Pucci P, Justino AZ, Pucci N, Silva ACBD.
Epidemiological profile of HIV patients in the southern region of Santa Catarina
state in 2010. Epidemiol Serv Saude 2010; 22:87-94.
(17)17 Bertoni RF, Bunn K, Silva J, Traebert J. Perfil demográfico e
socio-econômico dos portadores de HIV/AIDS do ambulatório de controle de DST/AIDS de
São José, SC. Arq Catarinenses Med 2010; 39:75-79.. However, it should be emphasized that few
individuals with higher levels of education were treated at the ADIPHB service, most
likely because this is a public regional reference center for infectious and parasitic
diseases.
Another trend characterizing the epidemic is that in addition to the major urban centers, the disease is also spreading to smaller towns (interiorization) and rural areas (ruralization). This result was also found by our group in a hospital in the City of Catanduva, located in a rural area of the State of São Paulo(2)2 Schiesari Jr A, Galisteu KJ, Cardoso LV, Schiesari VMB, da Cruz Furini AA, Rossit ARB, et al. Epidemiological patterns of AIDS in a reference center from Catanduva, São Paulo State, Brazil. Open J Med Microbiol 2012; 2:47-53.. The growth of the epidemic in rural areas is reported in the Brazilian literature(18)18 Soares VYR, Lúcio Filho CEP, Carvalho LIM, Silva AM, Eulálio KD. Clinical and epidemiological analysis of patients with HIV/AIDS admitted to a reference hospital in the northeast region of Brazil. Rev Inst Med trop São Paulo 2008; 50:327-332.. Although the present study demonstrated that only 8.3% of patients live in rural areas, this fact should not be underestimated in the region. This low rate of seropositive patients living in rural areas may be due to cultural and economic aspects or to their limited access to specialized health care services.
Only 30% of the patients were tested for HIV-1 before seeking care at the health care service. The current municipal health care policy recommends decentralized diagnostic testing for HIV-1, i.e., individuals should undergo rapid diagnostic testing at units that provide primary health care, and if necessary, they should be referred to a specialized service to confirm the diagnosis and for clinical follow-up(13)13 Sistema de Informação de Agravos de Notificação (SINAN) - Vigilância Epidemiológica. Programa Estadual DST/Aids-SP (VE-PE STD/AIDS - SP), 2010. Bepa 2011; 8:14-21.. Accordingly, our results are worrisome because the primary health care units are not performing diagnoses, and the diagnosis is typically established as a result of OIs or co-infections that can affect seropositive individuals. In addition, a delayed diagnosis may occur due to fear of a positive result and prejudice that make people avoid HIV serologic tests. When the diagnosis is postponed, a continuous cycle of transmission and lack of access to therapeutic measures ensues.
Adherence to treatment is a determining factor in improving the quality of life of
patients and the treatment success; however, it is one of the biggest challenges for
AIDS patients(19)19 Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de
DST, AIDSe Hepatites virias. Adesão ao tratamento antirretroviral no Brasil:
coletânea de estudos do projeto ATAR. Brasília: Ministério da Saúde; 2010 (accessed
2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/atar-web.pdf
http://www.aids.gov.br/sites/default/fil...
. For ART to be effective, i.e.,
undetectable plasma viral loads are achieved at least 95% of the daily doses must be
taken. In the present study, treatment adherence was measured by pharmacy records, which
indicated that 33.8% of patients displayed some degree of non-adherence. Treatment
adherence depends on changes in patient behavior, diet, and awareness of polytherapy use
for the rest of their lives. Measures such as providing information and guidance as well
as psychological counseling should be undertaken at the health care unit under study to
reduce treatment non-adherence. Another proposal that should be considered is the offer
of specific activities focused on treatment adherence, care provided by the entire
multidisciplinary team, and individualized pharmaceutical care with discussion about
drug and food interactions and adverse drug reactions(19)19 Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de
DST, AIDSe Hepatites virias. Adesão ao tratamento antirretroviral no Brasil:
coletânea de estudos do projeto ATAR. Brasília: Ministério da Saúde; 2010 (accessed
2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/atar-web.pdf
http://www.aids.gov.br/sites/default/fil...
. A bias of this analysis was the fact that the effects of
socio-demographic factors, health care service, and vulnerability to HIV, which may be
associated with non-adherence to treatment, were not evaluated.
Diseases caused by fungi are important causes of morbidity among AIDS patients and
frequent OIs among HIV-1 positive individuals(20)20 Tapia C, Gonzales P, Pereira A, Pérez J, Noriega LM, Palavecino E.
Antifungal susceptibility testing of Candida albicans isolates from AIDSpatients with
oropharyngeal and esophageal candidiasis. Experience with Etest(r). Rev Med Chile
2003; 131:515-519.
and can affect up to 94% of infected individuals, depending on the stage of the
infection and the population analyzed(7)7 Brooks JT, Kaplan JE, Masur H. What's new in the 2009 US Guidelines for
prevention and treatment of opportunistic infections among adults and adolescents
with HIV. Top HIV Med 2009; 17:109-114..
Candidiasis was the most common infection observed before the use of ART(8)8 Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de
DST, AIDS - Hepatites Virais;. Brasília: Ministério da Saúde; 2014 (accessed 2014
June 18). Available at: http://www.aids.gov.br/pcdt/
http://www.aids.gov.br/pcdt/...
. Esophageal candidiasis was reported in the
medical records of 10.2% of all patients whose LTCD4+ levels were below 200
cells/mm3 and 8.6% of those with viral loads ≥10,000 copies/mL. The
incidence of this disease in the ART era was 22% in the municipality of Catanduva, and
it was the most frequent OI(2)2 Schiesari Jr A, Galisteu KJ, Cardoso LV, Schiesari VMB, da Cruz Furini
AA, Rossit ARB, et al. Epidemiological patterns of AIDS in a reference center from
Catanduva, São Paulo State, Brazil. Open J Med Microbiol 2012;
2:47-53.
. The low incidence of candidiasis observed in the present study may be a
consequence of the types of candidiasis not being correctly specified in the medical
records and the CDC criteria being followed, which classify only esophageal candidiasis
as an OI(9)9 Centers of Disease Control and Prevention (CDC). Opportunistic
infections and their relationship to HIV/AIDS. Atlanta: CDC; 2014(Accessed 2014 April
10). Available at:
https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
https://www.aids.gov/hiv-aids-basics/sta...
. Increased viral load contributed to
the greater susceptibility to the development of esophageal candidiasis, even in
patients who are on antiretroviral therapy, which should result in a lower incidence of
OIs. The incidence of OIs in patients may also be due to immune reconstitution
syndrome(21)21 Lane HC. Pathogenesis of HIV infection: total CD4+ T-cell pool, immune
activation, and inflammation. Top HIV Med2010; 18:2-6.. Among the systemic mycoses,
cryptococcosis is the most frequently observed in AIDS patients, especially in the form
of meningoencephalitis. Its worldwide prevalence varies from 2.9% to 13.3%, and it is a
significant cause of mortality in AIDS. In the present study, this fungal disease was
detected in 8.4% of all patients with LTCD4+ levels below 200 cells/mm3 and
viral loads ≥10,000 copies/mL. A similar prevalence of cryptococcosis is observed in
European countries (6% to 13% of AIDS patients)(22)22 Vlchkova-Lashkoska M, Kamberova S, Starova A, Goleva-Mishevska L,
Tsatsa-Biljanovska N, Janevska V, et al. Cutaneous Cryptococcus laurentii infection
in a human immunodeficiency virus-negative subject. J Eur Acad Dermatol Venereol
2004; 18:99-100..
Pulmonary diseases are common and serious complications(23)23 Pedro HSP, Pereira MIF, Goloni MRA, Pires FC, Oliveira RS, da Rocha MA.
Mycobacterium tuberculosis in a HIV-1-infected population from Southeastern Brazil in
the TARV era. Trop Med Int Health 2011; 16:67-73. and the main cause of morbidity and mortality among individuals infected
with HIV-1
(9)9 Centers of Disease Control and Prevention (CDC). Opportunistic
infections and their relationship to HIV/AIDS. Atlanta: CDC; 2014(Accessed 2014 April
10). Available at:
https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
https://www.aids.gov/hiv-aids-basics/sta...
(23)23 Pedro HSP, Pereira MIF, Goloni MRA, Pires FC, Oliveira RS, da Rocha MA.
Mycobacterium tuberculosis in a HIV-1-infected population from Southeastern Brazil in
the TARV era. Trop Med Int Health 2011; 16:67-73.
(24)24 Furini AAC, Pedro HPS, Rodrigues JF, Montenegro LM, Machado RL, Franco
C, et al. Detection of Mycobacterium tuberculosis complex by nested polymerase chain
reaction in pulmonary and extrapulmonary specimens. J Bras Pneumol 2013;
39:711-718.. Despite regional differences, P.
jiroveci pneumonia is the most frequent OI among HIV-seropositive
individuals and is the most common clinical manifestation(7)7 Brooks JT, Kaplan JE, Masur H. What's new in the 2009 US Guidelines for
prevention and treatment of opportunistic infections among adults and adolescents
with HIV. Top HIV Med 2009; 17:109-114.
(9)9 Centers of Disease Control and Prevention (CDC). Opportunistic
infections and their relationship to HIV/AIDS. Atlanta: CDC; 2014(Accessed 2014 April
10). Available at:
https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
https://www.aids.gov/hiv-aids-basics/sta...
. However, an association between
pneumonia-causing agents and death was not found in the population studied, most likely
because information about the pneumonia causative agent was not
available in most of the medical records.
HIV infection is considered one of the main risk factors for tuberculosis (TB) and
mycobacteriosis. TB is the main cause of morbidity and mortality among HIV-seropositive
individuals at a rate of one-third of deaths among AIDS patients. Immunological
suppression caused by HIV increases the risk of latent TB infection progress to active
TB(24)24 Furini AAC, Pedro HPS, Rodrigues JF, Montenegro LM, Machado RL, Franco
C, et al. Detection of Mycobacterium tuberculosis complex by nested polymerase chain
reaction in pulmonary and extrapulmonary specimens. J Bras Pneumol 2013;
39:711-718.
(25)25 World Health Organization (WHO). Tuberculosis and HIV. Geneva: WHO; 2012
(accessed 2014 March 18). Available at:
http://www.who.int/hiv/topics/tb/en/
http://www.who.int/hiv/topics/tb/en/...
(26)26 Conde MB, Melo FAF, Marques ANC, Cardoso NC, Pinheiro VGF, Dalcin PTR,
et al. III. Brazilian Thoracic Association Guidelines on Tuberculosis. J Bras
Pneumol2009; 35:1018-1048.. According to the World Health Organization,
8.8 to 9.2 million TB cases were reported in 2010, and 1.2 million of these cases were
TB/HIV co-infections, which represents a challenge for public health programs. The
present study found a low incidence of tuberculosis, but with a significant association
between HIV-1/TB co-infection and death (23.5% of cases). The fact that HIV-1/TB
co-infection was found in 23.5% of patients who died at the BH in the ART era suggests a
late and/or erroneous clinical diagnosis of this co-infection(18)18 Soares VYR, Lúcio Filho CEP, Carvalho LIM, Silva AM, Eulálio KD.
Clinical and epidemiological analysis of patients with HIV/AIDS admitted to a
reference hospital in the northeast region of Brazil. Rev Inst Med trop São Paulo
2008; 50:327-332., and the lack of investigations for TB in these patients. In
2004, only 40% of TB patients were screened for HIV, and in 2007, this rate increased to
80%(25)25 World Health Organization (WHO). Tuberculosis and HIV. Geneva: WHO; 2012
(accessed 2014 March 18). Available at:
http://www.who.int/hiv/topics/tb/en/
http://www.who.int/hiv/topics/tb/en/...
. However, laboratory diagnoses of
Mycobacterium spp. in HIV/AIDS patients through bacilloscopy and
culture phenotypic methods typically have low sensitivity due to the paucibacillary
character (except in cavitations) of the disease in these individuals(24)24 Furini AAC, Pedro HPS, Rodrigues JF, Montenegro LM, Machado RL, Franco
C, et al. Detection of Mycobacterium tuberculosis complex by nested polymerase chain
reaction in pulmonary and extrapulmonary specimens. J Bras Pneumol 2013;
39:711-718.. In the Brazilian Public Health Care System, TB
diagnosis is typically based on bacilloscopy, and culture and biochemical tests for
Mycobacterium spp. are recommended only in cases of suspicion of
pulmonary TB with negative bacilloscopy. However, culture tests are available for
HIV-seropositive patients(26)26 Conde MB, Melo FAF, Marques ANC, Cardoso NC, Pinheiro VGF, Dalcin PTR,
et al. III. Brazilian Thoracic Association Guidelines on Tuberculosis. J Bras
Pneumol2009; 35:1018-1048..
Data from the World Health Organization (WHO) indicate that more than 180 million people
are chronically infected with HCV, and 7 million are co-infected with HIV(27)27 Victoria MB, Victoria FS, Torres KL, Kashima S, Covas DT, Malheiro A.
Epidemiology of HIV/HCV coinfection in patients cared for at the Tropical Medicine
Foundation of Amazonas. Braz J Infect Dis 2010; 14:135-140.. In Brazil, the incidence of HIV/HCV
co-infection varies according to geographical distribution and risk factors for disease
acquisition, such as age, gender and type of exposure, and ranges from 17% to 53%(27)27 Victoria MB, Victoria FS, Torres KL, Kashima S, Covas DT, Malheiro A.
Epidemiology of HIV/HCV coinfection in patients cared for at the Tropical Medicine
Foundation of Amazonas. Braz J Infect Dis 2010; 14:135-140.
(28)28 Mohammadi M, Talei G, Sheikhian A, Ebrahimzade F, Pournia Y, Ghasemi E,
et al. Survey of both hepatitis B virus (HBsAg) and hepatitis C virus (HCV-Ab)
coinfection among HIV positive patients. Virol J 2009; 18:202.
(29)29 Braga WSM, Castilho MC, Santos ICV, Moura MAS, Segurado AC. Low
prevalence of hepatitis B virus, hepatitis D virus and hepatitis C virus among
patients with human immunodeficiency virus or acquired immunodeficiency syndrome in
the Brazilian Amazon basin. Rev Soc Bras Med Trop2006; 39:519-522.. The similarity in the routes of
transmission, such as sexual, vertical and parenteral (including the use of injectable
drugs), associates HIV with several forms of hepatitis, especially those caused by
HCV(1)1 Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1
- até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013
(Accessed 2014 May 15). Available at:
http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
(27)27 Victoria MB, Victoria FS, Torres KL, Kashima S, Covas DT, Malheiro A.
Epidemiology of HIV/HCV coinfection in patients cared for at the Tropical Medicine
Foundation of Amazonas. Braz J Infect Dis 2010; 14:135-140.
(29)29 Braga WSM, Castilho MC, Santos ICV, Moura MAS, Segurado AC. Low
prevalence of hepatitis B virus, hepatitis D virus and hepatitis C virus among
patients with human immunodeficiency virus or acquired immunodeficiency syndrome in
the Brazilian Amazon basin. Rev Soc Bras Med Trop2006; 39:519-522.. Hepatitis is an important cause of
morbidity and mortality among HIV-seropositive patients(29)29 Braga WSM, Castilho MC, Santos ICV, Moura MAS, Segurado AC. Low
prevalence of hepatitis B virus, hepatitis D virus and hepatitis C virus among
patients with human immunodeficiency virus or acquired immunodeficiency syndrome in
the Brazilian Amazon basin. Rev Soc Bras Med Trop2006; 39:519-522.. The incidence of HIV/HCV co-infection observed in the present study is
similar to that reported in the literature. However, the incidence of HIV-1/HBV
co-infection was low in the population studied (2% in living patients and 6% in deceased
patients) and similar to the rate observed in the Western Brazilian Amazon (6.4%)(29)29 Braga WSM, Castilho MC, Santos ICV, Moura MAS, Segurado AC. Low
prevalence of hepatitis B virus, hepatitis D virus and hepatitis C virus among
patients with human immunodeficiency virus or acquired immunodeficiency syndrome in
the Brazilian Amazon basin. Rev Soc Bras Med Trop2006; 39:519-522.. In contrast, a study conducted in New Mexico,
United States, showed high rates of positivity for these two co-infections (82.2% and
61.1%, respectively)(30)30 Samuel MC, Doherty PM, Bulterys M, Jenison SA. Association between
heroin use, needle sharing and tattoos received in prison with hepatitis B and C
positivity among street-recruited injecting drug users in New Mexico, USA. Epidemiol
Infect 2001; 127:475-484. . It is known that the
incidence of HCV infection varies according to geographical area, risk behavior and
laboratory methods for virus detection(27)29 Braga WSM, Castilho MC, Santos ICV, Moura MAS, Segurado AC. Low
prevalence of hepatitis B virus, hepatitis D virus and hepatitis C virus among
patients with human immunodeficiency virus or acquired immunodeficiency syndrome in
the Brazilian Amazon basin. Rev Soc Bras Med Trop2006; 39:519-522.. In
addition, HIV/HCV and HIV/HBV co-infections were significantly associated with
progression to death in the ART era (p-value <0.01 and p-value <0.01,
respectively). ART and hepatitis therapy can cause severe hepatotoxicity and therefore
contribute to morbidity and mortality. In fact, HIV/HBV co-infected patients presented
5-6 times greater chances of progression to chronicity, reactivation and liver cancer.
The HIV/HCV co-infected patients can progress with liver failure and cirrhosis(31)31 Raboni SM, Tuon FF, Beloto NCP, Demeneck H, Oliveira A, Largura D, et
al. Human immunodeficiency virus and hepatitis C virus/hepatitis B virus co-infection
in southern Brazil: clinical and epidemiological evaluation. Braz J Infect Dis2014;
18:664-668.. Surveys and knowledge about HIV/HCV
co-infection are essential for public health agencies to devise strategies to control
and prevent HIV and HCV infections. Unfortunately, the lack of some information in the
records analyzed, especially related to genotyping and HCV treatment, restricted a
deeper analysis of the topic in question because the treatment for hepatitis C in
co-infected patients represented a major goal of this study, i.e., to assess HCV
infection in HIV-infected patients. Surveys and knowledge about HIV/HCV co-infections
are essential for public health agencies to devise strategies to control and prevent HIV
and HCV infections. In addition, understanding the factors associated with host-virus
interaction from a molecular perspective is important for HCV treatment. The emergence
of new strategies to achieve a more effective treatment, as well as monitoring patients
with chronic HCV infection and co-infection with HIV, in the coming years may help
reduce the number of infected patients.
In conclusion, OIs remain frequent in the ART era even in populations where access to medical care is considered satisfactory. Our findings demonstrated that these diseases can arise with any level of viral load and CD4+ T cell count. The low educational level described may explain the non-adherence to ART and/or prophylaxis for opportunistic diseases. While the cases reported here are representative of the community infected by HIV-1 in the northwest region of the State of São Paulo, the data can be used for future comparisons at different levels, such as institutional, inter-institutional, regional and other developing countries. Finally, the extensive qualifications of health care professionals indicate early diagnosis and appropriate treatment of AIDS as important measures for the survival of patients suffering from this condition. The effect of confounding factors, especially incomplete medical records, is a limitation of retrospective studies.
-
1Ministério da Saúde. Boletim Epidemiológico - Aids e DST, Ano II - nº 1 - até semana epidemiológica 26ª dezembro de 2013. Brasília: Ministério da Saúde; 2013 (Accessed 2014 May 15). Available at: http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
» http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf -
2Schiesari Jr A, Galisteu KJ, Cardoso LV, Schiesari VMB, da Cruz Furini AA, Rossit ARB, et al. Epidemiological patterns of AIDS in a reference center from Catanduva, São Paulo State, Brazil. Open J Med Microbiol 2012; 2:47-53.
-
3Silva LCF, Santos EM, Silva Neto ALS, Miranda AE, Talhari S, Toledo LM. Pattern of HIV/AIDS infection in Manaus, State of Amazonas, between 1996 and 2000. Rev Soc Bras Med Trop 2009; 42:543-550.
-
4Quinn TC. HIV epidemiology and the effects of antiviral therapy on long-term consequences. AIDS 2008; 22 (suppl III):7-12.
-
5Demarchi IG, Cardoso DM, Aristides SMA, Moliterno RA, Silveira TGV, Cardoso RF, et al. Activity of antiretroviral drugs in human infections by opportunistic agents. Braz J Pharm Sci 2012; 48:171-185.
-
6World Health Organization (WHO). HIV/AIDS. Geneva: WHO; 2014 (accessed 2014 May 15). Available at: http://www.who.int/hiv/en/
» http://www.who.int/hiv/en/ -
7Brooks JT, Kaplan JE, Masur H. What's new in the 2009 US Guidelines for prevention and treatment of opportunistic infections among adults and adolescents with HIV. Top HIV Med 2009; 17:109-114.
-
8Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, AIDS - Hepatites Virais;. Brasília: Ministério da Saúde; 2014 (accessed 2014 June 18). Available at: http://www.aids.gov.br/pcdt/
» http://www.aids.gov.br/pcdt/ -
9Centers of Disease Control and Prevention (CDC). Opportunistic infections and their relationship to HIV/AIDS. Atlanta: CDC; 2014(Accessed 2014 April 10). Available at: https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/
» https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/ -
10Karp CL, Auwaerter PG. Coinfection with HIV and tropical infectious diseases. I. Protozoal pathogens. Clin Infect Dis 2007; 45:1208-1213.
-
11Instituto Brasileiro de Geografia e Estatística (IBGE). Rio de Janeiro: IGBE; 2014 (accessed 2014 May 2). Available at: http://cidades.ibge.gov.br/xtras/perfil.php?lang=&ampcodmun=354980&search=sao-paulo|sao-jose-do-rio-preto.
» http://cidades.ibge.gov.br/xtras/perfil.php?lang=&ampcodmun=354980&search=sao-paulo|sao-jose-do-rio-preto -
12Nunes CLX, Gonçalves LA, Silva PT, Bina JC. Clinical-epidemiological characteristics of a group of HIV/AIDS infected women in Salvador-Bahia. Rev Soc Bras Med Trop2004; 37:436-440.
-
13Sistema de Informação de Agravos de Notificação (SINAN) - Vigilância Epidemiológica. Programa Estadual DST/Aids-SP (VE-PE STD/AIDS - SP), 2010. Bepa 2011; 8:14-21.
-
14Sharma A, Stephenson RB, White D, Sullivan PS. Acceptability and intended usage preferences for six HIV testing options among internet-using men who have sex with men. Springer Plus 2014; 3:109.
-
15Gabriel R, Barbosa DA, Viana LAC. Perfil epidemiológico dos clientes com HIV/AIDS da Unidade Ambulatorial de Hospital Escola de Grande Porte - Município de São Paulo. Rev Latino-Am de Enfermagem 2005; 13:509-513.
-
16Schuelter-Trevisol F, Pucci P, Justino AZ, Pucci N, Silva ACBD. Epidemiological profile of HIV patients in the southern region of Santa Catarina state in 2010. Epidemiol Serv Saude 2010; 22:87-94.
-
17Bertoni RF, Bunn K, Silva J, Traebert J. Perfil demográfico e socio-econômico dos portadores de HIV/AIDS do ambulatório de controle de DST/AIDS de São José, SC. Arq Catarinenses Med 2010; 39:75-79.
-
18Soares VYR, Lúcio Filho CEP, Carvalho LIM, Silva AM, Eulálio KD. Clinical and epidemiological analysis of patients with HIV/AIDS admitted to a reference hospital in the northeast region of Brazil. Rev Inst Med trop São Paulo 2008; 50:327-332.
-
19Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, AIDSe Hepatites virias. Adesão ao tratamento antirretroviral no Brasil: coletânea de estudos do projeto ATAR. Brasília: Ministério da Saúde; 2010 (accessed 2014 May 15). Available at: http://www.aids.gov.br/sites/default/files/atar-web.pdf
» http://www.aids.gov.br/sites/default/files/atar-web.pdf -
20Tapia C, Gonzales P, Pereira A, Pérez J, Noriega LM, Palavecino E. Antifungal susceptibility testing of Candida albicans isolates from AIDSpatients with oropharyngeal and esophageal candidiasis. Experience with Etest(r). Rev Med Chile 2003; 131:515-519.
-
21Lane HC. Pathogenesis of HIV infection: total CD4+ T-cell pool, immune activation, and inflammation. Top HIV Med2010; 18:2-6.
-
22Vlchkova-Lashkoska M, Kamberova S, Starova A, Goleva-Mishevska L, Tsatsa-Biljanovska N, Janevska V, et al. Cutaneous Cryptococcus laurentii infection in a human immunodeficiency virus-negative subject. J Eur Acad Dermatol Venereol 2004; 18:99-100.
-
23Pedro HSP, Pereira MIF, Goloni MRA, Pires FC, Oliveira RS, da Rocha MA. Mycobacterium tuberculosis in a HIV-1-infected population from Southeastern Brazil in the TARV era. Trop Med Int Health 2011; 16:67-73.
-
24Furini AAC, Pedro HPS, Rodrigues JF, Montenegro LM, Machado RL, Franco C, et al. Detection of Mycobacterium tuberculosis complex by nested polymerase chain reaction in pulmonary and extrapulmonary specimens. J Bras Pneumol 2013; 39:711-718.
-
25World Health Organization (WHO). Tuberculosis and HIV. Geneva: WHO; 2012 (accessed 2014 March 18). Available at: http://www.who.int/hiv/topics/tb/en/
» http://www.who.int/hiv/topics/tb/en/ -
26Conde MB, Melo FAF, Marques ANC, Cardoso NC, Pinheiro VGF, Dalcin PTR, et al. III. Brazilian Thoracic Association Guidelines on Tuberculosis. J Bras Pneumol2009; 35:1018-1048.
-
27Victoria MB, Victoria FS, Torres KL, Kashima S, Covas DT, Malheiro A. Epidemiology of HIV/HCV coinfection in patients cared for at the Tropical Medicine Foundation of Amazonas. Braz J Infect Dis 2010; 14:135-140.
-
28Mohammadi M, Talei G, Sheikhian A, Ebrahimzade F, Pournia Y, Ghasemi E, et al. Survey of both hepatitis B virus (HBsAg) and hepatitis C virus (HCV-Ab) coinfection among HIV positive patients. Virol J 2009; 18:202.
-
29Braga WSM, Castilho MC, Santos ICV, Moura MAS, Segurado AC. Low prevalence of hepatitis B virus, hepatitis D virus and hepatitis C virus among patients with human immunodeficiency virus or acquired immunodeficiency syndrome in the Brazilian Amazon basin. Rev Soc Bras Med Trop2006; 39:519-522.
-
30Samuel MC, Doherty PM, Bulterys M, Jenison SA. Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among street-recruited injecting drug users in New Mexico, USA. Epidemiol Infect 2001; 127:475-484.
-
31Raboni SM, Tuon FF, Beloto NCP, Demeneck H, Oliveira A, Largura D, et al. Human immunodeficiency virus and hepatitis C virus/hepatitis B virus co-infection in southern Brazil: clinical and epidemiological evaluation. Braz J Infect Dis2014; 18:664-668.
-
This study was funded by the São José do Rio Preto Medical School and by the São José do Rio Preto Base Hospital
Publication Dates
-
Publication in this collection
mar-apr 2015
History
-
Received
05 Dec 2014 -
Accepted
26 Mar 2015