Cross-Sectional Analysis of Late HAART Initiation in Latin America and the Caribbean: Late Testers and Late Presenters

Background: Starting HAART in a very advanced stage of disease is assumed to be the most prevalent form of initiation in HIV-infected subjects in developing countries. Data from Latin America and the Caribbean is still lacking. Our main objective was to determine the frequency, risk factors and trends in time for being late HAART initiator (LHI) in this region. Methodology: Cross-sectional analysis from 9817 HIV-infected treatment-naive patients initiating HAART at 6 sites (Argentina, Chile, Haiti, Honduras, Peru and Mexico) from October 1999 to July 2010. LHI had CD4$^+$ count $\leq$200cells/mm$^3$ prior to HAART. Late testers (LT) were those LHI who initiated HAART within 6 months of HIV diagnosis. Late presenters (LP) initiated after 6 months of diagnosis. Prevalence, risk factors and trends over time were analyzed. Principal Findings: Among subjects starting HAART (n = 9817) who had baseline CD4$^+$ available (n = 8515), 76% were LHI: Argentina (56%[95%CI:52–59]), Chile (80%[95%CI:77–82]), Haiti (76%[95%CI:74–77]), Honduras (91%[95%CI:87–94]), Mexico (79%[95%CI:75–83]), Peru (86%[95%CI:84–88]). The proportion of LHI statistically changed over time (except in Honduras) ($p\leq0.02$; Honduras p = 0.7), with a tendency towards lower rates in recent years. Males had increased risk of LHI in Chile, Haiti, Peru, and in the combined site analyses (CSA). Older patients were more likely LHI in Argentina and Peru (OR 1.21 per +10-year of age, 95%CI:1.02–1.45; OR 1.20, 95%CI:1.02–1.43; respectively), but not in CSA (OR 1.07, 95%CI:0.94–1.21). Higher education was associated with decreased risk for LHI in Chile (OR 0.92 per +1-year of education, 95%CI:0.87–0.98) (similar trends in Mexico, Peru, and CSA). LHI with date of HIV-diagnosis available, 55% were LT and 45% LP. Conclusion: LHI was highly prevalent in CCASAnet sites, mostly due to LT; the main risk factors associated were being male and older age. Earlier HIV-diagnosis and earlier treatment initiation are needed to maximize benefits from HAART in the region

Characterization of data-driven geriatric syndrome clusters in older people with HIV: a Mexican multicenter cross-sectional studyResearch in context

Summary: Background: As living with HIV has been proposed as a condition that may accelerate aging, the main objective of this work was to estimate the prevalence of geriatric syndromes (GS) among older Mexicans with HIV dwelling in the community. Secondly, to evaluate whether the accumulation of GS could be associated with an adverse HIV-related clinical profile, independent of chronological age. Methods: Multicenter, cross-sectional study including 501 community-dwelling people aged ≥50 years with HIV. The overall prevalence of nine selected GS and their cumulative number were estimated. An Age-Independent Cumulative Geriatric Syndromes scale (AICGSs) was constructed, and correlations between the AICGSs and HIV-related parameters assessed. Finally, k-mean clustering analyses were performed to test the secondary objective. Findings: Median age 56 (IQR: 53–61) years, 81.6% of men. Polypharmacy (74.8%), sensorial deficit (71.2%), cognitive impairment (53.6%), physical disability (41.9%), pre-frailty (27.9%), and falls (29.7%), were the more prevalent GS. A significant negative correlation was found between the AICGSs and normalized values of CD4+ nadir cell counts (r = −0.126; 95%: CI: −0.223 to −0.026, p < 0.05). Similarly, a significant inverse adjusted association between the CD4+ nadir cells and the AICGSs was observed on linear regression analysis (β −0.058; 95%: CI: −0.109 to −0.007, p = 0.03). Cluster analysis identified three differentiated groups varying by age, metabolic comorbidities, AICGSs, and HIV-related parameters. Interpretation: An elevated prevalence of GS was observed in the studied population. Moreover, the accumulation of GS was associated with adverse HIV-related profiles, independent of age. Thus, early detection and management of GS are crucial to promote healthier aging trajectories in people with HIV. Funding: This work was funded in part by the National Center for the Prevention and Control of HIV/AIDS in Mexico (CENSIDA)—National Ministry of Health

Increased mortality after tuberculosis treatment completion in persons living with Human Immunodeficiency Virus in Latin America

We assessed the association between cured tuberculosis (TB) and mortality among persons living with human immunodeficiency virus (HIV) in Latin America. We compared survival among persons with and without TB at enrollment in HIV care, starting 9 months after clinic enrollment. In multivariable analysis, TB was associated with higher long-term mortality (hazard ratio, 1.57; 95% confidence interval, 1.25-1.99).United States Department of Health & Human Services National Institutes of Health (NIH) - USA NIH National Institute of Allergy & Infectious Diseases (NIAID) R01 AI131998 United States Department of Health & Human Services National Institutes of Health (NIH) - USA U01AI069923 United States Department of Health & Human Services National Institutes of Health (NIH) - USA NIH Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD) Office of the Director United States Department of Health & Human Services National Institutes of Health (NIH) - USA United States Department of Health & Human Services National Institutes of Health (NIH) - USA NIH National Institute of Allergy & Infectious Diseases (NIAID) United States Department of Health & Human Services National Institutes of Health (NIH) - USA NIH National Cancer Institute (NCI) United States Department of Health & Human Services National Institutes of Health (NIH) - USA NIH National Institute of Mental Health (NIMH

Durability of efavirenz compared with boosted protease inhibitor based regimens in antiretroviral naive patients in the Caribbean and Central and South America

Background. Efavirenz (EFV) and boosted protease inhibitors (bPIs) are still the preferred options for firstline antiretroviral regimens (firstline ART) in Latin America and have comparable short-term efficacy. We assessed the long-term durability and outcomes of patients receiving EFV or bPIs as firstline ART in the Caribbean, Central and South America network for HIV epidemiology (CCASAnet). Methods. We included ART-naive, HIV-positive adults on EFV or bPIs as firstline ART in CCASAnet between 2000 and 2016. We investigated the time from starting until ending firstline ART according to changes of third component for any reason, including toxicity and treatment failure, death, and/or loss to follow-up. Use of a third-line regimen was a secondary outcome. Kaplan-Meier estimators of composite end points were generated. Crude cumulative incidence of events and adjusted hazard ratios (aHRs) were estimated accounting for competing risk events. Results. We included 14 519 patients: 12 898 (89%) started EFV and 1621 (11%) bPIs. The adjusted median years on firstline ART were 4.6 (95% confidence interval [CI], 4.4-4.7) on EFV and 3.8 (95% CI, 3.8-4.0) on bPI (P<.001). Cumulative incidence of firstline ART ending at 10 years of follow-up was 32% (95% CI, 31-33) on EFV and 44% (95% CI, 39-48) on bPI (aHR, 0.88; 95% CI, 0.78-0.97). The cumulative incidence rates of third-line initiation in the bPI-based group were 6% (95% CI, 2.4-9.6) and 2% (95% CI, 1.4-2.2) among the EFV-based group (P<.01). Conclusions. Durability of firstline ART was longer with EFV than with bPIs. EFV-based regimens may continue to be the preferred firstline regimen for our region in the near future due to their high efficacy, relatively low toxicity (especially at lower doses), existence of generic formulations, and affordability for national programs.National Institutes of Heatlh U01AI069923 Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Office of The Director (OD), National Institutes of Health National Institute of Allergy and Infectious Diseases (NIAID) National Cancer Institute (NCI) National Institute of Mental Health (NIMH

Time to HAART initiation after diagnosis and treatment of opportunistic infections in patients with AIDS in Latin America

CCASAnet- Caribbean, Central and South America Network for HIV Epidemiology;/ IeDEA- International Epidemiologic Databases to Evaluate AIDS Program.Submitted by Fábio Marques ([email protected]) on 2018-09-20T18:56:22Z No. of bitstreams: 1 Time to HAART initiation after diagnosis_Beatriz_Grinsztejn_etal_INI_Lapclin-AIDS_2016.PDF: 591315 bytes, checksum: 4d373b1ccee26425fede47135397d61f (MD5)Approved for entry into archive by Regina Costa ([email protected]) on 2018-10-04T13:43:55Z (GMT) No. of bitstreams: 1 Time to HAART initiation after diagnosis_Beatriz_Grinsztejn_etal_INI_Lapclin-AIDS_2016.PDF: 591315 bytes, checksum: 4d373b1ccee26425fede47135397d61f (MD5)Made available in DSpace on 2018-10-04T13:43:55Z (GMT). No. of bitstreams: 1 Time to HAART initiation after diagnosis_Beatriz_Grinsztejn_etal_INI_Lapclin-AIDS_2016.PDF: 591315 bytes, checksum: 4d373b1ccee26425fede47135397d61f (MD5) Previous issue date: 2016Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Infectious Diseases Department. Mexico City, Mexico.Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Infectious Diseases Department. Mexico City, Mexico.Vanderbilt University. Department of Biostatistics. Nashville, TN, USA.Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Laboratório de Pesquisa Clínica em DST/AIDS. Rio de Janeiro, RJ, Brasil.Universidad de Chile. Santiago, Chile / Fundación Arriarán. Santiago, Chile.Universidad de Chile. Santiago, Chile / Fundación Arriarán. Santiago, Chile.Instituto Hondureño de Seguro Social. Tegucigalpa, Honduras / Hospital Escuela Universitario. Tegucigalpa, Honduras.Instituto de Medicina Tropical Alexander von Humboldt. Lima, Peru.Fundación Huésped. Investigaciones Clínicas. Buenos Aires, Argentina.Vanderbilt University. Department of Medicine, Nashville, TN, USA.Vanderbilt University. Department of Medicine. Nashville, TN, USA.Vanderbilt University. Department of Medicine. Nashville, TN, USA.Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico.Since 2009, earlier initiation of highly active antiretroviral therapy (HAART) after an opportunistic infection (OI) has been recommended based on lower risks of death and AIDS-related progression found in clinical trials. Delay in HAART initiation after OIs may be an important barrier for successful outcomes in patients with advanced disease. Timing of HAART initiation after an OI in "real life" settings in Latin America has not been evaluated

Cancer in HIV-infected persons from the caribbean, central and South America

Background: HIV-infected individuals have heightened cancer risk. With the advent of highly active antiretroviral therapy (HAART), the frequency of some AIDS-defining cancers (ADC) has decreased although certain non-AIDS-defining cancers (NADC) are becoming more frequent. Cancers among HIV-infected individuals in Latin American and the Caribbean have not yet been carefully studied. Methods: Cancer cases among the Caribbean, Central and South American network for HIV Research (CCASAnet) cohort were identified reviewing clinical records and pre-existing databases. Results: There were 406 cancers reported: 331 ADC (224 Kaposi sarcomas and 98 non Hodgkin lymphomas). Most frequent NADC (n = 75) were Hodgkin lymphoma and skin cancers. Seventy-three percent of NADC and 45% of ADC were diagnosed &gt;1 year after HIV diagnosis. Fifty-six percent of ADC occurred before HAART start. Median time from HAART start until cancer diagnosis was 2.5 years for NADC and 0.5 years for ADC (P = &lt;0.001). Withi

Time to HAART Initiation after Diagnosis and Treatment of Opportunistic Infections in Patients with AIDS in Latin America.

BACKGROUND:Since 2009, earlier initiation of highly active antiretroviral therapy (HAART) after an opportunistic infection (OI) has been recommended based on lower risks of death and AIDS-related progression found in clinical trials. Delay in HAART initiation after OIs may be an important barrier for successful outcomes in patients with advanced disease. Timing of HAART initiation after an OI in "real life" settings in Latin America has not been evaluated. METHODS:Patients in the Caribbean, Central and South America network for HIV Epidemiology (CCASAnet) ≥18 years of age at enrolment, from 2001-2012 who had an OI before HAART initiation were included. Patients were divided in an early HAART (EH) group (those initiating within 4 weeks of an OI) and a delayed HAART (DH) group (those initiating more than 4 weeks after an OI). All patients with an AIDS-defining OI were included. In patients with more than one OI the first event reported was considered. Calendar trends in the proportion of patients in the EH group (before and after 2009) were estimated by site and for the whole cohort. Factors associated with EH were estimated using multivariable logistic regression models. RESULTS:A total of 1457 patients had an OI before HAART initiation and were included in the analysis: 213 from Argentina, 686 from Brazil, 283 from Chile, 119 from Honduras and 156 from Mexico. Most prevalent OI were Tuberculosis (31%), followed by Pneumocystis pneumonia (24%), Invasive Candidiasis (16%) and Toxoplasmosis (9%). Median time from OI to HAART initiation decreased significantly from 5.7 (interquartile range [IQR] 2.8-12.1) weeks before 2009 to 4.3 (IQR 2.0-7.1) after 2009 (p<0.01). Factors associated with starting HAART within 4 weeks of OI diagnosis were lower CD4 count at enrolment (p-<0.001), having a non-tuberculosis OI (p<0.001), study site (p<0.001), and more recent years of OI diagnosis (p<0.001). DISCUSSION:The time from diagnosis of an OI to HAART initiation has decreased in Latin America coinciding with the publication of evidence of its benefit. We found important heterogeneity between sites which may reflect differences in clinical practices, local guidelines, and access to HAART. The impact of the timing of HAART initiation after OI on patient survival in this "real life" context needs further evaluation

Monitoring of HIV treatment in seven countries in the WHO Region of the Americas

The Caribbean, Central and South America network for HIV epidemiology (CCASAnet) brings together the expertise and resources of Vanderbilt University and clinical and research sites in Argentina, Brazil, Chile, Haiti, Honduras, Mexico and Peru.Submitted by Fábio Marques ([email protected]) on 2018-10-15T14:34:07Z No. of bitstreams: 1 Monitoring of HIV treatment in seven countries_Paula_Luz_etal_INI_Lapclin-AIDS_2015.pdf: 1523750 bytes, checksum: 4a24030be8fe90fc9252034cda116a53 (MD5)Approved for entry into archive by Regina Costa ([email protected]) on 2018-10-17T14:38:56Z (GMT) No. of bitstreams: 1 Monitoring of HIV treatment in seven countries_Paula_Luz_etal_INI_Lapclin-AIDS_2015.pdf: 1523750 bytes, checksum: 4a24030be8fe90fc9252034cda116a53 (MD5)Made available in DSpace on 2018-10-17T14:38:56Z (GMT). No. of bitstreams: 1 Monitoring of HIV treatment in seven countries_Paula_Luz_etal_INI_Lapclin-AIDS_2015.pdf: 1523750 bytes, checksum: 4a24030be8fe90fc9252034cda116a53 (MD5) Previous issue date: 2015Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Departamento de Infectología. Clínica de Inmuno-Infectología. México Distrito Federal, Mexico.Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Departamento de Infectología. Clínica de Inmuno-Infectología. México Distrito Federal, Mexico.Vanderbilt University. Department of Biostatistics. Nashville, United States of America.Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Departamento de Infectología. Clínica de Inmuno-Infectología. México Distrito Federal, Mexico.Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Laboratório de Pesquisa Clínica em DST/AIDS. Rio de Janeiro, RJ, Brasil.Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Laboratório de Pesquisa Clínica em DST/AIDS. Rio de Janeiro, RJ, Brasil.Fundación Huésped. Buenos Aires, Argentina.Fundación Huésped. Buenos Aires, Argentina.Universidad de Chile. Fundación Arriarán. Santiago, Chile.Universidad de Chile. Fundación Arriarán. Santiago, Chile.Le Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes. Port-au-Prince, Haiti.Instituto Hondureño de Seguridad Social and Hospital Escuela. Tegucigalpa, Honduras.Instituto de Medicina Tropical Alexander von Humboldt. Lima, Peru .Vanderbilt University. Department of Medicine. Nashville, USA.Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Departamento de Infectología. Clínica de Inmuno-Infectología. México Distrito Federal, Mexico.To determine the prevalence of adequate monitoring and the costs of measuring CD4+ T-lymphocytes (CD4+ cell) and human immunodeficiency virus (HIV) viral load in people receiving antiretroviral therapy (ART) in seven countries in the WHO Region of the Americas

CD4 response up to 5 years after combination antiretroviral therapy in human immunodeficiency virus-infected patients in Latin America and the Caribbean

We describe CD4 counts at 6-month intervals for 5 years after combination antiretroviral therapy initiation among 12 879 antiretroviral-naive human immunodeficiency virusinfected adults from Latin America and the Caribbean. Median CD4 counts increased from 154 cells/mm3 at baseline (interquartile range [IQR], 60-251) to 413 cells/mm3 (IQR, 234-598) by year 5

The Population Impact of Late Presentation with Advanced HIV Disease and Delayed Antiretroviral Therapy in Adults Receiving HIV Care in Latin America

Late presentation to care and antiretroviral therapy (ART) initiation with advanced HIV-disease are common in Latin America. We estimated the impact of these conditions on mortality in the region. We included adults enrolled during 2001-2014 at HIV-care clinics. We estimated the adjusted attributable risk (AR) and population attributable fraction (PAF) for all-cause mortality of presentation to care with advanced HIV-disease (advanced-LP), ART initiation with advanced HIV-disease, and not initiating ART. Advanced HIV-disease was defined as CD4<200 cells/L or AIDS. AR and PAF were derived using marginal structural models. Of 9,229 patients, 56% presented with advanced HIV-disease. ARs of death for advanced-LP were 86%, 71%, and 58%, and PAFs were 78%, 58%, and 43% at 1, 5, and 10 years post-enrollment. Among people without advanced-LP, ARs of death for delaying ART were 39%, 32%, and 37% at 1, 5, and 10 years post-enrollment and PAFs were 20%, 14%, and 15%. Among people with advanced-LP, ART decreased the hazard of death by 63% in the first year post-enrollment, but 93% of these started ART; thus universal ART among them would only reduce mortality by 10%. Earlier presentation to care and earlier ART initiation would prevent most HIV-deaths in Latin America.United States Department of Health & Human Services National Institutes of Health (NIH) - USA U01AI069923 Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Cancer Institute, National Institute of Allergy and Infectious Diseases, National Institute of Mental Health United States Department of Health & Human Services National Institutes of Health (NIH) - USA United States Department of Health & Human Services National Institutes of Health (NIH) - USA NIH National Institute of Allergy & Infectious Diseases (NIAID) U01AI06992