Crosssectional study to evaluate factors associated with adherence to antiretroviral therapy by Brazilian HIV-infected patients.

ABSTRACT Antiretroviral therapy success is highly dependent on the ability of the patient to fully adhere to the prescribed treatment regimen. We present the results of a cross-sectional study that evaluates the predictive value of a self-administered questionnaire of adherence to antiretroviral (ARV) therapy. Study participants were interviewed using a 36-item Patient Medication Adherence Questionnaire (PMAQ) designed to assess knowledge about ARV therapy, motivation to adhere to treatment, and behavioral skills. Plasma HIV-1 RNA levels were correlated with the results obtained from the PMAQ. Of the 182 study participants, 82 (45%) were receiving their initial ARV regimen. Of the remaining patients, 39 (21%) and 61 (34%) were on a second or additional ARV regimen, respectively. An undetectable viral load was documented in 47/62 (76%) patients on their first regimen who reported missing medication on less than 4 days in the last 3 months. The PMAQ had a higher predictive value of plasma viral suppression for patients in the initial regimen than for patients in salvage therapy. The overall predictive value of the PMAQ to identify adherence was 74%, and 59% for nonadherence, with an overall efficacy of 64%. Of the 74 patients (45%) who did not understand the concept of antiretroviral therapy, 80% were failing or had previously failed the ARV treatment. Of 35 patients with doubts about their HIV status or skeptical of the benefits of ARV therapy, 29 (84%) were nonadherent. Despite the positive predictive value of PMAQ in identifying adherence, self-reported adherence is not a sufficiently precise predictor of treatment success to substitute for viral load monitoring. On the other hand, the use of such an instrument to identify factors associated with nonadherence provides an excellent opportunity to apply early intervention designed to specifically address factors that might be contributing to the lack of adherence prior to regimen failure

CINTURÕES DE ALTITUDE EM RELEVOS MONTANHOSOS TROPICAIS E A CONJUGAÇÃO ENTRE ZONALIDADE E EXTRAZONALIDADE NOS GEOSSISTEMAS MONTANHOSOS

As principais elevações da fachada atlântica brasileira ostentam cinturões de vegetação e de paisagem fortemente influenciados pelas variações mesoclimáticas que se sucedem dos sopés às superfícies somitais das montanhas tropicais. Na Serra da Mantiqueira, tais sucessões são muito bem marcadas, enfaticamente na estrutura concernente à Serra Fina, elevação cujas cimeiras se aproximam de 2900 metros localizada na divisa entre os estados de São Paulo e Minas Gerais. No âmbito da aludida unidade geomorfológica o presente trabalho objetivou interpretar os diferentes cinturões de altitude e suas variações estruturais e dinâmicas, encontrando uma zonação altitudinal bem marcada nas variáveis de estado, notadamente no clima, vegetação e solos, mas também no relevo, elemento invariante do geossistema. Embora a existência de cinturões de altitude seja característica no contexto dos grandes escarpamentos do Brasil Oriental, as elevações mais pronunciadas da Serra Fina associadas à uma identidade litológica própria a destacam como unidade própria, figurando como uma das principais paisagens de exceção em todo o domínio tropical atlântico

Evaluation of viral resistance to Reverse Transcriptase Inhibitors (RTI) in HIV-1-infected patients before and after 6 months of single or double antiretroviral therapy

We evaluated samples of peripheral blood mononuclear (PBMC) cells from 46 AIDS patients, before starting therapy with HIV-1 reverse transcriptase inhibitors (RTI), and after 6 months of drug use. PBMC were stored and tested by a Line Probe Assay (LiPA), in order to assess the frequency of RT mutations in this population. Six patients were taking AZT before initial blood collection (1 to 16 weeks of drug use) and 40 patients had no prior therapy. After baseline evaluation, 19 patients received AZT, 23 AZT plus DDI, 3 started AZT only with DDI added after 3 months, and 3 received a combination of AZT plus 3TC. Detection of at least one mutation was found in 33% (15/46) of patients at baseline, and 83% (38/46) had at least 1 mutation after 6 months of therapy. In the majority of cases, samples presented with the wild type and variants of HIV, simultaneously. Patients receiving monotherapy had a higher frequency of mutations (L41 and F214, Y215) than did patients receiving double-drug therapy (19 vs. 10). No specific mutation associated with DDI was identified in 26 patients so treated. Despite the finding of a mean increase in CD4 count and a mild decrease in viral load, patients tended to have an inverse correlation between the CD4 variation and number of mutations detected after 6 months, suggesting potential loss of drug efficacy in the presence of these genotypic changes

Brazilian Journal of Infectious Diseases

p.177-182We evaluated samples of peripheral blood mononuclear (PBMC) cells from 46 AIDS patients, before starting therapy with HIV-1 reverse transcriptase inhibitors (RTI), and after 6 months of drug use. PBMC were stored and tested by a Line Probe Assay (LiPA), in order to assess the frequency of RT mutations in this population. Six patients were taking AZT before initial blood collection (1 to 16 weeks of drug use) and 40 patients had no prior therapy. After baseline evaluation, 19 patients received AZT, 23 AZT plus DDI, 3 started AZT only with DDI added after 3 months, and 3 received a combination of AZT plus 3TC. Detection of at least one mutation was found in 33% (15/46) of patients at baseline, and 83% (38/46) had at least 1 mutation after 6 months of therapy. In the majority of cases, samples presented with the wild type and variants of HIV, simultaneously. Patients receiving monotherapy had a higher frequency of mutations (L41 and F214, Y215) than did patients receiving double-drug therapy (19 vs. 10). No specific mutation associated with DDI was identified in 26 patients so treated. Despite the finding of a mean increase in CD4 count and a mild decrease in viral load, patients tended to have an inverse correlation between the CD4 variation and number of mutations detected after 6 months, suggesting potential loss of drug efficacy in the presence of these genotypic changes.Salvado

Brazilian Journal of Infectious Diseases

p. 339-344Diarrhea due to intestinal microbial infections is a frequent manifestation among HIV-infected patients. It has been postulated that HIV-infected patients may have special types of intestinal infections, and that immune activation from such parasites may affect the progression of HIV disease. To evaluate these associations, the frequency of infections was examined in HIV-infected patients in Bahia, Brazil. To determine the potential impact of the presence of intestinal parasitic infections on HIV disease progression, a retrospective study approach was used. The medical charts of 365 HIV-infected patients who had been treated at the AIDS Clinic of the Federal University of Bahia Hospital were reviewed, and the prevalence of parasites was compared with 5,243 HIV-negative patients who had attended the hospital during the same period of time. Among HIV-infected subjects, CD4 count, RNA plasma viral load (VL), and number of eosinophils were compared according to their stool examination results. The overall prevalence of each parasite was similar for HIV-positive and HIV-negative patients. However, the prevalence of S. stercoralis (p<10-7) and G. lamblia (p=0.005) was greater for HIV-infected subjects. The mean CD4 count and viral load of HIV patients in our clinic who had stool examinations was 350 cells ± 340 and 4.4 ± 1.4 log RNA viral load, respectively. In this patient group there was no clear association between the level of the absolute CD4 count or the viral load and a specific parasitic infection. The presence of an intestinal parasitic infection was not associated with faster progression of the HIV disease among HIV-infected patients. We conclude that strongyloidiasis and giardiasis are more frequent in HIV-infected patients in Bahia, Brazil. If this association is due to immune dysregulation, as has been proposed elsewhere, it must occur in patients after only minor shifts in CD4 count from normal levels, or as a result of immune dysfunction not represented by CD4 count. These infections do not appear to alter the progression of HIV disease

The influence of CD 4+t cells, hiv disease stage and zidovudine on hiv isolation in Bahia, Brazil

HIV-l isolation was attempted on 72 individuais, including persons with knoum HIV infection and five without proven HIV infection but with indeterminate Western blot patterns, as well as on low-risk HIV seronegative persons. The ahility to detect HIV- 1 frorn culture supernatant by p24 antigen capture assay was evaluated by segregating patients by absolute CD4+ cell counts, clinicai stage of disease, p24 antigenemia and zidovudine use. The likelihood of a p24 positive HIV culture was highest among patients with CD4+ T-cell counts below 200/ul and patients with advanced clinical disease. Use of zidovudine did not affect the rate ofHIV positwity in cultures.<br>Tentativa de isolamento do vírus tipo 1 da imunodeficiência adquirida (VIH-1) foi realizada em 72 indivíduos sendo 51 pacientes com sorologia positiva para o VIH-1, confirmada por Western blot; 5 doadores de sangue com padrão indeterminado ao Western blot; 3 indivíduos com diagnóstico clínico de AIDS, porém com sorologia negativa, e 13 profissionais de saúde soronegativos. Os pacientes foram estratificados de acordo com a contagem de células CD4+, estágio clínico , antigenemia (p24) e uso de zidovudine. As culturas para o VIH-1 foram positivas em 45/50 (90%) tentativas. Houve uma correlação inversa entre o número de células CD4+ e a freqüência de isolamento do VIH-1. As culturas foram positivas em 84% dos indivíduos com CD4+ <200, contra 48% d positividade naqueles com contagem de célula CD4+ acima deste valor. O uso de zidovudine não interferiu na positividade das culturas. Concluímo. que a sensibilidade dos métodos de culture qualitativo e quantitativo é similar para a detecção do VIH-1. A taxa de positividade das culturas não foi afetada pelo uso prévio de zidovudine, mas foi diretamente proporcional ao grau de imunodeficiência dos pacientes