RESUMEN
Accelerating antiretroviral therapy (ART) administration, improving retention, and achieving viral suppression in low- and middle-income countries must be prioritized. We evaluated trends and disparities in these milestones in a large Latin American cohort. Adults starting ART (ARTstart) from 2003 to 2014 at Caribbean, Central, and South America network for HIV epidemiology sites were assessed for care cascade outcomes: CD4 cell count >200 cells/mm3 at ARTstart; retention (≥1 visit at one year after ARTstart); viral suppression (≥1 HIV-1 RNA <200 copies/ml at one year after ARTstart). Modified Poisson regression provided adjusted prevalence ratios by age, gender, and HIV transmission risk, accounting for site and year of ARTstart. Proportions achieving ARTstart and suppression improved over time (p < 0.05). Older age was associated with better retention and viral suppression, but not ARTstart at CD4 cell count >200 cells/mm3. Females and men who have sex with men (MSM) were more likely to have CD4 cell count >200 cells/mm3 at ARTstart. Injection drug users (IDUs) were less likely to be retained while MSM were more likely to achieve viral suppression (all p < 0.05). Despite improvements in these outcomes over the course of a decade in this cohort, significant disparities existed, disadvantaging younger patients, men, and IDUs. These gaps indicate continued progress in providing early diagnosis and ARTstart remain critical.
Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Terapia Antirretroviral Altamente Activa , Continuidad de la Atención al Paciente , Infecciones por VIH/tratamiento farmacológico , Carga Viral/efectos de los fármacos , Adolescente , Adulto , Recuento de Linfocito CD4 , Estudios Transversales , Femenino , Infecciones por VIH/inmunología , Infecciones por VIH/virología , VIH-1 , Humanos , América Latina , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: In Latin America, the first wave of HIV-infected patients initiated highly active antiretroviral therapy (HAART) 10 or more years ago. Characterizing their treatment experience and corresponding outcomes across a decade of HAART may yield insights relevant to the ongoing care of such patients and those initiating HAART more recently in similar clinical settings. METHODS: This retrospective study included adults initiating HAART before 2004 at 8 sites in Argentina, Brazil, Chile, Haiti, Honduras, and Mexico. Patient status (in care, dead, or lost to follow-up [LTFU]) was assessed at 6-month intervals for 10 years, along with CD4 count and HIV-1 viral load (VL) for patients in care. RESULTS: 4,975 patients (66% male) started HAART prior to 2004; 45% were not antiretroviral-naïve. At 1, 5, and 10 years, rates of mortality were 4.2%, 9.0%, and 13.6% respectively. LTFU rates for the same periods were 2.4%, 10.9%, and 24.2%. Among patients remaining in care at 10 years, 84.4% were estimated to have VL≤400 copies/mL (Haiti excluded) and median baseline CD4 increased from 158 to 525 cells/mm3. Only 11.4% of all patients remained on their first regimen, 12.6% were on their second, 11.5% were on their third, and 23.0% were on their fourth or subsequent regimen. Outcomes were generally better for patients who were not antiretroviral-naïve, except for viral suppression. Heterogeneity among sites was substantial. CONCLUSIONS: Despite advanced disease and predominant use of older antiretrovirals, a large percentage of early HAART initiators in this Latin American cohort were alive and in care with sustained virologic suppression and progressive immune recovery after 10 years.
Asunto(s)
Terapia Antirretroviral Altamente Activa , Infecciones por VIH/tratamiento farmacológico , Adulto , Terapia Antirretroviral Altamente Activa/tendencias , Recuento de Linfocito CD4 , Estudios de Cohortes , Femenino , Infecciones por VIH/inmunología , Infecciones por VIH/mortalidad , Humanos , América Latina/epidemiología , Masculino , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Carga ViralRESUMEN
OBJECTIVE: To evaluate impact of the program after up to 6 years of follow-up in survival, virologic, and immunologic response. METHODS: Prospective follow-up of patients initiating first highly active antiretroviral therapy from 2001 to 2007. Chile began in 2001 an expanded access program to antiretroviral therapy. The Chilean AIDS Cohort has enrolled >85% of patients from this program in the public health system. STATISTICAL ANALYSIS: χ², Fisher tests, survival, univariate and multivariate analysis. RESULTS: Five thousand one hundred fifteen adults (16% women); median follow-up: 3.64 years (18,159 patient-years). At baseline: median age, 35.8 years; 45.6% had clinical AIDS; median CD4 cell count, 102 cells per cubic millimeter. Global mortality, 9.0%; loss to follow-up, 6.8%. Probability of survival at 1 and 5 years were 0.95 and 0.89, respectively. First regimen was maintained in 72% of those alive and in control at 1 year and 48% at end of study. Main reason for therapy change/discontinuation was drug toxicity (44.9%). At last visit, 74% of active patients had viral suppression, and median CD4 cell count had reached 301 cells per cubic millimeter. CONCLUSIONS: In this middle-income country, wide access highly active antiretroviral therapy has been successfully implemented and evaluated. Despite advanced disease at initiation, survival, clinical, virologic, and immunologic outcomes have been comparable with that of industrialized countries.
Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Terapia Antirretroviral Altamente Activa , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Adulto , Animales , Recuento de Linfocito CD4 , Chile/epidemiología , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Infecciones por VIH/inmunología , Infecciones por VIH/virología , Humanos , Masculino , Estudios Prospectivos , Análisis de Supervivencia , Resultado del Tratamiento , Carga ViralRESUMEN
Chile, middle-income country with 15 million people, began an expanded access program (EAP) to antiretroviral therapy (ART) in 2001. EAP provides ART, monitoring, and funding for management of associated complications in 32 points of care. A national cohort (Chilean AIDS Cohort [ChiAC]), enrolling 98% of these patients, was created for standardized treatment and impact evaluation. Information exchange is mainly through the Internet. By December 2004, the ChiAC had 4365 participants (83.3% male). At baseline, 47.5% had clinical AIDS, 26.2% were asymptomatic, 80.2% had a CD4 count <200 cells/mm and 58.2% were ART naive; in these patients, the most frequent regimen is zidovudine, lamivudine, and efavirenz. A 6-month follow-up in 1057 patients showed a global mortality of 5% (0.5% if patients were asymptomatic at baseline and 8.3% if patients had baseline AIDS). There was a similar risk of death if the baseline CD4 count was 100 to 200 cells/mm or >200 cells/mm ( approximately 1%), but this increased to 4.8% (relative risk [RR] = 5.2) and 10.7% (RR = 11.5) if the CD4 count was 51 to 100 cells/mm or Asunto(s)
Fármacos Anti-VIH/uso terapéutico
, Infecciones por VIH/tratamiento farmacológico
, Accesibilidad a los Servicios de Salud/organización & administración
, Evaluación de Programas y Proyectos de Salud/métodos
, Infecciones Oportunistas Relacionadas con el SIDA/epidemiología
, Adulto
, Fármacos Anti-VIH/efectos adversos
, Chile/epidemiología
, Estudios de Cohortes
, Quimioterapia Combinada
, Femenino
, Infecciones por VIH/complicaciones
, Infecciones por VIH/mortalidad
, Humanos
, Incidencia
, Masculino
, Programas Nacionales de Salud/organización & administración
, Evaluación de Procesos y Resultados en Atención de Salud/métodos
, Evaluación de Procesos y Resultados en Atención de Salud/organización & administración
, Inhibidores de la Transcriptasa Inversa/efectos adversos
, Inhibidores de la Transcriptasa Inversa/uso terapéutico