We characterized the virologic failure after an initially successful 48-week course of antiretroviral therapy among HIV/AIDS patients in a retrospective cohort study involving patients from Santos, Brazil. Patients with plasma HIV RNA below 500 copies/mL for 48 weeks were included. Variables analyzed included gender, age, level of education, marital status, mode of HIV acquisition, viral load, and CD4 cell count upon admission. There were 4,909 patients registered with the clinic, of which 669 patients met all the inclusion criteria (41.6% female and 58.4% male). Only 27.5% of the patients maintained undetectable viral loads during up to one year of follow-up. After 48 weeks, virologic failure occurred earlier in females and in patients first treated with an antiretroviral regimen other than highly active antiretroviral therapy. Patients who were married or had a steady partner experienced virologic failure later than did those who were separated or widowed. The percentage of public health clinic patients who maintain undetectable viral loads for a period of over a year is much lower than that observed among patients enrolled in clinical trials. Females, individuals in unstable relationships, single individuals and widowed individuals should be given special attention in order to improve durability of viral suppression.
Brazil, and the antiretroviral coverage is estimated to be 100%. However, given the sequential use of antiretroviral drugs the proportion of patients experiencing virologic failure is assumed to be high in Brazil. Santos is a port city close to the epicenter of the Brazilian epidemics with a large prevalence of both primary resistance and recombinant HIV. 1 In this report we describe the frequency of patients with long-term viral suppression, defined as continuous viremia suppression, for at least 3 years. In addition we describe the immunologic benefit to individuals undergoing highly active antiretroviral therapy (HAART) with and without virologic suppression.We studied subjects enrolled at the HIV=AIDS program in Santos, Brazil. We studied 2854 patients treated with antiretroviral therapy (protease inhibitors, nucleoside reverse transcriptase inhibitors and=or non-nucleoside reverse transcriptase inhibitors), of whom 57% were male; the mean age was 35 years. Patients undergoing antiretroviral therapy presenting 3 years of continuous viremia suppression (viral load less than 50 HIV-RNA copies per milliliter) were classified as group 1; patients presenting virologic failure for 3 years (viral load 10,000 HIV-RNA copies per milliliter or more) were classified as group 2. A total of 12,141 CD4 þ and CD8 þ T cell counts and 11,103 viral loads have been analyzed for the years 2005-2007. Each patient underwent a median of two CD4 þ =CD8 þ T cell and viral loads per year.At follow-up, 267 patients (9.4%) belonged to group 1 and 48 (1.7%) patients were classified as group 2. The average CD4 þ T cell counts for group 1 was 642, 660, and 722 cells per microliter in 2005, 2006, and 2007, respectively, and CD8 þ T average was 1085, 987, and 1006 cells per microliter, respec-tively. The group 2 average CD4 þ T count was 427, 368, 315 cells per microliter and CD8 þ T mean 1310, 1247, and 1193 cells per microliter. There was a continuous increase in the CD4 þ T cell counts over time in group 1 (analysis of variance [ANOVA], p < 0.05), as well as a decrease in group 2 ( p < 0.01).In spite of the relative adequate levels of the CD4 þ T cells over time among individual with virologic failure, it is clear that moderate to high levels of viremia will lead to a decrease in the average CD4 counts in a relatively short period of time in this population. These findings are consistent with previous reports indicating that the median time to virologic failure was approximately 14 months among patients in Brazil. 2 Interestingly, both groups showed an equally high level of CD8 þ T cells in spite of the degree of viral suppression.Presumably, this massive level of antiretroviral virologic failure for extended periods of time will lead to an increased selection of antiretroviral resistance, as it has been demonstrated. 3 In fact, analysis of samples obtained from patients in the state of Sao Paulo=Brazil for whom antiretroviral therapy failed revealed that 96.6% presented resistance-related mutations in the reverse transcriptase-coding reg...
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