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

Abstract

BackgroundStarting 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.MethodologyCross-sectional analysis from 9817 HIV-infected treatment-naïve patients initiating HAART at 6 sites (Argentina, Chile, Haiti, Honduras, Peru and Mexico) from October 1999 to July 2010. LHI had CD4+ count ≤200cells/mm3 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 FindingsAmong 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≤0.02; 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.ConclusionLHI 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.

Cryptococcosis in Acquired Immunodeficiency Syndrome Patients Clinically Confirmed and/or Diagnosed at Necropsy in a Teaching Hospital in Brazil

“…21 According to several authors, a late HIV diagnosis was performed in 45-76% of cases in two great case series of cryptococcosis reported from that region contrasting with the figures of 15-38% from Europe. [22][23][24] Nowadays, the epidemiological scenario in poor-resource settings exhibits an unacceptable and high mortality rate of 63% directly related to cryptococcosis. Most of these patients are unaware of their HIV status or do not receive or present poor compliance to ART.…”

“…At admission, disseminated fungal infection and advanced immunodeficiency at admission are often seen. 23,24 Unfortunately, the ideal antifungal therapy for this disease is not available in most places due to its high cost, which also contributes to the poor outcome. In contrast, the reports from Europe and the United States have shown an impressive decrease of prevalence and mortality rates related to cryptococcosis and other opportunistic infections after the introduction of ART in 1995.…”

“…4 This figure is similar to that of Latin American countries where most HIV-infected patients are also severely immunocompromised when they start the ART or discover their HIV status and/or are hospitalized. 23,24 Probably, a high and unknown number of AIDS patients die before cryptococcosis diagnosis is performed or antifungal therapy started, and the lack and/or a progressive decrease of necropsy performance in most teaching hospitals hinder a definitive postmortem diagnosis in these cases. The prevalence of this mycosis associated to AIDS in necropsy reports from teaching hospitals around the world during the last years showed rates ranging from 3.8% to 22.8% (Table 3).…”

Histoplasmosis diseminada e infección por VIH: serie de casos en un hospital peruano

“…La HD constituye la forma clínica más frecuente de histoplasmosis en pacientes con infección por VIH y está asociada a recuentos bajos de LT CD4+ 3 , como ocurre en países de Latinoamérica y el Caribe, incluyendo Perú, donde existe una alta tasa de inicio tardío de la TARc 12,13 . Estudios previos en la región fueron reportados en Brasil, Guayana Francesa y Panamá registrando 164, 82 y 104 casos de HD, respectivamente 7,9,14 .…”

Mortalidad hospitalaria en pacientes con infección por VIH: a diez años del acceso universal a TARAA en México

“…14,15 Sin embargo, hay poca información reportada sobre las condiciones y principales causas de muerte de los pacientes con VIH que fallecen en el hospital. Tampoco se conocen los factores asociados con la búsqueda tardía de atención médica.…”