Pharmaceutical care and evaluation of adherence to antiretroviral therapy in people living with HIV/AIDS

Abstract Highly Active Antiretroviral therapy (HAART) depends on optimal adherence to be effective. Pharmacotherapeutic follow-up can be used as a strategy for treatment fidelity. To provide pharmaceutical care for HAART patients, to assess adherence, to identify and resolve drug related problems (DRP). This is a prospective, interventional study aimed at people on HAART. Data was collected using the pharmacotherapeutic follow-up form and CEAT-VIH. There was a predominance of women (59%), older than 33 years (75%), mostly single (43%). Regarding adherence, 64% had insufficient adherence at the start of the study, while 36% had strict/adequate adherence. After the pharmacotherapeutic follow-up, 70% presented strict/adequate adherence. Regarding HAART, the relationship between adhesion versus time of HAART and adherence versus regimen used was significant, considering that less time of therapy and regimen containing protease inhibitors are predictors for insufficient adherence. Regarding the DRP identified (f=77), missed pills (32%), untreated disease, incorrect management frequency, and undue self-medication (12%) were the most frequent. Pharmaceutical interventions (f=137) were predominantly advising related to specific pharmacological treatment (32%), non-pharmacological measures (20%), and medication suspension (9%). Pharmaceutical care was shown to be animportant strategy, within the multi professional team, to improve adherence, besides identifying and resolving DRP.

Nasal Septum Perforation Associated to Histoplasmosis: A Retrospective Study

Abstract Objective: To determine the prevalence of nasal septum perforation associated to Histoplasma sp. Material and Methods: A retrospective descriptive study was conducted with patients who developed nasal septum perforation associated to histoplasmosis. The diagnosis was made based on clinical manifestations and confirmed with mycological direct examination with Giemsa stain, culture, serologic tests (immunodiffusion method), and histopathology with hematoxylin-eosin, Grocott methenamine (GMS) and Periodic Acid-Schiff stain (PAS). Results: Out of 1654 medical records reviewed with diagnosis of histoplasmosis in the study period, we found 22 cases with nasal septum perforation. Autoimmune disease was present in 6 patients; all six were on immunosuppressive treatment. Two patients had HIV/AIDS, one of them had also paracoccidiodomycoses and the remaining had no apparent underlying disease or conditions. Conclusion: Physicians of endemic areas such as Venezuela, must consider this entity in the differential diagnosis with other diseases.

Epidermal necrolysis: SCORTEN performance in AIDS and non-AIDS patients

Abstract: Background: Stevens-Johnson syndrome and toxic epidermal necrolysis are life-threatening blistering drug reactions with high incidence of ocular sequela. The term 'Epidermal Necrolysis' has been recently used to better describe the full spectrum of the disease that includes Stevens-Johnson syndrome and toxic epidermal necrolysis at opposite ends, which differ by the extent of body surface area with epidermal detachment. SCORTEN is a mortality prognosis score for 'Epidermal Necrolysis' cases that still needed validation in acquired immunodeficiency syndrome. Objective: To evaluate the SCORTEN performance in acquired immunodeficiency syndrome, and the differences in outcomes between acquired immunodeficiency syndrome and non- acquired immunodeficiency syndrome cohorts. Methods: Retrospective cohort study of AIDS and non-AIDS 'Epidermal Necrolysis' cases admitted to a Brazilian reference center from 1990-2014. Results: Five deaths (16.7%) occurred as a consequence of EN in 30 AIDS patients, and seven (17.9%) in 39 non-AIDS patients, relative risk (RR) .92 (p=1.0). SCORTEN showed great performance, with an Area Under the Receiver Operating Curve (AUC) (ROC) of 0.90 with a 95% confidence interval ranging from .81 to .99. The performance of SCORTEN was better among non- AIDS patients than AIDS patients: AUC non- acquired immunodeficiency syndrome =0.99 (CI 05% 0.96-1.00), AUC acquired immunodeficiency syndrome = 0.74 (CI 95% 0.53-0.95), p=.02. Study Limitations: Heterogeneity of cases, wide variation of systemic corticosteroid doses when used. Conclusion: SCORTEN is valid for the Brazilian population, including among those patients with acquired immunodeficiency syndrome, and, as such, its use is recommended for aiding treatment choice in this subgroup of patients.

De onde vem para onde vai SIDA? Caminhos possíveis para erradicação da epidemia de HIV a partir do tempo presente / Where does SIDA come from and where does it go? Possible ways to eradicate the HIV epidemic from the present time

Ao nos aproximarmos da quarta década da epidemia brasileira de HIV/aids, o contexto epidêmico no país ganha contornos de extrema complexidade. Em 2016, o Brasil apresenta um quadro de reemergência e um perfil de epidemia concentrada em homens que fazem sexo com homens, usuários de drogas, jovens gays e profissionais do sexo, de diminuição dos investimentos internacionais e de acirramento de setores conservadores em relação às políticas públicas com refreamento da abordagem da epidemia com base nos direitos humanos. Ao mesmo tempo, a Organização das Nações Unidas afirma que é possível erradicar a epidemia de HIV/aids até 2030. Esta pesquisa teve por objetivo geral conhecer e analisar experiências de pessoas que vivenciam a epidemia HIV/aids no contexto atual de adoção de estratégias terapêuticas para alcançar metas nacionais e internacionais de erradicação da epidemia até 2030. Foram adotadas duas estratégias metodológicas centrais: entrevistas com foco em histórias de vida e pesquisa documental. Esta última analisou documentos produzidos pelo Sistema das Nações Unidas que tratam da política global de enfrentamento da epidemia no período de 2000 a 2016, em um total de 26 documentos. Foram explorados também documentos oficiais sobre a Política Brasileira de Controle e Erradicação da epidemia, no período de 1999 a 2016 e os Boletins Epidemiológicos de HIV/aids, entre 2001 a 2016, em um total de 24 documentos. Na realização das entrevistas, participaram cinco profissionais de saúde e quatro usuários. O exercício interpretativo das entrevistas com foco nas histórias de vida foi referenciado na Sociologia das Emergências, no Trabalho de Tradução e na Ecologia de Saberes, a partir de Boaventura de Sousa Santos. Na análise, buscou-se identificar no discurso local o que, da experiência e das expectativas dos sujeitos que vivenciam o cuidado das pessoas vivendo com HIV, afirmou ou negou saberes e práticas, novos e antigos, e identificou perspectivas que estão se construindo no presente através de práticas de cuidado com o futuro dos indivíduos e das coletividades. O Trabalho de Tradução entre as narrativas dos sujeitos que produzem saberes e práticas locais e as narrativas oficiais que produzem saberes globais, a partir do trabalho argumentativo, baseou-se na análise do material empírico produzido na pesquisa em diálogo com o referencial teórico adotado. A partir desse trabalho de tradução entre saberes e práticas globais, nacionais e locais, a prevenção emergiu como a etapa do cuidado ao HIV/aids mais negligenciada e mais sujeita a retrocessos, ao mesmo tempo que identificou uma diversidade de saberes práticos a ela associados. Trilhando os caminhos epistemológicos orientados pela ecologia dos saberes, identificamos a insuficiência do modelo de prevenção combinada proposto pelo Ministério da Saúde na representação do diagrama de práticas apresentadas pelos diferentes atores como sendo aquelas com potencial para conciliação, suscitando necessidade de sua ampliação. Desse modo, e com base nos resultados do estudo, propomos uma representação gráfica alternativa para a mandala da prevenção combinada, incorporando outros aspectos do cuidado aplicáveis à prevenção. Essa representação foi denominada de "Mandala Ecológica da Prevenção Combinada" e configura-se, nesta pesquisa, como uma contribuição da análise dos seus resultados com base na sociologia das emergências. O exercício interpretativo de aproximação entre diferentes saberes apontou a necessidade de colocar as pessoas e as comunidades e, em especial, o direito à prevenção no centro das respostas para o enfrentamento da epidemia de HIV/aids, se quisermos empreender a reinvenção do presente, mais que projetar um futuro (AU).

As the fourth decade of HIV/AIDS epidemic in Brazil approaches, the epidemic context in the country has extremely complex new characteristics. In 2016, what we find in Brazil is a picture of resurgence of the epidemic with a new profile centered in males who have sex with males, chemical dependents, young gays and sex workers; reduction on international investments; and the upsurge of conservative sectors against public policies, restraining the epidemic approach based on human rights. At the same time, the United Nations affirm that it is possible to eradicate the epidemic of HIV/AIDS until 2030. The general purpose of this research is to understand and to assess experiences of people who live the epidemic of HIV/AIDS in the present context of adoption of therapeutic strategies in order to achieve national and international goals of eradication of the epidemic until 2030. Two central research strategies have been adopted: interviews focused on life stories and documentary research. The later assessed documents produced by the United Nations System that address the global policy of confrontation of the epidemic in the period from 2000 to 2016, in a total of 27 documents.The researcher has also explored official documents about the Brazilian Policy of Control and Eradication of the epidemic, from 1999 to 2016, and the Epidemiologic Bulletins of HIV/AIDS, from 2001 to 2016, in a total of 24 documents. Five health professionals and four users have been interviewed. The interpretive exercise of the interviews, with emphasis on life stories, was referenced in Sociology of Emergencies, Translation Work and in the Ecology of Knowledge, inspired by Boaventura de Souza Santos, who sought on local speech what, from the experience and expectation of the subjects who experience the care to the people living with HIV routinely, affirmed or denied knowledge and practices, new and old, and identified possibilities of future that are being built in the present through care practices concerned with the future of individuals and collectivities. The Translation work between narratives of subjects that produce local knowledge and practices and the official narrative that produces global knowledge from the argumentative work of the researcher was based on the analysis of the empirical material produced on the research and from the theoretical framework that has been adopted. From this work of translation between global, national and local knowledge and practices, prevention emerged as the most neglected stage of HIV/aids care and, thus, the most prone to setbacks, at the same time that we notice a pluralism of practical knowledge associated to it. Setting the epistemological path oriented by the ecology of knowledge, we identified the insufficiency of the image associated to combination prevention proposed by the Health Ministry in the representation of practices announced by different actors as being the ones with the capability of conciliation, provoking the need for its expansion. For this reason, based on the results of the study, we propose an alternative representation of the combination prevention mandala that embodies other aspects of the care applicable to the combination prevention. The interpretive exercise of approximation between different knowledge highlighted the need to put people, community and specially the right to prevention in the center of the responses to the confrontation of the epidemic of HIV/aids, if we want to understand the reinvention of the present more than projecting a future (AU).

Association of NR1I2 gene polymorphisms and time of progression to AIDS

BACKGROUND The time of progression towards AIDS can vary greatly among seropositive patients, and may be associated with host genetic variation. The NR1I2 (PXR) gene, a ligand-activated transcription factor, regulates the transcription immune pathway genes and can therefore be targets of viral replication mechanisms influencing time of progression to AIDS. OBJECTIVE To verify the association of single nucleotide polymorphisms (SNPs) rs3814057, rs6785049, rs7643645, and rs2461817 in the NR1I2 (PXR) gene with progression to AIDS in HIV-1 infected patients. METHODS Blood samples were obtained from 96 HIV-1 positive individuals following informed consent. DNA was isolated and genotyped through real time polymerase chain reaction (PCR) for the presence of SNPs in the NR1I2. Questionnaires on socio-demographic features and behaviors were answered and time of progression to AIDS was estimated based on medical chart analysis. FINDINGS Patients with the GG genotype for rs7643645 were shown to be related with a more rapid disease progression when compared to GA and AA genotypes. This result was maintained by the Multivariate Cox Regression considering sex, ethnicity, and presence of HLA-B*57, HLA-B*27, and CCR5del32 polymorphisms. MAIN CONCLUSIONS Recent studies reported the expression of the nuclear receptors in T-Lymphocytes, suggesting their possible role in the immune response. In addition, nuclear receptors have been shown to inhibit the HIV replication, although no such mechanism has been thoroughly elucidated to date. This is the first time an association between NR1I2 polymorphism and time of progression to AIDS is reported and supports an apparent relationship between the gene in the immune response and identifies another genetic factor influencing AIDS progression.

Oral plasmablastic lymphoma as the first manifestation of AIDS

Abstract Plasmablastic lymphoma is a non-Hodgkin lymphoma characterized by its plasmacytic differentiation and predilection for the oral cavity. It is among the lymphomas most commonly associated with AIDS. This report details a case of a HIV-positive patient with a 1-month history of an exophytic mass in the gingival area of the upper left quadrant. The diagnosis of plasmablastic lymphoma was made based on its histopathological and immunophenotypical features. She was treated with chemotherapy followed by autologous hematopoietic stem cell transplantation. Despite complete resolution of the lesion, the patient died of cardiorespiratory arrest. This case illustrates plasmablastic lymphoma as the first clinical manifestation of AIDS, highlighting the importance of differentiating between a potentially malignant lesion and other pathologic processes.

Pulmonary Kaposi's sarcoma in a female patient: Case report / Sarcoma de Kaposi pulmonar em paciente do sexo feminino: Relato de caso

SUMMARY Kaposi’s sarcoma (KS) is a multicentric lymphoproliferative malignancy. Most of the time this tumor is confined to the skin and subcutaneous tissue, but it can present with widespread visceral involvement, such as in the lung. Pulmonary KS is the most frequent form in young adult males, in a ratio of 15:1. The disease usually affects individuals with low CD4 lymphocyte counts (<150-200 cells/mm3). We report a case of a female patient aged 35 years, with the presence of skin lesions, self-limiting episodes of diarrhea and weight loss of 15 kg for nearly 9 months, progressing to persistent fever. AIDS was diagnosed and biopsy of the lesions revealed Kaposi’s sarcoma. Computed tomography of the chest showed peribronchovascular thickening, areas of ground glass opacity, condensations with air bronchograms surrounded by ground glass opacity (halo sign) and bilateral pleural effusion. The diagnosis of pulmonary KS is still a challenge, especially due to the occurrence of other opportunistic diseases that may also occur concurrently. Therefore, suspecting this diagnosis based on clinical and laboratory manifestations, and even more with CT findings, is fundamental, especially in patients who already have the cutaneous form of the disease.

RESUMO O sarcoma de Kaposi (SK) é uma neoplasia angioproliferativa maligna multicêntrica. Na maioria das vezes, esse tumor restringe-se à pele e ao tecido subcutâneo, mas pode cursar com comprometimento visceral amplamente disseminado, como é o caso do pulmão. O SK pulmonar é a forma mais frequente em homens adultos jovens, em uma proporção de 15:1. A doença geralmente acomete indivíduos com baixa contagem de linfócitos CD4 (<150-200 células/mm3). Relatamos um caso de uma paciente do sexo feminino, 35 anos, com presença de lesões cutâneas, episódios de diarreia autolimitada e perda de peso de 15 kg havia aproximadamente 9 meses, evoluindo para quadro febril persistente. Foi dado o diagnóstico de aids e foi realizada biópsia das lesões evidenciando sarcoma de Kaposi. A tomografia computadorizada do tórax evidenciou imagens de espessamento peribroncovascular, áreas de vidro fosco, condensações com broncogramas aéreos circundados por área de vidro fosco (sinal do halo) e derrame pleural bilateral. O diagnóstico da forma pulmonar de SK ainda é um desafio, principalmente pela ocorrência de outras doenças oportunistas que, inclusive, podem ocorrer de forma concomitante. Portanto, a suspeição desse diagnóstico pelas manifestações clínicas, laboratoriais e, principalmente, tomográficas é de fundamental importância, sobretudo em pacientes que já apresentam a forma cutânea da doença.

Lesiones orales asociadas con la enfermedad del virus de inmunodeficiencia humana en pacientes adultos, una perspectiva clínica / Oral lesions associated with human immunodeficiency virus disease in adult patients, a clinical perspective

Among the clinical manifestations which may occur in HIV/AIDS patients, oral lesions are relevant because there are easily accessible and usually the diagnosis is made through clinical features. Some oral manifestations are strongly related with HIV/AIDS patients indicating infection and progression to AIDS and also allow monitoring the success or failure of using antiretroviral therapy. The massive introduction of antiretroviral therapy has changed the morbidity and mortality, frequency, type of clinical manifestation and the timing of the classic opportunistic complications. The aim of this review is to provide an updated of the classical clinical features of the most frequent and relevant HIV/AIDS oral manifestations, considering the fundamental clinical features for their diagnosis.

Dentro de las manifestaciones que pueden aparecer en los pacientes con infección por VIH/SIDA, las lesiones de la cavidad oral tienen gran relevancia debido a que son fácilmente accesibles y por lo general su diagnóstico se efectúa a través de signos clínicos. Además, algunas manifestaciones orales están fuertemente relacionadas con el síndrome por lo que indican sospecha de infección y progresión a etapa SIDA y permiten monitorizar el éxito o fracaso de la terapia anti-retroviral empleada. La introducción masiva de la terapia anti-retroviral ha modificado la morbi-mortalidad, la frecuencia, el tipo de manifestación clínica y el momento de aparición de las clásicas complicaciones oportunistas. El objetivo de esta revisión es entregar las características clínicas clásicas actualizadas de aquellas manifestaciones orales asociadas a la infección por VIH/SIDA que son más frecuentes y que tienen mayor relevancia clínica, considerando las características fundamentales para su diagnóstico.

Correção cirúrgica da lipodistrofia relacionada ao uso da terapia antirretroviral: uma análise sobre os procedimentos realizados e o impacto sobre os pacientes / Surgical lipodystrophy correction associated with the use of antiretroviral therapy: an analysis of procedures performed and impact on the patients

Introdução: O tratamento de pacientes portadores da síndrome da imunodeficiência adquirida deve ser integral e se basear no controle da doença e das complicações relacionadas ao uso de medicações antirretrovirais, como a lipodistrofia. Esse estudo tem como objetivo avaliar as principais queixas, os aspectos epidemiológicos e os procedimentos cirúrgicos realizados para corrigir a lipodistrofia em pacientes em uso crônico de antirretrovirais. Método: Estudo retrospectivo, no qual foram coletados dados dos prontuários de 27 pacientes submetidos a 36 procedimentos cirúrgicos relacionados à correção de lipodistrofia no período de março de 2010 a junho de 2014 no serviço de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto. Resultados: A idade média dos pacientes foi 47,2 anos, 22,2% homens e 77,8% mulheres. O tempo médio de uso da terapia antirretroviral (TARV) foi de 12,1 anos. As queixas mais encontradas foram: giba dorsal (44,4%), lipodistrofia abdominal (44,4%) e lipoatrofia glútea (37,04%). Na maioria dos pacientes (70,4%), foi realizada uma cirurgia. Quanto às cirurgias, a lipoaspiração de giba foi realizada em 48,1% dos pacientes, seguida da lipoaspiração de abdome, dorso ou flancos (44,4%) e gluteoplastia (22,2%). Entre todos os 36 procedimentos realizados, apenas dois apresentaram complicações. O tempo médio de seguimento pós-operatório foi de 11,2 meses. Do total, 70,4% dos pacientes mostraram-se satisfeitos após os procedimentos. Conclusões: O sucesso do tratamento cirúrgico da lipodistrofia causada pelo uso da TARV baseia-se na seleção pré-operatória adequada e em seguimento constante e prolongado. A melhoria da autoestima facilita a adesão ao tratamento com antirretrovirais.

Introduction: Treatment of patients with acquired immunodeficiency syndrome should be complete and based on controlling the disease and the complications related to the use of antiretroviral medications, such as lipodystrophy. This study aimed to evaluate the main complaints, epidemiological aspects, and surgical procedures performed for lipodystrophy correction among patients receiving long-term antiretroviral therapy. Method: In this retrospective study, data were collected from the medical records of 27 patients who underwent 36 surgical procedures associated with lipodystrophy correction, from March 2010 to June 2014, at the Plastic Surgery Service of the Hospital das Clínicas, Faculty of Medicine of Ribeirão Preto. Results: The average age of the patients was 47.2 years; 22.2% were men and 77.8% were women. The average duration of antiretroviral therapy (HAAR ) was 12.1 years. The most frequent complaints were dorsal hump (44.4%), abdominal lipodystrophy (44.4%), and gluteal lipoatrophy (37.04%). The majority of patients (70.4%) had undergone surgery . The most common type of surgery performed was hump liposuction (carried out in 48.1% of the patients), followed by abdominal, back, or flank liposuction (44.4%) and gluteoplasty (22.2%). Among all 36 procedures performed, only 2 resulted in complications. The average postoperative follow-up period was 11.2 months. In total, 70.4% of patients were satisfied with the results of their procedure. Conclusions: The success of surgical treatment of HAARinduced lipodystrophy is based on proper preoperative selection as well as constant and prolonged follow-up. Improved selfesteem facilitates the adherence to antiretroviral drug treatment.

Tratamento cirúrgico de 510 pacientes portadores de lipodistrofias secundárias ao uso de antirretrovirais / Surgical treatment of 510 patients with highly active antiretroviral therapy-associated lipodystrophy

INTRODUÇÃO O tratamento da Síndrome da Imunodeficiência Adquirida vem sofrendo importantes avanços desde a introdução da terapia antirretroviral altamente ativa, conhecida como HAART (high active antirretroviral therapy). Este tratamento levou à eliminação do vírus na corrente sanguínea e ao aumento na sobrevida, entretanto alterações metabólicas e estruturais tornaram-se evidentes. Uma dessas alterações é a redistribuição de gordura corpórea, também denominada lipodistrofia. Com uma das maiores casuísticas mundiais, o objetivo deste trabalho é demonstrar algumas das alternativas cirúrgicas, bem como os resultados obtidos na tentativa de minimizar o impacto da lipodistrofia. MÉTODO: No período de julho de 2005 a julho de 2013, 510 pacientes portadores de lipodistrofia secundária ao uso de HAART foram operados pela Clínica de Cirurgia Plástica do Hospital Heliópolis. Todos esses pacientes foram submetidos à prévia avaliação clínica e imunológica, sob auxílio da equipe de Infectologia. O presente trabalho foi aprovado pelo Comitê de Ética em Pesquisa da Fundação do ABC. RESULTADO: Dentre os 510 pacientes, 335 eram do sexo feminino e 175 do sexo masculino, com idades variando entre 16 e 74 anos. Quanto aos procedimentos, destacou-se lipoaspiração da giba e dorso, com 199 casos. Quanto à resposta estimulada através de questionário subjetivo, observou-se elevado grau de satisfação, aumento significativo da autoestima e maior adesão ao tratamento antirretroviral. CONCLUSÃO: A correção cirúrgica da lipodistrofia corporal comprovadamente melhora o aspecto estético do paciente que faz uso da HAART; porém, o efeito psicológico e social é ainda mais importante, elevando a autoestima, com diminuição dos estigmas, e proporcionando uma maior adesão ao tratamento antirretroviral.

INTRODUCTION The treatment of acquired immunodeficiency syndrome has undergone important advances since the introduction of highly active antiretroviral therapy (HAART). This treatment led to the elimination of the virus in the bloodstream and increased survival; however, metabolic and structural changes became evident. One of these changes is lipodystrophy, the redistribution of body fat. With one of the largest samples worldwide, the aim of this work was to present some of the various surgical alternatives as well as the results obtained for minimizing the impact of lipodystrophy. METHOD: From July 2005 to July 2013, 510 patients with HAART-associated lipodystrophy underwent surgery in the Clinic of Plastic Surgery, Heliópolis Hospital. All patients submitted to prior clinical and immunological assessments made with the aid of the infectious diseases team. The present study was approved by the Research Ethics Committee of the ABC Foundation. RESULTS: The 510 patients included 335 women and 175 men with an age range of 16-74 years. Liposuction of the cervicodorsal fat pad (buffalo hump) was predominant (199 cases). With regard to the response stimulated through a subjective questionnaire, a high degree of satisfaction was observed with a significant increase in self-esteem and greater adherence to antiretroviral treatment. CONCLUSION: The surgical correction of body lipodystrophy demonstrably improves the aesthetics of patients using HAART; however, its psychological and social effects are even more important since self-esteem increases and stigma decreases, which leads to better adherence to antiretroviral treatment.

Síndrome inflamatorio de reconstitución inmune (SIRI) en pacientes pediátricos que acuden a la consulta de VIH/SIDA del servicio de pediatría médica infecciosa del Hospital Universitario de Caracas / Immune reconstitution inflammatory syndrome (IRIS) in pediatric patients attending consultation HIV / AIDS medical service pediatric infectious Hospital Universitario de Caracas

La Organización Mundial de la Salud define al síndrome inflamatorio de reconstitución inmune (SIRI) como un grupo de signos y síntomas que resultan de la recuperación inmunológica del paciente VIH/SIDA después del inicio de la terapia retroviral de gran actividad (TARGA) cuya incidencia es del 10% al 25%. Estudiar los pacientes con diagnóstico de infección por VIH controlados en el Servicio de Pediatría Médica Infecciosa del Hospital Universitario de Caracas que desarrollaron SIRI. Se realizó estudio retrospectivo con revisión de datos de pacientes pediátricos con diagnóstico de VIH que presentaron SIRI. Los mismos fueron recabados de la base de datos de la consulta VIH/SIDA diseñada en Access 2010 y analizados con EPIINFO 3.5.4. El 15% de los pacientes con diagnóstico de VIH presentaron SIRI, siendo del sexo masculino 80%; 60% fueron clasificados inicialmente en estadio C3. La edad media fue de 5,26 años, (SD: ± 4,34). La carga viral de inicio de TARGA 320.318 copias/mL (SD: ± 260 727), contaje de linfocitos T CD4+: 127 células/mm³ (SD:±148) relación CD4/CD8: 0,17 (SD: ± 0,11); TARGA inicial: 90% utilizaron 3TC, 60% AZT, 40% ABC y 80% inhibidores de proteasa. Las manifestaciones clínicas más frecuentemente observadas fueron BCGitis (30%), tuberculosis (30%) y neumocistosis (20%). En un 90% las manifestaciones de SIRI ocurrieron en los primeros 3 meses de iniciado TARGA. Al momento del SIRI se observó en promedio un aumento del contaje de linfocitos T CD4+ en 411 células/mL y disminución de CV en 2 log. El SIRI es frecuente en pacientes pediátricos con VIH/SIDA y debe ser tomado en cuenta cuando se inicia tratamiento en estados severos de inmunodepresión

The World Health Organization defines the Immune Reconstitution Inflammatory Syndrome (IRIS) as a group of signs and symptoms as a result of the HIV/AIDS patients’ immune recovery after initiation of highly active antiretroviral therapy (HAART), being the incidence 10% to 25%. To study patients with HIV infection in control at the Pediatric Infectious Service of University Hospital of Caracas who developed IRIS. Retrospective data review of pediatric patients diagnosed with HIV who presented SIRI was performed. It was collected from 2010 Access - designed HIV/AIDS consultation database and analyzed with EPIINFO 3.5.4. 15% of patients diagnosed with HIV had IRIS, being 80% male, 60% were initially classified C3 stage. The average age was 5.26 years (SD: +4.34). Viral load (VL) starting HAART: 320 318 copies/mL (SD: ± 260,727), CD4 ± count: 127 cells/mm³ (SD: +148), CD4/CD8: 0.17 (SD: +0.11); initial HAART used: 90% 3TC,60% AZT, 40% ABC and 80% protease inhibitors. The most frequently clinical features observed were: BCGitis (30%), tuberculosis (30%) and pneumocystosis (20%). SIRI manifestations occurred, in 90% of cases, in the first 3 months after initiation of HAART. At the moment of IRIS diagnosis, an average CD4 + T count at 411 cells/ml increase and 2 log VL decreases were recorded. SIRI is common in HIV pediatric patients and should be considered when treatment is started in severe immunosuppression state

Associação de retalho mucoso e retalho cutâneo local na reconstrução de perda de substância em região da bochecha / Mucosal and local skin flap reconstruction for loss of substance in the cheek region

A face representa uma estrutura importante nos seres humanos, devido a ser a parte mais visível do corpo e conter elementos delicados e complexos, que são essenciais em termos de beleza e funcionalidade. As reconstruções faciais, em áreas de grandes perdas de substâncias, permanecem como um desafio para os cirurgiões. Apresentam várias opções de reparo, todas com suas vantagens e desvantagens. Mostramos o caso de um paciente apresentando perda de substância de espessura total em região de bochecha, que foi submetido à associação de retalho mucoso e retalho cutâneo local, apresentando bom resultado e preservação funcional.

The face is an important structure, because it is the most visible part of the body and contains delicate and complex elements that are essential for aesthetics and functionality. Facial reconstruction of areas with substantial substance loss remains a surgical challenge. There are several repair options, with corresponding advantages and disadvantages. We present a case of a patient with substance loss of the total thickness of the cheek region who received mucosal and local skin flap surgery, with good results and functional preservation.

Efeito dos alimentos na biodisponibilidade de medicamentos antirretrovirais: uma revisão sistemática da literatura / Effect of food on the bioavailability of antiretroviral drugs: a systematic review of literature

Objetivo: O objetivo do presente estudo foi identificar as intera��es medicamentoalimento em pacientes em uso de terapia antirretroviral descritas na literatura. Fonte de dados: Trata-se de uma revis�o sistem�tica utilizando os bancos de dados Medline e LILACS, no per�odo de 1998 at� 2012, com os seguintes descritores: food and bioavailability of antiretroviral drugs, food and antiretroviral failure and food and antiretroviral pharmacokinetic. A busca foi restrita aos idiomas ingl�s, portugu�s e espanhol. S�ntese dos dados: Foram selecionados 11 artigos, tendo como desenho estudos de coorte. Destes, seis estudos foram realizados nos Estados Unidos, dois na Espanha, um na Austr�lia, um na Alemanha e um na Su��a. A avalia��o da concord�ncia entre os avaliadores na classifica��o da qualidade dos artigos demonstrou boa concord�ncia (k=0,74), sendo este dado significativo (p<0,05). Do total de estudos analisados, nenhum foi considerado de qualidade A, sete (59,0%) foram de qualidade B e cinco (41,0%) de qualidade C. Todos os estudos consideram os efeitos da intera��o entre o alimento e o medicamento que possam resultar em aumento, decr�scimo, atraso ou que n�o afetem a absor��o do medicamento. Certos componentes dos alimentos, principalmente a gordura, s�o conhecidos por afetar significativamente a absor��o de medicamentos antirretrovirais e efeitos adversos proporcionados pelo medicamento podem acarretar piora na ades�o ao tratamento. Conclus�es: Escassos s�o os estudos prospectivos de qualidade que tenham descrito a associa��o entre a interfer�ncia dos alimentos na biodisponibilidade dos medicamentos antirretrovirais, sendo, os que investigaram esta associa��o, contradit�rios. N�o foram encontrados estudos que atendam a mais de 80% dos crit�rios de qualidade estabelecidos pelo Cochrane.

Objective: The objective of the present study was to identify drug-food interactions in patients on antiretroviral therapy reported in the literature. Data source: It is a systematic review that used the databases Medline and LILACS from 1998 until 2012, with the following descriptors: food and bioavailability of antiretroviral drugs, food and antiretroviral failure, and food and antiretroviral pharmacokinetic. The search was limited to English, Portuguese and Spanish. Data synthesis: Eleven articles were selected, with the design of cohort studies. Of these, six studies were performed in the United States, two in Spain, one in Australia, one in Germany, and one in Switzerland. The assessment of agreement among raters in classifying the quality of the articles showed good agreement (k=0.74), this factor being significant (p<0.05). None of the studies analyzed was considered as quality A, seven (59.0%) were quality B, and five (41.0%) were quality C. All studies consider the effects of the interaction between food and drug that may result in increase, decrease, delay, or that do not affect drug absorption. Certain components of food, especially fat, are known to significantly affect the absorption of antiretroviral drugs, and adverse effects provided by the drug may result in worsening of treatment adherence. Conclusions: Scarce are the prospective studies with quality that have described the association between the interference of food on the bioavailability of antiretroviral drugs, and those who have investigated this association are contradictory. No studies were found that meet more than 80% of the quality criteria set by the Cochrane.

Leucoplasia pilosa bucal: presentación de caso clínico / Bucal hairy leukoplakia: a case report

Se presenta caso clínico de paciente con lesiones blanquecinas en bordes laterales de lengua de 1 año de evolución aproximadamente; clínicamente asintomático, sin hábitos tóxicos ni antecedentes médicos de importancia. Actualmente bajo tratamiento ortodóntico, en donde el especialista lo alerta sobre la importancia de interconsultar con el Patólogo Bucal. Luego de una exhaustiva historia clínica, se toma muestra de la lesión y el examen histopatológico arrojó: hiperplasia epitelial exofítica, paraqueratosis excesiva y células superficiales en forma de globo con típica fragmentación nuclear, indicativo de inclusión viral (Cuerpos de Cowdry). Con estos hallazgos, la correlación con las características clínicas de la lesión y los exámenes serológicos (positivo para VIH), se llega a un diagnóstico conclusivo de Leucoplasia Pilosa Bucal (LPB). Se remitió el paciente al Instituto Anzoatiguense de la Salud (SALUDANZ), entidad encargada de problemas de Salud Pública en el Edo. Anzoátegui. La Leucoplasia Pilosa Bucal (LPB) se presenta comúnmente en pacientes VIH+ y representa un factor informativo y predictivo para el odontólogo, estomatólogo y cualquier especialista de la rama de la salud, en cuanto al tratamiento, diagnóstico y pronóstico bucal y sistémico del paciente.

We report the clinical case of a patient with whitish lesions on lateral tongue edges with 1 year of evolution approximately, clinically asymptomatic, without toxic habits or important medical history. The patient was in orthodontic treatment, when the specialist warns the importance of Bucal Pathologist review. After a thorough medical history, biopsy was taken and histopathological examination showed: exophytic epithelial hyperplasia, excessive parakeratosis and superficial balloon cells with typical nuclear fragmentation, indicative of viral inclusion (Cowdry Body´s). With these findings and correlation with lesion clinical features and serological tests (HIV positive), the final diagnosis was Bucal Hairy leukoplakia (OHL). The patient was referred Anzoatiguense Health Institute (Saludanz), entity responsible of public health problems in the Anzoátegui State, Venezuela. The Bucal Hairy Leukoplakia (OHL) occurs commonly in HIV patients and represents an informative and predictive factor for the dentist, stomatologist and any health branch specialist for treatment, diagnosis and prognosis of the patient.

Sarcoma de Kaposi en mucosas en pacientes PPVI: a propósito de 2 casos: revisión de bibliografía / Kaposi´s Sarkoma (KS) in patiens living with HIV: apropos of 2 cases: review of literature

El Sarcoma de Kaposi (SK) es un tumor vascular que puede comprometer la piel. En 1872 el dermatólogo vienés Moritz Kaposi describió por primera esta entidad. Tradicionalmente se la ha considerado un proceso crónico, decurso lento, que afecta sobre todo a hombres ancianos del este de Europa. No recibió mayor atención hasta que apareció como epidemia en hombres que tienen sexo con hombres (HSH) en la década de los 80 y fue reconocido como marcador clínico de SIDA. Describimos nuestra experiencia en la Unidad de Atención y Control en Salud Sexual (UNACESS) de dos varones PPVI: uno con lesión en cara mucosa del prepucio y otro con lesiones palatinas.

Kaposi’s Sarcoma (KS) is a vascular tumor that can involve the skin. In 1872 the Viennese dermatologist Moritz Kaposi first described this entity. Traditionally it has been considered a chronic, slow flowing, mainly affecting elderly men of Eastern Europe. KS received no more attention until it appeared as an epidemic among men who have sex with men (MSM) in the 80s and was recognized as a clinical marker of AIDS. We describe our experience in Care and Control Unit Sexual Health (UNACESS) in two men living with VIH infection, one with penile mucosa injury and another with palatal lesions.

Leishmaniasis and AIDS coinfection / Coinfeccao leishmaniose e AIDS

Cutaneous leishmaniasis and HIV coinfection has been reported in Brazil since the initial description of AIDS in the country. We report an HIV-positive patient under antiretroviral treatment who presented with cutaneous leishmaniasis which was successfully treated with meglumine antimoniate.

A coinfecção leishmaniose cutânea e HIV tem sido descrita no Brasil desde o início da endemia de Aids no país. É relatado caso de paciente masculino, HIV positivo, em uso de terapia antirretroviral, que apresentou quadro de leishmaniose cutânea, tratada com antimoniato de meglumina.

Vírus linfotrópicos de células T humanas dos tipos 1 e 2 (HTLV-1 e HTLV-2): estudo de segmentos do genoma proviral obtidos de pacientes com HIV/Aids de São Paulo e de Londrina e região / Human T-lymphotropic virus type 1 and 2 (HTLV-1 and HTLV-2): study on proviral genome segments obtained from patients with HIV/Aids from Sao Paulo and Londrina and vicinities

O Brasil é considerado o país com o maior número absoluto de indivíduos infectados pelos vírus linfotrópicos de células T humanas dos tipos 1 e 2 (HTLV-1 e HTLV2), perto de 2,5 milhões; além disso, é também considerado epidêmico para o HIV e, portanto, casos de coinfecção HIV/HTLV são frequentes no país. O presente trabalho efetuou o seqüenciamento das regiões LTR, env e tax do genoma proviral do HTLV-1 e do HTLV-2 isolados das amostras de sangue de pacientes coinfectados pelo HIV-1 de Londrina e região (n=34) e de São Paulo (n=20), para realizar a caracterização molecular e determinar subtipos virais. Foram utilizadas na análise das sequências as ferramentas Sequencher 4.7, BLAST, Genotyping-NCBI, Subtyping-REGA, BioEdit 7.0.5.3, ClustalW, GenBank, PAUP 4.0.b10, Modeltest 3.7, TreeView 1.6.6 e MEGA4. As diversas análises confirmaram como subtipos prevalentes o HTLV-1a, subgrupo Transcontinental A, e o HTLV-2a (variante -2c). Foram detectadas assinaturas moleculares nos isolados do Brasil. Detectou-se o genótipo brasileiro taxA para o HTLV-1 e para o HTLV-2 a Tax longa, a qual é característica da variante HTLV-2c. Houve também a confirmação da troca de aminoácido S1909P no env dos HTLV-2. Especulou-se sobre duas entradas do HTLV-1 no Brasil e sobre a disseminação do HTLV-2c em grupos distintos quanto ao comportamento de risco e região geográfica. O estabelecimento de métodos laboratoriais otimizados para isolados brasileiros de HTLV-1 e HTLV-2 possibilitou melhor compreensão da diversidade genômica e da origem e disseminação dos HTLVs em populações coinfectadas pelo HIV no Brasil

Brazil is considered the country with the major absolute number of individuals infected with human T-lymphotropic virus types 1 and 2 (HTLV-1 and HTLV-2), close to 2,500,000; moreover, it is also considered epidemic for HIV/Aids =and therefore HIV/HTLV coinfection is frequent in the country. This study aimed at sequencing the LTR, env and tax regions of the proviral genome of HTLV-1 and HTLV-2 isolated from blood samples obtained from patients coinfected with HIV-1 from Londrina and vicinities (n=34) and São Paulo (n=20), in order to perform the molecular characterization and viral subtyping. For sequences analysis, several bioinformatics tools were employed: Sequencher 4.7, BLAST, Genotyping-NCBI, Subtyping-REGA, BioEdit 7.0.5.3, ClustalW, GenBank, PAUP 4.0.b10, Modeltest 3.7, TreeView 1.6.6 and MEGA4. The results confirmed as prevalent the HTLV-1a subtype, the Transcontinental subgroup A, and the HTLV-2a (variant-2c). Molecular signatures characteristic of Brazilian isolates were detected: taxA Brazilian genotype in HTLV-1, and the long Tax which is characteristic of the HTLV-2c in HTLV-2. Also, it was confirmed the S1909P amino acid change in the env region of HTLV-2c. It was speculated on two entrances of HTLV-1 in Brazil, and on the spread of HTLV-2c in distinct groups related to risk factors and geographic region. The establishment and optimization of laboratory methods performed in this study allowed to get a better understanding on HTLVs genomic diversity, and to give insights on the origin and spread of HTLVs in populations coinfected with HIV in Brazil

Morphological changes in the digestive system of 93 human immunodeficiency virus positive patients: an autopsy study / Alterações morfológicas no sistema digestivo de 93 pacientes infectados pelo vírus da imunodeficiência humana: um estudo de autopsias

Involvement of the digestive system in patients with acquired immunodeficiency syndrome (AIDS) is frequent and many changes in these patients are diagnosed only at autopsy. There are few studies of autopsy with detailed analysis of this system and only one was conducted in Brazil. We evaluated each segment of the digestive system in 93 consecutive autopsies of patients infected with human immunodeficiency virus (HIV) and the importance of these lesions to death. Of these, 90 (96.8%) patients had AIDS. We reviewed medical records, autopsy reports and histological sections from tongue to rectum stained with hematoxylin-eosin. When necessary, we analyzed special stains and immunohistochemistry to investigate infections. There was damage to the digestive system in 73 (78.5%) cases. The most common infections were candidiasis (42%), cytomegalovirus (29%), histoplasmosis (11.8%), toxoplasmosis (9.7%) and mycobacterial infection (9.7%). Malignancies were rare, present in four (4.3%) cases (two Kaposi's sarcoma, one adenocarcinoma and one metastatic embryonal carcinoma). All segments showed lesions: tongue (48.6%), esophagus (44.8%), stomach (44.7%), colon (43.2%) and small intestine (28.9%). The lesions found were immediate cause of death in five (5.4%) cases. In another 36 (38.7%) cases the basic disease was systemic and also compromised the digestive system.

Envolvimento do sistema digestório em pacientes com síndrome da imunodeficiência adquirida (AIDS) é frequente e muitas alterações nesses pacientes são diagnosticadas apenas à autopsia. Há escassos estudos de autopsia com análise detalhada desse sistema e apenas um deles foi realizado no Brasil. Neste estudo avaliamos cada segmento do sistema digestório em 93 autopsias consecutivas de indivíduos infectados pelo vírus da imunodeficiência humana (HIV) e a importância dessas lesões para o óbito. Desses, 90 (96,8%) pacientes apresentavam AIDS. Revisamos prontuários médicos, relatórios de autopsias e cortes histológicos da língua ao reto corados pela técnica de hematoxilina-eosina. Quando necessário, analisamos colorações especiais e imuno-histoquímica para pesquisar infecções. Havia lesões no sistema digestório em 73 (78,5%) casos. As alterações mais comuns foram infecciosas: candidíase (42%), citomegalovirose (29%), histoplasmose (11,8%), toxoplasmose (9,7%) e infecção por micobactérias (9,7%). Neoplasias malignas foram raras, presentes em quatro (4,3%) casos (dois sarcomas de Kaposi, um adenocarcinoma gástrico e um carcinoma embrionário metastático). Todos os segmentos apresentaram lesões: língua (48,6%), esôfago (44,8%), estômago (44,7%), intestino grosso (43,2%) e intestino delgado (28,9%). As lesões encontradas foram causa imediata do óbito em cinco (5,4%) casos. Em outros 36 (38,7%) casos a doença básica era sistêmica comprometendo, também, o sistema digestório.

Malnutrición en niños colombianos con infección por VIH/SIDA / Malnutrition in Colombian children with HIV/AIDS infection

Introducción: La desnutrición (DNT) es una de las complicaciones más tempranas que se presenta en niños con infección por VIH/SIDA, asociada a su morbimortalidad. Igualmente como consecuencia de la terapia antriretroviral y otros medicamentos utilizados, se han encontrado problemas de resistencia a la insulina y obesidad. Objetivo: Determinar la prevalencia de malnutrición (MNT) en niños con infección por VIH/SIDA por carga viral de la Clínica de VIH/SIDA del Hospital Universitario del Valle de Cali, Colombia (HUV) y su posible asociación con algunos factores de riesgo. Metodología: Estudio descriptivo, observacional de corte transversal, con análisis de casos y controles, a quienes se les tomaron datos como carga viral, %CD4, peso y talla. Se categorizó la carga viral (copias/ml) en: <400, ≥400-<300000, ≥30000-<1 millón y ≥1 millón; y el %CD4 en: <15%, ≥15%-<25% y ≥25%. Se consideró DNT global (déficit P/E≥10%), DNT crónica (déficit T/E≥5%), DNT aguda (déficit P/T≥10%) y sobrepeso (exceso P/T≥10%). Resultados: Fueron incluidos 111 niños entre 0 meses y 15 años de edad, con predominio del género masculino (51,3%), con modo de transmisión vertical en 91,8%. El 58.5% tenían entre ≥400-<300000 copias/ml de carga viral; y el 59% presentaron %CD4 ≥25%. La valoración nutricional evidenció DNT global en 64%, DNT aguda en 58%, DNT crónica en 22% y sobrepeso en 18%. Hubo riesgo de 1.7, 1.5 y 2.0 veces más de presentar DNT global, aguda y crónica, respectivamente, si la carga viral era ≥400 copias/ml. Conclusión: En niños con infección por VIH/SIDA por carga viral de la Clínica Pediátrica de VIH/SIDA del HUV de Cali, Colombia, la prevalencia de MNT fue superior al 18%, con una relación positiva superior a 1.5 veces entre carga viral y los diferentes tipos de DNT.

Introduction: Undernutrition (UNT) is a complication that occurs earlier in children with HIV/AIDS associated morbidity and mortality. Also as a result of anti-retroviral therapies and other drugs used, have encountered problems of insulin resistance and obesity. Objective: To determine the prevalence of malnutrition (MNT) in children diagnosed with HIV/AIDS by viral load in the Pediatric Clinic HIV/AIDS at the Hospital Universitario del Valle in Cali, Colombia (HUV) and its possible association with certain risk factors. Methodology: A descriptive cross-sectional study, with case-control analysis, whose data were taken as viral load, CD4%, weight and height. Were categorized viral load (copies / ml): <400, ≥ 400 - <300000, ≥ 30000 - <1 million and ≥ 1 million, and the %CD4 <15%, ≥ 15% - <25% ≥ 25%. UNT is considered global (low W/A≥10%), chronic (low H/A≥5%), acute (low W/H≥10%) and overweight (excess W/H≥10%). Results: We included 111 children from 0 months to 15 years old with male predominance (51.3%), mode of transmission in 91.8%. 58.5% were aged ≥ 400 - <300,000 copies/ml viral load, and 59% had CD4% ≥25%. Nutritional assessment showed 64% global UNT, 58% acute UNT, 22% chronic UNT and 18% overweight. Risk was 1.7, 1.5 and 2.0 times the present global, acute and chronic UNT, respectively, if the viral load was ≥ 400 copies / ml. Conclusion: In children diagnosed with HIV/AIDS by viral load of Pediatric Clinic HIV/AIDS at the HUV in Cali, Colombia, the prevalence of MNT was higher than 18%, with a positive relationship more than 1.5 times between viral load and the different types of UNT.

Virus de la hepatitis B e infección por VIH/SIDA en niños / Hepatitis b and HIV/AIDS infection in children

La infección por VIH/SIDA en niños ha aumentado a nivel mundial y en nuestro medio no es la excepción, aunque desde hace muchos años se ha cambiado la historia natural de la enfermedad utilizando la terapia antirretroviral altamente efectiva (HAART). La manera más frecuente de transmisión del Virus de la Hepatitis B (VHB) son contactos con sangre o fluidos y a través de actividad sexual. La infección por VIH/SIDA es una enfermedad viral progresiva caracterizada por el desarreglo inmune. La infección concurrente de VIH con VHB y hepatitis C (VHC) se asocia con incremento en la severidad y empeora el pronóstico de la enfermedad hepática.

HIV/AIDS in children has increased worldwide and in our environment is no exception, although for many years has changed the natural history of disease using highly effective antiretroviral therapy (HAART). The most frequent way of transmission of Hepatitis B Virus (HBV) is contact with blood or body fluids and by sexual activity. HIV/AIDS is a viral disease characterized by progressive immune disorder. HIV concurrent infection with HBV and hepatitis C virus (HCV) is associated with increased severity and worsens the prognosis of liver disease.