Seguimiento prospectivo de una población infectada por VIH con y sin posibilidades de terapia anti retroviral: impacto en sobrevida y complicaciones / Prospective follow up of HIV positive patients with and without access to antiretroviral therapy: survival and complications

Background: Three-drug antiretroviral therapy (ART-3) has reduced complications and improved survival in HIV+ patients. The Chilean Public Health System began dual therapy (ART-2) in 1997, covering approximately 40 percent of patients in need. Aim: To report the results of a follow-up of patients with and without access to ART in a Chilean public hospital. Patient and Methods: Prospective follow-up of patients with ART-2 and 3 (cases) and patients with no access to ART (controls). All patients needed ART but it was available to a minority of them. Selection for ART was at random. Follow-up was between 6-24 months (11/96 to 3/99). Basal and periodic clinical and laboratory parameters were determined. Mortality and occurrence of new AIDS-defining events (ADE) were compared statistically using chi square. Results: One hundred and fifty cases (106 ART2, 28 ART3 and 16 ART2 expanded to ART3) and 166 controls were studied. Basal parameters were similar except prior ART (32.7 and 18.7 percent in cases and controls respectively). Close to 1/3 patients had AIDS. Cases had a mean follow up of 527 days; controls, 478. Six cases (4 percent) (5 in ART-2) and 17 controls (10 percent) died. Mortality x 100/pts/yr was 2.7 in cases and 7.7 in controls, p <0.05. ADE per 100/pts/yr was 21 in cases (24.4 in ART2, 15.1 in TAR3) and 54.5 in controls, p <0.05. Cases had a reduction of: esophageal candidiasis (84 percent), tuberculosis (75 percent), cryptococcosis and toxoplasmosis (66 percent), P carinii pneumonia (55 percent) and bacterial pneumonia (46 percent) and they had fewer hospitalizations (73 percent). Late assessment: 70 of 101 ART-2 patients had changed to ART-3 (1 death); 22 of 101 kept original ART-2 (12 dead, 10 alive), 39 of 43 ART-3 patients were alive and 1 died. Conclusions: Short-term ART-2 and 3 significantly reduced mortality (60 percent and 73 percent) ADE (65 percent and 76 percent respectively) and hospitalizations. Benefits of ART-2 were short lived. Resource-constrained countries cannot depend on weaker than standard ART for proper care of people with HIV disease

Acidosis láctica fatal en paciente con síndrome de inmunodeficiencia adquirido y tratamiento antiretroviral de alto grado de actividad: comunicación de un caso / Fatal lactic acidosis in a patient with acquired immunodeficiency syndrome treated with highly active antiretroviral therapy: case report

Type B lactic acidosis occurs without any evidence of cellular hypoxia and is associated with the use of drugs or toxins. We report a 36 years old woman with acquired immunodeficiency syndrome that was admitted to the hospital with a severe lactic acidosis. She had been treated with didanosine, stavudine and efavirenz for four months prior to admission. Despite the use of high bicarbonate doses and vasoactive drugs, the patient had a catastrophic evolution and died in shock and multiple organ failure, 68 hours after admission

Impacto de la terapia anti retroviral en la mortalidad de pacientes VIH+ chilenos: estudio caso control MORTAR / Impact of antiretroviral therapy in mortality of chilean HIV+ patients: a case control study

Background: Combined antiretroviral therapy (AVR) has shown a protective effect (PE) on morbidity and survival in HIV (+) patients of industrialised countries where triple-drug therapy (ARV-3) is standard. In Chile the public health system began providing double-drug therapy in 1997 (ARV-2) with 2 reverse transcriptase inhibitors. Aim: To assess the impact of ARV in morbimortality of HIV (+) patients in Chile after a year of follow up. Patients and methods: Retrospective case-control (1:1) study. Cases were 97 patients followed during 1997 for 6 or more months and dying during that period. Each case had a control of the same gender and CDC stage, similar age and CD4 count, but surviving a same period of follow up. A comparison of ARV before and during follow up (rate and type) was done. P carinii prophylaxis, pneumococcal immunization at baseline or follow up, frequency of hospital admissions and occurrence of opportunistic infections in both groups were assessed. Odds ratio (OR) for mortality, hospitalisation and opportunistic infections in ARV user, as well as treatment PE were calculated. Results: Twenty four (24.7 percent) cases and sixty six (68 percent) controls received ARV during follow up (p< 0.001), OR was 0.15 (CI 95 percent 0.08-0.3), p < 0.001, the PE was 6.6 for ARV users versus non users, among cases 19 patients received ARV-2 and five received ARV-3. Among controls, 41 patients received ARV-2 and 25 received ARV-3. These differences established an OR of 0.20 (CI 95 percent 0.09-0.04) and a PE of 5 for ARV-2 versus no ARV. For ARV-3 compared with no ARV the OR was 0.08 (CI 95 percent 0.003-0.26), and the PE 12.5. Fifty three (54.6 percent) cases and 13 (13.4 percent) controls required hospital admission, OR 0.49 (CI 95 percent 0.25-0.94), p=0.03, and PE of 2.04 of ARV versus no ARV; 82 (85.3 percent) cases and 50 (51 percent) controls had opportunistic infections, OR 0.5 (CI 95 percent 0.26-0.96), p=0.03 and PE of 2 for ARV versus no ARV. There were no significant differences in prior ARV, prophylaxis and immunisation between cases and controls. Conclusions: This study showed the high impact of ARV in short term morbimortality of HIV(+) patients and the need to implement antiretroviral therapy to all patients as an official health policy. This study did not answer the question of the role, if any, of weaker-than standard antiretroviral therapy

Infección por VIH y embarazo / VIH infection and pregnancy

El objetivo de este trabajo fue estudiar las características clínicas del embarazo con infección por virus de inmunodeficiencia humana (VIH) y la transmisión vertical. Se analizaron embarazadas con esta infección, controladas en la Fundación Arriarán, cuya gestación y parto fueron atendidos en la Maternidad del Hospital San Borja Arriarán. Durante la gestación se hizo pesquisa de otras infecciones. La zidovudina (AZT) fue usada según protocolo ACTG 076 en 6 mujeres. En el parto se prefirió la cesárea electiva. Se impidió la lactancia. Se hizo seguimiento de los niños. Diecisiete mujeres tuvieron 19 partos. Presentaron infección genitourinaria 4 pacientes (21,1 por ciento); infecciones no ginecológicas 5 (26,3 por ciento); patología del embarazo 4 (21,1 por ciento); rotura prematura de membranas de término 1 (5,3 por ciento); parto prematuro 3 (15,8 por ciento). El parto fue por cesárea en 15 casos (78,9 por ciento). La transmisión vertical fue 26,3 por ciento (5/19), 33,3 por ciento (5/15) en la cesárea y 16,7 por ciento con tratamiento de AZT. Un niño presentó muerte fetal y trece (68,4 por ciento) están sanos. Ocho mujeres están asintomáticas, tres sintomáticas, cuatro abandonaron controles y dos fallecieron. Es conveniente que la embarazada con infección por VIH use AZT y sea controlada por especialistas para disminuir los factores de riesgo en la transmisión vertical. La cesárea facilita la administración de AZT durante el parto. La lactancia materna debe suprimiese

Infección por VIH: recomendaciones para el manejo del adulto asintomático y de algunos síndromes clínicos / Infection by HIV: recommendations for the management of asymtomatic adults and some clinical syndromes

This paper presents recommendations on the care of HIV infected adults based upon the author's personal experience with close to 700 patients in a multiprofessional pilot center. This medical care has 5 main objectives: 1)Promotion of good health (through standard recommendation of hygiene, health habits and regular checkup) 2)Prevention of infectious complications (through detection of latent pathogens, chemoprophylaxis, vaccination and avoidance of risk exposures). 3)Treatment of complications (mainly infectious, through early diagnosis and proper treatment); 4)Delay of HIV disease progression (through timely and properly chosen antiretroviral therapy) 5)Reduction of HIV disease progression spread from index case of others (through promotion of responsible behavior and avoidance of pregnancy and HIV exposure to others). Studies for evaluating global health and immunologic status and carriage of potential pathogens are discissed as well as the criteria and timing for chemoprofilaxis for tuberculosis and P carinii pneumonia (PCP). Algorithms for the management of major clinical syndromes and presented: diarrhea (afebrile, mostly parasitic, versus febrile, frequently bacterial); pneumonia (lobar mostly bacterial versus interstitial, frequently PCP specially if lymphopenic and not receiving PCP prophylaxis); brain mass lesion (most commonly toxoplasmosis). Finally, the evaluation and diagnostic possibilities of febrile patients is presented, based upon the immunologic status and associated symptoms

SIDA y embarazo: manejo clínico de dos casos con infección por VIH / AIDS and pregnancy: clinical managment of 2 cases with HIV infection

Se presentan dos casos clínicos de embarazos con infección por VIH; una paciente con SIDA y la segunda portadora asintomática. Se detalla el manejo clínico de ellos, la resolución del parto y las medidas empleadas en su atención hospitalaria. Se analizan tanto las probables vías de contagio a los funcionarios de la salud como las precauciones universales que deben llevarse a cabo con este tipo de enfermos para evitar los riesgos de infección. La transmisión perinatal de la infección por VIH y los posibles factores de riesgos asociados a ella se estudian igualmente en la presentación. En la relación heterosexual de pareja con infección por VIH son importantes, asimismo, algunos factores de riesgos asociados. Parece ser que la educacion es primordial para prevenir la infección en pacientes gineco-obstétricas, por sobre el empleo de recursos para efectuar exámenes serológicos masivos en ellos

Análisis crítico del hemograma tífico / Thyfic hemogramme critical analysis

Es práctica común diagnosticar Fiebre Tifoidea (FT) a base del hemograma tífico (HT), y no en criterios bacteriológicos. Este estudio evaluó la sensibilidad del HT en pacientes (pts) con FT documentada bacteriológicamente y la especificidad para FT en pts que durante su estudio tenían HT. Se definió al HT con 5 parámetros: leucopenia (3500-6500), más de 40% de polimorfonucleares, 6% o más de baciliformes, aneosinofilia y VHS entre 25 y 50 mm. De 50 pts con FT, la mayoría adultos, sólo 13 (26%) tenían los 5 parámetros de HT, 41 (82%) al menos 4 y 49 (98%). Cuarenta y siete pts tenían HT; 25 adultos y 22 niños (sin lactantes). Sólo 14 (30%) tenían FT: 7 de 15 adultos (47%) y 7 de 21 niños (33%) con cuadro febril compatible. Los cuadros febriles no tíficos de adultos HT fueron: pericarditis, lupus, sarampión, colitis isquémica, pielonefritis, tuberculosis, peritonitis y psitacosis. En niños lo más frecuente fue: diarrea infecciosa y neumonía, también hepatitis, linfomas y celulitis. Se concluye que la sensibilidad del HT para FT es alta, pero el examen es poco específico