Evolución virológica de pacientes con infección por VIH que inician terapia antirretroviral con carga viral basales muy alta / Virological evolution of patients with HIV infection that start antiretroviral therapy with a very high baseline viral load

INTRODUCCIÓN: Se desconoce el grado de supresión viral en pacientes con infección por VIH que inician terapia antirretroviral (TAR) con cargas virales (CV) muy altas. OBJETIVO: Conocer el porcentaje de supresión viral en pacientes con VIH que inician TAR con CV ≥ 500.000 copias/mL a 96 semanas. PACIENTES Y MÉTODO: Estudio retrospectivo. Se incluyeron pacientes que iniciaron TAR con CV ≥ 500.000 copias/mL, entre los años 2008 y 2018, estratificándose en base a escala logarítmica. Se determinó el porcentaje de supresión viral, y las variables asociadas a este desenlace. RESULTADOS: Se incluyeron 221 pacientes. La mediana de edad y CV era de 43 años y 6,0 log, respectivamente, estando la mayoría (37%) en estadio C3 al inicio de TAR. El 48,8 y 87,7% de los pacientes logró la supresión viral al año y dos años de seguimiento, respectivamente. Se observó que, a mayor edad, a mayor inmunosupresión, y a mayor CV, mayor el tiempo para lograr la indetectabilidad. Sólo se demostró fracaso virológico en tres pacientes. DISCUSIÓN: Los pacientes con infección por VIH que inician TAR con CV muy altas demoran más tiempo en lograr la supresión viral, lo cual es proporcional a la magnitud de ésta y al grado de inmunosupresión, sin que esto conlleve mayor riesgo de fracaso virológico.

BACKGROUND: The degree of viral suppression in HIV patients who start antiretroviral therapy (ART) with very high viral loads (CV) is unknown. AIM: To know the percentage of viral suppression in HIV patients who start ART with CV ≥ 500,000 copies/mL at 96 weeks. METHOD: Retrospective study. Patients who started ART with a CV ≥ 500,000 copies/mL between 2008 and 2018 were included, stratifying on the basis of a logarithmic scale. The percentage of viral suppression and the variables associated with this outcome were determined. RESULTS: 221 patients were included. The median age and CV were 43 years and 6.0 log, respectively, with the majority (37%) being in stage C3 at the start of ART. 48.8 and 87.7% of the patients achieved viral suppression at one year and two years of follow-up, respectively. It was observed that the older the immunosuppression, and the higher CV, the longer the time to achieve undetectability. Virological failure was only demonstrated in three patients. DISCUSSION: Patients with HIV infection who start ART with very high CVs take longer to achieve viral suppression, which is proportional to the magnitude of this and the degree of immunosuppression, without this entailing a greater risk of virological failure.

Meningitis aguda posterior a vacuna tresvírica / Acute meningitis following mumps vaccine

Resumen En Chile, la cepa del virus parotídeo utilizada en la vacuna es Leningrad-Zagreb (L-Z). Aunque la relación entre meningitis y la cepa L-Z sigue siendo controvertida, la mayoría de los casos reportados han presentado un cuadro de curso benigno y sin secuelas neurológicas. Presentamos el caso de una paciente que tres semanas post-inmunización con la vacuna tresvírica evolucionó con una meningitis aséptica de predominio mononuclear, con serología para IgM positiva contra el virus parotídeo. En este caso clínico, existió una relación temporal entre la vacunación, el inicio del cuadro parotídeo y posteriormente el meníngeo; la curva de inmunoglobulinas demostró una infección aguda posterior a la vacuna. Si bien no se logró aislar el virus en LCR, es razonable atribuir el cuadro a una infección post-vacunal.

In Chile, the strain of the mumps virus used in the vaccine is Leningrad-Zagreb (L-Z). Although the relationship between meningitis and the L-Z strain remains controversial, most of the reported cases have shown a benign course without permanent neurological sequelae. We present a case of a patient who presented an aseptic meningitis three weeks after immunization with a mumps vaccine; and laboratory confirmation showed positive serum mumps IgM antibody. In this clinical case, there was a temporal relationship between vaccination and the onset of the mumps and subsequently the meningeal involvement; the immunoglobulin curve demonstrates acute infection after vaccination. Although it was not possible to isolate the virus in CSF, it is reasonable to attribute the picture to a post-vaccinal infection.

Evolución de mortalidad, abandono, traslado y retención a corto, mediano y largo plazo en pacientes con infección por VIH: Fundación Arriarán 1990-2015 / Evolution of mortality, retention and loss to follow up of HIV infected subjects followed in a special clinic

Background: The HIV epidemic reached Chile in late 1980s and as an early response, AIDS care centers were organized. Fundación Arriarán (FA) was the first center. Free antiretroviral therapy (ART) was later provided with progressive coverage and complexity over the years. Aim: To quantify evolution of mortality, retention and loss to follow up (LTFU) over 25 years according to different periods of access to ART, from no availability to full coverage with current drugs at FA center. Material and Methods: Retrospective analysis of FA database of 5,080 adults admitted between 1990 and 2014. The sample was distributed in 7 groups: A: no ART (1990-92), B: monotherapy, C: dual therapy, D: dual/triple ART, E: early triple therapy with incomplete coverage, F same as E but with complete coverage and G: contemporary ART (2008-14). Mortality, retention and LTFU were evaluated at 1, 3, 5, 7 and 10 years and at 31/12/2015. Results: Mortality varied from 40% to 2%, and 62% to 7% at 1 and 5 years, for groups A and G respectively; from 71% to 16% at 10 years for groups A and E, respectively. Retention at 5 years were 28%, 23%, 39%, 62%, 75%, 75% and 77% for groups A to G, respectively. LTFU was 10%, 19%, 15%, 17%, 9% 12% and 10% at 5 years for same groups, respectively. At 12/31/2015 22% of patients had died, 11% were LTFU, 60% were retained in care and 6% had been transferred. Conclusions: There is a marked reduction in mortality and increase in retention of HIV patients' concomitant to expanded access to modern therapy, although LTFU remains a problem.