[Persons living with HIV/AIDS: ethnic and sociocultural differences in Chile]. / Perfil de personas con infección por VIH/SIDA: diferencial étnico, económico y socio-cultural en Chile.

BACKGROUND: The association between ethnicity and HIV/AIDS is an emerging and unexplored issue in Chile. AIM: To determine the profile of patients with HIV/AIDS by ethnicity and socioeconomic factors associated with diagnostic-therapeutic opportunity in the Araucania and Metropolitan regions. METHODS: Cross-sectional study with 558 patients from two centers of HIV/AIDS in Chile. Data were collected using a questionnaire with clinical and sociocultural data obtained under informed consent. Descriptive analysis raw and stratified associations for each variable was performed. RESULTS: Mapuche patients were mostly male, heterosexual (53.1%), lower average age (36.7 years), educational and income level lower than no Mapuche patients. The median of CD4(+) lymphocytes from Mapuche patients was the lowest in the sample, less than 51 cells/mm3, under 25 percentile (CI 38-123). Lifestyle variables indicated that drug use, number of sexual partners, and relationships between men were associated with higher levels of income, education and no Mapuche ethnicity. CONCLUSION: There are differences between Mapuche and non Mapuche patients regarding their sociocultural and clinical status, which generates health inequalities.

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

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.

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.

Perfil de personas con infección por VIH/SIDA: diferencial étnico, económico y socio-cultural en Chile / Persons living with HIV/AIDS: ethnic and sociocultural differences in Chile

Resumen Introducción: La asociación entre etnicidad e infección por VIH/SIDA constituye un tema emergente y poco explorado en Chile. Objetivo: Describir el perfil de pacientes con infección por VIH/SIDA según etnia Mapuche y no Mapuche asociados a condiciones clínicas, factores socio-económicos y oportunidad terapéutica en pacientes de dos centros de atención de las regiones Araucanía y Metropolitana, Chile. Material y Método: Estudio de corte transversal con 558 pacientes cuyos datos se recolectaron mediante un formulario que contenía las variables del estudio, obtenidos tras consentimiento informado. Se realizó análisis descriptivo, asociaciones crudas y estratificadas por cada variable. Resultados: Los pacientes Mapuche fueron en su mayoría de sexo masculino, 53,1% heterosexuales, edad promedio 36,7 años, y nivel educacional e ingresos más bajos que los no Mapuche. La mediana de LT CD4 basal fue más baja en pacientes Mapuche, 51 céls/mm3 o menos y bajo el percentil 25 (IC 38-123). Se observó que existe mayor consumo de drogas, comercio sexual, sexo entre hombres y mayor número de parejas sexuales en último mes, en personas de la etnia no Mapuche y que, además, tienen mejores niveles de ingreso y educación. Conclusión: Existen perfiles diferenciados según etnia respecto de la condición sociocultural y de ingreso de los pacientes a control, generando inequidad en un tratamiento oportuno hacia los pacientes Mapuche, de baja escolaridad y menor educación.

Background: The association between ethnicity and HIV/AIDS is an emerging and unexplored issue in Chile. Aim: To determine the profile of patients with HIV/AIDS by ethnicity and socioeconomic factors associated with diagnostic-therapeutic opportunity in the Araucania and Metropolitan regions. Methods: Cross-sectional study with 558 patients from two centers of HIV/AIDS in Chile. Data were collected using a questionnaire with clinical and sociocultural data obtained under informed consent. Descriptive analysis raw and stratified associations for each variable was performed. Results: Mapuche patients were mostly male, heterosexual (53.1%), lower average age (36.7 years), educational and income level lower than no Mapuche patients. The median of CD4(+) lymphocytes from Mapuche patients was the lowest in the sample, less than 51 cells/mm3, under 25 percentile (CI 38-123). Lifestyle variables indicated that drug use, number of sexual partners, and relationships between men were associated with higher levels of income, education and no Mapuche ethnicity. Conclusion: There are differences between Mapuche and non Mapuche patients regarding their sociocultural and clinical status, which generates health inequalities.

Effects of prior effective therapy on the efficacy of daptomycin and ceftriaxone for the treatment of community-acquired pneumonia.

OBJECTIVE: We sought to compare daptomycin with ceftriaxone for the treatment of patients with community-acquired pneumonia (CAP). METHODS: Two phase-3 randomized, double-blind trials that enrolled adult patients hospitalized with CAP were conducted. Patients received intravenous daptomycin (4 mg/kg) or ceftriaxone (2 g) once daily for 5-14 days. Aztreonam could be added for patients with gram-negative infections. Clinical responses at the test-of-cure visit among patients in the intent-to-treat and clinically evaluable populations were the primary efficacy end points. RESULTS: After combining data from the trials, the intent-to-treat population included 413 daptomycin-treated patients and 421 ceftriaxone-treated patients, and the clinically evaluable population included 369 daptomycin-treated patients and 371 ceftriaxone-treated patients. In the intent-to-treat population, the clinical cure rate among daptomycin-treated patients with CAP was 70.9%, compared with 77.4% among ceftriaxone-treated patients (95% confidence interval for the difference between cure rates, -12.4% to -0.6%). In the clinically evaluable population, the clinical cure rate was lower among daptomycin-treated patients (79.4%) than among ceftriaxone-treated patients (87.9%; 95% confidence interval for the difference between cure rates, -13.8% to -3.2%). A posthoc analysis revealed that, among those who had received up to 24 h of prior effective therapy, cure rates were similar among daptomycin-treated (90.7%) and ceftriaxone-treated patients (88.0%; 95% confidence interval for the difference between cure rates, -6.1% to 11.5%). CONCLUSIONS: Daptomycin is not effective for the treatment of CAP, including infections caused by Streptococcus pneumoniae and Staphylococcus aureus. The observation that as little as 24 h of prior effective therapy may impact clinical outcome suggests that trials to evaluate CAP treatment may need to exclude patients who have received any potentially effective therapy before enrollment.

A multicenter randomized trial evaluating posaconazole versus fluconazole for the treatment of oropharyngeal candidiasis in subjects with HIV/AIDS.

BACKGROUND: Oropharyngeal candidiasis is the most common opportunistic infection among persons infected with human immunodeficiency virus (HIV). Use of some agents is hampered by lack of efficacy, emergence of resistance, adverse events, and need for intravenous administration. Posaconazole is an extended-spectrum triazole with potent in vitro activity against Candida species, including Candida albicans, Candida glabrata, and Candida krusei (including fluconazole-resistant strains). METHODS: This multicenter, randomized, evaluator-blinded study of subjects with HIV infection and oropharyngeal candidiasis compared efficacy of posaconazole with that of fluconazole. Subjects received either 200 mg of posaconazole or fluconazole oral suspension on day 1, followed by 100 mg/day for 13 days. The primary study end point--clinical success (cure or improvement) on day 14--was evaluated for 329 subjects. Durability of clinical success was evaluated on day 42. RESULTS: Three hundred fifty subjects received posaconazole (n = 178) or fluconazole (n = 172). Clinical success occurred in 155 (91.7%) of 169 posaconazole recipients and in 148 (92.5%) of 160 fluconazole recipients (95% confidence interval, -6.61% to 5.04%), indicating that posaconazole was not inferior to fluconazole. On day 14, mycological success was 68% in both arms, but by day 42, significantly more posaconazole recipients than fluconazole recipients continued to have mycological success (40.6% vs. 26.4%; P=.038). Fewer posaconazole recipients than fluconazole recipients experienced clinical relapse (31.5% vs. 38.2%). Adverse events were similar between treatment arms. CONCLUSIONS: Results demonstrate that posaconazole was as effective as fluconazole in producing a successful clinical outcome. However, posaconazole was more effective in sustaining clinical success after treatment was stopped.

[Human immunodeficiency virus infection in pregnant women. The importance of recognizing the infection during pregnancy and risk factors for perinatal transmission]. / Infección por virus de inmunodeficiencia humana en la embarazada. Importancia del conocimiento de la infección en el embarazo y factores de riesgo en la transmisión perinatal.

BACKGROUND: Using adequate infection control measures, the rate of vertical transmission of human immunodeficiency virus (HIV) during pregnancy, has been reduced to 3% in Chile. AIM: To determine vertical transmission rate and risk factors associated to perinatal infection in pregnant women with known (KI) and unknown HIV infection (UI). PATIENTS AND METHODS: HIV infected pregnant women whose deliveries were attended at the San Borja Arriaran Hospital were included. Antiretroviral therapy (ART) has been used since 1995 (Zidovudine 13 patients, biOtherapy 4 and triple therapy 14 patients). Newborns have received ART since 1995. Premature labor without evident cause, premature rupture of membranes, and rupture of membranes over 4 h before delivery were evaluated. Delivery was by elective cesarean section since 1993. Breast feeding was avoided. Pregnant women with UI (suspected disease after delivery due to child or mother pathology) did not received ART. Delivery and breast feeding were managed with common obstetrical-neonatal criteria. RESULTS: Fifty three HIV infected pregnant women were studied (43 with KI and 10 with UI). Four children (36.4%) from the KI group and seven (63.6%) from the UI group became infected. The global rate of vertical transmission among KI group was significantly lower than UI group: 9.5% (4/42) vs 70.0% (7/10) p < 0.001. Using ART, this rate was further reduced to 6.5% (2/31) and with bitherapy or triple therapy to 0% (0/18). Breast feeding, vaginal delivery, premature delivery with no clinical cause, premature rupture of membranes, rupture of membranes longer than 4 h and lack of ART, were significantly more common in the UI group, compared with KI group. CONCLUSIONS: Vertical transmission in pregnant women with KI is significantly lower compared with UI. Risk factors increasing HIV perinatal infection are: breast feeding, lack of ART, vaginal delivery, premature rupture of membranes, rupture of membranes > 4 h and premature labor without a clinical cause.