Managing HIV-infected patients on antiretroviral therapy in Rio de Janeiro, Brazil: do providers follow national guidelines?

The objective of the paper was to compare provider practices in prescribing antiretroviral (ARV) drug regimens and use of laboratory monitoring at three health care facilities and to determine whether Brazilian national guidelines are being followed. A retrospective, cross-sectional survey was employed. We selected a sequential sample of patients on ARV therapy who registered at three health care facilities in Rio de Janeiro, Brazil, during 2001. We abstracted 2001 patient visit data from medical records using standardized data forms. Provider practice was compared to the 2000 Brazil national guidelines for ARV use. Providers who prescribed recommended or acceptable regimens were considered as having conformed to guidelines. Only 2% of patient records (N=984) reported use of inappropriate regimens as defined by the Brazil 2000 national ARV guidelines. Forty-nine per cent of patients at the Evandro Chagas hospital, 17% of those at Hospital Geral, and 57% of those at Centro da Saude were prescribed recommended therapies. Twenty per cent of patients seen at the public district hospital received dual ARV therapy, an acceptable regimen at the time. Although the national guidelines do not provide recommendations on laboratory monitoring, during the 1 year study period a majority of patients had at least one CD4+ cell count (92%) or viral load measurement (86%). Providers' practices in prescribing ARV regimens at these Rio de Janeiro facilities conform to national guidelines. Physicians would benefit from Brazilian ARV guidelines which incorporate the international consensus on the frequency of laboratory monitoring appropriate for patients in resource-constrained settings.

Anti-HIV-1 seroreactivity and HIV transmission route[R1]. The HEC/FIOCRUZ AIDS Clinical Research Group.

BACKGROUND: Antibody binding assays carried out by our group have consistently indicated a higher reactivity of sera from male HIV-1 infected individuals. This study was carried out in order to analyze the importance of gender, route of transmission, disease progression and HIV-1 genotype in seroreactivity assays. STUDY DESIGN: Specificity of antibody binding was studied in plasma of 247 HIV-1 seropositive individuals belonging to patient groups of pregnant women, injecting drug users (IDUs) and recent seroconvertors, resident in Rio de Janeiro, RJ. Recognition of synthetic peptides corresponding to antigenically important epitopes in the envelope of HIV-1 (gp41 immunodominant epitope, V3 loop, V2 loop and gp41 735-752 epitope) was determined. RESULTS: The immunodominant gp41 peptide (amino acids 594-613, HIV-1 MN sequence) was recognized by 85% of all plasma tested. Reactivity with the gp41 735-752 peptide and gp120 V2 loop peptides was low but quite variable, being generally more often specific to a Brazilian V2 peptide used than to the HIV-1 MN derived V2 peptide. The overall recognition of the different V3 peptides tested varied from 41 to 76%. Patients with more advanced disease showed a more frequent reactivity with the peptides studied than did asymptomatic patients. Statistically significant differences in peptide recognition were observed by multiple logistic analyses comparing plasma derived from individuals infected by blood or sexual HIV transmission, adjusting for disease progression and gender. Plasma from individuals infected by sexual transmission showed lower peptide recognition than did plasma from individuals infected through HIV positive blood. Association attempts between seroreactivity and genotype indicated that plasma derived from patients infected with HIV-1 of the F subtype showed highest recognition of heterologous V3 peptides, as well as a slightly more frequent recognition of the non-V3 peptides tested. Recognition of homologous peptides was generally higher than recognition of heterologous peptides. Differences were most pronounced between the prototypical HIV-1 B subtype and the Brazilian B" variant of this subtype but almost non-existent between the HIV-1 B and F subtypes. CONCLUSIONS: Individual gender was shown to be a confounder when investigating the relationships of peptide reaction to HIV-1 route of transmission through multivariate statistical methods: patients infected by blood transmission (IDU) present higher frequency of peptide recognition than individuals infected by sexual HIV-1 transmission. Plasma from individuals infected with the B" variant (GWG) of B subtype HIV-1 showed lower heterologous peptide recognition than that from HIV-1 B (GPG) or F infected individuals.