Download Current challenges in HIV care from a Brazilian

Current challenges in HIV care from a
Brazilian cohort perspective
Aluisio Segurado
Department of Infectious Diseases
School of Medicine, University of São Paulo
Outline
 Current features of the Brazilian HIV epidemic
 Current challenges in HIV care in Brazil
 Research at USP Medical School HIV clinic
 Potential for interinstitutional collaboration
HIV/AIDS IN BRAZIL
(Nov 2012 - estimate)
718,000 people living with HIV
1st autochtonous AIDS case - 1983
686,478 AIDS cases
Dept. STD/AIDS/VH, Min. Health, 2013
HIV/AIDS IN BRAZIL
(Nov 2012 - estimate)
< 1% general population
> 5% > 1 populational subgoup
concentrated epidemic
0.31%
HIV prevalence = 0.4%
(15 – 49)
Dept. STD/AIDS/VH, Min. Health, 2013
0.52%
UNAIDS, 2013
HIV infection in Brazil: prevalence studies
Distribution of AIDS cases, Brazil
 territorial spread
Distribution of AIDS cases in Brazil
2005-2011
Baixo
Alto
Distribution of AIDS cases among MSM, Brazil
2010-2012
Baixo
Alto
Brazilian National ART Program
universal access to medication
distributed free of charge - SUS
 launched in 1991 – zidovudine (AZT)






progressively incorporated new ARVs
1997 - combined therapy (HAART)
local production of generic ARVs
2008 – compulsory license - efavirenz
2013 – “test and treat” strategy
2014 – expected TDF/3TC/EFZ pill
Current challenges - 1
 regional discrepancies – local epidemics
 late diagnosis
 uptake and retention in care
AIDS incidence in Brazil
(Dec 2012 - estimate)
Dept. STD/AIDS/VH, Min. Health, 2013
Clinical outcomes
 Reduced mortality (AIDS-related deaths)
RJ
Grinsztejn B, 2013
AIDS mortality in Brazil
Dept. STD/AIDS/VH, Min. Health, 2013
Late entry into HIV care
Grangeiro A, 2011
HIV/AIDS care cascade - Brazil
Dept. STD/AIDS/VH, Min. Health, 2013
USP Medical School HIV/AIDS clinic
 Founded in 1994
Training and research centre
HIV care centre - HIV testing site, outpatient
clinic, day hospital, ARV distribution unit
•
•
•
•
2700 aduts living with HIV
1/3 women
under ART
Multiprofessional and multidisciplinary
comprehensive care
•
•
physicians, nurses, nursing assistants,
pharmacist, dentist, psychologists,
social workers
administrative staff
Current challenges - 2
 ART sustainability
 More vulnerable populations
• MSM
• young women
 adherence to ART
Number of people on ART
Dept. STD/AIDS/VH, Min. Health, 2013
Vulnerable populations
 Sexuality of HIV-positive adolescents – Paiva V, Cien Saúde
Coletiva, 2011
 Disclosure of HIV diagnosis – bisexual
Paiva V, Cad Saúde Pública, 2011
and heterosexual men –
 Disclosure of HIV diagnosis – adolescents - Marques HH, Rev
Saude Publica, 2006
 HIV-infected youth care needs – Ayres JR, Am J Public Health,
2006
 Women’s care needs – Segurado AC, AIDS Patient Care STDs, 2003
 HIV shedding in women – Melo K, Menopause, 2012
 Gender differences in clinical manifestations – Braga PE, Cad
Saúde Pública, 2007
 Gender differences in survival – Braga PE, AIDS Patient Care STDs,
2007
Current challenges - 3
 coinfections – HCV, HPV, other
 comorbidities – mental health
 HIV drug resistance
 chronic AIDS – lipodystrophy,
and cardiovascular risk
metabolic abnormalities
 HPV
Coinfections
• Screening anal dysplasia in men – Nahas CS, Dis Colon Rectum,
2009
• Prevalence in women – Levi JE, J Clin Microbiol, 2002
 HTLV-1 – Etzel A, J Acquir Immune Defic Syndr, 2001
 HHV-8
• Diagnosis - de Souza VA, J Med Virol, 2007
• Prevalence and risk factors – Pierrotti LC, Sex Transm Dis, 2005
 Hepatitis C
• Prevalence and risk factors – Segurado AC, AIDS Patient Care
STDs, 2004
HIV drug resistance
 ARV rescue therapies - Vidal JE, Braz J Infect Dis, 2014
 Blips – intermittent low level viremia - Ibrahim KY, AIDS Patient
Care STDs, 2012
Comorbidities
 Mental health
• Depression in women – Mello VA, Arch Womens Ment
Health, 2010
 Lipodystrophy
• Self-perception of body changes – Santos CP, AIDS, 2005
HIV, nutrition and physical activity
 Vitamin A and beta-carotene - Kaio DJ, J Nutr Sci Vitaminol, 2013
 Diet quality – Duran AC, J Hum Nutr Diet, 2008
 Physical activity – Florindo A - Int J STD AIDS, 2007
 Obesity – Jaime PC, Rev Saude Publica, 2006
 Intervention studies
• Fish oil supplement - Oliveira JM, Int J STD AIDS, 2014
• Nutritional counselling - Almeida LB, AIDS Care, 2011
Current challenges - 4
 Stigma and discrimination
• need to address more vulnerable populations
• targeted prevention and care initiatives
• need to face structural dimensions of vulnerabiliy to
HIV acquisition and disease development
• recent retrenchment in human rights-based
response in Brazil
Malta C, 2013; Reis RK, 2013
Sexual and reproductive health
 Parenthood – Segurado AC, Reprod Health Matters, 2007
 Gender and reproductive rights – Paiva V, AIDS Patient Care
STDs, 2007
Important strategies
 scaling up HIV testing
 scaling up early ART – test and treat
 use of combined HIV prevention technologies –
behavioral, structural and biomedical approaches
 integrating HIV care and other health care programs
HIV integration
Tuberculosis care
Sexual and reproductive
health care
Primary
care
Antenatal and
child care
Non-communicable diseases
Opportunities for HIV research
Basic
Epidemiological
HIV
Operational
Clinical
Opportunities for HIV research
 Immunology and Virology laboratories, FMUSP
 HIV adult clinic cohort
 Outreach activities – primary and secundary care
 National databases – SINAM, SICLOM, SISCEL
 Collaboration – Ministry of Health, São Paulo State and
Municipal HIV/AIDS Programmes
[email protected]