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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]