Current challenges in HIV care from a Brazilian cohort perspective

Transcription

1 Current challenges in HIV care from a Brazilian cohort perspective Aluisio Segurado Department of Infectious Diseases School of Medicine, University of São Paulo

2 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

3 Dept. STD/AIDS/VH, Min. Health, 2013 HIV/AIDS IN BRAZIL (Nov estimate) 718,000 people living with HIV 1st autochtonous AIDS case ,478 AIDS cases

4 HIV/AIDS IN BRAZIL (Nov estimate) < 1% general population > 5% > 1 populational subgoup concentrated epidemic HIV prevalence = 0.4% (15 49) 0.31% 0.52% Dept. STD/AIDS/VH, Min. Health, 2013 UNAIDS, 2013

5 HIV infection in Brazil: prevalence studies

6 Distribution of AIDS cases, Brazil territorial spread

7 Distribution of AIDS cases in Brazil Baixo Alto

8 Distribution of AIDS cases among MSM, Brazil Baixo Alto

9 Brazilian National ART Program universal access to medication distributed free of charge - SUS launched in 1991 zidovudine (AZT) progressively incorporated new ARVs combined therapy (HAART) local production of generic ARVs 2008 compulsory license - efavirenz 2013 test and treat strategy 2014 expected TDF/3TC/EFZ pill

10 Current challenges - 1 regional discrepancies local epidemics late diagnosis uptake and retention in care

11 AIDS incidence in Brazil (Dec estimate) Dept. STD/AIDS/VH, Min. Health, 2013

12 Clinical outcomes Reduced mortality (AIDS-related deaths) RJ Grinsztejn B, 2013

13 AIDS mortality in Brazil Dept. STD/AIDS/VH, Min. Health, 2013

14 Late entry into HIV care Grangeiro A, 2011

15 HIV/AIDS care cascade - Brazil Dept. STD/AIDS/VH, Min. Health, 2013

16 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

17 Current challenges - 2 ART sustainability More vulnerable populations MSM young women adherence to ART

18 Number of people on ART Dept. STD/AIDS/VH, Min. Health, 2013

19 Vulnerable populations Sexuality of HIV-positive adolescents Paiva V, Cien Saúde Coletiva, 2011 Disclosure of HIV diagnosis bisexual and heterosexual men Paiva V, Cad Saúde Pública, 2011 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

20 Current challenges - 3 coinfections HCV, HPV, other comorbidities mental health HIV drug resistance chronic AIDS lipodystrophy, metabolic abnormalities and cardiovascular risk

21 Coinfections HPV 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

22 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

23 Comorbidities Mental health Depression in women Mello VA, Arch Womens Ment Health, 2010 Lipodystrophy Self-perception of body changes Santos CP, AIDS, 2005

24 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

25 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

26 Sexual and reproductive health Parenthood Segurado AC, Reprod Health Matters, 2007 Gender and reproductive rights Paiva V, AIDS Patient Care STDs, 2007

27 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

28 HIV integration Tuberculosis care Sexual and reproductive health care Primary care Antenatal and child care Non-communicable diseases

29 Opportunities for HIV research Basic Epidemiological HIV Operational Clinical

30 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

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