Incidence of opportunistic diseases after the “treat all” strategy: 10 years cohort for HIVAbstract
High active anti-retroviral therapy (HAART) has improved the life expectancy of people living with HIV/AIDS (PLWHA) and reduced the development of opportunistic diseases, supporting a strategy introduced in 2014, which sought to enhance prevention with early treatment and for all. This was a retrospective and comparative cohort study before and after the implementation of “treat all” strategy, based on primary and secondary data, extracted from the medical records followed at the Specialized Care Service between 2009 and 2018 and from public databases. Of the 892 patients selected, 790 were active, 28 abandoned treatment and 40 died, 92%, 3.3% and 4.7%, respectively. About 440 (51.2%) started follow-up between 2009 and 2013, before the “treat all” strategy, and 417 (48.9%) started follow-up after 2014, when the national recommendation was already the “treat all” strategy. A total of 508 (58.2%) male patients were counted, the mean age was 33.5 years on the date of entry, most of them had a total of 8 to 11 years of study (21.1%) and about 6.5% of the patients were illiterate. The main routes of HIV transmission were heterosexual intercourse (67.95%) and MSM (men who have sex with men) (31%). The mean CD4 cell count at presentation was 392 cells/mm3 and 23% of participants had a CD4 count less than 200 cells/mm3. Elevated levels of viral load were found at entry, with 30% having at least 100,000 copies/mL. During the ten years of observation, there were 245 episodes of opportunistic diseases. The five most common opportunistic diseases during the study period were tuberculosis (28.6%), herpes zoster (23.3%), oral candidiasis (15.5%), neurotoxoplasmosis (11.4%) and pneumocystosis (6.1%). Forty patients died during the study period, 4.7% of the total. There was a reduction in opportunistic infections in the second group of the study, especially for oral candidiasis (p = 0.03), as well as a better response to LogCV treatment (1.28±1.97). It is concluded that the diagnosis and treatment strategy has shown over the years an effective reduction in opportunistic infections.
Keywords:
AIDS-related complex; HIV seropositivity; opportunistic infections; antiretroviral therapy; highly active; “treat all” strategy
Resumo
A terapia antirretroviral altamente ativa (HAART) melhorou a expectativa de vida das pessoas vivendo com HIV/aids (PVHA) e reduziu o desenvolvimento de doenças oportunistas, apoiando uma estratégia introduzida em 2014, que buscou potencializar a prevenção com tratamento precoce e para todos. Trata-se de um estudo de coorte retrospectivo e comparativo antes e após a implementação da estratégia “tratar todos”, com base em dados primários e secundários, extraídos dos prontuários acompanhados no Serviço de Atenção Especializada entre 2009 e 2018 e de bancos de dados públicos. Dos 892 pacientes selecionados, 790 estavam ativos, 28 abandonaram o tratamento e 40 morreram, 92%, 3,3% e 4,7%, respectivamente. Cerca de 440 (51,2%) iniciaram o acompanhamento entre 2009 e 2013, antes da estratégia “tratar todos”, e 417 (48,9%) iniciaram o acompanhamento após 2014, quando a recomendação nacional já era a estratégia “tratar todos”. Foram contados 508 (58,2%) pacientes do sexo masculino, a média de idade foi de 33,5 anos na data de entrada, a maioria possuía um total de 8 a 11 anos de estudo (21,1%) e cerca de 6,5% dos pacientes eram analfabetos. As principais vias de transmissão do HIV foram a relação heterossexual (67,95%) e HSH (homem faz sexo com homem) (31%). A contagem média de células CD4 na apresentação foi de 392 células/mm3 e 23% dos participantes tinham uma contagem de CD4 inferior a 200 células/mm3. Níveis elevados de carga viral foram encontrados na entrada, com 30% tendo pelo menos 100.000 cópias/mL. Durante os dez anos de observação, houve 245 episódios de doenças oportunistas. As cinco doenças oportunistas mais comuns no período estudado foram tuberculose (28,6%), herpes zoster (23,3%), candidíase oral (15,5%), neurotoxoplasmose (11,4%) e pneumocistose (6,1%). Quarenta pacientes morreram durante o período do estudo, 4,7% do total. Houve redução das infecções oportunistas no segundo grupo do estudo, principalmente para candidíase oral (p = 0,03), bem como melhor resposta ao tratamento LogCV (1,28±1,97). Conclui-se que a estratégia de diagnóstico e tratamento tem demonstrado ao longo dos anos uma redução efetiva das infecções oportunistas.
Palavras-chave:
complexo relacionado à AIDS; soropositividade para HIV; infecções oportunistas; terapia antirretroviral altamente ativa; estratégia de “tratar todos”
1. Introduction
In 2015, the WHO recommended that all people living with HIV (PLWHA) start combination antiretroviral therapy as early as possible (WHO, 2015). The “treal all” strategy program is now recognized as the main strategy that, regardless of the stage of the disease, represents a paradigm shift in HIV treatment that has the potential to achieve epidemic control (Insight Start Study Group, 2015).
Unaids data shows that of the 39 million people living with HIV worldwide, 29.8 million are receiving treatment3. An additional 1.6 million people received HIV treatment in each of 2020, 2021 and 2022. If this annual increase is maintained, the global target of 35 million people on HIV treatment by 2025 could be achieved (Unaids, 2018). Access to antiretroviral therapy has expanded massively worldwide and three-quarters (71%) of people living with HIV in 2022 (76% of women and 67% of men) had suppressed viral loads (Unaids, 2018). Viral suppression allows people living with HIV to live a long, healthy life with minimal risk of sexual transmission of HIV.
Late presentation, diagnosis of HIV with CD4 <350 per mm3 or the development of AIDS within the first 6 months of HIV diagnosis were associated with an increased rate of AIDS/deaths, especially in the first year after HIV diagnosis (Mocroft et al., 2013). The results of the INSIGHT START Study Group reinforce the importance of treatment for all, which proved that the initiation of antiretroviral therapy in asymptomatic patients with CD4+ counts greater than 500 per mm3 of cells was greater than delaying the start of treatment until the CD4 count decreases to 350 per mm3 of cells or until the development of AIDS (Insight Start Study Group, 2015). Opportunistic diseases are the visible face of HIV-related harm. They can appear after an incubation period that can vary, on average, from 2 to 10 years (Sarabia and Bosque, 2019), between infection and the onset of symptoms, mainly attacking CD4 lymphocytes. HIV leads to the impairment of the immune system of the infected individual, up to its complete depletion of CD4 below 200 per mm3 (Tymejczyk et al., 2019).
HIV can evolve rapidly in both virulence (damage to the host) and risk of transmission. The evolution of HIV could increase the frequency of more virulent forms, requiring more intense precautions and controls. With treatment, an individual's viral load may become undetectable, with little or no risk of further transmission (Rodger et al., 2016) or progression to AIDS (Sterne et al., 2005). Since 2015, treatment guidelines have recommended immediate initiation of HAART after a positive diagnosis, also known as the “treat-all” strategy (Stansfield et al., 2021). This strategy, after HIV diagnosis, prevents the abrupt drop in CD4+ cell count, avoiding the appearance of opportunistic diseases and progression of HIV, being the most accepted therapy today and delays occur as a result of diagnosis and eligibility for the use of antiretroviral therapy (Linn et al., 2018).
The achievements of the HIV antiretroviral response have wide-ranging impacts: Improvements, and strengthened health and community systems are bringing benefits that go beyond public health and contribute to progress against several UN sustainable development goals (SDGs) such as SDG 3: Good health and well-being by protecting the lives of millions of people. In addition, HIV programmes protect them from poverty and food insecurity, enabling them to financially support their children's education and contribute to the continued reduction of child deaths and maternal mortality (SDG 10: Reduced inequalities) (Phanuphak et al., 2019). The aim of the research was to analyze the risk of opportunistic diseases in PLWHA before and after the recommendation of a “treat-all” strategy in the period from january 2009 to december 2018. We hypothesize that the implementation of the ‘Treat All’ strategy reduces the incidence of opportunistic diseases and improves immunological outcomes.
2. Material and Methods
This is a retrospective cohort study (2009-2018) based on primary data extracted from medical records registered and monitored at the Specialized Care Service of a reference center in Maceió/AL and secondary data from public databases: Laboratory Test Control System of the National Network of CD4+/CD8+ Lymphocyte Count and HIV Viral Load, Drug Logistics Control System and Disease Information System. This research was approved by the Research and Teaching Ethics Committee of the University Center under Nº 4.707.026. Following Hellsinki's statement of ethical principles in research involving human subjects.
The sample consisted of the medical records of patients regularly registered in the period between january 2009 and december 2018. Participants were divided into 2 groups, those diagnosed between january 2009 to december 2013 before the “treat-all” strategy and those diagnosed between january 2014 to december 2018 after the “treat-all” strategy.
Patients were classified as “retained in the service”, “treatment abandonment” or “deaths”: Patients who had regular follow-up, who attended the service for at least one medical consultation or other categories of the multidisciplinary team in the last eighteen months were considered “retained in the service”.
The patients who formed the “dropout” group were those who did not attend for a period of more than eighteen months, either for medical appointments or for consultations with other team members.
The “deaths” were identified in several ways: Communication of the fact by family members or people close to the patient, communication of the fact by health professionals from other services, or consultation of the Mortality Information System of the Unified Health System (SIM-SUS).
Data regarding the sociodemographic profile of the patients (gender, color/race, marital status, education) were filled in based on the information collected at the time of the patient's admission. Epidemiological, clinical, and treatment data were filled in according to the information contained in the medical records. The date of the HIV test was recorded in the medical records at the time of the first visit. The date of the patient's admission corresponds to his/her first visit to the service.
For the gender variable, the categories as male and female were considered. Regarding skin color, the five reference categories of the Brazilian Institute of Geography and Statistics (IBGE) were considered, namely: White, black, brown, yellow and indigenous, information self-declared by the patient and added to the categories “unknown” and “not informed”. The categories for the composition of the marital status variable were: “Single”; “stable union”; “separated/divorced/widowed” and “unknown”, whose information was also collected from the medical records at the time of enrollment.
The exposure was divided according to the sexual orientation revealed by the patient into: (1) Heterosexual; (2) bisexual; (3) male homosexual and (4) female homosexual and in blood exposure: (1) Transfusion of blood and blood products; (2) injecting drug users; (3) work/work accident and (4) vertical transmission. And in the absence of information: “Ignored”.
When available in the medical records, information on the level of education was placed depending on the number of years of study: (1) None; (2) from 1 to 3; (3) from 4 to 7; (4) from 8 to 11; (5) 12 years of age or older; (6) not informed.
Regarding the patients' immunity, the initial CD4 level (time of diagnosis) was considered; the last CD4 value (last test performed) and the lowest CD4 value during follow-up. In addition, viral loads were assessed at the first count (time of diagnosis); load at the beginning of treatment, and the last viral load record (last test performed). Viral loads were transformed into Logs, to facilitate comparison. Regarding the time of admission of patients to the service, they were categorized into HIV stages according to the centers for disease control and prevention (CDC) as: Stage 1 (CD4 cell count ≥500 mm3), stage 2 (CD4 cell count 200-499 mm3) and stage 3 (Opportunistic disease or CD4 cell count < 200 mm3).
Data on infectious/neoplastic opportunistic diseases were selected by searching the medical records of patients treated during the periods studied. The following opportunistic diseases adapted from the modified CDC criteria were recorded: Mycobacterium tuberculosis infection; disseminated Mycobacterium avium complex; toxoplasma gondii encephalitis; pneumocystis carinii pneumonia; oral candidiasis or hairy leukoplakia; extrapulmonary cryptococcosis; herpes zoster in individuals up to 60 years of age; cytomegalovirus; cryptosporidiasis; isosporiasis; disseminated histoplasmosis; candidiasis of the esophagus, trachea, bronchi or lung; progressive multifocal leukoencephalopathy; mucocutaneous herpes simplex of the bronchi; lung or gastrointestinal tract >1 month; primary lymphoma of the brain; other B-cell non-Hodgkin's lymphoma; Kaposi's sarcoma; cervical cancer. The following oral lesions were recorded: Pseudomembranous candidiasis; erythematous candidiasis; oral hairy leukoplakia; angular cheilitis; recurrent aphthous ulcers; Kaposi's sarcoma; linear gingival erythema (LGE); ulcer, unspecified; herpes simplex infection; necrotizing ulcerative gingivitis; necrotizing ulcerative periodontitis; condyloma or other oral HPV lesions; tuberculosis-specific ulcers; specific ulcers, histoplasmosis.
3. Statistical Analysis
Two periods were compared, the first period (2009 and 2013) and the second period (2014 and 2018). The independent variable was defined as the use of the “treat-all” strategy program and the outcome variable was defined as the incidence of opportunistic diseases, and the covariates studied were sociodemographic and clinical characteristics, forms of exposure to the virus, and immunological characteristics such as CD4 and viral cell count with viral load and LogCV value.
The analysis was subdivided into two parts: one descriptive and the other inferential. Inferential analysis was performed using logistic regression, estimating the Odds Ratio (OR) and the 95% Confidence Interval (95% CI). In the end, a multiple statistical regression model was designed to identify the influence of multiple factors (covariates) on the distribution of the outcome.
The prerequisites for regression were absence of multicollinearity (autocorrelation of the independent variable with the outcome), expressed by Tolerance values > 0.1 and VIF < 10, another item observed was the absence of outliers. The determination in the model followed mathematical and theoretical criteria for its modeling. The final model considered the classification capacity of the model and the significance of the Hosmer and Lemeshow test, which are important parameters for the evaluation of the model. In addition, the statistical significance of the final model was observed. In all analyses, the level of significance adopted was 5%, using the freeware statistical software SPSS (version 20.0) to assist in data processing.
4. Results
Data from 1249 PLWHA people between 2009 and 2018 were analyzed, relating them to the onset of opportunistic diseases between the two periods analyzed. Of the total of 1249 patients, 491 (39.3%) enrolled between 2009 and 2013, before the “treat-all” strategy, and 758 (60.69%) from 2014, when the recommendation was already the “treat-all” strategy. Age ranged from 18 to 79 years, with a mean of 33.8 years (±11) between men (p<0.001) and women (p<0.001) with a statistically significant difference in the relationship between age and gender, with men contracting the virus earlier.
The sociodemographic variables are shown in Table 1 with their relative and absolute frequencies. It was noticed that the pattern of those infected by HIV is mostly male, composed of self-declared brown people, single and with schooling ranging from 8 to 11 years. Of the sociodemographic factors analyzed in the bivariate comparative statistics, there was a statistically significant association for three variables: gender, marital relationship, and schooling. Males were more likely to be in the second period (2014 to 2018) compared to women (OR = 1.49; IC-95: 1.18-1.88; p = 0.001). Single individuals were more present in the second period than married/married individuals (OR = 1.64; IC-95: 1.27-2.10; p < 0.001). Regarding age, there was no statistically significant association for this variable with the times studied (p= 0.47; OR=1.00; CI-95: 0.99-1.01). The heterosexual exposure category was less likely to be compared to bisexual exposure for the second period analyzed (p = 0.04; OR of 0.61; 95% CI: 0.38-0.98).
Sociodemographic and epidemiological characterization of the population of a Specialized Care Service - Alagoas, Brazil, 2019.
The research noted that the final mean of CD4 T lymphocytes in the last analysis has a higher mean value than at the beginning of treatment, indicating the increase in CD4 T lymphocytes with the implementation of HAART: CD4initial (437±298), CD4last (572±323), CD4low (351±273) in all time periods analyzed (2009 to 2018). The measurement of CD4 cells in the last record is higher than at the beginning of the treatment, this difference is less marked in the second period (2014-2018). The mean CD4 cell count initially between 2009-2013 (378; 302.28%), and between 2014 and 2018 (430.5; 295.95%).
It can be seen that the viral load log at the patient's last record is lower than at the beginning of treatment: LogCVfirst (4.35±1.41) and LogCVlast (1.28±1.97) in all time periods analyzed (2009 to 2018).
CD4 cell counts were stratified into groups < 200 mm3, 200–350 mm3, 350–500 mm3, and > 500. It is observed that late access to the service (CD4 < 200 and CD4 between 200–350) predominates in all phases of the study. Initial CD4 cell count < 200 mm3 from 2009 to 2013 (132; 26.88%), from 2014 to 2018 (161; 21.24%). Baseline CD4 cell count 200–350 mm3 from 2009 to 2013 (92; 18.74%), from 2014 to 2018 (158; 20.84%). The initial CD4 cell count was 350–500 mm3 between 2009 and 2013 (108; 22.00%), and between 2014 and 2018 (136; 17.94%). The initial CD4 cell count ≥500 mm3 between 2009 and 2013 (159; 32.38%), between 2014 and 2018 (303; 39.97%). It is observed that immune recovery is similarly distributed among the phases of the study (CD4 ≥ 500).
The CD4 T lymphocyte count associated with an opportunistic disease characterizing AIDS and late access to health services had a slight predominance in the period from 2009 to 2013. Regarding the stages of HIV according to the CDC: Patients with stage 1 (n=160, 33%) before 2014 and (n=303, 40%) after 2014; patients with stage 2 (n=199, 41%) before 2014 and (n=294, 39%) after 2014; patients with stage 3 (n=132, 27%) before 2014 and (n=161, 21%) after 2014.
We observed that during the ten years of follow-up, a total of 264 episodes of opportunistic diseases were added in a universe of 216 patients who developed at least one AIDS-defining disease, there was a clear predominance of cases in the first period, 25.8% of the patients in the first group had at least one opportunistic disease against 11.7% in the second group. Patients who developed AIDS (s) defining disease within the study period: from 2009-2013 (127, 25.8%) and from 2014-2018 (89, 11.74%).
The opportunistic diseases studied that affected HIV carriers are described in Table 2. Observing them in isolation, we noticed that Mycobacterium tuberculosis infection; herpes zoster; Toxoplasma gondii encephalitis and Pneumocystis carinii pneumonia were the most frequent. Although the significant proportion of HIV/tuberculosis co-infection with 79 cases is noteworthy, the number of patients with Herpes zoster is noteworthy, corresponding to 59 cases. Of the oral lesions, candidiasis predominated in general.
Virtually all opportunistic infections are present in a smaller number in the second group (2014-2018). Mycobacterium tuberculosis infection is representative of this lower number, but it is Pneumocystis carinii pneumonia that best symbolizes this reduction (Table 3).
Distribution of opportunistic diseases within the study periods in patients with HIV, n = 1249.
The main oral lesions studied and their distribution among the groups and in this case as well, as well as among the opportunistic AIDS-defining diseases, it can be seen that in relative terms, practically all cases are present in a smaller number in the second group. The clinical characteristics of oral candidosis are the most prevalent, and the lowest number is significant in the second group, Table 3.
Considering the distribution of schooling and opportunistic infections between the groups, it can be seen that the relationship between reduced schooling and a lower number of infections in the second group. Mycobacterium tuberculosis infection in less than 8 years of schooling, before 2014 (13; 0.14%), after 2014 (17; 0.05%). Mycobacterium tuberculosis infection aged 8 years or more before 2014 (10; 0.21%), after 2014 (8; 0.02%).
Table 4 details the binary logistic regression comparing the differences between opportunistic diseases. Five opportunistic diseases were significantly absent in patients in the 2nd period (2014-2018): Mycobacterium tuberculosis infection; Toxoplasma gondii encephalitis; Pneumocystis carinii pneumonia; oral candidiasis/hairy leukoplakia; herpes zoster in an individual up to 60 years of age, Figure 1A-B. This indicates that HIV patients treated between 2014 and 2018 were less likely to have these opportunistic diseases. The Odds Ratio value was > 1 for all diseases/injuries listed in Table 4. This indicates that HIV patients in the second period were less likely to have the following diseases/lesions: Mycobacterium tuberculosis infection; Toxoplasma gondii encephalitis (Figure 1C-D); Pneumocystis carinii pneumonia; oral candidiasis or hairy leukoplakia; herpes zoster in individuals up to 60 years of age; pseudomembranous candidiasis. The only lesion that showed a significant association was pseudomembranous candidiasis (p < 0.001). The chance of a patient seen in the second period not having this infection was statistically significant by means of binary logistic regression (OR = 6.55; 95% CI: 1.85-23.1).
Clinicalphatological aspects of oral opportunistic diseases. A) Herpes zoster in right palate; B) Pseudomembranous candidosis in all extensions of oral mucosae, gingivae and tongue; C-D) Toxoplasma gondii encephalitis; E-F) Kaposi’s Sarcoma with purple color nodule.
The value of the last CD4 measurement presented a chance < 1, indicating that as the CD4 value increases, there is a lower chance of presenting patients with opportunistic diseases. On the other hand, the opposite happened with the Log value of the last viral load, where the chance was > 1, indicating that as the Log value increases, there is a greater chance of individuals with opportunistic disease appearing, Table 5.
5. Discussion
The alternative hypothesis that late initiation of treatment is a risk factor for HIV/AIDS progression was accepted, as well as the “treat all” strategy reduces the incidence of opportunistic diseases, corroborating the findings in the literature (Mossoro-Kpinde et al., 2016).
Currently, there is strong evidence and high adoption of policies, such as the “treat-all” strategy, Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP) that should be implemented as widely as possible to reduce transmission and control the HIV epidemic according to the WHO 90-90-90 target (Granich et al., 2017). More research is needed to optimize, not delay, its implementation.
Several studies have evaluated the efficacy of HAART in viral suppression and reduction of HIV transmission, such as HPTN 052 (HIV Prevention Trials Network) in 2011, which drew a parallel between early versus late HAART initiation, with one group starting HAART early (with CD4 levels between 350 and 550) and the other group starting treatment only with CD4 counts less than 250 or in the presence of symptoms which was, in this case, the indication for the initiation of treatment in force at the time. The study showed that the use of HAART reduced the risk of heterosexual transmission of HIV by 96% (Cohen et al., 2011; Gardner et al., 2011; Grinsztejn et al., 2014). Data from the two trials demonstrated that initiation of HAART early in HIV infection resulted in marked reductions in the risk of opportunistic disease and invasive bacterial infections. This indicates that HIV causes immune impairment early in the infection that is remedied by controlling viral replication. Interestingly, in START, a marked reduction in the risk of cancers, both infection-related and unrelated was observed (Lundgren et al., 2018).
The choice of 2014 as the dividing point was based on the premise that at that moment the recommendation to start treatment immediately and for all began to be fully implemented (Brasil, 2021). In Brazil, the “treat-all” strategy was initiated in 2014 prior to the WHO recommendation in 2015.
Most of the individuals studied, precisely 60.6%, entered the service between 2014 and 2018, in the second period of the evaluation, a fact structured in the gradual increase in the number of diagnoses that happened year after year due to the increase in the incidence of cases (Brasil, 2015). Regarding genders, males predominated in this study, with a ratio ratio of 1.5:1 when compared to females, when considering the two groups studied, and it was 1.18:1 in the first group, going to 1.75:1 in the second group. This follows a trend observed in the country as a whole, that of the increase in AIDS cases among males, primarily among the HSH group (Brasil, 2015). The mean age of the patients at the time of their admission was 32 years. The result is equivalent to that found in Brazil, where the predominant age group is young adults aged 25 to 39 years and in other places the majority are diagnosed in routine rapid tests (Brasil, 2015; Mutimura et al., 2015).
In the evaluation of schooling, we observed an increase in the level of schooling from one period to the next, which overlaps with what was found in Brazil in the same period, when considering the set of patients who completed 8 years or more of schooling, that is, 41.74% of the total, the patients in the study have a higher level of schooling than those in the rest of the country (Brasil, 2015). Sexual intercourse was the main route of HIV transmission among those surveyed, this information is in agreement with national data, the other routes had little representativeness (Brasil, 2015; Mutimura et al., 2015). A dizzying growth among the group of men who have sex with men in recent years, from the first to the second period, according to the literature (Pinheiro et al., 2022).
Socio-economic determinants of health include the social, political, and economic conditions in which people are born, develop, live, work, and age. Apart from medical care, there is increasing evidence of the role of these factors in health. Socioeconomic deprivation have a higher risk of contact with tuberculosis, higher likelihood of living and working in crowded and badly ventilated places, higher risk of malnutrition, smoking, alcohol abuse and face barriers to accessing health care (Duarte et al., 2018).
The results of CD4 T lymphocyte tests, when performed at the patients' admission to the service, showed that the vast majority started their follow-up late. Patients took an average of eighteen months from diagnosis to seeking and starting treatment.
The information that about 62.76% of the patients had CD4+ T lymphocyte results below 500 when they entered the service, corroborates the hypothesis that these patients already had compromised immune systems, a hypothesis strengthened when it is analyzed that a significant portion, 23% of the total, had already developed an intense immunodeficiency. When the last TCD4 lymphocyte test of each patient was analyzed, even though the access was delayed, there was a significant reversal, with an increase in TCD4 lymphocyte levels at the end of the observation, 55.2% of the patients with values greater than 500 cells. With a predominance in the first group 62.1% and 50.7% in the second group. It is inferred that even with late onset, if the patient adheres to the treatment, he has a high chance of immunological recovery.
The evaluation of the emergence of opportunistic diseases in the patients of this study gave greater emphasis to the identification of which of them, when present, can interfere with the loss of quality of life of PLWHA in an often precarious social context, which is aggravated when the need for prolonged treatment of an opportunistic infection is required. The advancement in the effectiveness of AIDS treatment since the advent of AZT in the 80s, more specifically, after the beginning of the HAART era, quality of life of PLWHA has also undergone significant changes when treatment care has been improved, which has been intensified with the “treat-all” strategy as seen in sub-Saharan African countries (Tymejczyk et al., 2019).
This research corroborates what is found in the literature that demonstrates a greater reduction of opportunistic diseases in the group of patients who were included in the “treat all” program (Lundgren et al., 2018). In the present cohort, when comparing the differences between opportunistic diseases, it was shown that five diseases had a significant reduction in patients in the 2nd period (2014-2018): Mycobacterium tuberculosis infection; Toxoplasma gondii encephalitis; Pneumocystis carinii pneumonia; oral candidiasis/hairy leukoplakia; herpes zoster in an individual up to 60 years of age. Indicating that those who started their follow-ups between 2014-2018 were 6.55 times less likely to have these opportunistic diseases.
Of the sociodemographic factors analyzed in the bivariate comparative statistics, there was a statistical association for three variables: Gender, marital relationship, and schooling. In the cohort studied, males were more likely to be in the second period compared to women (OR = 1.49; p = 0.001), probably related to the strong increase in the presence of HSH individuals in this period, an extensive and applicable explanation for the fact that single individuals were more present in the second period compared to married individuals (OR = 1.64; p < 0.001), a greater tendency for HSH to remain single.
In the context of HIV co-infection and Mycobacterium tuberculosis infection, with 79 cases out of 1249 patients screened, 29.9% of all infections is representative of the barriers that need to be overcome. We observed a much lower risk of developing Mycobacterium tuberculosis infection in the number of cases/number of patients followed up between the two periods, before “treat all” (p=0.10) and during “treat all” (p=0.04). Confirming that, as has been described in other moments, antiretroviral therapy is strongly associated with a reduction in the incidence of tuberculosis and the early initiation of antiretroviral therapy is a positive fator (Suthar et al., 2012; Gatechompol et al., 2022).
Mycobacterium tuberculosis infection is observed when considering the level of education and its distribution among the groups, and it can be seen that, in relative terms, there was a greater presence among those with reduced schooling (up to elementary school - 8 to 11 years of schooling), different from what was observed in another study (Pathmanathan et al., 2017) and fewer infections in the second group.
The deleterious effects of tuberculosis in association with HIV/AIDS on the health system and the negative repercussions, especially on quality of life, continue to be a major public health challenge in middle income countries such as Brazil, and the combined effect of the damage to health of HIV and TB has imposed challenges on the already overburdened health system similar to what occurs in other developing countries (Fekadu et al., 2020). Complementing the group of the most frequent opportunistic diseases are herpes zoster, Toxoplasma gondii encephalitis and Pneumocystis carinii pneumonia (Siripurapu and Ota, 2023), the difference between the number of co-infections of the two periods is clear, with a significant drop in the treatment phase for all.
It is concluded that during the ten years of observation, there were 245 episodes of opportunistic diseases. The five most common opportunistic diseases during the study period were tuberculosis, herpes zoster, oral candidiasis, neurotoxoplasmosis, and pneumocystosis, with a reduction in all opportunistic diseases during the second study period analyzed (2014 to 2018). In this way, the “treat all” program is effective in reducing opportunistic diseases.
Acknowledgements
We would like to thank the PAM Salgadinho and inclusion and all of the professionals who coordinated this supplement. This supplement was funded by Centro Universitário CESMAC.
References
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Publication Dates
-
Publication in this collection
07 Feb 2025 -
Date of issue
2024
History
-
Received
30 Oct 2024 -
Accepted
26 Nov 2024
