Resumo A infecção pelo HIV é tema de um dos capítulos do “Protocolo Clínico e Diretrizes Terapêuticas para Atenção Integral às Pessoas com Infecções Sexualmente Transmissíveis”, publicado pelo Ministério da Saúde do Brasil em 2020. É importante que profissionais de saúde e gestores conheçam os sinais e sintomas da infecção pelo HIV e saibam fazer o seu diagnóstico, a fim de oferecer tratamento adequado e reduzir complicações. A infecção pelo HIV tornou-se doença crônica e seu tratamento inclui a abordagem de comorbidades comuns na prática clínica, como hipertensão arterial, diabetes e dislipidemia, além da avaliação de risco cardiológico, prevenção de neoplasias e orientação para imunizações. O início do tratamento para todas as pessoas vivendo com HIV, independentemente de critérios clínicos ou imunológicos, adotado pelo Ministério da Saúde em 2013, foi agora simplificado com medicamentos de primeira linha mais toleráveis e com menos interações medicamentosas, o que torna seu manejo de fácil implementação, inclusive pela Atenção Primária à Saúde.

Abstract HIV infection is the subject of one of the chapters of the “Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections”, published by the Brazilian Ministry of Health in 2020. It is important that health professionals and managers learn the signs and symptoms of HIV infection and know how to diagnose it, in order to provide appropriate treatment and reduce complications. HIV infection has become a chronic disease and its treatment includes addressing common comorbidities in clinical practice such as arterial hypertension, diabetes and dyslipidemia, in addition to cardiac risk assessment, cancer prevention and guidance on immunization. Initiation of treatment for all HIV patients, regardless of clinical or immunological criteria, adopted by the Ministry of Health since 2013, has now been simplified with more tolerable first-line medications and with fewer drug interactions, which makes its management easy to implement, including by Primary Health Care.

Resumen La infección por VIH es uno de los capítulos del “Protocolo Clínico y Directrices Terapéuticas para la Atención Integral a las Personas con Infecciones de Transmisión Sexual”, publicado por el Ministerio de Salud de Brasil en 2020. Es importante que los profesionales de la salud y gestores conozcan los signos y síntomas de la infección por VIH y sepan diagnosticarla, para proporcionar un tratamiento adecuado y reducir complicaciones. La infección por VIH se ha convertido en una enfermedad crónica y su tratamiento incluye abordar comorbilidades comunes en la práctica clínica, como hipertensión arterial, diabetes y dislipidemia, además de la evaluación del riesgo cardíaco, prevención del cáncer y pautas de inmunización. El inicio del tratamiento de VIH, independientemente de criterios clínicos o inmunológicos, adoptado por el Ministerio de Salud en 2013, fue ahora simplificado con medicamentos de primera línea más tolerables y con menos interacciones medicamentosas, lo que facilita la implementación de su manejo, incluso en la atención primaria.

Resumo A infecção pelo HIV é tema de um dos capítulos do “Protocolo Clínico e Diretrizes Terapêuticas para Atenção Integral às Pessoas com Infecções Sexualmente Transmissíveis”, publicado pelo Ministério da Saúde do Brasil em 2020. É importante que profissionais de saúde e gestores conheçam os sinais e sintomas da infecção pelo HIV e saibam fazer o seu diagnóstico, a fim de oferecer tratamento adequado e reduzir complicações. A infecção pelo HIV tornou-se doença crônica e seu tratamento inclui a abordagem de comorbidades comuns na prática clínica, como hipertensão arterial, diabetes e dislipidemia, além da avaliação de risco cardiológico, prevenção de neoplasias e orientação para imunizações. O início do tratamento para todas as pessoas vivendo com HIV, independentemente de critérios clínicos ou imunológicos, adotado pelo Ministério da Saúde em 2013, foi agora simplificado com medicamentos de primeira linha mais toleráveis e com menos interações medicamentosas, o que torna seu manejo de fácil implementação, inclusive pela Atenção Primária à Saúde.

Resumen La infección por VIH es uno de los capítulos del “Protocolo Clínico y Directrices Terapéuticas para la Atención Integral a las Personas con Infecciones de Transmisión Sexual”, publicado por el Ministerio de Salud de Brasil en 2020. Es importante que los profesionales de la salud y gestores conozcan los signos y síntomas de la infección por VIH y sepan diagnosticarla, para proporcionar un tratamiento adecuado y reducir complicaciones. La infección por VIH se ha convertido en una enfermedad crónica y su tratamiento incluye abordar comorbilidades comunes en la práctica clínica, como hipertensión arterial, diabetes y dislipidemia, además de la evaluación del riesgo cardíaco, prevención del cáncer y pautas de inmunización. El inicio del tratamiento de VIH, independientemente de criterios clínicos o inmunológicos, adoptado por el Ministerio de Salud en 2013, fue ahora simplificado con medicamentos de primera línea más tolerables y con menos interacciones medicamentosas, lo que facilita la implementación de su manejo, incluso en la atención primaria.

Abstract HIV infection is the subject of one of the chapters of the “Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections”, published by the Brazilian Ministry of Health in 2020. It is important that health professionals and managers learn the signs and symptoms of HIV infection and know how to diagnose it, in order to provide appropriate treatment and reduce complications. HIV infection has become a chronic disease and its treatment includes addressing common comorbidities in clinical practice such as arterial hypertension, diabetes and dyslipidemia, in addition to cardiac risk assessment, cancer prevention and guidance on immunization. Initiation of treatment for all HIV patients, regardless of clinical or immunological criteria, adopted by the Ministry of Health since 2013, has now been simplified with more tolerable first-line medications and with fewer drug interactions, which makes its management easy to implement, including by Primary Health Care.

Abstract HIV infection is presented in the chapters of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. Health professionals and managers must learn the signs and symptoms of HIV infection and know how to diagnose it to provide appropriate treatment and reduce complications. HIV infection has become a chronic disease. Its treatment includes addressing common comorbidities such as arterial hypertension, diabetes, and dyslipidemia, in addition to cardiac risk assessment, cancer prevention, and guidance on immunization. Initiation of treatment for HIV patients is recommended regardless of clinical or immunological criteria as adopted by the Ministry of Health since 2013. Lately, it has been simplified with more tolerable first-line medications and fewer drug interactions, making its management easy to implement, including by primary health care.

ABSTRACT The aim of this study was to compare the predictions of Framingham cardiovascular (CV) risk score (FRS) and the American College of Cardiology/American Heart Association (ACC/AHA) risk score in an HIV outpatient clinic in the city of Vitoria, Espirito Santo, Brazil. In a cross-sectional study 341 HIV infected patients over 40 years old consecutively recruited were interviewed. Cohen's kappa coefficient was used to assess agreement between the two algorithms. 61.3% were stratified as low risk by Framingham score, compared with 54% by ACC/AHA score (Spearman correlation 0.845; p < 0.000). Only 26.1% were classified as cardiovascular high risk by Framingham compared to 46% by ACC/AHA score (Kappa = 0.745; p < 0.039). Only one out of eight patients had cardiovascular high risk by Framingham at the time of a myocardial infarction event registered up to five years before the study period. Both cardiovascular risk scores but especially Framingham underestimated high-risk patients in this HIV-infected population.

Abstract This cross-sectional study assessed the immunization status of human immune deficiency virus (HIV)-infected patients receiving care at an outpatient clinic in Brazil. The sociodemographic characteristics, CD4 count and HIV viral load of 281 out of 612 adult outpatients were analyzed. A total of 331 patients were excluded because of no availability of vaccination cards. Chi-square or Fisher's exact test were used. Immunization coverage was higher for diphtheria/tetanus (59.79%) and hepatitis B (56.7%), and lowest for hepatitis A (6.8%) and for meningococcal group C (6%). Only 11.74% of the patients had received the influenza virus vaccine yearly since their HIV-infection diagnosis. No vaccination against influenza (p < 0.034) or hepatitis B (p < 0.029) were associated with CD4 counts <500 cells/mL; no vaccination against flu or pneumococcus were associated with detectable HIV viral load (p < 0.049 and p < 0.002, respectively). Immunization coverage is still very low among HIV-infected adults in this setting despite recommendations and high infection-related mortality.

Abstract Background Development of drug-resistance mutations is the main cause of failure in antiretroviral therapy. In Brazil, there is scarce information on resistance pattern for patients failing antiretroviral therapy. Objectives To define the HIV mutational profile associated with drug resistance in Brazilian patients from 5 large cities, after first, second or further failures to antiretroviral therapy. Methods We reviewed genotyping results of 1520 patients failing therapy in five Brazilian cities. Frequency of mutations, mean number of active drugs, viral susceptibility to each antiretrovirals drug, and regional differences were assessed. Results Mean time of antiretrovirals use was 22.7 ± 41.1 months. Mean pre-genotyping viral load was 4.2 ± 0.8 log (2.1 ± 2.0 after switching antiretrovirals). Mean number of remaining active drugs was 9.4, 9.0, and 7.9 after 1st, 2nd, and 3rd failure, respectively. We detected regional variations in drug susceptibility: while BA and RS showed the highest (∼40%) resistance level to ATV/r, FPV/r and LPV/r, in the remaining cities it was around half of this rate. We detected 90% efavirenz/nevirapine resistance in SP, only 45% in RS, and levels between 25% and 30% in the other cities. Regarding NRTI, we found a similar pattern, with RJ presenting the highest, and CE the lowest susceptibility rates for all NRTI. Zidovudine resistance was detected in only 3% of patients in RJ, against 45–65% in the other cities. RJ and RS showed 3% resistance to tenofovir, while in CE it reached 55%. DRV/r (89–97%) and etravirine (61–85%) were the most active drugs, but again, with a wide variation across cities. Conclusions The resistance mutational profile of Brazilian patients failing antiretroviral therapy is quite variable, depending on the city where patients were tested. This variation likely reflects distinctive choice of antiretrovirals drugs to initiate therapy, adherence to specific drugs, or circulating HIV-1 strains. Overall, etravirine and DRV/r remain as the most active drugs.

Abstract In this study, 275 patients in use of tenofovir were retrospectively followed-up for three years to evaluate risk factors involved in impaired renal function. Analysis of variance (ANOVA) and Tukey's test were used to verify any differences in creatinine levels and estimated clearance at 0, 6, 12, 24 and 36 months, adjusting for the co-variables sex, skin color, age >50 years, arterial hypertension, diabetes and the use of the ritonavir-boosted protease inhibitors (PI/r) lopinavir/r or atazanavir/r. The software package STATISTICA 10® was used for statistical analysis. The patients’ mean age was 43.2 ± 10.7 years. Systemic arterial hypertension (SAH) and diabetes were found in 20.4% and 8.7% of the patients, respectively. Overall, 96.7% were on tenofovir associated with lamivudine (TDF + 3TC), 39.3% on lopinavir/r, 29.8% on efavirenz, and 17.6% on atazanavir/r. There was a statistically significant difference in estimated creatinine clearance at 24 months, when the co-variables male (F = 3.95; p = 0.048), SAH (F = 6.964; p = 0.009), and age over 50 years (F = 45.81; p < 0.001) were taken into consideration. Analysis of the co-variable use of atazanavir/r showed a tendency toward an increased risk over time (F = 2.437; p = 0.063); however, no significant time interaction was seen. At 36-month, a statistically significant difference was found for age over 50 years, (F = 32.02; p < 0.05) and there was a significant time-by-sex interaction (F = 3.117; p = 0.0149). TDF was discontinued in 12 patients, one because of a femoral neck fracture (0.7%) and 11 due to nephrotoxicity (4%). Of these latter cases, 9/11 patients were also using protease inhibitors. These data strongly alert that tenofovir use should be individualized with careful attention to renal function especially in male patients, over 50 years, with SAH, and probably those on ATV/r.

Abstract Presarcopenia and sarcopenia were evaluated in HIV-infected individuals and in healthy elderly controls according to the consensus definitions of the European Working Group on Sarcopenia in Older People. Bioelectrical impedance, a hydraulic hand dynamometer, and gait speed were used to evaluate muscle mass, muscle strength, and physical performance, respectively. Adjusted and unadjusted binary logistic regression predicted the risk of sarcopenia. Predictor contribution was assessed by the Wald test. Significance was established at p ≤ 0.05. The HIV-infected group consisted of 33 patients on treatment (42.4% women; mean age 59 ± 7 years; mean BMI 25 ± 6 kg/m2; viral load undetectable in 30 cases). The HIV-uninfected group consisted of 60 individuals (71.7% women; mean age 70 ± 7 years; mean BMI 28 ± 6 kg/m2). Of the controls, 4 (6.7%) individuals had presarcopenia and 4 (6.7%) sarcopenia compared to 4 (12.1%) and 8 (24.2%), respectively, in the HIV-infected group. The HIV-infected patients had a 4.95 higher risk (95% CI: 1.34–18.23) for sarcopenia compared to the controls. It should be pointed out that the control group was on average 10 years older. This risk increased further (RR = 5.20; 95% CI: 1.40–19.20) after adjusting for age and BMI. HIV-infected patients were shown to be at a greater risk of sarcopenia, an indicator of frailty, even following adjustment for age and BMI.

OBJECTIVE: To evaluate the cumulative incidence of dyslipidemia and fasting glucose impairment three years after initiating the first antiretroviral (ART) regimen and the association with the type of ART regimen in an AIDS outpatient clinic in Brazil. METHODS: Retrospective cohort of HIV-1 infected patients attending an outpatient HIV clinic in Vitoria, Brazil, between January/2010 and May/2011. Data, including blood pressure, dyslipidemia (high total cholesterol and low HDL-C), fasting glucose, and cardiovascular risk by Framingham Risk Score were abstracted from medical records from clinic visits six months prior and three years after starting ART. We assessed independent associated factors for dyslipidemia using multiple logistic regression. RESULTS: Four hundred and ninety-eight patients on ART were studied. Median age was 45 years (interquartile range (IQR): 37-52), and median time since HIV diagnosis was 7.7 years (IQR: 3.8-10.0). The proportion of patients with dyslipidemia was 22.3% (95% CI: 18.6-25.9%) 36 months after ART initiation. Triglycerides levels >150 mg/dL (55.2% vs. 25.4%, p = 0.021) and high fasting glucose (5.8% vs. 2.3%, p = 0.034) were diagnosed more frequently after ART use when compared to baseline values. Multiple logistic regression analysis has shown dyslipidemia to be associated with lopinavir/r use [OR = 1.74 (95% CI: 1.12-2.86)]. CONCLUSION: These data show high chance of dyslipidemia after initiation of ART. Long-term follow-up will help identify the impact of ART on cardiovascular risk.

INTRODUÇÃO: O presente estudo investigou a prevalência de câncer e fatores associados entre pacientes infectados pelo vírus HIV em clínica de AIDS em Vitória, Estado do Espírito Santo, Brasil. MÉTODOS: Um estudo transversal foi conduzido entre pacientes HIV positivos adultos atendidos em serviço especializado em AIDS, em Vitória, Estado do Espírito Santo, Brasil. Dados demográficos, epidemiológicos e clínicos foram coletados de prontuários, inclusive diagnóstico de câncer, contagem de CD4 corrente e a mais baixa, carga viral do HIV, tipo e tempo de tratamento antirretroviral, e tabagismo. RESULTADOS: Um total de 730 (91,3%) pacientes foi incluído no estudo. A mediana de idade foi de 44 anos (Diferença Inter Quartil [DIQ]: 35-50,3), a mediana de período desde diagnóstico de HIV foi de 5,5 anos (DIQ: 2-10), 60% eram homens e 59% eram brancos. Trinta (4,1%) casos de câncer foram identificados, dos quais 16 (53%) eram neoplasias definidoras de AIDS e 14 (47%) eram neoplasias não definidoras de AIDS. Pacientes diagnosticados com câncer apresentavam maior chance de serem fumantes [OR 2,2 (95% CI: 1,04-6,24)], terem nadir de CD4 ≤200 cels/mm³ [OR 3,0 (95% CI: 1,19-7,81)] e maior letalidade [OR 13,3 (95% CI: 4,57-38,72)]. CONCLUSÕES: Estes resultados corroboram a necessidade de rastreamento e prevenção de neoplasias não definidoras de AIDS em nossa população infectada pelo HIV, já que estas já assumem frequência similar às definidoras de AIDS.

INTRODUCTION: The present study investigated cancer prevalence and associated factors among HIV-infected individuals attending an AIDS outpatient clinic in Vitória, State of Espírito Santo, Brazil. METHODS: A sectional study was conducted among HIV infected adults attending an AIDS outpatient clinic in Vitória, State of Espírito Santo, Brazil. Demographic, epidemiological and clinical data were abstracted from medical records, including cancer diagnoses; nadir and current CD4 cell count, HIV viral load, time on antiretroviral treatment (ART), type of ART and smoking status. RESULTS: A total of 730 (91.3%) patients were included in the study. Median age was 44.0 [interquartile range (IQR): 35-50.3] years; median time since HIV diagnosis was 5.5 years (IQR: 2-10); 60% were male; and 59% were white. Thirty (4.1%) cases of cancer were identified of which 16 (53%) were AIDS defining cancers and 14 (47%) were non-AIDS defining malignancies. Patients diagnosed with cancer presented higher chance of being tobacco users [OR 2.2 (95% CI: 1.04-6.24)]; having nadir CD4 ≤200 cells/mm³ [OR 3.0 (95% CI: 1.19-7.81)] and higher lethality [OR 13,3 (95% CI: 4,57-38,72)]. CONCLUSIONS: These results corroborate the importance of screening for and prevention of non-AIDS defining cancers focus in HIV-infected population, as these cancers presented with similar frequency as AIDS defining cancers.

INTRODUÇÃO: A doença renal é uma das principais comorbidades envolvendo pacientes infectados com o HIV, em razão da melhora da sobrevida proporcionada pela terapêutica antirretroviral. O objetivo deste estudo foi detectar fatores de risco, possivelmente correlacionados com função renal alterada, em pacientes infectados pelo HIV. MÉTODOS: Estudo transversal foi realizado em 254 pacientes infectados pelo HIV, atendidos em ambulatório na Santa Casa de Vitória. Eles foram entrevistados e submetidos a coletas de amostras de sangue para contagem de células CD4, quantificação de carga viral do HIV-1, dosagens de glicose, lipídeos e creatinina. A proteinúria foi avaliada em amostra de primeira urina da manhã. A filtração glomerular foi estimada com as fórmulas de modified diet in renal disease (MDRD) simplificada e Cockcroft-Gault. RESULTADOS: Cento e três (40,6%) pacientes tinham alguma anormalidade no exame de urina, sendo proteinúria o achado mais comum (46; 18,1% pacientes). Vinte e cinco (9,8%) pacientes tinham filtração glomerular estimada inferior a 60ml/min/1.73m² de acordo com MDRD. A análise de regressão logística multivariada mostrou que baixa filtração glomerular foi positivamente correlacionada com raça negra [OR 9,6 (IC95% 1,28-23,80)], hipertensão arterial sistêmica [OR 3,3 (IC95% 1,28-23,81)], idade acima de 51 anos [OR 3,3 (IC95%1,11-9,90)], proteinúria [OR 5,2 {IC95% 1,67-16,25}]; hematúria [OR 3,2 (1,12-9,29)] e negativamente com pacientes em uso de zidovudina [OR 0,2 (0,04-0,78)]. CONCLUSÕES: Os fatores de risco tradicionais para doença renal como raça negra, hipertensão arterial e idade avançada foram correlacionados com menor filtração glomerular estimada em nossos pacientes.

INTRODUCTION: Renal disease has emerged as one of the primary comorbid conditions affecting HIV-infected patients, mainly because antiretroviral therapy has improved survival. This study aimed to detect risk factors possibly associated with altered renal function in HIV-infected patients. METHODS: A cross-sectional study was conducted involving 254 HIV-infected patients attending an outpatient clinic at Santa Casa de Vitoria< They were interviewed and blood samples were collected for CD4 cell counts, HIV-1 viral load, glucose, lipids and creatinine measurements. Urine protein was evaluated in the first voiding urine sample. Glomerular filtration was estimated by simplified modified diet in renal disease (MDRD) and Cockcroft-Gault formulas. RESULTS: One hundred and three (40.6%) patients presented some urinary abnormality, and proteinuria was the most common finding (46; 18.1% patients). Twenty-five (9.8%) patients showed estimated glomerular filtration below 60ml/min/1.73m² by MDRD. Multivariate logistic regression showed that low glomerular filtration was positively correlated with black race [OR 9.6 (IC95% 1.28-23.80)], arterial hypertension [OR 3.3 (IC95% 1.28-23.81)], age over fifty-one years-old [OR 3.3 (IC95%1.11-9.90)], proteinuria [OR 5.2 {IC95% 1.67-16.25}]; hematuria [OR 3.2 (1.12-9.29)] and negatively correlated with patients using zidovudine [OR 0.2 (0.04-0.78)]. CONCLUSIONS: Traditional risk factors for renal disease, such as black race, arterial hypertension and advancing age were correlated with low estimated glomerular filtration in the present patient sample.

A polineuropatia desmielinizante inflamatória cônica possui forte associação com a infecção pelo HIV e HCV. Uma rara associação entre PDIC e o tratamento da hepatite C com interferon peguilado alfa foi descrita recentemente. Nós descrevemos o primeiro caso de polineuropatia desmielinizante inflamatória crônica em um paciente branco, sexo masculino infectado por HIV e HCV associado a interferon peguilado alfa 2b. O paciente recuperou-se completamente após o uso de imunoglobulina hiperimune endovenosa. Infectologistas e hapatologistas devem estar atentos à esta rara e grave associação, que exige imediata descontinuação da droga e tratamento precoce.

Chronic inflammatory demyelinating polyneuropathy has a strong association with HIV and HCV infection. A rare association between chronic inflammatory demyelinating polyneuropathy and hepatitis C treatment with pegylated interferon alpha was described recently. We described the first case of chronic inflammatory demyelinating polyneuropathy associated with pegylated interferon alpha 2b in a white man infected with HIV and HCV. The patient recovered completely with the use of intravenous hyperimmune immunoglobulin. Infectologists and hepatologists should be alert regarding this rare and serious association, which requires immediately drug discontinuation and early treatment.

Genetic variability of human immunodeficiency virus type - 1(HIV-1) is a potential threat for both diagnosis and treatment of HIV/AIDS, as well as the development of effective vaccines. Up to now, HIV subtypes circulating among HIV-positive patients in the state of Espírito Santo were not known. In the present study, blood samples from 100 therapy-naïve HIV-1 infected patients were collected and the HIV subtype was determined through the Heteroduplex Mobility Assay (HMA). Ninety-seven out of 100 studied samples were subtyped by HMA, 73 samples (75.2%) were from subtype B, 9 (9.3%) from subtype F, 3 (3.1%) from subtype C, 6 (6.2%) Benv/Fgag, and another 6 (6.2%) Fenv/Bgag, what suggests that recombinant viruses were present in the studied samples. Twenty-eight percent of the subtype B samples were represented by the Brazilian B" subtype, which were identified by RFLP with Fok I. Data presented here demonstrate that the epidemiological characteristics of the HIV epidemic in the state of Espírito Santo are similar to those from the other Southeastern states and helped to better understand the genetic polymorphism of HIV in Brazil.

We analyzed the first 96 patients tested for HIV resistance to antiretroviral therapy in three Brazilian states. The HIV-1 reverse transcriptase (RT) and protease (PR) were sequenced by using the ABI ViroSeq system. The drugs previously used for each patient were recorded and correlated with the mutations found in the samples. Viral load (VL) and CD4 count were also recorded. Only one patient had the wild type sequence. The most prevalent mutations were: 184V (59%), 41L (47.9%), 63P (53%), 215Y (50%), 36I (46%), 10I (35%), 67N (42%), 77I (37%), 90M (36%) and 210W (33%). A positive correlation between the number of previously used ARVs and the number of mutations was observed (p<0.05). Associations between mutations and ARV drugs were identified at positions 69, 118, 184 and 215 with previous exposure to NRTI, mutations at positions 98, 100, 103, 181 and 190 with previous NNRTI use and at positions 10, 20, 30, 46, 53, 54, 71, 73, 82, 84, 88 and 90 with previous PI therapy (p<0.05). Previous exposure to ARV drugs was associated with previous genotypic resistance to specific drugs, leading to treatment failure in HIV patients. Genotypic resistance was clearly associated with virological and immunological failure.