Beatriz Grinsztejn

Instituto Evandro Chagas, Ananindeua, Pará, Brazil

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Publications (134)658.64 Total impact

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    ABSTRACT: Background. HIV-infected women are disproportionately affected by human papillomavirus (HPV)-related anogenital disease, particularly with increased immunosuppression. A5240 was a trial of 319 HIV-infected women in US, Brazil and South Africa to determine immunogenicity and safety of the quadrivalent HPV vaccine in 3 strata based on screening CD4: >350 (A), >200to350 (B), ≤200 cells/mm(3) (C). Methods. Safety and serostatus of HPV types 6, 11, 16, and 18 were examined. HPV serological testing was performed using competitive Luminex Immuno-Assay (HPV-4 cLIA). HPV type-specific seroconversion analysis was on participants who were seronegative for the given type at baseline. Results. Median age was 36 years, 11% were white, 56% black, 31% Hispanic. Median CD4 was 310 cells/mm(3), 40% had undetectable HIV-1 viral load. No safety issues were identified. Seroconversion proportions at week 28 among women in CD4 stratum A were 96%, 98%, 99%, and 91% for HPV types 6, 11,16, and 18 respectively; in stratum B 100% 98%, 98%, and 85% and in stratum C 84%, 92%, 93%, 75% for each type respectively. Conclusion. Quadrivalent HPV vaccine targeted at types 6, 11, 16, and 18 was safe and immunogenic in HIV-infected women 13-45 years old. Women with HIV viral load >10,000 copies/mL and/or CD4 counts <200 cells/mm&sup3; had lower seroconversion.
    Clinical Infectious Diseases 04/2014; · 9.37 Impact Factor
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    ABSTRACT: Concurrent treatment of HIV and tuberculosis is complicated by drug interactions. We explored the safety and efficacy of raltegravir as an alternative to efavirenz for patients co-infected with HIV and tuberculosis. We did a multicentre, phase 2, non-comparative, open-label, randomised trial at eight sites in Brazil and France. Using a computer-generated randomisation sequence, we randomly allocated antiretroviral-naive adult patients with HIV-1 and tuberculosis (aged ≤18 years with a plasma HIV RNA concentration of >1000 copies per mL) to receive raltegravir 400 mg twice a day, raltegravir 800 mg twice daily, or efavirenz 600 mg once daily plus tenofovir and lamivudine (1:1:1; stratified by country). Patients began study treatment after the start of tuberculosis treatment. The primary endpoint was virological suppression at 24 weeks (HIV RNA <50 copies per mL) in all patients who received at least one dose of study drug (modified intention-to-treat analysis). We recorded death, study drug discontinuation, and loss to follow-up as failures to achieve the primary endpoint. We assessed safety in all patients who received study drugs. This study is registered in ClinicalTrials.gov, number NCT00822315. Between July 3, 2009, and June 6, 2011, we enrolled and randomly assigned treatment to 155 individuals; 153 (51 in each group) received at least one dose of the study drug and were included in the primary analysis. 133 patients (87%) completed follow-up at week 48. At week 24, virological suppression was achieved in 39 patients (76%, 95% CI 65-88) in the raltegravir 400 mg group, 40 patients (78%, 67-90) in the raltegravir 800 mg group, and 32 patients (63%, 49-76) in the efavirenz group. The adverse-event profile was much the same across the three groups. Three (6%) patients allocated to efavirenz and three (6%) patients allocated to raltegravir 800 mg twice daily discontinued the study drugs due to adverse events. Seven patients died during the study (one in the raltegravir 400 mg group, four in the raltegravir 800 mg group, and two in the efavirenz group): none of the deaths was deemed related to study treatment. Raltegravir 400 mg twice daily might be an alternative to efavirenz for the treatment of patients co-infected with HIV and tuberculosis. French National Agency for Research on AIDS and Viral Hepatitis (ANRS), Brazilian National STD/AIDS Program-Ministry of Health.
    The Lancet Infectious Diseases 04/2014; · 19.97 Impact Factor
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    ABSTRACT: Increasing access and frequency of human immunodeficiency virus testing are critical to stemming the human immunodeficiency virus epidemic. In Brazil's concentrated epidemic, human immunodeficiency virus prevalence in the men who have sex with men/transgender population far exceeds that in the general population, but testing rates fall below what is needed to ensure early detection and treatment. Over-the-counter human immunodeficiency virus self-testing kits, now available in stores in the U.S., have enormous potential to facilitate human immunodeficiency virus testing access and frequency and to facilitate early detection and treatment. With the advent of human immunodeficiency virus self-testing upon us, it is timely to engage the scientific community, government, and civil society in a dialog around how to best utilize this technology in Brazil. We summarize recent research on over-the-counter testing among men who have sex with men, raise potential questions and challenges to using self-tests, suggest implementation strategies, and outline a research agenda moving forward.
    The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 04/2014; · 0.55 Impact Factor
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    ABSTRACT: Lopinavir/ritonavir (LPV/r) based regimen is recommended during pregnancy to reduce the risk of HIV mother-to-child transmission, but the appropriate dose is controversial. We compared the pharmacokinetics of standard and increased LPV/r doses during pregnancy. This randomized, open-label prospective study enrolled 60 HIV-infected pregnant women between gestational weeks 14 and 30. Participants received either the standard (400/100 mg BID) or increased dose (600/150 mg BID) of LPV/r tablets during pregnancy and the standard dose for six weeks after childbirth. Pharmacokinetic analysis was performed using a high-performance liquid chromatography-tandem mass spectrometry method. Adherent participants who received the standard dose presented minimum LPV concentrations of 4.4, 4.3 and 6.1μg/mL in the second and the third trimesters and postpartum, respectively. The increased dose group exhibited values of 7.9, 6.9 and 9.2 μg/mL at the same timepoints. Although LPV exposure was significantly higher in the increased dose group, the standard dose produced therapeutic levels of LPV against wild-type virus in all adherent participants, except one patient in the third trimester; 50%, 37.5%, 25% and 0%, 15%, 0% of the participants in the standard and increased dose groups, respectively, failed to achieve therapeutic levels against resistant viruses during the second and third trimesters and after childbirth. After 12 weeks of treatment and after childbirth, all adherent participants achieved undetectable HIV viral loads, and their babies (49/54) were uninfected. No serious drug-related adverse events were observed. We conclude that the standard dose is appropriate for use during pregnancy and an increased dose may be necessary for women harboring resistant HIV (clinicaltrials.gov identifier NCT00605098).
    Antimicrobial Agents and Chemotherapy 03/2014; · 4.57 Impact Factor
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    ABSTRACT: This study aimed to assess the prevalence of, and associated factors with, anal intraepithelial neoplasia (AIN) among HIV-positive men evaluated at public health services in Brazil. This is a multicenter cross-sectional study of HIV-positive male patients attending 6 public AIDS referral clinics in urban Brazil. Participants were interviewed for sociodemographic and behavioral characteristics. Anal swab specimens were collected for anal cytology and HPV DNA testing using L1 polymerase chain reaction. Univariate and multivariate analyses were performed to evaluate risk factors associated with the presence of low-grade squamous intraepithelial lesion (LSIL) and/or high-grade squamous intraepithelial lesion (HSIL). Anal swabs were collected from 343 participants. Prevalence of LSIL/HSIL was 24.8%. The majority (60.1%) reported sexual intercourse with both men and women in their lifetime. At least 36.7% had 1 or more oncogenic HPV types. Four variables were independently associated with the presence of LSIL/HSIL in multivariate analysis: history of sex with both men and women (odds ratio [OR] = 4.8) or men only (OR = 6.2) compared with those having sex with women only; current cigarette smoking (OR = 2.2); current CD4 level between 200 and 500 cells/mm (OR = 2.9) or below 200 cells/mm (OR = 3.8) compared with CD4 level above 500 cells/mm; and presence of oncogenic anal HPV infection (OR = 9.6). We found a high prevalence of AIN among HIV-positive men in Brazil. This population may serve as an important bridge population to women with implications for anogenital HPV infection in both men and women. Our findings confirm the need to assess screening programs for AIN among high-risk groups, similar to those used to prevent cervical cancer.
    Journal of Lower Genital Tract Disease 02/2014; · 1.21 Impact Factor
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    ABSTRACT: Reliable information on severe morbidity is essential for identifying priorities for case management and to guide resource allocation within the health sector. This study describes overall, AIDS and non-AIDS related severe morbidity as well as mortality and its determinants in an urban cohort of HIV-infected individuals from a public health care institution, the Evandro Chagas Research Institute (IPEC) of the Oswaldo Cruz Foundation in Rio de Janeiro, Brazil. Severe morbid events were defined as all clinical diagnoses listed in hospitalization discharge records; all diagnoses were checked and validated. Generalized estimating equations models were used to estimate incidence rates while adjusting for within subject correlation. Between 2000 and 2010, 3537 patients were followed for a total of 16960 person-years (PY) of follow-up. Over the years, annual incidence rate of severe morbid events, AIDS-related events, non-AIDS related events, and deaths significantly decreased from, respectively, 36.6, 12.9, 23.7, and 3.2 per 100PY in 2000 to 25.3, 7.9, 17.4, and 1.9 per 100PY in 2010. Patients' immunological profile significantly improved with time; 84% of the patients used antiretroviral therapy (cART) per year. Immunodeficiency was associated with a higher incidence rate of AIDS and non-AIDS related events as well as with the incidence rate of specific non-AIDS events (bacterial infections, toxicities, cardiovascular, renal and respiratory diseases). Our results show that in a middle income country with access to cART, non-AIDS-related events represent an important cause of severe morbidity alongside a still high incidence rate of AIDS-related events.
    Antiviral therapy 01/2014; · 3.07 Impact Factor
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    ABSTRACT: The remarkable viral diversity remains a big challenge to the development of HIV vaccines and optimal therapy worldwide. In the latest years, as a consequence of the large expansion of highly active antiretroviral therapy (HAART) availability worldwide, an increase in transmitted drug resistance mutations (TDRM) has been observed, varying according the region. This study assessed HIV-1 diversity and TDRM profile over time among newly HIV-1 diagnosed individuals from Rio de Janeiro, Brazil. Blood samples were collected from individuals seeking HIV diagnosis in four voluntary counseling and testing (VCTs) sites located in the Rio de Janeiro Metropolitan Area, in 2005-2007. Recent (RS) and long-term (LTS) HIV-1 seroconverters were distinguished using BED-CEIA. Pol viral sequences were obtained for 102 LTS identified in 2005 and 144 RS from 2005-2007. HIV-1 subtype and pol recombinant genomes were determined using Rega HIV-1 Subtyping Tool and by phylogenetic inferences and bootscanning analyses. Surveillance of HIV-1 TDRM to protease and reverse transcriptase inhibitors were performed according to the Calibrated Population Resistance (CPR) Tool 6.0. Overall, subtype B remains the most prevalent in Rio de Janeiro in both LTS and RS HIV-1 infected individuals. An increased proportion of recombinant samples was detected over time, especially in RS heterosexual men, due to the emergence of CRF02_AG and URF samples bearing a subtype K fragment. The prevalence of HIV-1 samples carrying TDRM was high and similar between LTS and RS (15.7% vs 14.6%) or age (<25yo 17.9% vs >25yo 16.6%) along the study period. The high resistance levels detected in both populations are of concern, especially considering the dynamics of HIV-1 diversity over time. Our results suggest that the incorporation of resistance testing prior to HAART initiation should be highly considered, as well as permanent surveillance, aiming to carefully monitoring HIV-1 diversity, with focus on CRF/URF emergence and putative transmission.
    PLoS ONE 01/2014; 9(1):e87622. · 3.73 Impact Factor
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    ABSTRACT: To describe the access to the interventions for the prevention of HIV mother to child transmission and mother to child transmission rates in the outskirts of Rio de Janeiro, from 1999 to 2009. This is a retrospective cohort study. Prevention of HIV mother to child transmission interventions were accessed and mother to child transmission rates were calculated. The study population is young (median: 26 years; interquartile range: 22.0-31.0), with low monthly family income (40.4% up to one Brazilian minimum wage) and schooling (62.1% less than 8 years). Only 47.1% (n=469) knew the HIV status of their partner; of these women, 39.9% had an HIV-seronegative partner. Among the 1259 newborns evaluated, access to the antenatal, intrapartum and postpartum prevention of HIV mother to child transmission components occurred in 59.2%, 74.2%, and 97.5% respectively; 91.0% of the newborns were not breastfed. Overall 52.7% of the newborns have benefited from all the recommended interventions. In subsequent pregnancies (n=289), 67.8% of the newborns received the full package of interventions. The overall rate of HIV vertical transmission was 4.7% and the highest annual rate occurred in 2005 (7.4%), with no definite trend in the period. Access to the full package of interventions for the prevention of HIV vertical transmission was low, with no significant trend of improvement over the years. The vertical transmission rates observed were higher than those found in reference services in the municipality of Rio de Janeiro and in the richest regions of the country.
    The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 01/2014; · 0.55 Impact Factor
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    ABSTRACT: To compare the effectiveness of first-line combination antiretroviral therapy (cART) between premenopausal and postmenopausal women. ART-naïve women initiating cART between January 2000/June 2010 at the Instituto de Pesquisa Clínica Evandro Chagas Cohort were studied. Women were defined as postmenopausal after 12 consecutive months of amenorrhea. CD4 cell counts and HIV-1 RNA viral load (VL) measurements were compared between pre- and postmenopausal at 6, 12 and 24 months after cART initiation. Women who modified/discontinued a drug class or died due to an AIDS defining illness were classified as ART-failures. Variables were compared using Wilcoxon test, χ2 or Fisher's exact test. The odds of cART effectiveness (VL<400 copies/mL and/or no need to change cART) were compared using logistic regression. Linear model was used to access relationship between CD4 change and menopause. Among 383 women, 328 (85%) were premenopausal and 55 (15%) postmenopausal. Median pre cART CD4 counts were 231 and 208 cells/mm(3) (p = 0.14) in pre- and postmenopausal women, respectively. No difference in the median pre cART VL was found (both 4.8 copies/mL). Median CD4 changes were similar at 6 and 12 months. At 24 months after cART initiation, CD4 changes among postmenopausal women were significantly lower among premenopausal women (p = 0.01). When the analysis was restricted to women with VL<400 copies/mL, no statistical difference was observed. Overall, 63.7% achieved cART effectiveness at 24 months without differences between groups at 6, 12 and 24 months. Menopause status at the time of first-line cART initiation does not impact CD4 cell changes at 24 months among women with a virologic response. No relationship between menopause status and virologic response was observed.
    PLoS ONE 01/2014; 9(2):e89299. · 3.73 Impact Factor
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    ABSTRACT: Increasing access and frequency of human immunodeficiency virus testing are critical to stemming the human immunodeficiency virus epidemic. In Brazil's concentrated epidemic, human immunodeficiency virus prevalence in the men who have sex with men/transgender population far exceeds that in the general population, but testing rates fall below what is needed to ensure early detection and treatment. Over-the-counter human immunodeficiency virus self-testing kits, now available in stores in the U.S., have enormous potential to facilitate human immunodeficiency virus testing access and frequency and to facilitate early detection and treatment. With the advent of human immunodeficiency virus self-testing upon us, it is timely to engage the scientific community, government, and civil society in a dialog around how to best utilize this technology in Brazil. We summarize recent research on over-the-counter testing among men who have sex with men, raise potential questions and challenges to using self-tests, suggest implementation strategies, and outline a research agenda moving forward.
    The Brazilian Journal of Infectious Diseases. 01/2014;
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    ABSTRACT: Mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) infection remains an important cause of new HIV infections worldwide, especially in low and middle-resource limited countries. Safety data from studies involving pregnant women and prenatal antiretroviral (ARV) exposure are still needed once these studies are often small and with a limited duration to assess adverse drug reactions (ADR). The aim of this study was to estimate the incidence of ADR related to the use of antiretroviral therapy (ART) in pregnant women in two referral centers in Rio de Janeiro State. A prospective study was carried out from February 2005 to May 2006. Women were classified according to their ART status during pregnancy diagnosis: ARV-experienced (ARTexp) or ARV-naïve (ARTn). Two hundred fourteen HIV-infected pregnant women were included: 36 ARTexp and 178 ARTn. ARTexp women have not experienced ADR. Among ARTn, 20.2% presented ADR. Incidence rate of ADR was 70.8 per 1000 person-months and the most common ADRs observed were: gastrointestinal (belly or abdominal cramps, diarrhea, nausea and vomit) in 16.3%, cutaneous (pruritus and rash) in 6.2%, anemia (2.2%) and hepatitis (1.7%). The frequency of obstetrical complications, pre-term delivery, low birth weight and birth abnormalities was low in this population. ADRs ranged from mild to moderate intensity, none of them being potentially fatal. Only in a few cases it was necessary to discontinue ART. In conclusion, the high effectiveness of ARV for HIV PMTCT overcomes the risk of ADR.
    The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 01/2014; · 0.55 Impact Factor
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    ABSTRACT: After antiretroviral therapy (ART) became available, there was a decline in the number of deaths in persons infected with HIV. Thereafter, there was a decrease in the proportion of deaths attributed to opportunistic infections and an increase in the proportion of deaths attributed to chronic comorbidities. Herein we extend previous observations from a nationwide survey on temporal trends in causes of death in HIV-infected patients in Brazil. We describe temporal trends in causes of death among adults who had HIV/AIDS listed in the death certificate to those who did not. All death certificates issued in Brazil from 1999 to 2011 and listed in the national mortality database were included. Generalized linear mixed-effects logistic models were used to study temporal trends in proportions. In the HIV-infected population, there was an annual adjusted average increase of 6.0%, 12.0%, 4.0% and 4.1% for cancer, external causes, cardiovascular diseases (CVD) and diabetes mellitus (DM), respectively, compared to 3.0%, 4.0%, 1.0% and 3.9%, in the non-HIV group. For tuberculosis (TB), there was an adjusted average increase of 0.3%/year and a decrease of 3.0%/year in the HIV and the non-HIV groups, respectively. Compared to 1999, the odds ratio (OR) for cancer, external causes, CVD, DM, or TB in the HIV group were, respectively, 2.31, 4.17, 1.76, 2.27 and 1.02, while for the non-HIV group, the corresponding OR were 1.31, 1.63, 1.14, 1.62 and 0.67. Interactions between year as a continuous or categorical variable and HIV were significant (p<0.001) for all conditions, except for DM when year was considered as a continuous variable (p = 0.76). Non HIV-related co-morbidities continue to increase more rapidly as causes of death among HIV-infected individuals than in those without HIV infection, highlighting the need for targeting prevention measures and surveillance for chronic diseases among those patients.
    PLoS ONE 01/2014; 9(4):e94636. · 3.73 Impact Factor
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    ABSTRACT: With the introduction of combined active antiretroviral therapy and the improved survival of HIV-infected patients, degenerative diseases and drug toxicity have emerged as long-term concerns. We studied the prevalence of decreased glomerular filtration rate (GFR) and associated risk factors in a cohort of HIV-infected patients from a middle-income country. Our cross-sectional study included all adult patients who attended an urban outpatient clinic in 2008. GFR was estimated using the CKD-EPI equation. The prevalence ratio (PR) of decreased GFR (defined as <60 mL/min/1.73 m2) was estimated using generalizing linear models assuming a Poisson distribution. We analyzed data from 1,970 patients, of which 82.9% had been exposed to ART. A total of 249 patients (12.6%) had a GFR between 60 and 89 mL/min/1.73 m2, 3.1% had a GFR between 30 and 59, 0.3% had a GFR between 15 and 29, and 0.4% had a GFR <15. Decreased GFR was found in only 74 patients (3.8%). In the multivariate regression model, the factors that were independently associated with a GFR below 60 mL/min/1.73 m2 were as follows: age ≥50 years (PR = 3.4; 95% CI: 1.7-6.8), diabetes (PR = 2.0; 95% CI: 1.2-3.4), hypertension (PR = 2.0; 95% CI: 1.3-3.2), current CD4+ cell count <350 cells/mm3 (PR = 2.1; 95% CI: 1.3-3.3), past exposure to tenofovir (PR = 4.7; 95% CI: 2.3-9.4) and past exposure to indinavir (PR = 1.7; 95% CI: 1.0-2.8). As in high-income countries, CKD was the predominant form of kidney involvement among HIV-infected individuals in our setting. The risk factors associated with decreased glomerular filtration were broad and included virus-related factors as well as degenerative and nephrotoxic factors. Despite the potential for nephrotoxicity associated with some antiretroviral drugs, in the short-term, advanced chronic renal disease remains very rare.
    PLoS ONE 01/2014; 9(4):e93748. · 3.73 Impact Factor
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    ABSTRACT: Background Concurrent treatment of HIV and tuberculosis is complicated by drug interactions. We explored the safety and efficacy of raltegravir as an alternative to efavirenz for patients co-infected with HIV and tuberculosis. Methods We did a multicentre, phase 2, non-comparative, open-label, randomised trial at eight sites in Brazil and France. Using a computer-generated randomisation sequence, we randomly allocated antiretroviral-naive adult patients with HIV-1 and tuberculosis (aged ≤18 years with a plasma HIV RNA concentration of >1000 copies per mL) to receive raltegravir 400 mg twice a day, raltegravir 800 mg twice daily, or efavirenz 600 mg once daily plus tenofovir and lamivudine (1:1:1; stratified by country). Patients began study treatment after the start of tuberculosis treatment. The primary endpoint was virological suppression at 24 weeks (HIV RNA <50 copies per mL) in all patients who received at least one dose of study drug (modified intention-to-treat analysis). We recorded death, study drug discontinuation, and loss to follow-up as failures to achieve the primary endpoint. We assessed safety in all patients who received study drugs. This study is registered in ClinicalTrials.gov, number NCT00822315. Findings Between July 3, 2009, and June 6, 2011, we enrolled and randomly assigned treatment to 155 individuals; 153 (51 in each group) received at least one dose of the study drug and were included in the primary analysis. 133 patients (87%) completed follow-up at week 48. At week 24, virological suppression was achieved in 39 patients (76%, 95% CI 65–88) in the raltegravir 400 mg group, 40 patients (78%, 67–90) in the raltegravir 800 mg group, and 32 patients (63%, 49–76) in the efavirenz group. The adverse-event profile was much the same across the three groups. Three (6%) patients allocated to efavirenz and three (6%) patients allocated to raltegravir 800 mg twice daily discontinued the study drugs due to adverse events. Seven patients died during the study (one in the raltegravir 400 mg group, four in the raltegravir 800 mg group, and two in the efavirenz group): none of the deaths was deemed related to study treatment. Interpretation Raltegravir 400 mg twice daily might be an alternative to efavirenz for the treatment of patients co-infected with HIV and tuberculosis. Funding French National Agency for Research on AIDS and Viral Hepatitis (ANRS), Brazilian National STD/AIDS Program-Ministry of Health.
    01/2014;
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    ABSTRACT: There is a continuous debate on how to adequately evaluate long-term CD4+ cell count in response to combination antiretroviral therapy (ART) among human immunodeficiency virus (HIV)-infected individuals. Our study evaluated the long-term CD4+ cell count response (up to ten years) after initiation of ART and described the differences in the CD4+ cell count response stratified by pretreatment CD4+ cell count, and other socio-demographic, behavioral, and clinical factors. The study population included patients starting ART in the clinical cohorts of Rio de Janeiro, Brazil, and Baltimore, United States. Inverse probability of censoring weighting was used to estimate mean annual CD4+ cell counts while adjusting for choice of initial ART regimen, ART discontinuation and losses-to-follow-up. From 1997 to 2011, 3116 individuals started ART; preferred initial regimen was NNRTI-based (63%). The median follow-up time was 5 years, 10% of the individuals had nine or more years of follow-up. Observed CD4+ cell counts increased throughout the ten years of follow-up. Weighted results, in contrast, increased up to year four and plateaued thereafter with 50% of the population reaching CD4+ cell counts of 449/μL or more. Out of all stratification variables considered, only individuals with pre-treatment CD4+ cell counts ≥350/μL showed increasing CD4+ cell counts over time with 76% surpassing the CD4+ cell count >500/μL threshold at year ten. The present study corroborates the growing body of knowledge advocating early start of ART by showing that only patients who start ART early fully recover to normal CD4+ cell counts.
    PLoS ONE 01/2014; 9(4):e93039. · 3.73 Impact Factor
  • Raquel De Boni, Valdilea Veloso, Beatriz Grinsztejn
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    ABSTRACT: The aim of the present review is to update HIV/AIDS Epidemiology in Latin America and the Caribbean highlighting the concentrated aspect of epidemic in the region. Among general population, HIV prevalence in Latin America is at stable levels (0.2-0.7%). The Caribbean still has one of the highest HIV prevalence rates in the world (<0.1-3%), but incidences have declined around 49%. This is not the current situation for high-risk key populations; most incident cases occur among MSM. Available data on transgender women suggest that they are the most-at-risk group. Female sex workers still have a 12-fold the chance of being HIV positive compared with other women. IDU prevalence was revised to 0.45%, but non-IDU has been suggested as a mediator between sexual risk and HIV. The increase in treatment coverage (mean is at 63%) resulted in modifications of HIV/AIDS epidemiology. New strategies to seek, test and link key populations to care are urgently needed and targeted interventions to prevent HIV expansion among them must be adopted. These strategies should consider the particular situation regarding social inequalities, discrimination and violence that pervade the HIV epidemic among key populations.
    Current opinion in HIV and AIDS 12/2013; · 4.75 Impact Factor
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    ABSTRACT: The natural history of HIV infection has changed dramatically after the introduction of highly active antiretroviral therapy. Currently, opportunistic illnesses still represent a major cause of death and hospitalization in this population. In this study, we review the trends in opportunistic illnesses incidence rates and compare the results observed in high-income settings with that for low/middle income settings, with special attention given to studies from Brazil. We systematically searched Pubmed, Web of Science, Lilacs and Google scholar for publications on HIV associated opportunistic illness. Studies reporting rates based on person-time for all opportunistic illnesses and/or the three opportunistic infections of interest, namely, Pneumocystis carinii pneumonia, cerebral toxoplasmosis, and Mycobacterium avium complex were included. Significant reductions in the incidence rates were demonstrated for opportunistic illnesses overall and also for the specific opportunistic infections included in the present study, both in high and low/middle income settings. Out of the 37 studies included in the present review, almost 70% were from high-income settings. All the studies conducted in low/middle income settings were single center studies and four were from Brazil. We found no study from Brazil reporting annual incidence rates of opportunistic illnesses. Opportunistic illnesses remain an important public health problem. To better guide health policies in low/middle income settings (LMIS), multicenter cohort studies should be encouraged. Studies from Brazil are urgently needed to assess the current burden of opportunistic illnesses in our population and to support the planning of HIV/AIDS health care services organization.
    The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 11/2013; · 0.55 Impact Factor
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    ABSTRACT: Toxicity is the most frequently reported reason for modifying or discontinuing the first combined antiretroviral therapy regimens, and it can cause significant morbidity, poor quality of life and also can be an important barrier to adherence, ultimately resulting in treatment failure and viral resistance. Elderly patients with HIV/AIDS (≥50 years) may have a different profile in terms of treatment modification due to higher incidence of comorbidities and polypharmacy. The aim of this study was to describe the incidence of modifying or discontinuing first combined antiretroviral therapy regimen due to toxicity (TOX-MOD) during the first year of treatment at the IPEC - FIOCRUZ HIV/AIDS cohort, Rio de Janeiro, Brazil, stratified by age. Demographic, clinical and treatment characteristics from antiretroviral-naïve patients who first received combined antiretroviral therapy between Jan/1996 and Dec/2010 were collected. Incidence rate and confidence interval of each event were estimated using quasipoisson model. To estimate hazard ratio (HR) of TOX-MOD during the first year of combined antiretroviral therapy Cox's proportional hazards regression was applied. Overall, 1558 patients were included; 957 (61.4%), 420 (27.0%) and 181 (11.6%) were aged <40, 40-49, and ≥50 years, respectively. 239 (15.3%) events that led to any modifying or discontinuing within the first year of treatment were observed; 228 (95.4%) of these were TOX-MOD, corresponding to an incidence rate of 16.6/100 PY (95% CI: 14.6-18.9). The most frequent TOX-MOD during first combined antiretroviral therapy regimen were hematologic (59; 26.3%), central nervous system (47; 20.9%), rash (42; 19.1%) and gastrointestinal (GI) (38; 16.7%). In multivariate analysis, incidence ratio of TOX-MOD during the first year of combined antiretroviral therapy progressively increases with age, albeit not reaching statistical significance. This profile was maintained after adjusting the model for sex, combined antiretroviral therapy regimen and year of combined antiretroviral therapy initiation. These results are important because not only patients are living longer and aging with HIV, but also new diagnoses are being made among the elderly. Prospective studies are needed to evaluate the safety profile of first line combined antiretroviral therapy on elderly individuals, especially in resource-limited countries, where initial regimens are mostly NNRTI-based.
    The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases 09/2013; · 0.55 Impact Factor
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    ABSTRACT: The HIV Prevention Trials Network (HPTN) 052 enrolled serodiscordant couples. HIV-infected index participants reported no prior antiretroviral (ARV) treatment at enrollment. ARV drug testing was performed retrospectively using enrollment samples from a subset of index participants. ARV drugs were detected in 45/96 (46.9%) participants with undetectable viral load (VL), 2/48 (4.2%) participants with low VL, and 1/65 (1.5%) participants with high VL (P<0.0001). ARV drugs were also detected in follow-up samples from participants who were not on study-administered treatment. ARV drug testing may be useful in addition to self-report of ARV drug use in some clinical trial settings.
    The Journal of Infectious Diseases 08/2013; · 5.85 Impact Factor
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    ABSTRACT: HIV-associated neurocognitive disorders (HAND) remain prevalent in highly active antiretroviral therapy (HAART) era. Tests to detect HAND are needed for early diagnosis and treatment. Validity of International HIV Dementia Scale (IHDS) has been determined in different countries. The aims of this study were validate IHDS in a Brazilian cohort of HIV-patients and verify if IHDS can be reliably administered by a non-clinician health professional. One hundred and eighty-seven (187) patients were submitted to a full neuropsychological assessment. IHDS was administered twice to each patient (by a non-clinician and by a neurologist). HAND was diagnosed in 98 individuals (68 on HAART). IHDS had sensitivity of 55% and specificity of 80%. IHDS had fair agreement with neuropsychological tests (k 0.355) and moderate-to-strong agreement between different evaluators (interclass correlation coefficient (ICC) 0.684). HAND is prevalent nowadays. IHDS is quick and easy to administer, but has marginal sensitivity for the detection of HIV cognitive impairment other than dementia.
    Arquivos de neuro-psiquiatria 06/2013; 71(6). · 0.55 Impact Factor

Publication Stats

3k Citations
658.64 Total Impact Points

Institutions

  • 1997–2014
    • Instituto Evandro Chagas
      • Laboratório de Pesquisa Clínica em DST/Aids
      Ananindeua, Pará, Brazil
  • 1998–2012
    • Fundação Oswaldo Cruz
      • • Laboratório de Aids e Imunologia Molecular (IOC)
      • • National Institute of Infectology (IPEC)
      • • Departamento de Imunologia
      Rio de Janeiro, Rio de Janeiro, Brazil
  • 2011
    • Wake Forest School of Medicine
      Winston-Salem, North Carolina, United States
    • Hospital Federal dos Servidores do Estado
      Rio de Janeiro, Rio de Janeiro, Brazil
    • Paris Diderot University
      Lutetia Parisorum, Île-de-France, France
  • 2009
    • Chelsea and Westminster Hospital NHS Foundation Trust
      Londinium, England, United Kingdom