A research report submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine in the branch of Diagnostic Radiology Johannesburg, 2013 / INTRODUCTION: There is limited information on the radiographic presentation of children eligible to start HAART in resource-limited settings. OBJECTIVES: Determine radiographic patterns on pre-HAART chest X-rays (CXRs) in children, compare findings in immune-suppressed vs. non immune-suppressed children, compare the percentage of children with radiographic features of pulmonary TB to the percentage of children on TB treatment and assess inter-observer agreement between 3 radiologists. METHODS: Children (0-8 years) participating in a cohort study of TB and BCG-IRIS who had an acceptable routine pre-HAART CXR were included. CXRs were independently assessed by 3 radiologists, blinded from clinical data, using a standardised assessment form. All 3 readings were used to create a majority consensus finding during the data analysis phase. RESULTS: Amongst 161 children, the median age at enrolment was 2.3 years (25% (41/161) were <1year), 54% (87/161) were on TB treatment and 65% (100/154) were immune-suppressed. The majority (71%) had an abnormal CXR finding, predominantly air space disease (42%) and parenchymal interstitial disease (21%). Of the sub-group of 112 (70%) CXRs that could be assessed for lymphadenopathy, 75(67%) had one or more features suggestive of TB (74 lymphadenopathy, 2 cavities, 18 miliary infiltration) and 65% (70/107) were immune-suppressed. Statistically significant differences between immune-suppressed and non-immune-suppressed children were noted for features of lymphadenopathy and radiographic pulmonary TB. Amongst the sub-group of 112 CXRs a high percentage 49/75 (65%) were on TB treatment, with 26/75 (35%) not on TB treatment. Inter-observer agreement between all 3 readers was fair for overall abnormal CXR findings (K=0.23), airspace disease (K=0.22), moderate for parenchymal interstitial disease (K=0.54) and slight for lymphadenopathy (K=0.05). CONCLUSION: Among children eligible to start HAART, most (71%) presented with abnormal CXR findings and the majority (67%) had one or more CXR signs suggestive of TB. Of concern was the high proportion of CXRs (30%) that were of insufficient quality to be assessed for lymphadenopathy and the poor inter-observer agreement for lymphadenopathy.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Science in Medicine in Pharmacotherapy, Johannesburg, 2011 / Long term antiretroviral therapy (ART) use is known to cause various toxic adverse effects in patients. Hepato-toxicity is one of the most significant adverse effects which have been associated with all antiretroviral therapy drugs in South Africa and worldwide.

Introduction: Stavudine is a commonly used drug in paediatric antiretroviral treatment (ART) regimens. Due to toxicity concerns, however, the drug abacavir has replaced stavudine in first-line paediatric regimens inmany countries.Wedescribe the frequency of stavudine toxicity in children receiving ART at a treatment clinic in Soweto, South Africa. Methods: Data on patient characteristics and outcomes of ART were collected from a cohort of 2222 HIV-infected children initiating ART between 2004 and 2008 when stavudine-containing regimenswere routinely recommended. At several time-points after treatment initiation, we estimate the proportion of children where an attending clinician discontinued stavudine due to lipodystrophy, pancreatitis, lactic acidosis or peripheral neuropathy. Factors associated with stavudine-related toxicities were identified. Results: At ART initiation, most children had advanced disease. The majority initiated an efavirenz/lamivudine/stavudine regimen (n¼1422), and 76% of children remained on their initial ART regimen after a median 19.9 months of ART. Replacement of stavudine due to drug toxicity occurred at a rate of 28.8 per 1000 child years on treatment (95% confidence interval¼23.6–35.2). Rates of toxicity increased with treatment duration (in their first year of ART stavudine was replaced in 0.5% of children, but after 3 years stavudine had been changed to abacavir in 12.6% of children). Toxicity was more common in older children and in girls. Lipodystrophy accounted for 87 of 96 toxic events. Conclusion: Stavudine-associated toxicity resulting in single-drug substitution was uncommon in this cohort, though its frequency increased steadily with ART duration, especially with lipodystrophy. Where drug options are limited, stavudine remains a relatively well tolerated and effective option for children.

Desde a sua descoberta, no início da década de 80, o HIV/aids, constituiu-se como uma doença que ultrapassa os limites da dimensão biomédica, apresentando diversos desafios à sociedade. No Brasil, estima-se que aproximadamente 734 mil pessoas vivem com HIV/aids. Foram desenvolvidas diferentes classes de drogas antirretrovirais para seu tratamento; as quais são eficazes para o controle parcial da replicação viral. Sem a descoberta da cura, é imprescindível que as pessoas vivendo com HIV/aids sigam as recomendações da equipe de saúde, aderindo ao tratamento proposto; aumentando sua qualidade de vida, bem como contribuindo para a diminuição da transmissão do vírus. Durante o tratamento, algumas dificuldades podem surgir, determinando momentos de maior ou menor adesão ao mesmo e os profissionais de saúde, dentre eles, os farmacêuticos, devem estar atentos a estes momentos. Este estudo transversal teve como objetivo analisar a retirada do TARV nos últimos 24 meses e investigar os possíveis fatores que levam a retirada desta medicação de forma irregular na Unidade Especial de Tratamento de Doenças Infecciosas (UETDI) do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo. Participaram 250 pessoas que vivem com HIV/aids que retiram a medicação na Farmácia do local do estudo. Os participantes foram separados em dois grupos: Grupo em Atraso e Grupo Controle segundo seus históricos de dispensação da TARV nos vinte e quatro meses anteriores a realização das entrevistas. Predominaram participantes do sexo masculino (57,6%), com mais de 40 anos (76%), brancos (51,6%), com baixa escolaridade (48,4%), sem parceiro fixo (52,4%), residentes em Ribeirão Preto (63,6%). Todas as variáveis foram relacionadas em um estudo univariado e aquelas com um valor de \"p\" igual ou menor que 0,2 foram selecionadas para análise multivariada. As associações entre variáveis selecionadas e a retirada irregular comparada com a retirada regular, foi estimada pela estimativa com intervalo de confiança de 95%. As variáveis que mostraram associação com a retirada da TARV em atraso foram: fazer uso de outro medicamento além da TARV, apresentar resultado de exame de carga viral como detectável, ter, no início do período analisado, contagem de linfócitos T CD4 menor que 200 células /mm3 e ter baixa adesão como resultado do Teste de Morisky- Green / Since its discovery in the early 80s, HIV / AIDS was established as a disease that pushes the boundaries of biomedical dimension, presenting many challenges to the society. In Brazil, there are almost 734,000 people carrying HIV / AIDS. Different classes of antiretroviral drugs were developed for their treatment, which are effective in partial control of viral replication. Yet incurable disease it is essential that people living with HIV / AIDS follow the recommendations of the health care agents, adhering to the proposed treatment, increasing their quality of life, and contributing to the reduction of transmission of the virus. During treatment, some difficulties may arise, determining moments of greater or lesser adherence, and pharmacists among other health professionals, should be aware of these moments. This cross-sectional study aimed to analyze the withdrawal of ART in the last 24 months, and investigate the possible factors that lead the medication withdrawal erratically on Special Treatment of Infectious Diseases Unit (UETDI) of the Clinics Hospital - School of Medicine of Ribeirao Preto, University of São Paulo. Two hundred and fifty people living with HIV / AIDS got medication in the study site pharmacy. Participants were divided into two groups: Group Control and Group Delay, according to their historical dispensing of ART in twenty-four months prior to the interviews; predominant male participants (57.6%) with more than 40 years (76%), white (51.6%), with low education (48.4%), with no steady partner (52.4%), residents in Ribeirão Preto (63.6%). All variables related in a univariate analysis, and those with a value of \"p\" equal to or smaller than 0.2 were selected for multivariate analysis. The associations between selected variables, and the irregular removal compared to regular withdrawal were estimated with 95% confidence interval. The variables that were associated with the withdrawal of ART arrears, and making use of another drug in addition to HAART, presented results of viral load test as detectable, having the beginning of period analyzed, CD4 lymphocyte count less than 200 cells / mm3, and have low compliance as a result of Morisky- Green test.

Orientador: Ricardo Augusto Monteiro de Barros Almeida / Resumo: Introdução: Até há cerca de uma década, a infecção pelo HIV era considerada contraindicação absoluta para transplantes de órgãos. Estudos recentes sugerem que o transplante renal (TxR) é viável para pessoas vivendo com HIV/aids (PVHA) adequadamente selecionadas. Apesar de bastante efetivos, os TxRs em PVHA apresentam dificuldades importantes. A maioria dos estudos relatam incidências mais elevadas de rejeição aguda, chegando a mais de 50%. Fatores imunológicos e farmacológicos teriam grande influência. A literatura atual mostra que o melhor esquema antirretroviral (ARV) para os TxRs em PVHA ainda não foi identificado. Objetivo: Devido à relevância do tema e à ausência de ensaios clínicos randomizados (ECRs), o objetivo do estudo foi identificar, através de metanálise proporcional de série de casos, os esquemas de ARVs mais efetivos e seguros para PVHA submetidas ao TxR. Métodos: Foram incluídos estudos de relato e série de casos que tivessem avaliado qualquer esquema ARV utilizado em PVHA submetidas ao TxR e que fornecessem dados relacionados aos desfechos de interesse, que foram mortalidade, sobrevida do enxerto, episódios de rejeição aguda, função renal e curso clínico e laboratorial da infecção pelo HIV. A pesquisa em bases de dados foi realizada através das fontes: MEDLINE, EMBASE, Scopus e LILACS (até dezembro de 2014). Dois revisores independentemente selecionaram os estudos identificados pelas bases de dados. Foram realizadas metanálises proporcionais de série de casos comparando a ocorrência dos desfechos em diferentes esquemas ARVs por meio do software StatsDirect. A heterogeneidade estatística foi avaliada utilizando o teste estatístico I2 . Resultados e discussão: Dos 2841 estudos inicialmente identificados pela pesquisa bibliográfica, 24 respeitaram os critérios de inclusão e exclusão, totalizando 57 pacientes. Não houve diferença... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Until about a decade ago, HIV infection was considered absolute contraindication for organ transplants. Recent studies suggest that kidney transplantation (KTx) is feasible for people living with HIV/AIDS (PLWHA) in select cases. Although highly effective, the KTx in PLWHA presents major difficulties. Most studies report higher incidences of acute rejection, reaching more than 50%. Immunological and pharmacological factors have great influence. Current literature shows that the best antiretroviral (ARV) regimen for KTx in PLWHA has not been identified. Objectives: Due to the relevance of the subject and the absence of randomized controlled trials (RCTs), the objective of the study was to identify, the most effective and safest ARV regimens for PLWHA submitted to KTx. Methods: Case series studies that have evaluated any ARV regimen used in PLWHA submitted to KTx and that provided data related to the outcomes of interest - mortality, graft survival, acute rejection, renal function and clinical and laboratory course of HIV infection - were included. Research in databases was performed using the sources: MEDLINE, EMBASE, Scopus, and LILACS (until December 2014). Two reviewers independently selected studies through the databases. Meta-analyses of case series were conducted comparing the occurrence of different outcomes in ARV schemes through software StatsDirect. Statistical heterogeneity was assessed using the I2 statistic. Results and Discussion: From 2,841 studies initially identified by the literature search, 24 studies complied with the inclusion and exclusion criteria, totaling 57 patients. There was no statistically significant difference between groups of patients who used ARV regimens based on two nucleoside/nucleotide reverse transcriptase inhibitors plus one non-nucleoside/nucleotide reverse transcriptase inhibitors (2NRTI+NNRTI), a combination of abacavir, lamivudine... (Complete abstract click electronic access below) / Mestre

Submitted by Maicon Juliano Schmidt (maicons) on 2015-07-07T13:47:50Z No. of bitstreams: 1 Guilhermo Prates Sesin.pdf: 711284 bytes, checksum: e0739573491866b29ecc98e92bf30a50 (MD5) / Made available in DSpace on 2015-07-07T13:47:50Z (GMT). No. of bitstreams: 1 Guilhermo Prates Sesin.pdf: 711284 bytes, checksum: e0739573491866b29ecc98e92bf30a50 (MD5) Previous issue date: 2013-01-31 / Nenhuma / OBJETIVO: Estudo de coorte histórica desenvolvido para descrever a freqüência e o motivo de trocas de esquemas antirretrovirais iniciais, analisar as trocas devido a reações adversas e investigar os fatores associados, em pacientes que iniciaram a terapia num centro de referência de HIV/AIDS em Porto Alegre/RS, Brasil. MÉTODOS: O estudo faz parte de um protocolo multicêntrico do qual apenas os dados referentes a Porto Alegre foram utilizados. Foram incluídos 819 indivíduos infectados pelo HIV que iniciaram terapia antirretroviral entre 2003 e 2010. Foram descritas as características sociodemográficas, comportamentais e clínicas da população e utilizou-se o modelo de regressão de Cox para verificar as associações com o desfecho. Uma curva de Kaplan Méier foi desenhada para avaliar a probabilidade dos indivíduos da amostra estarem livres de reações adversas ao longo do tempo. RESULTADOS: A média de idade da amostra foi de 38 anos, 53% eram homens, a maioria possuía até 4 anos de estudo (48,6%) e relatou exposição por relação heterossexual (74,9%). A contagem de linfócitos TCD4+ inicial foi < 250 células/mm3 em 70% dos participantes e a carga viral entre 10.000 a 99.999 cópias / mL em 46,5% da população. O esquema mais utilizado foi AZT+3TC+EFV (56,8%). A mediana do tempo até a troca do primeiro esquema terapêutico foi de 34 semanas. No total ocorreram 328 interrupções do primeiro esquema, 172 (52,4%) por reações adversas. As reações adversas mais comuns e que originaram a troca foram sintomas gastrointestinais (23%), anemia (19%), sintomas neuropsiquiátricos (14%) e dislipidemia (11%). Fatores associados com o aumento do risco significativo para troca do primeiro esquema, após ajuste, foram a escolaridade 5-8 anos (HR 1,57 IC95% 1,11-2,22), a 99 utilização de esquemas contendo AZT+3TC combinados com IPs (LOP/R [HR 1,95 IC95% 1,02-3,74] e ATZ/R [HR 3,32 IC95% 1,63-6,76) e ARVs classificados como “outros” (HR 3,24 IC95% 1,36-7,78), atualmente em desuso. CONCLUSÕES: As reações adversas causadas pelos ARVs foram o principal motivo de troca do esquema. A escolha do tratamento e o monitoramento do indivíduo que inicia a terapia são situações que devem receber uma atenção especial, buscando, assim, antecipar interrupções e trocas de medicações que, se não manejadas adequadamente, podem colaborar para a falha terapêutica. / OBJECTIVE: A historical cohort study was conducted to describe the frequency and reason for the exchange of initial antiretrovirals schemes, analyze the exchanges due to adverse reactions and investigate the associated factors in patients who initiated therapy at a referral center for HIV/AIDS in Porto Alegre/RS, Brazil. METHODS: The study is part of a multicentric protocol where only data from Porto Alegre/RS were used. The study included 819 HIV-infected individuals that started antiretroviral therapy (ART) between 2003 and2010. Sociodemographic characteristics and clinical behavior were described. A Cox regression model was used to verify the association of study factors with the outcome. A Kaplan Meier curve was designed to evaluate the probability of being free from adverse reactions over time. RESULTS: The sample average age was 38 years, 53% were men, the majority had up to 4 years of education (48.6%) and reported infection by heterosexual contact (74.9%). Seventy percent had initial CD4 <250 cells/mm3 and 46.5% a viral load between 10000-99999 copies/mL. The scheme mostly used was AZT+3TC+EFV (56.8%). The median time to the shift of the first regimen was 34 weeks. In total there were 328 exchanges of the first scheme, 172 (52,4%) due to adverse reactions. The most common adverse reactions that led to the exchange were gastrointestinal symptoms (23%), anemia (19%), neuropsychiatric symptoms (14%) and dyslipidemia (11%). Factors independently associated with increased risk for exchange of the first scheme, were schooling between 5-8 years (HR 1.57 95% CI 1.11 to 2.22), use of regimens containing AZT + 3TC combined with a boosted PI (LOP/R [HR 1.95 95% CI 1.02 to 3.74] and ATZ/R [HR 3.32 95% CI 1.63 to 6.76) besides antiretrovirals classified as "other" (HR 3, 24 95% CI 1.36 to 7.78), which are currently unused. CONCLUSIONS: Adverse reactions caused by antiretrovirals were the main reason for changing the first treatment schema and may impair the treatment outcome. The choice of treatment and individual close monitoring are conditions that should receive special attention, thus seeking to avoid disruptions and exchanges which, if not properly managed, can contribute to the therapeutic failure.

Submitted by Suzana Dias (suzana.dias@famerp.br) on 2018-11-09T18:53:26Z No. of bitstreams: 1 RenatoFerneda_dissert.pdf: 585980 bytes, checksum: 7c6b97dc0f3805fe789d0fdbee741928 (MD5) / Made available in DSpace on 2018-11-09T18:53:26Z (GMT). No. of bitstreams: 1 RenatoFerneda_dissert.pdf: 585980 bytes, checksum: 7c6b97dc0f3805fe789d0fdbee741928 (MD5) Previous issue date: 2018-04-27 / Although the antirretroviral therapy, in spite of having reduced the mortality for AIDS and increased the lifespan of the HIV bearers, it can contribute to the arrise of adverse long time effects, besides renal ones. The tenofovir (TDF), a first line antirretroviral (ARV) for treatment, has low general toxicity. TDF can take to moderate reduction in glomerular filtration rate (GFR) and a larger prevalence of renal tubular dysfunction (RTD) when compared to those patients who are not on therapy of this medication. The decline of the renal function found in the patients can vary from mild to chronic injuries or a simple reduction in GFR. The mechanism of RTD is not completely understood, and it has been attributed to the mitocondrial lesion in the proximal tubule cells caused by the increasing of the intracelular TDF concentration. Aditionaly, host´s genetic polymorphisms have been considered one of the TDF concentration increasing causes. RTD can be characterized concisely by the deficiency in the solutes reabsorption as bicarbonate, uric acid, phosphate, glucose and low weight molecular proteins. Objectives: verify the prevalence of RTD in the HIV bearers on TDF treatment, identify the risk factors associated and compare the 24-hours urine methods with the serum creatinine and its clearance for the RTD identification. Methods: longitudinal prospective study, performed in the Complexo de Doenças Transmissíveis em São José do Rio Preto/SP, between january 2011 to december 2015. Results: 163 patients were included in the study, in which 106 (68,4%) didn't use TDF and 57 (31,6%) used TDF. RTD occured in 8 patients that used TDF, a prevalence of 14%. The patients age was identified as significant risk factor for the development of RTD. The proteinuria (average 109,2mg/24h) and the phosphaturia (average 791,9mg/24h) were significant for the diagnosis of RTD. Conclusions: the prevalence of RTD was 14%. The age was determined as risk factor for RTD, mainly in patients over 60 years-old. Phosphaturia and the proteinuria showed the greatest diagnosis sensibility for RTD, respectively. The serum creatinine and phosphorus concentration, the creatinine clearance and the stand alone hyperproteinuria should not be used as diagnosis predictors for RTD. / A TARV, apesar de ter reduzido a mortalidade por AIDS e aumentado a expectativa de vida dos portadores de HIV, pode contribuir para o aparecimento de efeitos adversos de longo prazo, inclusive renal. O tenofovir (TDF), antirretroviral (ARV) de primeira linha para o tratamento, tem baixo perfil geral de toxicidade. No entanto, pode levar a uma moderada redução na taxa de filtração glomerular (TFG) e uma maior prevalência de disfunção tubular renal (DTR) quando comparado àqueles pacientes que não o utilizam. O declínio da função renal encontrado nos pacientes podem ser injúrias agudas, crônicas ou uma simples redução na TFG. O mecanismo da DTR não é totalmente conhecido; atribui-se à lesão mitocondrial nas células dos túbulos proximais pelo aumento da concentração do TDF intracelular, além da suspeita da influência de polimorfismos genéticos dos hospedeiros. Pode ser resumidamente caracterizada pela deficiência na reabsorção de solutos como bicarbonato, ácido úrico, fosfato, glicose e proteínas de baixo peso molecular. Objetivos: Verificar a prevalência da DTR nos portadores de HIV em uso de TDF; identificar os fatores de risco associados e comparar os métodos de Urina de 24 horas com a creatinina sérica e o clearance para a sua identificação. Casuística e método: estudo longitudinal prospectivo, com 163 pacientes, realizado no Complexo de Doenças Transmissíveis em São José do Rio Preto/SP, no período de janeiro de 2011 a dezembro de 2015. Resultados: Foram incluídos 163 pacientes no estudo, dos quais 106 (68,4%) não utilizaram TDF e 57 (31,6%) utilizaram TDF. A DTR ocorreu em 8 pacientes que utilizaram TDF; uma prevalência de 14%. A idade dos pacientes (média de 43,9 anos) foi identificada como fator de risco significante para o desenvolvimento da DTR. A proteinúria (média 109,2mg/24h) e a fosfatúria (média 791,9mg/24h) foram significantes para o diagnóstico da DTR. Conclusões: A prevalência da DTR foi de 14%. A idade foi determinada como fator de risco para a DTR, principalmente, na faixa acima dos 60 anos. Os exames laboratoriais que mostraram a maior sensibilidade diagnóstica para a DTR foram a fosfatúria e a proteinúria, respectivamente. A creatinina sérica, o fósforo sérico, o clearance de creatinina e a hiperproteinúria isolada não mostraram sensibilidade como preditores diagnósticos para a DTR.

Considerando a infecção pelo HIV uma condição crônica e de alta prevalência no ambiente carcerário, este estudo objetivou analisar os desafios relacionados à regularidade no uso da terapia antirretroviral (TARV) pelas pessoas vivendo com HIV em unidades prisionais (UP) da região de Ribeirão Preto (RP), São Paulo. Tratase de um estudo descritivo, do tipo inquérito. Foram incluídos indivíduos reclusos há mais de seis meses, com diagnóstico de HIV e em uso de TARV. Utilizou-se um banco de dados contendo variáveis sociodemográficas, clínicas e de acompanhamento dos casos; adesão à TARV e ações desenvolvidas pelas equipes de saúde das UP para o monitoramento da ingestão medicamentosa. Os dados foram analisados por meio de técnicas descritivas e testes de associação (Quiquadrado e Exato de Fisher). Identificou-se 67 indivíduos em uso de TARV, dos quais, 80,6% cumpriam pena em regime fechado e 38,8% possuíam de dois a cinco anos de clausura. Houve o predomínio de homens (79,1%); 25 a 39 anos (52,2%); não brancos (64,2%); solteiros (47,8%); ensino fundamental I e II (67,1%); possuíam profissão (88,1%) e ganhavam de um a três salários mínimos (50,7%) antes da reclusão. Quanto ao perfil clínico e de acompanhamento: 44,8% diagnosticaram HIV na prisão; 86,6% faziam acompanhamento em serviço de assistência especializada em HIV (SAE); 41,7% interromperam o tratamento em algum momento; 31,3% possuíam TCD4+ acima de 500 cópias e em 62,7% a carga viral era indetectável. Identificou-se o uso de drogas ilícitas (71,6%) e lícitas (80%) prévias ao encarceramento. Em relação ao atraso na entrega da TARV, 70,3% referiram nunca ou quase nunca ocorrer tal situação; 42,2% referiram nunca ou quase nunca perderem consultas nos SAE; 79,1% informaram que nunca ou quase nunca recebem os resultados dos exames laboratoriais processados fora das UP. Sobre o questionamento acerca do uso da TARV nos últimos sete dias: 76,1% tomaram medicamentos fora do horário; 80,6% deixaram de tomar medicamentos; 91% tomaram menos ou mais compridos. Em 58,2% dos casos houve retirada regular da TARV junto às unidades dispensadoras de medicamentos situadas na rede pública de saúde de Ribeirão Preto. Quanto às ações desenvolvidas dentro das UP voltadas ao monitoramento da TARV, considerou-se regular apenas o questionamento sobre o uso contínuo dos medicamentos, sendo que as demais foram insatisfatórias. A adesão à TARV apresentou associação estatisticamente significante com o sexo feminino (p=0,028); o uso de drogas lícitas (p=0,006) e a interrupção do acompanhamento médico (p=0,014) estiveram associadas à não adesão. Os achados deste estudo permitem refletir sobre a complexidade da assistência prestada às pessoas que vivem com HIV/aids no ambiente prisional, principalmente no que tange o monitoramento do uso da TARV, sinalizando a necessidade de desenvolvimento e incorporação de estratégias de intervenção que qualifiquem a produção do cuidado em saúde na perspectiva integral e resolutiva, capaz de produzir impactos condizentes com os desafios que perpassam a prevenção e o manejo do HIV / Considering that the HIV/aids infection constitutes a chronic condition with high prevalence in prisons, this study aimed to analyze the challenges related to regularity in the use of antiretroviral therapy (ART) by people living with HIV in prisons (UP) in the region of Ribeirão Preto (PR), São Paulo. This is a descriptive, inquiry-type study. We included individuals who had been incarcerated for more than six months, diagnosed with HIV/aids and using ART. We used a database containing sociodemographic and clinical information and variables on the case follow-up, ART adherence and actions developed by PU health teams to monitor drug intake. Data were analyzed using descriptive techniques and association tests (Chi-square and Fisher\'s Exact). A total of 67 individuals using ART were identified, of whom 80.6% were in closed regime and 38.8% had two to five years of incarceration. There was a predominance of men (79.1%); 25 to 39 years old (52.2%); non-white (64.2%); single (47.8%); elementary education I and II (67.1%); having a profession (88.1%) and earning one to three minimum wages (50.7%) before incarceration. In regard of the clinical and follow-up profile: 44.8% had HIV diagnosed in prison; 86.6% were attending a specialized HIV care service (SAE); 41.7% discontinued treatment at some point of time; 31.3% had TCD4+ over 500 copies and in 62.7% of participants the viral load was undetectable. The use of illicit drugs (71.6%) and licit drugs (80%) prior to incarceration was also identified. Regarding delays in ART delivery, 70.3% reported that a delayed delivery never or almost never occurred; 42.2% reported that they never or almost never miss appointments in SAE; 79.1% reported that they never or almost never receive the results of laboratory tests processed outside the PU. Regarding the use of ART in the last seven days: 76.1% took medicines outside medication time; 80.6% stopped taking medicines; 91% took a higher or a lower dosage. In 58.2% of the cases, the withdrawal of ART from the drug dispensing units located in the public health network of RP was regular. Regarding the actions developed within the PUs aimed at ART monitoring, the questioning about the continuous use of the drugs was assessed as regular and the others were unsatisfactory. Adherence to ART had a statistically significant association with woman (p = 0.028). The use of licit drugs (p = 0.006) and interruption of medical follow-up (p = 0.014) were associated with non-adherence. The findings of this study allow us to reflect on the complexity of care provided to people living with HIV/aids in prisons, especially regarding the monitoring of ART, suggesting the need for development and incorporation of strategies that qualify the health care delivery towards an integral and resolutive perspective, capable of producing impacts that are consistent with the challenges of HIV prevention and management

Submitted by Erika Demachki (erikademachki@gmail.com) on 2014-10-06T15:24:22Z No. of bitstreams: 2 Dissertação - Clarissa Alencar de Sousa - 2011.pdf: 2102130 bytes, checksum: 6bb83ef788c784420e40b39ebf41b26e (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2014-10-06T15:49:03Z (GMT) No. of bitstreams: 2 Dissertação - Clarissa Alencar de Sousa - 2011.pdf: 2102130 bytes, checksum: 6bb83ef788c784420e40b39ebf41b26e (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2014-10-06T15:49:03Z (GMT). No. of bitstreams: 2 Dissertação - Clarissa Alencar de Sousa - 2011.pdf: 2102130 bytes, checksum: 6bb83ef788c784420e40b39ebf41b26e (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2011-02-11 / Conselho Nacional de Pesquisa e Desenvolvimento Científico e Tecnológico - CNPq / Introduction: Highly active antiretroviral therapy (HAART) changed aids morbidity and mortality profile, decreasing opportunist diseases and deaths. However, adherence is determinant to ensure long-term benefits. This study aims to compare three measures of adherence to HAART and to estimate frequency and related factors of this event. Methods Cross-sectional study conducted among 249 adults, receiving HAART in a public referral center (Hospital das Clínicas/UFG), in Goiás, from 2009 through 2010. Three measures of adherence were investigated 1) Patients who scored > 75 points at the Questionnaire CEAT-VIH (Remor E et al, 2007) were considered adherent. 2) Patients who reported taking more than 95% of the prescribed antiretroviral pills in the past 7 days were considered adherent. 3) Pharmacy refill records measure. Considered adherent those withdrew antiretroviral drugs at the correct time. The prevalence of non adherence and its 95.0% confidence interval (CI) were calculated. Agreement between measures of adherence was assessed using Kappa test. To evaluate the reliability of the measures, undetectable HIV viral load was considered the gold standard. Statistical analyses were performed by using SPSS (13.0) P <.05 was considered significant Results: The majority of participants were men (77.1%), 57.0% had > 8 years of schooling and 61.4% were taking AZT, 3TC and EFV. The prevalence of no adherence, considering missing doses in previous 7 days, was 27.2% (CI95% 17.3 -31.2). According to questionnaire CEAT-VIH, 51.0% (CI95% 49.5 – 52.5) had low/insufficient adherence. According to pharmacy refill records 37.4% (CI95% 35.0 – 39.8) were no adherent. There was a low grade of agreement between the three measures used to evaluate adherence (kappa < 0.40). Adherence was significantly associated with undetectable viral load. Adherence was not associated with gender, schooling or number of pills/day. Being a heavy alcoholic user was associated to poor adherence. Conclusions: Different measures applied to the same patients yielded different levels of adherence, although all three measures were associated with adequate virological response. The estimative of non adherence can be considered high since the majority of patients were taking a low complexity and high tolerability antiretroviral drugs combination. / Introdução: A terapia antirretroviral de alta potencia (TARV) mudou o perfil de morbi-mortalidade da aids, reduzindo as doenças oportunistas e os óbitos. Entretanto, a adesão é fundamental para garantir benefícios duradouros. Objetivos: Avaliar três instrumentos para mensurar adesão à TARV e estimar a prevalência e fatores associados a esse evento. Metodologia: Estudo transversal, envolvendo 249 adultos, acompanhados em serviço público de referência (Hospital das Clinicas/UFG), em Goiás, entre 2009 e 2010. Foram utilizados três instrumentos: 1) Questionário CEAT-VIH (Remor E et al, 2007), com ponte de corte para não aderência >75 pontos; 2) Autorrelato do percentual de doses perdidas, sendo classificados como aderentes os pacientes que utilizaram ≥ 95% das doses, nos últimos 7 dias; 3) Registro de dispensação de TARV, sendo classificados como aderentes quem retirou as drogas na data correta. Estimaram-se as prevalências de não adesão e os respectivos intervalos de confiança (IC95%). Investigou-se a concordância (Kappa) entre instrumentos. Na avaliação da acurácia dos testes diagnósticos, utilizou-se, como padrão-ouro, o resultado da carga viral. Utilizou-se o programa SPSS (13.0) para análise estatística. Nível de significância, p<0.05. Resultados: Os participantes eram, em sua maioria, homens (77,1%), 57,0 % referiam > 8 anos de escolaridade e 61,4% usavam AZT, 3TC e EFV. A prevalência de não adesão, considerando o número de doses perdidas, foi de 27,2% (IC95% 17,3 - 31,2). Utilizando-se o CEAT-VIH, 51,0% dos pacientes (IC95% 49,5 - 52,5) tiveram adesão baixa/insuficiente. De acordo com registros da farmácia 37,4% (IC95% 35,0 – 39,8) foram não aderentes. Houve baixa concordância entre os instrumentos utilizados para avaliar adesão (kappa< 0.40) A adesão mensurada pelos diferentes métodos esteve associada à carga viral indetectável. O uso de álcool esteve associado a não adesão quando mensurada pelo autorrelato da perda de doses e pelo registro da perda de doses. Conclusão: Os instrumentos utilizados evidenciaram associação entre adesão adequada e boa resposta virológica. A prevalência de não adesão variou de acordo com o instrumento utilizado e foi alta, sobretudo, considerando que a maioria dos pacientes estava em uso de esquema terapêutico de baixa complexidade e boa tolerabilidade.

Thesis (M.Sc. (Pharmacology))--North-West University, Potchefstroom Campus, 2009.