Human immunodeficiency virus/acquired immunodeficiency syndrome and tropical diseases: a Brazilian perspective

Assessing dengue seroprevalence among people living with HIV (PLWH) in rome, Italy: Insights from the 2023 Italian autochthonous outbreak

BACKGROUND

Global warming has facilitated the spread of mosquito-borne diseases, including dengue, to non-endemic areas like Italy. People living with HIV (PLWH) are at increased risk of severe dengue, especially during secondary infections, but current vaccination options are constrained by safety considerations. This study assesses the seroprevalence of IgG anti-DENV among PLWH in Italy, after the 2023 Italian autochthonous outbreak.

METHODS

This cross-sectional study enrolled PLWH from July to November 2023 in Rome during the abovementioned outbreak. Blood samples were collected and analyzed for IgG anti-DENV using ELISA. Participants were stratified by country of birth and those with immune profiles suitable for live attenuated virus vaccination were identified. Cryopreserved serum samples from 2021 to 2022 were tested to trace the timing of infections.

RESULTS

We included 475 PLWH of whom 37 tested positive for IgG anti-DENV, resulting in an overall seroprevalence of 7.79 % (95 % CI 5.54-10.6). The seroprevalence was significantly higher among PLWH born in DENV-endemic countries (37.14 %) compared to Italian (2.86 %). Notably, among the Italian participants, three individuals who had not traveled outside Italy in the past 12 months showed seroconversion during the 2023 outbreak, providing further evidence of autochthonous dengue transmission in the country. This finding underscores the growing relevance of dengue as an emerging public health concern in Italy. Of the 37 seropositive individuals, 34 (91.9 %) had a CD4 count ≥200 cells/μl, indicating that a significant portion of the at-risk population could safely be vaccinated.

CONCLUSIONS

Many PLWH have been exposed to DENV, with some experiencing seroconversion during the 2023 outbreak. Most of these individuals could feasibly receive live attenuated virus vaccination without significant risks, but further studies are needed to confirm vaccine safety for PLWH.

Dengue Virus Coinfection in Human Immunodeficiency Virus-1-Infected Patients on the West Coast of Mexico

Dengue virus infection in human immunodeficiency virus (HIV)-positive patients is not well studied. Previous reports suggest a transitory inhibition of the HIV-1 viral load, as well as a benign clinical progression of dengue. The follow-up of six HIV-1-infected patients, diagnosed and hospitalized with dengue virus infection in the State of Colima, Mexico, was carried out to analyze the progression of this viral coinfection. The presence of dengue virus serotype 1 was confirmed through molecular tests. No severe complications were observed in any of the patients during dengue virus infection. Significant alteration of the HIV-1 viral loads was not observed during dengue virus infection and 6 months after coinfection. Further studies are required to understand the pathology, as well as the clinical course, of these viral coinfections.

Dengue Infection in a Human Immunodeficiency Virus-1 Positive Patient Chronically Infected with Hepatitis B Virus in Western Mexico

Human immunodeficiency virus (HIV) and dengue coinfection has not been extensively studied. We report herein a case of dengue serotype 1 infection in an HIV-1-positive patient coinfected with hepatitis B virus (HBV) in Colima State, Mexico. CD4⁺ cells and HIV-1 viremia remained at normal levels, and no severe complications were observed during this multiple viral infection. The alanine transaminase and aspartate transaminase values were elevated before and during dengue infection. Surprisingly, these parameters were significantly reduced 2 months later. Because of the lack of evidence regarding this multiple viral interaction, further research is required to understand the biologic and clinical course of dengue infection in HIV-1/HBV coinfected patients, especially in tropical regions where dengue virus transmission is highly active.

Epidemiological and clinical patterns of 92 patients co-infected with HIV and Mycobacterium leprae from Rio de Janeiro State, Brazil

BACKGROUND

Many articles have shown that HIV infection can modify the clinical course of leprosy, but very scant epidemiological and clinical data about this co-infection are available in the peer-reviewed literature.

METHODS

We herein describe the geographical distribution and demographic characteristics of 92 HIV/Mycobacterium leprae co-infected patients assisted in a Brazilian Leprosy referral center. A multivariate analysis was performed in order to establish clinical factors associated with type 1 reaction.

RESULTS

Co-infected patient admissions have steadily increased over the last years at this referral center. Most patients were men, with a mean age of 32.3 years and presenting with the paucibacillary form of leprosy. The use of antiretroviral therapy (ART) was the only factor associated with type 1 reaction. Most patients were living in the metropolitan area and the north sub area of Rio de Janeiro City.

CONCLUSION

Co-infected patients receiving ART have a greater chance to develop type 1 reaction. Patients living with both HIV and leprosy are likely to live in regions characterized by a high density impoverished population.

Co-infection Trypanosoma cruzi/HIV: systematic review (1980-2010)

INTRODUCTION

The co-infection Trypanosoma cruzi/HIV has been described as a clinical event of great relevance. The objective of this study was to describe clinical and epidemiological aspects published in literature.

METHODS

It is a systematic review of a descriptive nature from the databases Medline, Lilacs, SciELO, Scopus, from 1980 to 2010.

RESULTS

There were 83 articles (2.8 articles/year) with a total of 291 cases. The co-infection was described in 1980 and this situation has become the defining AIDS clinical event in Brazil. This is the country with the highest number of publication (51.8%) followed by Argentina (27.7%). The majority of cases are amongst adult men (65.3%) native or from endemic regions with serological diagnosis in the chronic stage (97.9%) and indeterminate form (50.8%). Both diseases follow the normal course, but in 41% the reactivation of the Chagas disease occurs. The most severe form is the meningoencephalitis, with 100% of mortality without specific and early treatment of the T. cruzi. The medication of choice was the benznidazole on doses and duration normally used for the acute phase. The high parasitemia detected by direct or indirect quantitative methods indicated reactivation and its elevation is the most important predictive factor. The lower survival rate was related to the reactivation of the Chagas disease and the natural complications of both diseases. The role of the antiretroviral treatment on the co-infection cannot yet be defined by the knowledge currently existent.

CONCLUSIONS

Despite the relevance of this clinical event there are still gaps to be filled.

Intestinal parasitic infections in HIV/AIDS patients: Experience at a teaching hospital in central Brazil

In order to verify the occurrence of intestinal parasitic infections in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients, 100 HIV/AIDS patients (Group 1) and 85 clinically healthy individuals (Group 2) were submitted to coproparasitological examination. Intestinal parasites were detected in 27% of patients from Group 1 and in 17.6% from Group 2. In Group 1 the most frequent parasites were Strongyloides stercoralis (12%), with 2 cases of hyperinfection; Isospora belli, 7%; Cryptosporidium sp., 4%; with 1 asymptomatic case and hookworm, 4%. Of the infected patients from Group 1 who reported to be chronic alcoholics, 64.3% had strongyloidiasis. Only 6 of the 27 infected patients from Group 1 were on highly antiretroviral therapy (HAART). In Group 2 the most frequent parasites were S. stercoralis, 7.1%; hookworm, 7.1% and Giardia lamblia, 3.5%. In conclusion, diagnosing intestinal parasites in HIV/AIDS patients is necessary especially in those who report to be chronic alcoholics or are not on antiretroviral treatment.

The first ten years: achievements and challenges of the Brazilian program of universal access to HIV/AIDS comprehensive management and care, 1996-2006

A review was carried out of papers published between 1996 and 2006, documenting the introduction of highly active anti-retroviral therapy (HAART) in Brazil. Papers indexed in the MEDLINE and SciELO databases were retrieved using different combinations of keywords related to the management and care of AIDS in the post-HAART era: opportunistic diseases and co-infections, adherence to therapy, survival in the pre- and post-HAART eras, adverse events and side-effects, emergence and possible transmission of resistant viral strains, metabolic and cardiovascular disorders, and issues related to access to care and equity. The review documents the dramatic changes in HIV/AIDS disease progression in the post-HAART era, including an increase in survival and quality of life and a pronounced decrease in the episodes of opportunistic diseases. Notwithstanding such major achievements, new challenges have emerged, including slow evolving co-infections (such as hepatitis C, metabolic and cardiovascular disorders), the emergence of viral resistance, with consequences at the individual level (virological failure) and the community level (primary/secondary resistance at the population level), and impacts on the cost of new therapeutic regimens.

Evolution of antiretroviral drug costs in Brazil in the context of free and universal access to AIDS treatment

BACKGROUND

Little is known about the long-term drug costs associated with treating AIDS in developing countries. Brazil's AIDS treatment program has been cited widely as the developing world's largest and most successful AIDS treatment program. The program guarantees free access to highly active antiretroviral therapy (HAART) for all people living with HIV/AIDS in need of treatment. Brazil produces non-patented generic antiretroviral drugs (ARVs), procures many patented ARVs with negotiated price reductions, and recently issued a compulsory license to import one patented ARV. In this study, we investigate the drivers of recent ARV cost trends in Brazil through analysis of drug-specific prices and expenditures between 2001 and 2005.

METHODS AND FINDINGS

We compared Brazil's ARV prices to those in other low- and middle-income countries. We analyzed trends in drug expenditures for HAART in Brazil from 2001 to 2005 on the basis of cost data disaggregated by each ARV purchased by the Brazilian program. We decomposed the overall changes in expenditures to compare the relative impacts of changes in drug prices and drug purchase quantities. We also estimated the excess costs attributable to the difference between prices for generics in Brazil and the lowest global prices for these drugs. Finally, we estimated the savings attributable to Brazil's reduced prices for patented drugs. Negotiated drug prices in Brazil are lowest for patented ARVs for which generic competition is emerging. In recent years, the prices for efavirenz and lopinavir-ritonavir (lopinavir/r) have been lower in Brazil than in other middle-income countries. In contrast, the price of tenofovir is US$200 higher per patient per year than that reported in other middle-income countries. Despite precipitous price declines for four patented ARVs, total Brazilian drug expenditures doubled, to reach US$414 million in 2005. We find that the major driver of cost increases was increased purchase quantities of six specific drugs: patented lopinavir/r, efavirenz, tenofovir, atazanavir, enfuvirtide, and a locally produced generic, fixed-dose combination of zidovudine and lamivudine (AZT/3TC). Because prices declined for many of the patented drugs that constitute the largest share of drug costs, nearly the entire increase in overall drug expenditures between 2001 and 2005 is attributable to increases in drug quantities. Had all drug quantities been held constant from 2001 until 2005 (or for those drugs entering treatment guidelines after 2001, held constant between the year of introduction and 2005), total costs would have increased by only an estimated US$7 million. We estimate that in the absence of price declines for patented drugs, Brazil would have spent a cumulative total of US$2 billion on drugs for HAART between 2001 and 2005, implying a savings of US$1.2 billion from price declines. Finally, in comparing Brazilian prices for locally produced generic ARVs to the lowest international prices meeting global pharmaceutical quality standards, we find that current prices for Brazil's locally produced generics are generally much higher than corresponding global prices, and note that these prices have risen in Brazil while declining globally. We estimate the excess costs of Brazil's locally produced generics totaled US$110 million from 2001 to 2005.

CONCLUSIONS

Despite Brazil's more costly generic ARVs, the net result of ARV price changes has been a cost savings of approximately US$1 billion since 2001. HAART costs have nevertheless risen steeply as Brazil has scaled up treatment. These trends may foreshadow future AIDS treatment cost trends in other developing countries as more people start treatment, AIDS patients live longer and move from first-line to second and third-line treatment, AIDS treatment becomes more complex, generic competition emerges, and newer patented drugs become available. The specific application of the Brazilian model to other countries will depend, however, on the strength of their health systems, intellectual property regulations, epidemiological profiles, AIDS treatment guidelines, and differing capacities to produce drugs locally.

Ultrasensitive monitoring of HIV-1 viral load by a low-cost real-time reverse transcription-PCR assay with internal control for the 5' long terminal repeat domain

BACKGROUND

Current HIV-1 viral-load assays are too expensive for resource-limited settings. In some countries, monitoring of antiretroviral therapy is now more expensive than treatment itself. In addition, some commercial assays have shown shortcomings in quantifying rare genotypes.

METHODS

We evaluated real-time reverse transcription-PCR with internal control targeting the conserved long terminal repeat (LTR) domain of HIV-1 on reference panels and patient samples from Brazil (n = 1186), South Africa (n = 130), India (n = 44), and Germany (n = 127).

RESULTS

The detection limit was 31.9 IU of HIV-1 RNA/mL of plasma (> 95% probability of detection, Probit analysis). The internal control showed inhibition in 3.7% of samples (95% confidence interval, 2.32%-5.9%; n = 454; 40 different runs). Comparative qualitative testing yielded the following: Roche Amplicor vs LTR assay (n = 431 samples), 51.7% vs 65% positives; Amplicor Ultrasensitive vs LTR (n = 133), 81.2% vs 82.7%; BioMerieux NucliSens HIV-1 QT (n = 453), 60.5% vs 65.1%; Bayer Versant 3.0 (n = 433), 57.7% vs 55.4%; total (n = 1450), 59.0% vs 63.8% positives. Intra-/interassay variability at medium and near-negative concentrations was 18%-51%. The quantification range was 50-10,000,000 IU/mL. Viral loads for subtypes A-D, F-J, AE, and AG yielded mean differences of 0.31 log(10) compared with Amplicor in the 10(3)-10(4) IU/mL range. HIV-1 N and O were not detected by Amplicor, but yielded up to 180 180.00 IU/mL in the LTR assay. Viral loads in stored samples from all countries, compared with Amplicor, NucliSens, or Versant, yielded regression line slopes (SD) of 0.9 (0.13) (P < 0.001 for all).

CONCLUSIONS

This method offers all features of commercial assays and covers all relevant genotypes. It could allow general monitoring of antiretroviral therapy in resource-limited settings.

Cytokine serum levels in patients infected by human immunodeficiency virus with and without Trypanosoma cruzi coinfection

This study assessed the number of CD4 T lymphocytes, the parasitemia and serum levels of interferon gamma (IFN-gamma), tumor necrosis factor alpha (TNF-alpha), interleukin-1 (IL-1), IL-4 and IL-10 of patients infected by human immunodeficiency virus (HIV) and human immunodeficiency virus/Chagas' disease coinfection. CD4 T lymphocytes were low in the two groups of patients, although significantly lower in patients without Chagas' disease. Serum levels of IFN-gamma, IL-4 and TNF-alpha were significantly higher in patients with HIV/Chagas' disease. IL-4/IFN-gamma ratios were higher in patients with HIV/Chagas' disease, which showed a clear balance in favor of Th2-like cytokines in this group of patients. This Th2 balance was higher in patients with detectable parasitemia. We conclude that, although immunosuppression was observed, with CD4 T lymphocytes bellow 200/µm³, these patients did not display reactivation of T. cruzi infection and that a balance favorable to Th2 was associated with the presence of parasitemia.

[Tuberculosis profile in HIV+ patient before and after the use of high activity antiretroviral treatment]

The high activity antiretroviral treatment (HAART) induces the restoration of the number and function of CD4+ T lymphocytes and is changing the landscape of tuberculosis in patients HIV-infected. The objective of this study is to evaluate the clinical, radiographic features and evolution of these patients and compare to the results obtained in a previous study with patients with no HAART use. A retrospective transversal study (with HAART) was done with patients HIV-infected that began the tuberculosis treatment in the Gaffrée e Guinle University Hospital, from 1997 to 2001 and compared to a previous study (no HAART) that was done from 1989 to 1990. The population studied was: 107 patients (with HAART) and 152 patients (no HAART) and in both studies there were a higher frequency in young white males. The relevant results included: (a) an increase in bacteriology and histopathology diagnosis confirmation; (b) a decrease number of associated diseases during tuberculosis treatment; (c) a higher end-treatment and the death rate decreased from 55% (no HAART) to 8% (with HAART); (d) pulmonary tuberculosis was more frequent in both studies although extra-pulmonary forms were more common than in general population. We concluded that the use of HAART turned the history of tuberculosis in HIV patients getting similar to that non-immunosupressed.

Opportunistic infections in patients with AIDS admitted to an university hospital of the Southeast of Brazil

Opportunistic diseases in HIV-infected patients have changed since the introduction of highly active anti-retroviral therapy (HAART). This study aims at evaluating the frequency of associated diseases in patients with AIDS admitted to an university hospital of Brazil, before and after HAART. The medical records of 342 HIV-infected patients were reviewed and divided into two groups: group 1 comprised 247 patients before HAART and, group 2, 95 patients after HAART. The male-to-female rate dropped from 5:1 to 2:1for HIV infection. There was an increase in the prevalence of tuberculosis and toxoplasmosis, with a decrease in Kaposi's sarcoma, histoplasmosis and cryptococcosis. A reduction of in-hospital mortality (42.0% vs. 16.9%; p = 0.00002) has also occurred. An agreement between the main clinical diagnoses and autopsy findings was observed in 10 out of 20 cases (50%). Two patients with disseminated schistosomiasis and 2 with paracoccidioidomycosis are reported. Overall, except for cerebral toxoplasmosis, it has been noticed a smaller proportion of opportunistic conditions related to severe immunosuppression in the post HAART group. There was also a significant reduction in the in-hospital mortality, possibly reflecting improvement in the treatment of the HIV infection.

Some aspects of protozoan infections in immunocompromised patients- a review

Protozoa are among the most important pathogens that can cause infections in immunocompromised hosts. These microorganisms particularly infect individuals with impaired cellular immunity, such as those with hematological neoplasias, renal or heart transplant patients, patients using high doses of corticosteroids, and patients with acquired immunodeficiency syndrome. The protozoa that most frequently cause disease in immunocompromised patients are Toxoplasma gondii, Trypanosoma cruzi, different Leishmania species, and Cryptosporidium parvum; the first two species cause severe acute meningoencephalitis and acute myocarditis, Leishmania sp. causes mucocutaneous or visceral disease, and Cryptosporidium can lead to chronic diarrhea with hepatobiliary involvement. Various serological, parasitological, histological and molecular methods for the diagnosis of these infections are currently available and early institution of specific therapy for each of these organisms is a basic measure to reduce the morbidity and mortality associated with these infections.