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Bienvenida

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Bienvenida

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  1. Bienvenida Bienvenue Welkom Welcome

  2. RETROVIRUS RESEARCH CENTER CLINICAL, SOCIODEMOGRAPHIC AND IMMUNOLOGICAL PROFILE: BEFORE, DURING AND AFTER THE IMPLEMENTATION OF HAART THERAPY. Universidad Central del Caribe School of Medicine, University Hospital Ramon Ruiz Arnau Bayamon, Puerto Rico

  3. Puerto Rico Health Regions

  4. Rationale • Retrovirus Research Center has been collecting data prospectively since 1992 • Availability of HAART began shortly after 1995 • Data on socio-demographic, clinical and immunological variables are available for study.

  5. Methods • Study Design: • A cross sectional study from a longitudinal cohort. • Setting: • The study group comes from the Bayamon area in the northern part of the island. Our health facilities serves eleven municipalities with a population of 660,440 inhabitants. • Study Group: • 3,151 HIV infected patients seen between 1992 through 2002.

  6. Methods • Variables: • Period of entry: (1992-1995, 1996-1998, 1999-2002) • Sociodemographic: age, gender. • HIV transmission mode and risk behaviors: IDU, heterosexual, MHSM, others • Clinical presentation (Stage of infection, patterns of chronic diseases, and profile of OI, medical therapy) • Immunological variables( CD4, CD8, HIV viral load • Survival analysis (time between AIDS diagnosis and last event (death or not death).

  7. Methods • Statistical Analyses: • Frequency, Percents, Mean, Median, SD, proportions, mortality rates. • Differences in proportions: Chi-Square, Fisher Exact test • Differences in mean: T-test for independent samples ANOVA. • Survival Analyses: Kaplan Meier procedure and Cox Model. • The overall significance level used was set to 0.05. • The statistical package used was SPSS 11.0 for Windows.

  8. Patient Flow Chart TOTAL (at December 2002) MALE 76% 72% 66% FEMALE 24% 28% 34% P=.0001

  9. Stage at Presentation Percent Years P=.0001

  10. AGE OF PATIENTS AT STUDY ENTRY Percent Years p<.0001

  11. Mean Age at Entry P<0.01

  12. AGE AND ENTRY WITH CLINICAL AIDS Percent Years P=.0001

  13. HIV RISK SCENARIO Percent P=.0001

  14. AIDS DEFINING CONDITIONS AS PER YEAR Percent of Patients <1996 1996-98 >1998 *p<.01

  15. PRESENCE OF CHRONIC CONDITIONS PERCENT OF PATIENTS <1996 1996-98 >1998 P<001

  16. USE OF ANTIRETROVIRAL THERAPY PERCENT OF PATIENTS ART <1996 1996-98 >1998 P<001

  17. Median Levels of CD4 Cell Count Per Year of Entry * P<.026

  18. Early MortalityMortality prior to last day of first interval Percent P<.0001

  19. MEDIAN OF SURVIVAL BY HIV/AIDS DIAGNOSIS

  20. Survival analysis within the HIV patientsdescribe by years of entry, n=982. P<.0001

  21. Survival analysis within the AIDS diagnosed patients describe by years of entry, n=2167. P< .0001

  22. CONCLUSIONS • INCREASED • FEMALES • HETEROSEXUAL BEHAVIOR AS RISK • AGE (OLDER PATIENTS IN PARTICULAR >55Y) • PATIENTS WITH IMMUNOLOGICAL AIDS AT ENTRY • CHRONIC CONDITIONS (DM,CV) • USE OF HAART INTERVENTION • MEDIAN SURVIVAL IN HIV AND AIDS

  23. CONCLUSIONS • DECREASED • IVU AS RISK FACTOR • CLINICAL AIDS AND HIV STAGE AT ENTRY • TOTAL CD4 CELL COUNT IN HIV AND AIDS • PCP, TOXO, TB AS INFECTIONS IN AIDS) • MORTALITY WITHIN SIX MONTHS OF ENTRY

  24. THANKS • INVESTIGATORS: • Robert Hunter Mellado, MD, FACP • María A. Gómez Escudero, Ph.D. • Diana M. Fernández Santos, MS, Ed.D. (candidate) • Angel M. Mayor Becerra, MD, MS • Eddy Ríos Olivares, Ph.D., MPH • José W. Rodríguez, Ph.D. • Carlos Leon Valiente, MD • Beatriz Martinez Ph.D. • Jose Rodriguez Ph.D. • Boukli Nawal Ph.D. • Data Analysts • Doris V. Báez Feliciano, MS • Alejandro Amill Rosario, MPH • Miriam Velázquez Díaz, MS • Data Abstractors • Gisela I. Cestero Salas, BA • Glenda L. Ortiz Torres, BA • Heidy Ortiz Marrero, BA • Data Entry • Wanda I. Marín Maldonado • Information Systems Specialist • Magaly Torres Talavera, BBA • Administrative Support • Lillian Santana Báez, BBA

  25. Facteurs de mauvais pronostique après l’initiation de la thérapie antirétrovirale en Haiti. Paul D. Leger, Patrice Severe, Marc Jean Marie Jean W. Pape Centres GHESKIO, Port-au-Prince, Haiti Weill Medical College of Cornell University, NY, USA Sponsored by : Global Funds

  26. Introduction • Extention thérapie antirétrovirale (ART) à Gheskio en 2003, Port-au-Prince, grâce au Fonds Mondial de lutte contre le Sida, la TB et le paludisme. • 1000 patients sous ART, en raison de 100 patients/mois. • Critères d’inclusion : • Signes cliniques de stade SIDA et/ou • Taux de CD4<200/ml et • Patients désireux de participer

  27. Objectifs • Bien que la grande majorité des patients évoluent très bien sous le traitement, certains meurent. • L’objectif de cette étude est d’évaluer les facteurs de risque associés à la mort

  28. Caractéristiques des patientsFévrier – Octobre 2003 N = 800

  29. Facteurs étudiés Facteurs associés à la mort étudiés : • Age, CD4 initial • Présence de syndrome constitutionnel • Présence de TB • Maladies concomitantes • Adhérence • Intervalle entre début ARV et décès

  30. Analyse des décès.N=47 (5.8% des enrollés)

  31. Age

  32. Causes de décèsN=47 • Wasting Syndrome : 42% (Syndrome Constitutionnel) • Tuberculose : 28 % • Autres : 30 % 8.5% Mauvaise adhérence associée aux autres conditions

  33. Délai de survie après début des ARV

  34. Analyse • Décès précoces pour la majorité des patients (60% en 1 mois ). • Décès non associés au régime utilisé, ni à l’âge. • Facteurs de risque identifiés : • Wasting Syndrome (42%) • TB (28%) • Taux de CD4 très bas au début du traitement.

  35. Conclusion • Nécessité d’hopitaliser les patients au stade très avancés à l’initiation ART. • Attention spéciale à ceux présentant Wasting syndrome ou TB.

  36. EFFICACY AND TOLERANCE OF COTRIMOXAZOLE AS A FIRST LINE TREATMENT OF TOXOPLASMA ENCEPHALITIS IN MARTINIQUES. Abel1, A. Foltzer1, Ph. Cabre2, D. Smadja2, B. Liautaud1, A. Cabié1 (1) Service de Maladies Infectieuses et Tropicales (2) Service de Neurologie CHU de Fort-de-France, Martinique

  37. MAIN CENTRAL NEUROLOGICAL DISEASES IN HIV INFECTED PATIENTS

  38. TOXOPLASMA ENCEPHALITIS IN AIDS PATIENTS • Major cause of morbidity and mortality • Often revealing HIV infection • Uneasy Diagnosis • Clinical • TDM or MRI where available • Probability based treatment • Sulfadiazine + pyriméthamine + acide folinique • Bad tolerance • Not always available • No IV form available • Costly • Need for Alternative choice of treatment

  39. TREATMENT OF TOXOPLASMOSIS WITH COTRIMOXAZOLE

  40. Efficacy and tolerance of Cotrimoxazole as a first line treatment of Toxoplasma Encephalitis in Martinique • Patients and methods • Open label prospective study, from August 1993 to December 2002 • Inclusion criteria • HIV seropositive status • Neurological disorders compatible with the diagnosis of toxoplasma encephalitis • Brain Scan imaging judged typical of TE by the radiologist, or • Abnormal brain scan imaging not typical of TE but with no other identified cause of laboratory workup • CD4 < 200 /mm3 • Exclusion criteria • Cotrimoxazole prophylaxis with good compliance • History of cotrimoxazole intolerance • Toxoplasma negative serology

  41. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE • Patients and methods • Induction therapy • [TMP (10 mg/kg) + SMZ (50 mg/kg)] /day • Intravenous or oral route • During 6 to 8 weeks • Until resolution of radiological lesions • Follow-up • Clinical and biological • CT or RMI at day 15, and between 4 to 8 weeks • Maintenance therapy • [TMP (160mg) + SMZ (800 mg)] x 1 /day (1 double-strength tablet)

  42. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE • Results • 61 patients (36 men and 25 women), 39.1 years MSM 15% IV drug use 8% Hetero. 77% HIV transmission group

  43. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE • HIV infection at time of toxoplasma encephalitis (TE) diagnosis

  44. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Clinical and radiographic features at presentation

  45. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Efficacy • In an intent-to-treat analysis

  46. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Tolerance

  47. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Relapses • 17 of 50 patients (34%) • Median time of relapse = 22 weeks • Always in patients with poor observance of maintenance therapy • Treatment of relapses • Cotrimoxazole = 75% • Efficacy = 87.5%

  48. TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN MARTINIQUE Survival after TE Since 1997 Probability of survival, % Logrank p =0.1 Before 1997 12 months Survival = 0.71 Months from TE diagnosis