Time to HAART Initiation after Diagnosis and Treatment of Opportunistic Infections in Patients with AIDS in Latin America.
BACKGROUND
Since 2009, earlier initiation of highly active antiretroviral therapy (HAART) after an opportunistic infection (OI) has been recommended based on lower risks of death and AIDS-related progression found in clinical trials. Delay in HAART initiation after OIs may be an important barrier for successful outcomes in patients with advanced disease. Timing of HAART initiation after an OI in "real life" settings in Latin America has not been evaluated.


METHODS
Patients in the Caribbean, Central and South America network for HIV Epidemiology (CCASAnet) ≥18 years of age at enrolment, from 2001-2012 who had an OI before HAART initiation were included. Patients were divided in an early HAART (EH) group (those initiating within 4 weeks of an OI) and a delayed HAART (DH) group (those initiating more than 4 weeks after an OI). All patients with an AIDS-defining OI were included. In patients with more than one OI the first event reported was considered. Calendar trends in the proportion of patients in the EH group (before and after 2009) were estimated by site and for the whole cohort. Factors associated with EH were estimated using multivariable logistic regression models.


RESULTS
A total of 1457 patients had an OI before HAART initiation and were included in the analysis: 213 from Argentina, 686 from Brazil, 283 from Chile, 119 from Honduras and 156 from Mexico. Most prevalent OI were Tuberculosis (31%), followed by Pneumocystis pneumonia (24%), Invasive Candidiasis (16%) and Toxoplasmosis (9%). Median time from OI to HAART initiation decreased significantly from 5.7 (interquartile range [IQR] 2.8-12.1) weeks before 2009 to 4.3 (IQR 2.0-7.1) after 2009 (p<0.01). Factors associated with starting HAART within 4 weeks of OI diagnosis were lower CD4 count at enrolment (p-<0.001), having a non-tuberculosis OI (p<0.001), study site (p<0.001), and more recent years of OI diagnosis (p<0.001).


CONCLUSIONS
The time from diagnosis of an OI to HAART initiation has decreased in Latin America coinciding with the publication of evidence of its benefit. We found important heterogeneity between sites which may reflect differences in clinical practices, local guidelines, and access to HAART. The impact of the timing of HAART initiation after OI on patient survival in this "real life" context needs further evaluation.
Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico.
Brenda
B
Crabtree-Ramírez
Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico.
Yanink
Y
Caro-Vega
Vanderbilt University, Department of Biostatistics, Nashville, TN, United States of America.
Bryan E
BE
Shepherd
Instituto Nacional de Infectologia Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil.
Beatriz
B
Grinsztejn
Universidad de Chile- Fundación Arriarán, Santiago, Chile.
Marcelo
M
Wolff
Universidad de Chile- Fundación Arriarán, Santiago, Chile.
Claudia P
CP
Cortes
Instituto Hondureño de Seguro Social and Hospital Escuela Universitario, Tegucigalpa, Honduras.
Denis
D
Padgett
Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru.
Gabriela
G
Carriquiry
Fundación Huésped, Investigaciones Clínicas, Buenos Aires, Argentina.
Valeria
V
Fink
Vanderbilt University, Department of Medicine, Nashville, TN, United States of America.
Karu
K
Jayathilake
Vanderbilt University, Department of Medicine, Nashville, TN, United States of America.
Anna K
AK
Person
Vanderbilt University, Department of Medicine, Nashville, TN, United States of America.
Catherine
C
McGowan
Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico.
Juan
J
Sierra-Madero
D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality*; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018572:Disease-Free Survival; D005260:Female; D015497:HIV-1; D006801:Humans; D007843:Latin America; D008297:Male; D015995:Prevalence; D015996:Survival Rate; D013997:Time Factors