HAART Access and Neurological Complication of HIV Infection: Impact  versus  Resources in Brazil. Marcus Tulius T Silva, M...
<ul><li>Brazil in numbers </li></ul><ul><li>Federative Republic </li></ul><ul><li>Population (2005) -  183.592.493  </li><...
<ul><li>AIDS in Brazil </li></ul><ul><li>Accumulated AIDS cases (1984-2004): 362.364  </li></ul><ul><ul><ul><li>Incidence ...
<ul><li>Trends </li></ul><ul><li>Heterosexual transmission </li></ul><ul><ul><li>Man (69.2%) – 42.1% </li></ul></ul><ul><u...
ARV Access Program  - Major aspects <ul><li>Universal and free of charge access to ARV’s since 1991 </li></ul><ul><ul><li>...
<ul><li>Why was these policies to reduction  </li></ul><ul><li>in prices so important? </li></ul>Brasília – the capital of...
Expenditures (US$ Millions) with ARV and  Average Number of Patients under treatment - Brazil (1997-2004)
Patients on HAART in Brazil
- National Aids Expenditures US$ Million
Access to treatment 3 imported drugs take up 63% of the budget - 2003 LPV.r NFV EFZ 12 other ARVs Expenditures (in million...
* generic version available – local production  - patented medicines <ul><li>ZIDOVUDINE (ZDV)* </li></ul><ul><li>DIDANOSIN...
ARV Access Program -  Major aspects <ul><li>National networks  </li></ul><ul><ul><li>HIV viral load - 66 labs </li></ul></...
HIV/AIDS units Qualified hospitals:  375 Day hospitals:  79 Home care assistance:  54 Outpatient services:  381 Source:  U...
<ul><li>What is the importance of all these efforts? </li></ul>Iguaçú Falls
<ul><li>1995 -  22.509 AIDS cases, 15.134 deaths (9.7:100000) </li></ul><ul><li>2002 -  32.526 AIDS cases, 11.276 deaths (...
Source: Chequer et al, 1992;  Marins et al. 2002 58 18 5 0 10 20 30 40 50 60 70 1989 1995 1996 Months of survival   Median...
Impact of the Brazilian ARV Policy <ul><li>Reduction of mortality    40% </li></ul><ul><ul><li>90,000 prevented deaths </...
Impact of ARV Therapy Policy <ul><li>Cost Savings - US$ 2.2 billion </li></ul><ul><ul><li>US$ 1.23 billion in hospitals an...
Neurological manifestations of HIV infection in Brazil Rio de Janeiro
<ul><li>Pathology of the CNS in Brazil -  252 autopsy cases </li></ul><ul><ul><li>CNS lesion in 230 cases (91.3%) </li></u...
<ul><li>Progressive Multifocal Leukoencephalopathy </li></ul><ul><ul><li>Brazil: Incidence < Europe / USA </li></ul></ul><...
<ul><li>JCV Seroprevalence in Brazil – 92% ( Padgett e Walker)   </li></ul><ul><li>Low incidence also in Africa and India ...
J Berger, J Neurovirol, 2003 Incidence of PML -  University of Miami
<ul><li>LMP in Brazil </li></ul><ul><ul><li>Federal University of Rio de Janeiro  </li></ul></ul><ul><ul><li>(Chimelli, pe...
IPEC / FIOCRUZ May 2004 June 2004 <ul><li>IRIS and the incidence of PML </li></ul><ul><ul><li>Cinque et al. J Neurovirol, ...
<ul><li>HIV-Dementia </li></ul><ul><ul><li>Developed country – 40 to 50% reduction </li></ul></ul><ul><ul><ul><li>Incidenc...
<ul><li>Peripheral neuropathy (PN) </li></ul><ul><ul><li>Most common neurological complication </li></ul></ul><ul><ul><li>...
Brazil – A Tropical country Special considerations Amazonian Jaguar (Onça pintada)
<ul><li>Chagas Disease –  Trypanosoma cruzi </li></ul><ul><ul><li>Chronic CD – reactivation </li></ul></ul><ul><ul><ul><li...
Silva N et al. J Acquir Immune Defic Syndr Hum Retrovirol, 1999.
<ul><li>Leprosy   </li></ul><ul><ul><li>HIV + patients unfavorable leprosy outcome? </li></ul></ul><ul><ul><li>Inflammator...
<ul><li>In summary </li></ul><ul><ul><li>Benefits of HAART  </li></ul></ul><ul><ul><ul><li>Brazil = Developed countries </...
Thank you! Grazie mille! Obrigado! [email_address]
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HAART Access and HIV Neurological Complications (Brazil)

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  • Good aternon. I´d like to thank the organizers for invitation. My name is Marcus Tulius Silva, and I´m neurologist of FIOCRUZ, in Rio de Janeiro. FIOCRUZ is one of the largest Latin American Research Institute devoted to infectious disease, and I work specifically with HIV and HTLV associated diseases. Today I will talk about HAART access and neurological complications of HIV infection in Brazil.
  • Brazil is the biggest country in Latin America, with almost 170 million inhabitants, and today the medium life expectative is around 68.7 years. Concerning economy, it occupies the 15th position in the Economic International Ranking, with a GDP of U$ 482 billion and GDP per capita of U$ 2.699,98.
  • From 1984 to 2004 a total of 362.364 cases of AIDS were officially reported to the National AIDS Case Registry in Brazil, representing an incidence rate of 18.4: 100.000 inhabitants. The majority of patients are more than 14 years old. At present, about 155.000 persons with AIDS in Brazil are receiving ARV treatment, and almost 20.000 patients/year start HAART. We expect achieve about 180.000 patients on HAART until December 2005. Unfortunately, Health Ministry estimates that there are, currently, about 600.000 HIV-infected individuals around the country.
  • The current phase of HIV epidemic is characterized both by an increasing tendency towards dissemination of HIV infection among heterosexuals (mainly in women) and further geographical expansion to smaller municipalities. Heterosexual transmission has become progressively more significant because this was the route of infection among 42.1% of infected men and 94.9% of infected women. Patients with less favorable socioeconomic status are the most affected, because 50.3% of the patients have less than 8 years of study, and 3.7% were illiterate.
  • The National Public Health Care System in Brazil provides, for all reported AIDS patients, free access to antiretroviral drugs (ARVs) since 1991, when Zidovudine was introduced. As early as 1996, protease inhibitors were also added, and nowadays 15 different ARV are freely distributed around the country. The high cost of HAART has been handled with a combination of political commitment, local generic drug production, and aggressive negotiation for high discounts in the price of imported drugs.
  • And why was this reduction in prices so important? It was really important because Brazil managed to increase the number of patients under treatment. While in 1999 we spent US$ 336 million dollars to treat 73.000 patients, in 2003 we spent US$ 181 million to treat almost the double of patients (132.000).
  • On this way, we could expand the number of patients under HAART. Initially we had 20.000 under treatment in 1997, and in 2004 we got 155.000 under HAART. It is expected that in next 2005 we will have 180.000 under treatment.
  • In 2004 the Brazilian government spent almost US$ 300 million dollars in the struggle against AIDS. We espect that until the end of 2005 the government will have spent US$ 400 million dollars.
  • However, today 3 antiretrovirals still correspond to 64% of the cost of the treatment against 37% of 12 other drugs.
  • This slide shows the 15 different antiretrovirals freely distributed in Brazil. Those which are in bold type are produced locally (generic medicines), and those which are in red are still patented.
  • In addition to the acquisition and the distribution of ARVs, Brazil has today 66 public labs entitled to measuring viral load, 78 to CD4 counting, 12 labs to genotypic testing and 480 points for the distributing of the drugs, thus organizing a qualified national network for diagnosis and treatment.
  • Besides drug distribution, the government of Brazil gave support to implementation of a national laboratory network to providing general access to CD4 testing, viral load testing, and genotypic testing for drug resistance. In 2002 we had 889 AIDS units to diagnosis and treatment, but now thi sfigure is over 1000. There are 375 qualified hospitals, 70 day hospitals, 54 home care assistance and 381 outpatient units.
  • And what is the importance of all these efforts?
  • Fortunately, mortality rates from AIDS are declining after introduction of HAART. In 1995 there were 9.7 deaths per 100.000 inhabitants. In 2002 this figure dropped to 6.4 deaths per 100.000 inhabitants. The benefits of HAART on mortality occurred in a way very similar as observed in developed countries.
  • This way, the medium survival arised from 5 months in 1989 to 58 months in the final of 1996, with a 2-year survival of 63%.
  • Besides the reduction of mortality rates in 40%, with 90000 prevented deaths, we observed a reduction of 70% in morbidity, 80% of reduction in hospitalization, 358.000 prevented hospitalizations.
  • The impact of HAART was also evident in economic aspects. Antiretroviral therapy policy represents a cost saving of US$ 2.2 billion, 1.23 of these in direct costs (hospitals and treatment) and US$ 960 million in reduction of drug prices .
  • Unfortunately, there is very little published information about epidemiology of neurological complication of HIV infection in Brazil, and the majority of papers refer to autopsy cases. In this study, Prof Leila Chimelli observed, in the era pre-HAART, that the most prevalent lesions on central nervous system in Brazilian patients were toxoplasmosis, cryptococcosis, CMV infection, HIV encephlitis, and primary lymphoma of the central nervous system.
  • Although there are no confirmed statistics, the perception of health care professionals involved in the care of AIDS patients is that the incidence of Progressive Multifocal Leukoencephalopathy (PML) in Brazilian patients is much less than that reported in Europe and United States patients. For example, in Italy, PML was the third most common neurological disturbance in a cohort of HIV patients.
  • Inasmuch as the seroprevalence among HIV negative individuals in Brazil is approximately 92%, the relative lack of Brazilian cases of PML comparing with United States and some countries of Europe could reflect a difficulty in diagnostic or some difference in JCV isolates or even in interactions between JCV and local HIV strains. The same explanation could be applied to India and Africa, where a low prevalence of PML is also reported 11.
  • However, the incidence of PML seems to increase around the world, different from the other opportunistic infection diseases. Dr Berger in University of Miami, for example, shows a increase of 20 fold in the incidence of PML from 1983 to 1994. And this could be also happening in Brazil.
  • From 1998 to nowadays, Prof Leila Chimelli observed 10 cases of PML in a big University Hospital in Rio de Janeiro, but she could not observe any PML case in 252 autopsies in 1992. In our center, only 11 cases were registered since 1985. It is remarkable the great discrepancy among the incidence in the era pos-HAART in our center. We could note that after 1995, 10 cases of PML were observed versus 1 case before 1995, reflecting either a more accurate diagnosis in recent years or a really increase in incidence of PML after HAART.
  • Like observed in one of our PML case, in witch a inflammatory response with gadolinium enhancement is showed 1 month after HAART.
  • Although the widespread use of HAART has led to a reduction of 40 to 50% in the incidence of HIV-dementia (HIV-D) it continues to be the major cause of morbidity and mortality. In the era pre-HAART, the prevalence of HIV-D was approximately 20 to 30%, with an incidence rate of 7% per year 14. Today, this figure is more likely to be approximately 3% per year in developed countries. There are no official statistics about HIV-D in Brazil, but we speculate that an important reduction in the incidence also occurred after HAART. In our center, we could observe 35 HIV-D cases (6.46% of the neurological manifestations in HIV infected patients) before 1996 against 19 (3.14%) after this year.
  • Peripheral neuropathy is the most common neurological complication of HIV infection. It is expected that the prevalence increases In the only paper about PN in Brazilian patients, Zanetti et al described a prevalence of 69.4% in a cohort of HIV-positive patients in São Paulo, Brazil. A subclinical peripheral neuropathy was disclosed in 64.7% of these patients, and this figure is in accordance with other authors. In our cohort, clinical peripheral neuropathy was seen in 13.3% of patients (81 out 605) after 1996.
  • Since Brazil is a tropical country, some particularities about infectious diseases are remarkable in the context of AIDS, and I will briefly discuss two of these.
  • Chagas’ disease is one of the most prevalent infectious diseases in Latin America, and Brazil has areas of great occurrence of it. The infection, caused by the protozoan Trypanosoma cruzi , is transmitted mainly by vectors (reduviid bugs) or by blood transfusion, and it is estimated that almost 18 million people are chronically infected in the Americas. The chronic nature of Chagas&apos; disease and an increasing number of immigrants from T. cruzi -endemic areas, suggest that it is a long-term public health problem for non-endemic countries. The reactivation of the illness in individuals with chronic Chagas’ disease, manifested as a febrile syndrome altogether with meningoencephalitis and/or myocarditis, has been associated with AIDS and other immunodeficiency states in Brazil. In a recent review, central nervous system involvement occurred in 75% of HIV+ patients, contrasting with a classical description of rare occurrence in immunocompetent patients with acute Chagas’ disease. Probably, the immuosuppression allows the reactivation of the T. cruzi infection, leading to an acute meningoencephalitis..
  • Lesions in the brain can mimic cerebral toxoplasmosis both clinically and radiologically, with CT scanning revealing single or multiple hypodense lesions, with or without ring enhancement, predominantly in subcortical areas. This finding can be useful for differential diagnosis with toxoplasmosis, in which involvement of the thalamus and basal ganglia is more common.
  • In the past, it was expected that a HIV+ patient infected by Mycobacterium leprae had an unfavorable leprosy outcome. However, some studies have indicated that individuals dually infected had not a worse outcome. Recently, an acute inflammatory reaction type 1 (T1R) trigged by immune reconstitution syndrome in association with HAART was described, and this is an important issue because T1R can cause nerve damage and short and long-term morbidity, like in this case observed in our center.
  • Summing up, the clinical benefits of HAART in Brazil are similar to those observed in developed countries and this was only possible because of a universal access to HAART and strict adherence to guidelines. However, we urgently need to provide a national network to surveillance of the incidence and the prevalence of neurological manifestations in HIV infection to ascertain the real impact of HAART in this field.
  • HAART Access and HIV Neurological Complications (Brazil)

    1. 1. HAART Access and Neurological Complication of HIV Infection: Impact versus Resources in Brazil. Marcus Tulius T Silva, MD, MSc. Neurologist – The Reference Center for Neuroinfections and HTLV Evandro Chagas Clinical Research Institute Oswaldo Cruz Foundation (FIOCRUZ) Rio de Janeiro – Brazil [email_address]
    2. 2. <ul><li>Brazil in numbers </li></ul><ul><li>Federative Republic </li></ul><ul><li>Population (2005) - 183.592.493 </li></ul><ul><li>Life Expectancy (2001) – 68.7 years </li></ul><ul><li>Economic Rank (2004) -15th </li></ul><ul><ul><li>GDP U$ 482 billion </li></ul></ul><ul><ul><li>Per capita GDP US$ 2,699 </li></ul></ul>
    3. 3. <ul><li>AIDS in Brazil </li></ul><ul><li>Accumulated AIDS cases (1984-2004): 362.364 </li></ul><ul><ul><ul><li>Incidence rate (2004): 18.4/100.000 </li></ul></ul></ul><ul><ul><li>Patients > 14 years old: 348.578 (96.2%) </li></ul></ul><ul><li>Patients under HAART (2005) – 155.000 </li></ul><ul><ul><li>20.000 patients/year </li></ul></ul><ul><li>Estimated number of people living with HIV (2005): 600.000 </li></ul>
    4. 4. <ul><li>Trends </li></ul><ul><li>Heterosexual transmission </li></ul><ul><ul><li>Man (69.2%) – 42.1% </li></ul></ul><ul><ul><li>Woman – 94.9% </li></ul></ul><ul><li>Education : 50.3% < 8 years </li></ul><ul><ul><li>Illiterate – 3.7% </li></ul></ul>
    5. 5. ARV Access Program - Major aspects <ul><li>Universal and free of charge access to ARV’s since 1991 </li></ul><ul><ul><li>Protease inhibitors - 1996 </li></ul></ul><ul><li>Local policies </li></ul><ul><ul><li>Political commitment </li></ul></ul><ul><ul><li>Local generic drug production </li></ul></ul><ul><ul><li>Negotiation for high discount </li></ul></ul>
    6. 6. <ul><li>Why was these policies to reduction </li></ul><ul><li>in prices so important? </li></ul>Brasília – the capital of Brazil
    7. 7. Expenditures (US$ Millions) with ARV and Average Number of Patients under treatment - Brazil (1997-2004)
    8. 8. Patients on HAART in Brazil
    9. 9. - National Aids Expenditures US$ Million
    10. 10. Access to treatment 3 imported drugs take up 63% of the budget - 2003 LPV.r NFV EFZ 12 other ARVs Expenditures (in millions of R$) 121 131 106 215 2003 21% 23% 19% 573 37% LPV.r+ EFZ+ NFV 63% 12 other ARVs 37%
    11. 11. * generic version available – local production - patented medicines <ul><li>ZIDOVUDINE (ZDV)* </li></ul><ul><li>DIDANOSINE (ddI)* </li></ul><ul><li>LAMIVUDINE (3TC)* </li></ul><ul><li>STAVUDINE (d4T)* </li></ul><ul><li>ABACAVIR </li></ul><ul><li>INDINAVIR* </li></ul><ul><li>TENOFOVIR </li></ul><ul><li>RITONAVIR* </li></ul><ul><li>SAQUINAVIR </li></ul><ul><li>NELFINAVIR </li></ul><ul><li>AMPRENAVIR </li></ul><ul><li>NEVIRAPINE* </li></ul><ul><li>EFAVIRENZ </li></ul><ul><li>LOPINAVIR / r </li></ul><ul><li>ATAZANAVIR </li></ul>
    12. 12. ARV Access Program - Major aspects <ul><li>National networks </li></ul><ul><ul><li>HIV viral load - 66 labs </li></ul></ul><ul><ul><li>CD4+ cell count - 78 labs </li></ul></ul><ul><ul><li>Genotypic - 12 labs </li></ul></ul><ul><ul><li>ARV Logistic control system - 480 dispensary units </li></ul></ul>
    13. 13. HIV/AIDS units Qualified hospitals: 375 Day hospitals: 79 Home care assistance: 54 Outpatient services: 381 Source: UDAT/PN-DST-AIDS. March/2002 Access to Treatment in Brazil - 889 units for treatment Laboratories: Viral Load, CD4+ count and Genotyping 2 1 1 1 1 2 2 1 1 2 2 1 5 3 1 1 1 1 5 3 1 1 4 3 2 1 2 1 1 9 3 1 4 1 1 2 2 1 3 1 1 1 11 1 3 2 1 1 1 4 4 6 3 3 1 33 2 10 5 50 15 18 6 158 17 49 24 11 1 7 1 14 4 10 3 21 9 9 1 6 1 8
    14. 14. <ul><li>What is the importance of all these efforts? </li></ul>Iguaçú Falls
    15. 15. <ul><li>1995 - 22.509 AIDS cases, 15.134 deaths (9.7:100000) </li></ul><ul><li>2002 - 32.526 AIDS cases, 11.276 deaths (6.4:100000) </li></ul>84 95 2002 Year of death per 100,000 inhab. men women Brazil Number of Deaths - 1995 vs 2002 16 14 12 10 8 4 2 0 Source: Brazilian STD/AIDS Program
    16. 16. Source: Chequer et al, 1992; Marins et al. 2002 58 18 5 0 10 20 30 40 50 60 70 1989 1995 1996 Months of survival Median survival after AIDS Diagnosis in Brazil
    17. 17. Impact of the Brazilian ARV Policy <ul><li>Reduction of mortality  40% </li></ul><ul><ul><li>90,000 prevented deaths </li></ul></ul><ul><li>Reduction of morbidity  70% </li></ul><ul><li>Reduction of hospitalizations  80% </li></ul><ul><ul><ul><li>Average hospitalizations / patient per year </li></ul></ul></ul><ul><ul><ul><ul><li>1,65 in 1996 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>0,28 in 2003 </li></ul></ul></ul></ul>
    18. 18. Impact of ARV Therapy Policy <ul><li>Cost Savings - US$ 2.2 billion </li></ul><ul><ul><li>US$ 1.23 billion in hospitals and treatment of OI </li></ul></ul>
    19. 19. Neurological manifestations of HIV infection in Brazil Rio de Janeiro
    20. 20. <ul><li>Pathology of the CNS in Brazil - 252 autopsy cases </li></ul><ul><ul><li>CNS lesion in 230 cases (91.3%) </li></ul></ul><ul><ul><ul><li>Toxoplasmosis 34.1% </li></ul></ul></ul><ul><ul><ul><li>Cryptococcosis 13.5% </li></ul></ul></ul><ul><ul><ul><li>CMV infection 7.9% </li></ul></ul></ul><ul><ul><ul><li>HIV encephalitis 6.7% </li></ul></ul></ul><ul><ul><ul><li>PLCNS 4% </li></ul></ul></ul>Chimelli L et al. Neuropathol Appl Neurobiol 1992;18(5):478-88
    21. 21. <ul><li>Progressive Multifocal Leukoencephalopathy </li></ul><ul><ul><li>Brazil: Incidence < Europe / USA </li></ul></ul><ul><ul><ul><li>Italy – 3 th neurological disturbance </li></ul></ul></ul><ul><ul><ul><ul><li>Antinori et al. J Neurovirol, 2001 </li></ul></ul></ul></ul>
    22. 22. <ul><li>JCV Seroprevalence in Brazil – 92% ( Padgett e Walker) </li></ul><ul><li>Low incidence also in Africa and India </li></ul><ul><ul><li>Shankar SK et al. J Neurovirol, 2003 </li></ul></ul><ul><ul><li>Difficulty in diagnostic? </li></ul></ul><ul><ul><li>Difference in JCV isolates? </li></ul></ul><ul><ul><li>Difference in interactions between JCV and local HIV strains? </li></ul></ul>
    23. 23. J Berger, J Neurovirol, 2003 Incidence of PML - University of Miami
    24. 24. <ul><li>LMP in Brazil </li></ul><ul><ul><li>Federal University of Rio de Janeiro </li></ul></ul><ul><ul><li>(Chimelli, personal communication) </li></ul></ul><ul><ul><ul><li>1998 to 2005 – 10 cases </li></ul></ul></ul><ul><ul><li>IPEC – FIOCRUZ </li></ul></ul><ul><ul><ul><li>1985 to 1995 – 1 case </li></ul></ul></ul><ul><ul><ul><li>1996 to 2005 – 10 cases </li></ul></ul></ul>
    25. 25. IPEC / FIOCRUZ May 2004 June 2004 <ul><li>IRIS and the incidence of PML </li></ul><ul><ul><li>Cinque et al. J Neurovirol, 2001 </li></ul></ul>
    26. 26. <ul><li>HIV-Dementia </li></ul><ul><ul><li>Developed country – 40 to 50% reduction </li></ul></ul><ul><ul><ul><li>Incidence rate 3% per year (7% before HAART) </li></ul></ul></ul><ul><ul><li>Brazil – lack of official statistics </li></ul></ul><ul><ul><ul><li>IPEC – FIOCRUZ </li></ul></ul></ul><ul><ul><ul><ul><li>35 cases (6.5% neurological cases) before 1996 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>19 cases (3.1% neurological cases) after 1996 </li></ul></ul></ul></ul>
    27. 27. <ul><li>Peripheral neuropathy (PN) </li></ul><ul><ul><li>Most common neurological complication </li></ul></ul><ul><ul><li>↑ prevalence </li></ul></ul><ul><li>PN in Brazil - São Paulo </li></ul><ul><ul><li>Prevalence of 69.4% </li></ul></ul><ul><ul><ul><ul><li>64.7% subclinical </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Zanetti et al. Arq Neuropsiquiatr, 2004 </li></ul></ul></ul></ul></ul><ul><ul><ul><li>IPEC – FIOCRUZ – clinical PN 13.3% (81 out 605) after 1996 </li></ul></ul></ul>
    28. 28. Brazil – A Tropical country Special considerations Amazonian Jaguar (Onça pintada)
    29. 29. <ul><li>Chagas Disease – Trypanosoma cruzi </li></ul><ul><ul><li>Chronic CD – reactivation </li></ul></ul><ul><ul><ul><li>Febrile syndrome </li></ul></ul></ul><ul><ul><ul><li>Meningoecephalitis +/- miocarditis </li></ul></ul></ul><ul><ul><ul><ul><li>Reactivation in HIV + patients </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CNS involvement 75% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rare CNS involvement in HIV negative patients </li></ul></ul></ul></ul></ul>T. Cruzi in a cardiac muscle fiber. Helene Santos Barbosa / IOC / Fiocruz Reduviid bugs
    30. 30. Silva N et al. J Acquir Immune Defic Syndr Hum Retrovirol, 1999.
    31. 31. <ul><li>Leprosy </li></ul><ul><ul><li>HIV + patients unfavorable leprosy outcome? </li></ul></ul><ul><ul><li>Inflammatory reaction type 1 - IRS </li></ul></ul>IPEC / FIOCRUZ
    32. 32. <ul><li>In summary </li></ul><ul><ul><li>Benefits of HAART </li></ul></ul><ul><ul><ul><li>Brazil = Developed countries </li></ul></ul></ul><ul><ul><ul><ul><li>Universal access HAART </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Strict adherence to guidelines </li></ul></ul></ul></ul><ul><ul><li>Urgent needs </li></ul></ul><ul><ul><ul><li>National network to surveillance about the incidence and the prevalence of neurological complications in HIV infection </li></ul></ul></ul>
    33. 33. Thank you! Grazie mille! Obrigado! [email_address]

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