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CCMHIV

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CCMHIV

  1. 1. <ul><li>Scientific Evidences of Neurologic Disabilities in AIDS Patients </li></ul><ul><li>José E. Vidal, M.D., Ph.D </li></ul><ul><li>Instituto de Infectologia Emílio Ribas – SP - Brasil </li></ul><ul><li>Universidade de São Paulo – SP - Brasil </li></ul>
  2. 2. Neurological affections - HIV 30 – 90% (Harrison & McArthur, 1995) First manifestation: 20% (Comblain et al. , 2005)
  3. 3. <ul><li>HIV Neurology </li></ul><ul><li>High complexity management </li></ul><ul><li>Functional Impact </li></ul><ul><li>(Harrison & McArthur, 1995) </li></ul>
  4. 4. Primary HIV-related Secondary (Price RW. AIDS Medicine, 1989)
  5. 5. Incidence of CNS-Diseases during follow-up 0,1 1 10 100 1994 1995 1996 1997 1998 1999 2000 ≥ 2001 Non CNS-D (40% decline/year) CNS-D (40% decline/year) Incidence per 100 PYFU (95%CI) d’Arminio Monforte et al . Ann Neurol 2004;55:320-8
  6. 6. McArthur et al. J Neurovirol 2003;9:205-21
  7. 7. HAART ERA - DEVELOPED COUNTRIES Important reduction in morbidity and mortality in patients with AIDS (Hogg RS et al., 1998)
  8. 8. HIV-associated neurocognitive disorders <ul><li>Asymptomatic neurocognitive impairment </li></ul><ul><li>HIV-associated mild neurocognitive disorder </li></ul><ul><li>HIV-associated dementia </li></ul><ul><li>Antinori A et al . Neurology 2007;69:1789-99 </li></ul>
  9. 9. Change in the Natural History of ADC in HAART era: CD4 cell count “disconnect” 518 (Sacktor, Personal communication) 286 (Sacktor 2001) 150 MACS 1999-2001 Mean CD4 cell count/mm3 at diagnosis ADC 1996-1998 Mean CD4 cell count/mm3 at diagnosis ADC 1990-1995 Mean CD4 cell count/mm3 at diagnosis ADC Study
  10. 10. HIV-related Peripheral Neuropathies 260 34% Maschke et al, 2000 168 35% Schifitto et al, 2002 440 44% Cherry et al, 2002 Mean CD4 cell/uL count at time of testing Prevalence Symptomatic Peripheral Neuropathy Study
  11. 11. HIV/AIDS World Epidemic Underdeveloped nations - 90% of AIDS cases - 95% 0f New Cases ( UNAIDS/WHO, 2007 )
  12. 12. People living with HIV, Brazil 2005 600,000 people living with HIV (2004 estimated from 15 to 49 years-old) 197,000 (33%) Most of them are not aware of his/ her HIV status 178,000 On ARV therapy 225,000 Off therapy 403,000 (67%) Diagnosed cases DATASUS, SIH; Brazilian National STD/AIDS Program Risk of opportunistic diseases, including CNS complications
  13. 13. Clinical studies in the HAART era 2 Oliveira JF et al. Rev Soc Bras Med Trop 2006;39:146-51 3 Vidal et al. Rev Inst Med Trop S Paulo ( in press ) *Hisotlogy confirmed * *PCR (+) in CSF and in brain Brazil 2 n = 155 (%) Brazil 3 n = 219 (%) Toxoplasmosis 82 (42.3) 110 (50.2) Cryptococcosis 25 (12.9) 53 (24.2) CNS tuberculosis 21 (10.8) 32 (14.6) PML 7 (3.6) 12 (5.5) HIV-encephalopathy 9 (4.6) (not evaluated) PCNSL* 1 (0.5) 4 (1.8) CMV encephalitis 3 (1.6) -- HSV encephalitis 1 (0.5) -- Chagas disease -- 1 (0.4) BK virus encephalitis ** -- 1 (0.4)
  14. 14. Prevalence of cerebral toxoplasmosis in Sao Paulo Epidemiology Service - CRT/AIDS - Sao Paulo ~ 20 % ~ 10 % Year
  15. 15. Impact of HAART on incidence of cerebral toxoplasmosis 1 Abgrall et al. Clin Infect Dis 2001;33:1747-55 2 Gaspar et al. 14th International AIDS Conference. 2002. Abstract ThPeC7458 3 Guimarães. Cad Saúde Pública 2000;16(Suppl 1):21-36 Before HAART era (cases / 100 person-year) During HAART era (cases /100 person-year) France 1 Spain 2 Brazil 3 3.9 2.8 17.5 1 0.6 10  4-fold  5-fold  0.5-fold
  16. 16. n = 55 Deaths n = 3 Partial response n = 36 Complete response n = 16 Partial response n = 25 Complete response n = 23 Deaths n = 4 Partial response n = 21 Complete response n = 23 Deaths n = 2 Clinical outcome of 55 AIDS patients with TE D 14 D 42 1 YEAR TE = 2 NI = 1 NI = 4 PCP = 1 IPD = 1 13% 48% Vidal et al. AIDS Patient Care and STD 2005
  17. 17. Neurologic clinical series at IIER, São Paulo Vidal et al. 2005; Andrade et al . 2007; Poliseli et al. 2007; Croda et al . 2007 Toxoplasmosis n = 55 Cryptococcosis n = 34 Tuberculosis n = 86 Syphilis n = 27 Male 60% 77% 75% 89% Age (years) 36 35 35 35 Heterosexual Transmission 58% -- -- -- No previous HIV diagnosis 35% -- -- -- Previous AIDS-defining disease 25% 38% 44% 22% CD4+ cell count (cells/ µL) 64 29 64 182 Mortality 13% (at 6 w) 26% (in-hospital) 30% (in-hospital) 0%
  18. 18. Syndromic Approach of Opportunistic CNS Diseases in HIV-infected Patients Emilio Ribas Institute of Infectious Diseases, 2006 1. Cryptococcosis 2. Tuberculosis 3. Syphilis With mass effect: 1. Toxoplasmosis 2. Tuberculosis 3. PCNSL 4. Bacterial abscess 5. Chagas disease Without mass effect: 1. PML 2. CMV 3. VZV 4. HSV Meningeal syndrome Encephalopathy Focal Diffuse Predominant syndrome 1. HIV 2. PML 3. CMV 4. VZV 5. HSV
  19. 19. Algoritmo diagnóstico das lesões cerebrais focais em pacientes HIV+ Lesão expansiva / Captação de contraste/ (TC/RM) SIM NÃO IgG anti- T. gondii / PCR s - + <ul><li>Tuberculose </li></ul><ul><li>LPSNC </li></ul><ul><li>outras </li></ul>- LEMP - EOI - outras Toxoplasmose cerebral Prova terapêutica (2 semanas) LCR se possível IIER, 2006
  20. 20. Transporting advances in neurological complications of HIV/AIDS <ul><li>developed </li></ul><ul><li>countries </li></ul><ul><li>socio-economic limitations: </li></ul><ul><li>“ Same country, different worlds” </li></ul>Addapted from: Cinque P et al. J Neurovirol 2005(Suppl. 3):1-5 Human Developmen Report 2006. UNDP Latin America
  21. 21. Neurological complications of HIV/AIDS Addapted from: Cinque P et al. J Neurovirol 2005(Suppl. 3):1-5 Developed Latin countries America Advances in diagnosis: Clinical studies +++ + Pathologic studies +++ + Neuroimaging +++ + Molecular diagnosis +++ +/- Advances in treatment: HAART +++ + Specific treatment +++ + Limitations of treatment (PML, CMV) ++ +++ Rehabilitation ++ +/- Challenges: OI continues to occur + +++ IRIS ++ + HIV and aging ++ + Neurocognitive disorders ++ +/++
  22. 22. HIV-associated Neurological Diseases are common despite HAART <ul><li>Remains a considerable concern to HIV-infected patients </li></ul><ul><li>Cause of disabilities </li></ul><ul><li>Specific Programs, including focus in disabilities </li></ul>

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