Jorge Arevalo

Etiologies and Manifestations of Persistent Diarrhea in Adults with HIV-1 Infection: A Case-Control Study in Lima, Peru

UNLABELLED OBJECTIVE We sought to determine the etiologies, manifestations, and risk factors for persistent (> or =7 days) diarrhea in human immunodeficiency virus type 1 (HIV-1)-infected persons in Peru. DESIGN The present study is a case-control study of 147 HIV-1-infected case subjects with persistent diarrhea and 147 HIV-1-infected control subjects without diarrhea. METHODS We obtained clinical, demographic, and exposure data, CD4 lymphocyte counts, and stool samples for detection of enteric parasitic and bacterial pathogens and rotavirus. RESULTS One or more enteric pathogen was identified in 55% of case subjects and 21% of control subjects (odds ratio adjusted for CD4 lymphocyte count, 3.8; 95% confidence interval, 2.2-6.5). The median CD4 lymphocyte count was highest with pathogen-free diarrhea and lowest with Cryptosporidium infection. Cryptosporidium species (the most frequent pathogen), Giardia lamblia, Aeromonas species, Campylobacter species, and rotavirus were all significantly associated with diarrhea. Bacterial pathogens were significantly associated with G. lamblia and rotavirus infection. Of the bacterial pathogens (Aeromonas, Campylobacter, Salmonella, and Vibrio species and enterotoxigenic Escherichia coli), only 24% were susceptible to cotrimoxazole, whereas 90% were susceptible to ciprofloxacin. In no case did the sensitivity or positive predictive value of specific clinical and laboratory findings for curable enteric infections exceed 50%. CONCLUSIONS Several enteric pathogens were associated with diarrhea in HIV-1-infected case subjects in Peru, especially among those who were heterosexual. Clinical findings were poor predictors of detectable microbial etiology. The guidelines for initial management of chronic diarrhea with sulfamethoxazole-trimethoprim in HIV-1-infected persons require revision, at least in settings where prophylaxis with this agent is common.

Multidrug-resistant Mycobacterium tuberculosis in HIV-Infected Persons, Peru

During 1999 to 2000, we identified HIV-infected persons with new episodes of tuberculosis (TB) at 10 hospitals in Lima-Peru and a random sample of other Lima residents with TB. Multidrug-resistant (MDR)-TB was documented in 35 (43%) of 81 HIV-positive patients and 38 (3.9%)of 965 patients who were HIV-negative or of unknown HIV status (p < 0.001). HIV-positive patients with MDR-TB were concentrated at three hospitals that treat the greatest numbers of HIV-infected persons with TB. Of patients with TB, those with HIV infection differed from those without known HIV infection in having more frequent prior exposure to clinical services and more frequent previous TB therapy or prophylaxis. However, MDR-TB in HIV-infected patients was not associated with previous TB therapy or prophylaxis. MDR-TB is an ongoing problem in HIV-infected persons receiving care in public hospitals in Lima and Callao; they represent sentinel cases for a potentially larger epidemic of nosocomial MDR-TB.

Burden of depression among impoverished HIV-positive women in Peru.

Objectives:In resource-poor settings, the mental health burden among HIV-positive women is exacerbated by poverty. We sought to describe the extent, risk factors, and experience of depression among impoverished HIV-positive women living in Lima, Peru. Methods:This is a case series of 78 HIV-positive women in Lima, Peru. We measured depression, stigma, and social support and performed a multivariable analysis to identify factors associated with depression. Results:Among 78 HIV-positive patients, 68% were depressed. Depression and suicidal ideation were rarely diagnosed by providers. In multivariable analysis, HIV-related stigma and food scarcity were associated with depression. Conclusions:In our cohort of HIV-positive women in Lima, Peru, poverty and socioeconomic vulnerability contributed to depression. Findings highlight the heavy burden of depression in this cohort of poor women and the need to incorporate mental health services as an integral component of HIV care.

Screening for sexually transmitted diseases in human immunodeficiency virus-positive patients in Peru reveals an absence of Chlamydia trachomatis and identifies Trichomonas vaginalis in pharyngeal specimens

To determine the prevalence of sexually transmitted diseases (STDs), we screened 107 human immunodeficiency virus-positive patients in Peru, where the virus is predominantly sexually transmitted. Patients had multiple risk factors for STDs, and 38% of women and 50% of men had at least 1 STD (gonorrhea, trichomoniasis, herpes simplex, anogenital warts, or syphilis seropositivity). No chlamydial infection was detected, even though infection rates in the general population are 5%-12%. Patients receiving trimethoprim-sulfamethoxazole(TMP-SMZ) for prophylaxis or treatment of respiratory infections were least likely to have cervicitis and/or urethritis (odds ratio, 0.37; 95% confidence interval, 0.15-0.89). Although not optimal treatment, administration of TMP-SMZ is effective against chlamydial infection. We speculate that the use of concomitant medications, such as TMP-SMZ, may be inadvertently preventing chlamydial infection in this population. Another finding was the presence of Trichomonas vaginalis in pharyngeal specimens of 3 men with histories of orogenital activity. This has not been previously reported and requires further study.

Prevalence of sexually transmitted infections and high-risk sexual behaviors in heterosexual couples attending sexually transmitted disease clinics in Peru.

Objectives: The objectives of this study were to determine the prevalence of sexually transmitted infection (STIs) in heterosexual couples and the sexual behaviors associated with their acquisition. Goal: The goal of this study was to better direct educational efforts to decrease STI among heterosexual couples in Lima, Peru. Study Design: We conducted a case-control study in 195 heterosexual couples without HIV infection who attended 2 sexually transmitted disease clinics in Lima, Peru. A case was defined as an individual with one or more newly diagnosed STIs such as gonorrhea, chlamydia, trichomoniasis, herpes simplex, syphilis, mycoplasma, or ureaplasma. Results: Thirty-three percent of individuals (41 men and 89 women) had at least one STI and 26 couples (13%) had the same STI detected. Men who have sex with men (MSM) accounted for 13% of all men, had higher rate of STIs and higher risk behaviors than non-MSM. Ureaplasma infection was the most prevalent STI found in both men and women and was associated with oral sexual contact. In heterosexual pairs, condom use during anal sex occurred less than 10% of the time. Conclusions: The heterosexual couples in sexually transmitted disease clinics have high-risk behaviors and STIs are frequent. The educational effort concerning prevention of STIs requires higher effort.

Mala calidad de sueño en pacientes que reciben terapia anti-retroviral de gran actividad: ¿necesidad de evaluación en la práctica ambulatoria?

Sr. Editor: El manejo de un paciente infectado por el virus de inmunodefi ciencia humana (VIH) implica un enfoque multidisciplinario que incluya diversas esferas de la salud de la persona1. Sin embargo, en muchas oportunidades la evaluación se centra en marcadores meramente biológicos descuidando aspectos de índole psicológico y social que tendrían importante repercusión en la calidad de vida de estos pacientes. Dentro de ellos, las alteraciones del sueño (AS), son un factor a considerar, más aún cuando han demostrado tener un impacto negativo en la calidad de vida de las personas2, asimismo, un incremento de la probabilidad de desarrollo de diabetes mellitus, enfermedad cardiovascular y dolencias respiratorias3. Por otro lado, el tratamiento anti-retroviral de alta actividad (TARGA) es uno de los pilares actuales en el manejo del paciente infectado por VIH, al ser una intervención de alto impacto que ha permitido una marcada reducción en la mortalidad y morbilidad, con especial énfasis en la disminución de infecciones oportunistas.4 No obstante, ha de reconocerse que uno de los factores claves asociados al éxito del tratamiento es la adherencia al mismo –situación que ha sido reconocida en diversas regiones y por diversos estudios– la cual puede verse afectada por múltiples factores y condiciones1. Si bien se ha descrito que el reconocimiento y tratamiento tardíos de los trastornos del sueño tendría una infl uencia negativa sobre la adherencia al TARGA, a su vez tendría implicancias de alta importancia en materia clínica y subsecuentemente en salud pública. Sin embargo, también puede ocurrir la asociación pero en sentido inverso, pues el TARGA tiene efectos adversos que podrían repercutir de modo negativo en el sistema nervioso, tanto a nivel periférico como central, donde el área de sueño se vería afectada de manera signifi cativa5,6. La calidad de sueño en población que recibe TARGA es un área interesante; sin embargo, al parecer no se encuentran series publicadas de esta realidad en América Latina resultando pertinente y novedoso efectuar una investigación que explore la frecuencia de los trastornos del sueño en este tipo de pacientes4. En ese sentido, nosotros llevamos a cabo una investigación piloto de corte transversal sobre un total de 22 pacientes del citado nosocomio a quienes se les aplicó la escala de calidad del sueño de Pittsburg, la escala de somnolencia diurna de Epworth y la escala de insomnio de Atenas, en sus versiones validadas al español. Un total de 15 pacientes tuvo mala calidad de sueño, 9 insomnios y 5 somnolencia diurna. Asimismo, la totalidad de los participantes tenía baja adherencia. Por lo expuesto previamente, el profesional de la salud debería incluir una visión más integral en la práctica clínica, en la que se tenga en cuenta los hábitos de sueño del paciente y tener presente que una buena calidad de sueño debe ser considerada como una forma esencial de un estilo de vida saludable, junto a una correcta nutrición, hacer ejercicio físico y evitar la práctica de hábitos nocivos4

Mental Health Burden Among Impoverished HIV-Positive Patients in Peru

HIV and poor mental health are intricately related. In settings of poverty, both are often rooted in structural factors related to material and social deprivation. We performed a qualitative analysis to understand factors contributing to poor emotional health and its impact among impoverished Peruvian HIV-infected individuals. We conducted focus group discussions with patients and providers consisting of semistructured, open-ended questions. Qualitative analysis provided insight into the profound impact of depression, isolation, stigma, and lack of social support among these patients. Living with HIV contributed significantly to mental health problems experienced by HIV-positive individuals; furthermore, long-standing stressors—such as economic hardship, fragmented family relationships, and substance use—shaped patients’ outlooks, and may have contributed not only to current emotional hardship but to risk factors for contracting HIV as well. Once diagnosed with HIV/AIDS, many patients experienced hopelessness, stigma, and socioeconomic marginalization. Patients tended to rely on informal sources of support, including peers and community health workers, and rarely used formal mental health services. In resource-poor settings, the context of mental health problems among HIV-positive individuals must be framed within the larger structural context of poverty and social exclusion. Optimal strategies to address the mental health problems of these individuals should include integrating mental health services into HIV care, task shifting to utilize community health workers where human resources are scarce, and interventions aimed at poverty alleviation.