From: https://espanol.medscape.com/verarticulo/5906943
By Roxana Tabakman
The life expectancy of people living with human immunodeficiency virus (HIV) in Latin America is almost comparable to that of those without the virus infection, according to a retrospective analysis of 30,000 participants from Argentina, Brazil, Chile, Haiti, Honduras, Mexico and Peru.
"It's a collaborative study between seven Latin American countries that form a network for epidemiological studies of human immunodeficiency virus. This allows us to draw conclusions based on large datasets; these studies wouldn't be possible with individual databases," explained Dr. Carina Cesar, an infectious disease specialist and member of the Clinical Research Area at the Huésped Foundation in Buenos Aires, Argentina.
Dr. Claudia P. Cortés, from the Arriarán Foundation and the Faculty of Medicine at the University of Chile in Santiago, Chile, stated: “More data on the human immunodeficiency virus is needed in Latin America and the Caribbean, and there are several countries in Latin America for which there is practically no information. Latin America and the Caribbean are large, heterogeneous, and diverse regions, with fewer resources available for clinical studies and research on the disease.”
“This work is very important because it shows how life expectancy has improved over time in the region. It is an example that it is possible to do quality science in Latin America. When there is no good quality data, there is no reference point for making appropriate interventions for the region,” added Dr. Brenda Crabtree Ramírez, an infectious disease specialist and researcher in the Department of Infectious Diseases at the Salvador Zubirán National Institute of Medical Sciences and Nutrition in Mexico City, Mexico.
A life expectancy of 69.9 to 78 years with greater gains in the period from 2013 to 2017
The authors analyzed data on adults who initiated antiretroviral treatment at institutions belonging to the Caribbean, Central, and South American HIV Epidemiology Network (CCASAnet) during three periods (2003–2008, 2009–2012, and 2013–2017). Slightly more than half of the patients were from Haiti; the remainder were from Peru (34.4%), Brazil (25.2%), Chile (19.6%), Honduras (7.8%), Mexico (8.9%), and Argentina (4.2%). Results were evaluated separately for Haiti and the other participants.
The life expectancy of this cohort reaches 69.9 years in Haiti and 78.0 in the rest.
Women have a longer life expectancy than men: 65.3 years in Haiti and 81.4 years in the other countries. For men, it is 56 years in Haiti and 58.8 years in the other countries for heterosexual men and 67 years for men who have sex with men.
Mortality rates decreased in all age groups throughout the three periods studied.
The greatest gains in life expectancy in the study occurred in the last period (2013-2017). Improvements in overall 20-year life expectancy for people with human immunodeficiency virus correlate with greater treatment availability. During that period, the World Health Organization (WHO) stopped recommending treatment decisions based on CD4 cell counts and, in 2015, began the era of treatment for all HIV-positive patients.
At the end of the study, the life expectancy of participants with CD4 counts greater than 200 cells/μl was 84.8 years, and for those with CD4 counts less than 200 cells/μl, it was 52.7 years. In Haiti, the ages were lower, but the trend remained the same.
According to the authors, the increased life expectancy among patients starting antiretroviral treatment with CD4 cell counts of more than 200 cells/μl supports the need for early detection of the human immunodeficiency virus and initiation of antiretroviral treatment.
"The biggest change was the treatment for everyone, regardless of the clinical stage, plus the improvement in antiviral programs in each country, which allowed for better access to treatment. Since patients with effective treatment have lower morbidity and mortality, this translates into an increase in years of life," summarized Dr. Cesar.
The specialist explained that although quality of life was not evaluated, the treatment has evolved in the last 15 years and today is very potent, better tolerated and with fewer adverse effects, therefore the better tolerance means a lower dropout rate.
Challenges, limitations and opportunities
"We believe these results should encourage people to get tested for HIV and begin antiviral treatment. The healthcare system should make testing even easier, develop new strategies to ensure diagnosed patients begin treatment as quickly as possible, and it's also essential that non-specialist physicians incorporate testing into their daily practice," he concluded.
Currently in Argentina it is estimated that between 25% and 30% of those infected are not diagnosed.
The authors acknowledged some limitations. Many patients were lost to follow-up, which may lead to an overestimation of life expectancy. The study included only people starting antiretroviral treatment for the first time and does not reflect all people with human immunodeficiency virus receiving care. Furthermore, most of the institutions are located in major urban centers.
"It's important to say that this study doesn't reflect what happens in Mexico, what happens to patients receiving care at the Salvador Zubirán National Institute of Medical Sciences and Nutrition in Mexico City. I don't know if it's the same in a small clinic in Chiapas. I mean, it's just one example of what's possible, but it doesn't necessarily happen everywhere or for everyone equally."
"Latin America is a very unequal region, where health equity is a utopian term," Dr. Crabtree Ramirez pointed out.
These are other, not so positive, conclusions from the study.
In a period of contrasts and…setbacks?
Medscape in Spanish spoke with Dr. Debora Fontenelle, from the Pedro Ernesto University Hospital of the State University of Rio de Janeiro, who has been accompanying patients with human immunodeficiency virus/acquired immunodeficiency syndrome since 1994.
The specialist, who was not involved in the study, said: "That research, which goes up to 2017, made me nostalgic. It shows the obvious: that antiretroviral treatment increases survival; earlier treatment is key."
“But from what I see with my patients, the challenge has increased for people with vulnerabilities.” Since then, what she observes in her patients from vulnerable areas of Brazil is a downward trend where “treatment is guaranteed, but benefits have been lost.” The doctor explains how “most places don’t have free transportation to get to the health unit.” She also mentions a decrease in the size of the teams, which no longer include a social support team that provides comprehensive assistance in people’s lives, even though they retain the doctors.
He also points out that "violence interferes with therapeutic compliance. There are patients who don't come to the appointment because that day there is a police operation or a drug war and they can't go because of the shooting."
Dr. Fontenelle stated that even the stigma and prejudice have worsened, and she has observed a setback in demystification and a reduction in fear. "People have gone back to hiding their condition from their families; they take medication in secret, and therefore, if they get sick, no one will seek treatment. When I started, there were few treatments available, and faith was the only option. Now there are treatments, but I'm again having problems with people who frequent church, where they are told to stop taking their medication."
"There are good things: single-dose treatment, we clear up doubts via WhatsApp, which allows us to communicate by audio with those who can't read; even so, they need to have a smartphone. If this research were done now, there could be surprises," he concluded.
Factors that also have an effect on life expectancy are: educational level (upper secondary education: 75.5 years and without upper secondary education: 57.0 years; for Haiti: 77.7 and 53.3, respectively) and history of tuberculosis (reduced from 74.1 to 48.0 years and from 66.6 and 44.1 years in Haiti).
Casi la mitad de las personas con virus de inmunodeficiencia humana incluidas en este estudio inició el tratamiento antirretroviral con recuentos de CD4 de menos de 200 cel/μl en los tres periodos. Para interpretar la magnitud de lo que esto significa, el análisis de CCASAnet 2020, con más de 9.000 adultos con la enfermedad, encontró que 86% de las muertes en el primer año, 71% de las muertes en los primeros 5 años y 58% de las muertes en los primeros 10 años después de la inscripción podrían haberse evitado si los pacientes se hubieran inscrito en la atención e iniciado el tratamiento antirretroviral antes de la progresión a la enfermedad avanzada (definida como recuento CD4 < 200 cel/μl).
In a commentary linked to the article, Drs. Lara Coelho and Paula Luz of the Evandro Chagas National Institute of Infectology in Rio de Janeiro, Brazil, who were not involved in the study, stated: "Unfortunately, the current challenges for Latin America and the Caribbean remain the same as in the early 2000s: high prevalence of late initiation of antiretroviral treatment and widespread socioeconomic inequalities."
Doctors Coelho and Luz also highlighted that late initiation of antiretroviral treatment remains the main modifiable risk factor for mortality in Latin America and the Caribbean.
And then the pandemic arrived.
The COVID-19 pandemic added to the existing challenges. All those interviewed agree that the gains in life expectancy among people with human immunodeficiency virus could decrease.
In Mexico, "a new government took office at the same time as the pandemic; we can't say that this trend of increased life expectancy is necessarily happening right now. Many patients have suffered shortages, they get depressed at home, they don't want to go out for their medications because they're afraid, and therefore, they discontinue treatment. How big is this problem? It hasn't been measured, we don't know," stated Dr. Crabtree Ramírez.
Dr. Cesar adds that the disruption of infection control practices in Argentina and throughout the region has also contributed to the problem. “In many places, healthcare has been so focused on COVID-19 that checkups for other HIV-related conditions have been postponed. Patients requiring urgent care are being seen, but it is very likely that in the coming months or years we will see a higher proportion of patients with late diagnoses due to the delays in seeking medical attention caused by the pandemic,” she added.
And in their commentary, Doctors Coelho and Luz conclude: "We anticipate that the syndemic effects of the COVID-19 pandemic in the region will disproportionately affect the most vulnerable groups, including people living with human immunodeficiency virus."