SUPPLEMENT ARTICLE
HIV and Noncommunicable Diseases (NCDs) in Latin America: A Call for an Integrated and Comprehensive Response Brenda Crabtree-Ramírez, MD,* Carlos Del Río, MD,†‡ Beatriz Grinsztejn, MD, PhD,§ and Juan Sierra-Madero, MD*
Abstract: The life expectancy of people living with HIV has dramatically improved with the much increased access to antiretroviral therapy. Consequently, a larger number of people living with HIV are living longer and facing the increased burden of noncommunicable diseases (NCDs). NCDs and HIV infection share common epidemiologic and sociodemographic characteristics that influence their outcomes, which may be difficult to address in the relatively weak health systems of the region. Data on the prevalence and interactions of NCDs and HIV in Latin American countries remain very limited, which hinders their governments’ ability to make informed decisions about health care policies. Therefore, there is an urgent need to develop a research agenda that will be the basis for an integrated and comprehensive health care approach to HIV and NCD comorbidities in Latin America. Key Words: noncommunicable diseases, HIV/AIDS, Latin America and the Caribbean, aging with HIV, cardiovascular disease, cancer (J Acquir Immune Defic Syndr 2014;67:S96–S98)
INTRODUCTION Latin America, which in 2012 had an estimated 1.5 million adults and children living with HIV,1 has a concentrated HIV epidemic among men who have sex with men, sex workers, and people who inject drugs.1 Men who have sex with men in Latin America are over 30 times more likely to be HIV positive compared with heterosexual men of the same age.2 In contrast, in the Caribbean countries, the epidemic is smaller but more generalized, and women account for approximately half of all HIV infections.2,3 Life expectancy of people living with HIV (PLHIV) has dramatically improved with the advent of antiretroviral therapy (ART).4 As a consequence, a larger number of From the *Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Mexico City, Mexico; †Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, GA; ‡Emory University Center for AIDS Research, Atlanta, GA; and §Instituto de Pesquisa Clinica Evandro Chagas-Fundação Oswaldo Cruz, Rio de Janeiro, Brazil. The authors have no funding or conflicts of interest to disclose. Correspondence to: Juan Sierra-Madero, MD, Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Vasco de Quiroga #15, Col. Sección XVI, Tlalpan; C.P. 14000, Mexico City, Mexico (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
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PLHIV are living longer and facing the double challenge of HIV infection, with its required lifelong treatment, and the increasing burden of chronic noncommunicable diseases (NCDs) such as diabetes, cancer, cardiovascular and renal diseases, and other chronic conditions.5 Over the past several years, Latin America has been experiencing rapid urbanization and its related demographic and epidemiological transitions. NCDs now represent an important and growing burden for the health systems and economies of Latin American countries (LACs). Common to both HIV and NCDs is patients’ late presentation for diagnosis and treatment.6,7 Cardiovascular diseases (CVDs), stroke, cancer, and diabetes represent a large share of the burden of disease in LACs, accounting for 3 of every 4 deaths and for 2 of every 3 disability-adjusted life years lost.8 In Brazil, the first country in the region that provided universal access to ART, non–HIVrelated conditions have emerged as important causes of death in PLHIV, with an important rise in non–AIDS-related malignancies, and other comorbidities such as CVD and end-stage liver and renal diseases.8–10 The burden of NCDs on the health of individuals living with HIV is likely to increase as the population ages and risk factors such as unhealthy diets, sedentary lifestyle, tobacco use, and alcohol abuse continue to increase.11
CVD AND METABOLIC SYNDROME Currently, CVD is the leading cause of death in most LACs and the Caribbean (as predicted by WHO a decade ago),12 where there is a high prevalence of hypertension, hypercholesterolemia, diabetes, and metabolic syndrome among the general population.13 A large Latin American cohort of PLHIV receiving ART showed a higher estimated risk of CVD than the risk observed in a similar population in high-income countries,14 with 10.2% of individuals presenting a high risk of developing CVD as measured by the Framingham risk factor score. The prevalence of CVD among Latin American populations living with HIV varies among the countries in the region, being lower than 10% in Ecuador, Colombia, and Peru, and around 10%–20% in Argentina, Brazil, Chile, and Venezuela.15 There is evidence from Mexico that applying the Framingham score to the general population could underestimate the CVD and metabolic risk because of their unique genetic predisposition,16 pointing to a need to validate, for both HIV-infected and HIV-uninfected persons, the region-specific CVD, and metabolic disease risks.
J Acquir Immune Defic Syndr Volume 67, Supplement 1, September 1, 2014
J Acquir Immune Defic Syndr Volume 67, Supplement 1, September 1, 2014
Results from a Latin American cohort of 6007 PLHIV showed that a low nadir CD4+ count at entrance to care, which is still a common occurrence in Latin America, was associated with cardiovascular events.17 Studies from Brazil evaluating factors associated with carotid intima-media thickness in cohorts of PLHIV under care showed that traditional CVD risk factors were the major determinants of an increased carotid intima-media thickness.18,19 These results complement other studies from both high-income countries and LMICs20–22 that highlight the need for HIV treatment programs to address well-established risk factors for CVD, such as smoking, obesity, and hypertension. In fact, such CVD risk factors are more prevalent in PLHIV than in the general population,23,24 and efforts to include their prevention and treatment in HIV treatment programs must become a priority to ensure that the survival gains resulting from treating HIV infection are accompanied by long-term health outcomes.
NON-AIDS MALIGNANCIES According to the Pan American Health Organization, cancer is the second most frequent cause of death in the Americas, with 480,000 deaths in LACs. In South America, prostate, stomach, and lung cancers are the most prevalent cancers in men, whereas cervical cancer (Andean region) and breast cancer (Southern Cone) are the most common cancers in women.25 There is limited information on the types of cancers observed in PLHIV in Latin America. Several studies conducted by individual centers in the region have focused on AIDS-defining cancers (ADCs), mostly Kaposi sarcoma and non-Hodgkin lymphoma.26–31 More recently, the Caribbean, Central and South America Network for HIV Research (CCASAnet) studied the frequency of malignancies in their HIV cohort; 82% were ADCs. The most frequent non-ADCs were Hodgkin lymphoma and skin cancers, which tended to occur in individuals who were older than those with ADCs and diagnosed more than 1 year after HIV diagnosis.32 Moreover, survival probability did not statistically differ between people diagnosed with ADCs and those with non-ADCs. However, a preART ADC was a strong predictor of mortality after adjusting for age, sex, and CD4 at ART initiation. Studies from Brazil showed a high prevalence of highgrade anal intraepithelial lesions and infections with oncogenic human papillomavirus types among men with HIV who were under care, highlighting the need for screening programs for anal intraepithelial lesions among high-risk groups.33,34
CHRONIC KIDNEY DISEASE The incidence and prevalence of chronic kidney disease have been growing steadily in the general population in LACs, probably as a result of the increase in life expectancy, aging of the population, a growing epidemic of type-2 diabetes, and a fast epidemiologic transition across the region.35 National health surveys in Chile, Mexico, and Argentina have shown that 21% of the Chilean population had a creatinine clearance ,80 mL/min. Among those surveyed, 8.6% of Argentines, 14.2% of Chileans, and 9.2% of Mexicans had proteinuria.34,36 Ó 2014 Lippincott Williams & Wilkins
HIV and NCDs in Latin America
A cross-sectional study from Brazil evaluated the prevalence of decreased glomerular filtration rate (,60 mL$min21$1.73 m22) and associated risk factors in a large cohort of PLHIV using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation; it showed that lower glomerular filtration rate was uncommon (3.8%). Risk factors associated with decreased glomerular filtration included HIVrelated factors (a current CD4+ cell count ,350 cells/mm3), past exposure to tenofovir and indinavir, and degenerative and nephrotoxic factors (older age, diabetes, hypertension).37 The widespread use of indinavir in the early years of ART scale up, and more recently the preference of tenofovir-containing regimens for therapy, as well as the traditional risk factors for renal dysfunction in PLHIV (such as older age and low CD4 counts at presentation) highlight the importance of studying the occurrence of kidney disease among PLHIV in LACs.
CONCLUSIONS AND PERSPECTIVES As the impact of NCDs in LACs becomes clearer, priorities are slowly shifting toward the establishment of the infrastructure necessary for NCD prevention and management.38 However, there is a lack of integration of such activities with HIV care and vice versa. For example, some LACs have launched national programs for early diagnosis and management of diabetes, metabolic diseases, and cervical cancer,8,13,14 and the opportunity exists for such facilities to also serve as points of access for HIV counseling and testing—and thus, early HIV diagnosis. Although some may not consider HIV testing among the general population in a concentrated epidemic, a cost-effective approach in Latin America, data from the United States, where there is also a concentrated epidemic, suggests that routine, voluntary HIV testing is cost-effective.39 In fact, the U.S. Preventive Services Task Force has recently recommended that clinicians screen adolescents and adults aged between 15 and 65 years for HIV infection based on cost-effectiveness analyses.40 In addition, offering HIV care in community health care settings used for other conditions may improve early HIV diagnosis, and incorporating HIV testing into routine care for NCDs may also help address the HIV stigma prevailing in the region. In turn, where HIV services are well developed, ensuring that they are also geared to NCD challenges in their aging patients is a vital necessity. In summary, there is evidence that in Latin America, NCDs are a growing health problem generally and for PLHIV. However, data on the intersection of NCDs and HIV in the region remain very limited and insufficient to adequately inform national governments’ health care planning and resources allocation. Therefore, there is a clear and urgent need to develop a thorough HIV and NCD research agenda for the region. High-quality data generation should be encouraged and translated into comprehensive and integrated health care for PLHIV/AIDS in LACs. REFERENCES 1. Dutta A, Wirtz A, Stanciole A, et al. The global HIV epidemics among people who inject drugs. 2013. Available at: http://www.worldbank.org/ content/dam/Worldbank/document/GlobalHIVEpidemicsAmongPeople WhoInjectDrugs.pdf. Accessed July 8, 2014.
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2. Kort R. XVII International AIDS Conference: from evidence to action -AIDS 2008 and the global response to AIDS. J Int AIDS Soc. 2009;12 (suppl 1):S7. 3. Negin J, Martiniuk A, Cumming RG, et al. Prevalence of HIV and chronic comorbidities among older adults. AIDS. 2012;26(suppl 1): S55–S63. 4. Greig J, Casas E, O’Brien D, et al. Association between older age and adverse outcomes on antiretroviral therapy: a cohort analysis of programme data from nine countries. AIDS. 2012;26(suppl 1): S31–S37. 5. Justice AC, Braithwaite RS. Lessons learned from the first wave of aging with HIV. AIDS. 2012;26(suppl 1):S11–S18. 6. Crabtree-Ramirez B, Caro-Vega Y, Shepherd BE, et al. Cross-sectional analysis of late HAART initiation in Latin America and the Caribbean: late testers and late presenters. PLoS One. 2011;6:e20272. 7. Trujillo AJ, Fleisher LK. Beyond income, access, and knowledge: factors explaining the education gradient in prevention among older adults with diabetes and hypertension in Latin America. J Aging Health. 2013;25: 1398–1424. 8. Pacheco AG, Tuboi SH, Faulhaber JC, et al. Increase in non-AIDS related conditions as causes of death among HIV-infected individuals in the HAART era in Brazil. PLoS One. 2008;3:e1531. 9. Grinsztejn B, Luz PM, Pacheco AG, et al. Changing mortality profile among HIV-infected patients in Rio de Janeiro, Brazil: shifting from AIDS to non-AIDS related conditions in the HAART era. PLoS One. 2013;8:e59768. 10. Paula AA, Schechter M, Tuboi SH, et al. Continuous increase of cardiovascular diseases, diabetes, and non-HIV related cancers as causes of death in HIV-infected individuals in Brazil: an analysis of nationwide data. PLoS One. 2014;9:e94636. 11. Bonilla-Chacin M. Promoting Healthy Living in Latin America and the Caribbean: Governance of Multispectral Activities to Prevent Risk Factors for Noncomunicable Diseases. Directions in Development. Washington, DC: World Bank; 2014. 12. Murray C, Lopez A. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. Cambridge, United Kingdom: Harvard University Press; 1996. 13. Schargrodsky H, Hernandez-Hernandez R, Champagne BM, et al. CARMELA: assessment of cardiovascular risk in seven Latin American cities. Am J Med. 2008;121:58–65. 14. De Socio GV, Martinelli L, Morosi S, et al. Is estimated cardiovascular risk higher in HIV-infected patients than in the general population? Scand J Infect Dis. 2007;39:805–812. 15. Cahn P, Leite O, Rosales A, et al. Metabolic profile and cardiovascular risk factors among Latin American HIV-infected patients receiving HAART. Braz J Infect Dis. 2010;14:158–166. 16. Aguilar S, Gómez P, Lerman G, et al. Diagnóstico y tratamiento de las dislipidemias: posición de la Sociedad Mexicana de Nutrición y Endocrinología. Rev Endocrinol Nutr. 2004;12:1–36. 17. Belloso WH, Orellana LC, Grinsztejn B, et al. Analysis of serious nonAIDS events among HIV-infected adults at Latin American sites. HIV Med. 2010;11:554–564. 18. Albuquerque VM, Zirpoli JC, de Barros Miranda-Filho D, et al. Risk factors for subclinical atherosclerosis in HIV-infected patients under and over 40 years: a case-control study. BMC Infect Dis. 2013;13:274. 19. Fonseca Pacheco AG, Grinsztejn B, Fonseca MDJ, et al. Carotid intimamedia thickness (cIMT) in HIV-infected patients in Rio de Janeiro, Brazil: overall and gender analysis. Abstract #MOPE073. Presented at the 7th IAS Confernece on HIV Pathogenesis, Treatment and Prevention. Kuala Lampur, Malaysia, 2013. 20. Ssinabulya I, Kayima J, Longenecker C, et al. Subclinical atherosclerosis among HIV-infected adults attending HIV/AIDS care at two large ambulatory HIV clinics in Uganda. PLoS One. 2014;9:e89537.
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21. Mangili A, Polak JF, Skinner SC, et al. HIV infection and progression of carotid and coronary atherosclerosis: the CARE study. J Acquir Immune Defic Syndr. 2011;58:148–153. 22. Volpe GE, Tang AM, Polak JF, et al. Progression of carotid intima-media thickness and coronary artery calcium over 6 years in an HIV-infected cohort. J Acquir Immune Defic Syndr. 2013;64:51–57. 23. Vagenas P, Lama JR, Ludford KT, et al. A systematic review of alcohol use and sexual risk-taking in Latin America. Rev Panam Salud Publica. 2013;34:267–274. 24. Lee JG, Griffin GK, Melvin CL. Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review. Tob Control. 2009;18: 275–282. 25. PAHO. PAHO Plan of Action for Cancer Prevention & Control: Cancer Stakeholders Meeting, Fact Sheet: Cancer in Latin American and the Caribbean. Available at: http://www.paho.org/hq/index.php?option=com_ content&view=category&layout=blog&id=3595&Itemid=3637. Accessed July 8, 2014. 26. Bacchi CE, Bacchi M, Rabenhorst SH, et al. AIDS-related lymphoma in Brazil. Histopathology, immunophenotype, and association with EpsteinBarr virus. Am J Clin Pathol. 1996;105:230–237. 27. Collins JA, Hernandez AV, Hidalgo JA, et al. High proportion of T-cell systemic non-Hodgkin lymphoma in HIV-infected patients in Lima, Peru. J Acquir Immune Defic Syndr. 2005;40:558–564. 28. Ferrera A, Melchers W, Velema J, et al. Association of infections with human immunodeficiency virus and human papillomavirus in Honduras. Am J Trop Med Hyg. 1997;57:138–141. 29. Laurido M, Uruena A, Vizzotti C, et al. Incidence variation in malignancies associated or not with AIDS at an outpatient care center, 1997–2005 [in Spanish]. Medicina (B Aires). 2007;67:243–246. 30. Osorio SG, Montenegro U. Linfomas asociados a infección por virus de inmunodeficiencia humana en un complejo hospitalario de la Región Metropolitana, Chile: 1990–2002 [in Spanish]. Rev Chilena Infectol. 2007;24:117–124. 31. Sampaio J, Brites C, Araujo I, et al. AIDS related malignancies in Brazil. Curr Opin Oncol. 2007;19:476–478. 32. Fink VI, Shepherd BE, Cesar C, et al. Cancer in HIV-infected persons from the Caribbean, Central and South America. J Acquir Immune Defic Syndr. 2011;56:467–473. 33. Melo VH, Guimaraes MD, Rocha GM, et al. Prevalence and risk factors associated with anal intraepithelial neoplasia among HIV-positive men in Brazil. J Low Genit Tract Dis. 2014;18:128–135. 34. Friedman R, Coutinho J, Cunha C, et al. Prevalence of anal human papillomavirus (HPV) infection in a cohort of Brazilian men. Abstract WEPE502. Kuala Lampur, Malaysia: IAS; 2013. 35. Cusumano AM, Gonzalez Bedat MC. Chronic kidney disease in Latin America: time to improve screening and detection. Clin J Am Soc Nephrol. 2008;3:594–600. 36. Bellorin-Font E, Ambrosoni P, Carlini RG, et al. Clinical practice guidelines for the prevention, diagnosis, evaluation and treatment of mineral and bone disorders in chronic kidney disease (CKD-MBD) in adults. Nefrologia. 2013;33(suppl 1):1–28. 37. Santiago P, Grinsztejn B, Friedman RK, et al. Screening for decreased glomerular filtration rate and associated risk factors in a cohort of HIVinfected patients in a middle-income country. PLoS One. 2014;9:e93748. 38. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011–2022. Brasilia, Brasil: Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde; 2011: 1–148. Available at: http://www.paho.org/bra/index. php?option=com_content&view=article&id=2337&Itemid=1. Accessed July 10, 2014. 39. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States—an analysis of cost-effectiveness. N Engl J Med. 2005;352:586–595. 40. Moyer VA. Screening for HIV: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159:51–60.
Ó 2014 Lippincott Williams & Wilkins
HIV and Noncommunicable Diseases (NCDs) in Latin America: A Call for an Integrated and Comprehensive Response Brenda Crabtree-Ramírez, MD,* Carlos Del Río, MD,†‡ Beatriz Grinsztejn, MD, PhD,§ and Juan Sierra-Madero, MD*
Abstract: The life expectancy of people living with HIV has dramatically improved with the much increased access to antiretroviral therapy. Consequently, a larger number of people living with HIV are living longer and facing the increased burden of noncommunicable diseases (NCDs). NCDs and HIV infection share common epidemiologic and sociodemographic characteristics that influence their outcomes, which may be difficult to address in the relatively weak health systems of the region. Data on the prevalence and interactions of NCDs and HIV in Latin American countries remain very limited, which hinders their governments’ ability to make informed decisions about health care policies. Therefore, there is an urgent need to develop a research agenda that will be the basis for an integrated and comprehensive health care approach to HIV and NCD comorbidities in Latin America. Key Words: noncommunicable diseases, HIV/AIDS, Latin America and the Caribbean, aging with HIV, cardiovascular disease, cancer (J Acquir Immune Defic Syndr 2014;67:S96–S98)
INTRODUCTION Latin America, which in 2012 had an estimated 1.5 million adults and children living with HIV,1 has a concentrated HIV epidemic among men who have sex with men, sex workers, and people who inject drugs.1 Men who have sex with men in Latin America are over 30 times more likely to be HIV positive compared with heterosexual men of the same age.2 In contrast, in the Caribbean countries, the epidemic is smaller but more generalized, and women account for approximately half of all HIV infections.2,3 Life expectancy of people living with HIV (PLHIV) has dramatically improved with the advent of antiretroviral therapy (ART).4 As a consequence, a larger number of From the *Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Mexico City, Mexico; †Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, GA; ‡Emory University Center for AIDS Research, Atlanta, GA; and §Instituto de Pesquisa Clinica Evandro Chagas-Fundação Oswaldo Cruz, Rio de Janeiro, Brazil. The authors have no funding or conflicts of interest to disclose. Correspondence to: Juan Sierra-Madero, MD, Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Vasco de Quiroga #15, Col. Sección XVI, Tlalpan; C.P. 14000, Mexico City, Mexico (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
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PLHIV are living longer and facing the double challenge of HIV infection, with its required lifelong treatment, and the increasing burden of chronic noncommunicable diseases (NCDs) such as diabetes, cancer, cardiovascular and renal diseases, and other chronic conditions.5 Over the past several years, Latin America has been experiencing rapid urbanization and its related demographic and epidemiological transitions. NCDs now represent an important and growing burden for the health systems and economies of Latin American countries (LACs). Common to both HIV and NCDs is patients’ late presentation for diagnosis and treatment.6,7 Cardiovascular diseases (CVDs), stroke, cancer, and diabetes represent a large share of the burden of disease in LACs, accounting for 3 of every 4 deaths and for 2 of every 3 disability-adjusted life years lost.8 In Brazil, the first country in the region that provided universal access to ART, non–HIVrelated conditions have emerged as important causes of death in PLHIV, with an important rise in non–AIDS-related malignancies, and other comorbidities such as CVD and end-stage liver and renal diseases.8–10 The burden of NCDs on the health of individuals living with HIV is likely to increase as the population ages and risk factors such as unhealthy diets, sedentary lifestyle, tobacco use, and alcohol abuse continue to increase.11
CVD AND METABOLIC SYNDROME Currently, CVD is the leading cause of death in most LACs and the Caribbean (as predicted by WHO a decade ago),12 where there is a high prevalence of hypertension, hypercholesterolemia, diabetes, and metabolic syndrome among the general population.13 A large Latin American cohort of PLHIV receiving ART showed a higher estimated risk of CVD than the risk observed in a similar population in high-income countries,14 with 10.2% of individuals presenting a high risk of developing CVD as measured by the Framingham risk factor score. The prevalence of CVD among Latin American populations living with HIV varies among the countries in the region, being lower than 10% in Ecuador, Colombia, and Peru, and around 10%–20% in Argentina, Brazil, Chile, and Venezuela.15 There is evidence from Mexico that applying the Framingham score to the general population could underestimate the CVD and metabolic risk because of their unique genetic predisposition,16 pointing to a need to validate, for both HIV-infected and HIV-uninfected persons, the region-specific CVD, and metabolic disease risks.
J Acquir Immune Defic Syndr Volume 67, Supplement 1, September 1, 2014
J Acquir Immune Defic Syndr Volume 67, Supplement 1, September 1, 2014
Results from a Latin American cohort of 6007 PLHIV showed that a low nadir CD4+ count at entrance to care, which is still a common occurrence in Latin America, was associated with cardiovascular events.17 Studies from Brazil evaluating factors associated with carotid intima-media thickness in cohorts of PLHIV under care showed that traditional CVD risk factors were the major determinants of an increased carotid intima-media thickness.18,19 These results complement other studies from both high-income countries and LMICs20–22 that highlight the need for HIV treatment programs to address well-established risk factors for CVD, such as smoking, obesity, and hypertension. In fact, such CVD risk factors are more prevalent in PLHIV than in the general population,23,24 and efforts to include their prevention and treatment in HIV treatment programs must become a priority to ensure that the survival gains resulting from treating HIV infection are accompanied by long-term health outcomes.
NON-AIDS MALIGNANCIES According to the Pan American Health Organization, cancer is the second most frequent cause of death in the Americas, with 480,000 deaths in LACs. In South America, prostate, stomach, and lung cancers are the most prevalent cancers in men, whereas cervical cancer (Andean region) and breast cancer (Southern Cone) are the most common cancers in women.25 There is limited information on the types of cancers observed in PLHIV in Latin America. Several studies conducted by individual centers in the region have focused on AIDS-defining cancers (ADCs), mostly Kaposi sarcoma and non-Hodgkin lymphoma.26–31 More recently, the Caribbean, Central and South America Network for HIV Research (CCASAnet) studied the frequency of malignancies in their HIV cohort; 82% were ADCs. The most frequent non-ADCs were Hodgkin lymphoma and skin cancers, which tended to occur in individuals who were older than those with ADCs and diagnosed more than 1 year after HIV diagnosis.32 Moreover, survival probability did not statistically differ between people diagnosed with ADCs and those with non-ADCs. However, a preART ADC was a strong predictor of mortality after adjusting for age, sex, and CD4 at ART initiation. Studies from Brazil showed a high prevalence of highgrade anal intraepithelial lesions and infections with oncogenic human papillomavirus types among men with HIV who were under care, highlighting the need for screening programs for anal intraepithelial lesions among high-risk groups.33,34
CHRONIC KIDNEY DISEASE The incidence and prevalence of chronic kidney disease have been growing steadily in the general population in LACs, probably as a result of the increase in life expectancy, aging of the population, a growing epidemic of type-2 diabetes, and a fast epidemiologic transition across the region.35 National health surveys in Chile, Mexico, and Argentina have shown that 21% of the Chilean population had a creatinine clearance ,80 mL/min. Among those surveyed, 8.6% of Argentines, 14.2% of Chileans, and 9.2% of Mexicans had proteinuria.34,36 Ó 2014 Lippincott Williams & Wilkins
HIV and NCDs in Latin America
A cross-sectional study from Brazil evaluated the prevalence of decreased glomerular filtration rate (,60 mL$min21$1.73 m22) and associated risk factors in a large cohort of PLHIV using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation; it showed that lower glomerular filtration rate was uncommon (3.8%). Risk factors associated with decreased glomerular filtration included HIVrelated factors (a current CD4+ cell count ,350 cells/mm3), past exposure to tenofovir and indinavir, and degenerative and nephrotoxic factors (older age, diabetes, hypertension).37 The widespread use of indinavir in the early years of ART scale up, and more recently the preference of tenofovir-containing regimens for therapy, as well as the traditional risk factors for renal dysfunction in PLHIV (such as older age and low CD4 counts at presentation) highlight the importance of studying the occurrence of kidney disease among PLHIV in LACs.
CONCLUSIONS AND PERSPECTIVES As the impact of NCDs in LACs becomes clearer, priorities are slowly shifting toward the establishment of the infrastructure necessary for NCD prevention and management.38 However, there is a lack of integration of such activities with HIV care and vice versa. For example, some LACs have launched national programs for early diagnosis and management of diabetes, metabolic diseases, and cervical cancer,8,13,14 and the opportunity exists for such facilities to also serve as points of access for HIV counseling and testing—and thus, early HIV diagnosis. Although some may not consider HIV testing among the general population in a concentrated epidemic, a cost-effective approach in Latin America, data from the United States, where there is also a concentrated epidemic, suggests that routine, voluntary HIV testing is cost-effective.39 In fact, the U.S. Preventive Services Task Force has recently recommended that clinicians screen adolescents and adults aged between 15 and 65 years for HIV infection based on cost-effectiveness analyses.40 In addition, offering HIV care in community health care settings used for other conditions may improve early HIV diagnosis, and incorporating HIV testing into routine care for NCDs may also help address the HIV stigma prevailing in the region. In turn, where HIV services are well developed, ensuring that they are also geared to NCD challenges in their aging patients is a vital necessity. In summary, there is evidence that in Latin America, NCDs are a growing health problem generally and for PLHIV. However, data on the intersection of NCDs and HIV in the region remain very limited and insufficient to adequately inform national governments’ health care planning and resources allocation. Therefore, there is a clear and urgent need to develop a thorough HIV and NCD research agenda for the region. High-quality data generation should be encouraged and translated into comprehensive and integrated health care for PLHIV/AIDS in LACs. REFERENCES 1. Dutta A, Wirtz A, Stanciole A, et al. The global HIV epidemics among people who inject drugs. 2013. Available at: http://www.worldbank.org/ content/dam/Worldbank/document/GlobalHIVEpidemicsAmongPeople WhoInjectDrugs.pdf. Accessed July 8, 2014.
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2. Kort R. XVII International AIDS Conference: from evidence to action -AIDS 2008 and the global response to AIDS. J Int AIDS Soc. 2009;12 (suppl 1):S7. 3. Negin J, Martiniuk A, Cumming RG, et al. Prevalence of HIV and chronic comorbidities among older adults. AIDS. 2012;26(suppl 1): S55–S63. 4. Greig J, Casas E, O’Brien D, et al. Association between older age and adverse outcomes on antiretroviral therapy: a cohort analysis of programme data from nine countries. AIDS. 2012;26(suppl 1): S31–S37. 5. Justice AC, Braithwaite RS. Lessons learned from the first wave of aging with HIV. AIDS. 2012;26(suppl 1):S11–S18. 6. Crabtree-Ramirez B, Caro-Vega Y, Shepherd BE, et al. Cross-sectional analysis of late HAART initiation in Latin America and the Caribbean: late testers and late presenters. PLoS One. 2011;6:e20272. 7. Trujillo AJ, Fleisher LK. Beyond income, access, and knowledge: factors explaining the education gradient in prevention among older adults with diabetes and hypertension in Latin America. J Aging Health. 2013;25: 1398–1424. 8. Pacheco AG, Tuboi SH, Faulhaber JC, et al. Increase in non-AIDS related conditions as causes of death among HIV-infected individuals in the HAART era in Brazil. PLoS One. 2008;3:e1531. 9. Grinsztejn B, Luz PM, Pacheco AG, et al. Changing mortality profile among HIV-infected patients in Rio de Janeiro, Brazil: shifting from AIDS to non-AIDS related conditions in the HAART era. PLoS One. 2013;8:e59768. 10. Paula AA, Schechter M, Tuboi SH, et al. Continuous increase of cardiovascular diseases, diabetes, and non-HIV related cancers as causes of death in HIV-infected individuals in Brazil: an analysis of nationwide data. PLoS One. 2014;9:e94636. 11. Bonilla-Chacin M. Promoting Healthy Living in Latin America and the Caribbean: Governance of Multispectral Activities to Prevent Risk Factors for Noncomunicable Diseases. Directions in Development. Washington, DC: World Bank; 2014. 12. Murray C, Lopez A. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. Cambridge, United Kingdom: Harvard University Press; 1996. 13. Schargrodsky H, Hernandez-Hernandez R, Champagne BM, et al. CARMELA: assessment of cardiovascular risk in seven Latin American cities. Am J Med. 2008;121:58–65. 14. De Socio GV, Martinelli L, Morosi S, et al. Is estimated cardiovascular risk higher in HIV-infected patients than in the general population? Scand J Infect Dis. 2007;39:805–812. 15. Cahn P, Leite O, Rosales A, et al. Metabolic profile and cardiovascular risk factors among Latin American HIV-infected patients receiving HAART. Braz J Infect Dis. 2010;14:158–166. 16. Aguilar S, Gómez P, Lerman G, et al. Diagnóstico y tratamiento de las dislipidemias: posición de la Sociedad Mexicana de Nutrición y Endocrinología. Rev Endocrinol Nutr. 2004;12:1–36. 17. Belloso WH, Orellana LC, Grinsztejn B, et al. Analysis of serious nonAIDS events among HIV-infected adults at Latin American sites. HIV Med. 2010;11:554–564. 18. Albuquerque VM, Zirpoli JC, de Barros Miranda-Filho D, et al. Risk factors for subclinical atherosclerosis in HIV-infected patients under and over 40 years: a case-control study. BMC Infect Dis. 2013;13:274. 19. Fonseca Pacheco AG, Grinsztejn B, Fonseca MDJ, et al. Carotid intimamedia thickness (cIMT) in HIV-infected patients in Rio de Janeiro, Brazil: overall and gender analysis. Abstract #MOPE073. Presented at the 7th IAS Confernece on HIV Pathogenesis, Treatment and Prevention. Kuala Lampur, Malaysia, 2013. 20. Ssinabulya I, Kayima J, Longenecker C, et al. Subclinical atherosclerosis among HIV-infected adults attending HIV/AIDS care at two large ambulatory HIV clinics in Uganda. PLoS One. 2014;9:e89537.
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21. Mangili A, Polak JF, Skinner SC, et al. HIV infection and progression of carotid and coronary atherosclerosis: the CARE study. J Acquir Immune Defic Syndr. 2011;58:148–153. 22. Volpe GE, Tang AM, Polak JF, et al. Progression of carotid intima-media thickness and coronary artery calcium over 6 years in an HIV-infected cohort. J Acquir Immune Defic Syndr. 2013;64:51–57. 23. Vagenas P, Lama JR, Ludford KT, et al. A systematic review of alcohol use and sexual risk-taking in Latin America. Rev Panam Salud Publica. 2013;34:267–274. 24. Lee JG, Griffin GK, Melvin CL. Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review. Tob Control. 2009;18: 275–282. 25. PAHO. PAHO Plan of Action for Cancer Prevention & Control: Cancer Stakeholders Meeting, Fact Sheet: Cancer in Latin American and the Caribbean. Available at: http://www.paho.org/hq/index.php?option=com_ content&view=category&layout=blog&id=3595&Itemid=3637. Accessed July 8, 2014. 26. Bacchi CE, Bacchi M, Rabenhorst SH, et al. AIDS-related lymphoma in Brazil. Histopathology, immunophenotype, and association with EpsteinBarr virus. Am J Clin Pathol. 1996;105:230–237. 27. Collins JA, Hernandez AV, Hidalgo JA, et al. High proportion of T-cell systemic non-Hodgkin lymphoma in HIV-infected patients in Lima, Peru. J Acquir Immune Defic Syndr. 2005;40:558–564. 28. Ferrera A, Melchers W, Velema J, et al. Association of infections with human immunodeficiency virus and human papillomavirus in Honduras. Am J Trop Med Hyg. 1997;57:138–141. 29. Laurido M, Uruena A, Vizzotti C, et al. Incidence variation in malignancies associated or not with AIDS at an outpatient care center, 1997–2005 [in Spanish]. Medicina (B Aires). 2007;67:243–246. 30. Osorio SG, Montenegro U. Linfomas asociados a infección por virus de inmunodeficiencia humana en un complejo hospitalario de la Región Metropolitana, Chile: 1990–2002 [in Spanish]. Rev Chilena Infectol. 2007;24:117–124. 31. Sampaio J, Brites C, Araujo I, et al. AIDS related malignancies in Brazil. Curr Opin Oncol. 2007;19:476–478. 32. Fink VI, Shepherd BE, Cesar C, et al. Cancer in HIV-infected persons from the Caribbean, Central and South America. J Acquir Immune Defic Syndr. 2011;56:467–473. 33. Melo VH, Guimaraes MD, Rocha GM, et al. Prevalence and risk factors associated with anal intraepithelial neoplasia among HIV-positive men in Brazil. J Low Genit Tract Dis. 2014;18:128–135. 34. Friedman R, Coutinho J, Cunha C, et al. Prevalence of anal human papillomavirus (HPV) infection in a cohort of Brazilian men. Abstract WEPE502. Kuala Lampur, Malaysia: IAS; 2013. 35. Cusumano AM, Gonzalez Bedat MC. Chronic kidney disease in Latin America: time to improve screening and detection. Clin J Am Soc Nephrol. 2008;3:594–600. 36. Bellorin-Font E, Ambrosoni P, Carlini RG, et al. Clinical practice guidelines for the prevention, diagnosis, evaluation and treatment of mineral and bone disorders in chronic kidney disease (CKD-MBD) in adults. Nefrologia. 2013;33(suppl 1):1–28. 37. Santiago P, Grinsztejn B, Friedman RK, et al. Screening for decreased glomerular filtration rate and associated risk factors in a cohort of HIVinfected patients in a middle-income country. PLoS One. 2014;9:e93748. 38. Ministério da Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011–2022. Brasilia, Brasil: Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde; 2011: 1–148. Available at: http://www.paho.org/bra/index. php?option=com_content&view=article&id=2337&Itemid=1. Accessed July 10, 2014. 39. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States—an analysis of cost-effectiveness. N Engl J Med. 2005;352:586–595. 40. Moyer VA. Screening for HIV: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159:51–60.
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