*Oswaldo Cruz University Hospital

HIV in HUOC*, Recife-PE, BrazilRicardo Bonifácio – Medical Resident

All HIV-infected and AIDS patients are entitled to free and universal access to medicines for treatment

Law 9.313/96

aids.gov.br

2001

1st patent breaking - Nelfinavir

US$ 1,36/pill US$ 0,40Savings of 35.2 million dollars – 100.000 HIV-infected patients

Patents to be broken: DRV, RAL, DTG*, MVC

2016

2005

Brazil: 0.4-0.7% population living with HIV 1.3 million people>> Recife: 12.150 (+ 0.75%)

>>> HUOC: 2530 patients (20.8% of patients in Recife)

Epidemiology (2015)

Oswaldo Cruz University Hospital

Infectious Disease Department32 hospital beds1 ICU – 7 beds

uniaids.org.brreuters.comfoxnews.com

• FOX News: Boy, 15, becomes 1 of only 3 known rabies survivors worldwide• REUTERS: Boy makes rare recovery from rabies

National Guideline (PCDT)TDF intolerance1st option: AZT2nd option: ABC3rd option: ddI

2nd line treatment = EFV intolerance

• LPV/r (PCDT) although HUOC rather use ATV/r• FPV/r is also an option but rarely used

Salvage TreatmentEtravirineDarunavirRaltegravirDolutegravir*Maraviroc

Options available after genotyping

That´s it!Thanks!

HIV/AIDS in BrazilFirst line ARV therapy and data on local transmitted

resistance

Letícia Ziggiotti de Oliveira, MD

Brazilian Guidelines on HIV/AIDS (National Ministery of Health)

• Who should we treat? Everyone living with HIV.

• Genotypic testing for HIV drug resistance is not wide available prior to ARV initiation.

Alternatives:AZT; ABC

Alternatives:LPV/r, ATV/r

Available on: http://www.aids.gov.br/publicacao/2013/protocolo-clinico-e-diretrizes-terapeuticas-para-manejo-da-infeccao-pelo-hiv-em-adulAccessed on July, 17th, 2016.

TENOFOVIR + LAMIVUDINE + EFAVIRENZFisrt line therapy

http://www.aids.gov.br/publicacao/2013/protocolo-clinico-e-diretrizes-terapeuticas-para-manejo-da-infeccao-pelo-hiv-em-adul

What do we know about local transmitted drug resistance (TDR) so far…

•Recent meta-analysis: Brazil —> 50 surveys between 2000-2015 (n=4.954)1

• 7 National surveys in multiple sites from different regions;

• Those performed before or around 2005 showed low TDR prevalence (

What do we know about local transmitted drug resistance (TDR) so far…

• 43 surveys separately according to the macro-regions of the country:Southeast (23 surveys), South (8 surveys), Central-West (7 surveys),Northeast (5 surveys). No surveys have been performed in the Northernregion.

• More recent surveys (after 2005) have shown moderate and eventhreshold high levels of TDR to any ARV class in Southeast: 10.7% inpregnant women in Rio de Janeiro, 14.1% in MSM in Belo Horizonte/Riode Janeiro and 15.7% in people seeking HIV diagnosis in voluntarycounseling and testing sites in Rio de Janeiro.1

• Increasing trends in TDR both in Rio de Janeiro and Sao Paulo can be observed,reaching high levels (>15%) in many of the most recent surveys, and with NRTIand NNRTI being the most affected drug classes.1

Avila-Rios S, Sued O, Rhee S-Y, Shafer RW, Reyes-Teran G, Ravasi G (2016) Surveillance of HIV Transmitted Drug Resistance in Latin America and the Caribbean: A Systematic Review and Meta- Analysis. PLoS ONE 11(6): e0158560. doi:10.1371/ journal.pone.0158560

Is it time to “update” our National Guidelines?

• The most recent multicenter brazilian study identified variable prevalences of TDR across thecountry, from intermediate (5 -15%) to high ( 15%), according to geographic region. Theprevalence of resistance was 6.9% to NRTIs and 4.9% to NNRTIs.2

• In general, an increasing trend in overall TDR can be seen in most regions of Brazil, reachingmoderate levels in most capital cities in the South, Central-West and Northeast regions; low TDRlevels in the Northeast; and high TDR levels reported in the most recent surveys on the Rio de Janeiroand Sao Paulo macro urban centers at the Southeast region.1

• In a meta-analysis, a significant temporal increase in overall TDR was observed, which was associatedwith a significant increase in NNRTI TDR and frequency of K103N and G190A mutations. Although nosignificant change was observed in NRTI TDR prevalence, there was a significant decrease in thefrequency of M41L.1

1. Avila-Rios S, Sued O, Rhee S-Y, Shafer RW, Reyes-Teran G, Ravasi G (2016) Surveillance of HIV Transmitted Drug Resistance in Latin America and the Caribbean: A Systematic Review and Meta- Analysis. PLoS ONE 11(6): e0158560. doi:10.1371/

journal.pone.0158560

2 d M S CMP t l J l f th I t ti l AIDS S i t 2014 17 19042

Thank you!

Brazil_BonifacioSlide Number 1Slide Number 2Slide Number 3Slide Number 4Slide Number 5

Brazil_ZiggiottiHIV/AIDS in BrazilBrazilian Guidelines on HIV/AIDS (National Ministery of Health)What do we know about local transmitted drug resistance (TDR) so far…What do we know about local transmitted drug resistance (TDR) so far…Is it time to “update” our National Guidelines?Slide Number 6