Estudo da resistência genotípica primária aos antirretrovirais nos pacientes com vírus da imunodeficiência humana (HIV-1) no município de Santos/SP-Brasil
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Arquivos
Data
2009
Autores
Gagliani, Luiz Henrique [UNIFESP]
Orientadores
Diaz, Ricardo Sobhie [UNIFESP]
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Uma das principais causas de falência terapêutica é o surgimento de
cepas resistentes aos inibidores da transcriptase reversa (IRT) e da protease (IP). O
processo de replicação do vírus HIV – 1 promove alta taxa de mutação devido aos
erros inerentes à atividade da transcriptase reversa. Portanto, é comum em
indivíduos sob tratamento e com carga viral detectável, o surgimento e seleção de
cepas resistentes. O Estado de São Paulo é considerado como um dos epicentros
da epidemia de Aids no Brasil, sendo que o município de Santos possui um dos
maiores portos da América Latina e devido às rotas de comércio internacional atua
como introdutor e difusor do HIV – 1 no sudeste brasileiro, com uma alta incidência
de infecção, alta prevalência da resistência antirretroviral primária e de alta
prevalência de vírus recombinante B/F. Tem sido também reconhecido que a
falência virológica ao tratamento antirretroviral é alta nesta cidade, entretanto, não
existem dados recentes e abrangentes a respeito da caracterização genotípica, da
freqüência dos subtipos e resistência primária do HIV – 1. O objetivo do estudo foi
avaliar os perfis virológico e imunológico e a resistência primária em pacientes
virgens de tratamento aos medicamentos antirretrovirais e os fatores relacionados à
falência virológica após 48 semanas de HAART nesta população. Foram analisados
os prontuários dos pacientes recém diagnosticados e cadastrados no ano de 2000 e
2001, num total de 594 pacientes. Destes pacientes estudados no período citado,
apenas 315 realizaram os exames de quantificação da carga viral e a contagem da
subpopulações dos linfócitos TCD4+/TCD8+ no momento do seu diagnóstico.
Posteriormente dos 315 pacientes foram selecionados 80 virgens de tratamento aos
antirretrovirais, para a realização do exame de genotipagem, no qual foram
comparados os perfis demográficos do HIV – 1 entre os indivíduos com sucesso
virológico versus falência virológica após 48 semanas de iniciação aos
antirretrovirais. Os pacientes que realizaram a genotipagem (N=80), foram divididos
em dois grupos: Grupo 1 (N=43) são os pacientes que após a introdução do
tratamento aos antirretrovirais não conseguiram atingir os níveis de quantificação de
carga viral abaixo de 50 cópias/mL, isto é a carga viral se manteve detectável após
seis meses de tratamento. Grupo 2 (N=37) são os pacientes que conseguiram se
manter com os níveis de quantificação da carga viral, indetectáveis após seis meses
de tratamento. Todos os indivíduos estudados iniciaram HAART, sendo que foram
considerados aderentes aos antirretrovirais, de acordo com a frequência que
obtiveram as suas medicações prescritas pelo médico e a partir de uma farmácia
centralizada. O HIV - 1 foi seqüenciado na região pol a partir do plasma em amostras
armazenadas a – 80° C, coletadas imediatamente antes do início do tratamento. Ao
avaliar os pacientes (N=315) a contagem média das células TCD4+ foi de 320
células/µL. Destes pacientes 98 (31%) tinham TCD4+ menor que 200 células/µL, 69
(22%) TCD4+ entre 200 e 350 células/µL; 57 (18%) TCD4+ entre 350 e 500
células/µL e 91 (29%) com TCD4+ acima de 500 células/µL, mostrando a
importância do diagnóstico. Em relação a carga viral a média foi de 180.000
cópias/ml e o “log” médio foi de 4,28. Ainda referente a quantificação da carga viral
avaliou-se que 40,2% estavam, acima de 30.000 cópias/mL e 22% maior que
100.000 cópias/mL, indicando uma imunossupressão e mostrando a importância do
diagnóstico precoce do vírus HIV-1. A determinação da contagem das
subpopulações dos linfócitos TCD4+ e a quantificação da Carga viral do HIV – 1,
ambos exames representam a pedra angular no acompanhamento, estadiamento e a avaliação da resposta terapêutica dos antirretrovirais. Deve-se considerar também
que a determinação da contagem das subpopulações dos linfócitos TCD4+ é um
indicador do estágio evolutivo da doença, bem como o determinante fundamental na
terapêutica. Avaliar as condições imunológicas dos pacientes recém diagnosticados,
que chegam ao serviço de referência em Aids de Santos, é de grande valia, no
momento que inicia o tratamento médico, sendo justificado pelos resultados
apresentados, no qual destacamos que 53% dos pacientes tinham contagem de
TCD4+ menor que 350 células/µL do total estudado (N=315), indicando uma
imunossupressão, mostrando nitidamente a importância do diagnóstico precoce pelo
HIV-1, sabendo que, segundo os critérios do Consenso Nacional Brasileiro de
tratamento para a infecção pelo vírus HIV -1, os mesmos já deveriam estar fazendo
uso de medicações antirretrovirais. Quando analisamos a resistência primária dos
pacientes do Grupo 1 (N=43) 21 (48,8%) comparada com o Grupo 2 (N=37) 6
(16,2%), ao longo de 48 semanas concluímos que os pacientes do grupo 1 por
apresentarem maior prevalência de mutações relacionadas à resistência aos
fármacos antirretrovirais prescritos (p<0,005), eles não conseguiram atingir os níveis
de quantificação de carga viral abaixo de 50 cópias/mL, isto é, a carga viral se
manteve detectável após seis meses de tratamento até final do estudo. Em relação
às classes dos medicamentos antirretrovirais, os pacientes do grupo 1 e 2
apresentaram resistência de 16.2% aos IRTNN; 20% aos IRTN e 2,5% aos IP.
Quanto a resistência de pelo menos duas classes de ARVs (IRTNN e IRTN) foram
5% e não foi observado nenhum paciente resistente as três classes de ARVs. Na
determinação da prevalência dos subtipos do HIV – 1 baseada nas seqüências do
gene pol, a classificação filogenética das seqüências puras foi de 80% do subtipo B
e 7,5% F. Quanto as seqüências recombinantes B/F foi de 12,5% mostrando uma
preocupação epidemiológica na cadeia de transmissão porque essas cepas
recombinantes estão infectando novos indivíduos e predominando nos pacientes
recém diagnosticados. Não foram encontradas diferenças significativas basais
observadas na carga viral e níveis de TCD4+ com relação aos antirretrovirais
utilizados ou a demografia entre os 2 grupos, pacientes portadores de vírus
resistentes e tipo selvagem. A prevalência de 33,7% de resistência primária aos
antirretrovirais entre os pacientes foi considerada extremamente elevada nesta
região, portanto, em regiões atípicas como a cidade de Santos, seria de grande valia
apoiar o conceito de realizar exames de genotipagem antes de iniciar o tratamento
antirretroviral, fato fundamental, efetivo e econômico para o serviço público, embora
alguns indivíduos com resistência primária têm conseguido uma supressão viral
empírica sob HAART, a estreita associação entre a resistência primária e falência
virológica pode sugerir que essa resistência dificulte gradativamente a atividade dos
antirretrovirais.
One of the main causes of therapeutic failure is the appearance of strains resistant to reverse transcriptase inhibitors (NRTIs) and protease (PI). The process of replication of HIV - 1 promotes high rate of mutation due to errors inherent in the activity of reverse transcriptase. Therefore, it is common in individuals under treatment and with detectable viral load, the appearance and selection of resistant strains. The State of São Paulo is considered one of the epicenters of the AIDS epidemic in Brazil, and the city of Santos has one of the biggest ports of Latin America and because the routes of international trade acts as a diffuser and introducer of HIV -1 in the Southeast Brazil, with a high incidence of infection, high prevalence of primary antiretroviral resistance and high prevalence of recombinant viruses B/F. It has also been recognized that virological failure to antiretroviral treatment is high in this city, however, there are no recent and comprehensive data on the genetic characterization of the frequency of subtypes and primary resistance of HIV–1. The objective of the study was to evaluate the virological and immunological profiles and primary resistance in patients naïve to antiretroviral drugs treatment and the factors related to virological failure after 48 weeks of HAART in this population. We analyzed the charts of newly diagnosed patients registered in 2000 and 2001, as a total of 594 patients. From these patients studied during the period cited, only 315 were tested for quantification of viral load and counts of lymphocyte subpopulations of CD4+T cells/+ TCD8 at the time of diagnosis. Later among the 315 patients were selected 80 naïve to antiretroviral treatment, for the test for genotyping, in which were compared the demographic profiles of HIV-1 among individuals with virological success versus virological failure after 48 weeks of initiation of antiretroviral. Patients in which we performed genotyping (n = 80) were divided into two groups: Group 1 (N=43) are the patients that after the introduction of antiretroviral treatment failed to achieve the quantification levels of viral load below 50 copies/mL, in other words, the viral load remained detectable after six months of treatment. Group 2 (N=37) patients who were able to remain with the quantification of viral load on undetectable levels after six months of treatment. All studied subjects started HAART, which were considered adherent to antiretroviral according to how often they obtained their medications prescribed by a doctor and from a centralized drugstore. The HIV-1 was sequenced in the pol region from plasma samples stored at – 176ºC, collected immediately before starting treatment. When evaluating the patients (N=315) the average cell count CD4+T cells was 320 cells/µL. 98 (31%) of these patients had CD4+T cells below 200 cells/µL, 69 (22%) CD4+T cells between 200 and 350 cells/µL, 57 (18%) CD4+T cells between 350 and 500 cells/µL and 91 (29%) with CD4+T cells above 500 cells/µL, showing the importance of diagnosis. In relation to the average viral load was 180,000 copies/mL and the "log" average was 4.28. Still concerning the quantification of viral load assessed that 40.2% were above 30,000 copies/mL and 22% higher than 100,000 copies/mL, indicating an immunosuppression and showing the importance of early diagnosis of HIV-1. The determination of the counts of lymphocyte subpopulations of CD4+T cells and quantification of viral load of HIV-1, both tests represent a cornerstone in monitoring, staging and assessment of antiretroviral therapeutic response. One should also consider that the determination of the counts of lymphocyte subpopulations of CD4+T cells is an indicator of the stage of the disease, and the decisive role in therapy. To evaluate the immunological conditions of patients newly diagnosed who come to the referral service on AIDS of Santos, is of great value in the moment you start the treatment, being justified by the results presented, in which is highlighted that 53% of patients had counting CD4+T cells below 350 cells/ul from the total studied (N=315), indicating a immunosuppression, showing clearly the importance of early diagnosis of HIV-1, knowing that according to the criteria of the Brazilian Consensus for the treatment of HIV-1 infection, they should already be using antiretroviral medications. When we analyze the primary resistance of the patients in Group 1 (N = 43) 21 (48.8%) compared with Group 2 (N = 37) 6 (16.2%) during over 48 weeks we conclude that group 1 patients, due to higher prevalence of mutations associated with resistance to antiretroviral drugs prescribed (p<0.005), failed to achieve the quantification of viral load below 50 copies/mL, in other words, viral load remained detectable after six months of treatment by the end of the study. Concerning the classes of antiretroviral drugs, patients in group 1 and 2 showed resistance of 16.2% to IRTNN; 20% to IRTN and 2.5% to PI. Regarding the resistance of at least two classes of ARVs (IRTNN and IRTN) were 5% and there was no studied patient resistant to at least two of the three classes of ARVs. In determining the prevalence of subtypes of HIV -1 based on the pol gene sequences, the phylogenetic classification of pure sequences was 80% of subtype B and 7.5% F. As the sequences recombinant B/F it was 12.5% showing a concern in the epidemiological chain of transmission because these recombinant strains are infecting new individuals and are predominant in newly diagnosed patients. No significant baseline differences were observed in viral load and levels of CD4 + T cells regarding the antiretroviral used or the demographics between the 2 groups, patients with resistant virus and patients with the wild type. The 33.7% prevalence of primary resistance to antiretroviral among patients was considered extremely high in this region, so as atypical regions in the city of Santos, would be of great value to support the concept of conducting examinations of genotyping before starting treatment antiretroviral, indeed essential, effective and economical for the public service, although some individuals with primary resistance have achieved an empirical viral suppression under HAART, the close association between primary resistance and virological failure may suggest that this resistance make the activity of antiretroviral gradually difficult.
One of the main causes of therapeutic failure is the appearance of strains resistant to reverse transcriptase inhibitors (NRTIs) and protease (PI). The process of replication of HIV - 1 promotes high rate of mutation due to errors inherent in the activity of reverse transcriptase. Therefore, it is common in individuals under treatment and with detectable viral load, the appearance and selection of resistant strains. The State of São Paulo is considered one of the epicenters of the AIDS epidemic in Brazil, and the city of Santos has one of the biggest ports of Latin America and because the routes of international trade acts as a diffuser and introducer of HIV -1 in the Southeast Brazil, with a high incidence of infection, high prevalence of primary antiretroviral resistance and high prevalence of recombinant viruses B/F. It has also been recognized that virological failure to antiretroviral treatment is high in this city, however, there are no recent and comprehensive data on the genetic characterization of the frequency of subtypes and primary resistance of HIV–1. The objective of the study was to evaluate the virological and immunological profiles and primary resistance in patients naïve to antiretroviral drugs treatment and the factors related to virological failure after 48 weeks of HAART in this population. We analyzed the charts of newly diagnosed patients registered in 2000 and 2001, as a total of 594 patients. From these patients studied during the period cited, only 315 were tested for quantification of viral load and counts of lymphocyte subpopulations of CD4+T cells/+ TCD8 at the time of diagnosis. Later among the 315 patients were selected 80 naïve to antiretroviral treatment, for the test for genotyping, in which were compared the demographic profiles of HIV-1 among individuals with virological success versus virological failure after 48 weeks of initiation of antiretroviral. Patients in which we performed genotyping (n = 80) were divided into two groups: Group 1 (N=43) are the patients that after the introduction of antiretroviral treatment failed to achieve the quantification levels of viral load below 50 copies/mL, in other words, the viral load remained detectable after six months of treatment. Group 2 (N=37) patients who were able to remain with the quantification of viral load on undetectable levels after six months of treatment. All studied subjects started HAART, which were considered adherent to antiretroviral according to how often they obtained their medications prescribed by a doctor and from a centralized drugstore. The HIV-1 was sequenced in the pol region from plasma samples stored at – 176ºC, collected immediately before starting treatment. When evaluating the patients (N=315) the average cell count CD4+T cells was 320 cells/µL. 98 (31%) of these patients had CD4+T cells below 200 cells/µL, 69 (22%) CD4+T cells between 200 and 350 cells/µL, 57 (18%) CD4+T cells between 350 and 500 cells/µL and 91 (29%) with CD4+T cells above 500 cells/µL, showing the importance of diagnosis. In relation to the average viral load was 180,000 copies/mL and the "log" average was 4.28. Still concerning the quantification of viral load assessed that 40.2% were above 30,000 copies/mL and 22% higher than 100,000 copies/mL, indicating an immunosuppression and showing the importance of early diagnosis of HIV-1. The determination of the counts of lymphocyte subpopulations of CD4+T cells and quantification of viral load of HIV-1, both tests represent a cornerstone in monitoring, staging and assessment of antiretroviral therapeutic response. One should also consider that the determination of the counts of lymphocyte subpopulations of CD4+T cells is an indicator of the stage of the disease, and the decisive role in therapy. To evaluate the immunological conditions of patients newly diagnosed who come to the referral service on AIDS of Santos, is of great value in the moment you start the treatment, being justified by the results presented, in which is highlighted that 53% of patients had counting CD4+T cells below 350 cells/ul from the total studied (N=315), indicating a immunosuppression, showing clearly the importance of early diagnosis of HIV-1, knowing that according to the criteria of the Brazilian Consensus for the treatment of HIV-1 infection, they should already be using antiretroviral medications. When we analyze the primary resistance of the patients in Group 1 (N = 43) 21 (48.8%) compared with Group 2 (N = 37) 6 (16.2%) during over 48 weeks we conclude that group 1 patients, due to higher prevalence of mutations associated with resistance to antiretroviral drugs prescribed (p<0.005), failed to achieve the quantification of viral load below 50 copies/mL, in other words, viral load remained detectable after six months of treatment by the end of the study. Concerning the classes of antiretroviral drugs, patients in group 1 and 2 showed resistance of 16.2% to IRTNN; 20% to IRTN and 2.5% to PI. Regarding the resistance of at least two classes of ARVs (IRTNN and IRTN) were 5% and there was no studied patient resistant to at least two of the three classes of ARVs. In determining the prevalence of subtypes of HIV -1 based on the pol gene sequences, the phylogenetic classification of pure sequences was 80% of subtype B and 7.5% F. As the sequences recombinant B/F it was 12.5% showing a concern in the epidemiological chain of transmission because these recombinant strains are infecting new individuals and are predominant in newly diagnosed patients. No significant baseline differences were observed in viral load and levels of CD4 + T cells regarding the antiretroviral used or the demographics between the 2 groups, patients with resistant virus and patients with the wild type. The 33.7% prevalence of primary resistance to antiretroviral among patients was considered extremely high in this region, so as atypical regions in the city of Santos, would be of great value to support the concept of conducting examinations of genotyping before starting treatment antiretroviral, indeed essential, effective and economical for the public service, although some individuals with primary resistance have achieved an empirical viral suppression under HAART, the close association between primary resistance and virological failure may suggest that this resistance make the activity of antiretroviral gradually difficult.
Descrição
Citação
GAGLIANI, Luiz Henrique. Estudo da resistência genotípica primária aos antirretrovirais nos pacientes com vírus da imunodeficiência humana (HIV – 1) no Município de Santos / SP – Brasil. 2009.175 f. Tese (Doutorado em Ciências) – Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2009.