A Randomized, Placebo-Controlled Trial of Abacavir Intensification in HIV-1–Infected Adults With Virologic Suppression on a Protease Inhibitor–Containing Regimen

HIV Clinical Trials, 01/17/2011

Hammer SM et al. – The strategy of intensification with abacavir in patients who are virologically suppressed on a stable antiretroviral regimen does not confer a clinical or virologic benefit. As antiretroviral regimens have become more potent since this trial was completed, it will be even more difficult to prove that late intensification of already virologically suppressed patients will add benefit. However, studies are warranted with drugs with new mechanisms of action to determine whether the level of persistent viremia below 50 copies/ mL can be further reduced and what influence this may have on latent HIV reservoirs.

http://www.mdlinx.com/family-medicine/sdoc-article.cfm/3448375

Cognitive and psychosocial development of HIV pediatric patients receiving highly active anti-retroviral therapy: a case-control study

Abstract
Background: The psychosocial development of pediatric HIV patients has not been extensively evaluated. The
study objectives were to evaluate whether emotional and social functions are differentially associated with HIVrelated
complications.
Methods: A matched case-control study design was conducted. The case group (n = 20) consisted of vertically
infected children with HIV (aged 3-18 years) receiving HAART in Greece. Each case was matched with two randomly
selected healthy controls from a school-based population. CNS imaging and clinical findings were used to identify
patients with HIV-related neuroimaging abnormalities. The Wechsler Intelligence Scale III and Griffiths Mental Abilities
Scales were applied to assess cognitive abilities. The age specific Strengths and Difficulties Questionnaire was used to
evaluate emotional adjustment and social skills. The Fisher’s exact test, student’s t-test, and Wilcoxon rank sum test
were used to compare categorical, continuous, and ordinal scores, respectively, of the above scales between groups.
Results: HIV patients without neuroimaging abnormalities did not differ from patients with neuroimaging
abnormalities with respect to either age at HAART initiation (p = 0.306) or months of HAART treatment (p = 0.964).
While HIV patients without neuroimaging abnormalities had similar cognitive development with their healthy
peers, patients with neuroimaging abnormalities had lower mean General (p = 0.027) and Practical (p = 0.042)
Intelligence Quotient scores. HIV patients without neuroimaging abnormalities had an increased likelihood of both
Abnormal Emotional Symptoms (p = 0.047) and Hyperactivity scores (p = 0.0009). In contrast, HIV patients with
neuroimaging abnormalities had an increased likelihood of presenting with Abnormal Peer Problems (p = 0.033).
Conclusions: HIV patients without neuroimaging abnormalities are more likely to experience maladjustment with
respect to their emotional and activity spheres, while HIV patients with neuroimaging abnormalities are more likely
to present with compromised social skills. Due to the limited sample size and age distribution of the study
population, further studies should investigate the psychosocial development of pediatric HIV patients following the
disclosure of their condition.

http://www.biomedcentral.com/content/pdf/1471-2431-10-99.pdfhttp://www.biomedcentral.com/content/pdf/1471-2431-10-99.pdf

Markers of atherosclerosis and inflammation and mortality in patients with HIV infection☆

Este es un artículo que nos hace ver la realidad de la atención integral en los pacientes que viven con VIH.

Espero que les sea útil

Saludos 

Dr. Carlos Erazo

http://www.atherosclerosis-journal.com/article/PIIS0021915010009135/abstract?rss=yes

Abstract 

Objective

HIV-infected patients are at increased risk for cardiovascular disease, which may be mediated in part by inflammation. Surrogate marker studies suggest an increased prevalence of vascular abnormalities in HIV infection. We examined the association of all-cause mortality in HIV-infected patients with carotid artery intima-media thickness (cIMT) and high-sensitivity C-reactive protein (hsCRP).

Design and methods

Baseline risk factors, cIMT and hsCRP were prospectively measured in 327 HIV-infected participants. Follow-up time with median of 3.1 years was calculated from baseline to death or censored dated 7/31/07. Cox Proportional Hazards models were used to study risk factors associated with mortality.

Results

Thirty-eight (11.6%) of participants have died since study enrollment. cIMT was significantly higher in those who died and decedents were significantly more likely to have cIMT above the 75th percentile. Those who died had higher hsCRP than those alive and more had hsCRP values above 3mg/L. CD4 count was lower and log10 viral load was higher in decedents, but antiretroviral regimens were similar in both groups. cIMT and hsCRP levels were significantly associated with mortality (HR=2.74, 95% CI 1.26–5.97, p=0.01; HR=2.38, 95% CI 1.15–4.9, p=0.02).

Conclusions

Our study demonstrated a strong association of carotid IMT and hsCRP with all-cause death in this HIV-infected population despite being similar with respect to exposure to antiretroviral medications. Together these surrogate markers may be indices of chronic inflammation and unfavorable outcomes in HIV-positive patients.

Oral Tenofovir/FTC for Pre-Exposure Prophylaxis: The iPrEx Study

In the first-ever efficacy trial of antiretroviral-based pre-exposure prophylaxis, once-daily oral tenofovir significantly reduced the risk for HIV acquisition among men who have sex with men.
The use of antiretroviral therapy (ART) for HIV prevention holds great promise, as demonstrated by two major trials this year: First, the CAPRISA 004 study demonstrated a 39% reduction in the risk for HIV acquisition among women who used a 1% tenofovir vaginal gel both shortly before and shortly after sex (JW AIDS Clin Care Jul 26 2010). Second, a phase II study demonstrated the safety of oral tenofovir monotherapy as pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) (Abstract FRLBC102, AIDS 2010). Now, results are available from iPrEx, the first-ever efficacy trial of ART-based PrEP.
Nearly 2500 HIV-negative MSM in South America, the U.S., Thailand, and South Africa were randomized 1:1 in double-blinded fashion to receive once-daily oral tenofovir/FTC or placebo. Both groups received condoms and intensive counseling regarding sexual risk behavior, and every 4 weeks, underwent rapid enzyme-linked immunosorbent assay (ELISA) testing. All participants were screened and treated for urethral sexually transmitted infections (STIs) and syphilis at study entry, every 24 weeks on-study, and for any clinical suspicion of STIs.
During 3324 person-years of follow-up (median, 1.2 years), 36 incident HIV infections were identified in the tenofovir/FTC group versus 64 in the placebo group, for a relative risk reduction of 44% (95% confidence interval, 15%–63%). As was seen in CAPRISA 004, efficacy was strongly related to product use, with risk reductions as follows:

• 32% (95% CI, –41%–67%) at adherence levels <50%
  
• 50% (95% CI, 18%–70%) at adherence levels 50%
  
• 73% (95% CI, 41%–88%) at adherence levels 90%
  

Adverse events and discontinuations were similar between groups, except for an early excess of nausea and weight loss in the tenofovir/FTC group. Serum creatinine elevations occurred in 25 patients in the tenofovir/FTC group versus 14 in the placebo group (P=0.08); all were resolved upon drug discontinuation. Risk compensation (an increase in high-risk sexual behavior in response to perceived protection from the intervention) was not observed in either treatment group.
Viral set points and CD4-cell counts were similar throughout follow-up between patients who seroconverted in the tenofovir/FTC group and those who did so in the placebo group. No drug resistance was observed among those who seroconverted on-study. A nested case-control analysis indicated that most seroconversions within the tenofovir/FTC group likely occurred when the drug was not detectable in plasma or intracellular compartments.
Comment: Although the overall efficacy of PrEP in this study (44%) is disappointing compared to projected estimates, the results demonstrate proof-of-principle and suggest that greater efficacy is possible with higher adherence levels. Interestingly, the case-control analysis hints that taking the drug shortly before exposure might be more relevant to efficacy than overall adherence levels are. Ongoing trials exploring different preparations, components, and intervals of ART within various at-risk populations will help clarify the optimal use of ART as a prevention tool. In the meantime, decisions about policy around ART as prevention — and about the obligations of research teams to offer PrEP and/or tenofovir-based microbicide gel as part of future prevention trials — just got exponentially more complicated.
— Raphael J. Landovitz, MD
Dr. Landovitz is Assistant Professor, Division of Infectious Diseases, Center for Clinical AIDS Research and Education, University of California, Los Angeles. He reports no conflicts of interest.
Published in Journal Watch HIV/AIDS Clinical Care November 23, 2010

Citation(s):

Grant RM et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010 Nov 23; [e-pub ahead of print]. (http://dx.doi.org/10.1056/NEJMoa1011205)

Michael NL. Oral preexposure prophylaxis for HIV — Another arrow in the quiver? N Engl J Med 2010 Nov 23; [e-pub ahead of print]. (http://dx.doi.org/10.1056/NEJMe1012929)

Interim Guidance: Preexposure Prophylaxis for the Prevention of HIV Infection in Men Who Have Sex with Men

The iPrEx study was conducted in Peru, Ecuador, Brazil, Thailand, South Africa, and the United States. Eligible participants were consenting HIV-uninfected men and male-to-female transgender adults (aged ≥18 years) who reported sex with a man and reported engaging in high-risk sexual behaviors during the preceding 6 months, and had no clinical contraindication to taking a combined formulation of 300 mg TDF and 200 mg FTC (TDF/FTC).*

LINK: http://www.cdc.gov/mmwr/pdf/wk/mm6003.pdf

HIV/AIDS Clinical Care / Guía del CDC para profilaxis pre exposición para HSH

HIV/AIDS Clinical Care

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HIV/AIDS Clinical Care for February 14, 2011 CLINICAL PRACTICE GUIDELINE WATCH Interim CDC Guidance on Pre-Exposure Prophylaxis for HIV Prevention in MSM Free! February 14, 2011 | Raphael J. Landovitz, MD, MSc In the wake of the iPrEx study, the CDC offers some general guiding principles for the implementation of pre-exposure prophylaxis. Reviewing: Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 2011 Jan 28; 60:65 SUMMARY AND COMMENT What's the Best Way to Measure ART Adherence? February 14, 2011 | Keith Henry, MD The matter is neither simple nor settled. Reviewing: McMahon JH et al. Clin Infect Dis 2011 Feb 15; 52:493 SUMMARY AND COMMENT More Evidence that Treatment Interruptions Are Not SMART February 14, 2011 | Yasir Ahmed, MD, and Helmut Albrecht, MD Intermittent antiretroviral therapy results in inferior CD4-cell recovery and increased rates of opportunistic infections and death, compared to continuous therapy. Reviewing: Kaufmann GR et al. AIDS 2011 Feb 20; 25:441 SUMMARY AND COMMENT Not So Fast: Hepatitis B Vaccination in HIV-Infected Patients February 14, 2011 | Rajesh T. Gandhi, MD An accelerated vaccination schedule improves compliance but sacrifices efficacy in those with CD4 counts <500 cells/mm3. Reviewing: de Vries-Sluijs TEMS et al. J Infect Dis 2011 Jan 25; SUMMARY AND COMMENT Pulmonary Disease in HIV February 14, 2011 | Paul E. Sax, MD Both infectious and noninfectious pulmonary diseases were more common among HIV-positive patients than among HIV-negative controls. Reviewing: Crothers K et al. Am J Respir Crit Care Med 2011 Feb 1; 183:388 SUMMARY AND COMMENT Starting and Switching Antiretroviral Therapy in Children February 14, 2011 | Holly Rawizza, MD First-line PI- and NNRTI-based therapies offer equivalent virologic efficacy in children without prior exposure to NNRTIs. However, when failure occurs, an immediate switch is necessary for those on NNRTIs. Reviewing: The PENPACT-1. (PENTA 9/PACTG 390) Study Team. Lancet Infect Dis 2011 Feb 1; SUMMARY AND COMMENT HIV and Stroke February 9, 2011 | Rajesh T. Gandhi, MD The proportion of hospitalized stroke patients who are HIV-infected is increasing; multiple reasons are likely. Reviewing: Ovbiagele B and Nath A. Neurology 2011 Feb 1; 76:444 Free Full-Text Article Clinical Practice Guideline Watch Interim CDC Guidance on Pre-Exposure Prophylaxis for HIV Prevention in MSM In the wake of the iPrEx study, the CDC offers some general guiding principles for the implementation of pre-exposure prophylaxis. The iPrEx study recently demonstrated proof-of-principle for the efficacy of oral chemoprophylaxis in preventing HIV infection among men who have sex with men (MSM). Daily tenofovir/FTC (Truvada) was associated with a 44% reduction in the risk for HIV acquisition, relative to placebo; efficacy was strongly associated with medication adherence (JW AIDS Clin Care Nov 23 2010). These results are tremendously exciting, but many questions remain about the appropriate use of pre-exposure prophylaxis (PrEP) in real-world clinical settings. On January 28, 2011, the CDC offered some interim guidance. The key points are as follows: PrEP should be considered for use only in MSM who are at ongoing high risk for HIV acquisition. PrEP candidates should undergo conventional HIV antibody testing to ensure that they are HIV-negative. Those with signs or symptoms of acute HIV infection should undergo viral-load testing or nucleic acid amplification testing (NAAT). All candidates should be screened for other sexually transmitted infections (STIs) and for hepatitis B. Tenofovir/FTC, dosed at 1 tablet daily, is the only currently recommended PrEP regimen. It should not be used in people with creatinine clearance <60 mL/minute. PrEP should be prescribed for only 3 months at a time, to ensure appropriate follow-up. Every 2 to 3 months, PrEP recipients should receive HIV antibody testing, counseling regarding risk reduction and medication adherence, and assessment for possible signs and symptoms of STIs. STI testing should be conducted every 6 months. Serum creatinine levels should be assessed 3 months after PrEP initiation and then yearly. HIV antibody testing should be performed at discontinuation of PrEP. Comment: These guidelines provide basic recommendations for clinicians who are interested in implementing PrEP based on the data that are currently available. The recommendation for follow-up every 2 to 3 months is clearly a concession to the reality that monthly follow-up (as was done in iPrEx) is unlikely to be feasible or practical outside the research setting. Many prevention experts will also take issue with the instruction to provide baseline viral-load testing and NAAT only to candidates who are clinically symptomatic; in the iPrEx study, investigators inadvertently enrolled 10 individuals with acute HIV infection, presumably because they were asymptomatic. Given the resistance consequences of missing such infection, one could argue that if an individual is at sufficient risk to warrant PrEP intervention, he should be screened at baseline with both HIV antibody testing and viral-load testing or NAAT. Alternatively, the fourth-generation HIV test that involves both antigen and antibody detection could be employed as a compromise between sensitivity and cost for detection of acute infection. More formal PrEP guidelines from the U.S. Department of Health and Human Services and the FDA are eagerly anticipated and are likely to include guidance on the type of provider that should be prescribing PrEP, application to other populations, and longer-term safety follow-up. — Raphael J. Landovitz, MD, MSc Dr. Landovitz is Assistant Professor, Division of Infectious Diseases, Center for Clinical AIDS Research and Education, University of California, Los Angeles. He reports no conflicts of interest. Published in Journal Watch HIV/AIDS Clinical Care February 14, 2011 Citation(s): Centers for Disease Control and Prevention (CDC). Interim guidance: Preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. MMWR Morb Mortal Wkly Rep 2011 Jan 28; 60:65. (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6003a1.htm) Medline abstract (Free)

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School: a place for children to learn their HIV status?

Estimados colegas, les dejo otro editorial interesante, la escuela puede ser el lugar donde los niños sepan y aprendan de su estatus serologico.
Saludos
Dr. Carlos Erazo

http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673611601839.pdf

"The South African Government has announced that it will soon launch a controversial step in its national campaign to test 15 million people for HIV by June this year. Under the plans, children and adolescents will be off ered voluntary HIV testing and counselling in high schools. The details of the initiative are thin at present. The health department has promised that the campaign will be “professional” and “responsible”; that testing will be done in private spaces on school premises during weekends and school holidays; that it will be phased in; and that extensive monitoring and evaluation will be done. An expert task team has been set up to work on implementation, including the provision of ageappropriate counselling, support, and care, and they will make their recommendations public in due course. The team has a lot to address. Under South African law, children aged 12 years and older can give consent to a HIV test. But how should a health worker determine whether consent provided by a 12-year-old or adolescent is suffi ciently informed? Will those who test positive get access to antiretroviral therapy? How will health workers ensure confi dentiality? Will children be pressured by peers or parents to divulge their test results? Will condoms be given to those who come for testing? And how often will testing be off ered? The task team should also be allowed to consider whether schools are the best place for children to learn their HIV status. Problems in the national HIV testing and counselling campaign, launched last April, also heed a cautionary warning. Monitoring and evaluation of the campaign has been poor and there have been reports of HIVpositive people not being referred for treatment, clinics not complying with national testing and counselling protocols, and anecdotal reports of coercive testing. 18% of young people (15–24 years) in South Africa report having fi rst sex by 15 years, and early sexual debut is associated with increased risk of HIV infection.
Improving access to age-appropriate HIV testing, treatment, and counselling for children and adolescents is, therefore, important. But South Africa must take its time and consider how best to do this, to ensure the campaign does not do more harm than good."  The Lancet

Potential utility of empirical tuberculosis treatment for HIV-infected patients with advanced immunodeficiency in high TB-HIV burden settings [Unresolved issues]

Estimados colegas , aquí les dejo otro artículo interesante sobre la co infección VIH-TB
Saludos 
Dr. Carlos Erazo
http://www.ingentaconnect.com/content/iuatld/ijtld/2011/00000015/00000003/art00002

Authors: Lawn, S.D.¹; Ayles, H.²; Egwaga, S.³; Williams, B.⁴; Mukadi, Y.D.⁵; Santos Filho, E.D.⁶; Godfrey-Faussett, P.⁷; Granich, R.M.⁸; Harries, A.D.⁹

Abstract:
"The human immunodeficiency virus (HIV) and HIV-associated tuberculosis (TB-HIV) epidemics remain uncontrolled in many resource-limited regions, especially in sub-Saharan Africa. The scale of these epidemics requires the consideration of innovative bold interventions and `out-of-the-box' thinking. To this end, a symposium entitled `Controversies in HIV' was held at the 40th Union World Conference on Lung Health in Cancun, Mexico, in December 2009. The first topic debated, entitled `Annual HIV testing and immediate start of antiretroviral therapy for all HIV-infected persons', received much attention at international conferences and in the literature in 2009. The second topic forms the subject of this article. The rationale for the use of empirical TB treatment is premised on the hypothesis that in settings worst affected by the TB-HIV epidemic, a subset of HIV-infected patients have such a high risk of undiagnosed TB and of associated mortality that their prognosis may be improved by immediate initiation of empirical TB treatment used in conjunction with antiretroviral therapy. In addition to morbidity and mortality reduction, additional benefits may include prevention of nosocomial TB transmission and TB preventive effect. Potential adverse consequences, however, may include failure to consider other non-TB diagnoses, drug co-toxicity, compromised treatment adherence, and logistical and resource challenges. There may also be general reluctance among national TB programmes to endorse such a strategy. Following fruitful debate, the conclusion that this strategy should be carefully evaluated in randomised controlled trials was strongly supported. This paper provides an in-depth consideration of this proposed intervention"

Keywords: empirical treatment; tuberculosis; HIV; Africa; mortality

CHIPREV ESTUDIO DE PREVALENCIA DE VIH Y FACTORES ASOCIADOS EN HOMBRES QUE TIENEN SEXO CON HOMBRES

 Este es otro estudio realizado en Chile sobre la prevalencia de HSH y sus factores asociados.
Saludos
Dr. Carlos Erazo

http://www.scribd.com/doc/34664715/Estudio-de-Prevalencia-de-VIH-y-Factores-Asosidados-en-Hombres-que-tienen-Sexo-con-Hombre-Chile-Enero-2009

"El informe final del Estudio de Prevalencia de VIH y Factores Asociados en Hombres que Tienen Sexo con Hombres (CHIPREV), representa el último documento elaborado en el marco del estudio, con el objetivo de dar a conocer los principales resultados de la investigación realizada en la Región Metropolitana.

En cuanto a su estructura, este informe se divide en siete partes o capítulos que

pueden sintetizarse de la siguiente manera:

•En primer lugar se incluye un resumen ejecutivo que señala brevemente la importancia del estudio, la metodología aplicada y los resultados más relevantes.

•Luego se presenta el detalle de los antecedentes que justificaron la realización de esta investigación, considerando el contexto epidemiológico internacional y nacional, así como las experiencias en materia de vigilancia epidemiológica desarrolladas previamente en Chile.

•En tercera instancia se exponen los aspectos metodológicos del estudio, incluyendo una detallada descripción de sus objetivos, el tipo de muestreo utilizado, y los  procedimientos y actividades que permitieron su implementación.

•A continuación se presentan los resultados referidos al proceso de reclutamiento, considerando el comportamiento de las cadenas de participantes derivadas de cada semilla incorporada al estudio, así como el cierre de los casos mediante la entrega de los resultados serológicos a los participantes.

•En la siguiente sección se exponen las características de las semillas o participantes iniciales de la investigación, así como la descripción de la muestra lograda, mediante un análisis efectuado a partir del programa SPSS.

•El capítulo de análisis de resultados se basa en el análisis estadístico realizado a través el programa RDSAT y permite conocer los resultados del estudio en cuanto a prevalencia de VIH, así como en relación a otras variables socio comportamentales y su vinculación con los resultados serológicos.

•Finalmente se detallan las conclusiones de la investigación, referidas a los aprendizajes metodológicos derivados de esta primera experiencia chilena con un muestreo basado en quienes responden y a la interpretación de los principales resultados generados."

SEXUALIDAD MASCULINA Y VIH EN BOLIVIA

 Estimados colegas  este estudio es interesante para entender otros estudios que se están realizando en el país.
Saludos
Dr. Carlos Erazo


http://www.ombres.org.gt/documentos/sexualidad-vih-bolivia.pdf

"Se trata del primer estudio desarrollado en Bolivia utilizando el método de muestreo RDS y el Software RDSAT para el análisis de la información; aspectos que permitieron obtener la seroprevalencias del VIH y de las ITS (herpes y sífilis) y conocer el comportamiento de la población de hombres que tienen sexo con hombres."

HIV and Stroke

"The proportion of hospitalized stroke patients who are HIV-infected is increasing; multiple reasons are likely.

Although HIV infection and specific antiretroviral agents have been linked to cardiovascular disease, little is known about the incidence of stroke in HIV-infected patients. To explore this topic, investigators examined time trends in the proportion of hospitalized stroke patients who have HIV infection.

The researchers analyzed data from the Nationwide Inpatient Sample, which includes discharge information on a large number of patients hospitalized throughout the U.S. They used ICD-9 codes to identify hospitalizations for stroke and applied a weighting factor to correct for potential overascertainment. They derived rate denominators from U.S. census data, including for the total number of persons living with HIV.

Between 1998 and 2006, the stroke-hospitalization rate in the general HIV-negative population decreased by 17% (from 375 to 311 per 100,000 persons). In contrast, the rate in the HIV-positive population — after an initial period of decline before 2001 — increased by 43% (from 90 to 129 per 100,000) between 2001 and 2006. Of all patients hospitalized with stroke, 0.09% were HIV-positive in 1997 and 0.15% were HIV-positive in 2006. This increase in the proportion of patients with HIV infection was seen for ischemic stroke but not for subarachnoid or intracerebral hemorrhage. During the study period, the prevalence of other risk factors for stroke, such as hypertension, increased in the HIV-infected population.

Comment: Although this study shows that a growing proportion of patients hospitalized for stroke are HIV-infected, it does not tell us why. The finding may be related, in part, to the fact that HIV-infected patients are now living long enough to develop complications such as stroke. Moreover, risk factors for stroke may be more common in HIV-infected patients than in the general population — this is certainly true for smoking. The authors speculate that HIV infection, metabolic derangements, or antiretroviral medications could be contributing to risk for stroke, but more research is needed before firm conclusions can be drawn.

— Rajesh T. Gandhi, MD

Published in Journal Watch Infectious Diseases February 9, 2011

Citation(s):

Ovbiagele B and Nath A. Increasing incidence of ischemic stroke in patients with HIV infection. Neurology 2011 Feb 1; 76:444.

• Original article (Subscription may be required)
• Medline abstract (Free)

A Recipe for Medical Schools to Produce Primary Care Physicians

Estimados colegas este artículo publicado en el New England Journal of Medicine , habla sobre la necesidad de más médicos de atención primaria.

Saludos 

Dr. Carlos Erazo

http://www.nejm.org/doi/full/10.1056/NEJMp1012495?query=TOC

The implementation of health care reform in the United States will add to the growing demand for primary care physicians. Only about a third of active physicians in this country currently practice primary care medicine, and the proportion would probably shrink if the only source of new primary care physicians were graduates of U.S. allopathic medical schools, since only 16 to 18% of those graduates are likely to go into primary care.1

Our country would be better served if an adequate supply of primary care services were available. Health care systems that rely too much on specialty care services are less efficient and more expensive than their counterparts that are focused on primary care.2 Preventive care, care coordination for the chronically ill, and continuity of care, which are the hallmarks of primary care, can all improve the overall quality of services that patients receive.

It seems clear to me that we need to find a way to increase the number of graduates of U.S. allopathic medical schools who go into primary care. The alternatives are to allow the status quo to continue (with larger proportions of primary care physicians being international medical graduates and graduates of osteopathic medical schools), to allow advanced practice nurses and physician assistants to assume a greater role in providing primary care, or to allow primary care to dwindle and move toward a system in which patients are cared for by multiple specialists. As someone who spent nearly a quarter of a century as an associate dean for medical education, I am loath to give up on the possibility that allopathic medical schools can do a better job of getting their graduates to go into primary care.

The recent launching of new allopathic medical schools provides an especially good opportunity to design the medical education experience in a way that fosters student selection of primary care careers. A majority of the new schools state that their mission is to produce primary care physicians or, more broadly, to meet the workforce needs of their region. Although the steps I outline below are intended as a recipe for new medical schools with just such a mission to follow, existing medical schools could also reengineer themselves to achieve the same goal.

New medical schools must recognize the current factors that discourage medical students from pursuing primary care careers and then devise ways to overcome these barriers. Most U.S. medical students gain a discouraging view of practice in primary care as they observe harried primary care physicians who have too much to do and too little time in which to do it. They hear disparaging remarks about primary care from residents and faculty members, who extol narrowly focused expertise. Students see the same values expressed in the wider society, which compensates subspecialists at far higher levels than primary care physicians. Students are intimidated by the breadth of knowledge required for primary care — but simultaneously concerned that primary care might be boring. And schools have difficulty finding high-quality ambulatory care teaching sites where students can learn the art and science of primary care.

Medical schools that are truly committed to training graduates for primary care must recognize that every decision they make should advance the mission of the school. Institutional decisions create a meta-curriculum that frames the other components of a medical school. Certainly, articulating a mission is important, but unless other institutional decisions clearly bolster that mission, the rhetoric will appear empty, if not disingenuous. The paramount decision, in my view, will be naming the leadership of the new medical school: the founding dean must be a primary care physician. Next, the dean must make it clear that the school's mission will not be held hostage to rankings inU.S. News & World Report. Taking such a stance will require courage and commitment and must be explicitly supported by the university president and the governing board of the medical school and its parent university.

The first test of this commitment will come in the way in which admissions are handled. The little evidence that is available on factors predicting career choice indicates that students who express a desire to serve underserved populations, who demonstrate altruism, and who are committed to social responsibility are more likely to go into primary care.3 I believe that admissions criteria need to be broadened beyond scores on the Medical College Admission Test (MCAT) to include these personal attributes. The school should adopt an “MCAT-blind” admissions policy, dictating that students whose MCAT scores are at or above a predefined minimum that predicts a likelihood of success in medical school should then be considered further for admission without the reporting of their MCAT scores to the admissions committee.

I would further advise that the curriculum be based on a patient-centered learning approach, in which the basic sciences are studied through case presentations of richly described virtual patients who are “seen” repeatedly by students over the course of the curriculum, just as a real panel of patients would be. The traditional head-to-toe cadaver dissection should be abandoned in favor of the examination of prosections that illustrate the specific anatomical problems of the virtual patients. Learning should be integrated into focused explorations of each patient's problems.

More generally, the curriculum should be built around the competencies expected of a primary care physician. Achievement of those competencies should be measured with performance-based methods of assessment that authentically reflect the tasks expected of primary care physicians. And the assessment tools used should place value on the ability of students to be comfortable with uncertainty and to use clinical resources wisely and prudently.

Teaching medical students to function effectively as part of an interprofessional team must be deliberately planned as part of the curriculum. Medical students must acquire knowledge about the healing traditions of other disciplines, show respect for other health care professionals, and appreciate the valuable services those disciplines provide to patient care. Medical students must acquire skills related to leading, following, decision making, communicating, and allocating tasks as members of a team.

Students should be offered the opportunity to do their clinical training in community-based settings, perhaps even in their hometowns if possible, where they should be assigned to a primary care practice. After an initial block of time spent exclusively in that practice, students should use the health care resources in their assigned community to acquire a broader set of clinical experiences in other medical specialties.

In addition to exploring methods of traditional biomedical research, new medical schools should emphasize sociomedical research, which examines the translation of scientific knowledge into clinical practice. In primary care, such research can address issues of patients' adherence to medications, smoking cessation, and other preventive practices. Research opportunities in these areas would be ideal for medical students who aspire to careers in primary care.

In a sense, the relationship between a faculty member and a medical student should mirror the doctor–patient relationship: it should be one of mutual respect and collaborative decision making. In addition, medical schools should embrace rituals and traditions that support primary care, such as National Primary Care Week. School policies should encourage cocurricular activities, such as a student-run free clinic, and grading polices should promote collaboration rather than competition.

Health care reform promises changes in the system of care that will promote some form of capitated payment and narrow the income disparity between primary care physicians and specialists. The anticipated result is primary care practice that will appeal to students as being both professionally and personally rewarding.

Even if a new medical school follows the recipe closely, many students will still choose to enter other specialties, but I believe that exposure to this curriculum will make them more “primary care responsive” clinicians. Students should be guided and supported in making career decisions that are well suited to their temperaments and talents. Even so, I believe that schools that follow these principles should expect to see a majority of their graduates entering primary care practice. And whether we succeed or not, we must try — the quality of U.S. health care hangs in the balance.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

SOURCE INFORMATION

From the Warren Alpert Medical School, Brown University, Providence, RI.

Transforming Graduate Medical Education to Improve Health Care Value

Estimados colegas , este artículo trata sobre el cambio en la visión de la educación médica , enfocada para el cuidado de salud.

Espero que les guste.

Saludos 

Dr. Carlos Erazo

http://healthpolicyandreform.nejm.org/?p=13728&query=TOC

NEJM | February 9, 2011 | Topics: Health Care Delivery

Glenn Hackbarth, J.D., and Cristina Boccuti, M.A., M.P.P.

U.S. health care is too expensive, and its quality too inconsistent. To ensure that health care will be affordable for future generations and appropriate for our burgeoning geriatric population, its delivery and organization must change. Physicians should be in the vanguard of this change, and transforming medical education will be instrumental in preparing tomorrow’s physicians to lead the way.

Swensen et al. have stated that U.S. physicians must shift from viewing themselves as “nonintegrated, dedicated artisans who eschew standardization” to become leaders of a system that values “wise standardization, meaningful measurement, and respectful reporting.”¹ To manage this transition, physicians will need the requisite new perspectives and skills for evidence-based practice, effective use of information technology, quality measurement and improvement, cost awareness, care coordination, leadership of interdisciplinary teams, and shared decision making. Mastering the necessary skills and shifting one’s perspective on what it means to be a good doctor will be a career-long endeavor that should begin during medical school and residency.

Because of the important role Medicare plays in financing residency training through payment to teaching hospitals for graduate medical education (GME), the Medicare Payment Advisory Commission (MedPAC) recently conducted a review of the U.S. GME system. This system is, in many ways, the envy of the world, annually producing thousands of new clinicians who are well trained in applying cutting-edge technology and techniques to aid severely ill or injured patients. Teaching hospitals also serve as linchpins of their local health care systems and contribute to stunning advances in medical science. Judged through this traditional frame of reference, the GME system is an extraordinary success. However, that success and frame of reference are no longer adequate. The GME system must join others in transforming the U.S. health care system into an economically sustainable enterprise that provides appropriate care for all Americans. Working with academic medicine and specialty boards, the Accreditation Council for Graduate Medical Education has taken important steps in reorienting its residency-program accreditation standards to support needed change. We applaud that progress, but it has been slower than MedPAC and some members of the GME community would like.

Medicare invested $9.5 billion in GME in 2009. It is the single largest payer for GME, but it establishes minimal accountability for achieving education and training goals. MedPAC has therefore recommended that Congress authorize Medicare to use this financial leverage to catalyze more rapid GME reform by linking about one third of its GME dollars to programs’ performance on newly developed measures. In essence, MedPAC recommended that Congress stimulate GME reform by bringing new voices and new forces to the table.

To establish new performance measures that focus on the skills needed to improve our health care delivery system, MedPAC recommends that the secretary of health and human services create an expert advisory body. This group would include leaders from accrediting and certifying organizations and GME faculties, along with representatives of specialty boards, high-performing health care systems, public and private purchasers, and consumer and patient organizations. This advisory body should be given 3 years to develop new standards and a method for linking those standards to new payment incentives. The secretary’s role would be not to develop the specific standards but rather to push the experts to be ambitious in addressing the problem.

Funding for the incentive payments should come from the $9.5 billion that Medicare contributes to GME. Because Medicare’s current payments toward the indirect costs of GME (e.g., higher costs incurred for testing or longer hospital stays that are attributable to an institution’s engagement in GME) exceed the estimated actual costs by about $3.5 billion,² we recommend that this portion be reallocated to fund the incentive payments. All, some, or none of this amount could be paid out, depending on whether the advisory body successfully develops standards for increased accountability and on the extent to which GME programs meet those standards. MedPAC’s goal is not to reduce Medicare outlays for GME: we would like to see programs receiving all $3.5 billion, because that would mean that new standards are in place and being met.

Recognizing the need for delivery-system reform and academic medicine’s potential role in leading it, the Association of American Medical Colleges (AAMC) has proposed the creation of health innovation zones (HIZs). Academic medical centers would be the hubs of these zones, which would include other health care providers. If payment methods were changed within these zones (for example, through the institution of population-based capitated payments) and laws and regulations that are perceived as inhibiting collaboration and change were repealed or relaxed, the AAMC believes that HIZs could deliver more efficient care and become exemplars for the rest of the health care system. Because the HIZ concept entails major changes in financing, regulation, and organizational structures, the development and implementation of HIZs will raise complicated issues and take considerable time. MedPAC does not see HIZs as an alternative to our recommended performance standards; rather, the two proposals are potentially complementary. Indeed, GME programs that fare well under new performance standards should be well positioned to lead HIZs.

In addition, MedPAC recommended that Medicare publish information about how much it pays each teaching hospital for GME — information that is sometimes not available even to the residency-program directors and teaching-hospital faculty. Medicare’s GME payments typically go into a hospital’s general fund, which in some cases may be allocated as the institution’s chief executive and board of directors see fit, without regard to the GME mission. This practice is not conducive to cooperative partnerships between GME programs and hospitals.

The AAMC and others have asked Congress to increase the number of GME positions funded by Medicare, arguing that we face a looming physician shortage. MedPAC believes that Congress should not fund additional GME slots, however, until it has reviewed a thorough assessment of those needs. That assessment must be based not on extrapolation from current patterns of care but rather on expectations about the workforce needed for a high-performing, sustainable health care system that includes a mix of physicians and other health care professionals. Simply funding more of the current mix of specialties could impede improvement of our health care delivery system. In the Patient Protection and Affordable Care Act, Congress established a National Health Care Workforce Commission charged with analyzing workforce needs.

MedPAC, like many others, is also concerned about the declining proportion of U.S. medical students choosing careers in primary care. GME programs could help to address this problem — for example, by expanding primary care programs and shrinking subspecialty programs or by investing sufficient resources in primary care programs to ensure that residents have high-quality experiences. GME sponsors should not be expected to carry the entire load, however. In fact, Medicare and private insurers may have control over the most important potential lever: the significant gap between the level of payments for primary care services and that for subspecialty procedures. Public and private insurers and the GME community all need to find ways to encourage careers in primary care.

The lessons learned and perspectives developed by physicians-in-training echo long into the future. One step toward a more effective and sustainable health care system is to match the content of training with anticipated needs. This is not a job for government, but for a partnership among GME faculties, residency-accreditation and physician-certifying organizations, insurers, and patient representatives. Government should serve as a catalyst, using its financing leverage to ensure that the necessary work is done and the proper parties are engaged.

This article (10.1056/NEJMp1012691) was published on February 9, 2011, at NEJM.org.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Source Information

From the Medicare Payment Advisory Commission, Washington, DC.

References

1. Swensen SJ, Meyer GS, Nelson EC, et al. Cottage industry to postindustrial care — the revolution in health care delivery. N Engl J Med 2010;362:e12-e12
   Full Text | Medline
2. Report to the Congress: Medicare payment policy. Section 2A. Washington, DC: Medicare Payment Advisory Commission, March, 2010:39-66.

Clients of Female Sex Workers in Lima, Peru A Bridge Population for Sexually Transmitted Disease/HIV Transmission

Abstract

Objectives: The objectives of this study were to determine the prevalence of risk behaviors, gonorrhea, and chlamydia in clients of female sex workers, and to compare them with men selected from the general population.

Study Design: We conducted a cross-sectional study of men recruited from commercial sex venues in Lima, Peru from January to February 2002. Subjects answered a survey and provided a urine sample.

Results: Men reported that in the recently concluded commercial sex encounter, 95.8% used condoms, and 85.8% always used condoms with female sex workers. Only 16% reported always using condoms with their stable partners; 50.8% always used condoms with casual, noncommercial partners; and 59.6% always used condoms for homosexual anal sex. There were 8 (2%) cases of chlamydia and no cases of gonorrhea.

Conclusions: Clients of female sex workers report high rates of condom use with sex workers and a low prevalence of chlamydia and gonorrhea. It is unlikely that they constitute a bridging population.

http://journals.lww.com/stdjournal/Abstract/2004/06000/Clients_of_Female_Sex_Workers_in_Lima,_Peru__A.3.aspx

Role of core and bridging groups in the transmission dynamics of HIV and STIs in Cotonou, Benin, West Africa

Estimados colegas, este es un artículo interesante que habla de los grupos puente en la dinamica de la epdiemia .

saludos

Dr. Carlos Erazo

"The potential for exposure of low and high risk women to HIV and sexually transmitted infections (STI) through unprotected sex with male clients of female sex workers in Cotonou could account for most if not all of the estimated yearly numbers of HIV infections in Cotonou women (~1000). As ongoing transmission of HIV, and also of the most predominant STIs such as gonorrhoea and HSV-2, appears to be largely fuelled by transmission within core and bridging groups in Cotonou, interventions targeted at both female sex workers and their male clients remain of the utmost importance and could have a significant effect on the evolution of HIV/STI epidemics in Benin."

 

 http://sti.bmj.com/content/78/suppl_1/i69.full.pdf

Nosocomial Pandemic (H1N1) 2009, United Kingdom, 2009–2010

 Esrimados colegas este es una rtículo interesante, recuerden que estamos haciendo atención integral de PVVS, todo lo referente a actualización de conocimientos clínicos nos mantendrá en la competencia del día a día por ayudar a nuestros pacientes.
Saludos
Dr. Carlos Erazo

"To determine the effect of nosocomial infections on health in the United Kingdom, we studied 1,520
patients in 75 National Health Service hospitals. We identified and characterized patients who acquired influenza in hospitals during the pandemic (H1N1) 2009 outbreak. Of 30 patients, 12 (80%) of 15 adults
and 14 (93%) of 15 children had serious underlying illnesses. Only 12 (57%) of 21 patients who received antiviral therapy did so within 48 hours after symptom onset, but 53% needed escalated care or
mechanical ventilation; 8 (27%) of 30 died. Despite national guidelines and standardized infection control procedures, nosocomial transmission remains a problem when influenza is prevalent. Health care
workers should be routinely offered influenza vaccine, and vaccination should be prioritized for all patients at high risk. Staff should remain alert to the possibility of influenza in patients with complex clinical problems and be ready to institute antiviral therapy while awaiting diagnosis during influenza outbreaks."

http://www.cdc.gov/eid/content/17/4/pdfs/10-1679.pdf?source=govdelivery

Gráfico con los estudios de buena calidad en el Análisis del ASAP Ecuador 2009

Análisis del ASAP 2009 Ecuador en los últimos 15 años

En los últimos 15 años , se han encontrado estudios que  han trabajado con las siguientes poblaciones y que según el análisi de calidad de los mismos es baja.

En la Población  HSH 9 estudios, TS (trabajadoras sexuales) 11 estudios , PPL 6 estudios, Jóvenes 11 estudios, P. General 8 estudios, PVVS 5 estudios, Otros 6 estudios , haciendo un total de  56  en los últimos 15 años.

Esto nos hace pensar en el desarrollo de la investigación de alta calidad metodológica en la linea de VIH-Sida e Its.

Dr. Carlos Erazo

Análisis del ASAP 2009 Ecuador