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Guaraldo L.,Escola Nacional de Saude Publica Sergio Arouca Fundacao Oswaldo Cruz | Guaraldo L.,Institute Pesquisa Clinica Evandro Chagas Fundacao Oswaldo Cruz | Cano F.G.,Escola Nacional de Saude Publica Sergio Arouca Fundacao Oswaldo Cruz | Cano F.G.,West Parana State University | And 2 more authors.
BMC Geriatrics | Year: 2011

Background: Inappropriate medication use (IMU) by elderly people is a public health problem associated with adverse effects on health. There are a number of methods for identifying IMU, some involving clinical judgment and others, consensually generated lists of drugs to be avoided. This review aims to describe studies that used information from insurance company and social security administrative databases to assess IMU among community-dwelling elderly and to present the risk factors most often associated with IMU. Methods. The paper search was conducted in Medline and Embase, using descriptors combined with free terms in the title or abstract. The limits applied were: publication date from January 1990 to June 2010, species (human) and publication type (excluding editorials, letters and reviews). Excluded were: case studies; studies in hospitals, nursing homes, or hospital emergency departments; studies of specific drugs or groups of drugs; studies exclusively of subgroups of ill, frail elderly or rural populations. Additional studies were identified from reference lists. Data were selected and extracted after independent reading by two of the authors, with disagreements resolved by a third author. The primary outcome assessed was prevalence of IMU, defined as the proportion of elderly who received at least one inappropriate medication. Results: Of the 628 studies, 19 met the inclusion criteria, 78.9% of them conducted in the USA. All papers included used explicit criteria of inappropriateness, most commonly Beers criteria (73.7%) in their three versions (1991, 1997 and 2002). Other methods used included Zhan, which is derived from on Beers criteria and was applied in 21% of the papers selected. The study found that prevalence of IMU ranged from 11.5% to 62.5%. Only 68.4% of the studies included examined inappropriate use-related factors, the most important being female sex, advanced age and larger number of drugs. Conclusions: The results show that the prevalence of IMU among community-dwelling elderly is high and depends partly on the method used to evaluate improper use. Besides the diversity of methods, other factors, such as patient sex, age and number of drugs used concurrently, appear to have influenced the estimates of IMU. © 2011 Guaraldo et al; licensee BioMed Central Ltd. Source

Crabtree-Ramirez B.,Instituto Nacional Of Ciencias Medicas Y Nutricion | Del Rio C.,Emory University | Grinsztejn B.,Institute Pesquisa Clinica Evandro Chagas Fundacao Oswaldo Cruz | Sierra-Madero J.,Instituto Nacional Of Ciencias Medicas Y Nutricion
Journal of Acquired Immune Deficiency Syndromes | Year: 2014

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. © 2014 by Lippincott Williams & Wilkins. Source

Cesar C.,Fundacion Huesped | Jenkins C.A.,Vanderbilt University | Shepherd B.E.,Vanderbilt University | Padgett D.,Instituto Hondureno Of Seguridad Social And Hospital Escuela | And 12 more authors.
The Lancet HIV | Year: 2015

Background: Access to combination antiretroviral therapy (ART) is expanding in Latin America (Mexico, Central America, and South America) and the Caribbean. We assessed the incidence of and factors associated with regimen failure and regimen change of initial ART in this region. Methods: This observational cohort study included antiretroviral-naive adults starting ART from 2000 to 2014 at sites in seven countries throughout Latin America and the Caribbean. Primary outcomes were time from ART initiation until virological failure, major regimen modification, and a composite endpoint of the first of virological failure or major regimen modification. Cumulative incidence of the primary outcomes was estimated with death considered a competing event. Findings: 14 027 patients starting ART were followed up for a median of 3·9 years (2·0-6·5): 8374 (60%) men, median age 37 years (IQR 30-44), median CD4 count 156 cells per μL (61-253), median plasma HIV RNA 5·0 log10 copies per mL (4·4-5·4), and 3567 (28%) had clinical AIDS. 1719 (12%) patients had virological failure and 1955 (14%) had a major regimen change. Excluding the site in Haiti, which did not regularly measure HIV RNA, cumulative incidence of virological failure was 7·8% (95% CI 7·2-8·5) 1 year after ART initiation, 19·2% (18·2-20·2) at 3 years, and 25·8% (24·6-27·0) at 5 years; cumulative incidence of major regimen change was 5·9% (5·3-6·4) at 1 year, 12·7% (11·9-13·5) at 3 years, and 18·2% (17·2-19·2) at 5 years. Incidence of major regimen change at the site in Haiti was 10·7% (95% CI 9·7-11·6) at 5 years. Virological failure was associated with younger age (adjusted hazard ratio [HR] 2·03, 95% CI 1·68-2·44, for 20 years vs 40 years), infection through injection drug use (vs infection through heterosexual sex; 1·60, 1·02-2·52), and initiation in earlier calendar years (1·28, 1·13-1·46, for 2002 vs 2006), but was not significantly associated with boosted protease inhibitor-based regimens (vs non-nucleoside reverse transcriptase inhibitor; 1·17, 1·00-1·36). Interpretation: Incidence of virological failure in Latin America and the Caribbean was generally lower than that reported in North America or Europe. Our results suggest the need to design strategies to reduce failure and major regimen change in young patients and those with a history of injection drug use. Funding: US National Institutes of Health. © 2015 Elsevier Ltd. Source

Wolff M.,University of Chile | Shepherd B.E.,Vanderbilt University | Cortes C.,University of Chile | Rebeiro P.,Vanderbilt University | And 7 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2016

Background: HIV-infected persons in resource-limited settings may experience high rates of antiretroviral therapy (ART) change, particularly because of toxicity or other nonfailure reasons. Few reports address patient outcomes after these modifications. Methods: HIV-infected adults from the 7 Caribbean, Central and South America network clinical cohorts who modified >1 drug from the first ART regimen (ART-1) for any reason thereby starting a second regimen (ART-2) were included. We assessed cumulative incidence of, and factors associated with, death, virologic failure (VF), and regimen change after starting ART-2. Results: Five thousand five hundred sixty-five ART-naive highly active ART initiators started ART-2 after a median of 9.8 months on ART-1; 39% changed to ART-2 because of toxicity and 11% because of failure. Median follow-up after starting ART-2 was 2.9 years; 45% subsequently modified ART-2. Cumulative incidences of death at 1, 3, and 5 years after starting ART-2 were 5.1%, 8.4%, and 10.5%, respectively. In adjusted analyses, death was associated with older age, clinical AIDS, lower CD4 at ART-2 start, earlier calendar year, and starting ART-2 because of toxicity (adjusted hazard ratio 1.5 vs. failure, 95% confidence interval: 1.0 to 2.1). Cumulative incidences of VF after 1, 3, and 5 years were 9%, 19%, and 25%. In adjusted analyses, VF was associated with younger age, earlier calendar year, lower CD4 at the start of ART-2, and starting ART-2 because of failure (adjusted hazard ratio 2.1 vs. toxicity, 95% confidence interval: 1.5 to 2.8). Conclusions: Among patients modifying the first ART regimen, risks of subsequent modifications, mortality, and virologic failure were high. Access to improved antiretrovirals in the region is needed to improve initial treatment success. © 2015 Wolters Kluwer Health, Inc. All rights reserved. Source

Crabtree-Ramirez B.,Instituto Nacional Of Ciencias Medicas Y Nutricion Salvador Zubiran | Vega Y.N.C.,Instituto Nacional Of Ciencias Medicas Y Nutricion Salvador Zubiran | Shepherd B.E.,Vanderbilt University | Turner M.,Vanderbilt University | And 9 more authors.
AIDS and Behavior | Year: 2015

In the United States (USA), the age of those newly diagnosed with HIV is changing, particularly among men who have sex with men (MSM). A retrospective analysis included HIV-infected adults from seven sites in the Caribbean, Central and South America network (CCASAnet) and the Vanderbilt Comprehensive Care Clinic (VCCC-Nashville, Tennessee, USA). We estimated the proportion of patients <25 years at HIV diagnosis by calendar year among the general population and MSM. 19,466 (CCASAnet) and 3,746 (VCCC) patients were included. The proportion <25 years at diagnosis in VCCC increased over time for both the general population and MSM (p < 0.001). Only in the Chilean site for the general population and the Brazilian site for MSM were similar trends seen. Subjects <25 years of age at diagnosis were less likely to be immunocompromised at enrollment at both the VCCC and CCASAnet. Recent trends in the USA of greater numbers of newly diagnosed young patients were not consistently observed in Latin America and the Caribbean. Prevention efforts tailored to young adults should be increased. © 2015, Springer Science+Business Media New York. Source

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