Sandra Liliana Valderrama-Beltrán

Background and objective: Despite expanded access to antiretroviral therapy (ART), people living with HIV (PLWH) continue to experience high hospitalization rates, particularly in low- and middle-income countries. This study aimed to describe the causes of hospitalization in a cohort of PLWH treated at a high-complexity referral center in Bogotá, Colombia, and to assess variations across the pre-pandemic, pandemic, and post-pandemic periods of COVID-19. Methodology: We conducted a retrospective cohort study including hospitalization episodes among adults with confirmed HIV infection between 2018 and 2024. Clinical characteristics, causes of hospitalization, and outcomes were compared across the epidemiological periods related to the COVID-19 pandemic. Results: A total of 872 hospitalization episodes corresponding to 584 patients were analyzed. The median age was 34 years, and 89.1% were men. Although 68.7% of patients had a history of ART use, 54.8% were admitted with detectable viral load. Non–AIDS-defining causes predominated across all periods (61.8%), with a progressive increase from the pre-pandemic to the post-pandemic period (55.3%, 63.1%, and 70.1%, respectively). A sustained increase in hospitalizations due to mental health disorders was observed over time (4.3%, 4.6%, and 7.8%). Among AIDS-defining conditions, tuberculosis (15.8%) and Pneumocystis jirovecii pneumonia (14.9%) were the most frequent. Hospitalizations due to opportunistic infections were associated with longer length of stay (median 14 vs. 6 days; p < 0.001) and higher 30-day mortality (8.6% vs. 2.6%; p < 0.001) compared with non–AIDS-defining hospitalizations, with a proportional increase in events attributable to tuberculosis and Kaposi sarcoma. Conclusions: An epidemiological transition towards non-AIDS-defining causes of hospitalization is evident, comparable to patterns observed in high-income countries; however, a substantial burden of tuberculosis, Kaposi sarcoma, and late HIV diagnosis persists, likely reflecting ongoing structural gaps in HIV care. Following the COVID-19 pandemic, an increase in hospitalizations related to mental health disorders was observed. Taken together, these findings highlight the urgent need to strengthen early diagnosis, active case finding, and tuberculosis prevention, as well as to enhance the implementation of comprehensive care models that improve retention in care for PLWH in low- and middle-income countries.

Introducción: El manejo de personas que viven con VIH ha experimentado avances significativos en las últimas décadas con el tratamiento antirretroviral (TAR); sin embargo, los profesionales de la salud continúan enfrentando desafíos en el manejo clínico, particularmente en lo que respecta a la interpretación de la carga viral y la toma de decisiones terapéuticas. El objetivo de este estudio fue unificar definiciones y directrices para la interpretación y manejo de las viremias de bajo nivel persistentes en personas con VIH que reciben terapia antirretroviral en Colombia. Materiales y métodos: Revisión sistemática de la literatura en torno a cuatro preguntas clínicas. La evidencia se clasificó según los niveles del Oxford Centre for Evidence-Based Medicine (2009). Se empleó un consenso Delphi modificado con expertos nacionales. El umbral de consenso fuerte se definió como el acuerdo de al menos el 80% de los expertos participantes. Resultados: Se revisaron dieciocho documentos relevantes. Se desarrollaron doce recomendaciones con consenso fuerte, enfocadas en la definición de viremias de bajo nivel persistente, el uso dirigido de genotipificación a partir de 200 copias/mL y la transición a esquemas de alta barrera genética. Discusión: Estudios recientes sugieren que la viremia de bajo nivel persistentemente detectable puede aumentar el riesgo de resistencia emergente y de fracaso virológico. Este documento adopta un enfoque más conservador y clínico, en línea con las recomendaciones del DHHS y de GeSIDA. Se enfatiza la importancia de evaluar la adherencia, optimizar los esquemas y usar la genotipificación de manera juiciosa. En conclusión, la evaluación cuidadosa de la adherencia, la utilización de esquemas de alta barrera genética y un enfoque individualizado permiten optimizar la atención de las personas con VIH con viremias de bajo nivel persistentes, especialmente en escenarios clínicos de incertidumbre.

Tuberculosis (TB) and human immunodeficiency virus (HIV) cause significant morbidity and mortality in South America. Despite the advances in active case finding and early treatment initiation as core strategies to decrease TB and HIV transmissions, additional efforts are needed to achieve control and eventual elimination of these 2 epidemics. Availability and implementation of preventive strategies using shorter, rifamycin-based regimens for TB preventive therapy and long-acting injectables for HIV prevention are still a challenge in the South American region. In this report, we discuss opportunities to accelerate TB and HIV prevention in the region. We present examples of novel TB and HIV surveillance and prevention initiatives among high-risk groups and vulnerable populations in countries within the region, using precision public health approaches and leveraging digital health and artificial intelligence tools. Finally, we propose a roadmap for ending TB and HIV in South America.

Background: Accurate risk stratification is essential for guiding hospitalization decisions in COVID-19. We evaluated the performance of CURB-65, CRB-65, NEWS2, qSOFA, and the 4C Mortality Score in predicting 30-day mortality among patients presenting to the emergency department with COVID-19. Methods: We conducted an external validation study using an ambispective cohort of COVID-19 patients who presented to emergency departments of seven high-complexity hospitals in Colombia between March 2020 and September 2021. We assessed discrimination using the area under the receiver operating characteristic curve (AUC) and calibration using the GiViTI belt, the observed-to-expected (O/E) ratio, and the calibration intercept and slope. Decision curve analysis and net benefit were used to evaluate clinical utility. The 4C model underwent logistic recalibration. Results: Among 7,973 patients included, 30-day mortality was 11.3%. The 4C model showed the highest discrimination (AUC 0.71, 95% CI 0.70–0.73) and clinical utility, but poor calibration. NEWS2, CURB-65, CRB-65, and qSOFA performed poorly across all performance metrics. After recalibration, the 4C model achieved an O/E ratio of 1 and showed a modest improvement in discrimination. Decision curve analysis confirmed its utility for guiding hospitalization decisions at a ≥4% mortality risk threshold. Conclusion: The 4C Mortality Score outperformed other models in predicting COVID-19 mortality. Its use in emergency settings alongside clinical judgment can enhance risk stratification, guide hospitalization decisions, and optimize resource allocation. Recalibration and decision analysis are essential for its clinical applicability. Further validation with contemporary data is essential to ensure its transportability across epidemiological settings.

Background: Real-world comparisons of initial antiretroviral third-drug classes are limited in middle-income settings. We evaluated whether the initial third-drug class predicts time to loss of virologic suppression in Colombia. Methods: Historical cohort of 609 ART-naïve adults (2016-2020). Outcome: first HIV RNA ≥200 copies/mL. We compared NNRTI, PI, and INSTI regimens using adjusted and IPTW-weighted Cox models. Results: Regimens were NNRTI (72%), PI (20%), and INSTI (8%); 19.9% lost suppression. Compared with NNRTI, PIs showed higher but nonsignificant hazards (aHR 1.50, 95% CI 0.98-2.27). For INSTIs, we did not detect significant differences (aHR 1.22, 95% CI 0.64-2.31). Diagnosis-to-ART delays and treatment interruptions were associated with loss of suppression. Conclusions: Treatment continuity and timely initiation predicted sustained suppression better than drug class. Low INSTI usage limits statistical power to detect differences. Structural barriers to continuity may limit the real-world benefit of newer regimens.

Background: Despite declining COVID-19 incidence, healthcare workers (HCWs) still face an elevated risk of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. We developed a diagnostic multivariate model to predict positive reverse transcription polymerase chain reaction (RT-PCR) results in HCWs with suspected SARS-CoV-2 infection. Methods: We conducted a cross-sectional study on episodes involving suspected SARS-CoV-2 symptoms or close contact among HCWs in Bogotá, Colombia. Potential predictors were chosen based on clinical relevance, expert knowledge, and literature review. Logistic regression was used, and the best model was selected by evaluating model fit with Akaike Information Criterion (AIC), deviance, and maximum likelihood. Results: The study included 2498 episodes occurring between March 6, 2020, to February 2, 2022. The selected variables were age, socioeconomic status, occupation, service, symptoms (fever, cough, fatigue/weakness, diarrhea, anosmia or dysgeusia), asthma, history of SARS-CoV-2, vaccination status, and population-level RT-PCR positivity. The model achieved an AUC of 0.79 (95% CI 0.77–0.81), with 93% specificity, 36% sensitivity, and satisfactory calibration. Conclusions: We present an innovative diagnostic prediction model that as a special feature includes a variable that represents SARS-CoV-2 epidemiological situation. Given its performance, we suggest using the model differently based on the level of viral circulation in the population. In low SARS-CoV-2 circulation periods, the model could serve as a replacement diagnostic test to classify HCWs as infected or not, potentially reducing the need for RT-PCR. Conversely, in high viral circulation periods, the model could be used as a triage test due to its high specificity. If the model predicts a high probability of a positive RT-PCR result, the HCW may be considered infected, and no further testing is performed. If the model indicates a low probability, the HCW should undergo a COVID-19 test. In resource-limited settings, this model can help prioritize testing and reduce expenses.

Introducción: Durante la pandemia por SARS-CoV-2 se describió un aumento en la morbimortalidad perioperatoria en el periodo previo a la vacunación. Objetivo: Determinar en pacientes intervenidos quirúrgicamente la incidencia acumulada de covid-19 y la mortalidad global a los 30 días del procedimiento. Metodología: Cohorte retrospectiva de 314 pacientes intervenidos quirúrgicamente entre el 6 de marzo de 2020 y el 30 de junio de 2021, seleccionados aleatoriamente. Se tomó prequirúrgicamente RT-PCR para SARS-CoV-2 en todos los pacientes y en el postoperatorio a los pacientes con aparición de síntomas. Resultados: A los 30 días de la intervención quirúrgica se encontró una incidencia acumulada de covid-19 del 0,97 %, y una mortalidad global del 2,2 %. De los pacientes con SARS-CoV-2 perioperatorio, 3 de 7 tenían importantes comorbilidades y fallecieron a los 30 días con una mortalidad asociada con covid-19. Conclusión: La incidencia acumulada de covid-19 fue similar a la reportada en otras cohortes. Se observó una mortalidad elevada a los 30 días entre los pacientes con covid-19 perioperatorio. Estos hallazgos deben reforzar la necesidad en las instituciones de salud de fortalecer las medidas de prevención perioperatorias, la búsqueda activa de pacientes infectados, así como la priorización de procedimientos quirúrgicos para el afrontamiento de futuras pandemias.

Objective: People living with HIV (PLWH); can be especially vulnerable to the effects of SARS Co V 2 and COVID 19. In this study, we evaluate the factors associated with acquiring COVID 19 and the severity of the infection among PLWH. Materials and methods: Through a case-control study nested in a cohort, where cases were PLWH diagnosed with COVID 19; and controls were PLWH without the infection, 476 people were evaluated between May 1, 2020, and February 28, 2021. A univariate analysis was performed with the variables considered candidates. Binary logistic regression models were conducted for the COVID 19 outcome, and among those diagnosed with the infection, regression models for the outcome of hospitalization vs. outpatient treatment. Results: Among 238 PLWH diagnosed with COVID 19, receiving integrase inhibitors p < 0.001 (CI 95% 0.27,0.72) or protease inhibitors p 0.034 (CI 95%0.42,0.97) within their antiretroviral regime, was associated with a lower probability of developing COVID 19. 196 (82,35%) of the 238 cases received outpatient treatment, and 42 (17,64%) required hospitalization. In this case, being older than 50 years p < 0.001 (CI 95% 1.8,9.64) and having obesity as a comorbidity p 0.017 (CI 95% 1.34,17.93) increased the possibility of requiring hospitalization, while receiving antiretroviral treatment or having received vaccination against influenza, decreased the likelihood of this outcome. Conclusions: There are still many questions regarding whether there is a differential risk of acquiring COVID 19 among PLWH. Antiretroviral treatment with inte­grase or protease inhibitors; was associated with a lower probability of developing the co-infection. Some factors related to comorbidities, such as older age and obesity, draw attention to possible risk factors for hospitalization in this population. Discussing the feasibility of new studies with proposed causal hypotheses that allow directing the research designs toward a more precise answer to these questions is essential

Methods: Over a four-year period, 123 Candida bloodstream isolates were collected at a quaternary care hospital. The isolates were identified by MALDI-TOF MS and their fluconazole (FLC) susceptibility patterns were assessed according to CLSI guidelines. Subsequently, sequencing of ERG11, TAC1 or MRR1, and efflux pump activity were performed for resistant isolates.Results: Out of 123 clinical strains,C. albicans accounted for 37.4%, followed by C. tropicalis 26.8%, C. parapsilosis 19.5%, C. auris 8.1%, C. glabrata 4.1%, C. krusei 2.4% and C. lusitaniae 1.6%. Resistance to FLC reached 18%; in addition, a high proportion of isolates were cross-resistant to voriconazole. Erg11 amino acid substitutions associated with FLC-resistance (Y132F, K143R, or T220L) were found in 11/19 (58%) of FLCresistant isolates. Furthermore, novel mutations were found in all genes evaluated. Regarding efflux pumps, 8/19 (42%) of FLC-resistant Candida spp strains showed significant efflux activity. Finally, 6/19 (31%) of FLC-resistant isolates neither harbored resistance-associated mutations nor showed efflux pump activity. Among FLC-resistant species, C. auris 7/10 (70%) and C. parapsilosis 6/24 (25%) displayed the highest percentages of resistance (C. albicans 6/46, 13%).Discussion: Overall, 68% of FLC-resistant isolates exhibited a mechanism that could explain their phenotype (e.g. mutations, efflux pump activity, or both). We provide evidence that isolates from patients admitted to a Colombian hospital harbor amino acid substitutions related to resistance to one of the most commonly used molecules in the hospital setting, with Y132F being the most frequently detected.