Infectious disease doctor is in charge of LPAids, a research unit installed at the Unicamp Hospital de Clínicas
Isolation. This was the name of a small building at the Irmandade de Misericórdia of Santa Casa de Campinas, where a group of professors from the area of Infectious Diseases at Unicamp received the first AIDS patient in Brazil, in 1982, “The little building was built due to the meningitis epidemic in the 1970s, isolated, because no one wanted to deal with infectious diseases – an opportunity well taken advantage of for our area to have its own headquarters. At the time, all medical areas of the University still operated at Santa Casa, especially with regard to hospitalizations”, recalls Professor Francisco Hideo Aoki.
While still a resident at the Faculty of Medical Sciences (FCM), Aoki today coordinates the AIDS Research Laboratory (LPAids), located at the Hospital de Clínicas (HC) and which is completing 30 years of activities, celebrated in an event on August 10th. “The first patient with acquired immunodeficiency was being treated in several hospitals and arrived very poorly at the Infectious Diseases Ward, with pneumonia, intense candidiasis (deep fungal infection in the oral cavity), very emaciated and with difficulty breathing – symptoms very characteristic of immunosuppressed individual.”
The patient's case was discussed by professors Rogério de Jesus Pedro, Luiz Jacintho da Silva (now deceased), Marcelo de Carvalho Ramos, Maria Luiza Moretti and Fernando Lopes Gonçales, says the coordinator of the LPAids. “No one knew exactly the cause, but the literature reported that Americans discovered, starting in 1979, that the first cases of unusual infection, previously attributed to a protozoan, Pneumocystis carinii, it was actually a fungus, known today as Pneumocystis jirovecii. The cases had been occurring in young males, probably with some degree of immunosuppression.”
Once this possibility was raised, the Brazilian patient's treatment began, empirically, with the medication considered ideal and still administered today for serious infections caused by such a large infectious agent: the antimicrobial sulfamethoxazole in conjunction with trimethoprim. “Unfortunately, the condition was too serious and the patient died. Taken for necropsy, professors Ingrid Almstalden and Liliana Andrade, from the Department of Pathological Anatomy, observed a double lung infection caused by Pneumocystis carinii and also by cytomegalovirus. This case with immunodeficiency was reported in the magazine of the Associação Paulista de Medicina. I remember perfectly the patient and the fear and prejudice of having contact with him, the fear of the unknown, which lasted for a long time and is still seen today, including in the medical community.”
According to Francisco Aoki, there was no test to prove the disease, which started to occur from 1985 onwards, with a methodology that was still in its infancy. “It was Elisa’s method (Enzyme linked immunosorbent assay), which has been improved to the point where it currently has a sensitivity and specificity rate of more than 97/99%, being quite reliable even for rapid tests. At that time, a number of patients began to visit our infectious disease outpatient clinics. Part of the outpatient clinics had already migrated to the Hospital de Clínicas in the late 70s, operating on Monday, Wednesday and Friday afternoons to handle new and returning cases.”
Aoki states that from 1983 to 85, Unicamp attended to 60 patients per outpatient period, in a search fueled by the fear of being infected with HIV, especially by those who belonged to “risk groups” – the term used at the time to refer to homosexuals , bisexuals, promiscuous heterosexuals, prostitutes, transvestites and drug users (especially injectable drugs). “Due to the large flow, and to be able to treat other types of infectious diseases, the teachers decided to open an outpatient clinic dedicated only to AIDS – or sexually transmitted diseases and infections (STD/MI), to alleviate prejudice – which began operating on a Tuesday morning, in 1985. I had taken the exam and joined the teaching staff at Unicamp that year, also working in that outpatient clinic.”
The AIDS Research Laboratory was physically implemented in 1988, on the 4th floor of the HC, and two years earlier, biologist Neiva Sellan Lopes Gonçales, encouraged by fellow Hemotherapy doctors, had already begun to develop studies on her own, initially serology , together with Ronald Menghini, at the time a laboratory technician, who later graduated in biology and remains on staff. “In addition to them, Moacir Rodrigues, a laboratory technician now retired, formed the trio that started the laboratory's activities, initially in borrowed locations. We always follow a motto: that we carry out tests in a public institution laboratory, and for patients in the Unified Health System, who fully depend on the services provided here. Quality, speed of delivery and large scale of fulfillment have always been constant concerns for the servers of the LPAids."
Evolution
The evolution of the laboratory, says the Unicamp professor, was also due to its inclusion in assistance networks, starting with the National Serology and HIV Screening Network, focused on diagnosis. “Later this network was decentralized, going to the states, then to the municipalities and now to each institution, which buys the inputs and carries out the diagnoses. We fight hard to belong to the networks that quantify lymphocytes [the body's defense cells], such as LTCD4 and LTCD8, which define the situation in which the individual's immune system is: if it is very low, they are immunosuppressed; if elevated, the disease is controlled, with appropriate treatment.”
The laboratory also began to integrate the HIV viral load and genotyping networks, the latter aimed at detecting types of resistance to treatments. “With the use of antiretroviral drugs, these patients improve, but occasionally, due to inappropriate use or lack of adherence to treatment, they can lead to the development of virus resistance to these drugs. Periodically, funding for research in other areas and extra aid for diagnoses in serious infectious diseases appears; or for endemic diseases such as dengue, always with colleagues in the area of infectious diseases. That’s more or less the life in the laboratory.”
Quality
Biologist Marcina Garcia, technical supervisor of the LPAids, reiterates that the team of professionals always keeps in mind that they are working for the patient. “The concern is to control the material that arrives (properly packaged and transported in accordance with ministerial orders), speed up the results of the exams and work with quality. We greatly preserve the issue of the quality of the exams, which is the objective of the course we offer to municipalities to guarantee the good condition of the material transported and allow us to carry out the exams quickly – the deadline is fifteen days, but we are delivering within 48 at the most. hours.”
According to Francisco Aoki, there are standards for biological samples that the laboratory must comply with and which also involve the pre-analytical area, that is, in the municipal outpatient clinics, where nurses and technicians collect and package the samples in an appropriate container. “The material must be transported at a specific temperature and time, and by a trained driver. Our training serves to stimulate local teams and has even become an example for the Ministry of Health, which proposes the practice in more than 50 cities in the Regional Directorates of Campinas and São João da Boa Vista.”
Marcina Garcia informs that today, approximately 2.200 viral load tests are carried out per month; between 1.600 and 1.800 TCD4 lymphocytes; and 1.300 to 1.600 screenings (serology). Between 200 and 220 patients from the macro-region are treated daily. Professor Aoki notes that the workload has increased with the federal government's encouragement of the diagnosis of hepatitis B and C, with the goal of eliminating infections with the virus by 2030. “A person with hepatitis has an 80% chance of developing chronic hepatitis and therefore cirrhosis. The liver starts to function so poorly that the only solution is a transplant, as there is a queue for donors and many patients die waiting for the organ. The earlier the diagnosis and treatment, the greater the possibility of a cure, as antivirals are very potent.”
Stabilization
The FCM professor observes a certain stabilization of AIDS in some regions of Brazil, but emphasizes that stabilization does not mean that the numbers are no longer rising. “The speed of propagation is no longer the same as before. Epidemics in general are like this: there is an explosion and when the control and treatment process comes, the number of new cases begins to stabilize; Over time, when new forms of treatment are discovered, avoiding transmission mechanisms and with adequate prevention, there is a decline. We are still at a level of stabilization and, depending on the area or region of the country, we still see an increase in the number of cases.”
The coordinator of LPAids It is the opinion that today's medications control the disease well, inducing fewer side effects and with a reduced number of pills or tablets, which facilitates adherence to treatment. “At the beginning of the epidemic, to combat various types of opportunistic infections, such as toxoplasmosis and tuberculosis (and at the same time), more than 50 pills were taken a day, along with specific AIDS treatment. The dose of AZT was 1.600 milligrams (16 capsules of 100mg) and is currently 300mg, as studies have indicated that a higher dosage is useless. In addition to AZT, we now have many more antiretrovirals, which inhibit viruses at different points, such as Lamivudine (300mg) or Tenofovir (300), plus Dolutegravir – which have also been combined into a single pill. Treatment is much easier in terms of dosage.”
Francisco Aoki admits that, as AIDS is no longer seen as lethal, there is a risk of the population relaxing sexual relations, with less rigor in the use of condoms, especially among young people. “Currently, the number of cases of syphilis and papillomavirus makes the government concerned about promoting vaccination for specific groups of young people who are about to begin their sexual life – and HIV is at the heart of these diseases. We see young people who are not taking care of themselves and becoming infected, and this is worrying. Care must be taken to use condoms. If in doubt, just look for the service at the basic health unit, where four tests are generally carried out: hepatitis B and C, syphilis and HIV. It is very fast."
Shot in the foot
Despite the successful service provided by the LPAids in 30 years, the coordinator sees with extreme concern the cut in public spending implemented by the government, especially in the health area. “There is a constant struggle to deal with difficulties related to public order budgetary resources. It has been an ongoing struggle since the SUS was created: in certain years funding stabilizes, in others it declines, bringing great difficulties to the public service system. There are still hundreds, perhaps thousands of municipalities dependent solely on the Mais Médicos program, just to cite a small example. Now we hear that Capes will not be able to release the grants from 2019 onwards. The country is shooting itself in the foot, as decisions like this could lead the country to an increasingly subservient situation. And we, who fight in this micro-area to make everything work well, must fight with our entire democratic arsenal so that Brazil can once again develop economically and socially.”
