Estimating HIV incidence from surveillance data indicates a second wave of infections in Brazil

Human immunodeficiency virus cascade-continuum of care stages and outcomes in a hospital in southern Brazil

BACKGROUND

The human immunodeficiency virus (HIV) continuum of care cascade illustrates the 90-90-90 goals defined by the Joint United Nations Program on HIV/acquired immunodeficiency syndrome (UNAIDS). The care cascade includes the following five steps: Diagnosis, linkage to care, retention in care, adherence to antiretroviral therapy (ART), and viral suppression.

AIM

To elaborate the HIV cascade of patients diagnosed with HIV at the Nossa Senhora da Conceição Hospital (HNSC) and to determine possible local causes for the loss of patients between each step of the cascade.

METHODS

This retrospective cohort study included patients diagnosed with HIV infection from January 1, 2015 to December 31, 2016 and followed up until July 31, 2019. The data were analyzed by IBM SPSS software version 25, and Poisson regression with simple robust variance was used to analyze variables in relation to each step of the cascade. Variables with P < 0.20 were included in multivariable analysis, and P < 0.05 was considered significant. Pearson's χ 2 test was used to compare the groups of patients followed up at the HNSC and those followed up at other sites.

RESULTS

The results were lower than those expected by the UNAIDS, with 94% of patients linked, 91% retained, 81% adhering to ART, and 84% in viral suppression. Age and site of follow-up were the variables with the highest statistical significance. A comparison showed that the cascade of patients from the HNSC had superior results than outpatients, with a significant difference in the last step of the cascade.

CONCLUSION

The specialized and continued care provided at the HNSC was associated with better results and was closer to the goals set by the UNAIDS. The development of the HIV cascade using local data allowed for the stratification and evaluation of risk factors associated with the losses occurring between each step of the cascade.

Recent HIV infection and associated factors among newly diagnosed HIV cases in the Southwest Ethiopia Regional State: HIV case-based surveillance analysis (2019-2022)

BACKGROUND

Globally, there were an estimated 39 million people living with HIV with 1.3 million new HIV infections by the end of 2023. The Sub-Saharan Africa accounted 51% of new HIV infections. HIV case-based Surveillance collects data on newly diagnosed HIV cases, recent HIV infections, and other sentinel events, aiding evidence-based decision making. There is limited evidence on these in Ethiopia. The objective of this study is to determine the incidence proportion of recent infections and associated factors among newly diagnosed HIV cases and their distribution by person, place, and time in the Southwest Ethiopia Regional State.

METHODS

A retrospective analysis was conducted on HIV case-based surveillance dataset (July 2019 to June 2022) from the Southwest Ethiopia Regional State. Recent HIV infection is an infection that acquired within the last 12 months as diagnosed by Asante recency test kits. Data were analyzed using SPSS version 26. ArcGIS version 10.8 was used for mapping recent infections. Logistic regression was employed to identify factors associated with recent infections. In multivariable logistic regression analysis, variables with p-value < 0.05 and an adjusted odds ratio with 95% confidence interval were considered to declare significant association.

RESULTS

A total of 1,167 newly diagnosed HIV cases (eligible cases) were identified. Among these, 786 (67.3%) recency tests were performed. The mean age of individuals with recent infection was 28.4 years. The proportion of recent infection is 89 (11.3%, 95% CI: 11.2, 11.5%). The highest proportion of recent infection is reported from the West Omo zone (42.9%), whereas 13.2% in Bench Sheko zone. Recent infection is significantly associated with age 15-24 years [AOR = 7.14, 95%CI: 2.89,17.57], age 25-34 years [AOR = 5.34, 95%CI: 2.20,12.94], females [AOR = 2.03, 95%CI: 1.26,3.25], and contact history with the index case [AOR = 0.48, 95%CI: 0.28, 0.83]. The incidence of recent infection increased from 86 (in 2019/20) to 132 (in 2022) recent infections per 1,000 newly diagnosed cases.

CONCLUSIONS

Recent HIV infection is a public health concern in the Southwest Ethiopia Regional State with an increasing incidence. Targeted prevention efforts are necessary, especially for females and younger people.

Tuberculosis in prison: What about after release? The example of French Guiana

INTRODUCTION

Tuberculosis is a major cause of mortality worldwide. Prisoners in Guiana have multiple risk factors. The primary objective of this study was to describe tuberculosis occurring in prison and after release in French Guiana between 2008 and 2020. Secondary objectives were to identify tuberculosis risk factors and determine annual incidences.

METHODS

A retrospective cohort study of tuberculosis cases was carried out at the Guiana prison between 2008 and 2020. Data were collected from prison registers and cross-referenced with the list of tuberculosis notifications in French Guiana.

RESULTS

A total of 36 cases of tuberculosis were studied. Incidence was high, at 263/100,000 per year, higher than elsewhere in France and comparable to that in Brazil. Despite visibly effective screening on entry, with little evidence of intra-prison circulation of tuberculosis, 39% of patients were diagnosed within two years of leaving prison (76% were symptomatic). This could be explained by the high prevalence of latent forms (LTI).

DISCUSSION

Continued screening on entry, in combination with annual radiological and clinical screening, and reinforced follow-up on release seem indicated to improve patient management and the search for possible LTI.

Longitudinal Assessment of Virological Failure and Antiretroviral Drug Resistance among Treatment-naive Subjects Living with HIV

INTRODUCTION

Human immunodeficiency virus (HIV) infection, the etiological agent of acquired immunodeficiency syndrome (AIDS), is a serious public health issue. Therapeutic measures have been successful in increasing the survival and improving the quality of life. However, some treatment-naive subjects living with HIV present resistance-associated mutations as a result of late diagnosis and/or mutant strain infections. The objective of this study was to identify the virus genotype and assess the antiretroviral resistance profile based on the results of HIV genotyping in treatment-naive subjects living with HIV, after six months of taking antiretroviral therapy.

METHODS

This was a prospective cohort study on treatment-naive adults living with HIV attending a specialized outpatient clinic in southern Santa Catarina State, Brazil. The participants were interviewed and had blood samples drawn. The genotypic antiretroviral drug resistance profile was examined in patients with detectable viral loads.

RESULTS

65 treatment-naive subjects living with HIV were recruited for this study. After six months of taking antiretroviral therapy, resistance-associated mutations were observed in 3 (4.6%) subjects living with HIV.

CONCLUSION

Subtype C was identified as the circulating subtype in southern Santa Catarina State, and L10V, K103N, A98G, and Y179D were the most common mutations found in treatment-naive subjects.

Measuring progress towards reaching zero new HIV acquisitions among key populations in Québec (Canada) using routine surveillance data: a mathematical modelling study

Introduction

Men who have sex with men (MSM) and people who inject drugs (PWID) are disproportionately impacted by the HIV epidemic in Canada. Having the second‐highest provincial diagnosis rate, an improved understanding of the epidemic among these populations in Québec could aid ongoing elimination efforts. We estimated HIV incidence and other epidemic indicators among MSM and PWID in Montréal and across Québec using a back‐calculation model synthesizing surveillance data.

Methods

We developed a deterministic, compartmental mathematical model stratified by age, HIV status and disease progression, and clinical care stages. Using AIDS and HIV diagnoses data, including self‐reported time since the last negative test and laboratory results of CD4 cell count at diagnosis, we estimated HIV incidence in each population over 1975–2020 by modelling a cubic M‐spline. The prevalence, undiagnosed fraction, fraction diagnosed that started antiretroviral treatment (ART) and median time to diagnosis were also estimated. Since the COVID‐19 pandemic disrupted testing, we excluded 2020 data and explored this in sensitivity analyses.

Results

HIV incidence in all populations peaked early in the epidemic. In 2020, an estimated 97 (95% CrI: 33–227) and 266 (95% CrI: 103–508) HIV acquisitions occurred among MSM in Montréal and Québec, respectively. Among PWID, we estimated 2 (95% CrI: 0–14) and 6 (95% CrI: 1–26) HIV acquisitions in those same regions. With 2020 data, unless testing rates were reduced by 50%, these estimates decreased, except among Québec PWID, whose increased. Among all, the median time to diagnosis shortened to <2 years before 2020 and the undiagnosed fraction decreased to <10%. This fraction was higher in younger MSM, with 22% of 15–24 year‐olds living with HIV in Montréal (95% CrI: 9–39%) and 31% in Québec (95% CrI: 17–48%) undiagnosed by 2020 year‐end. Finally, ART access neared 100% in all diagnosed populations.

Conclusions

HIV incidence has drastically decreased in MSM and PWID across Québec, alongside significant improvements in diagnosis and treatment coverage—and the 2013 introduction of pre‐exposure prophylaxis. Despite this, HIV transmission continued. Effective efforts to halt this transmission and rapidly diagnose people who acquired HIV, especially among younger MSM, are needed to achieve elimination. Further, as the impacts of the COVID‐19 pandemic on HIV transmission are understood, increased efforts may be needed to overcome these.

Adherence to Antiretroviral Therapy in People Living with HIV/AIDS: A Cross-Sectional Study

Adherence to antiretroviral therapy (ART) is essential to suppress HIV replication, preserve immune competence, and ensure quality of life for people living with HIV/AIDS. This is a cross-sectional study to assess adherence to ART in HIV-infected adults and its associated factors in São Carlos, SP, Brazil, from June 2018 to January 2019. Standardized interviews were conducted covering demographic, clinical, and laboratory characteristics and instruments to assess compliance to treatment (CEAT-VIH), HIV/AIDS-targeted quality of life (HAT-QoL), and self-efficacy expectations of adherence (SEA-ART). Each variable was analyzed for association with adherence to ART, by refilling at least 90% of the prescribed doses in the 6 months before the interview date. The study consisted of 220 participants, with a mean age of 43 years, 60.5% male, and 24.5% men who have sex with men. Previous consumption of alcohol or illicit drugs was reported by 44.1% of participants and current or previous smoking by 34.1%. The most common regimen was two nucleoside reverse transcriptase inhibitors combined with one non-nucleoside reverse transcriptase inhibitor (37.3%). The adherence to ART was 62%, and the factors associated with it were living alone [adjusted odds ratio (aOR) 2.79], not having an active sexual life (aOR 0.43), not being a smoker (aOR 0.36), having a CD4 count ≥350 cells/mm³ (aOR 2.50), and having a SEA-ART Score >100 (aOR 1.94). The fear of disclosing HIV status could make adherence to treatment difficult. This could be the reason that living alone and not having an active sexual life have been associated with better adherence. Encouraging healthy lifestyle habits and promoting self-efficacy tools can also improve adherence.

HIV incidence estimates by sex and age group in the population aged 15 years or over, Brazil, 1986-2018

INTRODUCTION

HIV incidence estimates are essential to monitor the progress of prevention and control interventions.

METHODS

Data collected by Brazilian surveillance systems were used to derive HIV incidence estimates by age group (15-24; 25+) and sex from 1986 to 2018. This study used a back-calculation method based on the first CD4 count among treatment-naïve cases. Incidence estimates for the population aged 15 years or over were compared to Global Burden of Disease Study (GBD) estimates from 2000 to 2018.

RESULTS

Among young men (15-24 years), HIV incidence increased from 6,400 (95% CI: 4,900-8,400), in 2000, to 12,800 (95% CI: 10,800-15,900), in 2015, reaching incidence rates higher than 70/100,000 inhabitants and an annual growth rate of 3.7%. Among young women, HIV incidence decreased from 5,000 (95% CI: 4,200-6,100) to 3,200 (95% CI: 3,000-3,700). Men aged ≥25 years and both female groups showed significant annual decreases in incidence rates from 2000 to 2018. In 2018, the estimated number of new infections was 48,500 (95% CI: 45300-57500), 34,800 (95% CI: 32800-41500) men, 13,600 (95% CI: 12,500-16,000) women. Improvements in the time from infection to diagnosis and in the proportion of cases receiving antiretroviral therapy immediately after diagnosis were found for all groups. Comparison with GBD estimates shows similar rates for men with overlapping confidence intervals. Among women, differences are higher mainly in more recent years.

CONCLUSIONS

The results indicate that efforts to control the HIV epidemic are having an impact. However, there is an urgent need to address the vulnerability of young men.

A spatial-mechanistic model to estimate subnational tuberculosis burden with routinely collected data: An application in Brazilian municipalities

Reliable subnational estimates of TB incidence would allow national policy makers to focus disease control resources in areas of highest need. We developed an approach for generating small area estimates of TB incidence, and the fraction of individuals missed by routine case detection, based on available notification and mortality data. We demonstrate the feasibility of this approach by creating municipality-level burden estimates for Brazil. We developed a mathematical model describing the relationship between TB incidence and TB case notifications and deaths, allowing for known biases in each of these data sources. We embedded this model in a regression framework with spatial dependencies between local areas, and fitted the model to municipality-level case notifications and death records for Brazil during 2016-2018. We estimated outcomes for 5568 municipalities. Incidence rate ranged from 8.6 to 57.2 per 100,000 persons/year for 90% of municipalities, compared to 44.8 (95% UI: 43.3, 46.8) per 100,000 persons/year nationally. Incidence was concentrated geographically, with 1% of municipalities accounting for 50% of incident TB. The estimated fraction of incident TB cases receiving diagnosis and treatment ranged from 0.73 to 0.95 across municipalities (compared to 0.86 (0.82, 0.89) nationally), and the rate of untreated TB ranged from 0.8 to 72 cases per 100,000 persons/year (compared to 6.3 (4.8, 8.3) per 100,000 persons/year nationally). Granular disease burden estimates can be generated using routine data. These results reveal substantial subnational differences in disease burden and other metrics useful for designing high-impact TB control strategies.

Oral lymphangioma-like Kaposi sarcoma: a Brazilian case report in a scenario of a still high number of HIV infections

We present a challenging case of HIV-related lymphangioma-like Kaposi sarcoma (LLKS) affecting the oral cavity. A 54-year-old Brazilian male patient was referred to our center complaining of bleeding lesions affecting the oral cavity for 2 months. Interestingly, these oral lesions were the first clinical manifestation of HIV infection. Clinically, multiple erythematous nodular and patch lesions were observed. An incisional biopsy was performed, revealing numerous microscopic angled and irregular vascular channels lined with flattened endothelial cells. More cellularized and solid areas consisting of more fusiform cells with little pleomorphism and with slit-like vascular channels were noted. Based on immunoreactivity for CD31, CD34, D2-40, and HHV-8, the final diagnosis was oral LLKS. Highly active antiretroviral therapy (HAART) was initiated with dolutegravir, tenofovir, and lamivudine. During follow-up, the patient showed KS metastases to other sites and a chemotherapeutic protocol was initiated. Regression of the oral lesion was clearly noted by the clinicians 1 year after the KS diagnosis. Dentists should be able to recognize systemic diseases that affect the oral cavity such as KS in order to make an early diagnosis of its oral manifestations and to implement effective therapeutic measures to ensure a better prognosis.

Factors associated with sexually transmitted infection/HIV diagnosis among a predominantly university population in Brazil

In Brazil, the increasing prevalence of HIV infection in young people makes it critical to know its distribution in university communities. In this cross-sectional study, we evaluated the impact of STI/HIV testing campaigns on university campuses from 2013 to 2017. The participants took part in rapid testing for HIV, syphilis, hepatitis B and C, and counseling sessions. A total of 2691 people participated in the campaigns. Of these, 79.4% were single, and 50.3% were women. The median age was 24 years old, and 77.9% of participants had ≥12 years of formal education. Most reported having unprotected sex in the last year (87.4%). The positivity rates for HIV, syphilis, hepatitis B virus, and hepatitis C virus were 0.56%, 1.20%, 0.19%, and 0.11%, respectively. The characteristics associated with HIV infection were being men who have sex with men (MSM) (aOR = 12.06; 95% CI = 3.83-37.99) and having <12 years of schooling (aOR = 3.28; 95% CI = 1.03-10.38). Factors associated with syphilis seropositivity were older age (aOR = 1.06; 95% CI = 1.03-1.09), multiple partners (aOR = 2.44; 95% CI = 1.08-5.50), and being MSM (aOR = 5.40; 95% CI = 2.49-11.72). Positivity for hepatitis B tended to decrease with the years of testing (p = 0.023) and for hepatitis C to increase with age (p = 0.035). Our study observed a high vulnerability to HIV and syphilis infection in a university community, which needs an early prevention strategy, including regular testing, continuing sexual education, easy access to condoms, and pre- and postexposure HIV prophylaxis.

Monitoring the progress of health-related sustainable development goals (SDGs) in Brazilian states using the Global Burden of Disease indicators

BACKGROUND

Measuring the Global Burden of Disease (GBD) has been the key to verifying the evolution of health indicators worldwide. We analyse subnational GBD data for Brazil in order to monitor the performance of the Brazilian states in the last 28 years on their progress towards meeting the health-related SDGs.

METHODS

As part of the GBD study, we assessed the 41 health-related indicators from the SDGs in Brazil at the subnational level for all the 26 Brazilian states and the Federal District from 1990 to 2017. The GBD group has rescaled all worldwide indicators from 0 to 100, assuming that for each one of them, the worst value among all countries and overtime is 0, and the best is 100. They also estimate the overall health-related SDG index as a function of all previously estimated health indicators and the SDI index (Socio-Demographic Index) as a function of per capita income, average schooling in the population aged 15 years or over, and total fertility rate under the age of 25 (TFU25).

RESULTS

From 1990 to 2017, most subnational health-related SDGs, the SDG and SDI indexes improved considerable in most Brazilian states. The observed differences in SDG indicators within Brazilian states, including HIV incidence and health worker density, increased over time. In 2017, health-related indicators that achieved good results globally included the prevalence of child wasting, NTD, household air pollution, conflict mortality, skilled birth attendance, use of modern contraceptive methods, vaccine coverage, and health worker density, but poor results were observed for child overweight and homicide rates. The high rates of overweight, alcohol consumption, and smoking prevalence found in the historically richest regions (i.e., the South and Southeast), contrast with the high rates of tuberculosis, maternal, neonatal, and under-5 mortality and WASH-related mortality found in the poorer regions (i.e., the North and Northeast).

CONCLUSIONS

The majority of Brazil's health-related SDG indicators have substantially improved over the past 28 years. However, inequalities in health among the Brazilian states and regions remain noticeable negatively affecting the Brazilian population, which can contribute to Brazil not achieving the SDG 2030 targets.

Prevalence and epidemiological characteristics of human immunodeficiency virus-1 infection in an iron mining area with intense migratory flow in Pará State, Brazilian amazon, 2005-2014

Acquired immunodeficiency syndrome (AIDS) caused by human immunodeficiency virus (HIV) is a major global public health problem. The aim of this study is to determine the prevalence of HIV-1 infection in four municipalities of Pará State (Marabá, Parauapebas, Curionópolis, and Canaã dos Carajás), in northern, Brazil. The municipalities are located in the Carajás Complex iron mining area. The employment opportunities result in extensive migratory flow of people. A total of 4771 serum samples were obtained from 2005 to 2014 and were sent to Evandro Chagas Institute, Belém-Pará, where they were tested by enzyme-linked immunosorbent assay, with reactive samples confirmed by Western blot analysis. The samples were from individuals from 23 Brazilian states and the Federal District, mainly Maranhão (39.53%) and other municipalities of Pará (34.25%). The total positivity rate was 0.48% (23/4771). The rate was 0.47% (14/2975) in males and 0.50% (9/1796) in females. Of these, 0.33% (14/4275) were from asymptomatic individuals whose serum were collected during the serological survey, 1.81% (9/497) were from cases featuring clinical symptoms including fever/diarrhea/jaundice, which were included in febrile, diarrheal, and icteric syndromes analyzed during the study. The findings indicated the presence of HIV-1 infection in the general population studied. The majority of cases (60.9%, 14 of 23 positive cases) were asymptomatic.