Expansion of HIV and syphilis into the Peruvian Amazon: a survey of four communities of an indigenous Amazonian ethnic group

Factors influencing adherence to anti-retroviral therapy in amazonian indigenous people living with HIV/AIDS

BACKGROUND

Indigenous communities in Peru has been historically affected by high mortality rates attributable to HIV-AIDS infection, associated with a low access to health services, and socio-cultural barriers. In this context, the study aimed to describe factors associated with antiretroviral treatment adherence in people from Awajun and Wampis indigenous communities, living with HIV-AIDS in a Peruvian Amazonian region.

METHODS

A cross-sectional study was completed with a consecutive sample of people from indigenous communities (Awajun or Wampis) living with HIV, who were receiving antiretroviral treatment for at least the last three months. Participants were recruited between October 1 and December 30, 2021, from four districts of Bagua and Condorcanqui provinces in the Amazonian region. An ad-hoc questionnaire was used to collect information about demographic, economic, and socio-cultural factors and access to health services. The Simplified Medication Adherence Questionnaire (SMAQ) was used to evaluate adherence to antiretroviral therapy. Multivariate logistic regression analysis with backward stepwise was performed to explore factors that might influence adherence.

RESULTS

Of the 208 participants, 28.8% reported complete adherence to antiretroviral treatment. The multivariate logistic regression showed that occupation (aPR: 1.86; 95%CI 1.15-3.02), economic income (aPR: 0.64; 95%CI 0.41-0.99), and adverse reactions to antiretroviral therapy (aPR: 0.36; 95%CI 0.18-0.70) were related to complete adherence to medication.

CONCLUSION

Only a third of participants reported complete adherence to antiretroviral therapy. Factors associated with adherence to antiretroviral medication were related to socioeconomic conditions and adverse reactions to the therapeutic scheme. Interventions to improve adherence in indigenous people living with HIV should consider these factors in order to develop effective implementation strategies.

COVID-19 among Amazonian indigenous in Peru: mortality, incidence, and clinical characteristics

Background

Few studies have described the clinical characteristics of patients with COVID-19 from ethnic minority groups. Our objective was to evaluate the mortality and incidence rates, clinical characteristics and factors associated with mortality in cases with COVID-19 belonging to the Amazonian indigenous ethnic group in Peru.

Methods

We performed a retrospective cohort study including all cases from COVID-19 among Peruvian people identified as Amazonian indigenous from 07 March to 31 October 2020. We calculated the standardized mortality and incidence ratios using the indirect age-adjusted method to determine the differences between Amazonian Indigenous and the general population. In addition, we used multivariable logistic regression to determine the risk factors for death.

Results

A total of 19 018 laboratory confirmed COVID-19 cases were analyzed. Indigenous people had 3.18 (95% CI, 3.13–3.23) times the risk of infection and 0.34 (0.31–0.37) times the mortality risk of the general Peruvian population. Males had 1.29 (1.04–1.61) times the odds of death compared with females and for each year of age, the odds of mortality increased 1.03 (1.03–1.04) times. Cases with respiratory distress had 2.47 (1.96–3.10) times more likely to die. Having an immunodeficiency was 18.7 (6.12–57.00) times more likely to die.

Discussion

The Amazonian indigenous population in Peru was strongly affected by COVID-19 compared with the general Peruvian population.

Acceptability of dual HIV/syphilis rapid test in community- and home-based testing strategy among transgender women in Buenos Aires, Argentina

BACKGROUND

Little is known of acceptability and feasibility of dual HIV and syphilis rapid tests in community- and home-based provider-initiated strategies among transgender women (TGW), in Latin America. Objectives were (1) to assess the acceptability of this strategy and, (2) to determine the percentage of positive results of HIV and syphilis, analyze the correlates of HIV or syphilis positive results, and measure the rates of effective referral and treatment completion among TGW.

METHODS

A multidisciplinary team tested 89 TGW in Buenos Aires. An acceptability survey was administered after the HIV/syphilis Duo test was used. All confirmed cases were referred for treatment initiation.

RESULTS

We found high levels of acceptability (98.8%) of this strategy among TGW. However, only 60.7% preferred simultaneous HIV and syphilis diagnosis test. Moreover, we found 9% of positive results of HIV, 51.7% of syphilis, and 3.4% of positive results for both infections. Only not being tested before was associated with an HIV positive result, and only low level of education was associated with a positive syphilis result. Among 8 TGW who tested positive for HIV, 37.5% (n = 3) started antiretroviral therapy. Of 46 who tested positive for syphilis, only 73.9% (n = 34) were effectively referred and from 23 who started treatment, only 39.1% completed it.

CONCLUSIONS

Community- and home-based dual HIV and syphilis rapid test is a feasible and highly acceptable approach for this hard-to-reach population. Implementing similar strategies could improve screening uptake and accessibility. However, these results highlight the need to improve strategies for treatment uptake, in order to reduce morbidity and risk of onward transmission.

Syphilis and HIV infection in indigenous Mbya Guarani communities of Puerto Iguazu (Argentina): diagnosis, contact tracking, and follow-up

The aim of study was to assess the prevalence of Treponema pallidum and HIV infection in Amerindian people (Mbya Guarani) over the age of 11 in Puerto Iguazu (Argentina) and to describe the contact tracking of cases. The method was a cross-sectional study in the Mbya Guarani people living in three villages of Puerto Iguazu (community A, pop. 1,146; community B, pop. 369; and community C, pop. 149). Participants were randomly invited to participate in the survey and in blood testing. Of the 551 participants, 48 were infected by T. pallidum (8.71%; 95% confidence interval [CI] 7.38-10.04). The infection prevalence decreased with age, standing at 9.66% in the 11-19 age group, 8.42% in 20-39 age group and 4.54% in people aged 40 and older. We tracked 130 contacts for the 48 T. pallidum cases; 39/40 (97.5%) sexual contacts tested positive for syphilis. Among the 90 children born to infected mothers, 76 aged 18 months or older tested negative, while 8/14 younger children were still at risk for congenital syphilis. There were four cases of HIV infection (0.72%, 95% CI 0.31-1.13). Prevalence of T. pallidum infection and HIV infection are relevant in this indigenous community of Argentina, representing a public health concern.

Proximate determinants of tuberculosis in Indigenous peoples worldwide: a systematic review

BACKGROUND

Indigenous peoples worldwide carry a disproportionate tuberculosis burden. There is an increasing awareness of the effect of social determinants and proximate determinants such as alcohol use, overcrowding, type 1 and type 2 diabetes, substance misuse, HIV, food insecurity and malnutrition, and smoking on the burden of tuberculosis. We aimed to understand the potential contribution of such determinants to tuberculosis in Indigenous peoples and to document steps taken to address them.

METHODS

We did a systematic review using seven databases (MEDLINE, Embase, CINAHL, Global Health, BIOSIS Previews, Web of Science, and the Cochrane Library). We identified English language articles published from Jan 1, 1980, to Dec 20, 2017, reporting the prevalence of proximate determinants of tuberculosis and preventive programmes targeting these determinants in Indigenous communities worldwide. We included any randomised controlled trials, controlled studies, cohort studies, cross-sectional studies, case reports, and qualitative research. Exclusion criteria were articles in languages other than English, full text not available, population was not Indigenous, focused exclusively on children or older people, and studies that focused on pharmacological interventions.

FINDINGS

Of 34 255 articles identified, 475 were eligible for inclusion. Most studies confirmed a higher prevalence of proximate determinants in Indigenous communities than in the general population. Diabetes was more frequent in Indigenous communities within high-income countries versus in low-income countries. The prevalence of alcohol use was generally similar to that among non-Indigenous groups, although patterns of drinking often differed. Smoking prevalence and smokeless tobacco consumption were commonly higher in Indigenous groups than in non-Indigenous groups. Food insecurity was highly prevalent in most Indigenous communities evaluated. Substance use was more frequent in Indigenous inhabitants of high-income countries than of low-income countries, with wide variation across Indigenous communities. The literature pertaining to HIV, crowding, and housing conditions among Indigenous peoples was too scant to draw firm conclusions. Preventive programmes that are culturally appropriate targeting these determinants appear feasible, although their effectiveness is largely unproven.

INTERPRETATION

Indigenous peoples were generally reported to have a higher prevalence of several proximate determinants of tuberculosis than non-Indigenous peoples, with wide variation across Indigenous communities. These findings emphasise the need for community-led, culturally appropriate strategies to address smoking, food insecurity, and diabetes in Indigenous populations as important public health goals in their own right, and also to reduce the burden of tuberculosis.

FUNDING

Canadian Institutes of Health Research.

HIV, syphilis, and viral hepatitis among Latin American indigenous peoples and Afro-descendants: a systematic review

Objective

To identify and summarize existing literature on the burden of HIV, sexually transmitted infections (STIs), and viral hepatitis (VH) in indigenous peoples and Afro-descendants in Latin America to provide a broad panorama of the quantitative data available and highlight problematic data gaps.

Methods

Published and grey literature were systematically reviewed to identify documents published in English, Spanish, or Portuguese with data collected between January 2000 and April 2016 on HIV, STI, and VH disease burden among indigenous peoples and Afro-descendants in 17 Latin American countries.

Results

Sixty-two documents from 12 countries were found. HIV prevalence was generally low (< 1%) but pockets of high prevalence (> 5%) were noted in some indigenous communities in Venezuela (Warao) (9.6%), Peru (Chayahuita) (7.5%), and Colombia (Wayuu females) (7.0%). High active syphilis prevalence (> 5%) was seen in some indigenous communities in Paraguay (11.6% and 9.7%) and Peru (Chayahuita) (6.3%). High endemicity (> 8%) of hepatitis B was found in some indigenous peoples in Mexico (Huichol) (9.4%) and Venezuela (Yanomami: 14.3%; Japreira: 29.5%) and among Afro-descendant quilombola populations in Brazil (Frechal: 12.5%; Furnas do Dionísio: 8.4% in 2008, 9.2% in 2003).

Conclusions

The gaps in existing data on the burden of HIV, STIs, and VH in indigenous peoples and Afro-descendants in Latin America highlight the need to 1) improve national surveillance, by systematically collecting and analyzing ethnicity variables, and implementing integrated biobehavioral studies using robust methodologies and culturally sensitive strategies; 2) develop a region-wide response policy that considers the needs of indigenous peoples and Afro-descendants; and 3) implement an intercultural approach to health and service delivery to eliminate health access barriers and improve health outcomes for these populations.

The changing face of HIV in Latin America and the Caribbean

Latin America and the Caribbean (LAC) is a region with similarities and important disparities. In recent years LAC has witnessed achievements, with HIV prevalence rates relatively stable for LA and decreasing for the Caribbean. However average values hide differences. General population HIV prevalence in LAC is 0.4 % on average. In the Caribbean there are fewer new HIV infections but HIV prevalence among adults exceeds 1 % in several countries. It is estimated that 31 % of adults living with HIV in LA and 52 % of adults in the Caribbean are women. Unprotected sex is the main route of HIV transmission in LAC. Men who have sex with men and transgender women are the populations with the highest prevalence (10.6 % and 17.7 % respectively); however other key populations such as female sex workers (4.9 %), drug users (range 1 %-49.7 % for intravenous drug users), prisoners and indigenous populations are also important. LAC has the highest anti-retroviral treatment coverage of any low- and middle-income region in the world, but women and children are less likely than men to receive treatment. There is an important pending agenda to address the gaps in information, prevention, and care for HIV in LAC.

Nonprobability and probability-based sampling strategies in sexual science

With few exceptions, much of sexual science builds upon data from opportunistic nonprobability samples of limited generalizability. Although probability-based studies are considered the gold standard in terms of generalizability, they are costly to apply to many of the hard-to-reach populations of interest to sexologists. The present article discusses recent conclusions by sampling experts that have relevance to sexual science that advocates for nonprobability methods. In this regard, we provide an overview of Internet sampling as a useful, cost-efficient, nonprobability sampling method of value to sex researchers conducting modeling work or clinical trials. We also argue that probability-based sampling methods may be more readily applied in sex research with hard-to-reach populations than is typically thought. In this context, we provide three case studies that utilize qualitative and quantitative techniques directed at reducing limitations in applying probability-based sampling to hard-to-reach populations: indigenous Peruvians, African American youth, and urban men who have sex with men (MSM). Recommendations are made with regard to presampling studies, adaptive and disproportionate sampling methods, and strategies that may be utilized in evaluating nonprobability and probability-based sampling methods.

Structural factors that increase HIV/STI vulnerability among indigenous people in the Peruvian amazon

We examined structural factors-social, political, economic, and environmental-that increase vulnerability to HIV among indigenous people in the Peruvian Amazon. Indigenous adults belonging to 12 different ethnic groups were purposively recruited in four Amazonian river ports and 16 indigenous villages. Qualitative data revealed a complex set of structural factors that give rise to environments of risk where health is constantly challenged. Ferryboats that cross Amazonian rivers are settings where unprotected sex-including transactional sex between passengers and boat crew and commercial sex work-often take place. Population mobility and mixing also occurs in settings like the river docks, mining sites, and other resource extraction camps, where heavy drinking and unprotected sex work are common. Multilevel, combination prevention strategies that integrate empirically based interventions with indigenous knowledge are urgently needed, not only to reduce vulnerability to HIV transmission, but also to eliminate the structural determinants of indigenous people's health.

HIV-1 epidemic in Warao Amerindians from Venezuela: spatial phylodynamics and epidemiological patterns

OBJECTIVES

We previously reported HIV-1 infection in Warao Amerindians from Venezuela. The aim of this study was to evaluate the extent and the dynamic of HIV-1 dissemination in eight Warao communities.

DESIGN AND SETTING

HIV-1 infection was evaluated in 576 Warao Amerindians from the Orinoco Delta. Partial HIV-1 pol sequences were analyzed to reconstruct the spatiotemporal and demographic dynamics of the epidemic.

RESULTS

HIV-1 antibodies were present in 9.55% of Warao Amerindians, ranging from 0 to 22%. A significantly higher prevalence was found in men (15.6%) compared with women (2.6%), reaching up to 35% in men from one community. All but one isolates were classified as subtype B. Warao's HIV-1 subtype-B epidemic resulted from a single viral introduction at around the early 2000s. After an initial phase of slow growth, the subtype B started to spread at a fast rate (0.8/year) following two major routes of migration within the communities.

CONCLUSION

A dramatic high prevalence was documented in almost all the communities of Warao Amerindians from the Orinoco Delta tested for HIV-1 infection. This epidemic resulted from the dissemination of a single HIV-1 subtype B founder strain introduced about 10 years ago and its size is probably doubling every year, creating a situation that can be devastating for this vulnerable Amerindian group.

Hepatitis B virus, syphilis, and HIV seroprevalence in pregnant women and their male partners from six indigenous populations of the Peruvian Amazon Basin, 2007-2008

OBJECTIVE

To assess the seroprevalence of hepatitis B virus (HBV), syphilis, and HIV and associated risk factors in pregnant women and their male partners from six indigenous populations of the Peruvian Amazon Basin.

METHODS

A cross-sectional study was performed in six indigenous populations from the Peruvian Amazon Basin. Blood samples were obtained and tested for HBV (antibodies to the hepatitis B core antigen (anti-HBc) and hepatitis B surface antigen (HBsAg)), for syphilis (rapid plasma reagin and microhemagglutination assay for Treponema pallidum antibodies), and for HIV (ELISA and indirect immunofluorescence test). A survey was also performed to identify associated risk factors.

RESULTS

One thousand two hundred and fifty-one pregnant women and 778 male partners were enrolled in the study. The seroprevalence of anti-HBc in pregnant women was 42.06% (95% confidence interval (CI) 39.28-44.85%) and in their male partners was 54.09% (95% CI 50.32-57.86%). The seroprevalence of HBsAg in pregnant women was 2.11% (95% CI 0.78-3.44%) and in their male partners was 3.98% (95% CI 1.87-6.08%). The seroprevalence of syphilis in pregnant women was 1.60% (95% CI 0.86-2.33%) and in their male partners was 2.44% (95% CI 1.22-3.66%). HIV seroprevalence in pregnant women was 0.16% (95% CI 0.02-0.58%) and in their male partners was 0.29% (95% CI 0.04-1.03%). Sexual risk factors were strongly related to blood markers of syphilis and HBV.

CONCLUSIONS

Hepatitis B was found to be hyperendemic and strongly related to sexual factors, suggesting an important sexual component in the transmission of the disease in the populations studied. Syphilis was found to have an endemicity in pregnant women above the national level and this may be indicative of high mother-to-child transmission. HIV has started to show its presence in indigenous populations of the Amazon Basin and the results suggest the epidemic is concentrated.

Comparison of the prevalence and distribution of human papillomavirus infection and cervical lesions between urban and native habitants of an Amazonian region of Peru

We made a study of the prevalence of human papillomavirus (HPV) and cervix lesions in an Amazonian Bora native population (Bn) and compared it with the prevalence in an urban population in Iquitos (Iq). We also examined the distribution of HPV types among abnormal cervical smears in the Iq population. Swabs and cytologies were collected from 472 females. DNA consensus PCR, followed by direct sequencing, were used to determinate the HPV types in the swabs. Cytologies were classified based on the lesion grade. HPV prevalence was 43.9% in Iq and 35.4% in Bn. Cervix lesion prevalence was 20.0% in Iq and 0.3% in Bn. The frequency of high-risk HPV types among HPV+ females was 71.9% in Iq and 56.3% in Bn. The frequencies of low-risk and undetermined risk HPV types were 19.3/6.3% (Iq/ Bn) and 12.3/37.5% (Iq/Bn), respectively. In lesIq (women seeking cytological services with a previous cervix lesion diagnosis) the prevalence of HPV, was 72.9%. The incidence of carcinoma and high-grade squamous intraepithelial cervix lesions in lesIq were 31.2 and 18.8%, respectively. The Bn population had a lower incidence of high-risk HPV and cervix lesions. The high-risk strain HPV16 was significantly more frequent in Iq compared with Bn. lesIq high-risk HPVs were more frequent in high-grade squamous intraepithelial lesions and carcinoma. High-risk HPV16 prevalence was significantly higher than the prevalence of the other high-risk HPVs, especially in the high-grade squamous intraepithelial lesions and carcinoma.

Evidence of at least two introductions of HIV-1 in the Amerindian Warao population from Venezuela

BACKGROUND

The Venezuelan Amerindians were, until recently, free of human immunodeficiency virus (HIV) infection. However, in 2007, HIV-1 infection was detected for the first time in the Warao Amerindian population living in the Eastern part of Venezuela, in the delta of the Orinoco river. The aim of this study was to analyze the genetic diversity of the HIV-1 circulating in this population.

METHODOLOGY/PRINCIPAL FINDINGS

The pol genomic region was sequenced for 16 HIV-1 isolates and for some of them, sequences from env, vif and nef genomic regions were obtained. All HIV-1 isolates were classified as subtype B, with exception of one that was classified as subtype C. The 15 subtype B isolates exhibited a high degree of genetic similarity and formed a highly supported monophyletic cluster in each genomic region analyzed. Evolutionary analyses of the pol genomic region indicated that the date of the most recent common ancestor of the Waraos subtype B clade dates back to the late 1990s.

CONCLUSIONS/SIGNIFICANCE

At least two independent introductions of HIV-1 have occurred in the Warao Amerindians from Venezuela. The HIV-1 subtype B was successfully established and got disseminated in the community, while no evidence of local dissemination of the HIV-1 subtype C was detected in this study. These results warrant further surveys to evaluate the burden of this disease, which can be particularly devastating in this Amerindian population, with a high prevalence of tuberculosis, hepatitis B, among other infectious diseases, and with limited access to primary health care.

Prevalence of serological markers and risk factors for bloodborne pathogens in Salvador, Bahia state, Brazil

This study aimed to determine the prevalence of serological markers for HIV-1/2, HBV, HCV, Treponema cruzi and T. pallidum infections. The association of these infections with risk factors in a population from Salvador, Bahia, Brazil was also analysed. Of the 780 enrolled individuals, 545 (70%) were female and 235 (30%) were male. Seroprevalence of 0·8% (6/702), 1·3% (9/678), 1·5% (10/684), 3·5% (23/663) and 11·5% (77/668) for HIV-1/2, HBV, HCV, T. cruzi and T. pallidum infections, respectively, was observed. The seroprevalence of T. pallidum was higher in males 20% (43/210) than in females 7% (34/458) (P < 0·01). An association between age and seroprevalence for T. cruzi (P = 0·02) and T. pallidum (P < 0·01) was observed. HBsAg was associated with having tattoos (3/37 vs. 6/623, P = 0·01) and not having a steady sexual partner (5/141 vs. 4/473, P = 0·04), while anti-HIV-1/2 was associated with having tattoos (2/39 vs. 4/647, P = 0·04); however, larger studies are needed to categorically state the relationship of these risk factors with infectious agents. The prevalence of serological markers for HIV-1/2, HBV, HCV and T. cruzi was consistent with other studies.

The Emphasis Program: a scholarly concentrations program at Vanderbilt University School of Medicine

In 1999, a faculty committee at Vanderbilt University School of Medicine reviewed the mission and goals of the school and determined that graduates should receive initial preparation to develop scholarly careers in medicine. The authors describe the design of a scholarly projects course, the Emphasis Program, which is required of all students in the first two years of medical school. Each student undertakes a mentored project in one of nine areas of scholarship related to medicine. Curricular time is devoted to the program during the first two academic years, and students also spend eight weeks working on their projects in the intervening summer. The program includes a core didactic curriculum on topics common to all areas of scholarly work, such as biostatistics and study design. Implemented with the entering class of 2004, 467 students had completed the program as of May 2010, and only two students have been unable to complete projects in the allotted time. The majority of graduating seniors reported that they felt this was a valuable aspect of their medical education. Whereas the program offers a broad spectrum of scholarship opportunities, most students have selected projects in more traditional areas, such as laboratory-based research and patient-oriented research. The authors describe early successes in meeting program goals as well as some of the ongoing challenges of administering a required but individualized program of this nature.