Antiretroviral treatment, government policy and economy of HIV/AIDS in Brazil: is it time for HIV cure in the country?

Individual satisfaction with HIV/AIDS care in Belo Horizonte, Brazil

Individual satisfaction is associated with increased retention in HIV/AIDS care services and adherence to treatment. This study assessed factors associated with individual satisfaction at the initiation of antiretroviral therapy and compared the proportions of satisfaction at the initiation of antiretroviral therapy and after three months of follow-up. Face-to-face interviews were carried out among 398 individuals of three HIV/ AIDS healthcare services in Belo Horizonte, Brazil. Variables included sociodemographic and clinical characteristics, perception about healthcare services, and domains of quality of life. Individuals that rated the quality of healthcare services as good or very good were classified as satisfied. A logistic regression analysis of the association between independent variables and individual satisfaction was performed. The proportion of individual satisfaction with healthcare services was 95.5% at the initiation of antiretroviral therapy and 96.7% after three months and these changes were not statistically significant (p = 0.472). The physical domain of quality of life was found to be associated with satisfaction at the initiation of antiretroviral therapy (OR = 1.38; CI = 1.11-1.71; p = 0.003). Training and supervision of health professionals for addressing the needs of individuals with lower levels of physical domain of quality of life may improve satisfaction with HIV/ AIDS care.

Cesarean delivery and risk of HIV vertical transmission in Southern Brazil, 2008-2018

BACKGROUND

Childbirth via cesarean delivery can prevent intrapartum vertical transmission for women who are not virally suppressed at the time of delivery. Few studies have compared cesarean delivery trends between women living with HIV and women without HIV and have examined the role of cesarean delivery in the prevention of vertical transmission in the era of potent combination antiretroviral therapy.

OBJECTIVE

We hypothesized that the cesarean delivery rate is high in women living with HIV compared with women without HIV and that cesarean delivery usage decreases over time among women living with HIV with advances in combined antiretroviral therapy in a country with a high national cesarean delivery rate. This study aimed (1) to evaluate cesarean delivery trends in women with and without HIV and (2) to examine its role in preventing vertical transmission among women living with HIV in a setting of free, universal combined antiretroviral therapy coverage in a retrospective cohort of nearly 56,000 deliveries at a major referral institution in a city with the highest prevalence of maternal HIV in Brazil.

STUDY DESIGN

Data from maternal-infant pairs from January 1, 2008, to December 31, 2018, were extracted. Cesarean delivery rates were compared using the Pearson chi-square test. Cesarean delivery predictors were evaluated by multivariate log-linear Poisson regression using a generalized estimating equations approach. HIV viral suppression was defined as a viral load of <1000 copies/ml at delivery. HIV vertical transmission was determined following national guidelines.

RESULTS

Over 11 years, 48,688 pregnancies occurred in 40,375 women; HIV seroprevalence was 2.7%; 18,886 cesarean deliveries (38.8%) were performed; 47.7% of women living with HIV and 38.6% of women without HIV underwent cesarean delivery (P<.001). Although HIV was associated with cesarean delivery (adjusted relative risk, 1.17 [95% confidence interval, 1.05-1.29]), women living with HIV with vertical transmission achieved similar cesarean delivery rates (36.7%) as women without HIV (39.8%) in 2018. Cesarean delivery in women living with HIV with an unknown viral load at delivery (42.6%) did not increase over time. HIV vertical transmission rate was 2.2%, the highest in women living with HIV with an unknown viral load (8.4%) vs women living with HIV without vertical transmission (4.1%) and women living with HIV with vertical transmission (0.5%) (P<.001).

CONCLUSION

In the HIV epicenter of Brazil, women living with HIV with vertical transmission had fewer surgical deliveries, likely because of the use of potent combination antiretroviral therapy. Nearly half of the women living with HIV with an unknown viral load did not undergo cesarean delivery, a potential missed opportunity for the prevention of HIV vertical transmission.

Adherence to antiretroviral therapy and viral suppression: Analysis of three periods between 2011 and 2017 at an HIV-AIDS center, Brazil

The increased effectiveness of antiretroviral therapy (ART) in the last 30 years is a scientific landmark, and viral suppression is directly associated with treatment adherence. The aim of this study was to compare the results of ART adherence and viral load suppression with the evolution of the protocols and other associated factors, in people living with HIV. A panel analysis of three descriptive longitudinal studies investigating ART adherence and viral load suppression was conducted in people with HIV treated at a drug dispensing unit in the Federal District. The studies were carried out during periods of 2011, 2013, and 2017, coinciding with the three different recommended treatment schemes for the country. Adherence was assessed using drug dispensing records. Viral load data were obtained from the Ministry of Healthʼs Laboratory Examination Information System. Analysis of the data of 522 individuals in the three periods showed sociodemographic differences such as a decline in the percentage of women (from 33% in period 1 to 4% in period 3) and an increase in the percentage of young people. ART adherence was higher in period 2 (tenofovir/lamivudine/efavirenz scheme). Viral load suppression was greater in period 3 (tenofovir/lamivudine/dolutegravir scheme). The relative detectable viral load risk was nearly two-fold higher (RR 1.83) in people living with HIV with less than 80% adherence when compared to those above 80%. With respect to the different schemes recommended in Brazil during the periods studied, ART containing dolutegravir was the most effective in achieving viral load suppression. By contrast, there was better ART adherence in the daily combined fixed dose consisting of tenofovir/lamivudine/efavirenz in tablet form. Adherence to ART above 80% seemed to be enough to promote an effective treatment in therapeutic schemes including efavirenz or dolutegravir.

Perfil sociodemográfico e farmacoepidemiológico de crianças infectadas pelo HIV

RESUMO A terapia antirretroviral interfere na replicação do vírus HIV, impede a progressão da infecção para a Aids e previne a mortalidade precoce das crianças infectadas. Esta pesquisa investigou o perfil sociodemográfico e os parâmetros relacionados com o tratamento antirretroviral das crianças HIV positivas residentes no estado do Paraná. Trata-se de um estudo observacional descritivo e analítico realizado com dados secundários do ano de 2020 referentes às crianças com até 12 anos de idade. Foram investigados: perfil, prevalência, medicamentos em uso, abandono da terapia, resistência e supressão viral. Foram identificadas 148 crianças, com uma prevalência igual a 8,1/100 mil no Paraná. Apesar de todas as crianças diagnosticadas com HIV terem iniciado o tratamento, 17,2% encontravam-se em abandono da terapia antirretroviral. Entre as crianças que permaneciam em tratamento, 9,8% não atingiram a supressão viral e suas cargas virais comumente ultrapassavam mil cópias virais/mL. Houve um predomínio de esquemas medicamentosos provavelmente prescritos após falhas terapêuticas. Os resultados indicam que o Paraná apresenta bons resultados quanto ao início rápido da terapia e à supressão viral das crianças. Entretanto, existe um número considerável de abandonos da terapia e de falhas terapêuticas, indicando a necessidade de reforçar a vinculação desta população aos serviços de saúde.

Frequency of CYP2B6 Alleles in Major Iranian Ethnicities, Affecting Response to Efavirenz

Introduction

Efavirenz is an antihuman immunodeficiency virus (HIV) drug metabolized by cytochrome P450 2B6 (CYP2B6) enzyme. Cytochrome P450 2B6 is an enzyme that in humans is encoded by the CYP2B6 gene. Polymorphisms of this gene play a crucial role in the metabolism of drugs such as Efavirenz. This study aims to evaluate the frequency of three clinically significant CYP2B6 polymorphisms (CYP2B6^∗6 (516G > T), CYP2B6^∗4 (785A > G), and CYP2B6^∗5 (1459C > T)) in three major Iranian ethnicities.

Methods

One hundred forty-seven participants from three main Iranian ethnicities were included in this study. After DNA extraction, CYP2B6^∗6 (516G > T), CYP2B6^∗4 (785A > G), and CYP2B6^∗5 (1459C > T) were genotyped using tetra-primer amplification refractory mutation system polymerase chain reaction (ARMS-PCR).

Results

The frequency of the mutated allele in the Iranian population for CYP2B6^∗6 (516G > T) was 41.50 (95% CI: 35.81, 47.36), which was significantly lower than in Kurds (59.62, 95% CI: 45.10, 72.99). Similarly, Kurds had a higher frequency of mutated allele of CYP2B6^∗5 (1459C > T) (46.15%, 95% CI: 32.23, 60.53) than in Iranians (24.49%, 95% CI: 19.68, 29.82). The frequency of A and G alleles of CYP2B6^∗4 (785A > G) was 62.59% (95% CI: 56.78, 68.13) and 37.41 (95% CI: 31.87, 43.22), respectively.

Conclusion

Kurds are at higher risk of adverse drug reactions (ADRs) and insufficient anti-HIV response compared to other Iranians.

Disparities in Excess Mortality Between Indigenous and Non-Indigenous Brazilians in 2020: Measuring the Effects of the COVID-19 Pandemic

This study aimed to estimate the number of excess deaths among Indigenous Peoples associated with the COVID-19 pandemic in 2020 and to assess the disparities in excess mortality between Indigenous and non-Indigenous Brazilians. A time series analysis of weekly mortality data including all deaths from January 2015 to December 2020 was conducted. The number of expected deaths for 2020 was estimated using an over-dispersed Poisson model that accounts for demographic changes, temporal trends, and seasonal effects in mortality. Weekly excess deaths were calculated as the difference between the number of observed deaths and the expected deaths. Regional differences in Indigenous mortality were investigated. A significant increase in Indigenous mortality was observed from April 1 to December 31, 2020. An estimated 1149 (95% CI 1018-1281) excess deaths was found among Indigenous Brazilians in 2020, representing a 34.8% increase from the expected deaths for this population. The overall increase in non-Indigenous mortality was 18.1%. The Indigenous population living in the Brazilian Amazon area was the earliest-affected Indigenous group, with one of the highest proportional increases in mortality. Disparities in excess mortality revealed a disproportionate burden of COVID-19 among Indigenous Brazilians compared to their non-Indigenous counterparts. Findings highlight the importance of implementing an effective emergency plan that addresses the increased vulnerability of Indigenous Peoples to COVID-19.

Relationship Between Lipodystrophy, Body Composition, Metabolic Profile, and Serum Levels of Adipocytokines

Background: Despite the benefits in improving the clinical state of people living with HIV/aids (PLWHA), some side effects associated with the use of antiretroviral therapy (ART) are reported. Redistribution of body fat has been associated with treatment and is characterized by morphological changes, also known as lipodystrophy. The complications of metabolic and morphological changes in these individuals seem to increase the risk of cardiovascular disease. Adipocytokines are proteins that have essential functions in biological processes, in which the levels of these proteins are related to the pathogenesis of metabolic syndrome (MS) and cardiovascular disease. Recent studies have shown that such levels are generally modified in PLWHA, regardless of whether the treatment is established or not. An application of methods for body fat estimation in patients with fat redistribution, as in the case of aids, especially those that quantify body fat by segments, appears to clarify these alterations and plays an important role in the development of multiprofessional treatment. Objectives: This investigation was carried out to compare and correlate body composition, biochemical metabolic parameters, and levels of adipocytokines and cytokines of PLWHA, with and without lipodystrophy, with individuals with negative HIV serology and stratified by sex. Material and Methods: This is a cross-sectional study in which body composition, metabolic and anthropometric changes, and levels of adipocytokines of 110 individuals were assessed. These individuals were paired in sex, age, and body mass index (BMI) and subdivided into three groups: PLWHA with and without a clinical diagnosis of lipodystrophy associated with HIV, and a group control. Results: Collinearity was identified both in the general sample and for genders of the waist-to-height ratio (WHtR) with all anthropometric parameters, except for muscle mass. The results show strong association between IFN-γ and TNF-α both in the general sample and for genders and moderate correlation between leptin and fasting glucose for women; worsening of the triglyceride profile in both women with lipodystrophy compared with the control group and men without lipodystrophy compared with the control group; higher serum TNF-α values among men without lipodystrophy compared to those with HIV-associated lipodystrophy (HALS). Conclusions: The results of this study underline that, considering the manifestations of the syndrome, these patients have a high-risk endocrine metabolic profile for cardiovascular events.

Immunologic biomarkers, morbidity and mortality among HIV patients hospitalised in a Tertiary Care Hospital in the Brazilian Amazon

Background

The irregular use of antiretroviral therapy (ART) and late diagnosis still account for a large part of HIV-associated mortality in people living with HIV (PLHIV). Herein, we describe HIV-associated morbidity among hospitalised HIV/AIDS patients with advanced immunosuppression and assess the comorbidities, laboratory parameters, and immunological markers associated with mortality.

Methods

The cross-sectional study was conducted at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado (FMT-HVD) in Manaus, Brazil. In all, 83 participants aged between 12 and 70 years were enrolled by convenience within 72 h of their hospitalisation. Clinical and laboratory data were obtained from electronic medical records. We prospectively measured the cytokines Th1/Th2/Th17 and inflammatory cytokines IL-8, IL-1β, and IL-12 using cytometric bead array, and the soluble CD14 using in-house enzyme-linked immunosorbent assay.

Results

The HIV/AIDS inpatients presented a scenario of respiratory syndromes as the most prevalent comorbidity. Almost all patients had CD4 T counts below 350 cells/mL and the mortality rate was 20.5%. Pulmonary tuberculosis, neurotoxoplasmosis and oropharyngeal–esophageal candidiasis were the most prevalent opportunistic infections. TB and weight loss were more prevalent in HIV/AIDS inpatients who died. The Mann Whitney analysis showed that those who died had higher platelet distribution width (PDW) on admission, which is suggestive for platelet activation. The Poisson multivariate analysis showed the prevalence of TB, digestive syndrome and increases in IL-8 and lactate dehydrogenase (LDH) associated to death.

Conclusions

The advanced immunosuppression characterized by the opportunistic infections presented in these HIV/AIDS inpatients was the major factor of mortality. The role of platelet activation in worse outcomes of hospitalisation and the IL-8 associated with the context of advanced immunosuppression may be promising markers in the prediction of mortality in HIV/AIDS patients.

Maternal HIV and syphilis are not syndemic in Brazil: Hot spot analysis of the two epidemics

While the annual incidence of HIV diagnosis in pregnancy in Brazil remains relatively stable, rates of maternal syphilis increased over six-fold in the past decade. We hypothesized that maternal HIV and syphilis are two distinct epidemics. Data on all cases of maternal HIV or syphilis detected in pregnancy between January 1, 2010 to December 31, 2018 were requested from the Brazilian Ministry of Health. In order to evaluate how the epidemics evolved over the time period, ArcGIS software was used to generate spatiotemporal maps of annual rates of detection of maternal HIV and syphilis in 2010 and 2018. We utilized Euclidean-distance hot spot analysis to identify state-specific clusters in 2010 and 2018. From 2010 to 2018, there were 66,631 cases of maternal HIV, 225,451 cases of maternal syphilis, and 150,414 cases of congenital syphilis in Brazil. The state of Rio Grande do Sul had the highest rate of maternal HIV detection in both 2010 and 2018. Hot spots of maternal HIV were identified in the three most Southern states in both 2010 and 2018 (99% confidence, z-score >2.58, p <0.01). While syphilis incidence >30 per 1,000 live births in 2018 in four states, only the two coastal states of Rio de Janeiro and Espirito Santo in Southeastern Brazil were significant hot spots (90% confidence, z-score 1.65-1.95, p <0.10). Contrary to the general assumption, HIV and syphilis epidemics in Brazil are not syndemic in pregnant women. There is a spatial cluster of maternal HIV in the South, while syphilis is increasing throughout the country, more recently on the coast. Focusing on maternal HIV hot spots in the Southern states is insufficient to curtail the maternal and congenital syphilis epidemics throughout the country. New strategies, including ongoing hot spot analysis, are urgently needed to monitor, identify and treat maternal syphilis.

Sociodemographic, behavioral, and geriatric characteristics in older adults with and without HIV: A case-control study

Older adults with human immunodeficiency virus (HIV) have higher risks for early manifestations of age-related disabilities. The objective of this study was to compare HIV-positive and HIV-negative adults aged ≥50 years in relation to sociodemographic, behavioral, and geriatric characteristics. A case-control study was conducted with a >90% estimated statistical power. A total of 52 individuals living with HIV were matched by age, sex, and neighborhood of residence with 104 community controls. Age-related disabilities were assessed throughout a comprehensive geriatric assessment. Review of medical records and interviews were used to obtain behavioral and clinical covariates. No statistical differences on clinically significant age-related disabilities were found. However, multivariate regression analyses, controlling for education and income, revealed that behavioral (use of condom [odds ratio {OR}: 7.03; 95% confidence intervals {CI}: 2.80-7.65] and number of medical visits [OR: 1.25; 95%CI: 1.09-1.43]), along with faster gait speed (OR: 17.68; 95%CI: 2.55-122.85) and lower body and muscle mass indexes were independently associated with HIV (OR: .88; 95%CI: .79-.98 and OR: .72; 95%CI: .54-.97, respectively). In summary, results on age-related disabilities between groups could mean that public policies on HIV might be contributing to patients' positive outcomes regardless of the effects of aging, albeit gait speed, body and muscle mass indexes were independently associated with HIV. Screenings for age-related disabilities in specialized HIV services are recommended.

Seroprevalence and associated factors of HIV and Hepatitis C in Brazilian high-security prisons: A state-wide epidemiological study

The prevalence of hepatitis C virus (HCV) and the acquired immunodeficiency virus (HIV) is much higher in prisons than in community settings. Some explanatory factors for this burden include putative aspects of the prison environment, such as unprotected sexual relations and sexual violence, use of injectable drugs and syringe sharing. Nonetheless, efforts in better understanding the dynamics of both HCV and HIV are scarce in developing countries such as Brazil, which poses a risk not only to the inmates but to the community as well. In this investigation, we sought to determine the seroprevalence and sociodemographic and behavioral risk factors associated with HIV and anti-HCV antibodies among men detained at high-security institutions. This is an epidemiological, proportionally stratified observational study including 1,132 inmates aged 18 to 79 years-old (M_age = 32.58±10.18) from eleven high-security prisons located in the State of Paraná, Brazil. We found that HIV and anti-HCV prevalence were 1.6% (95% CI: 1.0–2.5) and 2.7% (95% CI: 1.0–2.5), respectively. Risk factors associated with HIV included not receiving intimate visits (OR = 8.80, 95% CI: 1.15–66.88), already having another sexually transmitted infection (OR = 3.89, 95% CI: 1.47–10.29), and reporting attendance in HIV preventive campaigns (OR = 4.24, 95% CI: 1.58–11.36). Moreover, anti-HCV seroprevalence was associated with higher age (OR = 4.03, 95% CI: 1.61–10.07), criminal recidivism (OR = 2.58, 95% CI 1.02–6.52), and the use of injectable drugs (OR = 7.32, 95% CI 3.36–15.92). Although prisons might increase the risk for acquiring and transmitting HIV and HCV, the adoption of permanent epidemiological surveillance programs could help reducing the circulation of viruses, involving strategies focusing on screening, treating, and preventing infections to assure proper prisoner health. Moreover, these policies need to take place inside and outside the prison environment to offer continued assistance to former prisoners once they leave the institution.

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.

Nationwide Study of Drug Resistance Mutations in HIV-1 Infected Individuals under Antiretroviral Therapy in Brazil

The success of antiretroviral treatment (ART) is threatened by the emergence of drug resistance mutations (DRM). Since Brazil presents the largest number of people living with HIV (PLWH) in South America we aimed at understanding the dynamics of DRM in this country. We analyzed a total of 20,226 HIV-1 sequences collected from PLWH undergoing ART between 2008–2017. Results show a mild decline of DRM over the years but an increase of the K65R reverse transcriptase mutation from 2.23% to 12.11%. This increase gradually occurred following alterations in the ART regimens replacing zidovudine (AZT) with tenofovir (TDF). PLWH harboring the K65R had significantly higher viral loads than those without this mutation (p < 0.001). Among the two most prevalent HIV-1 subtypes (B and C) there was a significant (p < 0.001) association of K65R with subtype C (11.26%) when compared with subtype B (9.27%). Nonetheless, evidence for K65R transmission in Brazil was found both for C and B subtypes. Additionally, artificial neural network-based immunoinformatic predictions suggest that K65R could enhance viral recognition by HLA-B27 that has relatively low prevalence in the Brazilian population. Overall, the results suggest that tenofovir-based regimens need to be carefully monitored particularly in settings with subtype C and specific HLA profiles.

Estimated life expectancy gains with antiretroviral therapy among adults with HIV in Latin America and the Caribbean: a multisite retrospective cohort study

BACKGROUND

There are few data on life expectancy gains among people living with HIV in low-income and middle-income settings where antiretroviral therapy (ART) is increasingly available. We aimed to analyse life expectancy trends from 2003 to 2017 among people with HIV beginning treatment with ART within the Caribbean, central America, and South America.

METHODS

We did a multisite retrospective cohort study and included people with HIV who had started treatment with ART and were aged 16 years or older between Jan 1, 2003, and Dec 31, 2017, from Caribbean, Central and South America network for HIV epidemiology (CCASAnet) sites in Argentina, Brazil, Chile, Haiti, Honduras, Mexico, and Peru, who contributed person-time data from the age of 20 years until date of death, last contact, database closure, or Dec 31, 2017. We used the Chiang method of abridged life tables to estimate life expectancy at age 20 years for three eras (2003-08, 2009-12, and 2013-17) overall and by demographic and clinical characteristics at ART initiation. We used Poisson regression models to weight mortality rates to account for informative censoring.

FINDINGS

30 688 people with HIV were included in the study; 17 491 (57·0%) were from the Haiti site and 13 197 (43·0%) were from all other sites. There were 2637 deaths during the study period: 1470 in Haiti and 1167 in other sites. Crude and weighted mortality rates decreased among all age groups over calendar eras. From 2003-08 to 2013-17, overall life expectancy for people with HIV at age 20 years increased from 13·9 years (95% CI 12·5-15·2) to 61·2 years (59·0-63·4) in Haiti and from 31·0 years (29·3-32·8) to 69·5 years (67·2-71·8) in other sites. Life expectancies at the end of the study period were within 10 years of those of the general population (69·9 years in Haiti and 78·0 years in all other sites in 2018). Disparities in life expectancy among people with HIV by sex or HIV transmission risk factor, CD4 cell count, level of education, and history of tuberculosis at or before ART initiation persisted across calendar eras.

INTERPRETATION

Life expectancy among people with HIV receiving ART has significantly improved in Latin America and the Caribbean. Persistent disparities in life expectancy among people with HIV by demographic and clinical factors at ART initiation highlight vulnerable populations in the region.

FUNDING

National Institutes of Health.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

Mapping subnational HIV mortality in six Latin American countries with incomplete vital registration systems

BACKGROUND

Human immunodeficiency virus (HIV) remains a public health priority in Latin America. While the burden of HIV is historically concentrated in urban areas and high-risk groups, subnational estimates that cover multiple countries and years are missing. This paucity is partially due to incomplete vital registration (VR) systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. In this analysis, we address this gap and provide novel estimates of the HIV mortality rate and the number of HIV deaths by age group, sex, and municipality in Brazil, Colombia, Costa Rica, Ecuador, Guatemala, and Mexico.

METHODS

We performed an ecological study using VR data ranging from 2000 to 2017, dependent on individual country data availability. We modeled HIV mortality using a Bayesian spatially explicit mixed-effects regression model that incorporates prior information on VR completeness. We calibrated our results to the Global Burden of Disease Study 2017.

RESULTS

All countries displayed over a 40-fold difference in HIV mortality between municipalities with the highest and lowest age-standardized HIV mortality rate in the last year of study for men, and over a 20-fold difference for women. Despite decreases in national HIV mortality in all countries-apart from Ecuador-across the period of study, we found broad variation in relative changes in HIV mortality at the municipality level and increasing relative inequality over time in all countries. In all six countries included in this analysis, 50% or more HIV deaths were concentrated in fewer than 10% of municipalities in the latest year of study. In addition, national age patterns reflected shifts in mortality to older age groups-the median age group among decedents ranged from 30 to 45 years of age at the municipality level in Brazil, Colombia, and Mexico in 2017.

CONCLUSIONS

Our subnational estimates of HIV mortality revealed significant spatial variation and diverging local trends in HIV mortality over time and by age. This analysis provides a framework for incorporating data and uncertainty from incomplete VR systems and can help guide more geographically precise public health intervention to support HIV-related care and reduce HIV-related deaths.

The Effect of Partnership Presence and Support on HIV Viral Suppression Among Serodiscordant Partnered and Single Heterosexual HIV-Positive Individuals in Brazil

HIV-negative individuals in serodiscordant partnerships experience reduced risk of HIV acquisition when their partners adhere to ART and achieve undetectable viral loads. Partnership support may encourage ART adherence, reducing viral load and the risk of HIV transmission. This study aims to determine whether HIV viral suppression is associated with partnership status and partnership support among 201 HIV positive (HIV+ individuals in serodiscordant partnerships and 100 HIV+ unpartnered individuals receiving care at Hospital Nossa Senhora da Conceição in Porto Alegre, Brazil between 2014 and 2016. Clinical data and patient-reported questionnaire data were assessed, and propensity scores were used to control for confounding variables in adjusted logistic regression models. Viral suppression did not significantly differ between HIV+ partnered (78.5% virally suppressed) and unpartnered (76.0% virally suppressed) individuals. Among individuals in partnerships, viral suppression was significantly associated with having a partner who attended monthly clinic visits (AOR 2.99; 95% CI 1.00-8.93). Instrumental social support-attending monthly visits-may improve the odds of viral suppression among HIV+ individuals in serodiscordant relationships.

Factors associated with attitudes towards HIV cure research among transgender women and travestis: a cross-sectional survey in São Paulo, Brazil

OBJECTIVE

Characterising the perceptions of groups most affected by HIV is fundamental in establishing guidelines for biomedical advancement. Although Brazil has successfully fought HIV/AIDS through several measures, transgender women still have a likelihood of HIV infection 55 times higher than the general population. This study aimed to better understand the perception and awareness of HIV cure research among the trans-identifying population in São Paulo, Brazil, and to determine factors that motivate or discourage participation in HIV cure studies.

SETTING

This cross-sectional study analysed data collected from a questionnaire administered to 118 transgender women and travestis at 5 sites within the city of São Paulo. It uses quantitative methodology to describe the perspectives of transgender and travesti people in relation to HIV cure research and the context in which such perspectives are produced.

RESULTS

Of 118 participants, most participants (73%) had some knowledge of HIV cure research and were most willing to participate in online surveys (52%), interviews (52%), focus groups (52%) and studies involving blood draws (57%). Those with a higher education or employment status were more likely to agree that someone had been cured of HIV, people living with HIV are discriminated against, and more information about HIV cure research is needed before the community embraces it. Only 55% of participants completely trusted their physician. The biggest motivational factors included gaining additional knowledge about HIV infection (77%) and the potential for a longer, healthier life for all (73%).

CONCLUSIONS

As a primary analysis of HIV cure attitudes among the transgender and travesti population as well as the social context in which they are formed, this study identifies opportunities to strengthen the dialogue and develop more educational collaborations between scientific investigators, community educators and the trans-identifying population to ensure that HIV cure research is inclusive of diverse perspectives.

Population attributable fractions of mortality in people living with HIV: roles of delayed antiretroviral therapy, hepatitis coinfections and social factors

OBJECTIVES

Despite free access to antiretroviral therapy (ART) from 1996 onward, and treatment for all people living with HIV (PLWHIV) from 2013, mortality in Brazil has not homogeneously decreased. We investigated to what extent delayed ART, hepatitis coinfections and sociodemographic factors predict all-cause mortality in Brazilian PLWHIV.

DESIGN

We included PLWHIV at least 18 years, with complete CD4 cell count data, followed up between 2007 and 2015 in Brazil.

METHODS

After multiple imputation, an extended Cox model helped estimate the effects of fixed and time-varying covariates on mortality.

RESULTS

The study population (n = 411 028) were mainly male (61%), white (55%), 40 years or less (61%), heterosexually HIV infected (71%), living in the Southeast region (48%) and had basic education (79%). Hepatitis C virus and hepatitis B virus coinfection prevalences were 2.5 and 1.4%, respectively. During a 4-year median follow-up, 61 630 deaths occurred and the mortality rate was 3.45 (95% confidence interval: 3.42-3.47) per 100 person-years. Older age, male sex, non-white ethnicity, illiteracy/basic education and living outside the Southeast and Central-West regions were independently associated with increased mortality. The main modifiable predictors of mortality were delayed ART (i.e. CD4 cell count <200 cells/μl at ART initiation) (adjusted population attributable fraction: 14.20% [95% confidence interval: 13.81-14.59]), being ART-untreated (14.06% [13.54-14.59]) and ART-treated with unrecorded CD4 at ART initiation (5.74% [5.26-6.21]). Hepatitis C virus and hepatitis B virus coinfections accounted for 2.44 [2.26-2.62] and 0.42% [0.31-0.53] of mortality, respectively.

CONCLUSION

The current study demonstrates that besides early ART and coinfection control, actions targeting males, non-whites and illiterate people and those with basic education are important to reduce avoidable deaths among Brazilian PLWHIV.

Economic and epidemiological evaluation of text message-based interventions in patients with the Human Immunodeficiency Virus

OBJECTIVE

to evaluate the cost-effectiveness ratio and the budget impact of sending text messages associated with medical consultations in order to reduce the viral load of patients infected with the Human Immunodeficiency Virus.

METHOD

a randomized clinical trial, basis for the development of a dynamic cohort model with Markov states in order to compare medical appointments for adults infected with the Human Immunodeficiency Virus versus the alternative strategy that associated medical consultations to sending text messages through telephone.

RESULTS

156 adults participated in the study. As for the viral load, it was verified that in the control group there was an increase, in the intervention group A (weekly messages) there was a reduction (p = 0.002) and in group B (biweekly messages) there was no statistically significant difference. Sending text messages would prevent 286,538 new infections by the Human Immunodeficiency Virus and 282 deaths in the 20-year period, compared to the standard treatment. The alternative strategy would result in saving R$ 14 billion in treatment costs.

CONCLUSION

weekly sending messages in association with the standard treatment can reduce the circulating viral load due to its effect in decreasing new infections, in addition to reducing health costs.

Late diagnosis of Human Immunodeficiency Virus infection and associated factors

OBJECTIVE

to analyze the occurrence of late diagnosis of infection by the Human Immunodeficiency Virus and its associated factors.

METHOD

this is an epidemiological, cross-sectional and analytical study, carried out with 369 people followed-up by Specialized Assistance Services, undergoing anti-retroviral treatment, and interviewed by means of a questionnaire. Univariate analysis was performed using Pearson's chi-square test or Fisher's exact test and Kruskall-Wallis test, and multivariate analysis using the ordinal logistic regression model of proportional odds.

RESULTS

the occurrence of 59.1% for late diagnosis of the infection was observed; the probability of later diagnosis is greater among people who have a steady partnership, when compared to those who do not; with increasing age, particularly above 35 years old; among those with lower schooling; for those who seek the health services to have an HIV test when they feel sick; and for those who test HIV less often or never do it after sex without a condom with a steady partner.

CONCLUSION

the knowledge on the high proportion of late diagnosis and its associated factors verified in this study make the planning and implementation of new policies and strategies aimed at the timely diagnosis of the infection imperative.

Development of algorithms to estimate EQ-5D and derive health utilities from WHOQOL-HIV Bref: a mapping study

PURPOSE

This study aimed to develop and evaluate different families of applicable models available for utility mapping between World Health Organization Quality of Life for HIV-abbreviated version (WHOQOL-HIV Bref) and EQ-5D-3L and to propose an optimised algorithm to estimate health utilities of people living with HIV.

METHODS

Estimation dataset was collected between July 2014 and September 2016 in a cross-sectional study including 1526 people living with HIV/Aids (PLWH) under care at the Instituto Nacional de Infectologia Evandro Chagas-FIOCRUZ, in Brazil. Data of WHOQOL-HIV Bref and EQ-5D-3L questionnaires were collected. Fisher's exact tests were used for testing WHOQOL-HIV Bref response frequencies among groups of responses to each of the five EQ-5D-3L domains. Multiple correspondence analyses (MCA) were used to inspect the relationships between both instrument responses. Different families of applicable models available for utility mapping between WHOQOL-HIV Bref and EQ-5D-3L were adjusted for the prediction of disutility.

RESULTS

Candidate models' performances using mean absolute error (MAE), mean squared error (MSE), and root mean squared error (RMSE) were similarly good, which was evidenced by the overlapping of its 95% confidence intervals of the mean tenfold cross-validation or estimated generalisation errors. However, the Hurdle Logistic-Log-Normal model was better on average according to generalisation errors both in the prediction of Brazilian utility values (MAE = 0.1037, MSE = 0.0178, and RMSE = 0.1332) and for those of the UK (MAE = 0.1476, MSE = 0.0443, and RMSE = 0.2099).

CONCLUSIONS

Mapping EQ-5D-3L responses or deriving health utilities directly from WHOQOL-HIV Bref responses can be a valid alternative for settings with no preference-based health utility data.