[The social geography of AIDS in Brazil]

The Epidemiological Impact of STIs among General and Vulnerable Populations of the Amazon Region of Brazil: 30 years of Surveillance

Sexually transmitted infections (STIs) represent a worldwide public health problem and, although many of them are curable, they continue to be neglected, especially in areas with a low human development index, such as in the northern region of Brazil. This review describes the results of 30 years of studies at the Virus Laboratory at the Federal University of Pará, including the prevalence and molecular epidemiology of HIV-1, HTLV-1/2, HPV, HBV, Treponema pallidum and Chlamydia trachomatis among urban and non-urban populations, and also in vulnerable groups in the Brazilian Amazon. Control strategies and challenges in preventing STIs are discussed considering this immense geographic region, where essential health services are unable to reach the entire population, especially the most vulnerable, such as female sex workers, people who use illicit drugs, remnants of quilombolos and indigenous communities.

How many AIDS epidemics can occur in São Paulo city?

OBJECTIVE

An ecological study describring the spatial characteristics of AIDS in São Paulo city between 2001 and 2010 according to the place of residence of reported cases in adults.

METHODS

The AIDS reported cases (28,146), grouped by sex, were geocodified (25,969) and linked with a census tract database (18,953). Case and population at risk data supplied spatial cluster identification and relative risk estimate by the scan method, using the discrete Poisson model. Incidence rate and proportional distribution allowed comparing people living in the high-risk clusters areas to other locations by age, race/ethnicity, schooling and transmission category.

RESULTS

The AIDS incidence rate decreased in both sexes except among young men and older people. The identification of spatial high-risk clusters showed that the decrease of AIDS did not occur in the same way in the city. Clusters located in the central area presented the highest AIDS incidence rates (245.7/100,000 men), especially among black women (RR = 7.9), men who have sex with men (66.2%) and injection drug users (10.7%) participation. In peripheral clusters, identified only in the female population, the epidemic can be related to the poverty of these women (22.5% low education level). Residents in the north and central-south areas of the city are generally black, with little schooling, and predominantly heterosexually infected.

CONCLUSIONS

The study of spatial clusters using a census tract helps to determine epidemiological patterns inside the city and in specific populations. Spatial stratification and key population epidemiological patterns were identified in four regions in São Paulo city.

Path of infectious diseases in Brazil in the last 50 years: an ongoing challenge

In this article, we comment on the main features of infectious diseases in Brazil in the last 50 years, highlighting how much of this path Revista de Saúde Pública could portray. From 1967 to 2016, 1,335 articles focusing on infectious diseases were published in Revista de Saúde Pública. Although the proportion of articles on the topic have decreased from about 50.0% to 15.0%, its notability remained and reflected the growing complexity of the research required for its control. It is noteworthy that studies design and analysis strategies progressively became more sophisticated, following the great development of epidemiology in Brazil in the recent decades. Thus, the journal has followed the success of public health interventions that permitted to control or eliminate numerous infectious diseases - which were responsible, in the past, for high rates of morbidity and mortality -, and also followed the reemergence of diseases already controlled and the emergence of until then unknown diseases, with a strong impact on the Brazilian population, establishing a little predictable and very challenging path. RESUMO Neste artigo, comentamos as principais características das doenças infecciosas no Brasil, nos últimos 50 anos, destacando o quanto a Revista de Saúde Pública conseguiu capturar essa trajetória. De 1967 a 2016, foram publicados 1.335 artigos na Revista de Saúde Pública com foco em doenças infecciosas. Ainda que a proporção de artigos sobre esse tema tenha declinado de cerca de 50,0% para 15,0%, seu destaque se manteve e refletiu a crescente complexidade das pesquisas necessárias para o seu controle. Nota-se que os desenhos dos estudos e as estratégias de análise ganharam progressivamente maior sofisticação, acompanhando o grande desenvolvimento da epidemiologia no Brasil, nas últimas décadas. Assim, foi registrado não apenas o sucesso de intervenções de saúde pública que permitiram o controle ou a eliminação de inúmeras doenças infecciosas responsáveis, no passado, por elevadas taxas de morbimortalidade, como também a reemergência de males já controlados e o surgimento de doenças até então desconhecidas, com forte impacto na população brasileira, desenhando uma trajetória pouco previsível e muito desafiadora.

Spatial dynamics of AIDS incidence in the elderly in Rio de Janeiro, Brazil, 1997-2011

The dynamics of the spread of the AIDS epidemic ranges according to the characteristics of each geographical region in different population groups. The aim of this study was to evaluate spatial and temporal trends of the AIDS epidemic among the elderly in the State of Rio de Janeiro, Brazil. A retrospective study using spatial analysis techniques was conducted among AIDS cases (≥ 60 years) diagnosed from 1997-2011. The Poisson regression model was used to assess the relationship between year of diagnosis and incidence of AIDS, adjusted by sex. The AIDS epidemic began in the south coast of the state and gradually reached neighboring cities. The highest rates were found in regions around Rio de Janeiro and Niterói cities. The highest smoothed rates of the period were observed in Niterói in 2002-2006: 11.87/100,000 (men) and 8,5/100,000 (women). AIDS incidence rates among the elderly have stabilized in recent decades. To prevent HIV from spreading further among the general population, greater attention should be given to the older population.

Social geography of AIDS in Brazil: identifying patterns of regional inequalities

The trend towards decline and stabilization of the AIDS epidemic in Brazil should be analyzed carefully, since aggregate data can mask regional or local inequalities in such a large and diverse country. The current study reevaluates the epidemic’s spatial dissemination and the AIDS-related mortality pattern in Brazil. The study considered all AIDS cases diagnosed in individuals over 18 years of age and living in Brazil, as well as AIDS deaths recorded in 1998-2008. Three-year moving average rates were estimated, and a spatial analysis was conducted using a local empirical Bayesian method. The epidemic was only found to be expanding in the North and Northeast regions, while declining in the rest of the country, especially in the Southeast. According to the findings, the apparent stabilization of AIDS mortality tends to mask regional disparities. Social determinants of health and regional disparities should be taken into account in program development and policymaking.

Logistic model for determining factors associated with HIV infection among blood donor candidates at the Fundação HEMOPE

Objective

To determine factors associated with HIV infection in blood donor candidates in Recife, Brazil.

Methods

A transversal study was performed of 106,203 blood donor candidates found eligible by the routine clinical screening process in the blood bank in Recife of the Fundação de Hematologia e Hemoterapia de Pernambuco (HEMOPE) in the period from January 1998 to November 2003. Additional indirect immune and western blot confirmation tests for HIV infection were performed and the candidates were classified as HIV positive or negative. The Chi-squared test and stepwise multiple logistic regression were conducted to examine any association between HIV infection and age, gender, place of residence, schooling, number of donations and serological tests for core hepatitis B antigen virus (anti-HBc), the hepatitis C antivirus (anti-HCV), human T-type antivirus lymph cells (anti-HTLV 1 and 2), serological tests for syphilis (VDRL) and the hepatitis B virus surface antigen (HBsAg).

Results

In the observed sample, 0.204% of blood donor candidates were found to be HIV positive. Among the studied variables, the age, education level, residency, donation type, and serologic status for anti-HBc and VDRL tests were found to be associated with HIV infection.

Conclusions

The younger, spontaneous donor candidates living in the Recife metropolitan area with a low level of education and positive for anti-HBc and VDRL have an higher risk of HIV infection than the other candidates. Data such as these are useful to understand the dynamics of infection and to guide healthcare policies.

The geography of institutional psychiatric care in France 1800-2000: historical analysis of the spatial diffusion of specialised facilities for institutional care of mental illness

As in other European countries, specialised psychiatric hospitals were established throughout France during the 19th Century. The construction of these hospitals can be considered as the concrete expression of a therapeutic innovation which recognized insanity as an illness that could be treated in such specialised institutions. The spatial diffusion of these innovative institutions through 19th and 20th century France is analysed and we explore how far this can be understood through theories of diffusion of innovations including geographical models of hierarchical and expansion diffusion (or whether other conceptual models are more appropriate). The research reported here particularly focuses on the period 1800-1961. It involved the construction of an original historical database of both psychiatric hospitals and information on the cities where these institutions were located. This was used to examine and interpret the different phases of development of psychiatric institutions and the parts of the country and types of geographical setting where they were concentrated. A multiple correspondence analysis was then performed to examine the connections between different aspects of the diffusion process. The study shows the limitations of classical models of spatial diffusion, which are found to be consistent with some, but not all aspects of the development of psychiatric institutions in France. An alternative political ecology approach seems more appropriate to conceptualise the various processes involved; national policies, social representations, medicalisation of care of mental illness, and urban and economic growth all seem to be associated with the emergence of a variable and complex pattern. This paper also opens a large field of research. Compared with other western countries, the geography of French psychiatric care is relatively under-researched, although there has been a strong spatial dimension to mental health policy in the country. This analysis provides a context for studies of more contemporary processes of French deinstitutionalisation, which is strongly structured by the past heritage of these large asylum facilities.

Magnitude and trend of the AIDS epidemic in Brazilian cities, from 2002 to 2006

OBJECTIVE

To analyze different patterns of occurrence of AIDS in Brazilian cities between 2002 and 2006, associating trend and magnitude with socio-demographic indicators and local characteristics of the epidemic.

METHODS

This was an ecological study that categorized cities according to magnitude and trend of the epidemic and subsequently analyzed, considering social indicators, types of HIV transmission and year of first case reported. Data came from the Brazilian Epidemiological Surveillance System, the Brazilian Institute of Geography and Statistics and the United Nations Development Program for Brazil. Linear regression was used to estimate trend and chi-square statistics and ANOVA to analyze indicators.

RESULTS

A total of 4,190 cities (75.3%) reported AIDS cases between 2002 and 2006. Of these, 3,403 (81.2%) had an occurrence of "small magnitude" (mean=4.7 cases), 367 (8.8%) of "average magnitude" (mean=30.3 cases) and 420 (10.0%) of "great magnitude" (mean=378.7 cases). Cases of "small magnitude" were associated with lower incidence; beginning of the epidemic after 1991; presence of one or two types of transmission; especially heterosexual contact; with occurrences of cases in one or two years of the period; and lower human development index (HDI). Those of a "great magnitude" were associated with larger cities and higher HDI; presence of all types of transmission; beginning of the epidemic between 1980/1991; and trend towards reduction/stabilization, especially due to a decrease in transmission among injecting drug users. Growth of the epidemic was concentrated in "small magnitude" cities, although without significance to the point of changing proportional participation (8.7%) of these cities in the group of cases in Brazil.

CONCLUSIONS

The AIDS epidemic remains concentrated in urban centers and the spread of cases to the countryside is characterized by irregular occurrence and small magnitude. Cities with low HDI and exclusive transmission through heterosexual contact showed low capacity of increase and the reduction of the epidemic is especially associated with the decrease in transmission among injecting drug users.

Drugscapes and the role of place and space in injection drug use-related HIV risk environments

Although considerable research has been conducted to identify the behavioural characteristics that predispose individuals to inject drugs or become infected with HIV via injection drug use, much less research has been conducted on structural and policy determinants, cultural norms, stigma, and ecological factors which may affect drug use risk behaviour, users' networks and HIV rates associated with drug use across geographic areas. For programme planners, whether official or grassroots, an understanding of place-based characteristics can help better identify risk environments to injection drug use-related HIV, and determine how to facilitate actions regarding public policy and harm reduction to aid in the reduction of risk. As such, we consider in this commentary the importance of geographic place and the socio-spatial and political processes related to place that may help determine where IDU-related HIV risk environments occur.

A interiorização da epidemia de HIV/AIDS e o fluxo intermunicipal de internação hospitalar na Zona da Mata, Minas Gerais, Brasil: uma análise espacial

O objetivo deste artigo foi analisar o processo de interiorização da epidemia de AIDS e investigar o acesso aos serviços em HIV/AIDS, entre 1988-2002, na Zona da Mata, Minas Gerais, Brasil. Realizou-se estudo ecológico, com abordagem têmporo-espacial. Construiu-se um fluxo de internação hospitalar, tendo como referência pacientes maiores de 15 anos, internados pelo Sistema Único de Saúde, nos anos de 1996 e 2004, residentes nos municípios da região. Foram registrados 2.469 casos de AIDS em maiores de 15 anos no período; as taxas médias de incidência e mortalidade foram calculadas e reestimadas pelo estimador bayesiano empírico local para representar de maneira mais clara os municípios com maior concentração de casos e de óbitos. Verificou-se a interiorização da epidemia. Juiz de Fora é o município com maior número de casos e provável centro difusor da AIDS na região. A assistência hospitalar dos casos de AIDS da Zona da Mata está concentrada nesse município. Destaca-se necessidade de investigações adicionais sobre causas da não-participação de hospitais de referência em outros municípios da região na gerência e prestação de cuidados aos pacientes que vivem com HIV/AIDS.

Twenty-five years of the AIDS epidemic in Brazil: principal epidemiological findings, 1980-2005

The Brazilian AIDS epidemic is undergoing important changes in its third decade. The present article reviews some central findings: the proportional reduction in cases related to injection drug use; the stability, in recent years, of new cases in the male homosexual/bisexual population; and the relative and absolute increment in heterosexual transmission, even though the estimates of incident rates still point to the first two categories mentioned as those most affected by the epidemic. Still should be detached the persistent increase in incidence rates among women and its stability in the younger age groups, probably the result of behavior changes (such as the consistent use among youth of condoms in sexual relations with casual partners and a reduction in cases related to injection drug use). It is well-know that HIV prevalence in the general population has stabilized at less than 1%, which characterizes Brazil as one of the countries with a concentrated epidemic. The article also emphasizes the growth of AIDS morbidity-mortality in the less favored socioeconomic strata and in women, and the stability of the mortality rate among men.

[Use of condoms during sexual intercourse: a population-based study]

OBJECTIVE

To describe characteristics associated with failure to use condoms during sexual intercourse by women.

METHODS

We conducted a cross-sectional population-based study including 1,026 women aged 20-60 years living in the urban area of a city in Southern Brazil, in 2003. Cluster sampling was carried out by randomly selecting 40 of the city's 270 census sectors. We performed logistic regression analysis of failure to use condoms in relation to socioeconomic, demographic, obstetric, and health care usage variables.

RESULTS

Among studied women, 867 (84.5%) reported being sexually active; of these, 252 (29.1%) wore condoms during sexual intercourse. Logistic regression showed that the most vulnerable groups were women who were married or in stable partnerships, and women aged more than 40 years. We found no associations with the other variables explored.

CONCLUSIONS

Prevalence of condom use was low; we were able to identify a group of women that needs to be targeted by health policies and services in order to improve perception of the risk of acquiring sexually transmitted diseases.

[AIDS mortality and socioeconomic indexes in the city of Sao Paulo, 1994-2002]

OBJECTIVE

To investigate the correlation between AIDS mortality rates and social inclusion/exclusion indexes among male and female populations aged between 25 to 49 years.

METHODS

The study was carried out in 96 administrative districts of the municipality of Sao Paulo in the period 1994-2002. Mortality data were collected from the Program for Improving Local Mortality Data and from population estimates based on the 1991 and 2000 census of the State System Data Analysis (SEADE) Institute and the Municipal Department of Planning. The indicators were obtained from the city's map of exclusion (1996 and 2000). Statistical analysis was performed using Pearson's correlation test (at 5% level).

RESULTS

A significant positive correlation was seen among men between AIDS mortality and the district life quality index from 1994 to 1998 (p<0.05). Among women, a significant negative correlation (p<0.05) was seen for the whole study period between AIDS mortality and the equity index, which measures the proportion of illiterate women who are family heads. From 2000, it was also observed a significant negative correlation (p<0.05) among women between AIDS mortality and the global social exclusion index.

CONCLUSIONS

The study results suggest a shift of AIDS mortality to exclusion areas and might indicate a relationship between AIDS mortality and socioeconomic factors. Further epidemiological and social sciences studies are needed to investigate these associations.

Is it possible to reduce AIDS deaths without reinforcing socioeconomic inequalities in health?

BACKGROUND

The wide use of highly active antiretroviral therapy has led to an impressive improvement in AIDS survival after the mid-1990s in cities and countries with a high access to these medications. Notwithstanding its beneficial overall effect, antiretroviral therapy was also reported as a factor for the increase in socioeconomic inequalities in health, because AIDS patients have unequal access and adherence to these medications.

METHODS

We assessed trends AIDS mortality in districts of Sao Paulo, Brazil, from 1995 to 2002, in order to test their association with area-level socioeconomic indices in a city with a large-scale and cost-free distribution of highly active antiretroviral therapy. We gathered information on yearly death rates due to AIDS, adjusted for gender, age group, income, instruction, living standards, and the human development index. Trend estimation used the autoregression procedure of exact maximum-likelihood estimation for time-series analysis. Regression analysis was used to study the association between the annual percentage decrease in AIDS deaths and socioeconomic indices.

RESULTS

AIDS mortality decreased in Sao Paulo from 32.1 deaths (per 100 000 inhabitants) in 1995 to 11.2 deaths (per 100 000 inhabitants) in 2002. District-level figures of social development did not show an association with the annual percentage decrease in AIDS mortality, with all correlation coefficients corresponding to P-values >0.27.

CONCLUSIONS

This observation indicates that the perspective of public policies addressed to the entire population contribute to reducing inequalities in health, while attaining an overall reduction in AIDS deaths, may have been feasible in the Brazilian context.

Tendências da morbi-mortalidade por aids e condições socioeconômicas no Município de São Paulo, 1994 a 2001

INTRODUÇÃO: As tendências na epidemia de Aids têm se caracterizado pelos diversos contextos socioculturais das populações. OBJETIVO: Descrever a evolução da morbi-mortalidade por aids em indivíduos de 15 a 49 anos no Município de São Paulo, segundo sexo e áreas homogêneas socioeconômicas, no período de 1994 a 2001. MATERIAL E MÉTODOS: Foram utilizados dados do Programa de DST/AIDS e do Programa de Aprimoramento das Informações de Mortalidade no Município de São Paulo. As áreas homogêneas foram constituídas a partir do Mapa da Exclusão Social da Cidade: áreas 1 e 2 (centrais e de inclusão); áreas 3, 4 e 5 (mais periféricas e de exclusão). Foram calculados os coeficientes por 100.000 e as razões entre 1995 e 2001, tomando como referência o ano de 1994. REULTADOS: Entre os homens, observou-se diminuição da incidência em todas as áreas desde 1998-1999, e entre as mulheres, no mesmo período, nas quatro primeiras áreas. A queda da incidência e da mortalidade masculina foi maior na área 2: razão 2001/94 = 0,43 e 0,21, e mais lenta nas áreas de exclusão. Entre as mulheres, a área 5 apresentou crescimento da incidência no final do período (54%), e as áreas 3, 4 e 5 apresentaram a menor velocidade de queda na mortalidade. DISCUSSÃO: Entre os homens, o padrão de mortalidade acompanha a morbidade: as áreas mais centrais são as mais atingidas e com maior queda da mortalidade, mas com tendência à "periferização". Entre as mulheres, confirma-se o crescimento mais tardio da epidemia em direção à periferia, e uma tendência de queda na mortalidade inversamente proporcional à exclusão social das áreas.

A epidemia de AIDS no Brasil, 1991-2000: descrição espaço-temporal

A incidência de AIDS foi retratada por um estudo ecológico dos municípios brasileiros, considerando as notificações entre 1991 e 2000. Observou-se aumento da incidência em mulheres e em indivíduos com baixa escolaridade. O Estado de São Paulo, com 46% das notificações registradas no País, apresentou perfil epidemiológico distinto, quando a capital foi comparada com as cidades do interior; o Estado de Pernambuco apresentou um perfil epidemiológico semelhante àquele do início da epidemia no Brasil; o Estado Santa Catarina mostrou o predomínio de casos usuários de drogas injetáveis. O aumento de notificações pela via de transmissão ignorada indica que o viés de classificação foi crescente no sistema de vigilância epidemiológica.

[Distribution of AIDS cases in women in Rio de Janeiro, Brazil, 1982-1997: a spatial analysis]

The AIDS epidemic has spread and reached various population groups differently. The epidemic's dynamics have also differed according to the characteristics of different areas within cities, related to the principal modes of spread. This study analyzes the AIDS epidemic in women in the city of Rio de Janeiro using the space referential. The epidemic is on the rise among women, particularly in the Northern and Western Zones of the city. In this group it constitutes a "sub-epidemic", to the extent that it displays different characteristics in terms of clinical presentation, access to health services, and knowledge of risks. There was a high proportion of unknown transmission category among the women, thus revealing ignorance of their own risk situation. In addition, the high proportion of unknown level of schooling emphasizes the implications of the investigative system on quality of data recorded for women.

A aids no Estado de São Paulo: as mudanças no perfil da epidemia e perspectivas da vigilância epidemiológica

O HIV, inicialmente vinculado a homens que fazem sexo com homens (HSH), particularmente nos países industrializados e na América Latina, disseminou-se rapidamente entre os diversos segmentos, alcançando mulheres, homens com prática heterossexual e crianças. A crescente desigualdade entre países desenvolvidos e em desenvolvimento reflete-se, tanto na magnitude da propagação do HIV, quanto na mortalidade por aids. Na medida em que se acentuam as diferenças de acesso ao tratamento, diminui a mortalidade por aids nos países mais ricos e aumenta nos países mais pobres, exceção feita ao Brasil, um dos poucos países que adotaram a política de distribuição gratuita de anti-retrovirais. Aqui, a mortalidade vem apresentando queda acentuada a partir de 1996 e o uso de anti-retrovirais, entre outros, é um dos principais fatores associados a esta diminuição. No presente artigo foram analisados os dados do Sistema de Vigilância Epidemiológica de DST/aids do Estado de São Paulo, com o intuito de descrever o perfil da epidemia e discutir os termos juvenilização, pauperização, heterossexualização e feminização, introduzidos no discurso sobre a epidemia, para acompanhar as mudanças de seu padrão epidemiológico. Até 31/12/2001, no Estado de São Paulo, foram notificados 106.873 casos da doença, o que representa cerca de 50% do total de notificações do país. Os maiores coeficientes de incidência aparecem nos indivíduos de 30 a 39 anos, sendo que tanto o número de casos como o de óbitos mostra um ligeiro aumento nas idades mais avançadas, indicando um leve "envelhecimento" da epidemia. A aids aparece em todas as camadas sociais. Ao longo dos anos tem havido um aumento do número de casos entre pessoas de menor escolaridade, com ocupações menos qualificadas. O crescimento do número de casos entre homens heterossexuais, junto ao marcante predomínio desta forma de transmissão na população feminina, corrobora a hipótese de heterossexualização da epidemia. O atual sistema de vigilância epidemiológica de aids é baseado principalmente na notificação de casos e tem sido utilizado como principal fonte de informação para observação das tendências da epidemia e para o planejamento das atividades de prevenção e assistência, assim como para divulgação da doença para a população em geral. Reflete uma situação de vários anos após a infecção ter acontecido, e este intervalo de tempo tende a aumentar em virtude de diversos fatores, tais como a introdução dos anti-retrovirais, entre outros, levando ao aumento do tempo para os casos entrarem no sistema de informação, fazendo com que as informações do sistema atual fiquem cada vez mais distantes da real magnitude da infecção pelo HIV. Dessa forma, outras estratégias têm sido implementadas para se avaliar as tendências da infecção pelo HIV e para subsidiar novas atividades de prevenção e controle, tais como: a notificação compulsória de gestantes HIV positivas e crianças expostas ao HIV; notificação dos portadores assintomáticos do HIV; aprimoramento da investigação sobre a situação de risco dos casos de HIV/aids e incorporação do quesito cor/raça na notificação de casos de aids para subsidiar a definição de grupos de risco acrescido e de maior vulnerabilidade; assim como os sistemas de vigilância de segunda geração, que objetivam identificar as tendências do comportamento e de prevalência da infecção.

[AIDS epidemic dynamics in the municipality of Rio de Janeiro, Brazil, 1988-1996: Spatial-temporal statistic modeling]

This study uses a spatial-temporal model to analyze the spatial spread of the AIDS epidemic (adult cases) in the municipality of Rio de Janeiro, Brazil, during three periods: 1988-1990, 1991-1993, and 1994-1996. City districts were used as the geographic units of analysis. A spatial analysis was also performed for pediatric AIDS cases due to vertical HIV transmission, according to period of birth, 1985-90 and 1991-96. For total adult AIDS cases, the initial period was characterized by a polygonal cluster located around the harbor area, which expanded from west to east. Among homosexual cases, in situ growth predominated, and a decrease in the intensity of the diffusion process was observed from the second to the final period. Among heterosexual cases, the epidemic displayed a relevant geographic spread, mainly from 1988-1990 to 1991-1993. Among female cases in the final time period, a cluster of high incidence rates was found towards the northwest, including very poor areas. Among pediatric cases in 1991-1996, a significant correlation was found between AIDS incidence rates and poverty levels in the respective municipal districts. The results suggest that a more complete understanding of AIDS spatial-temporal dynamics can make a major contribution to preventive measures.

[Analysis of spatial diffusion patterns for AIDS cases in some Brazilian States]

Despite new improvements in AIDS treatment, preventive measures are still essential to control the epidemic. Effective programs almost always depend on correct and efficient allocation of scarce health resources. Detailed information on the epidemic, such as where, when, and how the epidemic will spread are of great value. This study was conducted to obtain a better understanding of the dissemination of AIDS cases in four important Brazilian States. Spatial diffusion patterns were evaluated qualitatively by studying sequential maps and quantitatively by analyzing spatial correlograms. Ten years were analyzed, grouped in three periods (1987-1989, 1990-1992, and 1993-1996). The diffusion process was studied for both total AIDS cases and male and female cases. Diffusion of AIDS cases presented specific characteristics for each of the four States. Information derived from the study, especially the results of the correlogram analysis, improve our understanding of the epidemic's spatial diffusion in different parts of the country and can also be used to determine parameters for other AIDS epidemiological models.

Human immunodeficiency virus/acquired immunodeficiency syndrome and tropical diseases: a Brazilian perspective

The paper summarizes recent findings on the epidemiology and pathogenesis of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/Aids), highlighting the role of co-infections with major tropical diseases. Such co-infections have been studied in the Brazilian context since the beginning of the Aids epidemic and are expected to be more frequent and relevant as the Aids epidemic in Brazil proceeds towards smaller municipalities and the countryside, where tropical diseases are endemic. Unlike opportunistic diseases that affect basically the immunocompromised host, most tropical diseases, as well as tuberculosis, are pathogenic on their own, and can affect subjects with mild or no immunosuppression. In the era of highly active anti-retroviral therapies (HAART), opportunistic diseases seem to be on decrease in Brazil, where such medicines are fully available. Benefiting from HAART in terms of restoration of the immune function, putative milder clinical courses are expected in the future for most co-infections, including tropical diseases. On the other hand, from an ecological perspective, the progressive geographic diffusion of Aids makes tropical diseases and tuberculosis a renewed challenge for Brazilian researchers and practitioners dealing with HIV/Aids in the coming years.

AIDS e grau de escolaridade no Brasil: evolução temporal de 1986 a 1996

Este trabalho analisa a evolução temporal dos casos de AIDS por grau de escolaridade como variável identificadora do nível sócio-econômico do caso. Todos os casos de AIDS em indivíduos com idades entre 20 e 69 anos, notificados até 29 de maio de 1999, diagnosticados entre 1986 e 1996, foram incluídos no estudo. As taxas de incidência para ambos os sexos foram calculadas segundo dois graus de escolaridade - "grau 1" (casos com até oito anos de estudo) e "grau 2" (com mais de oito anos de estudo) -, por região e ano de diagnóstico. Entre os homens, as taxas de incidência de AIDS para aqueles com menor escolaridade ultrapassam (sendo mais evidente na Região Sudeste) ou se aproximam das taxas dos homens com maior escolaridade. Para as mulheres, a evolução temporal das taxas mostrou maior ritmo de crescimento entre as mulheres de menor escolaridade para todas as regiões, sendo que, na Sudeste, as taxas entre as mulheres com menor escolaridade ultrapassa as taxas daquelas com maior escolaridade em anos anteriores a 1989. Concluindo, a presente análise mostra, de forma consistente, que a epidemia de AIDS no Brasil se iniciou nos estratos sociais de maior escolaridade, com progressiva disseminação para os estratos sociais de menor escolaridade.

[AIDS information systems: limits and possibilities]

The article makes an analysis of the current System of Information (SI) in AIDS, aiming the difficulties with that was confronted when looking for to characterize the way as it happened and it developed in 1995 the epidemic of the AIDS in the Regional Administration of Health of Pirituba-Perus (ARS-8) of the municipal district of São Paulo. Some are enumerated critics that the Epidemic Surveillance and the SI they come suffering in the last years, such as the centralization and the disaggregation of the information; the data that contemplate aspects eminently biological, the use of complex forms. These subjects, added to the difficulties that were imposed to the he/she/it to look for to characterize the epidemic in the area, he/she revealed that the system, just as her found structured, it hindered the characterization of the epidemic and the systematic accompaniment for the local levels of health. He/she gets himself the attention for the need of revision of the purpose of the SI in AIDS, of the nature and of the quality of the collected data. It is reiterated the importance of the integration of the several databases partner-demographics of the focus microlocalizado of SI for the District of Health.

Adesão de pacientes HIV positivos à dietoterapia ambulatorial

É conhecida a importância do estado nutricional para a evolução clínica de pacientes HIV positivos. Entretanto, é desconhecida a expectativa do paciente com relação à dietoterapia. Por um período de 30 semanas foram acompanhados 50,0% dos pacientes HIV positivo (grupos II e IV) atendidos pelo ambulatório de Doenças Sexualmente Transmissíveis do Hospital e Maternidade Celso Pierro. Neste período foram realizadas duas entrevistas, sendo o intervalo entre elas de 10 semanas. Na primeira foram colhidos dados socioeconômicos, antropométricos, verificadas as modificações voluntárias feitas na alimentação e também a expectativa do paciente quanto a este tipo de tratamento. Na segunda foram colhidos indicadores diretos e indiretos de adesão ao tratamento. A adesão foi maior entre os pacientes do grupo IV (64,7%) do que entre os do grupo II (35,3%). No entanto, 81,3% dos pacientes do grupo II, após tomarem conhecimento da sorologia positiva para HIV, modificaram voluntariamente sua alimentação, demostrando ser este um importante período para sensibilização do paciente para o tratamento.

Vulnerabilidade de adolescentes no SILOS-Butantã

O objeto deste estudo diz respeito à vulnerabilidade dos adolescentes que moram em uma região do Município de São Paulo: o SILOS-Butantã. Parte dos seguintes pressupostos: primeiro, de que o adolescente é um sujeito social cujo desenvolvimento é determinado pela sua história de vida, de acordo com sua inserção social e seu desenvolvimento psicológico particular, num contexto histórico e cultural dado; segundo, de que o processo saúde-doença é socialmente determinado, e portanto, a vulnerabilidade dos adolescentes para os problemas de saúde se encontra inquestionavelmente articulada às condições de trabalho e de vida de suas famílias. O objetivo deste estudo, é o de caracterizar, na Região Metropolitana de São Paulo, espaços sociais em que vivem, trabalham e estudam adolescentes cuja inserção social torna-os vulneráveis à problemas específicos de saúde. A partir do trabalho no SILOS-Butantã - área de abrangência do Hospital Universitário - procedeu-se a uma trajetória metodológica que permitiu reunir dados secundários a respeito dos vários Distritos componentes desse SILOS. A análise dos dados permitiu eleger o Distrito de Raposo Tavares como território prioritário a ser focalizado por futuras investigações e processos de intervenção do âmbito da saúde coletiva. Isto porque fundamentalmente, oferece a maior concentração de famílias pertencentes ao Grupo Homogêneo-3 (deficientes formas de viver e de trabalhar) e a menor concentração de famílias pertencentes ao Grupos Homogêneo-1 (adequadas formas de viver e de trabalhar) dentre os distritos componentes do SILOS-Butantã. Este foi o distrito que recebeu a menor nota no Mapa da exclusão/ inclusão social entre os distritos do SILOS-Butantã.

[The challenge of emergent diseases and the return to descriptive epidemiology]

The definition of emergent and re-emergent diseases, patterns of occurrence during the last 25 years, and the determinants of this occurrence are presented. The importance of descriptive epidemiology and its use in the investigation of these health problems, especially in view of epidemiologists' tendency to give less attention to it, finally, is emphasized the challenges that the emergent diseases pose for public health practice and for the methodological development of descriptive epidemiology are also set out. These challenges are considered in three fields: biosecurity, surveillance systems and descriptive epidemiology techniques.

[Are geoprocessing, environment, and health a possible combination?]

The use of geoprocessing techniques allows one to gather socioeconomic, health, and environmental data on a spatial basis. However, interpretation of associations between epidemiological and environmental variables requires the geoprocessing system design. The study scale and object choices precede conception of the system, conditioning the possible statistical and visual results. This scale must be compatible with the phenomenon on which one intends to focus, aiming at internal homogeneity and external heterogeneity of spatial units. The interdependency of spatial processes, reflected in the spatial configuration of social, environmental, and epidemiological data distribution, affects interpretation of causes for simultaneous processes. Geoprocessing allows for knowledge of the context or situational surroundings in which the damage to health takes place.