[AIDS epidemic trends after the introduction of antiretroviral therapy in Brazil]

Amplified HIV Transmission Risk Among People Living With HIV in Southeast Brazil

ABSTRACT

This study investigated the factors associated with amplified HIV transmission risk among people living with HIV from a city in southeast Brazil. A cross-sectional study was conducted with 397 people living with HIV recruited in infectious diseases clinics. Data on risk of HIV transmission, sociodemographic characteristics, sexual behaviors, professional counseling, serological HIV status, HIV-related clinical data, and beliefs about risk of HIV transmission were collected through interviews and medical records. Hierarchical ordered multinomial regression analyses were performed. Amplified HIV risk transmission was associated with lower age, alcohol consumption before having sex, illicit drug use before sexual intercourse, and not receiving professional counseling about HIV transmission. The belief that HIV can be transmitted to a partner not living with HIV was associated with lower likelihood of amplified risk for HIV transmission. Our findings suggest the importance of minimizing substance use before having sex, professional counseling, and beliefs about HIV transmission on amplified HIV risk transmission.

STING and cGAS gene expressions were downregulated among HIV-1-infected persons after antiretroviral therapy

Background

The HIV-1 epidemic is still considered a global public health problem, but great advances have been made in fighting it by antiretroviral therapy (ART). ART has a considerable impact on viral replication and host immunity. The production of type I interferon (IFN) is key to the innate immune response to viral infections. The STING and cGAS proteins have proven roles in the antiviral cascade. The present study aimed to evaluate the impact of ART on innate immunity, which was represented by STING and cGAS gene expression and plasma IFN-α level.

Methods

This cohort study evaluated a group of 33 individuals who were initially naïve to therapy and who were treated at a reference center and reassessed 12 months after starting ART. Gene expression levels and viral load were evaluated by real-time PCR, CD4⁺ and CD8⁺ T lymphocyte counts by flow cytometry, and IFN-α level by enzyme-linked immunosorbent assay.

Results

From before to after ART, the CD4⁺ T cell count and the CD4⁺/CD8⁺ ratio significantly increased (p < 0.0001), the CD8⁺ T cell count slightly decreased, and viral load decreased to undetectable levels in most of the group (84.85%). The expression of STING and cGAS significantly decreased (p = 0.0034 and p = 0.0001, respectively) after the use of ART, but IFN-α did not (p = 0.1558). Among the markers evaluated, the only markers that showed a correlation with each other were STING and CD4⁺ T at the time of the first collection.

Conclusions

ART provided immune recovery and viral suppression to the studied group and indirectly downregulated the STING and cGAS genes. In contrast, ART did not influence IFN-α. The expression of STING and cGAS was not correlated with the plasma level of IFN-α, which suggests that there is another pathway regulating this cytokine in addition to the STING–cGAS pathway.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12985-021-01548-6.

TB-HIV co-infection: spatial and temporal distribution in the largest Brazilian metropolis

OBJECTIVE

To describe the spatial and temporal distribution of TB-HIV co-infection, as well as the profile of the characteristics of the co-infected population in the municipality of São Paulo.

METHODS

This is an ecological and time series study with data from the Tuberculosis Patient Control System (TBWeb), including all new cases of tuberculosis co-infected individuals with HIV living in the municipality from 2007 to 2015. Time trends of the disease were analyzed using Prais-Winsten regression. The cases were geocoded by the address of residence for the elaboration of maps with the incidence rates smoothed by the local empirical Bayesian method. The global and local Moran indexes evaluated spatial autocorrelation. Individuals' profiles were described and the characteristics of the cases with and without fixed residence were compared by Pearson's chi-square or Fisher's exact tests.

RESULTS

We analyzed 6,092 new cases of TB-HIV co-infection (5,609 with fixed residence and 483 without fixed residence). The proportion of TB-HIV co-infection ranged from 10.5% to 13.7%, with a drop of 3.0% per year (95%CI -3.4 - -2.6) and was higher in individuals without fixed residence. Incidence rates decreased by 3.6% per year (95%CI -4.4% - -2.7%), declining from 7.0 to 5.3 per 100,000 inhabitants/year. Co-infection showed positive and significant spatial autocorrelation, with heterogeneous spatial pattern and a high-risk cluster in the central region of the municipality. Cure was achieved in 55.5% of cases with fixed residence and in 32.7% of those without a fixed residence.

CONCLUSIONS

The data indicate an important advance in the control of TB-HIV co-infection in the period analyzed. However, we identified areas and populations that were unequally affected by the disease and that should be prioritized in the improvement of actions to prevent and control co-infection.

HIV/AIDS case definition criteria and association between sociodemographic and clinical aspects of the disease reported in the State of Minas Gerais from 2007 to 2016

INTRODUCTION

Over 30 years after the acquired immunodeficiency syndrome epidemic, several strategies have been implemented to verify the trend of the infection, the profile of the affected individuals, and the impact of prevention and control measures, with notification of asymptomatic carriers being the most recent measure. This study aimed to verify the geographic distribution of human immunodeficiency virus/acquired immunodeficiency syndrome and analyze the association between case definition criteria, sociodemographic data, and clinical aspects of the disease in the State of Minas Gerais between 2007 and 2016.

METHODS

In this ecological and analytical study, 35,349 cases of human immunodeficiency virus/acquired immunodeficiency syndrome reported in the State of Minas Gerais between 2007 and 2016 were analyzed. The data were analyzed using multiple correspondence factor analysis, time series analysis, descriptive statistics, and spatial distribution of the cases by macro-region.

RESULTS

The majority of the patients were brown-skinned individuals, alive, diagnosed with human immunodeficiency virus/acquired immunodeficiency syndrome on the basis of the criteria adapted from the Centers for Disease Control and Prevention, and living in municipalities with more than 50,000 (80.5%) inhabitants. Between 2007 and 2016, there was an increase in the number of criteria used for diagnosing human immunodeficiency virus. By contrast, a consequent decrease was observed in the number of criteria used for defining cases, which were adapted from the Centers for Disease Control and Prevention, Rio de Janeiro/Caracas, and for identifying AIDS-related deaths. Young people aged between 13 and 29 years, individuals whose education level is compatible with the observed age, and homosexual men were associated with the HIV+ criterion.

CONCLUSIONS

Out study showed that after the mandatory notification of human immunodeficiency virus-positive cases in 2014, there was a decrease in other criteria for defining human immunodeficiency virus/acquired immunodeficiency syndrome cases and changes in the profile of people living with human immunodeficiency virus/acquired immunodeficiency syndrome.

Homosexual desire after AIDS: an analysis of the criteria adopted by men in the search for same sex partners

This article analyzes changes and continuities in partner search criteria by homosexual men considering the impact of the HIV-AIDS epidemic in the city of São Paulo, Brazil. Thus, it compares two different historical moments: between 1979 and 1981 (pre-epidemic) and 2015 to 2017 (post-epidemic). In the first period, the source incorporated 120 classified ads collected from the Lampião da Esquina newspaper and in the second period, the preferences and criteria used to search for partners were analyzed using geolocalized applications, based on 120 online profiles. The data show that that between 1979-1981 the search for "discreet" partners took place, while the sexual panic created in the deadliest period of the AIDS epidemic boosted the use of the Internet in search of partners less likely to be infected with HIV, the "out of the (gay) scene". Since then, the search for "discreet and out of the (gay) scene" has consolidated itself by shaping the body's ideals and conduct that shape the current São Paulo online sex market in which part of the homosexuals take part.

Anthropometric measures of central adiposity are highly concordant with predictors of cardiovascular disease risk in HIV patients

Background

Body fat redistribution and metabolic abnormalities found in HIV patients receiving highly active antiretroviral therapy (HAART) contribute to an atherogenic profile, increasing cardiovascular disease risk.

Objective

We aimed to evaluate adiposity measures/indexes and propose cutoffs associated with predictors of cardiovascular disease risk in HIV patients on HAART.

Design

To evaluate cardiovascular disease risk in this cross-sectional study, we conducted electrocardiogram exams and stress electrocardiography, measured the ankle brachial index and blood pressure arterial hypertension, conducted lipid biochemical tests, and measured blood glucose. We measured circumferences [waist (WC), hip, thigh, calf, neck, trunk] and skinfold thicknesses (biceps, triceps, subscapular, suprailiac), conducted bioelectrical impedance analysis (BIA), and calculated indexes [body mass index, waist-to-hip ratio, waist-to-thigh ratio, waist-to-calf ratio, waist-to-height ratio (WHtR), trunk-to-arm ratio, body mass index corrected for body fat mass, Body Adiposity Index, conicity index, body shape index, fat mass (percentage), and phase angle]. For evaluating the performance of all adiposity measures/indexes, we used receiver operating characteristic (ROC) curves.

Results

Measures of central adiposity WC and WHtR showed the best performances-WC area under the curve (AUC) for men: 0.83 (95% CI: 0.78, 0.89; P < 0.05); WC AUC for women: 0.86 (95% CI: 0.81, 0.91; P < 0.05); WHtR AUC for men: 0.83 (95% CI: 0.78, 0.88; P < 0.05); and WHtR AUC for women: 0.85 (95% CI: 0.80, 0.91; P < 0.05). All adiposity measures/indexes presented different cutoffs from those proposed for the HIV seronegative population. The cutoffs for WC were 87.75 cm (sensitivity: 82.2%; specificity: 75.5%) for men and 90.5 cm (sensitivity: 84.0%; specificity: 73.0%) for women.

Conclusions

The measures/indexes of central adiposity presented excellent associations with predictors of cardiovascular disease risk, and the use of the cutoffs proposed in the present study aims to contribute to the early identification of increasing risk of cardiovascular diseases, enabling interventions. This trial was registered at the Brazilian clinical trials registry Registro brasileiro de ensaios clínicos (Rebec) as RBR-9rcxbq.

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.

A terapia antirretroviral combinada, a política de controle da Aids e as transformações do Espaço Aids no Brasil dos anos 1990

RESUMO Estudo sócio-histórico, utilizando o referencial teórico de Bourdieu, que analisou as condições de possibilidade para a construção da estratégia de distribuição universal de Antirretrovirais (ARV) no Brasil e as transformações do Espaço Aids. A oferta de ARV não era uma proposta inicial e resultou da pressão dos movimentos sociais, mas também do campo médico e da mídia. Mais tarde, a partir da articulação entre militantes da Reforma Sanitária, foi elaborado o projeto de lei que proporcionou uma situação diferenciada de acesso a ARV, impôs importantes transformações no Espaço Aids e sepultou a possibilidade de uma política de controle da Aids sem acesso ou com acesso restrito a ARV.

Overweight and abdominal obesity in adults living with HIV/AIDS

OBJECTIVE

To investigate the prevalence of overweight, abdominal obesity and associated factors in people living with HIV/AIDS (PLWHA).

METHOD

Cross-sectional study with 270 PLWHA. A questionnaire was applied to investigate sociodemographic, clinical and lifestyle characteristics. Weight, height and waist circumference were measured. BMI ≥25 kg/m2 was considered overweight, while abdominal obesity referred to waist circumference ≥102 cm for men and ≥88 cm for women. The authors used multiple Poisson regression with 5% significance level.

RESULTS

The prevalence of overweight and abdominal obesity was 33.7% and 12.6%, respectively, referring to 37.9% of women and 5.7% of men (p<0.001). Overweight was associated with age of 40-49 years and ≥50 years, non-use of ARV therapy, and lower tertile of consumption of risk foods. Abdominal obesity was associated with: female gender, age of 40-49 years and ≥50 years, income greater than four times the minimum wage, and CD4+ lymphocyte count >350 cells/mm3.

CONCLUSION

There was a high prevalence of overweight and abdominal obesity associated with sociodemographic and clinical conditions, and consumption of risk foods. This scenario indicates the need for reorientation of the health care focus in this population.

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.

Long-term immune and virological response in HIV-infected patients receiving antiretroviral therapy

WHAT IS KNOWN AND OBJECTIVE

The trajectory of HIV viral load and CD4 count and the occurrence of clinical events are primary considerations in the evaluation of antiretroviral therapy (ART) success or failure, yet a large number of studies do not describe these events from the point of therapy initiation. This study aims to describe the virological and immune response to ART and factors associated with immune and virological success in outpatients from a HIV/AIDS clinic in southern Brazil from therapy initiation.

METHODS

Longitudinal observational with ambidirectional data collection study with adult patients followed for at least 12 months after enrolment. Outcomes include (i) favourable immune response, defined as CD4 count ≥200 cells/mm³; and (ii) virological success, defined as viral load below the limit of detection (50 copies/mL).

RESULTS

The study included 332 patients, mostly men (63%), whose mean age was 40 (±10) years and with median family income of BR$ 490·00 per month (IQR: 350-875). Before starting ART, 43% of patients had indications of stable immune status (CD4 count ≥200 cells/mm³); the median CD4 count was 179 cells/mm³ (IQR: 93·5, 267) and increased to 379·5 cells/mm³ (IQR: 236·5, 591·3). The proportion of patients with CD4 count ≥200 cells/mm³ increased from 76% to 83%, and with undetectable viral load (UVL) increased from 51·7% to 73%. Factors associated with immune success at the end of study follow-up were as follows: female gender, pretreatment CD4 count ≥200 cells/mm³, previous UVL (measured when started prospective follow-up) and treatment with three drugs compared with ≥4. Factors associated with virological success were as follows: UVL (measured when started prospective follow-up) and use of three drugs compared with ≥4.

WHAT IS NEW AND CONCLUSIONS

Results of this study show that a large proportion (73%) of patients have rapid and successful immune and virological responses to ART and that factors which predict this response include starting ART early, whereas viral load is low and CD4 count is high, with fewer drugs. These results further support the ongoing need for ongoing programmes to increase early HIV testing, early linkage to and treatment with ART, and increased viral suppression.

Geographic distribution of patients affected by Cryptococcus neoformans/Cryptococcus gattii species complexes meningitis, pigeon and tree populations in Southern Brazil

Cryptococcal meningitis is mainly caused by members of the C. neoformans/C. gattii species complexes. The ecological niches of Cryptococcus species have extensively been studied, but its epidemiological relationship with meningitis cases is still unknown. In this study, we estimate the relationship between cryptococcal meningitis cases and tree and pigeon populations, the classical niches of members of C. neoformans/C. gattii sensu lato. We analysed the records of every patient whose cerebrospinal fluid culture yielded Cryptococcus spp. during the last 30 years at Clinical Hospital of Curitiba. Data about Curitiba's pigeon and tree distribution were obtained from Curitiba's Secretaries of Zoonosis and Environment archives. We used ArcGis9 software to plot the distribution of the pigeon and tree populations in this city as well as cryptococcal meningitis cases, distinguishing them according to the causal agent in C. neoformans or C. gattii s.l. In total, 489 cryptococcal cultures were documented, with 140 corresponding to patients eligible for this study (134 affected by C. neoformans s.l. and 6 by C. gattii s.l.). The map showed a relationship between C. neoformans s.l. patients and pigeon population. C. gattii s.l. patients were associated with neither tree nor pigeon populations, but lived close to large unbuilt, unforested areas.

Factors associated with undernourishment among people 20 years old or over with HIV/AIDS, attending public health services in the São Paulo municipality, Brazil

The study evaluated the nutritional status of 629 people living with HIV/AIDS attended at 12 specialized services of São Paulo's Municipal Health Department, Brazil. Data were obtained from medical records and through interviews during nutritional consultation. We used the classification criteria established by World Health Organization to assess malnourished individuals, a BMI < 18.5kg/m2. The prevalence of malnutrition in people with AIDS is 3.12 times that observed among people with HIV, and among people with co-infection it is 3.41 times that obtained among people without co-infection. This indicates how these conditions can harm the maintenance of the nutritional status, and shows that they demand a comprehensive understanding of the mechanisms involved in this phenomenon, as well as the development of strategies to improve the health care of individuals at nutritional risk.

Comparing the Ability of Anthropometric Indicators in Identifying Metabolic Syndrome in HIV Patients

BACKGROUND

Highly active antiretroviral therapy (HAART) can cause side effects in HIV patients, as the metabolic syndrome. Early identification of risk for development of cardiovascular diseases using available reliable and practical methods is fundamental. On this basis, the aim of this study was to compare the effectiveness of anthropometric indicators to identify metabolic syndrome in HIV patients on HAART.

METHODS

It is a cross-sectional study. A number of 280 stable HIV patients were studied. It measured weight, height, waist circumference (WC), hip circumference (HP), thigh circumference (TC) and calculated body mass index (BMI), body adiposity index (BAI), waist to hip ratio (WHR) and waist to thigh ratio (WTR). There was also a performance of biochemical tests of lipid profile and fasting glucose. Systemic blood pressure was measured. The criteria proposed by the National Cholesterol Education Program III (NCEP-ATP III) to metabolic syndrome classification was used. Individuals were divided in groups with or without metabolic alterations and their anthropometric indicators were compared. Receiver operating characteristic (ROC) curves were designed for each anthropometric indicator using the metabolic syndrome classification to identify sensitivity and specificity.

RESULTS

WC was a good tool to identify each metabolic disorder separately: total cholesterol (only females, p<0.05), triglycerides (only males, p<0.001), HDL cholesterol (p<0.05), LDL cholesterol (p<005) and fasting glycemic (p<005). WC also showed the best performance to identify metabolic syndrome in both genders (areas under the curve (AUCs): 0.79 and 0.76 for male and female, respectively), while BAI proved to be an inadequate indicator (AUCs: 0.63 and 0.67 for males and females), respectively, in this population.

CONCLUSIONS

The central adiposity measure (WC) had the best performance to identify metabolic syndrome, and it is a convenient, cheap and reliable tool that can be used in clinical practice routinely to prevent cardiovascular complications in HIV patients.

Transitioning through AIDS epidemics - gender and temporality

OBJECTIVE

To understand the evolution of AIDS over time in Mato Grosso do Sul, Brazil, using incidence, lethality, and mortality coefficients.

METHODS

A descriptive epidemiological study based on time series analysis of secondary data from the Notifiable Diseases Information System reported between 1985 and 2012.

RESULTS

The prevalence of AIDS was higher among men, with evidence of feminization during the first 14 years of the epidemic. There was no statistically significant sex difference in AIDS lethality. Women were 1.3 times more likely to survive than men.

CONCLUSIONS

Gender differences must be considered when designing new HIV/AIDS prevention strategies.

HIV testing and clinical status upon admission to a specialized health care unit in Pará, Brazil

OBJECTIVE

To analyze the clinical and laboratory characteristics of HIV-infected individuals upon admission to a reference health care center.

METHODS

This cross-sectional study was conducted between 1999 and 2010 on 527 individuals with confirmed serological diagnosis of HIV infection who were enrolled in an outpatient health care service in Santarém, PA, Northern Brazil. Data were collected from medical records and included the reason for HIV testing, clinical status, and count of peripheral CD4+ T lymphocytes upon enrollment. The data were divided into three groups, according to the patient’s year of admission – P1 (1999-2002), P2 (2003-2006), and P3 (2007-2010) – for comparative analysis of the variables of interest.

RESULTS

In the study group, 62.0% of the patients were assigned to the P3 group. The reason for undergoing HIV testing differed between genders. In the male population, most tests were conducted because of the presence of symptoms suggesting infection. Among women, tests were the result of knowledge of the partner’s seropositive status in groups P1 and P2. Higher proportion of women undergoing testing because of symptoms of HIV/AIDS infection abolished the difference between genders in the most recent period. A higher percentage of patients enrolling at a more advanced stage of the disease was observed in P3.

CONCLUSIONS

Despite the increased awareness of the number of HIV/AIDS cases, these patients have identified their serological status late and were admitted to health care units with active disease. The HIV/AIDS epidemic in Pará presents specificities in its progression that indicate the complex characteristics of the epidemic in the Northern region of Brazil and across the country.

Survival of AIDS patients in Sao Paulo-Brazil in the pre- and post-HAART eras: a cohort study

BACKGROUND

Brazil was the first middle-income country to provide free and universal access to AIDS treatment. Understanding the impact of this policy is key to promote ongoing improvement of current intervention strategies. The aim of this study was to compare mortality rates and survival in a cohort of AIDS patients before and after the introduction of antiretrovirals (ARV) and to investigate predictors of survival.

METHODS

A retrospective cohort study of AIDS patients aged 13 years or more living in the city of Sao Paulo was conducted. All patients were recruited from an STD/HIV outpatient clinic between 1988 and 2003 and followed up until 2005. We estimated AIDS mortality rates in person-years (py) and carried out a survival analysis using the Kaplan-Meier method. The Cox proportional hazards model was used to assess predictors of survival in AIDS patients.

RESULTS

The study cohort comprised 6,594 patients. The yearly mean mortality rates were 17.6, 23.2, and 7.8 per 1,000 py for the study periods 1988-1993, 1994-1996, and 1997-2003, respectively. Median survival time was 13.4 and 22.3 months for patients entering the study in the first and second study periods and survival time was 108 months or more in 72% of those entering the study during 1997-2003. Factors independently associated with shorter survival included: AIDS diagnosis during the 1994-1996 (HR 2.0) and 1988-1993 (HR 3.2) periods; 50 years of age or more (HR 2.0); exposure category of injection drug users (IDU) (HR 1.5); 8 years of schooling or less (HR 1.4); no schooling (HR 2.1); and CD4+ counts between 350 and 500 cells/mm(3) (HR 1.2) and less than 350 cells/mm(3) at AIDS diagnosis (HR 1.3).

CONCLUSIONS

The study showed a strong impact following the introduction of HAART in 1996 with decreased AIDS mortality, increased survival rates, and benefits with early introduction of HAART. However, some groups of patients were less likely to benefit from the new drug regimens. Public policies promoting health equity create an enabling environment helping AIDS control programs in developing countries to achieve their goals as effectively as in developed countries.

Saúde mental, suporte familiar e adesão ao tratamento: associações no contexto HIV/Aids

A adesão dos pacientes ao tratamento antirretroviral tem sido um dos maiores desafios no contexto HIV/Aids. São muitos os fatores implicados, e este estudo buscou privilegiar os relativos à saúde mental e suporte familiar, investigando sua associação com a adesão. Para tanto, foram utilizados um questionário semiestruturado composto de informações sociodemográficas, clínicas e adesão, e os instrumentos Questionário de Saúde Geral de Goldberg (QSG) e Inventário de Percepção de Suporte Familiar (IPSF). A amostra foi composta por 73 pacientes com HIV/Aids, com idades entre 29 e 67 anos, em tratamento antirretroviral em um ambulatório de São Paulo. Os resultados apontaram índices significativos de adesão irregular aos antirretrovirais e de perfis sintomáticos para transtornos mentais nessa população. Foram encontradas correlações significativas entre adesão e o fator "desejo de morte" do QSG, e entre adesão e quase todos os fatores do IPSF, evidenciando a importância desses fatores na adesão ao tratamento.

Fatores associados à infecção pelo HIV/AIDS entre adolescentes e adultos jovens matriculados em Centro de Testagem e Aconselhamento no Estado da Bahia, Brasil

O estudo procura investigar fatores associados à infecção pelo HIV entre adolescentes e adultos jovens, registrados no Centro de Testagem e Aconselhamento/CTA de Feira de Santana, Bahia. Estudo analítico com delineamento transversal, utilizando dados do Sistema de Informação do CTA (SI-CTA) no período de 2007 a 2011. Foram processadas informações de 3.768 indivíduos, sendo verificada a diferença de proporções, com Qui-quadrado de Pearson e análise estratificada, através da Razão de Prevalência/RP, com Intervalos de Confiança de 95%, considerando como desfecho o status sorológico. No período estudado, 73 jovens estavam infectados pelo HIV (1,94%). Na população feminina, foram identificadas associações, estatisticamente significantes, para soropositividade e consumo de drogas, consumo de bebidas alcoólicas e outras drogas; estar casada ou em união estável. No sexo masculino, associaram-se com a soropositividade o consumo de outras drogas e orientação homossexual/bissexual. Em ambos os sexos, na categoria com parceiro estável, a soropositividade mostrou associação com companheiro usuário de drogas e/ou portador de DST e/ou HIV. Esses achados sinalizam a necessidade de medidas eficazes no controle e prevenção da infecção pelo HIV, entre jovens.

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.

Cardiovascular risk assessment: a comparison of the Framingham, PROCAM, and DAD equations in HIV-infected persons

This study aims to estimate the risk of cardiovascular disease (CVD) and to assess the agreement between the Framingham, Framingham with aggravating factors, PROCAM, and DAD equations in HIV-infected patients. A cross-sectional study was conducted in an outpatient centre in Brazil. 294 patients older than 19 years were enrolled. Estimates of 10-year cardiovascular risk were calculated. The agreement between the CVD risk equations was assessed using Cohen's kappa coefficient. The participants' mean age was 36.8 years (SD = 10.3), 76.9% were men, and 66.3% were on antiretroviral therapy. 47.8% of the participants had abdominal obesity, 23.1% were current smokers, 20.0% had hypertension, and 2.0% had diabetes. At least one lipid abnormality was detected in 72.8%, and a low HDL-C level was the most common. The majority were classified as having low risk for CV events. The percentage of patients at high risk ranged from 0.4 to 5.7. The PROCAM score placed the lowest proportion of the patients into a high-risk group, and the Framingham equation with aggravating factors placed the highest proportion of patients into the high-risk group. Data concerning the comparability of different tools are informative for estimating the risk of CVD, but accuracy of the outcome predictions should also be considered.

The influence of age, smoking, antiretroviral therapy, and esophagitis on the local immunity of the esophagus in patients with AIDS

Studies have shown immunological and morphological alterations in the esophagus during the course of AIDS. Esophageal postmortem samples of 22 men with AIDS autopsied in a teaching hospital between 1982 and 2009 were collected. We carried out revision of the autopsy reports and medical records, morphometric analysis (Image J and KS-300 Kontron-Zeiss), and immunohistochemical (anti-S100, anti-IgA, anti-IgG, and anti-IgM) analysis of the esophagus. In accordance with most of the parameters evaluated, age and the smoking habit harmed the esophageal local immunity, whereas the use of antiretroviral therapy improved the immune characteristics of this organ. Patients with esophagitis also presented immunological fragility of the esophagus. This leads to the conclusion that alterations in the esophageal epithelium of patients with AIDS are not only caused by direct action of HIV but also the clinical and behavioral characteristics of the patient.

Sexual behavior among high school students in Brazil: alcohol consumption and legal and illegal drug use associated with unprotected sex

OBJECTIVE

Alcohol and other drug use appears to reduce decision-making ability and increase the risk of unsafe sex, leading to possible unplanned pregnancies, sexually transmitted diseases/human immunodeficiency virus/HIV transmission, and multiple sexual partners. This study aimed to test the hypothesis that risky sexual behaviors among adolescents are associated with legal and illegal drug use.

METHODS

A national cross-sectional survey of 17,371 high-school students was conducted in 2010. Students were selected from 789 public and private schools in each of the 27 Brazilian state capitals by a multistage probabilistic sampling method and answered a self-report questionnaire. Weighted data were analyzed through basic contingency tables and logistic regressions testing for differences in condom use among adolescents who were sexually active during the past month.

RESULTS

Approximately one third of the high school students had engaged in sexual intercourse in the month prior to the survey, and nearly half of these respondents had not used a condom. While overall sexual intercourse was more prevalent among boys, unsafe sexual intercourse was more prevalent among girls. Furthermore, a lower socioeconomic status was directly associated with non-condom use, while binge drinking and illegal drug use were independently associated with unsafe sexual intercourse.

CONCLUSION

Adolescent alcohol and drug use were associated with unsafe sexual practices. School prevention programs must include drug use and sexuality topics simultaneously because both risk-taking behaviors occur simultaneously.

[Trends in the epidemic of Aids cases in Southern Brazil from 1986 to 2008]

OBJECTIVE

To describe trends in the incidence of Aids cases according to age and gender from 1986 to 2008.

METHODS

Analyses of Aids trends according to age group and to gender was carried out Londrina, Southern Brazil. The timeframe was divided into two periods (1986-1995 and 1996-2008). Of the polynomial models, it was the first-degree polynomial model which best explained the Aids epidemic within the two periods. The incidence rate of Aids among men who have sex with other men (MSM), injecting drug users (IDU), heterosexual men and women was calculated.

RESULTS

During the first period, from 1986 to 1995, there was an increase in the incidence of Aids in almost all age groups and the epidemic spread across both sexes (p < 0.001), although this was more marked in men aged 14-39. The second period (1996-2008) did not show a positive or negative statistical increase, indicating that the epidemic had stabilized. A significant fall in the rate for the male 14 to 29 age group was found, with increases of 0.88 and 0.87 for the first and second period respectively. Cases in women aged 50 and over showed a marked increase (p = 0.019). The IDU and MSM groups predominated as the categories with the most exposure, with MSM taking over from IDU in the last three years of the study. From 2000 onwards, incidences in females aged 15 to 49 overtook that of heterosexual men.

CONCLUSIONS

The study showed a decrease in incidence in the younger age groups and stabilization in the other age groups. There is a need for different approaches in order to reach groups with several characteristics due to the increase in the proportion of women and MSM within the exposure categories.

[The profile of women with HIV/AIDS and their adherence to the antiretroviral therapy]

The objectives of this study were to characterize the sociodemographic and clinical profiles, health behaviors, beliefs and attitudes towards the disease and treatment of women with HIV/AIDS, outpatients of a university hospital located in the interior of São Paulo state, and to identify the factors that affect their adherence to antiretroviral therapy. The participants were 60 female outpatients of the referred service. The data were collected through semi-structured interviews. The women's mean age was 39.8 (standard deviation of 9.1) years; most of the women had a low education level, lived in deprived socioeconomic conditions, and were in a stable relationship. The most frequent form of infection was through a heterosexual relationship; 55% of the women had abandoned treatment, and their main reasons were the imposed therapeutic schemes, the side effects of antiretroviral drugs, coping with the disease, and the perspective of imminent death; 35% did not meet the adherence criteria, considered as taking 95% of the prescribed antiretroviral therapy.

The impacts of AIDS movements on the policy responses to HIV/AIDS in Brazil and South Africa: a comparative analysis

Brazil and South Africa were among the first countries profoundly impacted by the HIV/AIDS epidemic and had similar rates of HIV infection in the early 1990s. Today, Brazil has less than 1% adult HIV prevalence, implemented treatment and prevention programmes early in the epidemic, and now has exemplary HIV/AIDS programmes. South Africa, by contrast, has HIV prevalence of 18% and was, until recently, infamous for its delayed and inappropriate response to the HIV/AIDS epidemic. This article explores how differing relationships between AIDS movements and governments have impacted the evolving policy responses to the AIDS epidemic in both countries, including through AIDS programme finance, leadership and industrial policy related to production of generic medicines.

Prevalence and characteristics associated with malnutrition at hospitalization among patients with acquired immunodeficiency syndrome in Brazil

Background

Brazil’s National STD/AIDS Program is considered a model of success worldwide. However, AIDS-associated malnutrition continues in subgroups of Brazilian patients despite access to free highly active antiretroviral therapy (HAART). We aimed to identify the prevalence of malnutrition and associated factors among patients hospitalized with AIDS.

Methods

We conducted a cross-sectional nutritional assessment among 127 adults hospitalized with AIDS in Brazil’s third largest city. Using anthropometric measurements, we determined the prevalence of malnutrition (body mass index <18.5 kg/m2) at hospitalization. Prevalence ratios of malnutrition by demographic, socioeconomic, and clinical conditions were estimated using log-binomial regression.

Results

One-third of participants were first informed of their HIV disease during the current hospitalization and recent treatment interruption was common (71%) among those on HAART. Forty-three percent were malnourished and 35% had severe weight loss at admission. Patient characteristics independently associated with malnutrition were older age (2% increased prevalence for each year; 95% confidence interval [CI] 0–4%) and very low daily per capita household income. Living on <USD 2.00, USD 2.00–4.99 or USD 5.00–9.99 increased the prevalence of malnutrition by 2.01 (95% CI 1.06–3.81), 1.75 (95% CI 0.92–3.35) and 1.42 (95% CI 0.76–2.65) times, respectively, compared to ≥USD 10.00 per day. Chronic diarrhea was marginally associated with malnutrition (RR 1.42; 95% CI 0.99–2.04). Overall, 16% of the patients died during hospitalization. We observed a trend toward higher in-hospital case fatality among malnourished patients (22% vs. 12% for patients with and without malnutrition, respectively; chi square P = 0.14).

Conclusions

Unacceptably high rates of malnutrition persist in Brazilians hospitalized with AIDS and our results reinforce the importance of nutritional evaluations in these patients. Improved early testing and treatment adherence strategies may continue to help reduce AIDS-related morbidity and mortality in Brazil, yet novel interventions to disrupt the cycle of poverty, HIV, and malnutrition are also urgently needed.

Evaluation of inadequate anti-retroviral treatment in patients with HIV/AIDS

INTRODUCTION: Since the emergence of antiretroviral therapy, the survival of patients infected with human immunodeficiency virus has increased. Non-adherence to this therapy is directly related to treatment failure, which allows the emergence of resistant viral strains. METHODS: A retrospective descriptive study of the antiretroviral dispensing records of 229 patients from the Center for Health Care, University Hospital, Federal University of Juiz de Fora, Brazil, was conducted between January and December 2009. RESULTS: The study aimed to evaluate patient compliance and determine if there was an association between non-adherence and the therapy. Among these patients, 63.8% were men with an average age of 44.0 ± 9.9 years. The most used treatment was a combination of 2 nucleoside reverse transcriptase inhibitors with 1 non-nucleoside reverse transcriptase inhibitor (55.5%) or with 2 protease inhibitors (28.8%). It was found that patients taking lopinavir/ritonavir with zidovudine and lamivudine had a greater frequency of inadequate treatment than those taking atazanavir with zidovudine and lamivudine (85% and 83.3%, respectively). Moreover, when the combination of zidovudine/ lamivudine was used, the patients were less compliant (χ2 = 4.468, 1 degree of freedom, p = 0.035). CONCLUSIONS: The majority of patients failed to correctly adhere to their treatment; therefore, it is necessary to implement strategies that lead to improved compliance, thus ensuring therapeutic efficacy and increased patient survival.

[The (un)said about AIDS in the quotidian transition from childhood to the adolescence]

HIV children infected by vertical transmission are crossing from childhood to adolescence, however, we do not know how they are caring for themselves during those transitional age. The objective was to understand the (un)said about AIDS in their quotidian. After approval by the Research Ethics Committee of three hospitals in Rio de Janeiro, the interview was conducted with eleven boys/girls from 12-14 years old, who knew their diagnosis. The Heideggerian hermeneutics unveiled that the adolescent-being knows that the disease was acquired by his/her mother; he/she was said that his/her relatives are sick; he/she reminds when the diagnosis was disclosure, and its relation to prejudice. He/she projects him/her as a being-of-possibilities inside an existential movement. One concludes that the care for adolescent-being needs to integrate the biological, clinical, socio-cultural, ethical, political, and existential dimensions.

Comportamentos em saúde de uma população portadora do HIV/Aids

Estudo descritivo exploratório, com abordagem quantitativa e corte transversal, cujo objetivo foi identificar comportamentos de idosos portadores do HIV/Aids e analisar associação com sexo. Utilizou-se instrumento testado e validado quanto ao conteúdo. As variáveis foram analisadas pelos testes Qui-quadrado e Exato de Fisher. Participaram cento e nove pessoas. Os resultados revelaram que eram sexualmente ativos (57,8%), heterossexuais (85,5%), com companheiro fixo (66,1%). Relataram dificuldade para utilizar o preservativo (22,2% dos homens) pelo comprometimento da ereção; 97,2% referiram não usar drogas para estimulação sexual; 90,8% afirmaram não ter usado proteção nas relações antes de se saberem infectados. Trata-se de população sexualmente ativa, que passou a utilizar proteção nas relações sexuais após saber da infecção.

[The AIDS epidemic in Brazil and differences according to geographic region and health services supply]

The aim of this study was to identify different profiles in the AIDS epidemic in Brazil by relating them to the health sector's organization, situations involving increased risk of infection, and the degree of implementation of the response by health services. The Brazilian municipalities (counties) were grouped according to the magnitude of the epidemic and its trends from 2002 and 2006, and were then studied using indicators obtained from secondary databases. Municipalities with large epidemics (39%) displayed more situations associated with risk of infection, and those with an upward trend in incidence (11.5%) showed a lower degree of response. Cities with large epidemics but with downward or stable trends had 68.6% of all the anonymous testing centers and 75.8% of the outpatient clinics, and performed 81.4% of all the HIV antibody tests in the health system. Preventive measures in schools and primary health services showed low coverage rates. Differences were observed between geographic regions. Inequalities in the degree of implementation of the response to HIV may contribute to different profiles in the epidemic around the country.

Predictors of long-term anti-retroviral therapy effectiveness among Brazilian HIV-1-infected children in a hybrid scenario: what really matters?

The study objective was to evaluate the effectiveness and durability of highly active anti-retroviral therapy (HAART) in perinatally HIV-1-infected children and adolescents and its predictors. A historical cohort study was done at IMIP's Hospital in Recife, Brazil. The study included 195 subjects, 102 (52.3%) had successful response to HAART with a mean time of any HAART use of 4.9 [standard deviation (SD) 2.5; min. 0.7, max. 9.9] years. The time to failure of first HAART was negatively associated with male sex [relative hazard (RH) = 0.5, p = 0.021) and living out of metropolitan area (RH = 0.4, p = 0.009), and associated with Centres for Diseases Control and Prevention (CDC) immunological Stage 1 (RH = 2.9, p = 0.003) and patients who were adherent (RH = 2.2, p = 0.003). HAART success rate and mean time durability was similar to developed country data. However, the main predictors of success were: female sex, living in a metropolitan area, CDC1 immunological category and adherence.

Vitamin D deficiency in HIV-infected individuals: one more risk factor for bone loss and cardiovascular disease?

The epidemiological profile of the HIV virus has undergone substantial modifications with advances in antiretroviral therapy. There has been a sharp decline in morbi-mortality levels of HIV-infected patients, which has resulted in higher survival rates. The HIV seropositive population is living longer and more exposed to chronic complications caused by the disease itself and the prolonged use of antiretrovirals. Initially, metabolic alterations were reported, increasing cardiovascular disease risk. Subsequently, damage on bone metabolism was related. Vitamin D insufficiency has now reached epidemic proportions, even in healthy individuals living in the tropics. Recent data suggest the hypovitaminosis D association with metabolic syndrome, immune diseases, diabetes and hypertension. Little is known regarding the effects of HIV/Aids and its treatment on the metabolism of vitamin D. In HIV-positive patients, factors linked to the virus itself and the use of antiretrovirals may be added to the other causes of hypovitaminosis D.

Vitamin D Deficiency in HIV-Infected Women on Antiretroviral Therapy Living in the Tropics

The effects of HIV/AIDS and antiretroviral drugs on vitamin D metabolism are still mostly unknown. This was a cross-sectional study to estimate the prevalence of vitamin D deficiency and identify its association with the clinical and metabolic parameters among 214 HIV-positive female patients on antiretroviral therapy (ART) in Brazil. The prevalence of vitamin D deficiency (< 30 ng/ml) was 40.65% (87/214). Hypercholesterolemia, high LDL-c, duration of use of current antiretroviral regimen, hypertriglyceridemia, body mass index, age, hypertension, time with AIDS ≥ 10 years and hyperglycemia were selected for multivariate analysis (p < 0.20). After this analysis, hypercholesterolemia and use of current antiretroviral regimen ≥ 3 years remained independently associated with vitamin D deficiency. There was an inverse statistically significant correlation between total cholesterol and serum 25(OH)D levels. High prevalence of vitamin D deficiency was found among HIV-positive women on ART and was independently associated with its prolonged use and with hypercholesterolemia.

AIDS treatment in Brazil: impacts and challenges

Brazil has one of the developing world's largest, and arguably most successful, AIDS treatment programs. In this paper we review the treatment program, including controversial policies that Brazil has used to promote widespread local and global access to AIDS treatment. We also examine the lessons learned from this program and highlight the challenges Brazil faces, including the rising costs of AIDS treatment and changes in donors' funding priorities. Finally, we explore the relevance of Brazil's treatment program for other countries and its broad implications for global AIDS and health policy.

[Study of the under-reporting of AIDS cases in Alagoas (Brazil), 1999-2005]

The under-reporting of Aids (Acquired Immune Deficiency Syndrome) cases makes it difficult and even impossible to plan means to control the epidemic. This study aims to check out the under-reporting of Aids cases from 1999 to 2005 in Alagoas (Brazil). The deaths certificates causes by Aids stored at the Mortality Data System (SIM) in comparison to the Data System of Notification Diseases (Sinan), has been analyzed using the technique of relationship between these two data systems in Alagoas. According to the study, the proportion of under-reporting of Aids cases during this period was of 12.4%. Among the 49 deaths studied, 67% (33) were men and 33% (16) were women configuring a gender rate of 2:1. As to education level, 4,08% (2) and 6,12% (3) of the deaths by Aids were of people having 1 to 3 and from 4 to 7 years of study, respectively. The age group that presented the largest number of deaths was from 20 to 49 years old, either female (11; 68,7%) or male gender (23; 69,6%). The comparison between the Mortality Data System and Data System for Disease Notification revealed a high proportion of under-reporting of deaths by Aids, stressing the need for a specific public policy on the matter.

Association between intimate partner violence against women and HIV infection

OBJECTIVE

To analyze the association between intimate partner violence against women and infection or suspected infection by the human immunodeficiency virus (HIV).

METHODS

A cross-sectional study was conducted, based on data from questionnaires applied face-to-face and medical records of 2,780 women aged between 15 and 49 years, cared for in Sistema Único de Saúde (Unified Health System) units of the Greater São Paulo area, Southeastern Brazil, in 2001-2002. Women were categorized into: users in treatment because they are "HIV seropositive", those "suspected of having HIV" and others who sought health services for different reasons. Intimate partner violence against women throughout life was categorized according to the severity and recurrence of episodes of violence. The association with the outcome was tested using the Poisson model with robust and adjusted variance for sociodemographic, sexual and reproductive variables.

RESULTS

The prevalence of violence was 59.8%. Suffering repeated and severe violence was more closely associated with confirmed HIV infection (PR = 1.91). Violence independent from severity and recurrence of episodes showed greater association with suspected HIV infection (PR = 1.29).

CONCLUSIONS

Intimate partner violence against women has a key role in situations of suspected and confirmed HIV infection. Thus, it is essential to include its detection, control and prevention as part of the comprehensive care provided for women's health.

Survival of AIDS patients in the Southeast and South of Brazil: analysis of the 1998-1999 cohort

The aim of this study was to evaluate survival time for AIDS patients 13 years and older in the South and Southeast regions of Brazil, according to socio-demographic, clinical, and epidemiological characteristics. The sample was selected from all cases diagnosed in 1998 and 1999 and notified to the Epidemiological Surveillance System of the National STD/AIDS Program. Use of a questionnaire allowed analyzing 2,091 patient charts. Based on the Kaplan-Meier method, estimated survival was at least 108 months after diagnosis in 59.5% of patients in the Southeast and 59.3% in the South. Cox regression models showed, in both regions, an increase in survival in patients on antiretroviral therapy, those classified as AIDS cases according to the CD4 T-cell criterion, females, and those with more schooling. Other factors associated with longer survival in the Southeast were: white skin color, no history of tuberculosis since the AIDS diagnosis, negative hepatitis B serology, and access to a multidisciplinary health team. In the South, age below 40 years was associated with longer survival.

Ancestralidade Genômica, nível socioeconômico e vulnerabilidade ao HIV/aids na Bahia, Brasil

O curso clínico da infecção pelo HIV é determinado por complexas interações entre características virais e o hospedeiro. Variações no hospedeiro, a exemplo das mutações CCR5Δ32 e CCR264I, são importantes para a vulnerabilidade e progressão do HIV/aids. Atualmente, observa-se um aumento do número de casos da infecção entre os segmentos da sociedade com menor nível de escolaridade e pior condição socioeconômica. Com o objetivo de estimar a ancestralidade e verificar a sua associação com renda, escolaridade vulnerabilidade e progressão ao HIV/aids foram analisados 517 indivíduos infectados pelo HIV-1, sendo 289 homens e 224 mulheres. Os pacientes foram classificados segundo a ancestralidade genômica avaliada por 10 AIMs e pela vulnerabilidade e progressão ao HIV/aids através das mutações CCR5Δ32 e CCR264I. Os indivíduos infectados pelo HIV-1 apresentaram contribuição africana de 47%. As mutações CCR5Δ32 e CCR264I foram mais frequentes nos indivíduos brancos (3%) e negros (18%) respectivamente, e essas mutações mostraram frequência mais elevada nos tipicamente progressores (TP), quando comparados com os rapidamente progressores (RP) para aids. Não foi encontrada associação entre ancestralidade e vulnerabilidade ao HIV na análise para o grau de instrução. A pauperização da infecção pelo HIV-1 nessa população foi confirmada pela relação inversa entre renda e ancestralidade africana, pois quanto menor a renda maior a ancestralidade africana. Os resultados deste estudo sugerem associação entre as condições socioeconômicas e vulnerabilidade ao HIV/aids da população afrodescendente.

Long-term follow-up outcomes of perinatally HIV-infected adolescents: infection control but school failure

Perinatally human immunodeficiency virus (HIV)-infected children are fighting acquired immune deficiency syndrome (AIDS) and becoming adolescents. The objective of this study was to examine long-term outcomes among perinatally HIV-1-infected adolescents. Cross-sectional clinical and laboratory data were collected for 49 perinatally HIV-infected adolescents followed at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP's) Hospital from 1987 to 2007. The mean age of these adolescents was 12.5 years, the majority were female (73.5%) with a mean follow-up duration of 9.0 years, 71.4% of adolescents had no signs of HIV infection, 81.6% had normal CD4(+) lymphocyte count, and 53.1% had undetectable HIV viral load. HIV disclosure to the adolescent was reported in 31 (63.3%) participants. The majority were in school (89.8%) but failure and drop-out were reported by 51% and 28.6% of the subjects, respectively. All five domains of quality of life (QOL) measured revealed high scores. The majority of long-term adolescent survivors showed HIV-infection control and high scores of QOL, but with problems in schooling functioning that need early detection and intervention.

Condições sociodemográficas de crianças de zero a dois anos filhas de mães com HIV/Aids, Fortaleza, CE, Brasil

OBJETIVOS: identificar as condições sociodemográficas das crianças de 0 a 2 anos de idade nascidas de mães HIV + / AIDS em Fortaleza, Ceará, Nordeste do Brasil. MÉTODOS: estudo transversal utilizando um questionário semiestruturado com cuidadores (63 mães e 5 avós) de crianças no ambulatório de um hospital estadual, entre Dezembro de 2005 e Abril de 2006. RESULTADOS: a idade média das mães foi de 26 anos de idade. Aproximadamente 16% eram analfabetas, 57,3% eram casadas e 5,9% viúvas. Mais de dois terços (79,4%) das mulheres participantes do estudo tornou-se ciente de seu status de HIV + no último parto e 51,5% relataram não receber qualquer tipo de assistência social do governo. A idade média das crianças foi de 15,6 meses e 13% não tiveram um teste de HIV. A maioria delas era proveniente de áreas rurais (60,3%), com renda familiar média mensal de R$ 446,32. Verificou-se que 57,9% das crianças viviam em uma casa com cinco ou mais pessoas, e 31% relataram ter quatro ou mais crianças morando na mesma casa. CONCLUSÕES: há necessidade de estratégias de prevenção e promoção à saúde, levando em consideração o contexto social das famílias que vivem com HIV/AIDS.

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.

Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento

OBJETIVO: Analisar fatores associados à não-amamentação na primeira hora de vida, sobretudo a influência do momento do resultado do teste rápido anti-HIV. MÉTODOS: Estudo de coorte, sendo o ponto inicial a submissão ao teste rápido e o final a primeira mamada do bebê. A população estudada incluiu 944 parturientes submetidas ao teste rápido anti-HIV, com resultado negativo, em 2006, nos cinco hospitais amigos da criança do Sistema de Gestação de Alto Risco no município do Rio de Janeiro, RJ. Entrevistadoras treinadas obtiveram dados do laboratório e do prontuário e no pós-parto aplicaram questionário para entrevista às mães. O modelo multinível foi adotado para analisar a influência de características sociodemográficas, de assistência pré-natal e ao parto sobre a não-amamentação na primeira hora de vida. RESULTADOS: Dentre as participantes, apenas 15,6% receberam seu resultado antes do parto, 30,8% depois do parto e 53,6% ainda desconheciam o resultado ao ser entrevistada. A prevalência de não-amamentação na primeira hora de vida foi de 52,5% (IC 95%: 49,3;55,8). Após ajuste, o recebimento do resultado do teste rápido após o parto dobrou o risco da não-amamentação na primeira hora de vida (RR=2,06; IC 95%: 1,55;2,75). Outros fatores de risco foram: cor não branca, renda materna de um salário mínimo ou menos, parto cesáreo, mãe não querer amamentar o bebê ao nascimento e mãe referir que a equipe hospitalar não a escutava. O desconhecimento da realização do teste rápido anti-HIV pela mãe se mostrou como fator de proteção. CONCLUSÕES: O principal fator de risco para a não-amamentação na primeira hora de vida foi o recebimento do resultado do teste rápido após o parto. O teste anti-HIV deve ser amplamente disponibilizado no pré-natal e o teste rápido deve ser realizado sob indicação, na admissão, com busca ativa e pronta comunicação do resultado à mulher.

Civil society, political mobilization, and the impact of HIV scale-up on health systems in Brazil

This article examines the role of civil society in shaping HIV and AIDS policies and programs in Brazil. It focuses on the historical context of the redemocratization of Brazilian society during the 1980s, when the initial response to the epidemic took shape, and emphasizes the role of social movements linked to the progressive Catholic Church, the sanitary reform movement in public health, and the emerging gay rights movement in the early response to the epidemic in Brazil. It highlights the broad-based civil society coalition that took shape over the course of the 1990s and the political alliances that were built up shortly after the 1996 International AIDS Conference in Vancouver, Canada, to pass legislation guaranteeing the right to access to antiretroviral treatment. It emphasizes the continued importance of civil society organizations-in particular, AIDS-related nongovernmental organizations-and leading AIDS activists in exerting continued pressure to guarantee the sustainability of treatment access and the impact that action focused on HIV and AIDS has had on the Brazilian public health system more broadly, particularly through strengthening health infrastructures and providing a model for health-related social mobilization.

Embracing a family-centred response to the HIV/AIDS epidemic for the elimination of pediatric AIDS

There are 2.1 million children under the age of 15 living with HIV/AIDS, and 290,000 children died of AIDS in 2007. Despite recent increases in the number of adults on antiretroviral therapy (ART), the number of children receiving treatment remains inappropriately small, and prevention of mother to child transmission (PMTCT) efforts have been grossly inadequate. In sub-Saharan Africa, 14% of those in need of treatment are children, but only 6% of those are receiving treatment. Globally, only 23% of HIV-positive pregnant women have access to PMTCT programmes, which led to 420,000 new pediatric infections last year. Countries with comprehensive, integrated family-centred care programmes are better equipped to prevent and treat pediatric HIV/AIDS. True family-centred care offers prompt maternal and pediatric HIV diagnosis, antiretroviral prophylaxis, cotrimoxazole prophylaxis, and long-term ART for the entire family, as appropriate. Simple child health interventions, prompt treatment of opportunistic infections, nutritional supplementation and infant replacement feeding, as well as malaria treatment and prevention have been proven to synergistically improve pediatric HIV care and increase service uptake. To eliminate pediatric HIV/AIDS, national governments must embrace family-centred care, implement pediatric-friendly infrastructure, and train healthcare workers to treat children.