[Brazilian psychosocial and operational research vis-à-vis the UNGASS targets]

[Volunteers and negotiation of anti-HIV vaccine protocols in Brazil]

This study monitored the protocol of a clinical trial for experimental anti-HIV vaccines in Rio de Janeiro, Brazil, focusing on the recruitment, selection, and follow-up of volunteers. The techniques included observation of the research center's routine and interviews with health professionals and volunteers. The results show that the trial is a collective activity, in which constant negotiations are needed between the protocol requirements and what can, should, or must be adapted in order for it to work, as a function of: prolonged time before the trial's approval by the regulatory bodies, difficulties in recruiting volunteers, and even larger problems like discontinuity in the vaccines (which occurred in a specific protocol). The article discusses how the protocol's application extends beyond the technical and scientific "script", transforming it into a boundary object between different social worlds. The protocol is adapted according to a local order, based on the dynamics of social relations and the constant interrelationship between science, society, technique, and politics.

Avaliação da continuidade de uso do preservativo feminino em usuárias do Sistema Único de Saúde em unidades da região metropolitana de São Paulo, Brasil

O perfil da epidemia da Aids vem exigindo alternativas que, além de prevenir a entrada do HIV, facilitem a negociação de uso com o parceiro e possibilitem dupla proteção - contra as infecções transmitidas sexualmente, inclusive a Aids, e contra a gravidez não desejada - como o preservativo feminino. O objetivo do presente estudo foi verificar se a alta aceitabilidade inicial do preservativo feminino, descrita em outros estudos, é mantida na rotina de atendimento às diferentes populações vulneráveis. Foram monitorados durante 12 meses 16 serviços do Sistema Único de Saúde da Grande São Paulo (7 serviços especializados em atendimento às doenças sexualmente transmissíveis, 6 unidades básicas de saúde e 3 projetos comunitários). Foram incluídas no estudo 2.469 mulheres, das quais 713 em serviços de atenção especializada às DST/Aids, 1.417 em unidades básicas e 339 em projetos comunitários. A análise da continuidade de uso foi realizada por tábua de sobrevida Kaplan-Meier, teste log-rank e modelo de regressão de Cox, com intervalo de confiança de 95% (IC=95%). Observou-se que, ao final do seguimento, estavam em uso contínuo do preservativo feminino 14,4% das mulheres (355). O tempo médio de uso foi de 3,55 meses (IC 95%: 3,37- 3,73). Os resultados evidenciaram que o tipo de serviço de dispensação do insumo e a frequência mensal de relações sexuais interferiram na continuidade de uso de forma estatisticamente significante. O número de mulheres que iniciaram o uso do preservativo feminino nos diferentes tipos de serviços mostrou que há uma demanda para alternativas de prevenção, e que é fundamental a criação de espaços onde elas possam ter acesso adequado a orientações e aos insumos.

AIDS in Latin America: assessing the current status of the epidemic and the ongoing response

BACKGROUND

This article provides a summary of the current status of the HIV/AIDS epidemic in Latin America, as well as an outline of the diverse responses to it.

METHODS

A search of international databases (Pubmed and ISI-Web of Science), regional databases (Scielo and Lilacs), regional and national documents and UNAIDS reports. Data are presented according to subregion.

RESULTS

In Mexico HIV remains concentrated among urban men who have sex with men (MSM), and has been growing among injecting drug users (IDU) and in rural areas in relation to migration. An increasing proportion of women among those affected is observed in all countries in Central America, the most affected region, as well as increasing the impact on other vulnerable groups, such as indigenous populations. The Andean Countries have urban epidemics concentrated among MSM. In Peru, non-traditional vulnerable populations were identified. In the Southern Cone heterosexual transmission became more relevant, probably in connection with IDU epidemics and is increasingly affecting lower income groups. Incidence rates have been declining since 2002 in Brazil, the first country to guarantee free, universal access to antiretrovirals, where one-third of drug-naïve patients are still initiating treatment at an advanced stage. Generally, access to treatment has improved as a result of support from the Global Fund and other initiatives, but there are concerns regarding coverage, equity and sustainability.

CONCLUSIONS

HIV is still concentrated among MSM in Latin America. Non-traditional vulnerable groups such as migrants and lower income populations, usually considered part of the general population, deserve attention. Programmes confronting sexual exclusion are still needed. Access to treatment has improved over time, but inequalities persist.

The first ten years: achievements and challenges of the Brazilian program of universal access to HIV/AIDS comprehensive management and care, 1996-2006

A review was carried out of papers published between 1996 and 2006, documenting the introduction of highly active anti-retroviral therapy (HAART) in Brazil. Papers indexed in the MEDLINE and SciELO databases were retrieved using different combinations of keywords related to the management and care of AIDS in the post-HAART era: opportunistic diseases and co-infections, adherence to therapy, survival in the pre- and post-HAART eras, adverse events and side-effects, emergence and possible transmission of resistant viral strains, metabolic and cardiovascular disorders, and issues related to access to care and equity. The review documents the dramatic changes in HIV/AIDS disease progression in the post-HAART era, including an increase in survival and quality of life and a pronounced decrease in the episodes of opportunistic diseases. Notwithstanding such major achievements, new challenges have emerged, including slow evolving co-infections (such as hepatitis C, metabolic and cardiovascular disorders), the emergence of viral resistance, with consequences at the individual level (virological failure) and the community level (primary/secondary resistance at the population level), and impacts on the cost of new therapeutic regimens.

The utilization of testing and counseling for HIV: a review of the social and behavioral evidence

Against the background of debates about expanding HIV testing and counseling, we summarize the evidence on the social and behavioral dimension of testing and its implications for programs. The discrepancy between acceptance of testing and returning for results and the difficulties of disclosure are examined in light of research on risk perceptions and the influence of gender and stigma. We also summarize the evidence on the provision of testing and counseling, the implementation of practices regarding confidentiality and consent, and the results of interventions. We demonstrate that social factors have a considerable impact on testing, show that the services linked to testing are key determinants of utilization, and consider the implications of these findings for HIV testing programs.