Is human immunodeficiency virus/acquired immunodeficiency syndrome decreasing among Brazilian injection drug users? Recent findings and how to interpret them

The risks of HCV infection among Brazilian crack cocaine users: incorporating diagnostic test uncertainty

Despite the initiative by WHO and other international organizations to eliminate HCV in the medium term, hepatitis C infection is still a major public health problem. Even non-injecting drugs users who engage in harmful or addictive drug use are at greater risk of acquiring the infection, when compared to the general population. This study evaluate risk factors for HCV infection in users of crack/cocaine in Brazil, using multilevel models that incorporate variations in the sensitivity and specificity of the respective diagnostic tests. The sample included all the participants of a national survey on street crack cocaine users with serologically reactive result in the rapid test for the HCV as well as 4 non-reactive controls, matched by sex, age category, and major geographic region of residence. Multilevel logistic regression models were used, with and without incorporation of the diagnostic test’s sensitivity and specificity values. The odds of HCV infection were 85% higher among polydrug users, 7.81 times higher among injecting drug users, and 3.69 times higher in those reporting to have genital ulcers. Statistical modeling strategies that incorporate the sensitivity and specificity of diagnostic tests in challenging settings are useful for studying the association between risk factors and infection status.

[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.

Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs

Despite pronounced reductions in the number of deaths due to infectious diseases over the past six decades, infectious diseases are still a public health problem in Brazil. In this report, we discuss the major successes and failures in the control of infectious diseases in Brazil, and identify research needs and policies to further improve control or interrupt transmission. Control of diseases such as cholera, Chagas disease, and those preventable by vaccination has been successful through efficient public policies and concerted efforts from different levels of government and civil society. For these diseases, policies dealt with key determinants (eg, the quality of water and basic sanitation, vector control), provided access to preventive resources (such as vaccines), and successfully integrated health policies with broader social policies. Diseases for which control has failed (such as dengue fever and visceral leishmaniasis) are vector-borne diseases with changing epidemiological profiles and major difficulties in treatment (in the case of dengue fever, no treatment is available). Diseases for which control has been partly successful have complex transmission patterns related to adverse environmental, social, economic, or unknown determinants; are sometimes transmitted by insect vectors that are difficult to control; and are mostly chronic diseases with long infectious periods that require lengthy periods of treatment.

Knowledge of AIDS and HIV transmission among drug users in Rio de Janeiro, Brazil

Background

Proper knowledge of HIV transmission is not enough for people to adopt protective behaviors, but deficits in this information may increase HIV/AIDS vulnerability.

Objective

To assess drug users' knowledge of HIV/AIDS and the possible association between knowledge and HIV testing.

Methods

A Cross-sectional study conducted in 2006/7 with a convenience sample of 295 illicit drug users in Rio de Janeiro, assessing knowledge on AIDS/HIV transmission and its relationship with HIV testing. Information from 108 randomly selected drug users who received an educational intervention using cards illustrating situations potentially associated with HIV transmission were assessed using Multidimensional Scaling (MDS).

Results

Almost 40% of drug users reported having never used condoms and more than 60% reported not using condoms under the influence of substances. Most drug users (80.6%) correctly answered that condoms make sex safer, but incorrect beliefs are still common (e.g. nearly 44% believed HIV can be transmitted through saliva and 55% reported that HIV infection can be transmitted by sharing toothbrushes), with significant differences between drug users who had and who had not been tested for HIV. MDS showed queries on vaginal/anal sex and sharing syringes/needles were classified in the same set as effective modes of HIV transmission. The event that was further away from this core of properly perceived risks referred to blood donation, perceived as risky. Other items were found to be dispersed, suggesting inchoate beliefs on transmission modes.

Conclusions

Drug users have an increased HIV infection vulnerability compared to the general population, this specific population expressed relevant doubts about HIV transmission, as well as high levels of risky behavior. Moreover, the findings suggest that possessing inaccurate HIV/AIDS knowledge may be a barrier to timely HIV testing. Interventions should be tailored to such specific characteristics.

Doubts remain, risks persist: HIV prevention knowledge and HIV testing among drug users in Rio de Janeiro, Brazil

Brazil has been recognized for being the first developing country to provide universal AIDS treatment. Brazil also implemented a comprehensive prevention initiative. These efforts have been successful, with about half the number of HIV/AIDS cases forecast in 1992 developing by 2000. However, HIV/AIDS continues to spread, including among not-in-treatment drug users. Questions have been raised about gaps in existing prevention efforts. Based on qualitative research in 2006-2008 with street drug users in Rio de Janeiro (focus groups, N=24; a pile sort, N=108; open-ended interviews, N=34), this paper examines enduring gaps in HIV knowledge and prevailing risk patterns and proposes strategies for strengthening prevention.

Prevalence, estimated HIV-1 incidence and viral diversity among people seeking voluntary counseling and testing services in Rio de Janeiro, Brazil

BACKGROUND

BED-EIA HIV-1 Incidence Test (BED-CEIA) has been described as a tool to discriminate recent (RS) from long-term (LTS) seroconversion of HIV-1 infection, contributing to a better understanding of the dynamics of the HIV/AIDS epidemic over time. This study determined the prevalence, estimated incidence and HIV-1 subtype infection among individuals seeking testing in Voluntary Counseling and Testing centers (VCTs) from Rio de Janeiro, Brazil.

METHODS

Demographics and behavioral data were obtained from 434 individuals, diagnosed as HIV-positive among 9,008 volunteers screened from November 2004 to October 2005 in three VCTs located in the Rio de Janeiro Metropolitan area, Brazil. BED-CEIA protocol was performed to identify RS. DNA samples from RS and a subset of LTS (under a proportion of 1:2) were selected for gp120 C2-V3 and pol (protease and reverse transcriptase) regions genomic sequencing.

RESULTS

Overall HIV-1 prevalence was 4.8%. Sixty-one of 434 seropositive individuals were classified as RS, corresponding to an incidence rate of 1.68%/year (95%CI 1.26% -2.10%). Estimated incidence between Men Who Have Sex with Men (MSM) was 11 times higher than among heterosexual men and 55% of the new cases were identified in volunteers aged 25-40 years. A similar distribution of different HIV-1 subtypes was found among RS and LTS.

CONCLUSIONS

Our data suggest that prevention for MSM remains a challenge and efforts focusing on prevention targeting this population should be prioritized. No significant changes in HIV-1 subtypes were observed among the RS and LTS subgroups. One case of HIV-1 AUK (pol)/A (env) recombinant genome was detected for the first time in Brazil.

[Trends in the AIDS epidemic in groups at highest risk in Brazil, 1980-2004]

The objective of this paper was to present the trends in the AIDS epidemic in the population groups at highest risk in Brazil. Discriminant analysis was used to reclassify cases with unknown risk into one of the three groups: IDU (injecting drug users), MSM (men who have sex with men), and heterosexuals. AIDS incidence rates by gender and exposure category were estimated for the period 1980-2004. In 1980-1988, 63.6% of AIDS cases were homosexual or bisexual males and 10% were females. Since 1988, there has been a decrease in the proportion of MSM and an increase in the other categories. Despite the incidence trends observed by exposure category, when the incidence rates were compared, the risk was much higher among MSM as compared to heterosexuals. Analysis of the AIDS epidemic dynamics in Brazil emphasizes the importance of MSM and male IDU as higher-risk groups.

Epidemiological and genetic analyses of Hepatitis C virus transmission among young/short- and long-term injecting drug users from Rio de Janeiro, Brazil

BACKGROUND

Injecting drug users (IDU) have a key role in Hepatitis C Virus (HCV) epidemiology. Young/short-term IDUs constitute a target group for preventive/harm reduction interventions.

OBJECTIVES

To investigate HCV transmission among young/short-term (ST) and long-term (LT) IDUs, from the perspective of epidemiology and molecular biology.

STUDY DESIGN

Cross-sectional study assessing the prevalence of HCV infection/genotypes, as well as risk behaviours/practices among IDUs from Rio de Janeiro. Phylogenetic analyses were performed and the extent of segregation between sequences was quantified by the Association Index.

RESULTS

ST were more likely to engage into needle-sharing (p=.021) and LT to attend Needle Exchange Programs (p=.006). HCV prevalence was 10.1% vs. 23.4% among initiates and LT, respectively (p<.001). Older age vs. imprisonment and longer duration of IDU career were independent predictors for HCV infection among ST and LT, respectively. Among the latter, NEP attendance was inversely associated with viral infection. HCV3a infections were the most prevalent. A moderate extent of phylogenetic segregation between sequences was found, suggestive of transmission between IDU subgroups.

CONCLUSIONS

The lower HCV prevalence among young/short-term IDUs cannot be viewed with complacency, due to their frequent engagement into direct/indirect sharing practices and the ongoing transmission between IDU subsets. To avert new infections, preventive/harm reduction policies must be tailored to empirical findings.

Trends in HCV prevalence, risk factors and distribution of viral genotypes in injecting drug users: findings from two cross-sectional studies

In the last decade, a declining prevalence of HCV infection has been described in injecting drug users (IDUs) in different countries. This study is the first to assess temporal trends in drug-injecting patterns, HCV infection rates and viral genotype distribution in 770 Brazilian IDUs, recruited by two cross-sectional studies (1994-1997 and 1999-2001). A substantial decline in the prevalence of HCV infection was found over the years (75% in 1994 vs. 20.6% in 2001, P<0.001) that may be a consequence of the significant reduction in the overall frequencies of drug injection and needle-sharing, as well as the participation of IDUs in initiatives aimed at reducing drug-related harm. No trend was found in terms of viral genotype distribution. Despite the favourable scenario, preventive measures must be maintained, especially in vulnerable subgroups such as young or new injectors, where risky behaviours through direct and indirect sharing practices remain common.

[Decentralization, AIDS, and harm reduction: the implementation of public policies in Rio de Janeiro, Brazil]

This paper assesses how decentralization of resources and initiatives by the Brazilian National SDT/AIDS Program has impacted the transfer of funds for programs to prevent HIV/AIDS among injecting drug users in Rio de Janeiro, Brazil (1999-2006). The effects of the decentralization policy on Rio de Janeiro's Syringe Exchange Programs (SEPs) are assessed in detail. Decentralization effectively took place in Rio de Janeiro in 2006, with the virtual elimination of any direct transfer from the Federal government. The elimination of direct transfers forced SEPs to seek alternative funding sources. The structure of local SEPs appears to be weak and has been further undermined by current funding constraints. Of 22 SEPs operating in 2002, only two are still operational in 2006, basically funded by the State Health Secretariat and one municipal government. The current discontinuity of SEP operations may favor the resurgence of AIDS in the IDU population. A more uniform, regulated decentralization process is thus needed.

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.

Trends in drug resistance mutations in antiretroviral-naïve intravenous drug users of Rio de Janeiro

DNA sequencing of a pol gene fragment from drug-naive injecting drug users samples obtained at two time points of the Brazilian AIDS epidemic (Pre-HAART era: 1994 to early 1997, n = 27; post-HAART era: 1999-2001, n = 38) was undertaken to assess HIV-1 antiretroviral drug resistance mutations and subtyping profiles. Genotypic analysis revealed the presence of PR primary L90M, D30N, M46I, and V82A mutations in 7.9% of the post-HAART group, and a high frequency of secondary mutations (84.2%). Nucleoside RT-associated mutations were observed in 13.2%. In the pre-HAART group, a higher frequency of RT mutations was observed (22.2%) and no PR primary mutations were found, in agreement with the introduction of protease inhibitors (PIs) in therapy during the same period. The identification of 7.9% of drug-naive injecting drug users already bearing RT/PR primary resistance mutations in the post-HAART era group constitutes a major concern in terms of dissemination of drug resistant viruses. The resistance mutations profile of the individuals may reflect the context of antiretroviral treatment in Brazil at the sample collection periods (1994-1997 and 1999-2001). In spite of the differences observed in the drug resistance profiles, similar frequencies of subtype B (63.0 vs. 73.7%), F (22.2 vs. 10.5%), and recombinant B/F (14.8 vs. 15.8%) viruses were found, respectively, in the pre- and post-HAART groups.

[The right to prevention and the challenges of reducing vulnerability to HIV in Brazil]

The study evaluates the Brazilian response to the targets established by UNGASS for the prevention of HIV/AIDS. The analysis was based on national research, documents and information from the National Program STD/AIDS and on state-level action plans and targets. Brazil relies on various prevention policies to attain the UNGASS targets proposed for 2005. These include: addressing discrimination issues, promotion of HIV testing, distribution of condoms, needle exchange programs, discussion of sexuality in schools, prevention initiatives for sex workers and homosexuals and prevention in the workplace. These have resulted in increases in testing and condom use. Various challenges are discussed, including: overcoming discontinuity in action plans (particularly with more vulnerable groups), training prevention teams, increasing monitoring of quantity and quality of preventative actions and overcoming regional, racial and gender inequalities. It is concluded that the right to prevention is not a public priority, nor is it on the social movement agendas. This contrasts with the right to better HIV treatment. In order to increase the efficacy of these programs, it is suggested that they be understood and incorporated based on the promotion and guarantee of human rights, thereby advancing the ethical/political debate at local and national levels.

Syringe exchange programs in Brazil: preliminary assessment of 45 programs

The present study aims to evaluate the current operation of Brazilian syringe exchange programs (SEP). After consulting national and regional networks of people working in projects/programs aiming to reduce drug-related harm, we identified 134 potential participant programs. Unfortunately, only 45 SEPs answered a survey, even after repeated attempts. The survey addressed: coverage, funding, procurement of basic supplies, managerial capacity, and the local political environment. Findings were triangulated with in-depth interviews with key informants. The main findings included: satisfactory adherence to the initiatives and adequate documentation, but deficiencies in terms of coverage and monitoring, and uneven procurement of resources. Program personnel work mostly on a provisional basis, despite the efforts of local coordinators. Most programs are funded by the National STDs/AIDS Program. A comprehensive agenda aiming to improve current operations should include: concerted efforts to improve local and regional databanks, incentives/sanctions toward full accountability of initiatives carried by the programs, and a genuine culture of monitoring and evaluation.

"The first shot": the context of first injection of illicit drugs, ongoing injecting practices, and hepatitis C infection in Rio de Janeiro, Brazil

The context of first drug injection and its association with ongoing injecting practices and HCV (hepatitis C virus) infection were investigated. Injection drug users (IDUs) (N = 606) were recruited in "drug scenes" (public places, bars) in Rio de Janeiro, Brazil, interviewed, and tested for HCV. Sharing of needles/syringes was more prevalent at the first injection (51.3%) than at the baseline interview (36.8%). Those who shared syringes/needles at first injection were more likely to be currently engaged in direct/indirect sharing practices. Among young injectors (< 30 years), those reporting sharing of needles/ syringes at the first injection were about four times more likely to have been infected by HCV. Hepatitis C virus prevalence among active IDUs (n = 272) was 11%. Prison history and longer duration of drug injection were identified as independent predictors of HCV infection. To effectively curb HCV transmission among IDUs and minimize harms associated with risk behaviors, preventive strategies should target individuals initiating drug injection beginning with their very first injection and discourage the transition from non-injecting use to the self-injection of illicit drugs.

HIV seroprevalence among drug users: an analysis of selected variables based on 10 years of data collection in Porto Alegre, Brazil

Data from five studies were pooled to describe associations between drug use and HIV. The Risk Assessment. Battery in Porto Alegre, Brazil, was used to collect data from 1449 subjects in 5 separate studies conducted between 1995 and 2004. The subjects were divided into categories based on their pattern of drug use: (1) injection drug users (IDUs), (2) crack smokers, (3) frequent drug users, and (4) infrequent cocaine/alcohol/marijuana users. The sample consisted primarily of young males with low education and income levels. Half of the subjects reported frequent condom use, and exchanges involving drugs, sex, and money were infrequent (although more common in groups 1 and 2). The overall seroprevalence was 20.6%, and the prevalence was different across the four groups, showing a linear decrease from group 1 (57.1%) to group 4 (11.7%). The IDU and crack-smoking groups showed similarities in their risk levels when compared with the other two groups, and individuals in group 1, 2, and 3 were more likely to report having had four or more sex partners. After controlling for all other risk factors, IDU, males having sex with males, and crack use were highly associated with HIV (OR 7.30, 95% CI: 5.10.10.40; OR 3.04, 95%CI: 1.89,4.80; OR 2.03, 95%CI: 1.40, 2.92, respectively). The findings confirm that poverty, low education, and IDU remain risk factors for HIV in Porto Alegre, Brazil, and the study identities crack smoking as a new risk factor.