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

HIV prevention among gay and other men who have sex with men: public policy and social movements in Brazil, 1983-2019

This article revisits the history of HIV prevention for gay and other men who have sex with men in relation to public health policy and the role of LGBT and AIDS-related social movements in Brazil. An interpretive study was undertaken informed by philosophical and phenomenological hermeneutics. It included interviews with policymakers, researchers and activists involved in HIV and AIDS, especially HIV prevention among gay and other men who have sex with men. Prevention initiatives were analysed with a focus on the social and programmatic aspects of vulnerability to HIV, and advances and setbacks in the Brazilian response to the epidemic. The recent crisis in HIV prevention triggered by a growing conservatism in Brazilian politics and the current government's LGBT-phobia pose barriers that compromise issues of profound importance with regards to policy on HIV and AIDS: namely, engagement with human rights and social participation.

Zika virus public health crisis and the perpetuation of gender inequality in Brazil

BACKGROUND

In 2015-2017, the Americas experienced a highly consequential epidemics for pregnancy and childbearing. Mainly transmitted by the mosquito Aedes aegypti, but also through sexual intercourse, the Zika virus poses the risk of congenital Zika syndrome to fetus, which includes microcephaly and other child development complications. When a public health crisis taps directly into reproductive health, typically a feminine realm, responses to the emergency may exacerbate deeply-rooted gender norms. This paper investigates the role of gender in two relational contexts: (a) the government-led response to the pandemic in terms of communication campaigns aimed at preventing Zika infections; and (b) an individual level of response to the emergency, concerning women's negotiation with their sexual partners with regard to the prevention of Zika as well as pregnancies.

METHODS

We conducted content analysis of 94 unique pieces from public health communication campaigns produced by governmental agencies with the goal of promoting Zika awareness. Print and online materials were collected from May 2016 to August 2017, and included TV ads, Internet Pop-ups, and pamphlets. We also analyzed transcripts from 16 focus groups conducted with reproductive-aged women (18-40) in Belo Horizonte and Recife, two large cities differently affected by the Zika outbreak. Women answered open-ended questions connected to the epidemic, in areas such as personal knowledge and experiences with the Zika virus, experiences of their friends and acquaintances, their primary information sources, their perceptions of public health efforts toward containing the outbreak, as well as women's contraceptive use.

RESULTS

Campaign pieces handling pregnancy and microcephaly were largely gendered. Pieces targeted women, placing on their shoulders the responsibility for protecting a potential fetus from the disease. Importantly, campaigns neglected addressing male's participation on Zika prevention and contraceptive management, while failing to take into account Brazil's large proportion of unplanned pregnancies. Women were placed in a double bind by being expected to prevent both pregnancy and Zika, in a context where gendered power imbalances often translate in women having little power/means for condom negotiation/avoiding unprotected sexual intercourse.

CONCLUSION

Government and individual responses to the epidemics reinforced gender roles, situating pregnant women as responsible for averting mosquito bites and microcephaly. Further, prevention campaigns largely excluded men. Since low-socioeconomic status women possessed fewer resources to preclude infection, we also found that beyond the gender divide, this subgroup faced more pronounced Zika prevention challenges as they found it harder to negotiate condom use with their sexual partners and often could not access other types of contraceptives resulting in unplanned pregnancies.

The Intersection of HIV, Social Vulnerability, and Reproductive Health: Analysis of Women Living with HIV in Rio de Janeiro, Brazil from 1996 to 2016

Comprehensive care for sexual and reproductive health (SRH) and social needs for women living with HIV remains limited globally. We aimed to assess trends in baseline sociodemographic, clinical, sexual, and reproductive characteristics among a cohort of HIV-infected women in Rio de Janeiro from 1996 to 2016. Participants were stratified into four time periods based on year of enrollment; we compared cross-sectional data from each period. Of 1361 participants (median age 36), most were black or mixed race (60.1%), unemployed (52.1%), and without secondary education (54%). Adolescent pregnancy was common (51.5%), and 18.3% reported sexual debut at < 15 years old. Nearly half (45.2%) had < 5 lifetime sexual partners, yet prior syphilis and oncogenic human papillomavirus prevalence were 10.9% and 43.1%, respectively. Lifetime prevalence of induced abortion was 30.3%, and 16% used no contraceptive method. Future research should explore interactions between social vulnerability, HIV, and poor SRH outcomes and healthcare models to alleviate these disparities.

Estimating HIV incidence from surveillance data indicates a second wave of infections in Brazil

Emerging evidence suggests that HIV incidence rates in Brazil, particularly among men, may be rising. Here we use Brazil's integrated health systems data to develop a mathematical model, reproducing the complex surveillance systems and providing estimates of HIV incidence, number of people living with HIV (PLHIV), reporting rates and ART initiation rates. An age-structured deterministic model with a flexible spline was used to describe the natural history of HIV along with reporting and treatment rates. Individual-level surveillance data for 1,077,295 cases (HIV/AIDS diagnoses, ART dispensations, CD4 counts and HIV/AIDS-related deaths) were used to calibrate the model using Bayesian inference. The results showed a second wave of infections occurring after 2001 and 56,000 (95% Credible Interval 43,000-71,000) new infections in 2015, 37,000 (95% CrI 28,000-54,000) infections in men and 16,000 (95% CrI 10,000-23,000) in women. The estimated number of PLHIV by end-2015 was 838,000 (95% CrI 675,000-1,083,000), with 80% (95% CrI 62-98%) of those individuals reported to the Ministry of Health. Women were more likely to be diagnosed and reported than men; 86.8% of infected women had been reported compared with 75.7% of men. Likewise, ART initiation rates for women were higher than those for men. The second wave contradicts previous estimates of HIV incidence trends in Brazil and there were persistent differences in the rates of accessing care between men and women. Nevertheless, the Brazilian HIV program has achieved high rates of detection and treatment, making considerable progress over the past ten years.

Spatiotemporal patterns of AIDS incidence among adults in São Paulo, Brazil

INTRODUCTION

AIDS remains a major public health concern in Brazil.

METHODS

This study investigated spatiotemporal patterns of reported AIDS cases among adults in São Paulo between 2000 and 2016, and their associations with human development index.

RESULTS

In the early 20th century, the more developed administrative districts (ADs) indicated higher AIDS incidences among men. From the 2010s, ADs with lower development indicate higher rates of the disease among women.

CONCLUSIONS

The results are useful to support the planning of actions aimed at controlling the incidence and transmission of AIDS in certain areas, based on diversification by gender and risk populations.

Exploring Evolutionary and Transmission Dynamics of HIV Epidemic in Serbia: Bridging Socio-Demographic With Phylogenetic Approach

Previous molecular studies of Serbian HIV epidemic identified the dominance of subtype B and presence of clusters related HIV-1 transmission, in particular among men who have sex with men (MSM). In order to get a deeper understanding of the complexities of HIV sub-epidemics in Serbia, epidemic trends, temporal origin and phylodynamic characteristics in general population and subpopulations were analyzed by means of mathematical modeling, phylogenetic analysis and latent class analysis (LCA). Fitting of the logistic curve of trends for a cumulative annual number of new HIV cases in 1984–2016, in general population and MSM transmission group, was performed. Both datasets fitted the logistic growth model, showing the early exponential phase of the growth curve. According to the suggested model, in the year 2030, the number of newly diagnosed HIV cases in Serbia will continue to grow, in particular in the MSM transmission group. Further, a detailed phylogenetic analysis was performed on 385 sequences from the period 1997–2015. Identification of transmission clusters, estimation of population growth (Ne), of the effective reproductive number (Re) and time of the most recent common ancestor (tMRCA) were estimated employing Bayesian and maximum likelihood methods. A substantial proportion of 53% of subtype B sequences was found within transmission clusters/network. Phylodynamic analysis revealed Re over one during the whole period investigated, with the steepest slopes and a recent tMRCA for MSM transmission group subtype B clades, in line with a growing trend in the number of transmissions in years approaching the end of the study period. Contrary, heterosexual clades in both studied subtypes – B and C – showed modest growth and stagnation. LCA analysis identified five latent classes, with transmission clusters dominantly present in 2/5 classes, linked to MSM transmission living in the capital city and with the high prevalence of co-infection with HBV and/or other STIs.Presented findings imply that HIV epidemic in Serbia is still in the exponential growth phase, in particular, related to the MSM transmission, with estimated steep growth curve until 2030. The obtained results imply that an average new HIV patient in Serbia is a young man with concomitant sexually transmitted infection.

High prevalence of sexual Chlamydia trachomatis infection in young women from Marajó Island, in the Brazilian Amazon

BACKGROUND

Chlamydia trachomatis is the most prevalent bacterial sexually transmitted infection (STI) in the world. Approximately 80% of infected women are asymptomatic, although this infection can lead to serious complications in the female reproductive tract. Few data on Chlamydia infection are available in rural Amazonian communities.

OBJECTIVES

To evaluate the prevalence of sexual C. trachomatis infection in women from Marajó Archipelago communities in the Amazon region of Brazil and to identify associated factors and genotypes.

METHODS

We utilized amplification of the ompA gene by nested PCR. Positive samples were genotyped by sequencing. Study participants completed a questionnaire on social, epidemiological, and reproductive health variables. A Poisson regression was used to evaluate the degree of association of these variables with the infection.

RESULTS

The sexual infection by C. trachomatis was observed in 4% (16/393) of the subjects, and was more often found in women aged ≤25 (14.3%; 95% CI = 2.83-35.47; p <0.001), and in women with a household income of less than one Brazilian monthly minimum wage (5.2%; 95% CI = 1.33-11.37; p = 0.014). The ompA gene was sequenced in 13 samples, revealing F genotypes (38.4%, n = 5), D (23%, n = 3), E (15.3%, n = 2), Ia (7.6%, N = 1), J (7.6%, n = 1) and B (7.6%, n = 1).

CONCLUSIONS

We recorded a high prevalence of sexual infection by C. trachomatis in young and poor women from the interior of the Brazilian Amazon. This high prevalence and the frequencies of the main genotypes were similar to those found in major Brazilian urban centers. Our results reinforce the importance of the screening of this neglected infection, and the prevention of later sequelae in young women from rural and urban areas of Brazil.

Incidence and Persistence of Depression Among Women Living with and Without HIV in South Africa: A Longitudinal Study

Depression and trauma are common among women living with HIV. This is the first study to track the longitudinal course of depression and examine the relationship between depression and trauma over time among women in South Africa. HIV-infected and uninfected women (N = 148) were assessed at baseline and one year later. Results of a path analysis show the multi-directional and entwined influence of early life stress, other life-threatening traumas across the lifespan, depression and PTSD over the course of HIV. We also observed higher rates of depressive symptomatology and more persistent cases among infected women compared to uninfected women, as well as a more consistent and enduring relationship between childhood trauma and depression among women living with HIV. The present study is unique in documenting the course of untreated depression and PTSD in women with and without HIV infection with a high prevalence of early childhood trauma.

Spatial risk of death in patients with AIDS in Campinas, São Paulo, Brazil

OBJECTIVE

To analyze the spatial risk of AIDS mortality in census tracts in a large Brazilian city.

METHOD

We studied three retrospective cohorts of individuals with AIDS, who were residents in the city of Campinas, in the State of São Paulo, Brazil. The occurrence of death was analyzed from 1980 to 1990 (cohort 1), 1996 to 2000 (cohort 2), and from 2001 to 2005 (cohort 3). We adjusted a Bayesian semi-parametric model, using the Integrated Nested Laplace Approximation (INLA) method, which allowed for the mapping of mortality risk for the three cohorts.

RESULTS

The incidence of death in cohorts 1, 2 and 3 were, respectively, 72.73, 32.21 and 13.11%. The death risk maps showed a tendency of mortality decrease, and presented the sectors with the highest and lowest risk for each period. The model showed that, in the three cohorts, factors associated with the highest risk of death were: being male, and having an age at diagnosis greater than 49 years old. The homosexual/bisexual orientation was associated with lower risk of dying.

CONCLUSIONS

Even considering the reduction in the risk of death from AIDS in recent years, after access to highly active antiretroviral therapy, the highest incidence was found among the poorest individuals in the three studied cohorts. The maps and risk factors obtained suggest possible actions for monitoring the disease in the city.

Inequalities in HAART uptake and differential survival according to exposure category in Rio de Janeiro, Brazil

Despite substantial improvement in prognosis and quality of life among people living with HIV/AIDS (PLWHA) in Brazil, inequalities in access to treatment remain. We assessed the impact of these inequalities on survival in Rio de Janeiro over a 12-year period (2000/11). Data were merged from four databases that comprise the national AIDS monitoring system: SINAN-AIDS (Brazilian Information System for Notificable Diseases; AIDS cases), SISCEL (laboratory tests), SICLOM (electronic dispensing system), and SIM (Brazilian Mortality Information System), using probabilistic linkage. Cox regressions were fitted to assess the impact of HAART (highly active antiretroviral therapy) on AIDS-related mortality among men who have sex with men (MSM), people who inject drugs (PWID), and heterosexuals diagnosed with AIDS, between 2000 and 2011, in the city of Rio de Janeiro, RJ, Brazil. Among 15,420 cases, 60.7% were heterosexuals, 36.1% MSM and 3.2% PWID. There were 2,807 (18.2%) deaths and the median survival time was 6.29. HAART and CD4+ > 200 at baseline were associated with important protective effects. Non-whites had a 33% higher risk of dying in consequence of AIDS than whites. PWID had a 56% higher risk and MSM a 11% lower risk of dying of AIDS than heterosexuals. Non-white individuals, those with less than eight years of formal education, and PWID, were more likely to die of AIDS and less likely to receive HAART. Important inequalities persist in access to treatment, resulting in disparate impacts on mortality among exposure categories. Despite these persistent disparities, mortality decreased significantly during the period for all categories under analysis, and the overall positive impact of HAART on survival has been dramatic.

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.

Compulsory notification at skilled nursing facilities

Introduction:

Notifiable diseases (NDs) encompass conditions of high clinical severity and/or contagious. Being closed communities, long-term care facilities (LTCF) are places that deserve attention on their own, but one might be left wondering: what is the reality of NDs at Brazilian LTCFs?

Objective:

To determine the prevalence and type of NDs at large LTCF.

Method:

Active search for NDs conducted by the Hospital Infection Control Committee (HICC) in 459 beds. Due to the low turnover of patients, the monthly list kept by the HICC on NDs was analyzed. Data were grouped into males and females, and into elderly (age ≥ 60 years) and non-elderly (age ≤ 59 years).

Results:

31 diseases in 29 patients (6.9% of all inpatients - 19 males and 10 females): 23 cases of hepatitis C, five of hepatitis B, two of human immunodeficiency virus (HIV), and one case of renal tuberculosis. One patient with hepatitis B and another HIV-positive also had hepatitis C. There was no statistical significance in the comparison of the two groups with the total number of other institutionalized patients - by age and gender - for total number of NDs and cases of hepatitis C (p>0.05).

Conclusion:

Chronic NDs and those requiring chronic treatment observed in this study suggest that Brazil needs more studies to define the dynamics of these diseases at LTCFs.

High HIV infection prevalence in a group of men who have sex with men

Brazil is characterized by a concentrated AIDS epidemic, it has a prevalence of less than 1% in the general population. However, there are higher rates in specific populations, especially in men who have sex with men. The study's aim was to analyze the association between sociodemographic characteristics, sexual practices, sexual behaviors and the HIV infection in a group of men who have sex with men. Secondary data was collected between June 2014 and September 2015 in a research of cross-sectional design in the city of Rio de Janeiro, Brazil. Volunteers answered an online computerized questionnaire and took HIV test. Chi-squared distribution and multiple logistic regression was used. There were 341 participants. Most of them were racially mixed, single, average age of 30.6 years and with a higher education level. The HIV prevalence was 13.9%. Two logistic models were fit (insertive or receptive anal intercourse). Both models showed an association with HIV among those who had a HIV positive sexual partner (Odds Ratio ≈ 2.5) and a high self-perception of acquiring HIV (Model 1: Odds Ratio ≈ 7/Model 2: Odds Ratio ≈ 10). Low condom usage in receptive anal intercourse with casual partners had a direct association with HIV seropositivity, whereas insertive anal intercourse with casual partners with or without condoms were inversely related. The study identified a high prevalence of HIV infections among a group of men who sex with men with a high self-perception risk of acquiring HIV. The findings also showed a relation with sociodemographic and sexual behavior variables.

Body Composition and Metabolic Syndrome Components on Lipodystrophy Different Subtypes Associated with HIV

HIV-associated lipodystrophy syndrome (HALS) is characterized by body fat redistribution as a consequence of the antiretroviral therapy (ART) introduction, associated with an increased risk of cardiovascular disease development. Subjective diagnosis, classified between three subtypes according to the body region on which fat is lost and/or accumulated, named lipoatrophy, lipohypertrophy, and mixed lipodystrophy, is possibly accompanied with metabolic alterations. Forty people living with HIV/AIDS (PLHA), with clinical diagnosis of HALS and from both genders, were assessed. They performed ambulatorial follow-up and used ART regularly. The main findings were greater lipid profile alterations among women, while no metabolic profile differences were found between the HALS subtypes. The lipohypertrophy group showed major alterations, with higher values for total body fat percent, visceral fat area (VFA), body mass index (BMI), and abdominal and neck circumferences when compared to the other groups. Lean body mass was superior only compared to the mixed lipodystrophy group, and fat mass only compared to the lipoatrophy group. BMI showed strong correlation with the VFA. In conclusion, despite anthropometric alterations related to HALS these individuals present, those are not accompanied with metabolic alterations. Strategies, as behavioral changes and disorders prevention, are important to decrease the risk of cardiovascular disease development.

[Evaluation of the cascade of care in prevention of mother-to-child HIV transmission in Brazil]

This study aimed to assess the cascade of care in the reduction of mother-to-child HIV transmission in the states of Amazonas, Ceará, Espírito Santo, Rio de Janeiro, and Rio Grande do Sul and the Distrito Federal, Brazil, using data from the Brazilian Information System on Diseases of Notification (SINAN). From 2007 to 2012, there was an increase (from 7.3% in Distrito Federal to 46.1% in Amazonas) in intra-gestational detection of HIV in 5 states, with a 18.6% reduction in Rio de Janeiro. Fewer than 90% of the women received antiretroviral therapy during their prenatal care, including those that already knew they were HIV-positive. The elective cesarean rate was low. The AIDS detection rate in children under 5 years as a proxy for mother-to-child HIV transmission showed a reduction of 6.3% from 2007 to 2012, and was highest in Rio Grande do Sul (50%), the state with the highest rates in the period, while Espírito Santo showed the highest increase (50%). Evaluation of the cascade of HIV care in pregnant women identified flaws in all the points. A link is needed between primary care and referral centers for HIV/AIDS, organizing care for the family and better outcomes for the children.

HIV-testing among female sex workers on the border between Brazil and French Guiana: the need for targeted interventions

The border between Brazil and French Guiana is a place of economic, cultural, social and sexual exchange. Female sex workers represent a high risk population for HIV in this area where sexual tourism is particularly developed. HIV testing seems to be an important element in the fight against the epidemic. Indeed, early HIV testing gives access to treatments and prevention. An HIV/AIDS knowledge, attitudes, behaviors and practices survey was conducted in 2011 among sex workers along the border between Brazil and French Guiana. A total of 213 female sex workers were interviewed. One third (31.5%) of the interviewed had never tested for HIV. Factors associated with non HIV-testing were the lack of knowledge of places where to do an HIV test, to be 30 or older, feeling at risk of HIV, not evaluating one's own risk towards HIV, and living in Oiapoque. These results clearly suggest that targeted interventions are needed to encourage and assist female sex workers to get tested regularly.

HIV-1 epidemiology and circulating subtypes in the countryside of South Brazil

INTRODUCTION

Human immunodeficiency virus type 1 (HIV-1) has spread worldwide, with several subtypes and circulating recombinant forms. Brazil has an incidence of 20.5 HIV-1/acquired immunodeficiency syndrome (AIDS) patients per 100,000 inhabitants; however, the Southernmost State of Rio Grande do Sul (RS) has more than twice the number of HIV-1-infected people (41.3/100,000 inhabitants) and a different pattern of subtype frequencies, as previously reported in studies conducted in the capital (Porto Alegre) and its metropolitan region. This study examined HIV-1/AIDS epidemiological and molecular aspects in the countryside of Rio Grande do Sul.

METHODS

Socio-demographic, clinical and risk behavioral characteristics were obtained from HIV-1-positive adult patients using a structured questionnaire. HIV-1 subtypes were determined by nested-polymerase chain reaction (PCR) and sequencing of the pol and env genes.

RESULTS

The study sample included 149 (55% women) patients with a mean age of 41.8 ± 11.9 years. Most (73.8%) patients had a low education level and reported heterosexual practices as the most (91.9%) probable transmission route. HIV-1 subtypes were detected in 26 patients: 18 (69.2%) infected with subtype C, six (23.1%) infected with subtype B and two (7.7%) infected with BC recombinant forms.

CONCLUSIONS

These data highlight the increasing number of HIV-1 subtype C infections in the countryside of South Brazil.

High HIV Prevalence among Men who have Sex with Men in a Time-Location Sampling Survey, São Paulo, Brazil

We conducted a time-location sampling sero-behavioral surveillance survey of men who have sex with men (MSM) in São Paulo, Brazil, the largest city in Latin America and the Southern Hemisphere (N = 1,217 interviewed with serological results for 771). HIV prevalence was 15.4 % (95 % CI 11.6-20.1), with only 45.8 % previously aware of their infection. HIV prevalence achieved 6.4 % among youth 18-24 years and was higher among MSM with lower socio-economic status. In multivariate analysis, correlates of HIV were older age, gay identity, lower socio-economic status, social networks with HIV-positive MSM, receptive anal sex, and internet sex partners. Policy change towards increasing avenues for HIV testing coupled with antiretroviral treatment regardless of CD4 count or stage of disease stand to benefit the MSM community if scaled up fast enough.

High-risk human papillomavirus and cervical lesions among women living with HIV/AIDS in Brazilian Amazon, Brazil

Objective

The goal of this study was to determine the prevalence of human papillomavirus infection infection and cervical lesions and its associated factors among HIV infected women attending an AIDS clinic in Amazonas state, Brazil.

Methods

Cross-sectional study. Women attending an AIDS clinic in the city of Manaus between March and December 2011 for gynecological examination were invited to participate. Enrolled patients answered a standardized interview including demographical, behavioral, and clinical data. Additionally, patients underwent a gynecological evaluation with collection of cervical samples for cytological analysis and high-risk human papillomavirus infection hybrid capture. A blood sample was also obtained to determine CD4 and viral load levels.

Results

A total of 310 (82.9%) women participated in the study. High-risk human papillomavirus infection was detected in 191 (61.6%) cases; 24 (13.5%) had low-grade squamous intraepithelial lesion (SIL) and 4 (2.2%) high-grade SIL. No invasive cervical cancer was diagnosed. Median age was 32 (interquartile range (IQR): 27–38) years and median of education was 8.5 (IQR 4–11) years of schooling and 56.1% had a monthly income up to US$180. In multivariate analysis, being less than 30 years old [OR = 1.7 (95% CI: 1.2–2.4, p = 0.005)], high-grade SIL [OR = 6.5 (95% CI: 1.6–23.0, p = 0.009)], and CD4 counts <200 cells/mm³ [OR = 1.6 (95% CI: 1.2–2.0, p < 0.001)] were associated with high risk human papillomavirus infection infection.

Conclusions

In the present study high-risk human papillomavirus infection was frequent and it was associated to high-SIL. These results show the importance of gynecologic examinations in routine care and follow-up required by those who present with cervical lesions.

Characteristics relating to the interiorization of acquired immunodeficiency syndrome in Brazil: a cross-sectional study

Background

In recent years there has been changes in the social and geographic profile of acquired immunodeficiency syndrome (AIDS). The aim of this study was to evaluate the internalization of AIDS in the state of Rondônia, Brazil.

Findings

In Rondônia, 1473 AIDS cases were reported, with an average annual incidence of 15.8/100,000 persons (42.7 % women). The most common mode of viral transmission was sexual (96.5 %), and the majority of the individuals had not completed their primary education (64.8 %). There was heterogeneity in relation to case distribution, involving almost all of the municipalities in the state. The average annual mortality rate was 2.5/100,000 persons.

Conclusion

Rondônia has a higher incidence of AIDS than the national average and the northern region. Efforts to provide access to treatment and follow-up of these individuals should be implemented, prioritizing areas where the incidence is higher and decentralizing the treatment of patients with AIDS in the state.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-015-0060-2) contains supplementary material, which is available to authorized users.

History of syphilis in women living with AIDS and associated risk factors in São Paulo, Brazil

OBJECTIVE

to describe the epidemiological profile, risk behaviors, frequency of prior history of syphilis in women living with AIDS and to investigate associated factors.

METHODS

a cross-sectional study conducted with women living with HIV attending at Reference Center for AIDS in São Paulo. Demographic, behavioral, and clinical data were analyzed based on medical records.

RESULTS

a total of 598 women were included in the study and the prevalence of previous syphilis was 6.2% (95% CI 4,3-8,1). Seventy-three percent of women were less than 40 years of age when diagnosed with AIDS and 49.6% had more than eight years of formal education. 67.2% were white and 65.9% were not married or living with a partner, 53.2% reported that their first sexual intercourse aged more than 15 years, 56.5% reported having only one partner in the last year and 13% reported drug use. Regarding laboratory data, 83.8% had CD4+ <500 cells/ mm3 upon diagnosis of AIDS. Previous syphilis was associated with the use of crack cocaine [AOR = 6.8 (95% CI 1.7 - 27.5)], >1 sexual partner in the last year [AOR = 6.6 (95% CI 1.2 - 37.1)], CD4 + <500 cells/mm3 [AOR = 3.8 (women 1.1 - 13.6)], HIV diagnosis > 8 years [AOR = 2.4 (95% CI 1.0 - 5.8)].

CONCLUSION

a high prevalence of previous syphilis was found in the population studied, and crack use was identified among the main associated risk factors. Interventions to reduce the risk of sexual transmission of HIV and syphilis must be strengthened, with the implementation of control actions, screening strategies, early diagnosis and treatment, preventing complications, reducing morbidity and improving sexual and reproductive health.

Changes in the prevalence, incidence and residual risk for HIV and hepatitis C virus in Southern Brazilian blood donors since the implementation of NAT screening

INTRODUCTION

Previous studies have shown high residual risk of transfusing a blood donation contaminated by human immunodeficiency virus (HIV) or hepatitis C virus (HCV) in Brazil and motivated the development of a Brazilian platform for simultaneous detection of both viruses by nucleic acid amplification test (NAT) denominated HIV/HCV Bio-Manguinhos/Fundação Oswaldo Cruz (FIOCRUZ). The objective of this study was to verify seroprevalence, incidence and residual risk for both viruses before and after the implementation of NAT.

METHODS

Over 700,000 blood samples from all blood banks in the southern Brazilian State of Santa Catarina were analyzed during the period between January 2007 and July 2013.

RESULTS

Compared with the period preceding the NAT screening, HIV prevalence increased from 1.38 to 1.58 per 1,000 donors, HIV incidence rate increased from 1.22 to 1.35 per 1,000 donor-years, and HIV residual risk dropped almost 2.5 times during the NAT period. For HCV, seroprevalence increased from 1.22 to 1.35 per 1,000 donors, incidence dropped from 0.12 to 0.06 per 1,000 donor-years, and residual risk decreased more than 3 times after the NAT implementation.

CONCLUSIONS

NAT reduced the duration of the immunologic window for HIV and HCV, thus corresponding to approximately 2.5- and 3-fold respective residual risk reductions.

Socioeconomic disadvantage increasing risk for depression among recently diagnosed HIV patients in an urban area in Brazil: cross-sectional study

Depression is the most common psychiatric co-morbidity among people living with HIV (PLHIV), with prevalence rates ranging from 25% to 36%. Depression impacts negatively upon adherence and response to combined antiretroviral therapy (CART) and the transmission of HIV infection through increased sexually risky behavior. This cross-sectional study presents data from a reference HIV-outpatient service in Dourados (Brazil) that evaluated the association between depressive symptoms, health-related quality of life, and clinical, socioeconomic, and demographic factors in newly diagnosed HIV/AIDS patients. Using the Beck Depression Inventory (BDI), the prevalence of depressive symptoms was 61% with a predominance of self-deprecating and cognitive-affective factors. Depressive symptoms were associated with lower income (p=0.019) and disadvantaged social class (p=0.005). Poorer quality of life was related to depressive symptoms (p<0.0001), low educational level (p=0.05), and lower income (p=0.03). These data suggest that socioeconomic factors, including level of income and education, are mediating the risk of depression and poor quality of life of PLHIV. Possible explanations for this effect are discussed, including the possible role of stigma.

[Coping and perception of women with HIV infection]

OBJECTIVE

To analyze women’s perceptions and coping regarding the discovery of an HIV infection.

METHODS

A qualitative study in an HIV/AIDS Specialist Helpdesk in Recife, PE, Northeastern Brazil, from January to September 2010, involving eight women living with asymptomatic HIV aged between 27 and 37 years, without criteria for diagnosis of AIDS infected through intercourse and monitored by the service for at least one year. Forms were used to characterize the clinical situation and semi-structured interviews to understand perceptions and feelings related to personal trajectory after diagnosis and different ways of facing the diagnosis in family and social life. Content analysis was performed as suggested by Bardin.

RESULTS

The thematic category that emerged was stigma and discrimination. The women had life trajectories marked by stigma, which was perceived as discrimination after the diagnosis and in the experiences of everyday life. The revelation of the infection was perceived as limiting to a normal life, leading to the need to conceal the diagnosis. The discriminatory attitudes of some health care professionals, non-specialist in HIV/AIDS, had a negative impact on future experiences in other health services. Besides the effects of institutional stigma, the perception of women was that the service did not include dedicated space for the expression of other needs beyond the disease, which could help in fighting the infection.

CONCLUSIONS

Living with HIV was strongly linked to stigma. The results show the importance of strengthening educational approaches and emotional support at the time of diagnosis in order to facilitate coping with the condition of seropositivity.

Growth patterns and scaling laws governing AIDS epidemic in Brazilian cities

Brazil holds approximately 1/3 of population living infected with AIDS (acquired immunodeficiency syndrome) in Central and South Americas, and it was also the first developing country to implement a large-scale control and intervention program against AIDS epidemic. In this scenario, we investigate the temporal evolution and current status of the AIDS epidemic in Brazil. Specifically, we analyze records of annual absolute frequency of cases for more than 5000 cities for the first 33 years of the infection in Brazil. We found that (i) the annual absolute frequencies exhibit a logistic-type growth with an exponential regime in the first few years of the AIDS spreading; (ii) the actual reproduction number decaying as a power law; (iii) the distribution of the annual absolute frequencies among cities decays with a power law behavior; (iv) the annual absolute frequencies and the number of inhabitants have an allometric relationship; (v) the temporal evolution of the annual absolute frequencies have different profile depending on the average annual absolute frequencies in the cities. These findings yield a general quantitative description of the AIDS infection dynamics in Brazil since the beginning. They also provide clues about the effectiveness of treatment and control programs against the infection, that has had a different impact depending on the number of inhabitants of cities. In this framework, our results give insights into the overall dynamics of AIDS epidemic, which may contribute to select empirically accurate models.

The AIDS epidemic in the Amazon region: a spatial case-control study in Rondonia, Brazil

OBJECTIVE

To analyze spatial changes in the risk of AIDS and the relationship between AIDS incidence and socioeconomic variables in the state of Rondonia, Amazon region.

METHODS

A spatial, population case-control study in Rondonia, Brazil, based on 1,780 cases reported to the Epidemiological Surveillance System and controls based on demographic data from 1987 to 2006. The cases were grouped into five consecutive four-year periods. A generalized additive model was adjusted to the data; the dependent variable was the status of the individuals (case or control), and the independent variables were a bi-dimensional spline of the geographic coordinates and some municipality-level socioeconomic variables. The observed values of the Moran's I test were compared to a reference distribution of values generated under conditions of spatial randomness.

RESULTS

AIDS risk shows a marked spatial and temporal pattern. The disease incidence is related to socioeconomic variables at the municipal level in Rondônia, such as urbanization and human capital. The highest incidence rates of AIDS are in municipalities along the BR-364 highway and calculations of the Moran's I test show positive spatial correlation associated with proximity of the municipality to the highway in the third and fourth periods (p = 0.05).

CONCLUSIONS

Incidence of the disease is higher in municipalities of greater economic wealth and urbanization, and in those municipalities bisected by Rondônia's main roads. The rapid development associated with the opening up of once remote regions may be accompanied by an increase in these risks to health.

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.

HIV infection among young pregnant women in Brazil: prevalence and associated risk factors

Our goal was to estimate prevalence of HIV among young women in labor. A national, probability-based, cross-sectional study was performed among pregnant women, aged 15-24 years, who were attending Brazilian public hospitals. The study included 2,071 of 2,400 women selected (86.3 % participation). Mean age was 20.2 years (SD = 2.7). HIV prevalence was 0.7 % (95 % CI, 0.4-1.1 %). Living in the North region of the country and having previous sexually transmitted infections were associated with HIV infection. Our survey of young pregnant women found higher prevalence than expected for women of all ages in Brazil (0.42 %), indicating that the epidemic persists among heterosexuals.

Syphilis and HIV co-infection in patients who attend an AIDS outpatient clinic in Vitoria, Brazil

Our goal was to determine the prevalence of, and risk factors associated with, syphilis in HIV-infected patients who attend an AIDS outpatient clinic in Vitoria, Brazil. We conducted a cross-sectional study-including interviews for demographic, behavioral, and clinical characteristics-and blood collection (venipuncture and fingerstick) for VDRL and treponemal tests (rapid test) in a total of 438 patients. The mean age was 43.0 years (SD = 11), and mean years of school was 8.1 (SD = 4.2). The prevalence of syphilis was 5.3 % (95 % CI 3.3-7.3). The treponemal test was positive in 18.9 % of participants. In multivariate analysis, prevalent syphilis infection was independently associated with male gender (AOR 4.6, 95 % CI 1.1-20.0), a history of male-male sex (AOR 1.8, 95 % CI 1.6-4.1), current use of antiretroviral therapy (AOR 5.5, 95 % CI 1.7-16.7), and history of treated syphilis infection (AOR 5.5, 95 % CI 2.0-15.8). Syphilis prevalence was high in patients living with HIV/AIDS who attend an AIDS clinic; therefore, routine sexually transmitted infections counseling and screening should be included in their care.

Aspectos demográficos e manifestações clínicas bucais de pacientes soropositivos para o HIV/Aids

INTRODUÇÃO: As lesões bucais e peribucais são comuns nos pacientes infectados pelo vírus HIV e podem representar os primeiros sinais da doença, antes mesmo das manifestações sistêmicas. OBJETIVO: Este estudo objetivou estimar a prevalência de manifestações bucais em indivíduos soropositivos para o HIV, considerando aspectos sociodemográficos, imunológicos e terapêuticos. MATERIAL E MÉTODO: Foi realizado um estudo de natureza clínico-epidemiológica transversal, entre outubro de 2007 e abril de 2008, com amostra composta por 40 pacientes. Utilizou-se a técnica de observação direta intensiva por meio de exame clínico apropriado. Os dados foram registrados em fichas pré-elaboradas e analisados por estatística descritiva e inferencial. RESULTADO: Verificou-se a prevalência do gênero feminino (52,5%), na faixa etária de 40 a 49 anos (45%). O tratamento com antirretrovirais foi constatado em 85,0% dos casos, sendo todos com terapia de alta potência (HAART). Observou-se que 52,5% dos pacientes apresentaram a contagem de linfócitos TCD4+ acima de 500cél/mm³ e 50,0% apresentaram carga viral indetectável. A prevalência das manifestações bucais foi 42,5%, sendo a mais expressiva a candidose pseudomembranosa (19,23%), seguida da periodontite úlcero-necrosante (15,38%), da leucoplasia pilosa (11,54%) e da queilite angular (11,54%). Não foi verificada associação entre manifestações bucais e carga viral (p=0,1268), nem com o número de células T CD4 (p=0,3458). CONCLUSÃO: A prevalência de algumas manifestações bucais associadas à infecção pelo HIV ainda é alta, sendo a candidose pseudomembranosa a infecção mais prevalente, principalmente entre pessoas com baixo nível de escolaridade e maior tempo de infecção pelo vírus HIV, independentemente da terapia utilizada e do estado imunológico do paciente.

AIDS-related Kaposi's sarcoma in Brazil: trends and geopolitical distribution

BACKGROUND

AIDS-related Kaposi's sarcoma (KS) is a unique model of the relationship between viral infection, immunity, environmental, and genetic factors in viral cancers. The goal was to determine the distribution of KS cases among Brazilian geopolitical regions, looking at the ecological relationship with median CD4 cell count.

METHODS

Ecological study using Brazilian National Diseases Reporting Databases: 1982-2009. Subjects ≥ 13 years of age who have KS cited in their AIDS reporting form were selected, and demographic and HIV exposure data were collected.

RESULTS

We found 11,731 KS cases in the period, with a prevalence of 2.4% among AIDS cases; 88% were male, and 68% lived in the Southeast region, which accounted for 59% of AIDS cases. The regional and national prevalence trends were similar, although the highest proportion among women was found in the North region, which has the lowest number of both AIDS and KS cases. Heterosexual transmission accounted for 87% of HIV among women compared to 18% among men. Fifty-seven percent of all KS cases were diagnosed before antiretroviral therapy (ART). Injection drug use accounted for 11% of KS cases. Median survival was 472 days before the ART era and 1482 after it (P < 0.001). Median CD4 counts increased in all regions in the period as ART coverage expanded, and a resulting correlating decline in KS cases was observed.

CONCLUSIONS

Prevalence of KS declined after the introduction of ART in all regions of Brazil, suggesting individual protection conveyed by ART.

Maternal risk factors for HIV infection in infants in northeastern Brazil

INTRODUCTION

While the rate of vertically transmitted HIV infection has fallen in most regions of Brazil, there have been no similar decreases in northern and northeastern Brazil.

OBJECTIVE

The objective of this study was to evaluate the risk factors associated with vertical transmission in the state of Sergipe in northeastern Brazil.

METHODS

This was a retrospective cohort study. We recorded clinic and registry data for all HIV-infected pregnant women and exposed children diagnosed in Sergipe from 1990 to 2011.

RESULTS

We identified 538 deliveries and 561 HIV-exposed infants (23 sets of twins). One hundred one (18.9%) infants were HIV-infected. In the multivariate analysis, infant antiretroviral prophylaxis was a significant protective factor (adjusted odds ratio (aOR) 0.07, 95% confidence interval (CI) 0.01-0.41, p=0.003). Breastfeeding was marginally associated with an increased odds of perinatal transmission (aOR 4.52, 95% CI 0.78-26.17, p = 0.092). The attributable risk percentage for breastfeeding over the study period was 91.0%. Transmission decreased from 91 per 100 live births before 1997 to 2 per 100 in 2011 following the adoption of the prevention protocol.

CONCLUSION

Transmission declined over the study period. The screening of pregnant women and timely initiation of prophylaxis and therapy are issues that require further attention.

Incidence rate of modifying or discontinuing first combined antiretroviral therapy regimen due to toxicity during the first year of treatment stratified by age

Toxicity is the most frequently reported reason for modifying or discontinuing the first combined antiretroviral therapy regimens, and it can cause significant morbidity, poor quality of life and also can be an important barrier to adherence, ultimately resulting in treatment failure and viral resistance. Elderly patients with HIV/AIDS (≥50 years) may have a different profile in terms of treatment modification due to higher incidence of comorbidities and polypharmacy. The aim of this study was to describe the incidence of modifying or discontinuing first combined antiretroviral therapy regimen due to toxicity (TOX-MOD) during the first year of treatment at the IPEC – FIOCRUZ HIV/AIDS cohort, Rio de Janeiro, Brazil, stratified by age. Demographic, clinical and treatment characteristics from antiretroviral-naïve patients who first received combined antiretroviral therapy between Jan/1996 and Dec/2010 were collected. Incidence rate and confidence interval of each event were estimated using quasipoisson model. To estimate hazard ratio (HR) of TOX-MOD during the first year of combined antiretroviral therapy Cox's proportional hazards regression was applied. Overall, 1558 patients were included; 957 (61.4%), 420 (27.0%) and 181 (11.6%) were aged <40, 40–49, and ≥50 years, respectively. 239 (15.3%) events that led to any modifying or discontinuing within the first year of treatment were observed; 228 (95.4%) of these were TOX-MOD, corresponding to an incidence rate of 16.6/100 PY (95% CI: 14.6–18.9). The most frequent TOX-MOD during first combined antiretroviral therapy regimen were hematologic (59; 26.3%), central nervous system (47; 20.9%), rash (42; 19.1%) and gastrointestinal (GI) (38; 16.7%). In multivariate analysis, incidence ratio of TOX-MOD during the first year of combined antiretroviral therapy progressively increases with age, albeit not reaching statistical significance. This profile was maintained after adjusting the model for sex, combined antiretroviral therapy regimen and year of combined antiretroviral therapy initiation. These results are important because not only patients are living longer and aging with HIV, but also new diagnoses are being made among the elderly. Prospective studies are needed to evaluate the safety profile of first line combined antiretroviral therapy on elderly individuals, especially in resource-limited countries, where initial regimens are mostly NNRTI-based.

Individual and contextual factors of influence on adherence to antiretrovirals among people attending public clinics in Rio de Janeiro, Brazil

BACKGROUND

There are inconsistencies in the determinants of adherence to antiretrovirals (ARVs) across settings as well as a lack of studies that take into consideration factors beyond the individual level. This makes it necessary to examine factors holistically in multiple settings and populations while taking into consideration the particularities of each context, in order to understand the patterns of ARV adherence. This research explored ARV adherence and individual, relational and environmental-structural factors.

METHODS

A cross-sectional survey was conducted from August 2008 through July 2009 among participants currently on ARVs recruited from 6 public health clinics, selected to maximize diversity in terms of caseload and location, representing the range of clinics within Rio de Janeiro city, Brazil. Multivariate logistic regression analysis was used to assess the association between our multilevel factors with ARV adherence among participants with complete cases (n = 632).

RESULTS

Eighty-four percent of respondents reported adherence to all of their ARV doses in the last 4 days. Of the socio-demographic variables, those who had one child were positively associated with adherence (AOR 2.29 CI [1.33-3.94]). On the relational level, those with high social support (AOR 2.85 CI [1.50-5.41]) were positively associated with adherence to ARVs. On the environmental-structural level, we found gender was significant with women negatively associated with adherence to ARVs (AOR 0.58 CI [0.38-0.88]) while those with a high asset index (AOR 2.47 CI [1.79-3.40]) were positively associated with adherence to ARVs.

CONCLUSIONS

This research highlights the importance of examining the multiple levels of influence on ARV adherence. Intervention research in lower and middle-income settings should address and evaluate the impact of attending to both gender and economic inequalities to improve ARV adherence, as well as relational areas such as the provision of social support.

Políticas públicas de saúde face à epidemia da AIDS e a assistência às pessoas com a doença

Objetivou-se identificar as principais políticas públicas sobre HIV/AIDS no cenário brasileiro, a partir de 1980 e refletir sobre seu impacto na assistência às pessoas que convivem com HIV/AIDS. A partir dos descritores políticas públicas de saúde, Síndrome da Imunodeficiência Adquirida e assistência integral à saúde, obtive-se uma amostra de 23 artigos, nas bases de dados Medline e Lilacs. Após análise, verificaram-se dois momentos: o primeiro, do surgimento das políticas públicas em resposta à epidemia da AIDS; e o segundo, de melhoria da assistência às pessoas que convivem com HIV/AIDS. Apesar dos reconhecidos avanços conquistados em termos de políticas públicas de saúde no país, há ainda um complexo caminho em busca da qualidade da assistência às pessoas com HIV/AIDS.

Evaluation of preventive measures for mother-to-child transmission of HIV in Aracaju, State of Sergipe, Brazil

INTRODUCTION: The main route of human immunodeficiency virus (HIV) infection in children is from mother to child. The preventive measures established for the Aids Clinical Trial Group protocol 076 (ACTG 076) significantly reduces HIV vertical transmission rates. This study aims to evaluate the implementation of the ACTG 076 protocol in the maternity units of State of Sergipe, Brazilian northeast. METHODS: This is a descriptive, retrospective study with a quantitative approach, with HIV positive women and children exposed, attending a Maternity reference for high-risk pregnancies. Data were obtained from patient records registered in the years 1994 to 2010. RESULTS: Amongst the 110 pregnant women and exposed newborns, the ACTG 076 protocol was fully utilized in only 31.8% of the participants. During the prenatal period, zidovudine (ZDV) was taken by 79.1% of the pregnant women. Only 49.1% of HIV seropositive patients used ZDV during delivery. Two (1.8%) children were considered infected and 50 (45.5%) do not have a conclusive diagnosis to date. CONCLUSIONS: There were significant deficiencies in the prevention of mother-to-child transmission of HIV, including lack of compliance with the three phases of the ACTG 076 protocol; inadequacies in prenatal care; inappropriate mode of delivery and lack of adequate follow up of exposed children.

Co-infection Trypanosoma cruzi/HIV: systematic review (1980-2010)

INTRODUCTION

The co-infection Trypanosoma cruzi/HIV has been described as a clinical event of great relevance. The objective of this study was to describe clinical and epidemiological aspects published in literature.

METHODS

It is a systematic review of a descriptive nature from the databases Medline, Lilacs, SciELO, Scopus, from 1980 to 2010.

RESULTS

There were 83 articles (2.8 articles/year) with a total of 291 cases. The co-infection was described in 1980 and this situation has become the defining AIDS clinical event in Brazil. This is the country with the highest number of publication (51.8%) followed by Argentina (27.7%). The majority of cases are amongst adult men (65.3%) native or from endemic regions with serological diagnosis in the chronic stage (97.9%) and indeterminate form (50.8%). Both diseases follow the normal course, but in 41% the reactivation of the Chagas disease occurs. The most severe form is the meningoencephalitis, with 100% of mortality without specific and early treatment of the T. cruzi. The medication of choice was the benznidazole on doses and duration normally used for the acute phase. The high parasitemia detected by direct or indirect quantitative methods indicated reactivation and its elevation is the most important predictive factor. The lower survival rate was related to the reactivation of the Chagas disease and the natural complications of both diseases. The role of the antiretroviral treatment on the co-infection cannot yet be defined by the knowledge currently existent.

CONCLUSIONS

Despite the relevance of this clinical event there are still gaps to be filled.

Aspectos epidemiológicos da AIDS em Florianópolis/SC, Brasil

O estudo teve como objetivo descrever os aspectos epidemiológicos das pessoas com 13 anos e mais, com AIDS, residentes em Florianópolis/SC entre 1986 e 2006. Estudo descritivo, transversal, com coleta das variáveis: ano de diagnóstico, sexo, idade, categoria de exposição, escolaridade, cor da pele e Regional de Saúde de residência, no Sistema Nacional de Agravos de Notificação e Sistema de Informação sobre Mortalidade. Constata-se a magnitude da AIDS em homens, com ensino fundamental, de cor da pele branca, idade entre 20 e 49 anos e heterossexuais. Observou-se a vulnerabilidade feminina na redução da razão entre os sexos masculino/feminino no período avaliado. Apresentam-se a base social e a especificidade dos doentes de AIDS em Florianópolis/SC, e sugerem-se investimentos no diagnóstico territorial na Estratégia de Saúde da Família e acompanhamento dos sistemas de informação pelas Regionais de Saúde, para avaliar a eficiência e a efetividade das estratégias de prevenção à AIDS em Florianópolis/SC.

Morphological and immunological changes in the skin of autopsied women with AIDS

Acquired immunodeficiency syndrome (AIDS) is characterized by decreased immunity, making a patient more susceptible to opportunistic infections which can have cutaneous manifestations. The aim of this study was to evaluate the local immunity of the skin through morphological and immunohistochemical analysis. Skin samples of 52 women, 27 without AIDS and 25 with AIDS, autopsied in an academic referral hospital in Brazil were evaluated. The autopsy reports and medical records were reviewed, and histochemical Hematoxylin-eosin, Picrosirius red, and Verhoeff stains as well as morphometric (Image J and KS-300 Kontron-Zeiss) and immunohistochemical (S-100 and anti-IgA) analyses of the skin were performed. Women with AIDS presented a thinner epidermis than women without AIDS (33.33 [12.00-317.66] vs 67.42 [12.00-530.02] μm; p < 0.001), with a lower number of epithelial cell layers (4.00 [2.00-11.00] vs 4.00 [2.00-16.00]; p < 0.001), a smaller cell diameter (12.92 [6.00-28.87] vs 24.32 [6.00-33.12] μm; p < 0.001), and a lower number of Langerhans cells (LC) (12.58 [0.00-81.74] vs 31.44 [0.00-169.77] LC/mm(2); p < 0.001). The dermis contained more collagen fibers (8.20 % [2.40-19.40] vs 6.30 % [0.40-13.90]; p < 0.001). Some of these parameters were negatively correlated with viral load and positively correlated with the number of CD4+ T-lymphocytes. We conclude that a decrease of the local skin immunity in women with AIDS may contribute to the development of skin lesions.

Cervical cytological abnormalities and factors associated with high-grade squamous intraepithelial lesions among HIV-infected women from Rio de Janeiro, Brazil

Although cervical cancer remains a major public health problem in Brazil, knowledge of cervical cytological abnormalities among HIV-infected women remains scarce. At baseline evaluation of a cohort followed in Rio de Janeiro, Brazil, 703 HIV-infected women underwent cytology-based cervical cancer screening and human papillomavirus (HPV) DNA testing. Poisson regression analysis was used to evaluate the association of factors with the presence of high-grade squamous intraepithelial lesions (HSIL). Cervical cytology was abnormal in 24.3% of the women; 4.1% had HSIL. Beyond HPV infection, factors independently associated with the presence of HSIL was age (≥25 and ≤40 years, prevalence ratio [PR] 2.60, 95% confidence interval [CI] 1.11-6.10), and more than three pregnancies was protective (PR 0.33, 95% CI 0.11-0.94). High coverage of cervical cancer screening is warranted to prevent morbidity and mortality from cervical cancer in this population.

Behavior assessment of women attending a sexually transmitted disease clinic in Vitória, Brazil

BACKGROUND

Studies about sexual risk behaviors can provide information to support design strategies to control the spread of HIV infection.

OBJECTIVE

To assess sexual risk behaviors among women attending a sexually transmitted diseases clinic in Vitória, Brazil.

METHODS

A cross-sectional study was performed among women attending an STD/AIDS reference center. Enrolled participants were interviewed and provided a blood sample to determine HIV status.

RESULTS

A total of 276 women participated. among 284 selected; 109 (39.5%) were HIV-positive and 167 (60.5%) HIV-negative. Median age was 31 years (interquartile range (IQR)24-36) and 69% of women were between 18 and 34 years of age. Women reported high access to information about STD (87%) and AIDS (90%) but information about sexuality was less common (55%). HIV-positive women asked their partners to use condoms more often than HIV-negatives (31% vs. 5%, p=0.02), and were more likely to have used a condom at last intercourse (65% vs. 33%, p<0.01). Among all patients, questions regarding risk of HIV transmission through sexual intercourse (99.6%) and needle sharing (99.2%) were most frequently answered correctly, while questions regarding risk of HIV transmission through blood donation (57%) were least.

CONCLUSION

Though this population reports easy access to information and services for HIV/sexually transmitted diseases, most report little understanding of unsafe sexual behaviors, particularly HIV-negative women.

Human immunodeficiency virus prevalence, incidence, and residual risk of transmission by transfusions at Retrovirus Epidemiology Donor Study-II blood centers in Brazil

BACKGROUND

In Brazil nationally representative donor data are limited on human immunodeficiency virus (HIV) prevalence, incidence, and residual transfusion risk. The objective of this study was to analyze HIV data obtained over 24 months by the Retrovirus Epidemiology Donor Study-II program in Brazil.

STUDY DESIGN AND METHODS

Donations reactive to third- and fourth-generation immunoassays (IAs) were further confirmed by a less-sensitive (LS) IA algorithm and Western blot (WB). Incidence was calculated for first-time (FT) donors using the LS-EIA results and for repeat donors with a model developed to include all donors with a previous negative donation. Residual risk was projected by multiplying composite FT and repeat donor incidence rates by HIV marker-negative infectious window periods.

RESULTS

HIV prevalence among FT donors was 92.2/10(5) donations. FT and repeat donor and composite incidences were 38.5 (95% confidence interval [CI], 25.6-51.4), 22.5 (95% CI, 17.6-28.0), and 27.5 (95% CI, 22.0-33.0) per 100,000 person-years, respectively. Male and community donors had higher prevalence and incidence rates than female and replacement donors. The estimated residual risk of HIV transfusion transmission was 11.3 per 10(6) donations (95% CI, 8.4-14.2), which could be reduced to 4.2 per 10(6) donations (95% CI, 3.2-5.2) by use of individual-donation nucleic acid testing (NAT).

CONCLUSION

The incidence and residual transfusion risk of HIV infection are relatively high in Brazil. Implementation of NAT will not be sufficient to decrease transmission rates to levels seen in the United States or Europe; therefore, other measures focused on decreasing donations by at-risk individuals are also necessary.

Predicting condom use in young women: demographics, behaviours and knowledge from a population-based sample in Brazil

The goal of this study was to assess condom use and related behaviour in young women in Vitória, Brazil. From March to December 2006, a cross-sectional sample of women aged 18-29 years was recruited into a population-based study. Risk behaviours for HIV and sexually transmitted infections (STIs) were surveyed. Condom use at last intercourse was assessed as a principal outcome describing protective sexual behaviour. Of 1200 eligible women identified, 1029 (85.8%) enrolled. Among them, 904 (87.9%) reported a history of sexual activity. Only 36.6% reported condom use at last intercourse; those who did were more likely to report commercial sex work (odds ratio [OR] 9.01 [1.46-55.55]), to state that STI prevention was a primary reason for using condoms (OR = 6.84 [4.81-9.71]), to have been previously diagnosed with an STI (OR = 2.39 [1.36-4.21]), to report that 'it is easy to tell a sexual partner they will not have vaginal/anal sex without a condom' (OR = 2.30 [1.56-3.39]), to report that sexual intercourse is only risky when people have anal sex (OR = 1.98 [1.22-3.22]); and less likely to be married (OR = 0.65 [0.54-0.78]), and to find it difficult to use condom consistently in all sexual encounters (OR = 0.36 [0.25-0.52]). Women who reported condom use were more concerned with preventing STIs, and to report less difficulty insisting on condom use with partners.

Is food insecurity associated with HIV risk? Cross-sectional evidence from sexually active women in Brazil

BACKGROUND

Understanding how food insecurity among women gives rise to differential patterning in HIV risks is critical for policy and programming in resource-limited settings. This is particularly the case in Brazil, which has undergone successive changes in the gender and socio-geographic composition of its complex epidemic over the past three decades. We used data from a national survey of Brazilian women to estimate the relationship between food insecurity and HIV risk.

METHODS AND FINDINGS

We used data on 12,684 sexually active women from a national survey conducted in Brazil in 2006-2007. Self-reported outcomes were (a) consistent condom use, defined as using a condom at each occasion of sexual intercourse in the previous 12 mo; (b) recent condom use, less stringently defined as using a condom with the most recent sexual partner; and (c) itchy vaginal discharge in the previous 30 d, possibly indicating presence of a sexually transmitted infection. The primary explanatory variable of interest was food insecurity, measured using the culturally adapted and validated Escala Brasiliera de Segurança Alimentar. In multivariable logistic regression models, severe food insecurity with hunger was associated with a reduced odds of consistent condom use in the past 12 mo (adjusted odds ratio [AOR] = 0.67; 95% CI, 0.48-0.92) and condom use at last sexual intercourse (AOR = 0.75; 95% CI, 0.57-0.98). Self-reported itchy vaginal discharge was associated with all categories of food insecurity (with AORs ranging from 1.46 to 1.94). In absolute terms, the effect sizes were large in magnitude across all outcomes. Underweight and/or lack of control in sexual relations did not appear to mediate the observed associations.

CONCLUSIONS

Severe food insecurity with hunger was associated with reduced odds of condom use and increased odds of itchy vaginal discharge, which is potentially indicative of sexually transmitted infection, among sexually active women in Brazil. Interventions targeting food insecurity may have beneficial implications for HIV prevention in resource-limited settings.

Mortality in Brazilian children with HIV/AIDS: the role of non-AIDS-related conditions after highly active antiretroviral therapy introduction

AIDS-related mortality has been significantly reduced in areas that systematically adopted highly active antiretroviral therapy (HAART). In Brazil, despite advances in control policy, there is still a lack of evidence about trends in children on causes of death related or not related to HIV/AIDS. We evaluate temporal trends in mortality due to non-HIV-related causes of death in relation to HIV/AIDS-related conditions among children with and without HIV infection. This nationwide study included all deaths in children reported from 1999 to 2007. Mortality odds ratios (MOR) and rates were calculated to assess time trends of death in children with or without HIV/AIDS. These data were analyzed by calendar year, as obtained from official national database. A total of 680,763 deaths occurred in Brazilian children under 13 years of age; of these, 2191 (0.32%) had causes related to HIV/AIDS listed on the death certificate. The mortality rate from HIV/AIDS-related causes in Brazilian children ranged from 0.72 per 100,000 children in 1999 to 0.40 per 100,000 children in 2007, while for selected nonrelated causes the rate of death among HIV-infected children was stable at 0.08 per 100,000 Brazilian children. In children with HIV/AIDS, the MOR of having selected conditions unrelated to HIV/AIDS as a cause of death in 2007 (compared to 1999) was 1.85 (95% confidence interval [CI] = 1.11-3.08, p = 0.02), but without a significant temporal trend (p = 0.413) through the analyzed period. In Brazil, deaths related to HIV/AIDS mortality in children significantly decreased, while the unrelated causes in HIV-infected children maintained a stable trend. These data reinforce the success of national public health policies and the need to offer comprehensive care to children with HIV/AIDS.

AIDS morbidity and mortality in Brazilian children before and after highly active antiretroviral treatment implementation: an assessment of regional trends

BACKGROUND

The objective of this study was to analyze regional trends over time of acquired immunodeficiency syndrome (AIDS) cases and deaths in Brazilian children, before and after implementation of free access to highly active antiretroviral treatment (HAART).

METHODS

We performed a nation-wide study with an ecologic design and a time-series analysis of AIDS incidence and mortality rates in children (0-12 years of age), using polynomial regression models. Data were obtained from official national databases on age group, residence region, and year of AIDS diagnosis and death (1984-2008).

RESULTS

Between 1984 and 2008, 14,314 (2.7%) AIDS cases and 5041 deaths (2.3% of all AIDS-related deaths) were reported in Brazilian children. Incidence after 1996 was reduced by 23%, as compared with the pre-HAART era. The mortality rate observed in the HAART era was reduced by 63.6%. There was a significant reduction in the incidence in the Southeast and Central-West regions (P < 0.001), but the less industrialized North region showed an increase in the pre-HAART era (P < 0.001), and the Northeast region showed a stabilization trend (P < 0.001). In the South region, the incidence of AIDS increased in the 0 to 4 years subgroup. A reduction of AIDS mortality in the Southeast (P < 0.001), South, and Central-West regions (P < 0.001) was seen, but the Northeast and North regions maintained an increasing mortality trend (P < 0.001).

CONCLUSIONS

Despite the overall reduction in AIDS-related cases and deaths among children in Brazil since HAART, marked regional differences continue to exist. These reflect structural factors, different transmission dynamics, and operational issues. There is a need for improving the health service network with special emphasis on the less developed regions.