Voluntary counseling and testing (VCT) services and their contribution to access to HIV diagnosis in Brazil

Government communication pieces on HIV pre-exposure (PrEP) and post-exposure (PEP) prophylaxis (2016-2019): analysis of their content and circulation among gay men, trans women/travestis, and sex workers

Abstract This article analyzes the advertisement of pre-exposure (PrEP) and post-exposure (PEP) prophylaxis treatment for HIV considering the historical role of AIDS prevention campaigns in Brazil. A total of 24 pieces of communication on PrEP, PEP, and CP (Combined Prevention), produced from 2016 to 2019 and published on the website and social media of the Brazilian Ministry of Health were analyzed in addition to the testimony of 30 users of prophylaxis - including gays, trans women/travestis, and sex workers - in the metropolitan region of Rio de Janeiro. The materials were classified according to type, year, audience, and access information, and the results were interpreted from four axes: contextualization of the communication pieces and the experience of the interlocutors with the information; sexuality and risk; gender, emotions, and moralities; and condom displacements. The analysis indicated the erasure of expressions of sexuality and the predominance of an abstract and structured language, presupposing a rational and individualistic public, with condoms associated with “sexual risk.” Users’ reports regarding the advertisement of information on these prophylaxis reveals its insufficiency. We conclude that the potential of information and communication campaigns, guided by the sociocultural reality of social segments, has been little explored, compromising access to prophylaxis. Thus, the biomedicalization of prevention and the advance of conservatism in Brazil hinder the Brazilian response to AIDS.

Peças de comunicação governamentais sobre as profilaxias pré (PrEP) e pós-exposição (PEP) ao HIV (2016-2019): análise de seus conteúdos e circulação entre gays, mulheres trans/travestis e trabalhadoras sexuais

Resumo Este artigo analisa a divulgação das profilaxias pré (PrEP) e pós-exposição (PEP) ao HIV, considerando o papel histórico das campanhas de prevenção à aids. São utilizadas 24 peças de comunicação sobre PrEP, PEP e PC (Prevenção Combinada), produzidas entre 2016 e 2019 e publicadas no site e mídias sociais do Ministério da Saúde, e o depoimento de 30 usuários(as) das profilaxias - que incluem gays, mulheres trans/travestis e profissionais do sexo - na região metropolitana do Rio de Janeiro. As peças foram classificadas quanto ao tipo, ano, público e informação de acesso, e os resultados foram interpretados a partir de três eixos: sexualidade e risco; gênero, emoções e moralidades; deslocamentos do preservativo. A análise indicou o apagamento das expressões de sexualidade e o predomínio de uma linguagem abstrata e esquemática, pressupondo um público racional e individualista, com o preservativo associado à ideia de “risco sexual”. Os relatos dos(as) usuários(as) quanto à divulgação de informações sobre essas profilaxias evidenciaram sua insuficiência. Concluímos que ocorre uma baixa exploração do potencial das campanhas de comunicação, orientadas pela realidade sociocultural dos segmentos sociais, comprometendo o acesso às profilaxias. Assim, a biomedicalização da prevenção e o avanço do conservadorismo prejudicam a resposta brasileira à aids.

Perception of pre- and post-HIV test counseling among patients diagnosed with aids in adolescence HIV test counseling for adolescents

Pre- and post-HIV test counseling has singular importance in adolescence, since it is a phase of great changes, and AIDS is an incurable chronic disease. In order to comprehend the perception of young people with AIDS diagnosed in adolescence regarding the counseling received upon testing, we conducted 39 in-depth interviews, with 23 in female patients and 16 male patients, and then analyzed the data with extensive reading, categorization and interpretation on a comprehensive basis. The results revealed that less than one third received pre-test counseling (30.8%), which often was limited to the explanation of the reason of the test, and 51.2% were counseled post-test. We found that most patients were unaccompanied when receiving the communication of their seropositivity, some of which were later informed by the adolescent's guardian. Some patients felt secure after counseling, realizing that the disease is something that would not change their lives, if they properly followed the guidelines. On the other hand, the feelings of desperation and suicide expressed by some of the patients may have been influenced by the lack of adequate counseling. We have concluded that, for the improved management of the epidemic, there is a need to enhance the communications of health professionals, especially those that are in primary care, pre-natal services, gynecology and family health strategy.

Institutional context and VCT practitioner narratives: possibilities and limitations for HIV prevention in Rio de Janeiro, Brazil

BACKGROUND

Voluntary Counseling and Testing (VCT) is an HIV prevention strategy that promotes the principles of confidentiality and informed consent. International research has highlighted VCT counselors' isolation from service planning and the contradictions they negotiate between local values and global testing recommendations. In Brazil, studies have identified many limitations, including counselors' difficulties to implement a vulnerability approach to HIV prevention as recommended in the country's national guidelines. These studies, however, have not considered the particularities of the institutional contexts where counselors work. This research addresses these gaps in the VCT literature by exploring how VCT services are organized and how counselors perceive and perform their practices in the state of Rio de Janeiro, Brazil.

METHODS

This is a case study of VCT services in the state of Rio de Janeiro. The research design included individual structured interviews with seven VCT service coordinators and twenty individual semi-structured interviews with VCT counselors. Participants were sampled according to gender, undergraduate degree and work trajectory to capture a diverse range counselor narratives.

RESULTS

The VCT services were relatively homogenous in terms of functioning and had a similar restricted roll of activities including individual counseling and occasional external prevention activities with groups vulnerable to HIV. All VCT services reported reductions in staff size. Some counselors used dialogical practices to build trust, guarantee confidentiality and adjust their practices in accordance with their clients' values and practices. Others emphasized imperative messages or focused on risk and individual responsibility. Connections between how counselors perceive their practices and the organization of their work environment were observed.

CONCLUSIONS

Due to the importance of counseling as a prevention strategy we recommend rethinking the relationship between counselors' practices and the organization of VCT services. The challenges brought about by the expansion of "test and treat" programs globally and other social and symbolic aspects of the HIV epidemic, such as gender inequalities, must also be taken into account. Further reflection is also needed on the relationship between counseling guidelines and practices within the vulnerability approach to HIV prevention.

Self-reported historic human immunodeficiency virus (HIV) testing in a Brazilian blood donor HIV case-control study

BACKGROUND

There has been increased worldwide emphasis on the many benefits of human immunodeficiency virus (HIV) serostatus awareness for both infection prevention and improved treatment outcomes. Previous studies indicate that donors may use blood donation to be tested; the objectives of this analysis were to assess, among donors with previously undisclosed risk behavior in the 12 months before donation, the frequency of those who have previously been tested for HIV and the demographic and behavioral factors associated with such testing.

STUDY DESIGN AND METHODS

In this secondary analysis from an HIV case-control study of blood donors in Brazil, we analyzed the response to the question, "Other than blood donation, have you ever been tested for HIV?" Demographic and disclosed risk behaviors associated with previous testing were determined.

RESULTS

The study included 341 HIV-positive cases and 791 HIV-negative controls (1:2 case/control ratio). Overall, 31% of blood donors (40% of cases and 26% of controls) reported having been tested for HIV outside of blood donation. History of HIV testing varied according to sex, HIV status, and reported sexual risk behavior.

CONCLUSION

Although it is encouraging that previous testing was more frequent in donors with acknowledged sexual risk behavior in Brazil, 60% still had not been tested for HIV outside of the blood donation setting. Educating donors on the importance of not using blood centers as a means to get tested for HIV in Brazil, especially if they engage in higher risk behaviors, and seeking alternate testing venues instead could improve the safety of donated blood.

The Men Who Have Sex with Men HIV Care Cascade in Rio de Janeiro, Brazil

Brazil has a concentrated HIV epidemic and men who have sex with men (MSM) are disproportionately affected. Yet, no data is available on the HIV care cascade for this population. This study aimed to assess the HIV care cascade among MSM newly diagnosed through innovative testing strategies in Rio de Janeiro. Data from 793 MSM and travestites/transgender women (transwomen) tested for HIV at a non-governmental LGBT organization and a mobile testing unit located at a gay friendly venue were analyzed. A 12-month-after-HIV-diagnosis-censored cohort was established using CD4, viral load and combination antiretroviral therapy (cART) longitudinal data from those diagnosed with HIV. A cross-sectional HIV care cascade was built using this data. The relative risks of achieving each cascade-stage were estimated using generalized linear models according to age, self-declared skin-color, education, history of sexually transmitted diseases (STD), drug use and prior HIV testing. From Jan-2013 to Jan-2014, 793 MSM and transwomen were tested, 131 (16.5%) were HIV-infected. As of January 2015, 95 (72.5%) were linked to HIV care, 90 (68.7%) were retained in HIV care, 80 (61.1%) were on cART, and 50 (38.2%) were virally suppressed one year after HIV diagnosis. Being non-white (Relative risk [lower bound; upper bound of 95% confidence interval] = 1.709 [1.145; 2.549]) and having a prior HIV-test (1.954 [1.278; 2.986]) were associated with an HIV-positive diagnosis. A higher linkage (2.603 [1.091; 6.211]) and retention in care (4.510 [1.880; 10.822]) were observed among those who were older than 30 years of age. Using community-based testing strategies, we were able to access a high-risk MSM population and a small sample of transwomen. Despite universal care coverage and the test-and-treat policy adopted in Brazil, the MSM cascade of care indicates that strategies to increase linkage to care and prompt cART initiation targeted to these populations are critically needed. Interventions targeting non-white and young MSM should be prioritized.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HIV-1, HBV, HCV, HTLV, HPV-16/18, and Treponema pallidum infections in a sample of Brazilian men who have sex with men

Background

Men who have sex with men (MSM) are more vulnerable to blood-borne infections and/or sexually-transmitted infections (STI). This study was conducted to estimate the prevalences of mono and co-infections of HIV-1 and other blood-borne/STIs in a sample of MSM in Campinas, Brazil.

Methods

Responding Driven Sampling (RDS) was used for recruitment of MSM. Serum samples collected from 558 MSM were analyzed for the presence of serological markers for HIV-1, HBV, HCV, HTLV, HPV-16/18, and T. pallidum infections.

Results

The highest prevalences of infection in serum samples were found for HPV-16 and 18 (31.9% and 20.3%, respectively). Approximately 8% of the study population showed infection with HIV-1, and within that group, 27.5% had recently become infected with HIV-1. HBV infection and syphilis were detected in 11.4% and 10% of the study population, respectively, and the rates of HTLV and HCV infection were 1.5% and 1%, respectively. With the exception of HTLV, all other studied infections were usually found as co-infections rather then mono-infections. The rates of co-infection for HCV, HPV-18, and HIV-1 were the highest among the studied infections (100%, 83%, and 85%, respectively). Interestingly, HTLV infection was usually found as a mono-infection in the study group, whereas HCV was found only as a co-infection.

Conclusions

The present findings highlight the need to educate the MSM population concerning their risk for STIs infections and methods of prevention. Campaigns to encourage vaccination against HBV and HPV could decrease the rates of these infections in MSM.

Disseminated histoplasmosis in HIV-infected patients: determinants of relapse and mortality in a north-eastern area of Brazil

Many relapses and deaths resulting from disseminated histoplasmosis (DH) in acquired immunodeficiency syndrome (AIDS) patients have been observed in an endemic area in north-eastern Brazil. The objective of this study was to evaluate the risk factors associated with the clinical outcomes of DH/AIDS coinfection in patients from the state of Ceará, Brazil. A retrospective cohort of AIDS patients, after their hospital discharge due to first DH episode in the period 2002-2008, was followed until December 31, 2010, to investigate the factors associated with relapse and mortality. A total of 145 patients were evaluated in the study. Thirty patients (23.3%) relapsed and the overall mortality was 30.2%. The following variables were significantly (P < 0.05) associated with relapse and overall mortality (univariate analysis): non-adherence to highly active antiretroviral therapy (HAART), irregular use of an antifungal, non-recovery of the CD4+ count and having AIDS before DH; histoplasmosis relapse was also significantly associated with mortality. In the multivariate analysis, non-adherence to HAART was the independent risk factor that was associated with both relapse (Adj OR = 6.28) and overall mortality (Adj OR = 8.03); efavirenz usage was discovered to be significant only for the overall mortality rate (Adj OR = 4.50). Adherence to HAART was the most important variable that influenced the outcomes in this specific population.

Testagem anti-HIV: indagações sobre a expansão da oferta sob a perspectiva do acesso e da construção da demanda

Reconhecendo a relevância do incremento na oferta de testagem anti-HIV, problematiza-se a concepção de oferta à luz dos conceitos de acesso e demanda. O mero foco na oferta da testagem mostra-se insuficiente frente à complexidade e dinamicidade do processo, desde a identificação da sua necessidade até a realização do teste e seus possíveis desdobramentos, incluindo o tratamento. Ademais, o modelo de campanha para incentivo à testagem não se coaduna com proposições que valorizem o protagonismo social dos cidadãos nem atendam às especificidades da disseminação da epidemia de AIDS. Postula-se a importância de desenvolver estudos que focalizem mais detidamente a demanda por testagem anti-HIV.

Late entry into HIV care: estimated impact on AIDS mortality rates in Brazil, 2003-2006

BACKGROUND

Worldwide, a high proportion of HIV-infected individuals enter into HIV care late. Here, our objective was to estimate the impact that late entry into HIV care has had on AIDS mortality rates in Brazil.

METHODOLOGY/PRINCIPAL FINDINGS

We analyzed data from information systems regarding HIV-infected adults who sought treatment at public health care facilities in Brazil from 2003 to 2006. We initially estimated the prevalence of late entry into HIV care, as well as the probability of death in the first 12 months, the percentage of the risk of death attributable to late entry, and the number of avoidable deaths. We subsequently adjusted the annual AIDS mortality rate by excluding such deaths. Of the 115,369 patients evaluated, 50,358 (43.6%) had entered HIV care late, and 18,002 died in the first 12 months, representing a 16.5% probability of death in the first 12 months (95% CI: 16.3-16.7). By comparing patients who entered HIV care late with those who gained timely access, we found that the risk ratio for death was 49.5 (95% CI: 45.1-54.2). The percentage of the risk of death attributable to late entry was 95.5%, translating to 17,189 potentially avoidable deaths. Averting those deaths would have lowered the 2003-2006 AIDS mortality rate by 39.5%. Including asymptomatic patients with CD4(+) T cell counts >200 and ≤ 350 cells/mm(3) in the group who entered HIV care late increased this proportion by 1.8%.

CONCLUSIONS/SIGNIFICANCE

In Brazil, antiretroviral drugs reduced AIDS mortality by 43%. Timely entry would reduce that rate by a similar proportion, as well as resulting in a 45.2% increase in the effectiveness of the program for HIV care. The World Health Organization recommendation that asymptomatic patients with CD4(+) T cell counts ≤ 350 cells/mm(3) be treated would not have a significant impact on this scenario.