HIV, syphilis, and viral hepatitis among Latin American indigenous peoples and Afro-descendants: a systematic review.

OBJECTIVE: To identify and summarize existing literature on the burden of HIV, sexually transmitted infections (STIs), and viral hepatitis (VH) in indigenous peoples and Afro-descendants in Latin America to provide a broad panorama of the quantitative data available and highlight problematic data gaps. METHODS: Published and grey literature were systematically reviewed to identify documents published in English, Spanish, or Portuguese with data collected between January 2000 and April 2016 on HIV, STI, and VH disease burden among indigenous peoples and Afro-descendants in 17 Latin American countries. RESULTS: Sixty-two documents from 12 countries were found. HIV prevalence was generally low (< 1%) but pockets of high prevalence (> 5%) were noted in some indigenous communities in Venezuela (Warao) (9.6%), Peru (Chayahuita) (7.5%), and Colombia (Wayuu females) (7.0%). High active syphilis prevalence (> 5%) was seen in some indigenous communities in Paraguay (11.6% and 9.7%) and Peru (Chayahuita) (6.3%). High endemicity (> 8%) of hepatitis B was found in some indigenous peoples in Mexico (Huichol) (9.4%) and Venezuela (Yanomami: 14.3%; Japreira: 29.5%) and among Afro-descendant quilombola populations in Brazil (Frechal: 12.5%; Furnas do Dionísio: 8.4% in 2008, 9.2% in 2003). CONCLUSIONS: The gaps in existing data on the burden of HIV, STIs, and VH in indigenous peoples and Afro-descendants in Latin America highlight the need to 1) improve national surveillance, by systematically collecting and analyzing ethnicity variables, and implementing integrated biobehavioral studies using robust methodologies and culturally sensitive strategies; 2) develop a region-wide response policy that considers the needs of indigenous peoples and Afro-descendants; and 3) implement an intercultural approach to health and service delivery to eliminate health access barriers and improve health outcomes for these populations.

Progress of implementation of the World Health Organization strategy for HIV drug resistance control in Latin America and the Caribbean.

By the end of 2010, Latin America and the Caribbean (LAC) achieved 63% antiretroviral treatment (ART) coverage. Measures to control HIV drug resistance (HIVDR) at the country level are recommended to maximize the efficacy and sustainability of ART programs. Since 2006, the Pan American Health Organization has supported implementation of the World Health Organization (WHO) strategy for HIVDR prevention and assessment through regional capacity-building activities and direct technical cooperation in 30 LAC countries. By 2010, 85 sites in 19 countries reported early warning indicators, providing information about the extent of potential drivers of drug resistance at the ART site. In 2009, 41.9% of sites did not achieve the WHO target of 100% appropriate first-line prescriptions; 6.3% still experienced high rates (> 20%) of loss to follow-up, and 16.2% had low retention of patients (< 70%) on first-line prescriptions in the first year of treatment. Stock-outs of antiretroviral drugs occurred at 22.7% of sites. Haiti, Guyana, and the Mesoamerican region are planning and implementing WHO HIVDR monitoring surveys or threshold surveys. New HIVDR surveillance tools for concentrated epidemics would promote further scale-up. Extending the WHO HIVDR lab network in Latin America is key to strengthening regional lab capacity to support quality assured HIVDR surveillance. The WHO HIVDR control strategy is feasible and can be rolled out in LAC. Integrating HIVDR activities in national HIV care and treatment plans is key to ensuring the sustainability of this strategy.

WORLD HEALTH ORGANIZATION GLOBAL HEALTH SECTOR STRATEGY ON SEXUALLY TRANSMITTED INFECTIONS: AN EVIDENCE-TO-ACTION SUMMARY FOR COLOMBIA.

Curable and incurable sexually transmitted infections (STI) are acquired by hundreds of millions of people worldwide each year. Undiagnosed and untreated STIs cause a range of negative health outcomes including adverse birth outcomes, infertility and other long term sequelae such as cervical cancer. In 2016, the World Health Organization (WHO) launched the Global STI Strategy (2016-2021). The WHO Global STI Strategy's public health approach focuses on three causative organisms of STIs that need immediate action and for which cost-effective interventions exist: (a) Neisseria gonorrhoeae as a cause of infertility, a risk factor for coinfection with other STIs and because of increasing bacterial resistance to antibiotic treatment, (b) Treponema pallidum given the contribution of syphilis to adverse birth outcomes including stillbirth and neonatal death and (c) Human papillomavirus due to its link to cervical cancer. The range of actions recommended for countries includes: (a) strengthening surveillance, with program monitoring and progress evaluation, (b) STI prevention, (c) early diagnosis of STIs, (d) patient and partner management, and (e) approaches to reach the most vulnerable populations. This summary describes the WHO Global STI Strategy alongside findings from a STI surveillance workshop held in Colombia in May of 2017. Observations related to the Global STI Strategy and findings from the STI estimation workshop are described here for stakeholders in Colombia to consider as they identify opportunities to improve STI services and surveillance.

En el mundo, cientos de millones de personas adquieren anualmente infecciones de transmisión sexual (ITS), algunas de ellas curables y otras incurables. Las ITS que no se diagnostican y no se tratan producen una serie de desenlaces negativos para la salud, entre los cuales se cuentan malos resultados perinatales, infertilidad y otras secuelas crónicas, además del cáncer de cuello uterino. En 2016, la Organización Mundial de la Salud (OMS) lanzó la Estrategia Mundial contras las ITS (2016­2021). El enfoque de salud pública contemplado en la Estrategia Global de la OMS se centra en tres microorganismos causantes de las ITS que requieren acciones inmediatas y para los cuales existen intervenciones costo-efectivas: (a) Neisseria gonorrhoea como causa de infertilidad y factor de riesgo para coinfección con otras ITS, y por su mayor resistencia al tratamiento con antibióticos; (b) Treponema pallidum por la contribución de la sífilis a resultados adversos al nacimiento, entre ellos muerte fetal y muerte neonatal; y (c) virus del papiloma humano debido a su relación con el cáncer de cuello uterino. Entre las acciones recomendadas para los países están las siguientes: (a) fortalecer la vigilancia, el monitoreo y la evaluación de los programas y los avances logrados; (b) prevención de las ITS; (c) diagnóstico temprano de las ITS; (d) manejo del paciente y la pareja; (e) mecanismos para llegar a las poblaciones más vulnerables. Esta síntesis de la política resume la Estrategia Mundial de la OMS contra las ITS, además de los hallazgos de un taller de vigilancia llevado a cabo en Colombia en mayo de 2017. Aquí se describen las observaciones relacionadas con la Estrategia, y los hallazgos del taller a fin de que los distintos grupos de interés en Colombia, los tomen en consideración a la hora de identificar las oportunidades de mejorar los servicios y la vigilancia en lo que atañe a las ITS.

HIV, syphilis, and viral hepatitis among Latin American indigenous peoples and Afro-descendants: a systematic review / Infección por el VIH, sífilis y hepatitis virales en las poblaciones indígenas y afrodescendientes en América Latina: una revisión sistemática / HIV, sífilis e hepatite viral em povos indígenas e afrodescendentes da América Latina: uma revisão sistemática

ABSTRACT Objective To identify and summarize existing literature on the burden of HIV, sexually transmitted infections (STIs), and viral hepatitis (VH) in indigenous peoples and Afro-descendants in Latin America to provide a broad panorama of the quantitative data available and highlight problematic data gaps. Methods Published and grey literature were systematically reviewed to identify documents published in English, Spanish, or Portuguese with data collected between January 2000 and April 2016 on HIV, STI, and VH disease burden among indigenous peoples and Afro-descendants in 17 Latin American countries. Results Sixty-two documents from 12 countries were found. HIV prevalence was generally low (< 1%) but pockets of high prevalence (> 5%) were noted in some indigenous communities in Venezuela (Warao) (9.6%), Peru (Chayahuita) (7.5%), and Colombia (Wayuu females) (7.0%). High active syphilis prevalence (> 5%) was seen in some indigenous communities in Paraguay (11.6% and 9.7%) and Peru (Chayahuita) (6.3%). High endemicity (> 8%) of hepatitis B was found in some indigenous peoples in Mexico (Huichol) (9.4%) and Venezuela (Yanomami: 14.3%; Japreira: 29.5%) and among Afro-descendant quilombola populations in Brazil (Frechal: 12.5%; Furnas do Dionísio: 8.4% in 2008, 9.2% in 2003). Conclusions The gaps in existing data on the burden of HIV, STIs, and VH in indigenous peoples and Afro-descendants in Latin America highlight the need to 1) improve national surveillance, by systematically collecting and analyzing ethnicity variables, and implementing integrated biobehavioral studies using robust methodologies and culturally sensitive strategies; 2) develop a region-wide response policy that considers the needs of indigenous peoples and Afro-descendants; and 3) implement an intercultural approach to health and service delivery to eliminate health access barriers and improve health outcomes for these populations.

RESUMEN Objetivo Identificar y resumir la bibliografía existente sobre la carga de la infección por el VIH, las infecciones de transmisión sexual (ITS) y las hepatitis virales en las poblaciones indígenas y afrodescendientes en América Latina para proporcionar un panorama amplio de los datos cuantitativos disponibles y poner de relieve las brechas problemáticas que pudiera haber en los datos. Métodos Se hizo un examen sistemático de la bibliografía publicada y la bibliografía gris para encontrar documentos publicados en inglés, español o portugués con datos recogidos entre enero del 2000 y abril del 2016 sobre la carga de la infección por el VIH, las ITS y las hepatitis virales en las poblaciones indígenas y afrodescendientes en 17 países latinoamericanos. Resultados Se encontraron 62 documentos de 12 países. La prevalencia de la infección por el VIH fue generalmente baja (< 1%), pero se observaron focos de prevalencia alta (> 5%) en algunas comunidades indígenas en Venezuela (Warao) (9,6%), Perú (Chayahuita) (7,5%) y Colombia (las mujeres Wayuus) (7,0%). Se observó prevalencia alta de sífilis activa (> 5%) en algunas comunidades indígenas en Paraguay (11,6% y 9,7%) y Perú (Chayahuita) (6,3%). Se encontró endemicidad alta (> 8%) de la hepatitis B en algunos pueblos indígenas en México (Huichol) (9,4%) y Venezuela (Yanomami: 14,3%; Japreira: 29,5%) y en las poblaciones quilombola de afrodescendientes en Brasil (Frechal: 12,5%; Furnas do Dionísio: 8,4% en el 2008, 9,2% en el 2003). Conclusiones Las brechas en los datos existentes sobre la carga de la infección por el VIH, las ITS y las hepatitis virales en las poblaciones indígenas y afrodescendientes en América Latina destacan la necesidad de: 1) mejorar la vigilancia nacional mediante la recolección y el análisis sistemáticos de las variables de etnicidad y la ejecución de estudios bioconductuales integrados que utilicen metodologías sólidas y estrategias sensibles a diferencias entre las culturas; 2) elaborar una política de respuesta de alcance regional que considere las necesidades de las poblaciones indígenas y de afrodescendientes; y 3) aplicar un enfoque intercultural de la salud y de la prestación de servicios conexos para eliminar las barreras de acceso a la salud y mejorar los resultados en materia de salud para estas poblaciones.

RESUMO Objetivo Identificar e sintetizar a literatura existente sobre a carga de HIV, infecções sexualmente transmissíveis (IST) e hepatite viral nos povos indígenas e afrodescendentes da América Latina para traçar um amplo panorama dos dados quantitativos disponíveis e destacar as lacunas problemáticas nos dados. Métodos Foi realizada uma revisão sistemática da literatura publicada e da literatura cinzenta para identificar documentos publicados em inglês, espanhol ou português com dados coletados entre janeiro de 2000 e abril de 2016 sobre a carga de HIV, IST e hepatite viral nos povos indígenas e afrodescendentes em 17 países latino-americanos. Resultados Sessenta e dois documentos de 12 países foram encontrados. A prevalência de HIV observada foi em geral baixa (<1%), com focos de alta prevalência (>5%) observados em comunidades indígenas da Venezuela (warao) (9,6%), Peru (chayahuita) (7,5%) e Colômbia (mulheres wayúu) (7,0%). Foi verificada uma alta prevalência de sífilis ativa (> 5%) em comunidades indígenas no Paraguai (11,6% e 9,7%) e Peru (chayahuita) (6,3%). A alta endemicidade (>8%) de hepatite B foi observada em povos indígenas no México (huichol) (9,4%) e Venezuela (ianomâmi 14,3%; japrería 29,5%) e em comunidades negras quilombolas no Brasil (Frechal 12,5%; Furnas do Dionísio 8,4% em 2008 e 9,2% em 2003). Conclusões As lacunas nos dados existentes sobre a carga de HIV, IST e hepatite viral nos povos indígenas e afrodescendentes na América Latina destacam a necessidade de: melhorar a vigilância nacional com coleta sistemática e análise de variáveis de etnicidade e realizar estudos integrados de análise biocomportamental com o uso de metodologias robustas e estratégias sensíveis à diversidade cultural; desenvolver uma política de resposta regional que considere as necessidades dos povos indígenas e afrodescendentes; e implementar um enfoque intercultural à saúde e prestação de serviços para derrubar as barreiras de acesso à saúde e melhorar os resultados de saúde nestas populações.

World health organization global health sector strategy on sexually transmitted infections: an evidence-to-action summary for Colombia / Estrategia global de la Organización Mundial de la Salud contra infecciones de transmisión sexual: de la evidencia a la acción. Resumen para Colombia

ABSTRACT Curable and incurable sexually transmitted infections (STI) are acquired by hundreds of millions of people worldwide each year. Undiagnosed and untreated STIs cause a range of negative health outcomes including adverse birth outcomes, infertility and other long term sequelae such as cervical cancer. In 2016, the World Health Organization (WHO) launched the Global STI Strategy (20162021). The WHO Global STI Strategy's public health approach focuses on three causative organisms of STIs that need immediate action and for which cost-effective interventions exist: (a) Neisseria gonorrhoeae as a cause of infertility, a risk factor for coinfection with other STIs and because of increasing bacterial resistance to antibiotic treatment, (b) Treponema pallidum given the contribution of syphilis to adverse birth outcomes including stillbirth and neonatal death and (c) Human papillomavirus due to its link to cervical cancer. The range of actions recommended for countries includes: (a) strengthening surveillance, with program monitoring and progress evaluation, (b) STI prevention, (c) early diagnosis of STIs, (d) patient and partner management, and (e) approaches to reach the most vulnerable populations. This summary describes the WHO Global STI Strategy alongside findings from a STI surveillance workshop held in Colombia in May of 2017. Observations related to the Global STI Strategy and findings from the STI estimation workshop are described here for stakeholders in Colombia to consider as they identify opportunities to improve STI services and surveillance.

RESUMEN En el mundo, cientos de millones de personas adquieren anualmente infecciones de transmisión sexual (ITS), algunas de ellas curables y otras incurables. Las ITS que no se diagnostican y no se tratan producen una serie de desenlaces negativos para la salud, entre los cuales se cuentan malos resultados perinatales, infertilidad y otras secuelas crónicas, además del cáncer de cuello uterino. En 2016, la Organización Mundial de la Salud (OMS) lanzó la Estrategia Mundial contras las ITS (2016-2021). El enfoque de salud pública contemplado en la Estrategia Global de la OMS se centra en tres microorganismos causantes de las ITS que requieren acciones inmediatas y para los cuales existen intervenciones costo-efectivas: (a) Neisseria gonorrhoea como causa de infertilidad y factor de riesgo para coinfección con otras ITS, y por su mayor resistencia al tratamiento con antibióticos; (b) Treponema pallidum por la contribución de la sífilis a resultados adversos al nacimiento, entre ellos muerte fetal y muerte neonatal; y (c) virus del papiloma humano debido a su relación con el cáncer de cuello uterino. Entre las acciones recomendadas para los países están las siguientes: (a) fortalecer la vigilancia, el monitoreo y la evaluación de los programas y los avances logrados; (b) prevención de las ITS; (c) diagnóstico temprano de las ITS; (d) manejo del paciente y la pareja; (e) mecanismos para llegar a las poblaciones más vulnerables. Esta síntesis de la política resume la Estrategia Mundial de la OMS contra las ITS, además de los hallazgos de un taller de vigilancia llevado a cabo en Colombia en mayo de 2017. Aquí se describen las observaciones relacionadas con la Estrategia, y los hallazgos del taller a fin de que los distintos grupos de interés en Colombia, los tomen en consideración a la hora de identificar las oportunidades de mejorar los servicios y la vigilancia en lo que atañe a las ITS.

[Diagnostic yield of the extended prostatic biopsy with 10 cores. Prospective study on 222 patients]. / Rentabilidad de la biopsia ampliada con 10 muestras prostáticas. estudio prospectivo sobre 222 pacientes.

OBJECTIVES: The number of biopsy samples for a proper prostate cancer diagnosis has not yet been established. We report our experience with the 10-sample extended biopsy. METHODS: We collected the results of a group of 222 patients undergoing extended ultrasound guided prostate biopsy with 10 samples. In addition to the sextant biopsies 2 extra samples were obtained from the dorsal-apex area on each lobe. Results of this group were compared with a control group of 552 patients undergoing sextant biopsy in 2002 with the same inclusion in criteria. RESULTS: 60 patients had cancer (27.15%). The extra samples gave the diagnosis in 5 out of 60 patients, 8.33% of the tumors and 2.25% of all patients. Control group showed cancer in 24.5%, not having the difference statistical significance. The incidence in prostates smaller than 20 cc was 69.2%, 11.6% in prostates bigger than 50 cc. 80% of the patients with prostate cancer only in the extra samples have a volume smaller than 35 cc. Multivariate logistic regression study for the probability of prostate cancer only showed association with serum PSA and prostate volume but not with the number of samples. CONCLUSIONS: The extended biopsy is not indicated as an initial diagnostic technique, being reserved for specific cases such as repeated biopsies in patients with high risk pathology reports. Neither it is indicated in the bigger volume prostates.

[Results of a series of transrectal ultrasound guided biopsy of the prostate in 6000 patients. Part I: pathology, digital rectal examination, transrectal ultrasound, and PSA]. / Resultados de una serie de 6000 pacientes con biopsia transrectal ecodirigida de próstata. Parte I: anatomía patológica, tacto rectal, ecografía transrectal y psa.

OBJECTIVES: To analyze the results of transrectal ultrasound (TRUS) guided biopsy of the prostate in 6000 patients, and their relation to common-use clinical parameters. METHODS: We collected PSA, digital rectal examination, TRUS characteristics, and pathology report in a data- base including 6000 patients who underwent sextant TRUS biopsy from 1994 to December 2002. 861 of them underwent more than one biopsy, accounting for a total of 7127 biopsies. Sextant biopsy with samples from the most lateral portions of the prostate was the standard procedure so that they included peripheral zone only. We analyze pathological results and their relation with clinical variables. RESULTS: Total percentage of cancer in biopsy samples was 42.6%, with 39.1% in the first biopsy. Overall, repeated biopsies resulted in a 3.5% diagnostic yield increase. PIN or focal glandular atypia were detected in 2.0% and 2.1% of the cases respectively. The percentage of patients with Gleason score =<6 increased from 41.8% in the first biopsy to 70% in the third. Similarly, single core involvement increased from 21.% to 65%. Digital rectal examination and presence of hypoechogenic nodules specificity were 82.6 and 78.2% respectively. The incidence of prostate cancer with PSA between 4 and 10 ng/ml was 29.6%, 16.7% in those with PSA lower than 4 ng/ml. CONCLUSIONS: TRUS biopsy of the lateral prostatic areas offers a good diagnostic yield in comparison with most series of extensive biopsies. The sensitivity of TRUS has decreased but it maintains a high specificity which should not be forgotten when planning the TRUS strategy

[Tolerability and complications of the ultrasound guided transrectal biopsy of the prostate extended to 10 cores. The role of neurovascular bundle blockage with lidocaine]. / Tolerancia y complicaciones de la biopsia transrectal ecodirigida prostática ampliada a diez cilindros. papel del bloqueo de haces neurovasculares con lidocaína.

OBJECTIVES: The growing interest on increasing the number of biopsy samples during ultrasound guided prostatic biopsies moved us to evaluate the tolerability and complications of the extensive biopsy with/without blockage of neurovascular bundles. METHODS: A group of 222 patients underwent prostatic biopsy with the aim to obtain 10 cores on each. After evaluation of the first 50 cases performed without anesthesia, decision was taken to proceed with neurovascular blockage with 2% lidocaine, comparatively evaluating both groups for results on tolerability, complications and global adverse events. RESULTS: The aimed number of cores could not be completed in 16% of the patients without anesthesia in comparison with 2.33% with anesthesia (p < 0.002); the biopsy was qualified as painful or very painful by 10.9% and 1.9% respectively (p < 0.0002). The results of the visual analogical scale for pain were 2.46 +/- 1.67 and 4.5 +/- 2.11 for the anesthesia/without anesthesia groups respectively, with mild-moderate vagal reactions in 28% of these latter in comparison with 7.7% in patients receiving lidocaine. Rectal bleeding was the most worrying complication, being moderate-severe in 4.7% of the patients, with 2% hospital admission. CONCLUSIONS: The increase in the number of ultrasound guided prostatic biopsy samples may be associated with a higher frequency of complications, mainly bleeding, and requires the application of local anesthesia due to worse tolerance. Neurovascular bundle blockage with lidocaine is very effective to diminish biopsy associated pain.

[The role of prostate volume in ultrasound guided transrectal prostate biopsy: is it as important as a marker as PSA?]. / Papel del volumen prostático en la biopsia transrectal ecodirigida de próstata: es un marcador tan importante como el psa?

OBJECTIVES: The limitations of PSA to identify patients with prostate cancer prompted the definition of different parameters trying to increase specificity without reducing sensitivity. This paper studies the relationship of volume and presence of prostate cancer in sextant biopsies. METHODS: We collected the results of prostate biopsies performed to 6000 patients between 1994 and 2002. 861 of them underwent more than one biopsy, adding up for a total of 7127 biopsies. Various predictive models to identify factors related to positive biopsy were constructed. RESULTS: Mean prostate volume is 14.6 +/- 66.2 cc for the first biopsy, increasing in successive biopsies to 85.17 cc. A high incidence of prostate cancer was observed in small prostates, reaching 67.2% of those with normal size (< 20 cc) and diminishing with the increase of volume down to only 19.7% in those larger than 50 cc (p < 0.0001). In second biopsies of patients with PSA between 4 and 10 ng/ml and gland volume higher than 50 cc percentage of biopsies positive for cancer was below 10%. Multivariant logistic regression showed that PSA, volume and PSA density were related with positive biopsies, but not free/total PSA ratio. CONCLUSIONS: Standard PSA cutoffs are not adequate for a proper diagnosis of prostate cancer by ultrasound guided transrectal biopsy Volume (BPH) has a significant influence in PSA values and results of the biopsy, so that it should be taken into consideration when indicating biopsies.

[Results of a series of transrectal ultrasound guided biopsy of the prostate in 6000 patients. Part II: PSA derived parameters]. / Resultados de una serie de 6000 pacientes con biopsia transrectal ecodirigida de prostata. Parte II: parámetros derivados del PSA.

OBJECTIVES: We review the results of 6000 patients with the clinical suspect of prostate cancer who underwent one or more prostate, biopsies, analyzing the role of PSA derived parameters in the probability of having prostate cancer in the TRUS biopsy. METHODS: We selected 6000 patients who under- went TRUS biopsy between 1994 and 2002. 861 of them underwent more than one is biopsy, adding up to a total of 7127 biopsies. For the study of PSA derived indexes we established ranges based on the 10th percentile for the first biopsy for all patients and also for those with PSA between 4 and 10 ng/ml. Several predictive models were determined by logistic regression of the variables related with presence/no presence of cancer. RESULTS: For first biopsies the ranges of PSAD established showed a diagnostic effectiveness below 8% with PSA densities lower than 0.11 ng/ml/cc. The free/total PSA ratio is less discriminant in the ranges obtained with a 13.7% incidence of prostate cancer for values above 0.24. In the case of second biopsies the group of patients with PSAD below 0.12 had only a 5.3% incidence, and only one patient with F/T PSA ratio higher than 0.24 had a prostate cancer (2.9%). All studied parameters but F/T PSA ratio showed statistical significance in the multivariant analysis. CONCLUSIONS: Although the establishment of a cut point for PSAD diminishes sensitivity, prostate biopsy habits should be modified assuming the loss of tumors in patients with low PSAD and increasing the number of biopsies in patients with total PSA values below 4 ng/ml with higher densities.