Contextualizing and optimizing novel strategies to improve the latent TB continuum of care: Insights from people living with HIV and health care providers in Brazil.

Tuberculosis (TB) causes 1 in 3 deaths among people living with HIV (PLHIV). Diagnosing and treating latent tuberculosis infection (LTBI) is critical to reducing TB incidence and mortality. Blood-based screening tests (e.g., QuantiFERON-TB Gold Plus (QFT+)) and shorter-course TB preventive therapy (TPT) regimens such as 3HP (3 months weekly isoniazid-rifapentine) hold significant promise to improve TB outcomes. We qualitatively explored barriers and solutions to optimizing QFT+ and 3HP among PLHIV in three cities in Brazil. We conducted 110 in-depth interviews with PLHIV, health care providers (HCP) and key informants (KI). Content analysis was conducted including the use of case summaries and comparison of themes across populations and contexts. LTBI screening and treatment practices were dependent on HCP's perceptions of whether they were critical to improving TB outcomes. Many HCP lacked a strong understanding of LTBI and perceived the current TPT regimen as complicated. HCP reported that LTBI screening and treatment were constrained by clinic staffing challenges. While PLHIV generally expressed willingness to consider any test or treatment that doctors recommended, they indicated HCP rarely discussed LTBI and TPT. TB testing and treatment requests were constrained by structural factors including financial and food insecurity, difficulties leaving work for appointments, stigma and family responsibilities. QFT+ and 3HP were viewed by all participants as tools that could significantly improve the LTBI cascade by avoiding complexities of TB skin tests and longer LTBI treatment courses. QFT+ and 3HP were perceived to have challenges, including the potential to increase workload on over-burdened health systems if not implemented alongside improved supply chains, staffing, and training, and follow-up initiatives. Multi-level interventions that increase understanding of the importance of LTBI and TPT among HCP, improve patient-provider communication, and streamline clinic-level operations related to QFT+ and 3HP are needed to optimize their impact among PLHIV and reduce TB mortality.

Same-day initiation of oral pre-exposure prophylaxis among gay, bisexual, and other cisgender men who have sex with men and transgender women in Brazil, Mexico, and Peru (ImPrEP): a prospective, single-arm, open-label, multicentre implementation study.

BACKGROUND: Although gay, bisexual, and other cisgender men who have sex with men (MSM) and transgender women have the highest HIV burden in Latin America, pre-exposure prophylaxis (PrEP) implementation is poor. We aimed to assess the feasibility of same-day oral PrEP delivery in Brazil, Mexico, and Peru. METHODS: Implementation PrEP (ImPrEP) was a prospective, single-arm, open-label, multicentre PrEP implementation study conducted in Brazil (14 sites), Mexico (four sites), and Peru (ten sites). MSM and transgender women were eligible to participate if they were aged 18 years or older, HIV-negative, and reported one or more prespecified criteria. Enrolled participants received same-day initiation of daily oral PrEP (tenofovir disoproxil fumarate [300 mg] coformulated with emtricitabine [200 mg]). Follow-up visits were scheduled at week 4 and quarterly thereafter. We used logistic regression models to identify factors associated with early loss to follow-up (not returning after enrolment), PrEP adherence (medication possession ratio ≥0·6), and long-term PrEP engagement (attending three or more visits within 52 weeks). This study is registered at the Brazilian Registry of Clinical Trials, U1111-1217-6021. FINDINGS: From Feb 6, 2018, to June 30, 2021, 9979 participants were screened and 9509 were enrolled (Brazil n=3928, Mexico n=3288, and Peru n=2293). 543 (5·7%) participants were transgender women, 8966 (94·3%) were cisgender men, and 2481 (26·1%) were aged 18-24 years. There were 12 185·25 person-years of follow-up. 795 (8·4%) of 9509 participants had early loss to follow-up, 6477 (68·1%) of 9509 were adherent to PrEP, and 5783 (70·3%) of 8225 had long-term PrEP engagement. Transgender women (adjusted odds ratio 1·60, 95% CI 1·20-2·14), participants aged 18-24 years (1·80, 1·49-2·18), and participants with primary education (2·18, 1·29-3·68) had increased odds of early loss to follow-up. Transgender women (0·56, 0·46-0·70), participants aged 18-24 years (0·52, 0·46-0·58), and those with primary education (0·60, 0·40-0·91) had lower odds of PrEP adherence. Transgender women (0·56, 0·45-0·71), participants aged 18-24 years (0·56, 0·49-0·64), and those with secondary education (0·74, 0·68-0·86) had lower odds of long-term PrEP engagement. HIV incidence was 0·85 per 100 person-years (95% CI 0·70-1·03) and was higher for transgender women, participants from Peru, those aged 18-24 years, Black and mixed-race participants, and participants who were non-adherent to PrEP. INTERPRETATION: Same-day oral PrEP is feasible for MSM and transgender women in Latin America. Social and structural determinants of HIV vulnerability need to be addressed to fully achieve the benefits of PrEP. FUNDING: Unitaid, WHO, and Ministries of Health in Brazil, Mexico, and Peru. TRANSLATIONS: For the Portuguese and Spanish translations of the abstract see Supplementary Materials section.

Danger in the streets: exposures to bloodborne pathogens after community sharp injuries in Rio de Janeiro, Brazil

ABSTRACT Objective: Exposures to sharps injuries occurring in the community are relatively frequent. We describe characteristics of community sharp exposures reported in the city of Rio de Janeiro from 1997 to 2010. Methods: A cross-sectional analysis of exposure reports to sharps in the community reported to a surveillance system, designed for health care workers, of the Municipal Health Department of Rio de Janeiro. The characteristics of exposed individuals analyzed included types of exposure, the circumstances of the accident, and the prophylaxis offered. Results: 582 exposures were studied. Median age was 30 years and 83 (14%) involved children with less than 10 years of age. Two hundred and seventeen (37%) occurred with sharps found in the streets. The exposure was percutaneous in 515 (89%) and needles where involved in 406 (70%) of them. The sharps were present in the trash in 227 (39%) or in the environment in 167 (29%) of the reports. Professionals who work with frequent contact with domestic or urban waste were 196 (38%). The source was known in 112 (19%) of the exposures and blood was involved in 269 (46%). Only 101 (19%) of the injured subjects reported a complete course of vaccination for hepatitis B. Antiretroviral prophylaxis was prescribed for 392 (68%) of the exposed subjects. Conclusions: Sharps injuries occurring in the community are an important health problem. A great proportion would be avoided if practices on how to dispose needles and sharps used outside health units were implemented.

Danger in the streets: exposures to bloodborne pathogens after community sharp injuries in Rio de Janeiro, Brazil.

OBJECTIVE: Exposures to sharps injuries occurring in the community are relatively frequent. We describe characteristics of community sharp exposures reported in the city of Rio de Janeiro from 1997 to 2010. METHODS: A cross-sectional analysis of exposure reports to sharps in the community reported to a surveillance system, designed for health care workers, of the Municipal Health Department of Rio de Janeiro. The characteristics of exposed individuals analyzed included types of exposure, the circumstances of the accident, and the prophylaxis offered. RESULTS: 582 exposures were studied. Median age was 30 years and 83 (14%) involved children with less than 10 years of age. Two hundred and seventeen (37%) occurred with sharps found in the streets. The exposure was percutaneous in 515 (89%) and needles where involved in 406 (70%) of them. The sharps were present in the trash in 227 (39%) or in the environment in 167 (29%) of the reports. Professionals who work with frequent contact with domestic or urban waste were 196 (38%). The source was known in 112 (19%) of the exposures and blood was involved in 269 (46%). Only 101 (19%) of the injured subjects reported a complete course of vaccination for hepatitis B. Antiretroviral prophylaxis was prescribed for 392 (68%) of the exposed subjects. CONCLUSIONS: Sharps injuries occurring in the community are an important health problem. A great proportion would be avoided if practices on how to dispose needles and sharps used outside health units were implemented.

[Treatment of syphilis during pregnancy: knowledge, practices and attitudes of health care professionals involved in antenatal care of the Unified Health System (SUS) in Rio de Janeiro City]. / Manejo da sífilis na gestação: conhecimentos, práticas e atitudes dos profissionais pré-natalistas da rede SUS do município do Rio de Janeiro.

This article seeks to evaluate knowledge, practices and attitudes of health care workers (HCW) involved in antenatal care in the Unified Health System (SUS) in Rio de Janeiro City (RJC) and to identify major barriers to the implementation of treatment for syphilis in pregnancy care protocols. A cross-sectional study was conducted with 102 HCW in antenatal care at SUS, corresponding to 70% of the eligible pool. Univariate and bivariate analysis were performed using SPSS version 16.0. A number of barriers were identified with respect to knowledge of and familiarity with the current protocols, difficulties related to DST management, relationship with patients and clinics organizational context, which were distinct according to the type of health unit. HCW who had greater access to training and technical manuals had a better performance, although the overall effect was discrete. Identifying barriers to adherence to health care protocols is essential to formulate intervention strategies. Access to protocols through training and technical manuals showed a discrete effect in the improvement of the care delivered to patients, pointing to the need of innovative ongoing education of HCW.

Manejo da sífilis na gestação: conhecimentos, práticas e atitudes dos profissionais pré-natalistas da rede SUS do município do Rio de Janeiro / Treatment of syphilis during pregnancy: knowledge, practices and attitudes of health care professionals involved in antenatal care of the Unified Health System (SUS) in Rio de Janeiro City

Este artigo objetiva avaliar os conhecimentos, as práticas e as atitudes dos profissionais pré-natalistas da rede de serviços públicos de saúde (SUS) do município do Rio de Janeiro (MRJ) e identificar as principais barreiras para a implantação dos protocolos assistenciais de manejo da sífilis na gestação. Estudo transversal com 102 profissionais pré-natalistas da rede SUS do MRJ, correspondendo a uma taxa de resposta de 70% dentre os elegíveis. Foi realizada análise uni e bivariada com utilização do software SPSS 16.0. Foram verificadas diversas barreiras relacionadas ao conhecimento e à familiaridade com os protocolos assistenciais, dificuldades na abordagem das DST, questões dos usuários e contexto organizacional, que apresentaram distribuição distinta segundo tipo de serviço de saúde. Profissionais com mais acesso a treinamentos e manuais técnicos apresentaram melhor desempenho, sendo esses efeitos discretos. A identificação de barreiras para a adoção de protocolos assistenciais é fundamental para a formulação de estratégias de intervenção. O acesso ao conteúdo dos protocolos por treinamentos e manuais técnicos mostraram efeito discreto na melhoria das condutas assistenciais, sendo necessárias outras abordagens de educação continuada dos profissionais.

This article seeks to evaluate knowledge, practices and attitudes of health care workers (HCW) involved in antenatal care in the Unified Health System (SUS) in Rio de Janeiro City (RJC) and to identify major barriers to the implementation of treatment for syphilis in pregnancy care protocols. A cross-sectional study was conducted with 102 HCW in antenatal care at SUS, corresponding to 70% of the eligible pool. Univariate and bivariate analysis were performed using SPSS version 16.0. A number of barriers were identified with respect to knowledge of and familiarity with the current protocols, difficulties related to DST management, relationship with patients and clinics organizational context, which were distinct according to the type of health unit. HCW who had greater access to training and technical manuals had a better performance, although the overall effect was discrete. Identifying barriers to adherence to health care protocols is essential to formulate intervention strategies. Access to protocols through training and technical manuals showed a discrete effect in the improvement of the care delivered to patients, pointing to the need of innovative ongoing education of HCW.

Estimating the extent of underreporting of mortality among HIV-infected individuals in Rio de Janeiro, Brazil.

Non-HIV-related causes of death have been increasing after the introduction of highly active antiretroviral therapy. Underlying and contributing causes of death were assessed in respect to the presence/absence of HIV/AIDS among HIV-infected/AIDS patients in Rio de Janeiro, Brazil. Demographic variables (age, gender, ethnicity, and schooling) and CD4 cell counts closest to death were assessed through logistic regression models comparing those who did not have with those who had HIV/AIDS mentioned on the death certificate. The linkage with the two cohorts identified 1249 records, of which 370 (29.6%) did not have HIV/AIDS listed on any field of the death certificate [77 (20.8%) attributed to undefined and 72 (19.5%) to external causes]. After excluding external causes, 25.3% still did not have HIV/AIDS listed on the death certificate. Multiple logistic regression analysis showed that age >40 years (OR = 2.09; 95%CI = 1.49-2.93; p < 0.001) and CD4 cell count closest to the date of death (OR = 1.15; 95% CI = 1.07-1.23; p < 0.001 for 100 cell increase) were associated with an increased probability of not having HIV/AIDS mentioned on the death certificate, when external causes were excluded. Mortality among HIV-infected individuals is underreported in the Rio de Janeiro Mortality Registry, particularly among older individuals and those with higher CD4 counts. Physicians should be aware of the changing patterns of mortality among HIV individuals, and public health officials should regularly perform linkages between all-cause mortality and available HIV-infected patients databases, such as AIDS registries and large cohort studies.

Vigilância da sífilis na gravidez / Surveillance of syphilis in pregnancy

A sífilis congênita persiste como grave problema de Saúde Pública. Este artigo tem por objetivo apresentar os dados da vigilância da sífilis na gravidez, realizada pela Secretaria Municipal de Saúde do Rio de Janeiro no período de 1999 a 2004. Realizou-se um estudo descritivo, com análise dos dados dos relatórios trimestrais enviados pelas unidades municipais de saúde, mediado pelo programa Epi Info 6.04 d [Centers for Disease Control and Prevention, dos Estados Unidos da América (CDC/EUA). Seus resultados foram: cobertura de testagem das gestantes superior a 70 por cento; idade gestacional média de 19 semanas, no momento da testagem; baixa proporção de gestantes e parceiros tratados durante a gestação; e redução da incidência de sífilis na gravidez e de sífilis congênita. Ainda se mantiveram, entretanto, taxas elevadas para esses agravos. Esses resultados demonstram a importância da vigilância da sífilis na gravidez para a eliminação da sífilis congênita. Somente a qualificação das ações realizadas durante a assistência pré-natal permitirá a redução da transmissão vertical dessa doença...

Congenital syphilis (CS) is still ongoing as a huge public health matter. This paper describes the surveillance of syphilis in pregnancy by the Municipal Health Secretariat of Rio de Janeiro, from 1999 to 2004. The analysis was done based upon the quarterly reports sent by the municipal health units, using Epi Info 6.04 d [Centers for Disease Control and Prevention, of The United States of America (CDC/USA)]. Their results were: more than 70% of pregnant women were subjected to VDRL testing; mean gestational age at testing of 19 weeks; low proportion of partners treated during pregnancy; and reduction on both syphilis in pregnancy and incidence of congenital syphilis, although high level rates of these diseases still persist. The results also point out the relevance of surveillance strategy for syphilis in pregnancy, regarding the goal of congenital syphilis elimination. Only a better antenatal care, achieved by means of training health care providers, will allow the reduction of vertical transmission of syphilis.

Tuberculose como doença definidora de síndrome da imunodeficiência adquirida: dez anos de evolução na Cidade do Rio de Janeiro / Tuberculosis as a disease defining acquired immunodeficiency syndrome: ten years of surveillance in Rio de Janeiro, Brazil

OBJETIVO: Analisar a freqüência da tuberculose e das outras principais doenças oportunistas definidoras de síndrome da imunodeficiência adquirida, no momento em que estes casos são notificados, no Município do Rio de Janeiro. MÉTODOS: Análise do banco de dados do Sistema de Vigilância Epidemiológica do Programa de Doenças Sexualmente Transmissíveis e Síndrome da Imunodeficiência Adquirida da Cidade do Rio de Janeiro, no período de 1993 a 2002. RESULTADOS: A expansão da definição de casos de síndrome da imunodeficiência adquirida ocorrida em 1998 criou um aumento substancial no número de casos notificados de síndrome da imunodeficiência adquirida, principalmente por aqueles que passaram a ser definidos pelo critério imunológico. Dentre os casos de síndrome da imunodeficiência adquirida que foram definidos apenas por doença, a candidíase em suas diversas formas manteve-se como a doença oportunista de maior freqüência no momento da notificação. Embora a pneumonia por Pneumocystis carinii se apresentasse como a segunda doença mais freqüente na maioria dos anos observados, a partir de 2001, a tuberculose ultrapassou-a em freqüência, tornando-se a segunda doença mais freqüente no momento da notificação dos casos de síndrome da imunodeficiência adquirida. CONCLUSÃO: Apesar da diminuição do número de casos de síndrome da imunodeficiência adquirida definidos por doença, a tuberculose manteve-se como um importante evento definidor dessa síndrome, sendo atualmente de ocorrência mais freqüente do que a pneumonia por Pneumocystis carinii e a toxoplasmose, provavelmente por sua alta taxa de prevalência na cidade.

OBJECTIVE: To analyze the frequency of tuberculosis and of the other principal opportunistic infections defining acquired immunodeficiency syndrome at the time such cases were reported in the city of Rio de Janeiro, Brazil. METHODS: Analysis of the data compiled in the Rio de Janeiro Municipal Program for the Surveillance of Sexually Transmitted Diseases and Acquired Immunodeficiency Syndrome database from 1993 to 2002. RESULTS: The expanded definition of a case of acquired immunodeficiency syndrome, implemented in 1998, resulted in a substantial increase in the number of reported cases of acquired immunodeficiency syndrome, especially of those defined by immunologic criteria. Among the cases of acquired immunodeficiency syndrome defined only by disease, esophageal candidiasis, in its various forms, remained the most common opportunistic infection present at the time the cases of acquired immunodeficiency syndrome were reported. Although Pneumocystis carinii pneumonia was the second leading opportunistic infection in most of the years evaluated, it was surpassed by tuberculosis in 2001. CONCLUSION: Despite the decreased numbers of cases of acquired immunodeficiency syndrome defined by disease, tuberculosis remains a significant acquired immunodeficiency syndrome-defining event, currently more common than P. carinii pneumonia and toxoplasmosis. This is probably due to the high rate of tuberculosis prevalence in the city.

Tuberculosis as a disease defining acquired immunodeficiency syndrome: ten years of surveillance in Rio de Janeiro, Brazil.

OBJECTIVE: To analyze the frequency of tuberculosis and of the other principal opportunistic infections defining acquired immunodeficiency syndrome at the time such cases were reported in the city of Rio de Janeiro, Brazil. METHODS: Analysis of the data compiled in the Rio de Janeiro Municipal Program for the Surveillance of Sexually Transmitted Diseases and Acquired Immunodeficiency Syndrome database from 1993 to 2002. RESULTS: The expanded definition of a case of acquired immunodeficiency syndrome, implemented in 1998, resulted in a substantial increase in the number of reported cases of acquired immunodeficiency syndrome, especially of those defined by immunologic criteria. Among the cases of acquired immunodeficiency syndrome defined only by disease, esophageal candidiasis, in its various forms, remained the most common opportunistic infection present at the time the cases of acquired immunodeficiency syndrome were reported. Although Pneumocystis carinii pneumonia was the second leading opportunistic infection in most of the years evaluated, it was surpassed by tuberculosis in 2001. CONCLUSION: Despite the decreased numbers of cases of acquired immunodeficiency syndrome defined by disease, tuberculosis remains a significant acquired immunodeficiency syndrome-defining event, currently more common than P. carinii pneumonia and toxoplasmosis. This is probably due to the high rate of tuberculosis prevalence in the city.

Trends and characteristics of AIDS mortality in the Rio de Janeiro city after the introduction of highly active antiretroviral therapy.

We examined the characteristics of AIDS mortality in Rio de Janeiro city from 1995 to 2003. During this period, highly active antiretroviral therapy with protease inhibitors was made available, and it changed the pattern of the epidemics. There was a 47.5% reduction in the number of AIDS deaths within the period, with an increase in the proportion of women among the deceased; their schooling was lower than that of the men, similar to the trends of the national-level epidemics. The main place of death changed from university hospitals to emergency rooms. The proportion of cases reported to the National Diseases Surveillance System (SINAN) reported only through the death certificate remained high. Although there is free distribution of antiretrovirals by the public health system, many patients still lack access to diagnosis and treatment. We need to give priority to access to anti-HIV testing and treatment, to increase the quality of care and to look into the issue of adherence in order to further reduce AIDS mortality.

Trends and characteristics of AIDS mortality in the Rio de Janeiro city after the introduction of highly active antiretroviral therapy

We examined the characteristics of AIDS mortality in Rio de Janeiro city from 1995 to 2003. During this period, highly active antiretroviral therapy with protease inhibitors was made available, and it changed the pattern of the epidemics. There was a 47.5 percent reduction in the number of AIDS deaths within the period, with an increase in the proportion of women among the deceased; their schooling was lower than that of the men, similar to the trends of the national-level epidemics. The main place of death changed from university hospitals to emergency rooms. The proportion of cases reported to the National Diseases Surveillance System (SINAN) reported only through the death certificate remained high. Although there is free distribution of antiretrovirals by the public health system, many patients still lack access to diagnosis and treatment. We need to give priority to access to anti-HIV testing and treatment, to increase the quality of care and to look into the issue of adherence in order to further reduce AIDS mortality.

Situação epidemiológica da tuberculose no munícipio do Rio de Janeiro: Revisão dos casos notificados de 1995 a 2000 / Epidemiology of tuberculosis in Rio de Janeiro city: Cases from 1995 to 2000

Introdução: a rede municipal de saúde do Rio de Janeiro vem sendo reorganizada e ampliada para fazer frente à demanda de controle da tuberculose que continua representando endemia importante entre nós. Os autores apresentam os dados epidemiológicos, demográficos e clínicos, assim como informações sobre as ações do Programa de Controle de Tuberculose do Município do Rio de Janeiro com a finalidade de descrever o perfil desta doença em nossa cidade. Material e métodos: estudo de prevalência sobre tuberculose no período compreendido entre 1995 e 2000. Resultados: a incidência de tuberculose em 2000 foi de 112/ 100.000 habitantes (o dobro da média nacional) e vem se mantendo neste patamar desde 1994. Os casos de retratamento representaram , em média, 20% do total de casos notificados no período de entre 1995 e 2000. Apesar de encontrar-se em ligeiro declínio desde 1997, a taxa média de abandono do tratamento continuou elevada em 1999 (15%). Conclusão: diante deste quadro epidemiológico, faz-se necessária a implantação e implementação de novas estratégias que contribuam para a melhoria do Programa de Tuberculose da Cidade.

Epidemiologia da Tuberculose no Município do Rio de Janeiro / - Revisão dos casos notificados de 1995 a 1997

Os autores apresentam dados epidemiológicos, demográficos e clínicos dos casos de tuberculose (TB) notificados à Gerência de Pneumologia Sanitária da Secretaria Municipal de Saúde do Rio de Janeiro (SMS - RJ) no período de 1995 à 1997. As informações obtidas a partir das notificações de casos e óbitos de tuberculose são descritas neste artigo com a finalidade de apresentar o perfil da doença no município do Rio de Janeiro. Tal conhecimento permitirá a identificação das necessidades e a definição de prioridades para o planejamento de ações de combate à TB