Strategies to increase HIV testing among men who have sex with men and transgender women: an integrative review.

BACKGROUND: Men who have sex with men (MSM) and transgender women (TGW) are disproportionately affected by HIV, with much higher incidence and prevalence rates than in the general population in different countries. There are several barriers to testing among MSM and TGW, such as low risk perception, anticipation of HIV-related stigma, discrimination of sexual orientation, in addition to difficulties related to care and access to health services. Therefore, analyzing the available evidence of the effectiveness of strategies for scaling up HIV testing among key populations is essential to point out potential knowledge gaps which may need to be addressed and develop public health policies to promote testing and early diagnosis of HIV infection. METHODS: An integrative review was carried out to evaluate strategies for scaling up HIV testing in these populations. Search strategy was performed on eight electronic databases, without language restriction. We included clinical trials, quasi-experimental studies, and non-randomized studies. Study selection and data extraction were both performed independently by pairs and disagreements were solved by a third revisor. The screening of the studies was carried out through the selection of titles/abstracts and the reading of the full texts of the pre-selected studies based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Data extraction was performed using a structured form. RESULTS: Thirty-seven publications referring to 35 studies were included, mostly being carried out in the United States of America and Australia. No studies were found evaluating disaggregated data on TGW. The studies were grouped into four types of intervention strategies: self-test distribution system (n = 10), organization of health services (n = 9), peer education (n = 6), and social marketing campaign (n = 10). Strategies that focused on the first three groups, combined or not, were more effective in increasing HIV testing among MSM. CONCLUSIONS: Considering the diversity of interventions and the methodological heterogeneity of the included studies, strategies especially involving self-test distribution systems, associated with new information and communication technologies, should be evaluated in different communities and social contexts. Research evaluating specific studies on TGW population is still needed.

Perceived Risk of HIV Infection and Acceptability of PrEP among Men Who Have Sex with Men in Brazil.

The HIV epidemic affects men who have sex with men (MSM) disproportionally in Brazil, and pre-exposure prophylaxis (PrEP) is effective for preventing HIV in this population. However, low perceived risk of HIV may influence the acceptability and decision to use PrEP. This study estimated the association between self-perception of HIV risk and acceptability of daily oral PrEP among Brazilian MSM. Respondent-driven sampling (RDS) was used for behavioral and biological surveillance to recruit 4,176 MSM 18 years or over in 12 Brazilian cities in 2016. Results were weighted using Gile's estimator in RDS Analyst software. Adjusted odds rations (OR) with 95% confidence intervals were calculated using multivariate logistic regression. Acceptability of daily oral PrEP was high (69.7%) among the 3,544 MSM available for analysis. Most participants self-reported low or moderate risk of HIV infection (67.2%) and a small proportion (9.3%) reported high risk. A dose-response relationship was observed between acceptability of PrEP and self-reported risk: PrEP acceptability was 1.88 times higher (OR 1.8; 95% CI: 1.24-2.85) among MSM whose perceived risk of HIV infection was low or moderate, and 5 times higher (OR 5.68; 95% CI: 2.54-12.73) among those who self-reported high risk compared to MSM reporting no HIV risk. MSM with the highest risk perception of HIV reported higher rates of PrEP acceptability. Given the availability of daily oral PrEP in the public health care system in Brazil, we suggest emphasizing counseling about self-perception of HIV risk as part of routine HIV prevention services.

High Rates of Unprotected Receptive Anal Intercourse and Their Correlates Among Young and Older MSM in Brazil.

The aim of this study was to estimate the prevalence and factors associated with unprotected receptive anal intercourse (URAI), stratified by age (18-24 or 25 + years old), in a sample of 4,129 MSM recruited by respondent driven sampling in 12 Brazilian cities in 2016. The prevalence of URAI was higher among younger MSM (41.9% vs 29.7%) (p < 0.01). Multivariate analysis indicated that perception of risk, sexual identity, self-rated health status, and having commercial sex were associated with URAI among younger MSM. History of sexual violence, sex with younger partners, having 6 + partners and unprotected sexual debut were associated with URAI among older MSM. Marital status, having stable partner, and reporting sex with men only were associated with URAI in both groups. Despite access to condoms and lubricants, preventive efforts may not be reaching MSM effectively. Age specific intervention approaches, including stigma, discrimination, and perception of risk must be considered.

Acceptability of HIV self-testing is low among men who have sex with men who have not tested for HIV: a study with respondent-driven sampling in Brazil.

BACKGROUND: Brazil has many people living with HIV (PLWH) who are unaware of their serostatus. The public health system has recently added HIV self-testing (HIVST) for key populations such as men who have sex with men (MSM). This study estimates HIVST acceptability among Brazilian MSM and explores factors associated with acceptability among MSM who have never tested for HIV or who had a previous negative result. METHODS: Respondent-driven sampling (RDS) was used to recruit 4176 MSM in 12 Brazilian cities in 2016 to this biological and behavioral surveillance study. We excluded from this analysis all MSM who were aware of their positive HIV serostatus. Descriptive, bivariate and multivariate analyses were conducted. Overall proportions were weighted with Gile's estimator in RDS Analyst software and 95% confidence intervals were calculated. The analyses of HIVST acceptability were stratified by prior HIV testing (never or one or more times). RESULTS: For this analysis, 3605 MSM were included. The acceptability of HIVST was 49.1%, lower among those who had never tested for HIV (42.7%) compared to those who had a previous HIV negative test (50.1%). In the subgroup of MSM who had never tested for HIV, those who reported discrimination or who had a medical appointment in the last 12 months reported higher HIVST acceptability. Among MSM who had a previous negative HIV test, only those reporting condomless receptive anal sex reported higher HIVST acceptability. In addition, we observed that high levels of knowledge of HIV/AIDS, taking part in lesbian, gay, bisexual, and transgender nongovernmental organizations (LGBT-NGO), or complete secondary or incomplete higher undergraduate education reported higher acceptability. CONCLUSIONS: The acceptability of HIVST was low among MSM, especially among those who never tested for HIV. Given access to HIVST in Brazil, we point to the need for programs that enhance promotion of testing addressed to MSM.

Sex work stigma and non-disclosure to health care providers: data from a large RDS study among FSW in Brazil.

BACKGROUND: Stigma in health services may be detrimental to health seeking attitudes and practices. This study investigates non-disclosure of sex work to health care providers among female sex workers (FSW) in Brazil and its association with the utilization of health care services. METHODS: This study used cross-sectional respondent-driven sampling, carried out in 12 Brazilian cities to identify HIV risk behaviors among FSW. We first assessed statistical associations of sociodemographic, human right violations, health service access and utilization, and discrimination variables with non-disclosure of FSW status to health care providers as outcome. Secondly, we investigated the association of non-disclosure of FSW status with selected preventive health care outcomes: HIV testing, PAP smear exam, and post-exposure prophylaxis (PEP). Adjusted odds ratio with 95% confidence intervals were calculated by multivariable logistic regressions. RESULTS: Among 4245 recruited FSW, a high percentage received free condoms (82%) but only 24.4% were counseled on STI. Most FSW used non-specialized public healthcare routinely (62.6%), but only 51.5% had a Pap smear exam in the last two years and less than 40% were tested for HIV in the last 12 months. Among FSW who engaged in risky behavior (49.6%), only 8.3% used PEP. Regarding human rights violations, approximately 15% were required to give part of their earnings to owners of workplace establishments, 38% started sex work under 18 years old and 6% were required to periodically present their HIV test results. 21.3% reported having faced discrimination in health services, and 24.3% always disclosed their FSW status. Multivariable logistic models indicated significant associations of non-disclosure on the four healthcare outcomes, with lower odds of using preventive health services among women who did not disclose their sex work status, even after controlling for age, educational level, NGO affiliation, and type of health care routinely used. CONCLUSIONS: Our results indicate that sex work stigmatization within health services may be one of the main barriers to STI control and HIV response among FSW. It is essential to combat stigmatization and discrimination against FSW in health services to guarantee the appropriate uptake of preventive services available in the public health system in Brazil.

Risk factors for human Mycobacterium bovis infections in an urban area of Brazil.

BACKGROUND: The World Health Organization (WHO) has classified human zoonotic tuberculosis (TB) due to Mycobacterium bovis as a neglected issue in the developing world. In a recent cross-sectional study in Brazil, three of 189 TB patients presented with a coinfection of M. bovis and M. tuberculosis and were selected as cases for this study. OBJECTIVE: The aim was to evaluate risk factors (RF) for zoonotic TB in an urban area of Brazil in order to guide preventive programmes. METHODS: A matched case-control study was carried out nested within a cross-sectional study. For each of the three cases, 14 age- and sex-matched controls (TB due to M. tuberculosis) were selected. FINDINGS: Zoonotic potential exposures (ZE) and extrapulmonary TB (EPTB) were independently associated with zoonotic TB in multivariate analyses. CONCLUSIONS: ZE by occupation and consumption of raw milk and derivative products that place individuals in direct and indirect contact with animals and their excretions/secretions increase the risk for zoonotic TB in Brazil, especially among those with EPTB. Therefore, measures such as efficient control of bovine TB, distribution of pasteurised milk and its derivative products, and the diagnosis and monitoring of zoonotic TB in humans are essential steps, especially in developing countries where bovine TB is enzootic, and further studies are necessary.

[Depression in former slave communities in Brazil: screening and associated factors]. / Depressão em comunidades quilombolas no Brasil: triagem e fatores associados.

OBJECTIVE: To assess the prevalence and the factors associated with positive screening for major depressive episode (MDE) in former slave communities in the state of Bahia, Brazil. METHODS: In this population-based, cross-sectional study, 764 participants were randomly selected from five former slave communities in Vitória da Conquista, Bahia, Brazil. Depression was defined as a cutoff score of 10 or more points and the presence of five or more symptoms according to the Patient Health Questionnaire (PHQ-9). Poisson regression was used to assess prevalence ratios (PR), with a 95% confidence interval (95%CI). RESULTS: Screening for MDE was positive in 12% of participants (95%CI: 10 - 14%), but only 2.3% reported a previous diagnosis. Depression was associated with self-reported poor or very poor health status (PR = 1.14; 95%CI: 1.04 - 1.26), chronic disease (PR = 1.08; 95%CI: 1.04 - 1.13), no physical activity (PR = 1.06; 95%CI: 1.01 - 1.11), and reasonable (PR = 1.07; 95%CI: 1.01 - 1.13) or poor access to health services (PR = 1.07; 95%CI: 1.02 - 1.12). CONCLUSIONS: The prevalence of MDE in this population was similar to that of the general Brazilian population. The association between MDE and poor access to health services indicates a missed opportunity for early diagnosis. Public measures against social and health inequalities are necessary to ensure equity in these communities.

Prevalence and risk factors associated with anal intraepithelial neoplasia among HIV-positive men in Brazil.

OBJECTIVE: This study aimed to assess the prevalence of, and associated factors with, anal intraepithelial neoplasia (AIN) among HIV-positive men evaluated at public health services in Brazil. MATERIALS AND METHODS: This is a multicenter cross-sectional study of HIV-positive male patients attending 6 public AIDS referral clinics in urban Brazil. Participants were interviewed for sociodemographic and behavioral characteristics. Anal swab specimens were collected for anal cytology and HPV DNA testing using L1 polymerase chain reaction. Univariate and multivariate analyses were performed to evaluate risk factors associated with the presence of low-grade squamous intraepithelial lesion (LSIL) and/or high-grade squamous intraepithelial lesion (HSIL). RESULTS: Anal swabs were collected from 343 participants. Prevalence of LSIL/HSIL was 24.8%. The majority (60.1%) reported sexual intercourse with both men and women in their lifetime. At least 36.7% had 1 or more oncogenic HPV types. Four variables were independently associated with the presence of LSIL/HSIL in multivariate analysis: history of sex with both men and women (odds ratio [OR] = 4.8) or men only (OR = 6.2) compared with those having sex with women only; current cigarette smoking (OR = 2.2); current CD4(+) level between 200 and 500 cells/mm(3) (OR = 2.9) or below 200 cells/mm(3) (OR = 3.8) compared with CD4(+) level above 500 cells/mm(3); and presence of oncogenic anal HPV infection (OR = 9.6). CONCLUSIONS: We found a high prevalence of AIN among HIV-positive men in Brazil. This population may serve as an important bridge population to women with implications for anogenital HPV infection in both men and women. Our findings confirm the need to assess screening programs for AIN among high-risk groups, similar to those used to prevent cervical cancer.

Unprotected receptive anal intercourse among men who have sex with men in Brazil.

The aim of this study was to assess factors associated with unprotected receptive anal intercourse (URAI) in a sample of MSM recruited by respondent driven sampling in Brazil. Among 3,449 participants, 36.5 % reported URAI. Final logistic model indicated that living with a male partner, illicit drug use, having stable partnership, having sex with men only, having few friends encouraging condom use, and high self-perceived risk for HIV infection were characteristics independently associated with URAI. Intervention strategies should focus on the role of anal sex practices on HIV transmission, address illicit drug use, stigma and expansion of HIV testing and care.

Tuberculosis patients co-infected with Mycobacterium bovis and Mycobacterium tuberculosis in an urban area of Brazil.

In this cross-sectional study, mycobacteria specimens from 189 tuberculosis (TB) patients living in an urban area in Brazil were characterised from 2008-2010 using phenotypic and molecular speciation methods (pncA gene and oxyR pseudogene analysis). Of these samples, 174 isolates simultaneously grew on Löwenstein-Jensen (LJ) and Stonebrink (SB)-containing media and presented phenotypic and molecular profiles of Mycobacterium tuberculosis, whereas 12 had molecular profiles of M. tuberculosis based on the DNA analysis of formalin-fixed paraffin wax-embedded tissue samples (paraffin blocks). One patient produced two sputum isolates, the first of which simultaneously grew on LJ and SB media and presented phenotypic and molecular profiles of M. tuberculosis, and the second of which only grew on SB media and presented phenotypic profiles of Mycobacterium bovis. One patient provided a bronchial lavage isolate, which simultaneously grew on LJ and SB media and presented phenotypic and molecular profiles of M. tuberculosis, but had molecular profiles of M. bovis from paraffin block DNA analysis, and one sample had molecular profiles of M. tuberculosis and M. bovis identified from two distinct paraffin blocks. Moreover, we found a low prevalence (1.6%) of M. bovis among these isolates, which suggests that local health service procedures likely underestimate its real frequency and that it deserves more attention from public health officials.

Factors associated with self-report of sexual violence against men and women with mental disorders in Brazil.

OBJECTIVES: Patients with mental illness (PMI) are more vulnerable to sexual violence (SV). This study aimed at assessing factors associated with SV against PMI, stratified by gender in Brazil. METHODS: Cross-sectional multicenter study with a national sample of 2,475 PMI randomly selected from 26 psychiatric services. Odds ratios were estimated with 95% confidence interval using logistic regression. RESULTS: A high prevalence of lifetime SV against PMI was observed (19.8%) and it was higher among women (26.6%) than men (12.5%). Among women, episodes of SV were more often caused by intimate partners and in the domestic environment, and among men, by strangers and in the streets. Among women, the following variables were independently associated (p < 0.01) with SV: younger age, living alone, history of homelessness, previous psychiatric hospitalization, lifetime STD diagnosis, early debut of sexual intercourse, irregular condom use, receiving/offering money for sex, and psychiatric diagnosis. Among men, younger age, previous and earlier psychiatric hospitalization, lifetime illegal drug use, receiving/offering money for sex, and psychiatric diagnosis were independently associated with SV. CONCLUSIONS: The prevalence of SV in the studied population was high, especially among women. Women have more behavior factors associated with SV and they need protection, especially those in isolation and socially deprived. However, men also suffer SV, usually more often during childhood than adulthood and special attention should be given to lifetime illegal drug use and earlier psychiatric hospitalization. Preventive actions beyond mental health are important, such as social and economic actions to improve the living conditions of PMI.

Metabolic comorbidities and systemic arterial hypertension: the challenge faced by HIV patients on long-term use of antiretroviral therapy.

OBJECTIVE: Our objective was to estimate the frequency of comorbidities and assess its relationship with exposure factors after long-term ART use. METHODS: A cross-sectional study with PLHIV (≥18 years-old), who initiated ART between 2001 and 2005 and attended an HIV/AIDS public referral center (Belo Horizonte/Brazil), was performed. Demographic, clinical, therapeutic, and lifestyle data were obtained through interviews, medical charts, public database, routine laboratory examinations, and bone densitometry. The outcome was the number of comorbidities: hyperglycemia, dyslipidemia, systemic arterial hypertension (SAH), and low bone mineral density (BMD). Absolute/relative frequencies were calculated. Factors associated with the outcome were assessed by quasi-Poisson regression. RESULTS: Of the 98 participants, 53% were male and 79% and over 43 years-old. Moderate physical activity was observed in 82%, overweight/obesity in 50%, and 58% used ART based on two nucleoside reverse transcriptase inhibitors (NRTIs) plus one non-nucleoside reverse transcriptase inhibitor (NNRTI). After a mean of 15.6 years of ART exposure, 207 comorbidities were identified and 93% participants presented at least one comorbidity (mean = 2.1/participant). The most frequent overlapping constituted two co-occurrences: dyslipidemia + hyperglycemia or dyslipidemia + SAH, n = 36 for each co-occurrence. The quasi-Poisson regression showed an increase of 3% in the number of comorbidities per year of age (OR = 1.03; 95%CI = 1.02-1.04) and 84% among PLHIV on moderate physical activity (ref = heavy physical-activity) (OR = 1.84; 95%CI = 1.08-3.13). CONCLUSIONS: Our study shows that the aging slightly contributed to comorbidities. However, the practice of physical-activities is crucial to prevent chronic-diseases. Treatment and preventive measures should be encouraged to diminish the burden of disease and improve quality of life among PLHIV.

Factors associated with symptoms of major depression disorder among transgender women in Northeast Brazil.

INTRODUCTION: Transgender women (TGW) are one of the most vulnerable groups, including higher prevalence of HIV and mental health disorders, such as anxiety and depression than in the general population. Major Depression Disorder (MDD) is one of the most important mental health conditions due to an increasing trend in prevalence in the general population. This study aims at describing the prevalence of symptoms of MDD (SMDD) and associated factors among TGW in capitals of three States in Northeast Brazil. METHODS: TGW n = (864) were selected from the cities of Salvador (n = 166), Recife (n = 350), and Fortaleza (n = 348) using Respondent Driven Sampling methodology. Symptoms of MDD were defined according to the Patient Health Questionnaire-9 scale. Multinomial logistic regression was used to compare those with mild/moderate or moderately severe/severe symptoms of depression with those with no depression, respectively, using complex sample design. Weighted Odds Ratio with 95% confidence interval were estimated. RESULTS: 51.1% of the sample was classified as mild/moderate and 18.9% as moderately severe/severe SMDD. Mild/moderate SMDD was associated with a history of sexual violence (OR = 2.06, 95%CI: 1.15-3.68), history of physical violence (OR = 2.09, 95%CI: 1.20-3.67),) and poor self-rated quality of life (OR = 2.14, 95%CI: 1.31-3.49).). Moderately severe/severe SMDD was associated with history of sexual violence (OR = 3.02, 95%CI: 1.17-7.77), history of physical violence (OR = 4.34, 95% CI:1.88-6.96), poor self-rated quality of life (OR = 3.32, 95%CI:1.804-6.12), lack of current social support (OR = 2.53, 95%IC: 1.31-4.88) and lack of family support in childhood (OR = 2.17, 95%IC 1.16-4.05)). CONCLUSIONS: Our findings strengthens the evidence of a higher prevalence of SMDD among TGW as compared to the general population. Public health policies and actions that target social determinants of risk and protection for MDD among TGW must be urgently implemented.

Perception of discrimination due to sexual orientation and associated factors among men who have sex with men in 12 Brazilian cities.

Discrimination due to sexual orientation (DDSO) has an important association with health outcomes among men who have sex with men (MSM). This study aimed to analyze factors associated with DDSO among MSM in 12 Brazilian cities. This is a cross-sectional study with 4,176 MSM participants recruited in 2016 which used a respondent-driven sampling method in 12 Brazilian cities. DDSO levels were previously identified by a latent class analysis based on 13 variables from the discrimination section. An ordinal logistic regression was used to assess associations with these DDSO levels, and weighted ordinal odds ratios (OR) and their respective 95% confidence intervals (95%CI) were estimated using Gile's estimator. Most participants were young (< 25 years old) black or of mixed-race (pardo), single individuals who had a religious affiliation, primary or incomplete secondary education, and a high and average socioeconomic status. More than half (65%) reported DDSO in the 12 months prior to this study. We observed an independent association among the four latent DDSO classes and the following variables: age < 25 years old (OR = 1.66; 95%CI: 1.21-2.27), white skin color (OR = 1.43; 95%CI: 1.02-2.01), history of sexual (OR = 2.33; 95%CI: 1.58-3.43) and physical violence (OR = 3.08; 95%CI: 2.11-4.49), disclosure of their sexual orientation as MSM to their fathers (OR = 2.00; 95%CI: 1.47-2.72), experienced suicidal ideation in the two weeks prior to this study (OR = 2.09; 95%CI: 1.46-2.98), and use of any illicit drugs in the last six months (OR = 1.61; 95%CI: 1.19-2.18). Our results indicate that contextual factors may contribute to high DDSO levels among MSM in Brazil. Public health policies toward human rights surveillance and protection among MSM must be urgently addressed.

Prevalence, Characteristics, and Factors Associated With Sexual Violence in Adulthood Among Brazilian MSM.

Most studies of sexual violence are with women, and although men who have sex with men (MSM) is the group of the men that has been most investigated for sexual violence, there are still several questions to be answered about sexual violence and sexual revictimization among MSM. This study aimed to estimate the prevalence of sexual violence in different stages of life and identify factors associated with sexual violence in adulthood among Brazilian MSM. We conducted an analysis with data from the study conducted in 2016 with 4,176 MSM from 12 Brazilian cities recruited through respondent-driven sampling (RDS), who answered a survey to a set of questions, among which some specific about sexual violence. Most participants were under 25 years old (56.5%), with more than 12 years of schooling (71.2%), mixed race (40.8%), single (86.2%), and belonging to some religion (50.9%). The lifetime prevalence of sexual violence was 20.3%. In our analyses, having experienced sexual violence in childhood and adolescence increased the odds of experiencing sexual violence in adulthood (prevalence ratio ratios [PRR] 4.93 (95% CI [1.99, 12.21]), as did experiencing physical violence (PRR 1.99; 95% CI [1.07, 3.71]) and receiving money for sex (PRR 2.26; 95% CI [1.17, 4.36]). In addition to violence in childhood and adolescence being risk factors for sexual violence in adulthood, we also observed that half of the sample experienced sexual violence repeatedly, characterizing sexual revictimization. It is important that health services are prepared to receive boys and men victims in order to reduce the chances of revictimization and other outcomes.

Identification of Mycobacterium tuberculosis complex based on amplification and sequencing of the oxyR pseudogene from stored Ziehl-Neelsen-stained sputum smears in Brazil.

A cross-sectional analysis of stored Ziehl-Neelsen (ZN)-stained sputum smear slides (SSS) obtained from two public tuberculosis referral laboratories located in Juiz de Fora, Minas Gerais, was carried out to distinguish Mycobacterium bovis from other members of the Mycobacterium tuberculosis complex (MTC). A two-step approach was used to distinguish M. bovis from other members of MTC: (i) oxyR pseudogene amplification to detect MTC and, subsequently, (ii) allele-specific sequencing based on the polymorphism at position 285 of this gene. The oxyR pseudogene was successfully amplified in 100 of 177 (56.5%) SSS available from 99 individuals. No molecular profile of M. bovis was found. Multivariate analysis indicated that acid-fast bacilli (AFB) results and the source laboratory were associated (p < 0.05) with oxyR pseudogene amplification. SSS that were AFB++ SSS showed more oxyR pseudogene amplification than those with AFB0, possibly due to the amount of DNA. One of the two source laboratories presented a greater chance of oxyR pseudogene amplification, suggesting that differences in sputum conservation between laboratories could have influenced the preservation of DNA. This study provides evidence that stored ZN-SSS can be used for the molecular detection of MTC.

Sexual, reproductive health and health status of female sex workers in 12 Brazilian cities, 2016.

OBJECTIVE: To investigate differences in sexual, reproductive health and health status indicators of female sex workers in 12 Brazilian cities. METHODS: Cross-sectional study of biological and behavioral surveillance survey with a minimum sample of 350 female sex workers per city, recruited by respondent driven sampling, in 2016. Complex sample design was considered in the data analysis. Indicators and 95% confidence intervals related to sexual and reproductive health, and health status were described separately by city and for the total sample. RESULTS: The total sample consisted of 4,328 female sex workers. The coverage of Pap smear exam, human immunodeficiency virus and syphilis tests and antenatal care indicators varied by 20 percentages points or more. Pap smear exam coverage ranged from 53.4% in Recife to 73.0% in Porto Alegre. The highest percentage of female sex workers who had never been tested for human immunodeficiency virus and syphilis was in Fortaleza (36.8 and 63.8%, respectively). Antenatal coverage ranged from 61.1% in Salvador to 99.0% in Curitiba. In five cities, the proportion of female sex workers who disclosed their sex work status in health services was over 20.0%. CONCLUSION: The differences between the indicators in the 12 cities followed the Brazilian population profile, with more vulnerable sex workers in the North and Northeast regions. The results show that it is essential to consider the barriers to accessing health, such as stigma and discrimination, which restrict the addressing of female sex workers specific needs.

Immune recovery after antiretroviral therapy initiation: a challenge for people living with HIV in Brazil.

Immune recovery reflects health conditions. Our goal was to estimate the time it takes to achieve immune recovery and its associated factors, in people living with HIV (PLHIV), after antiretroviral therapy (ART) initiation. A historical cohort study was performed among PLHIV (> 18 years-old) in Minas Gerais State, Brazil, using data from healthcare databases. Patients initiating ART between 2009-2018, with T-CD4+ lymphocytes and viral load recorded before and after antiretroviral therapy were included. The outcome is achievement of immune recovery, defined as the first T-CD4+ > 500 cells/µL after ART initiation. Explanatory variables were age, gender, place of residence, year of ART initiation, baseline viral load and T-CD4+, viral load status, and adherence to ART at follow-up. Descriptive analysis, cumulative, and person-time incidences of immune recovery were estimated. Median-time to immune recovery was estimated using Kaplan-Meier method. Factors associated with immune recovery were assessed by Cox regression. Among 26,430 PLHIV, 8,014 (30%) were eligible. Most were male (67%), mean age 38.7 years, resided in non-central region, median-baseline T-CD4+ = 228 cells/µL (< 200 cells/µL = 43%) and viral load median-baseline = 4.7 log10 copies/mL (detectable viral load = 99%). Follow-up time = 15,872 person-years. Cumulative and incidence rate were 58% (95%CI: 57-58) (n = 4,678) and 29.47 cases/100 person-years, respectively. Median-time to immune recovery was of 22.8 months (95%CI: 21.9-24.0). Women living with HIV, younger than 38 years of age, with T-CD4+ baseline > 200 cells/µL, detectable viral load (baseline), antiretroviral therapy-adherence and undetectable viral load (follow-up) were independently associated with immune recovery. Time to immune recovery remains long and depends on early treatment and antiretroviral therapy-adherence.

Anxiety and depression symptoms as risk factors for non-adherence to antiretroviral therapy in Brazil.

Depression and anxiety are common among HIV-infected people and rank among the strongest predictors of non-adherence to antiretroviral therapy (ART). This longitudinal study aimed to assess whether symptoms of anxiety and depression are predictors of non-adherence among patients initiating ART at two public referral centers (n = 293) in Belo Horizonte, Brazil. Prevalence of severe anxiety and depression symptoms before starting ART was 12.6% and 5.8%, respectively. Severe anxiety was a predictor of non-adherence to ART during follow-up period (RH = 1.87; 95% CI = 1.14-3.06) adjusted for low education, unemployment, alcohol use in the last month and symptoms of AIDS; while a history of injection drug use had borderline statistical significance with non-adherence. These findings suggest that using a brief screening procedure to assess anxiety and depression symptoms before initiating ART help identify individuals for interventions to improve adherence and quality of life.

Individual and treatment setting predictors of HIV/AIDS knowledge among psychiatric patients and their implications in a national multisite study in Brazil.

The objective of this study is to measure HIV/AIDS knowledge among patients with mental illness in Brazil and to examine individual and treatment setting predictors of knowledge. We conducted a cross-sectional national multicenter study among 2,475 patients in 26 randomly selected mental health institutions throughout Brazil. We used Item Response Theory to standardize knowledge scores and multilevel multiple linear regression to determine the effect of individual and treatment setting characteristics on standardized knowledge score. Schizophrenia was the main diagnosis (48%) of participants. Mean knowledge score was 6.78 (range 1-10). Treatment setting characteristics were not associated with knowledge scores. Higher HIV/AIDS knowledge scores were significantly associated with a history of sexually transmitted disease (STD), previous HIV testing and consistent condom use; lower HIV/AIDS knowledge scores were significantly associated with specific sociodemographic, psychiatric, and HIV risk-perception factors. Psychiatric patients in Brazil lag behind the general population with knowledge scores comparable to those of nearly a decade ago. The mental health system in Brazil and elsewhere must consider strategies beyond dispensing information, for preventing HIV/AIDS transmission in the psychiatric population.