Variability in life expectancy among people with HIV in Brazil by gender and sexual orientation

Abstract Introduction In Brazil, though Antiretroviral Therapy (ART) is available to all, the benefits may not be experienced uniformly. We projected Life Expectancy (LE) for People Living with HIV (PLHIV) in care as currently observed and estimated the impact of guideline-concordant care. Methods Using a microsimulation model, we projected LE for a cohort of PLHIV and for four population groups: cisgender Men who have Sex with Men (MSM), cisgender Men who have Sex with Women (MSW), Cisgender Women (CGW), and Transgender Women (TGW). Cohort data from Evandro Chagas National Institute of Infectious Diseases/Oswaldo Cruz Foundation (INI/Fiocruz) informed model parameters. We modeled five scenarios: 1) Current care: ART initiation, adherence, and retention in care as currently observed, 2) Guideline-concordant care: immediate ART initiation, full adherence to treatment, and consistent retention in care, 3) Immediate ART initiation with observed adherence to treatment and retention in care, 4) Full adherence to treatment with observed timing of ART initiation and retention in care, and 5) Consistent retention in care with observed timing of ART initiation and adherence. Results With current care, LE from age 15 would be 45.9, 44.4, 54.2, and 42.3 years, for MSM, MSW, CGW, and TGW. With guideline-concordant care, LE would be 54.2, 54.4, 63.1, and 53.2 years, for MSM, MSW, CGW and TGW, with TGW experiencing the greatest potential increase in LE (10.9 years). When investigating the components of care separately, MSW and CGW would gain most LE with immediate ART initiation, whereas for MSM and TGW consistent retention in care would be most impactful. Conclusions In settings like INI/Fiocruz, MSW and CGW would benefit most from interventions focused on earlier diagnosis and linkage to care, whereas TGW and MSM would benefit from interventions to sustain engagement in care. Assessment of the HIV care continuum for specific populations should inform care priorities.

Moderating Effect of Pre-Exposure Prophylaxis Use on the Association Between Sexual Risk Behavior and Perceived Risk of HIV Among Brazilian Gay, Bisexual, and Other Men Who Have Sex With Men: Cross-Sectional Study.

BACKGROUND: Gay, bisexual, and other men who have sex with men (MSM) with a higher perceived risk of HIV are more aware of and willing to use pre-exposure prophylaxis (PrEP). PrEP is an effective HIV prevention strategy, but there is a lack of data on how PrEP use might moderate the relationship between sexual risk behavior and perceived risk of HIV. Moreover, most studies measure perceived risk of HIV via a single question. OBJECTIVE: We estimated the moderating effect of PrEP use on the association between sexual risk behavior and perceived risk of HIV, measured with the 8-item Perceived Risk of HIV Scale (PRHS), among Brazilian MSM. METHODS: A cross-sectional, web-based survey was completed by Brazilian Hornet app users aged ≥18 years between February and March 2020. We included data from cisgender men who reported sex with men in the previous 6 months. We evaluated the moderating effect of current PrEP use on the association between sexual risk behavior, measured via the HIV Incidence Risk Index for MSM (HIRI-MSM), and perceived risk of HIV, measured by the PRHS. Higher HIRI-MSM (range 0-45) and PRHS (range 10-40) scores indicate greater sexual behavioral risk and perceived risk of HIV, respectively. Both were standardized to z scores for use in multivariable linear regression models. RESULTS: Among 4344 cisgender MSM, 448 (10.3%) were currently taking PrEP. Current PrEP users had a higher mean HIRI-MSM score (mean 21.0, SD 9.4 vs mean 13.2, SD 8.1; P<.001) and a lower mean PRHS score (mean 24.6, SD 5.1 vs mean 25.9, SD 4.9; P<.001) compared to those not currently taking PrEP. In the multivariable model, greater HIRI-MSM scores significantly predicted increased PRHS scores (ß=.26, 95% CI 0.22-0.29; P<.001). PrEP use moderated the association between HIRI-MSM and PRHS score (interaction term ß=-.30, 95% CI -0.39 to -0.21; P<.001), such that higher HIRI-MSM score did not predict higher PRHS score among current PrEP users. CONCLUSIONS: Our results suggest current PrEP users have confidence in PrEP's effectiveness as an HIV prevention strategy. PrEP's effectiveness, positive psychological impact, and the frequent HIV testing and interaction with health services required of PrEP users may jointly influence the relationship between sexual risk behavior and perceived risk of HIV among PrEP users.

Reproductive health syndemics impact retention in care among women living with HIV in Rio de Janeiro, Brazil

ABSTRACT Syndemic psychosocial and reproductive factors affecting women's retention in HIV care remain understudied. We analyzed correlates of non-retention in a cohort of women with HIV in Brazil from 2000-2015. Participants self-reported exposure to physical/sexual violence, illicit drug use, adolescent pregnancy, or induced abortion. Lifetime history of these psychosocial stressors were used to create a syndemic score based on the presence or absence of these conditions. All dichotomous variables were summed (range 0 to 4), with greater scores indicating more syndemic factors experienced. Logistic regression models identified predictors of non-retention, defined as < 2 HIV viral load or CD4 results within the first year of enrollment. Of 915 women, non-retention was observed for 18%. Prevalence of syndemic factors was adolescent pregnancy (53.2%), physical/sexual violence (38.3%), induced abortion (27.3%), and illicit drug use (17.2%); 41.2% experienced > 2 syndemic conditions. Syndemic scores of 2 and 3 were associated with non-retention, as well as low education, years with HIV and seroprevalent syphilis. Psychosocial and reproductive syndemics can limit women's retention in HIV care. Syphilis infection predicted non-retention and could be explored as a syndemic factor in future studies.

Mortality rates by gender and sexual orientation reveal a disproportionally high mortality among cisgender men of unknown sexual orientation and men who have sex with women in a cohort of people living with HIV in Rio de Janeiro, Brazil

ABSTRACT Background: Antiretroviral therapy use has led to a decline in HIV-related mortality yet disparities by gender and/or sexual orientation may exist. In this study, we estimated hazards of death in people living with HIV (PLWH) according to gender and sexual orientation. Methods: We included PLWH ≥ 18 years enrolled between 2000 and 2018 at INI/Fiocruz, Rio de Janeiro, Brazil. Participants were grouped as cisgender or transgender women, cisgender men who have sex with men (MSM) or men who have sex with women, or cisgender men with unknown sexual orientation. We assessed disparities in the hazard of death using Cox proportional hazards models. Results: Among 5,576 PLWH, median age at enrollment was 35 years, 39% were MSM, 28% cisgender women, 23% men who have sex with women, 5% transgender women, and 5% men with unknown sexual orientation. A total of 795 deaths occurred in 39,141 person-years of follow-up. Mortality rates per 1,000 person-years were: 82.4 for men with unknown sexual orientation, 24.5 for men who have sex with women, 18.3 for cisgender, 16.6 for transgender women, and 15.1 for MSM. Compared to MSM, men with unknown sexual orientation had the highest death hazard ratio (adjusted hazard ratio [aHR] 2.93, 95% confidence interval [CI] 2.35-3.81), followed by men who have sex with women (aHR 1.17, 95%CI 0.96, 1.43); death hazard ratios for cisgender and transgender women were not statistically different. Conclusion: We observed disparities in the hazard of death for men with unknown sexual orientation and men who have sex with women despite universal access to antiretroviral therapy in Brazil. Future work should characterize and assist men with unknown sexual orientation with tailored policies and interventions. Increased hazard of death was not observed for transgender women, which probably results from interventions implemented in our service to reach, engage, retain, and support this population.

HIV knowledge and its correlation with the Undetectable = Untransmittable slogan in Brazil

ABSTRACT Knowledge about HIV transmission and prevention is a necessary step for adopting preventive behaviors. We assessed HIV knowledge and its correlation with the perceived accuracy of the "Undetectable = Untransmittable" (U=U) slogan in an online sample with 401 adult Brazilians. Overall, 28% of participants showed high HIV knowledge level. The perceived accuracy of the U=U slogan significantly correlated with HIV knowledge. Younger participants, those reporting lower income or lower education, or who had never tested for HIV showed poorer HIV knowledge. Filling gaps of knowledge among specific populations is urgent in order to increase preventive behaviors and decrease HIV stigma.

SARS-CoV-2 testing disparities across geographical regions from a large metropolitan area in Brazil: Results from a web-based survey among individuals interested in clinical trials for COVID-19 vaccines

ABSTRACT After more than a year since the novel coronavirus (SARS-CoV-2) disease 2019 or COVID-19 has reached the status of a global pandemic, the number of COVID-19 cases continues to rise in Brazil. As no effective treatment been approved yet, only mass vaccination can stop the spread of SARS-CoV-2 and end the COVID-19 pandemic. Multiple COVID-19 vaccine candidates are under development and some are currently in use. This study aims to describe the characteristics of individuals who have registered in an online platform to participate in clinical trials for COVID-19 vaccines. Additionally, participants' characteristics according to age and presence of comorbidities associated with severe COVID-19 and differences of SARS-CoV-2 testing across different geographical areas/neighborhoods are provided. This was a cross-sectional web-based study conducted between September and December/2020, aiming to reach individuals aged ≥18 years who live in Rio de Janeiro metropolitan area, Brazil. Among 21,210 individuals who completed the survey, 20,587 (97.1%) were willing to participate in clinical trials for COVID-19 vaccines. Among those willing to participate, 57.8% individuals were aged 18-59 years and had no comorbidity, 33.7% were aged 18-59 years and had at least one comorbidity, and 8.6% were aged ≥ 60 years regardless the presence of any comorbidity. Almost half (42.6%) reported ever testing for COVID-19, and this proportion was lower among those aged ≥ 60 years (p < 0.001). Prevalence of positive PCR results was 16.0%, higher among those aged 18-59 years (p < 0.009). Prevalence of positive antibody result was 10.0%, with no difference across age and comorbidity groups. Participants from areas/neighborhoods with higher Human Development Index (HDI) reported ever testing for SARS-CoV-2 more frequently than those from lower HDI areas. Interest to participate in clinical trials for COVID-19 vaccines candidates in Rio de Janeiro was significantly high. The online registry successfully reached out a large number of individuals with diverse sociodemographic, economic and clinical backgrounds.

A call to improve understanding of Undetectable equals Untransmittable (U = U) in Brazil: a web-based survey.

INTRODUCTION: Currently, the slogan "Undetectable = Untransmittable" (U = U), launched to disseminate scientific evidence on how people living with HIV (PLHIV) on antiretroviral treatment with suppressed viral load cannot transmit HIV to their sexual partners, is still challenged by individuals with differential acceptance across populations. In this study, we documented the perceived accuracy of U = U in Brazil in three different groups: PLHIV, HIV-negative/unknown cisgender gay/bisexual men who have sex with men (GBM) and HIV-negative/unknown other populations (POP). METHODS: Adult (age ≥ 18y) Brazilians were recruited during October 2019 to complete a web-based survey advertised on Grindr, Facebook and WhatsApp. Perceived accuracy of U = U was assessed with the question: "With regards to HIV-positive individuals transmitting HIV through sexual contact, how accurate do you believe the slogan U = U is?" Response options ranged from 1 (Completely inaccurate) to 4 (Completely accurate) plus a fifth option (I don't know what "undetectable" means). Participants' characteristics were described according to perceived accuracy of U = U. Logistic regression models assessed the factors associated with perceived accuracy of U = U (completely accurate vs. partially accurate/inaccurate or completely inaccurate) by group. RESULTS: Of 2311 individuals accessing the questionnaire, 1690 (73.1%) met inclusion/exclusion criteria and completed it. Of these, 347 (20.5%) were PLHIV, 785 (46.4%) GBM and 558 (33.0%) POP. More PLHIV perceived U = U as completely accurate (79.0%), compared to 44.2% GBM and 17.2% POP (p < 0.001). Among PLHIV, Black identity was associated with decreased odds of perceiving U = U as completely accurate while having a steady partner was associated with increased odds. Among GBM, being gay, having middle/higher income, being a resident of state capital metropolitan areas and ever testing for HIV were associated with increased odds. Lastly, among POP, ever testing for HIV increased the odds of perceiving U = U as completely accurate. CONCLUSIONS: There was a significant difference in perceived accuracy of U = U across population groups. Accurate understanding of the slogan needs to be promoted in more vulnerable populations such as PLHIV of Black identity and GBM of lower income to maximize individual and societal prevention benefits. Moreover, broader understating of U = U among the general population can help decrease societal stigma towards PLHIV.

COVID-19: a meta-analysis of diagnostic test accuracy of commercial assays registered in Brazil

ABSTRACT The accuracy of commercially available tests for COVID-19 in Brazil remains unclear. We aimed to perform a meta-analysis to describe the accuracy of available tests to detect COVID-19 in Brazil. We searched at the Brazilian Health Regulatory Agency (ANVISA) online platform to describe the pooled sensitivity (Se), specificity (Sp), diagnostic odds ratio (DOR) and summary receiver operating characteristic curves (SROC) for detection of IgM/IgG antibodies and for tests using naso/oropharyngeal swabs in the random-effects models. We identified 16 tests registered, mostly rapid-tests. Pooled diagnostic accuracy measures [95%CI] were: (i) for IgM antibodies Se = 82% [76-87]; Sp = 97% [96-98]; DOR = 168 [92-305] and SROC = 0.98 [0.96-0.99]; (ii) for IgG antibodies Se = 97% [90-99]; Sp = 98% [97-99]; DOR = 1994 [385-10334] and SROC = 0.99 [0.98-1.00]; and (iii) for detection of SARS-CoV-2 by antigen or molecular assays in naso/oropharyngeal swabs Se = 97% [85-99]; Sp = 99% [77-100]; DOR = 2649 [30-233056] and SROC = 0.99 [0.98-1.00]. These tests can be helpful for emergency testing during the COVID-19 pandemic in Brazil. However, it is important to highlight the high rate of false negative results from tests which detect SARS-CoV-2 IgM antibodies in the initial course of the disease and the scarce evidence-based validation results published in Brazil. Future studies addressing the diagnostic performance of tests for COVID-19 in the Brazilian population are urgently needed.

Prevalência e fatores associados ao aborto induzido no ingresso em uma coorte de mulheres vivendo com HIV/aids, Rio de Janeiro, Brasil, 1996-2016 / Prevalencia y factores asociados al aborto inducido en el ingreso en una cohorte de mujeres que viven con VIH/SIDA, Río de Janeiro, Brasil, 1996-2016 / Prevalence of induced abortion and associated factors in a cohort of women living with HIV/AIDS, Rio de Janeiro, Brazil, 1996-2016

O objetivo deste estudo é verificar a prevalência e os fatores associados ao aborto induzido no ingresso em uma coorte de mulheres vivendo com HIV/aids, no Município do Rio de Janeiro, Brasil, no período 1996-2016. O critério de elegibilidade para o ingresso na coorte era ser do sexo feminino ao nascimento, ter mais de 18 anos de idade e ter infecção comprovada pelo HIV. Na visita inicial, dados sobre aspectos sexuais, reprodutivos, comportamentais e da infecção pelo HIV foram obtidos durante entrevista face a face com o médico assistente. Foi calculada a prevalência de aborto induzido na vida e verificados os fatores associados ao aborto induzido por meio de regressão logística múltipla, para o total de mulheres e entre aquelas com gestação prévia. Do total de mulheres, 30,4% referiram algum aborto induzido na vida, sendo este valor de 33,5% em mulheres com gestação prévia. A frequência de aborto induzido relatado apresentou queda significativa no período analisado (41,7% de 1996-2000 vs. 22,5% de 2011-2016, p < 0,001). Os fatores associados ao aborto induzido, tanto para o total de mulheres quanto para aquelas com gestação prévia, foram o aumento da idade, escolaridade mais elevada, número de parceiros sexuais na vida ≥ 5, gestação na adolescência, uso de qualquer droga ilícita na vida e período de ingresso na coorte após 2005. Mudanças no perfil socioeconômico, sexual, reprodutivo e da infecção pelo HIV são explicações possíveis para a redução da prática do aborto no período. Estudos que utilizem métodos de aferição direta do aborto devem ser conduzidos em outras populações, para confirmar a tendência de queda do aborto induzido no país e seus determinantes.

El objetivo de este estudio es verificar la prevalencia y los factores asociados al aborto inducido en el ingreso en una cohorte de mujeres, que viven con VIH/sida, en el municipio de Rio de Janeiro, durante el período 1996-2016. El criterio de elegibilidad para el ingreso en la cohorte era ser del sexo femenino al nacer, tener más de 18 años de edad y sufrir una infección comprobada por VIH. En la visita inicial, datos sobre aspectos sexuales, reproductivos, comportamentales y de infección por el VIH se obtuvieron durante la entrevista cara a cara con el médico asistente. Se calculó la prevalencia del aborto inducido en la vida y se verificaron los factores asociados al aborto inducido mediante regresión logística múltiple, para el total de mujeres y entre aquellas con gestación previa. Del total de mujeres, un 30,4% refería algún aborto inducido en la vida, siendo ese valor de un 33,5% en mujeres con gestación previa. La frecuencia de aborto inducido relatado presentó una caída significativa durante el período analizado (un 41,7% en el período 1996-2000 vs. 22,5% en el período 2011-2016, p < 0,001). Los factores asociados al aborto inducido, tanto para el total de mujeres, como para aquellas con gestación previa, fueron el aumento de la edad de la mujer, escolaridad más elevada, número de parejas sexuales en la vida ≥ 5, gestación en la adolescencia, consumo de cualquier droga ilícita en la vida y período de ingreso en la cohorte tras 2005. Cambios en el perfil socioeconómico, sexual, reproductivo y de infección por VIH son explicaciones posibles para la reducción de la realización de abortos durante el período. Se deben llevar a cabo estudios que utilicen métodos de medición directa del aborto en otras poblaciones para confirmar la tendencia de caída del aborto inducido en el país y sus determinantes.

The aim of this study was to verify the prevalence of induced abortion and associated factors at the time of inclusion in a cohort of women living with HIV/AIDS in the city of Rio de Janeiro, Brazil, from 1996 to 2016. Eligibility criteria for inclusion in the cohort were female sex at birth, age 18 years and older, and confirmed HIV infection. At the baseline visit, data on sexual, reproductive, and behavioral aspects and HIV infection were obtained through a face-to-face interview with the attending physician. Lifetime prevalence of induced abortion was calculated, and factors associated with induced abortion were verified by multiple logistic regression for all the women and for those with previous pregnancy. In the entire cohort of women, 30.4% reported a history of induced abortion, compared to 33.5% in women with previous pregnancy. Frequency of reported induced abortion showed a significant reduction during the period (41.7% in 1996-2000 versus 22.5% in 2011-2016, p < 0.001). Factors associated with induced abortion, both for the entire cohort and for the women with previous pregnancy, were age, schooling, ≥ 5 lifetime sexual partners, teenage pregnancy, lifetime use of any illicit drug, and inclusion in the cohort after the year 2005. Changes in the socioeconomic, sexual, reproductive, and HIV infection profile are possible explanations for the reduction in abortions during the period. Studies that use direct methods to measure abortion should be conducted in other populations to confirm the downward trend in induced abortion and its determinants in Brazil.

Factors associated with PrEP awareness according to age and willingness to use HIV prevention technologies: the 2017 online survey among MSM in Brazil.

Brazil has the largest population of individuals living with HIV/AIDS in Latin America with a disproportional prevalence of infection among men who have sex with men (MSM). This study evaluated PrEP awareness by age (18-24, 25-35, ≥36 years), its associated factors and the willingness to use HIV prevention technologies among MSM using a GSN app in Brazil. Inclusion criteria were ≥18 years-old, cisgender men and HIV-negative serostatus. Of 7242 individuals, 4136 (57%) completed the questionnaire. PrEP awareness was reported by 51% (though lower among MSM aged 18-24 and ≥36 years) and its associated factors were higher family income, most friends with the same sexual orientation, high number of male sexual partners and marijuana use. HIV testing (never vs. at least once) lead to an almost 3-fold increase in the odds of PrEP awareness. High HIV risk perception led to increased PrEP awareness only among MSM aged 18-24 years. A total of 2335 (56%) was willing to use daily oral PrEP. PrEP awareness remains low in Brazil and mobile tools are key strategies to reach MSM and increase awareness of prevention technologies. Community-based interventions could add to online campaigns to reach the most vulnerable, which include young, non-white and lower-income MSM.

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

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

Health-related quality of life assessment among people living with HIV in Rio de Janeiro, Brazil: a cross-sectional study.

PURPOSE: To assess health-related quality of life (HRQoL) and its associated factors among people living with HIV/AIDS (PLWHA) in Rio de Janeiro, Brazil. METHODS: A cross-sectional study including PLWHA receiving usual HIV-care at Instituto Nacional de Infectologia Evandro Chagas (INI/Fiocruz) was conducted between 2014 and 2016 in Rio de Janeiro, Brazil. The EQ-5D-3L assessed HRQoL; PHQ-2 and ASSIST were used for screening depression and substance use, respectively. Clinical variables were obtained from the INI/Fiocruz cohort database, and structured questions evaluated intimate partner violence, sexual abstinence and relationship status. Data were analysed using multivariable Tobit regression model. RESULTS: A total of 1480 PLWHA were included: 64.7% were male at birth (38.4% men who have sex with men [MSM], 24.3% heterosexual men and 2% transgender women [TGW]); median age was 43.1 years, and 95.8% were receiving antiretroviral therapy. The median EQ-5D-3L utility score was 0.801. Results showed that the following factors: MSM and women; older age; lower educational level; no engagement in a relationship; depression screening positive; polysubstance use; and, detectable viral load were independently associated with worse HRQoL. CONCLUSIONS: PLWHA under care at INI/Fiocruz presented good HRQoL. Polysubstance use, depression and lower educational level were among the factors negatively associated with HRQoL. This was the first time that the EQ-5D-3L utility scores were calculated for a considerable number of PLWHA in Brazil, which is a fundamental piece of information for future cost-effectiveness analysis.

Hybrid capture as a tool for cervical lesions screening in HIV-infected women: insights from a Brazilian cohort

ABSTRACT Introduction: Cervical cancer remains an important burden for HIV-infected women in the era of combination antiretroviral therapy. Recommendations for cervical screening in these women diverge and may include high-risk HPV (HRHPV) testing. We aimed to evaluate the clinical usefulness of a single HRHPV testing for cervical screening of HIV-infected women. Methods: 723 HIV-infected women from a Brazilian prospective cohort were included between 1996 and 2012. Inclusion criteria were: normal cervical cytology at baseline and having a HRHPV-test at baseline. We calculated incidence rates of any squamous intraepithelial lesion (SIL) and high grade SIL+ (HSIL+) and negative predictive values (NPV) within 12 and 36 months. Hazard Ratios were obtained using Cox proportional hazards regression models. Results: Incidence rate for both outcomes was low (9.9 cases per 100 PY [95% CI 8.8-11.0] for any SIL and 1.3 cases per 100 PY [95% IC 0.9-1.8] for HSIL+). Women with a HRHPV positive status at baseline had 1.7-fold (95% CI 1.3-2.2) and 3.2-fold (95% CI 1.5-7.1) increased risk of presenting any SIL and HSIL+, respectively, during follow-up. Negative-HRHPV test presented high NPV for both periods and outcomes (any SIL: 92.4% [95% CI 89.7-94.6] for 12 months and 80.9% [95% CI 77.2-84.3] for 36 months; and HSIL+: 99.8% [95% CI 98.9-100.0] for 12 months and 99.0 [95% CI 97.6-99.7] for 36 months). Conclusions: Incidence of any and high grade cytological abnormality was significantly higher among HIV-infected women with positive-HRHPV test. A single negative-HRHPV test helped reassure follow-up free of cytological abnormalities through three years of follow-up in HIV-infected women with negative cytology.

Hybrid capture as a tool for cervical lesions screening in HIV-infected women: insights from a Brazilian cohort.

INTRODUCTION: Cervical cancer remains an important burden for HIV-infected women in the era of combination antiretroviral therapy. Recommendations for cervical screening in these women diverge and may include high-risk HPV (HRHPV) testing. We aimed to evaluate the clinical usefulness of a single HRHPV testing for cervical screening of HIV-infected women. METHODS: 723 HIV-infected women from a Brazilian prospective cohort were included between 1996 and 2012. Inclusion criteria were: normal cervical cytology at baseline and having a HRHPV-test at baseline. We calculated incidence rates of any squamous intraepithelial lesion (SIL) and high grade SIL+ (HSIL+) and negative predictive values (NPV) within 12 and 36 months. Hazard Ratios were obtained using Cox proportional hazards regression models. RESULTS: Incidence rate for both outcomes was low (9.9 cases per 100 PY [95% CI 8.8-11.0] for any SIL and 1.3 cases per 100 PY [95% IC 0.9-1.8] for HSIL+). Women with a HRHPV positive status at baseline had 1.7-fold (95% CI 1.3-2.2) and 3.2-fold (95% CI 1.5-7.1) increased risk of presenting any SIL and HSIL+, respectively, during follow-up. Negative-HRHPV test presented high NPV for both periods and outcomes (any SIL: 92.4% [95% CI 89.7-94.6] for 12 months and 80.9% [95% CI 77.2-84.3] for 36 months; and HSIL+: 99.8% [95% CI 98.9-100.0] for 12 months and 99.0 [95% CI 97.6-99.7] for 36 months). CONCLUSIONS: Incidence of any and high grade cytological abnormality was significantly higher among HIV-infected women with positive-HRHPV test. A single negative-HRHPV test helped reassure follow-up free of cytological abnormalities through three years of follow-up in HIV-infected women with negative cytology.

HIV testing and the care continuum among transgender women: population estimates from Rio de Janeiro, Brazil.

INTRODUCTION: Evidence suggests that, of all affected populations, transgender women (transwomen) may have the heaviest HIV burden worldwide. Little is known about HIV linkage and care outcomes for transwomen. We aimed to estimate population-level indicators of the HIV cascade of care continuum, and to evaluate factors associated with viral suppression among transwomen in Rio de Janeiro, Brazil. METHODS: We conducted a respondent-driven sampling (RDS) study of transwomen from August 2015 to January 2016 in Rio de Janeiro, Brazil and collected data on linkage and access to care, antiretroviral treatment and performed HIV viral load testing. We derived population-based estimates of cascade indicators using sampling weights and conducted RDS-weighted logistic regression analyses to evaluate correlates of viral suppression (viral load ≤50 copies/mL). RESULTS: Of the 345 transwomen included in the study, 89.2% (95% CI 55-100%) had been previously tested for HIV, 77.5% (95% CI 48.7-100%) had been previously diagnosed with HIV, 67.2% (95% CI 39.2-95.2) reported linkage to care, 62.2% (95% CI 35.4-88.9) were currently on ART and 35.4% (95% CI 9.5-61.4%) had an undetectable viral load. The final adjusted RDS-weighted logistic regression model for viral suppression indicated that those who self-identified as black (adjusted odds ratio [aOR] 0.06, 95% CI 0.01-0.53, p < 0.01), reported earning ≤U$160/month (aOR 0.11, 95% CI 0.16-0.87, p = 0.04) or reported unstable housing (aOR 0.08, 95% CI 0.01-0.43, p < 0.01) had significantly lower odds of viral suppression. CONCLUSIONS: Our cascade indicators for transwomen showed modest ART use and low viral suppression rates. Multi-level efforts including gender affirming care provision are urgently needed to decrease disparities in HIV clinical outcomes among transwomen and reduce secondary HIV transmission to their partners.

Substance use among HIV-infected patients in Rio de Janeiro, Brazil: Agreement between medical records and the ASSIST questionnaire.

BACKGROUND: Substance use assessment is a challenge in busy clinical settings that may adversely affect HIV-infected persons. This study aimed to evaluate agreement between the medical chart and a standardized substance use screening questionnaire. METHODS: Of adults (n=1050) in HIV care in Rio de Janeiro who completed the World Health Organization's Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), we randomly selected 200 participants for medical chart review. Lifetime use of tobacco, alcohol, marijuana, and cocaine agreement between the medical record and ASSIST was evaluated using Kappa statistics. Sensitivity and specificity of chart information were also calculated. RESULTS: The median age was 42.4 years, 60.3% were male and 49.5% were white. Prevalence of lifetime use reported in ASSIST was 55.3% (tobacco), 79.4% (alcohol), 23.1% (marijuana), and 20.7% (cocaine). Any information on lifetime use was found in the medical chart for tobacco (n=180, 90.5%), alcohol (n=183, 92.0%), marijuana (n=143, 71.8%), and cocaine (n=151, 75.9%). The Kappa statistic, sensitivity and specificity of the medical chart accurately identifying lifetime substance users per ASSIST were respectively 0.60, 0.71, and 0.91 for tobacco; 0.22, 0.75, and 0.51 for alcohol; 0.58, 0.51, and 0.98 for marijuana; and 0.73, 0.75, and 0.96 for cocaine. CONCLUSION: Considering inaccuracies in the medical chart, the implementation of brief, standardized substance use screening is recommended in HIV care settings.

Age-Standardized Mortality Rates Related to Cirrhosis in Brazil from 2000 to 2012: A Nationwide Analysis

ABSTRACT Background. Cirrhosis remains the most frequent liver-related cause of death worldwide and we aimed to evaluate its burden in Brazil from 2000 to 2012. Material and methods. The Brazilian National Death Registry was analyzed from 2000 to 2012. Death by cirrhosis was defined by the presence of I85, K73 and/or K74 ICD 10 codes in contributing or underlying causes of death on the death certificate (DC). Crude mortality rates were calculated as the ratio of the absolute number of deaths and the estimated population. Mortality rates were age-adjusted by the direct standardization method using the WHO standard population. Results. A total of 265,180 deaths where cirrhosis was mentioned on the DC [77% male, aged 56 years] occurred from 2000 to 2012. Cirrhosis codes were present in 46% of liver-related deaths and 2% of all deaths in this period. Despite an increase in the absolute number of deaths (n = 18,245 to 22,340), the age-standardized mortality rates (95%CI) decreased from 13.32 (13.16-13.48) to 11.71 (11.59-11.83) per 100,000 inhabitants from 2000 to 2012 (p < 0.001). This trend was not uniform across the country, with decreases in death rates in the South [14.46 (14.07-14.87) to 10.89 (10.59-11.19)] and Southeast [15.85 (15.6-16.09) to 12.52 (12.34-12.70)] and increases in the North [8.84 (8.24-9.43) to 11.53 (11.08-11.99)] and Northeast [9.41 (9.13-9.69) to 10.93 (10.68-11.17)] (p < 0.001 for all). Conclusion. Cirrhosis remains a major public health issue, despite the reduction in mortality rates in the last decade.

Hospitalization rates, length of stay and in-hospital mortality in a cohort of HIV infected patients from Rio de Janeiro, Brazil

Abstract In this study, we evaluated trends in hospitalization rates, length of stay and in-hospital mortality in a cohort of HIV-infected patients in Rio de Janeiro, Brazil, from 2007 through 2013. Among the 3991 included patients, 1861 hospitalizations occurred (hospitalization rate of 10.44/100 person-years, 95% confidence interval 9.98-10.93/100 person-years). Hospitalization rates decreased annually (per year incidence rate ratio 0.92, 95% confidence interval 0.89-0.95) as well as length of stay (median of 15 days in 2007 vs. 11 days in 2013, p-value for trend < 0.001), and in-hospital mortality (13.4% in 2007 to 8.1% in 2013, p-value for trend = 0.053). Our results show that, in a middle-income setting, hospitalization rates are decreasing over time and non-AIDS hospitalizations are currently more frequent than those related to AIDS. Notwithstanding, compared with high-income settings, our patients had longer length of stay and higher in-hospital mortality. Further studies addressing these outcomes are needed to provide information that may guide protocols and interventions to further reduce health-care costs and in-hospital mortality.

Self-rated health and substance use among individuals in HIV care in Rio de Janeiro, Brazil: a cross-sectional study.

Self-rated health (SRH) is associated with morbidity and mortality in HIV-uninfected populations but is understudied in HIV. Substance use may affect SRH in addition to its deleterious effect on HIV disease. This analysis aimed to estimate SRH and substance use prevalence and evaluate factors associated with poor SRH among individuals in HIV care in Rio de Janeiro, Brazil. A convenience sample of HIV-infected adults completed one item of SRH, the Alcohol, Smoking and Substance Involvement Screening Test, and the Patient Health Questionnaire-2 (PHQ-2). Logistic regression models identified factors associated with poor SRH. Participants' (n = 1029) median age was 42.9 years, 64.2% were male, and 54.5% were nonwhite. Poor SRH was reported by 19.5% and the use of alcohol, tobacco, marijuana, and crack/cocaine by 30.1, 19.5, 3.9, and 3.5%, respectively. Less than high school education (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI]: 1.08-2.20), lack of sexual activity in previous 12 months (aOR 1.53, 95% CI: 1.01-2.30), crack/cocaine use (aOR 3.82, 95% CI: 1.80-8.09), positive PHQ-2 screen (aOR 3.43, 95% CI: 2.09-5.62), and HIV-1 RNA ≥40 c/ml (aOR 2.51, 95% CI: 1.57-4.02) were significantly associated with poor SRH as identified by logistic regression analyses. Alcohol, marijuana, and sedative use were not significantly associated with poor SRH. These results emphasize the need for substance use and mental health screening and treatment in this population. Further research may elucidate the consequences of poor SRH on treatment adherence, morbidity, and mortality in HIV-infected individuals.

DEB TACE for Intermediate and advanced HCC - Initial Experience in a Brazilian Cancer Center.

BACKGROUND: According to Barcelona Clinic Liver Cancer classification transarterial chemoembolization is indicated in patients with Hepatocellular Carcinoma in the intermediate stage. Drug-eluting microspheres can absorb and release the chemotherapeutic agent slowly for 14 days after its intra-arterial administration. This type of transarterial chemoembolization approach appears to provide at least equivalent effectiveness with less toxicity. METHODS: This is a prospective, single-center study, which evaluated 21 patients with intermediate and advanced hepatocellular carcinoma who underwent transarterial chemoembolization with drug-eluting microspheres. The follow up period was 2 years. Inclusion criteria was Child-Pugh A or B liver disease patients, intermediate or advanced hepatocellular carcinoma and performance status equal or below 2. Transarterial chemoembolization with drug-eluting microspheres was performed at 2-month intervals during the first two sessions. The third and subsequent sessions were performed according to the image findings on follow-up, on a "demand schedule". Tumor response and time to progression were evaluated along the two-year follow up period. RESULTS: Of the 21 patients 90% presented with liver cirrhosis, 62% had Barcelona Clinic Liver Cancer stage B and 38% had Barcelona Clinic Liver Cancer stage C hepatocellular carcinoma. Average tumor size was 6.9 cm. The average number of Transarterial chemoembolization with drug-eluting microspheres procedures was 3 with a total of 64 sessions. The predominant toxicity was mild. Liver function was not significantly affected in most patients. Two deaths occurred within 90 days after Transarterial chemoembolization with drug-eluting microspheres (ischemic hepatitis and hydropic decompensation). Technical success was achieved in 63 of 64 procedures. The mean hospital stay was 1.5 days. The progression free and overall survival at 1 and 2 years were 73.0% and 37.1%, 73.7% and 41.6%, respectively. CONCLUSION: Transarterial chemoembolization with drug-eluting microspheres is able to deliver significant tumor response and progression free survival rate with acceptable toxicity. Larger studies are needed to identify exactly which subset of advanced hepatocellular patients may benefit from this treatment. TRIAL REGISTRATION: study ID ISRCTN16295622. Registered October 14th 2016. Retrospectively registered. Website registration: http://www.isrctn.com/ISRCTN16295622.