Sexual behavior and self-declaration of sexual orientation among people 18-64 years in Brazil: results from the Knowledge, Attitudes, and Practices survey, 2013 and the National Health Survey, 2019.

BACKGROUND: Population surveys involving the monitoring of high-risk sexual behavior have been recognized as important public health tools to control the HIV epidemic and other sexually transmitted infections (STIs). METHODS: Using data from the Knowledge, Attitudes, and Practices survey (PCAP-2013) and from the National Health Survey (PNS-2019), indicators of sexual behavior were compared according to sociodemographic characteristics among individuals aged 18-64 years, including size (%) estimates of men who have sex with men (MSM) and women who have sex with women (WSW). Specifically, the PNS-2019 prevalence estimates of homosexual, bisexual, heterosexual males and females were compared with those from the PCAP-2013. To compare PCAP and PNS proportional distributions, the Pearson's chi-square test, adjusted by the Rao-Scott's correction, was applied. RESULTS: Size (%) estimates of MSM and WSW obtained by direct questions from the PCAP-2013, showed higher homosexuality prevalence estimates than those resulting from the PNS-2019 self-declared sexual orientation. Significant differences were found between the MSM proportions according to the PCAP-2013 (3.7%; 95% CI 3.1-4.4%) and to the PNS-2019 (2.2%; 95% CI 1.9-2.5), and between the WSW proportions (4.6%; 95% CI 4.0-5.4%) and (2.1%; 95% CI 1.8-2.4), respectively. Results from both surveys showed MSM and WSW prevalence estimates increase with educational level, decrease with age, and is larger among people who do not live with partner, live in urban areas and in state capitals. Regarding condom use at last sexual intercourse, no differences between the PCAP-2013 and the PNS-2019 estimates were found at the national level, but significant improvements were found for MSM, people aged 18-24 and 25-34 years, and individuals not living with a partner. CONCLUSIONS: The underestimation of MSM and WSW prevalence by self-declared sexual orientation suggests that sexual minorities face many difficulties related to disclosing their sexuality and reinforces the importance of developing public health interventions for changing population attitudes and promoting sexual orientation disclosure. Moreover, the low use of condoms in both surveys (PCAP-2013 and PNS-2019) carried out 6 years apart highlights the need of public policies to expand prevention strategies for HIV infection and other STIs.

HIV/Aids and COVID-19 in Brazil: in four decades, two antithetical approaches to face serious pandemics.

In the space of four decades, Brazil has faced two serious pandemics: human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and Coronavirus disease 2019 (COVID-19). The country's response to HIV/AIDS was coordinated by several stakeholders and recognised the importance of scientific evidence in guiding decision-making, and a network offering monitoring and antiretroviral treatment was provided through coordinated efforts by the country's universal health system. Conversely, the lack of a centrally coordinated strategy and misalignment between government ministries regarding the COVID-19 pandemic response, together with the denial of scientific evidence, promotion of ineffective treatments and insufficient vaccination efforts, have all led to the uncontrolled spread of infection, the near-total collapse of the health system and excess deaths.

Homeopathic Treatment of Overweight and Obesity in Pregnant Women With Mental Disorders: A Double-blind, Controlled Clinical Trial.

Context • Worldwide, 35 million people suffer from obesity. Mental disorders have been associated with being overweight or obese. Considerable evidence has shown a correlation between stress and the use of homeopathy and stress and obesity. However, few studies have examined the relationship between weight loss and homeopathic treatment of obesity. Objective • The study intended to evaluate the efficacy of a homeopathic treatment in preventing excessive weight gain during pregnancy in overweight or obese women who were suspected of having a common mental disorder. Design • The study was a randomized, controlled, double-blinded clinical trial. Setting • The study took place at the Center for the Social Support of Motherhood (São Paulo, Brazil). Participants • Participants were pregnant women who were enrolled at the center. Intervention • For the homeopathic group, 9 drugs were preselected, including (1) Pulsatilla nigricans, (2) Sepia succus, (3) Lycopodium clavatum, (4) sulphur, (5) Lachesis trigonocephalus, (6) Nux vomica, (7) Calcarea carbonica, (8) phosphorus; and (9) Conium maculatum. From those 9 drugs, 1 was prioritized for administration for each participant. After the first appointment, a reselection or selection of a new, more appropriate drug occurred, using the list of preselected drugs. The dosage was 6 drops orally 2 ×/d, in the morning and at night, on 4 consecutive days each wk, with an interval of 3 d between doses, up until the next appointment medical appointment. The control group received the equivalent placebo drug. Both groups also received a diet orientation. Outcome Measures • We evaluated pregnant women who were overweight or had class 1 or 2 obesity and were suspected of having a common mental disorder, with no concomitant diseases, in 2 groups: those receiving a placebo (control group, n = 72); and those receiving homeopathic treatment (homeopathy group, n = 62). Weight change during pregnancy was defined as the difference between the body mass index (BMI) at the initial evaluation and that recorded at the final evaluation, adjusted for 40 wk of gestation. In addition, the APGAR index in the newborn was evaluated as a possible complication. Results • The mean variation between baseline BMI and BMI at week 40 of gestation was +4.95 kg/m2 in the control group and +5.05 kg/m2 in the homeopathy group. The difference between the 2 groups was not significant (P = .815; 95% confidence interval [CI], -0.916 to 0.722). APGAR 10 at 5 min (59.6%in homeopathy group and 36.4% among control) was statistically significant (P = .016). Conclusions • Homeopathy does not appear to prevent excessive body mass gain in pregnant women who are overweight or obese and suspected of having a common mental disorder. Homeopathy did not change the APGAR score to modified clinical attention at delivery room. However, the evidence observed at APGAR 10 at minute 5 suggests that homeopathy had a modulating effect on the vitality of newborns, warranting further studies designed to investigate it.

Using Respondent-Driven Sampling (RDS) to Identify the Healthcare Needs among Women of Reproductive Age Who Migrated from Venezuela to Brazil, 2018-2021.

In 2021, an RDS survey was conducted among Venezuelan migrant women of reproductive age who migrated to two Brazilian cities (Manaus and Boa Vista) from 2018 to 2021. To start the RDS recruitment, we chose seeds non-randomly in both cities. The study variables were age, educational level, self-rated health, pregnancy, migratory status and use of health services. We estimated the prevalence, confidence intervals and homophily effects by variable category. We used a multivariate logistic regression model to identify the main factors associated with healthcare use. A total of 761 women were recruited in Manaus and 1268 in Boa Vista. Manaus showed more irregular migrants than Boa Vista. The main reasons for using health services were as follows: illness, disease prevention and prenatal care. The logistic regression model showed the use of health services was associated with educational level and healthcare needs but not with migratory status. The social inclusion of Venezuelan migrants is extremely relevant, although many challenges must be overcome. The strategy of the Brazilian Federal Government for providing humanitarian assistance to Venezuelan migrants should be expanded to include and facilitate their integration into labor markets, access to healthcare and education, benefiting both migrants and the Brazilian people by reducing social inequality.

Chemonucleolysis in lumbar disc herniation: a meta-analysis.

PURPOSE: To carry out a systematic review and meta-analysis of the efficacy of chemonucleolysis in the treatment of lumbar disc herniation. METHODS: Clinical trials were selected from 3 electronic databases (The Cochrane Controlled Trials Register, MEDLINE, and EMBASE). Data were analyzed with the software STATA, using the meta command. RESULTS: Twenty-two clinical trials were eligible. For chemonucleolysis versus placebo, the summary risk ratio estimate for pain relief as outcome was 1.51 (95% CI: 1.27-1.80). The summary estimate was 1.07 (95% CI: 0.95-1.20) for the comparison between chymopapain and collagenase. Regarding chemonucleolysis with chymopapain versus surgery, the fixed-effect summary estimate of effect for pain relief was 0.93 (95% CI: 0.88-0.98) with surgery as the reference group. In this case, heterogeneity was statistically significant. CONCLUSIONS: Chemonucleolysis with chymopapain was superior to placebo and was as effective as collagenase in the treatment of lumbar disc prolapse. Results for studies comparing chemonucleolysis with surgery were heterogeneous, making it difficult to interpret the summary measure of effect.

Delay in introducing antiretroviral therapy in patients infected by HIV in Brazil, 2003-2006.

PURPOSE: To characterize the population of HIV+ Brazilian patients with late introduction of antiretroviral therapy (ARVT), using information from the Laboratory Exam Control System. METHODS: The study analyzed 84,694 patients, representing all individuals in Brazil age 15 or over with an initial CD4+ T lymphocyte count requested between 2003 and 2006, and whose ARVT start date was later than their initial CD4+ T cell count. These patients were considered antiretroviral treatment naive. The initial CD4+ T cell distribution was analyzed according to sex, age, region and year. RESULTS: Most of the patients were between 15 and 49 years of age (91%); 56% were males; 76% were asymptomatic; 50% lived in the Southeastern region of the country, with an additional 20% in the South. Initial CD4+ counts for one-third of the patients were less than 200 cells/mm(3). When combined with the number of symptomatic individuals, 41% of the total group was in need of immediate ARVT. This group included 47% of the men and 53% of the patients aged 50 years and over. CONCLUSIONS: Despite universal access to ARVT in Brazil, results show that a high proportion of patients initiate ARVT at an advanced stage of disease, indicating the need to develop strategies to promote early diagnosis of HIV infection nationwide.

Use of cerebrospinal fluid and serum samples impregnated on FTATM Elute filter paper for the diagnosis of infections caused by Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae.

BACKGROUND: The lack of information regarding the burden of acute bacterial meningitis in Latin America leads to a reduction in the estimated incidence rates of the disease, and impairs public health decisions on the use and follow-up of preventive interventions, particularly, the evaluation of existing vaccination policies. The use of the real-time PCR in diagnostic routine procedures has resulted in a substantial increase in confirmed bacterial meningitis cases. However, in resource-poor countries, these assays are only available in reference laboratories. Sample transportation to these laboratories is a critical constraint, as it requires specialized, high cost courier services. To overcome this barrier we evaluated the use of FTATM Elute filter paper cards for the conservation and processing of samples under normal environmental conditions, as they would be when transported from remote and under-equipped healthcare facilities to the reference centers. A total of 401 samples received in 2015 as part of Sao Paulo's national surveillance for routine diagnosis were selected for this study. METHODS: The sensitivity and specificity of real-time PCR were evaluated using fresh serum and cerebrospinal fluid (CSF) samples processed using our laboratory's standard DNA extraction, and processing the same samples after being dried and stored on FTATM card, and DNA extracted following the manufacturer's instructions. RESULTS: The sensitivities for detection of Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae from CSF dried and stored on FTATM cards were 98%, 92%, and 100%, respectively, and with serum samples were 73%, 88%, and 100%, respectively. When compared to our laboratory's standard methodology, results showed high concordance, with Kappa index ranges of 0.9877-1.00 for CSF, and 0.8004-1.00 for serum samples. CONCLUSION: The use of FTATM cards for CSF and serum conservation and transport represents a rapid, reliable, and cost-effective alternative that will allow obtaining valuable epidemiological information that would otherwise be lost.

[Spatial distribution of M. tuberculosis-HIV coinfection in São Paulo State, Brazil, 1991-2001]. / Distribuição espacial da co-infecção M. tuberculosis/HIV no Estado de São Paulo, 1991-2001.

OBJECTIVE: To assess the spatial pattern of tuberculosis incidence in relation to the AIDS epidemic, with the aim of investigating the geographical influence on causality. METHODS: All AIDS cases from State of São Paulo, notified to the Brazilian Ministry of Health between 1991 and 2001, were included. The cases were stratified by municipality, by administrative health regions, AIDS transmission categories, gender and years since diagnosis. A Gaussian geostatistical model was used to construct a thematic risk map, utilizing the tuberculosis incidence among AIDS cases as the response variable. RESULTS: Exploratory analysis showed two patterns of AIDS incidence: one for the state capital, and another, with increasing risk, for the other municipalities. The more populous regions presented higher risk of tuberculosis transmission, with a pattern that matched the land occupation pattern, from east to west. The health regions with the highest AIDS incidence coefficients (per 10,000 inhabitants) were Santos (53.5), São José do Rio Preto (43.1), Ribeirão Preto (42.4) and São Paulo (40.3). The health regions with greatest tuberculosis incidence among AIDS cases were Santos (44.9%), Franco da Rocha (39.9%), Osasco (39.6%) and São Paulo (38.9%). CONCLUSIONS: The results allow the conclusion that geographical coordinates presented an association with tuberculosis risk, but not with AIDS risk.

[Cofactors of antiretroviral treatment interruption in cases of adults with AIDS: Rio Grande do Norte, Brazil, 1999-2002]. / Fatores associados à interrupção de tratamento anti-retroviral em adultos com AIDS: Rio Grande do Norte, Brasil, 1999 - 2002.

BACKGROUND: The purpose of this study is to determine factors associated to the interruption of antiretroviral treatment in adults with AIDS in the State of Rio Grande do Norte, Brazil. METHODS: This was a population-based study, using data from the State's sources of vital statistics. Interruption was calculated using data on the number of programmed visits to the pharmacies, taking into account the date of the first prescription. It was considered that patients had adhered to the treatment if they came to at least 80% of the programmed visits. RESULTS: The overall percentage for non interruption of the antiretroviral therapy was 64.1%. No association was found with the following: gender, type of exposure, residence, nor with the type of antiretroviral combination prescribed. After multivariate analysis, significant associations continued to be found between interruption and in-hospital stay, use of drugs, psychiatric treatment, low level of education and age ranging from 25 to 34 years. CONCLUSIONS: These results point towards significant associations between interruption of antiretroviral treatment and the beginning of antiretroviral therapy during the in-hospital stay, the use of legal or illegal drugs, a history of psychiatric treatment, low level of education, and age ranging from 25 to 34 years.

Regional patterns of the temporal evolution of the AIDS epidemic in Brazil following the introduction of antiretroviral therapy.

We examined the characteristics of the AIDS epidemic in the northeastern region of Brazil, comparing it to the epidemic in Brazil as a whole, and to the state of São Paulo, with respect to the temporal evolution of morbidity and mortality during the period 1990 to 1999, using information from communicable disease reports and mortality records. Since 1996, the incidence rate of AIDS in adults in Brazil as a whole and in São Paulo has been showing a trend towards stability, whereas in the Brazilian northeast the incidence rates of the disease continue to grow. In the northeast, sexual transmission is responsible for more than 80% of cases, injectable drug users (IDU) comprising only a small percentage of cases. There is a greater incidence of AIDS among groups with lower educational levels throughout the country. The comparative analysis of cases of AIDS and of deaths from AIDS shows growth, both in the number of cases and in the number of deaths; however, from 1996 onwards there has been a progressive reduction in the number of deaths in all regions analyzed. With respect to the incidence of cases of the disease acquired by vertical transmission, a significant growth trend can be seen in all regions for cases born in the period 1990-6, but in 1997 temporal analysis showed evidence of a reduction in this growth. In conclusion, temporal changes have occurred in the AIDS epidemic in Brazil, which has been showing a trend towards stability since 1996, when potent ARV therapy was introduced. However, this deceleration is not homogenous throughout all the regions.

Temporal trends of HIV-related risk behavior among Brazilian military conscripts, 1997-2002.

PURPOSE: To present selected results of military conscript surveys related to HIV/AIDS, conducted in Brazil, 1997-2002. METHODS: Questionnaires including information on socio-demographic data, sexual behavior practices, sexually transmitted infections-related problems, and use of injecting drugs were completed by 30970 individuals, obtained through a 2-stage sampling. An index of sexual risk behavior was developed to take into account multiplicity of partners and irregularity of condom use. The HIV infection prevalence rate was estimated for 2002. Logistic regression was used to identify the most important determinants of HIV infection. RESULTS: The percentage of regular condom use increased from 38% (1997) to 49% (2002), and the index of sexual risk behavior decreased from 0.98 in 1997 to 0.87, in 2002. The HIV infection prevalence rate was 0.09%, in 2002, which remained unchanged since 1998 Riskier sexual practices among young men with incomplete education and among "men who have sex with men" were found as well as among the participants who reported at least one sexually transmitted infections - related problem. The most important predictor of HIV infection was to be positive for syphilis. CONCLUSIONS: The estimated value of the HIV infection prevalence supports the diagnosis of a concentrated HIV epidemic, in Brazil. Results indicate that particular attention needs to be paid for regional differentials, and for special subgroups, in Brazil.

[Ethics and medical research: principles, guidelines, and regulations]. / Etica e pesquisa médica: princípios, diretrizes e regulamentações.

The issue of ethics in medical research grew in importance at the end of World War II, after the Nuremberg Code. In this period, some cases in the United States had demonstrated the need for the establishment of rules and procedures in medical research. In this article, the authors discuss some ethical concepts and their philosophical basis, stressing aspects related to research. Ethics in medical research is based upon three items: peer approaches, subject informed consent, and confidentiality of individual obtained data. The authors also summarize the Brazilian laws and directives to follow the precepts and to control the process of ethical issues in research with human participants. Finally, they approach practical questions of the Informed Consent Form as a consequence of their experiences analyzing more than one thousand research projects per year as members of the Internal Review Board of the University of São Paulo School of Medicine, São Paulo, Brazil.

Pre-exposure and postexposure prophylaxes and the combination HIV prevention methods (The Combine! Study): protocol for a pragmatic clinical trial at public healthcare clinics in Brazil.

INTRODUCTION: Few results from programmes based on combination prevention methods are available. We propose to analyse the degree of protection provided by postexposure prophylaxis (PEP) for consensual sexual activity at healthcare clinics, its compensatory effects on sexual behaviour; and the effectiveness of combination prevention methods and pre-exposure prophylaxis (PrEP), compared with exclusively using traditional methods. METHODS AND ANALYSIS: A total of 3200 individuals aged 16 years or older presenting for PEP at 5 sexually transmitted disease (STD)/HIV clinics in 3 regions of Brazil will be allocated to one of two groups: the PEP group-individuals who come to the clinic within 72 h after a sexual exposure and start PEP; and the non-PEP group-individuals who come after 72 h but within 30 days of exposure and do not start PEP. Clinical follow-up will be conducted initially for 6 months and comprise educational interventions based on information and counselling for using prevention methods, including PrEP. In the second study phase, individuals who remain HIV negative will be regrouped according to the reported use of prevention methods and observed for 18 months: only traditional methods; combined methods; and PrEP. Effectiveness will be analysed according to the incidence of HIV, syphilis and hepatitis B and C and protected sexual behaviour. A structured questionnaire will be administered to participants at baseline and every 6 months thereafter. Qualitative methods will be employed to provide a comprehensive understanding of PEP-seeking behaviour, preventive choices and exposure to HIV. ETHICS AND DISSEMINATION: This study will be conducted in accordance with the resolution of the School of Medicine Research Ethics Commission of Universidade de São Paulo (protocol no. 251/14). The databases will be available for specific studies, after management committee approval. Findings will be presented to researchers, health managers and civil society members by means of newspapers, electronic media and scientific journals and meetings.

[Male circumcision and HIV infection: an international debate with no Brazilian participation]. / Circuncisão masculina e infecção pelo HIV: uma polêmica mundial sem voz brasileira.

The authors discuss male circumcision as a protective factor against HIV transmission. The absence is noted of Brazilian data published in the international literature regarding this issue. Finally, it is emphasized that self-declared circumcision status is subject to substantial misclassification with the generation of biased risk estimates.

[The AIDS epidemic in Brazil, 1991-2000: space-time description]. / A epidemia de AIDS no Brasil, 1991-2000: descrição espaço-temporal.

The incidence of AIDS was described by an ecological study of Brazilian municipalities, considering cases reported from 1991 to 2000. An increasing incidence was observed in women and among individuals with a low educational level. São Paulo State had different epidemiological profiles when the State Capital was compared to other cities, with an overall 46% of reported cases in the Country; Pernambuco State had almost the same profile since the beginning of the epidemic in Brazil; In Santa Catarina State the category of intravenous drug users had the greatest exposure. The increasing number of cases reported under the category of unknown transmission showed the increased bias in measurement by the surveillance system.

[HIV infection during pregnancy: the Sentinel Surveillance Project, Brazil, 2002]. / Infecção pelo HIV durante a gestação: estudo-Sentinela Parturiente, Brasil, 2002.

OBJECTIVE: To evaluate the actual coverage of HIV infection detection during pregnancy at national level. METHODS: The actual coverage of HIV testing during pregnancy was defined as the proportion of women who attended prenatal care visits (at least one visit), ordering HIV testing and knowledge of test result before delivery. The coverage was estimated by sampling procedures based on the 2002 Sentinel Surveillance Study data. Actual coverage Inequalities were assessed by: country regions; population size of the municipality where delivery took place; and mother's schooling. RESULTS: The actual coverage of HIV testing during pregnancy was 52%. Huge sociogeographic inequalities are seen between the Northeastern (24%) and Southern regions (72%); illiterate mothers (19%) and those with complete basic education (64%); mothers who delivered in small municipalities (36%) and those who delivered in municipalities with more than 500,000 inhabitants (66%). Ministry of Health recommendations were fully followed by only 27% pregnant women. CONCLUSIONS: The study results show a need for actions aiming at increasing HIV detection coverage during pregnancy, and indicate that HIV/STD programs should be intensified with joint strategies between the National AIDS Program and infant-maternal programs.

Spatial distribution of the human development index, HIV infection and AIDS-Tuberculosis comorbidity: Brazil, 1982-2007.

INTRODUCTION: AIDS epidemic has given visibility to the incidence of tuberculosis, for being the most frequent opportunistic infection. It is known that individuals who are socially vulnerable are more susceptible to HIV transmission and tuberculosis as well. OBJECTIVE: This study aims to conduct a geoepidemiological study on HIV/AIDS, AIDS-Tuberculosis co-infection and social vulnerability. METHOD: This is an ecological study using incidence rates and the human development index to produce thematic maps and a descriptive analysis of epidemiology. The records of reported cases of HIV/AIDS from 1982 to 2007 were used, considering as cases of AIDS-Tuberculosis those records that were positively diagnosed with tuberculosis and those records with unknown diagnosis of tuberculosis, but showing compatible signs and symptoms with tuberculosis (fever, cough, cachexia and asthenia). RESULTS: The maps allowed the identification of areas with social differences and different patterns of incidence of HIV/AIDS and AIDS-Tuberculosis; regional differences were similar to those found by Josué de Castro, in 1940; regions with higher human development index values also showed higher incidence HIV/AIDS and AIDS-Tuberculosis. CONCLUSION: The prevention of HIV infection must be geographically specific, given socioeconomic and cultural differences. Although official records show decline in AIDS-TB co-infection, treatment of cases of HIV/AIDS should observe the occurrence of opportunistic diseases, which should be notified and/or updated.

The HIV-Brazil cohort study: design, methods and participant characteristics.

BACKGROUND: The HIV-Brazil Cohort Study was established to analyze the effectiveness of combination antiretroviral therapy (cART) and the impact of this treatment on morbidity, quality of life (QOL) and mortality. The study design, patients' profiles and characteristics of cART initiation between 2003 and 2010 were described. METHODOLOGY/PRINCIPAL FINDINGS: Since 2003, the HIV-Brazil Cohort has been following HIV-infected adults receiving cART at 26 public health care facilities, using routine clinical care data and self-reported QOL questionnaires. When not otherwise available, data are obtained from national information systems. The main outcomes of interest are diseases related or unrelated to HIV; suppression of viral replication; adverse events; virological, clinical and immunological failures; changes in the cART; and mortality. For the 5,061 patients who started cART between 2003 and 2010, the median follow-up time was 4.1 years (IQR 2.2-5.9 years) with an 83.4% retention rate. Patient profiles were characterized by a predominance of men (male/female ratio 1.7∶1), with a mean age of 36.9 years (SD 9.9 years); 55.2% had been infected with HIV via heterosexual contact. The majority of patients (53.4%) initiated cART with a CD4+ T-cell count ≤200 cells/mm3. The medications most often used in the various treatment regimens were efavirenz (59.7%) and lopinavir/ritonavir (18.2%). The proportion of individuals achieving viral suppression within the first 12 months of cART use was 77.4% (95% CI 76.1-78.6). Nearly half (45.4%) of the patients presented HIV-related clinical manifestations after starting cART, and the AIDS mortality rate was 13.9 per 1,000 person-years. CONCLUSIONS/SIGNIFICANCE: Results from cART use in the daily practice of health services remain relatively unknown in low- and middle-income countries, and studies with the characteristics of the HIV-Brazil Cohort contribute to minimizing these shortcomings, given its scope and patient profile, which is similar to that of the AIDS epidemic in the country.