Postcoital vaginal bleeding as a risk factor for transmission of the human immunodeficiency virus in a heterosexual partner study in Brazil. Rio de Janeiro Heterosexual Study Group.

BACKGROUND: Several risk factors for male-to-female human immunodeficiency virus (HIV) transmission are well established, but few studies have examined the role of postcoital vaginal bleeding. METHODS: Couples recruited from AIDS centers in Rio de Janeiro, Brazil, were interviewed for risk factors and had blood collected for examinations. Eligibility criteria included confirmed HIV positivity for the male partner, aged 18 years of older, heterosexual contact in the past year, and no other risk factor for female partners except sexual contact with the HIV-infected male partner. Logistic regression was used to assess the association between HIV serostatus and risk factors in the female partners. RESULTS: The prevalence of HIV infection was 47.6% among the 418 women available for analysis. The following factors were independently associated with HIV infection; anal sex (odds ratio [OR], 3.06), condom use during vaginal sex sometimes (OR, 1.42) and rarely to never (OR, 2.00) compared with always, frequency of sexual contacts (> 100 in the previous year) (OR, 1.71), HIV-infected male partners with symptoms of acquired immunodeficiency syndrome (OR, 1.70), and postcoital vaginal bleeding (OR, 1.89). The association of postcoital bleeding and HIV infection was more pronounced among women who did not engage in anal sex. CONCLUSIONS: The results support previous studies showing that advanced HIV infection in the male partner, anal sex, inconsistent condom use, and frequent sex are associated with HIV infection among the female partners of HIV-infected men. Postcoital vaginal bleeding was also identified as a risk factor for infection. In addition to other established preventive measures, a recommendation for seeking diagnosis and treatment of sexually transmitted diseases that are associated with postcoital bleeding and using water-soluble lubricants during sex to minimize trauma seems prudent.

HIV infection in 567 active pulmonary tuberculosis patients in Brazil.

We studied 567 patients with active pulmonary tuberculosis (APT) in Rio de Janeiro, Brazil, by using a standardized questionnaire and by testing blood for HIV antibodies. The rate of HIV infection was 3.9% in 1987, 4.8% in 1988, and 5.2% in 1989, and did not differ by sex. It was highest (7.4%) in the 15- to 39-year age group. There was no difference between patients infected and not infected by HIV with regard to education, income, housing, or employment. Among all patients with definite HIV risk behavior, the HIV infection rate was 23.3%, rising to 31.2% among homo/bisexual men and 36.4% among intravenous drug users, and the rate was 6.5% for blood-transfusion recipients. Among patients who denied risk behavior, the rate was 1.2%. Generalized lymphadenopathy and oral candidiasis occurred with greater frequency among HIV-infected patients (p < 0.0001). Applying the World Health Organization 1985 clinical criteria and revised case definition for AIDS, we found, respectively, sensitivities of 34% and 76.9% and specificities of 31% and 26.3%; in the Rio de Janeiro environment, these clinical criteria without HIV serology should not be adopted for tuberculosis patients. For chest radiographs, a significant association was found between HIV infection and the occurrence of atypical images (p = 0.0001), and hilar and/or mediastinal adenopathy (p = 0.0002) and absence of cavities (p = 0.0003). A PPD (purified protein derivative) skin test induration of < 5 mm was identified in 53% of the HIV-positive cases and in 31.3% of the HIV-negative cases. Only 11.5% of HIV-infected APT patients met the Centers for Disease Control 1987 AIDS criteria.

V3 region polymorphisms in HIV-1 from Brazil: prevalence of subtype B strains divergent from North American/European prototype and detection of subtype F.

Viral DNA sequences were determined over the V3 region of env from 28 infected individuals living in the high HIV-1 prevalence Brazilian cities of Rio de Janeiro and São Paulo. Twenty-six belonged to envelope sequence subtype B, prevalent in North America and Europe, and one was classified as subtype F, found recently in Brazil and in Romania (one appeared to be a B/F recombinant). Octameric sequences at the tip of the subtype B V3 loops were variable and distinct from those prevalent in North America and Europe. The GPGR motif, prevalent in North American/European strains, was found in only 8 (28.5%) sequences, whereas GWGR was found in 12 (43%) and novel sequences in 8 (28.5%). Brazilian subtype B sequences also diverged from the consensus North American/European strains over the remainder of the V3 loop. These results suggest that Brazilian HIV-1 B strains may have important antigenic differences from prototype subtype B strains currently being evaluated for use in HIV vaccines. These results should be taken into account for future vaccine programs in Brazil.

Immunoenzymatic assy (ELISA) in mucocutaneous leishmaniasis, kala-azar, and Chagas' disease: an epimastigote Trypanosoma cruzi antigen able to distinguish between anti-Trypanosoma and anti-Leishmania antibodies.

Areas where mucocutaneous leishmaniasis, kala-azar and Chagas' disease are prevalent often overlap in Latin America. Due to a variable degree of cross-reactivity between the three etiological agents and antibodies synthesized during the course of the disease, a test able to distinguish between them is greatly needed. Saline-extracted antigen from live Trypanosoma cruzi epimastigotes behaved towards Chagas' disease sera in immunoenzymatic assays (ELISA) with the same specificity and sensitivity as the antigen used routinely for such tests. In tests using mucocutaneous leishmaniasis or kala-azar sera, the live T. cruzi antigen showed a much lower geometric mean titer (GMT) than the standard T. cruzi antigen. In ELISA tests with L. braziliensis antigen a higher GMT was seen with kala-azar sera than with those from cases of mucocutaneous leishmaniasis. Also, sera from Vale do Ribeira leishmaniasis showed higher GMT with an L. donovani antigen than with a homologous one. Such discrepancies were not seen in immunofluorescence tests employing the same sera and antigens.

Safe sexual behaviour among female partners of HIV-infected men in Rio de Janeiro, Brazil.

A cross-sectional study was designed to assess safe sexual behaviour among heterosexual couples after the woman learned of her partner's infection with HIV. Female partners who had known their partners' serostatus for at least 4 weeks were eligible for participation. Couples were interviewed separately and independent predictors of safe sexual behaviour were identified using multiple logistic regression. Safe sexual behaviour was defined as no unprotected vaginal, oral, or anal intercourse. Of 328 women, 197 (60%) reported safe sexual behaviour since learning of their partners' infection. Significant independent predictors of safe sexual behaviour included older women (>30 years old) (odds ratio [OR]=1.89; 95% confidence intervals [CI]=1.01-3.51), current negative HIV serostatus (OR=2.72; 95% CI=1.50-4.94), advanced clinical stage of the index case (OR=1.96; 95% CI=1.07-3.59), longer duration of relationship (10+ years) (OR= 2.35; 95% CI=1.15-4.82), fewer sex contacts (<100) (OR=2.01; 95% CI=1.14-3.56), only one lifetime partner (OR=2.29; 95% CI=1.26-4.17), non-smoking (OR=2.67; 95% CI=1.43-4.99), not practising oral sex (OR=3.35; 95% CI=1.82-6.19) and previous HIV testing (OR=2.11; 95% CI=1.09-4.07). In addition, women who had known their partner's infection for longer were less likely to report safe sexual behaviour (P < 0.001). Our results indicate that among female partners of HIV-positive Brazilian men, learning of their partner's infection does not uniformly result in safe sexual behaviour. Counselling must emphasize disclosure of serostatus to female partners and target couples with short-term relationships, as well as those where the woman has known about her male partner's infection for a long time, because these are the least likely to maintain safe sexual behaviour.

Evaluation of enzyme-linked immunosorbent and alternative assays for detection of HIV antibodies using panels of Brazilian sera.

Sera from 472 Brazilian subjects, confirmed to be either positive or negative for HIV antibodies and comprising the total clinical spectrum of HIV infection, were utilized in the evaluation of six commercially available enzyme-linked immunosorbent assays (ELISA), as well as of four alternative assays, namely indirect immunofluorescence (IIF), passive hemagglutination (PHA), dot blot and Karpas AIDS cell test. The sensitivities ranged from 100% (Abbott and Roche ELISA) to 84.2% (PHA) and the specificities ranged from 99.3% (IIF) to 80.2% (PHA). The sensitivity and specificity of the PHA and the sensitivity of the Karpas cell test were significantly lower than those of the other tests. Although the IFF and dot blot had good sensitivities and specificities, the six ELISA were more attractive than those tests when other parameters such as ease of reading and duration of assay were considered.

PIP: 6 commercially available ELISA kits and 4 new Brazilian made methods for detecting HIV were compared on 2 panels of sera, 292 from AIDS patients, HIV-positives and negatives, and 180 sera from asymptomatic blood donors, including 90 HIV-positives. The kits tested were 5 ELISAs: Roche Diagnostica (Basel), Hoechst Enzygnostic (Sao Paulo), Virgo Electronuclionics (Columbia MD), Organon Teknika (Boxtel, Netherlands), Salck Industria e Comercio de Produtos Biologicos (Sao Paulo), and a passive hemagglutination test, (Salck Ind), and indirect immunofluorescence IIF (Virgo electronucleonics, Columbia), a dot blot (Embrabio, Empressa Brasiliera de Biotecnologia Ltda, Sao Paolo) and Karpas AIDS cell test, Fujichemical Industries Ltd (Chokeiji, Takaoka, Japan). The sensitivities ranged from 84.2% to 100% with no significant differences in sera from panel A. In panel B, the sensitivity of the PHA test was significantly lower than that of the ELISA and the AIDS cell tests. The specificities of the PHA and the AIDS cell tests were also lower than that of the ELISA. The costs of all the tests were similar, but the equipment needs varied. The simplest tests to perform were the dot blot assay, PHA and Karpas AIDS cell test. The Hoechst ELISA is simpler because it does not require dilution of the serum. The dot takes too long for use in a blood bank, 16-18 hours. Immunofluorescence tests would be practical in countries already screening blood for malaria or Changes disease. Brazil is not doing so on a large scale due to lack of political will. In countries with high incidence of malaria, Chagas disease, leishmania, hepatitis and leprosy, HIV test need to be tested on local sera because of possible B cell activation.

[The epidemiological aspects of HIV/AIDS in Brazil]. / Aspectos epidemiológicos da AIDS/HIV no Brasil.

A trend analysis of the AIDS epidemics in Brazil is presented, emphasizing temporal changes among the population groups most affected. Regional comparisons as well as projections of the extension of HIV infection and AIDS cases are also reported. Amongst the most relevant conclusions the alarming increase of cases in heterosexual populations and intravenous drug users is emphasised, specially in the southeast region.

[AIDS and HIV infection in Brazil: a multifaceted epidemic]. / AIDS e infecção pelo HIV no Brasil: uma epidemia multifacetada.

The HIV/AIDS epidemic is a dynamic unstable global phenomenon, constituting a veritable mosaic of regional sub-epidemics. As a consequence of the deep inequalities that exist in Brazilian society, the spread of HIV infection has revealed an epidemic of multiple dimensions undergoing extensive epidemiological transformations. Initially restricted to large urban centers and markedly masculine, the HIV/AIDS epidemic is currently characterized by heterosexualization, feminization, interiorization and pauperization. The evolution of the profile of AIDS in Brazil is above all due to the geographical diffusion of the disease from large urban centers towards medium and small municipalities in the interior, to the increase in heterosexual transmission and the persistent growth of cases among injecting drug users. The increase in transmission through heterosexual contact has resulted in substantial growth of cases among women, which has been pointed out as the most important characteristic of the epidemic's current dynamic in Brazil.

[Estimated number of HIV-infected individuals aged 15-49 years in Brazil, 1998]. / Estimativa do número de pessoas de 15 a 49 anos infectadas pelo HIV, Brasil, 1998.

This study estimates the number of HIV-infected individuals from 15 to 49 years of age in Brazil in 1998 based on sentinel population studies in pregnant women, with a selection bias in the sample. A principal components procedure was used to group 44 counties in homogeneous 13 clusters. Two indicators were constructed for each cluster: a) the logarithm of the accumulated AIDS incidence rate among women from 15 to 34 years of age (1996) and b) the logarithm of the growth ratio for the mean AIDS incidence rate for women from 15 to 34 years of age for the period from 1990-1992 to 1993-1996. Taking the log of the proportion of HIV-infected pregnant women as the dependent variable and the two above-mentioned indicators as the independent variables, a regression line was fitted to the aggregate data. Estimation of the model's parameters allowed us to calculate the proportion of infected individuals by macro-region, by age (15-34 and 35-49 years) and gender. The point estimate was 536 thousand HIV-infected adults with a 68% CI (470.689 - 603.305).

[On the Brazilian National Medical Educational Examination]. / Considerações sobre o Provão.

In Brazil, implementation of the so-called "Provão", or National Medical Course Examination, has raised numerous levels of discussion. This article aims to identify patterns in some of the more controversial issues: whether the Exam is really an instrument for evaluation of medical courses themselves, or that of future physicians; adequacy of assumptions underlying the questions as formulated; and lack of precision in the questions.

[Estimated number of orphans due to maternal AIDS in Brazil, 1987-99]. / Estimativa do número de órfãos decorrentes da AIDS materna, Brasil, 1987-1999.

This study proposes a procedure to estimate the number of orphans due to maternal AIDS. The procedure estimates the number of orphans by calendar year, multiplying the cumulative fertility rate by the number of AIDS deaths among women aged 15-49 years. Because the procedure refers to the number of children that are alive, the estimate is adjusted by contemplating the proportion of pediatric AIDS cases due to vertical transmission and the probability of survival in the 5-9-year age group. To estimate the number of AIDS orphans in Brazil from 1987 to 1999, the procedure was applied by stratifying according to geographical region, taking into account the differences in regional fertility rates, completeness of death reporting, and misclassification of AIDS-related deaths as due to other causes. The total number of cumulative AIDS orphans for 1987-99 was estimated at approximately 30,000.

[AIDS epidemic dynamics in the municipality of Rio de Janeiro, Brazil, 1988-1996: Spatial-temporal statistic modeling]. / Dinâmica da epidemia de AIDS no Município do Rio de Janeiro, no período de 1988-1996: uma aplicação de análise estatística espaço-temporal.

This study uses a spatial-temporal model to analyze the spatial spread of the AIDS epidemic (adult cases) in the municipality of Rio de Janeiro, Brazil, during three periods: 1988-1990, 1991-1993, and 1994-1996. City districts were used as the geographic units of analysis. A spatial analysis was also performed for pediatric AIDS cases due to vertical HIV transmission, according to period of birth, 1985-90 and 1991-96. For total adult AIDS cases, the initial period was characterized by a polygonal cluster located around the harbor area, which expanded from west to east. Among homosexual cases, in situ growth predominated, and a decrease in the intensity of the diffusion process was observed from the second to the final period. Among heterosexual cases, the epidemic displayed a relevant geographic spread, mainly from 1988-1990 to 1991-1993. Among female cases in the final time period, a cluster of high incidence rates was found towards the northwest, including very poor areas. Among pediatric cases in 1991-1996, a significant correlation was found between AIDS incidence rates and poverty levels in the respective municipal districts. The results suggest that a more complete understanding of AIDS spatial-temporal dynamics can make a major contribution to preventive measures.

[Risk behavior among Brazilian Military conscripts, 1998: an study of HIV infections following socioeconomic differences]. / Comportamento de risco dos conscritos do Exército Brasileiro, 1998: uma apreciação da infecção pelo HIV segundo diferenciais sócio-econômicos.

A study of HIV-related risk behavior was carried out in 1998 among Brazilian military conscripts aged 17-20 years. A sample of 30,318 subjects was selected in three strata, pertaining to counties from: 1) the North and Central-West (N/CW); 2) South (S); and the states of Rio de Janeiro and São Paulo. HIV prevalence rates were estimated in all strata. The objective of this paper was to analyze the results according to differences in socioeconomic status (SES). The statistical analysis used an index of sexual risk behavior and logistic regression models. The N/CW stratum showed the worst indicators for SES, sexual risk behavior, and sexually transmitted infections (STIs), as well as the highest HIV seroprevalence rate. The best indicators for all variables were found in the RJ/SP stratum. The South showed intermediate results. Level of schooling also played a relevant role. In all three strata the conscripts with an incomplete high school education displayed the worst sexual risk behavior index, shown to be a relevant predictor of STI-related problems, including HIV infection.

[Estimates of infant mortality in Brazil in the 80's: a proposal for a methodological procedure]. / Estimativas da mortalidade infantil no Brasil, década de oitenta: proposta de procedimento metodológico.

A procedure for the estimation of the infant mortality rate in Brazil, in the 1980's, based only on the age distribution of registered deaths, is here proposed. Using this technique, it is possible to estimate the probabilities of dying in the first year of life in a continuous way, year by year, for different regions of the country. The space-time distribution of the main causes of infant deaths is analysed and the relevance of using this coefficient to express the social and economic conditions of the Brazilian population from 1979 to 1989 is discussed.

[Proposal for a model for the desaggregation of demographic projections of large areas into their geographical components]. / Proposta de um modelo para desagregar projeções demográficas de grandes áreas em seus componentes geográficos.

The problem of the preparation of estimates of the total population of geographic subdivisions after the 1980 census is studied with a view to the tabulation on mortality data of Rio de Janeiro State (Brazil) by municipal districts and the estimation of regional mortality rates. In Brazil, the calculation of the official population estimates is undertaken by the Brazilian Institute of Geography and Statistics. The method employed to estimate the population of geographic subdivisions is known as the "AiBi method". This procedure is analysed and an alternative mathematical model is proposed that also satisfies the closure condition, that is, the projected values for the sum of the segments up to the total population projection. As an application of the proposed model, estimates of the population of the municipal districts of Rio de Janeiro State were prepared covering the period from 1981 to 1990.

[Regional differentials in cancer mortality in the state of Rio de Janeiro, Brazil, 1979-1981]. / Diferenciais regionais de mortalidade por câncer no estado do Rio de Janeiro, Brasil, 1979-1981.

In 1980, malignant neoplasms ranked 3rd as a cause of death in the State of Rio de Janeiro, Brazil, with a crude mortality rate of 89.8 per 100,000. Cancer mortality data for 1979-1981 are presented for the State, with the objective of analyzing regional differentials. For the purpose of comparing mortality from the most important cancers, the State was divided into three regions: Capital, Metropolitan Belt and Interior, on the basis of the geographical structure of the State--which gave rise to the present urbanization patterns. Average annual age and sex-specific mortality rates per 100,000 were calculated for the period 1979-1981 for each cancer site and for 5-year age groups up to 79 years and for 80 years and above. Age standardized rates (ASR) were calculated by direct standardization to the world population and standardized mortality ratios (SMR) were also calculated with the objective of comparing different geographical areas. It was found that the most important malignant neoplasms among males were those of the lung (ASR 27.9), stomach (ASR 24.0), prostate, oesophagus and liver. The breast was the most important site for females (ASR 16.0), followed by the stomach (ASR 10.8), lung, cervix uteri and uterus (unspecified). The highest ASR were in the Capital (164.4 in males, 106.2 in females) and the lowest in the Interior (126.5 in males, and 91.3 in females). The highest SMR were found for breast (1.28), colon (1.71) and lung (1.70) cancers, the mortality rates for which were almost two-times higher in the Capital than in the Interior.(ABSTRACT TRUNCATED AT 250 WORDS)