Assessing the best time interval between doses in a two-dose vaccination regimen to reduce the number of deaths in an ongoing epidemic of SARS-CoV-2.

The SARS-CoV-2 pandemic is a major concern all over the world and, as vaccines became available at the end of 2020, optimal vaccination strategies were subjected to intense investigation. Considering their critical role in reducing disease burden, the increasing demand outpacing production, and that most currently approved vaccines follow a two-dose regimen, the cost-effectiveness of delaying the second dose to increment the coverage of the population receiving the first dose is often debated. Finding the best solution is complex due to the trade-off between vaccinating more people with lower level of protection and guaranteeing higher protection to a fewer number of individuals. Here we present a novel extended age-structured SEIR mathematical model that includes a two-dose vaccination schedule with a between-doses delay modelled through delay differential equations and linear optimization of vaccination rates. By maintaining the minimum stock of vaccines under a given production rate, we evaluate the dose interval that minimizes the number of deaths. We found that the best strategy depends on an interplay between the vaccine production rate and the relative efficacy of the first dose. In the scenario of low first-dose efficacy, it is always better to vaccinate the second dose as soon as possible, while for high first-dose efficacy, the best strategy of time window depends on the production rate and also on second-dose efficacy provided by each type of vaccine. We also found that the rate of spread of the infection does not affect significantly the thresholds of the best window, but is an important factor in the absolute number of total deaths. These conclusions point to the need to carefully take into account both vaccine characteristics and roll-out speed to optimize the outcome of vaccination strategies.

Impact of the COVID-19 pandemic on the mental health of frontline healthcare workers in a highly affected region in Brazil.

BACKGROUND: The COVID-19 pandemic had a major impact on the mental health of healthcare workers (HCWs), especially in low and middle-income countries, which had to face additional political, social, and economic challenges. We thus aimed to assess the prevalence of mental health outcomes and the associated factors in HCWs treating COVID-19 patients in one of the most affected regions in Brazil. METHODS: We used the Respondent-Driven Sampling method to assess the risks of COVID-19 infection and symptoms of mental disorders in nurses, nursing technicians, and physicians who worked on the frontline in the metropolitan region of Recife. 865 healthcare workers completed a survey regarding sociodemographic data, work-related risks, and symptoms of mental disorders - SRQ-20 for common mental disorders (CMD); AUDIT-C for problematic alcohol use; GAD-7 for anxiety; PHQ-9 for depression; PCL-5 for post-traumatic stress disorder (PTSD). Gile's successive sampling estimator was used to produce the weighted estimates by professional category. A Poisson regression model with robust variance was used to analyze factors associated with a positive screening for CMD. We will present the results of a cross-sectional analysis of the mental health outcomes after the first peak of COVID-19 - from August 2020 to February 2021. RESULTS: The prevalence ratios for a positive screening for CMD were 34.9% (95% CI: 27.8-41.9) in nurses, 28.6% (95% CI: 21.3-36.0) in physicians, and 26.6% (95% CI: 16.8-36.5) in nursing technicians. Nurses presented a higher prevalence of depressive symptoms (23%). Positive screening for problematic alcohol use (10.5 to14.0%), anxiety (10.4 to 13.3%), and PTSD (3.3 to 4.4%) were similar between the professional categories. The main factors associated with CMD in nurses and physicians were related to an intrinsic susceptibility to mental illness, such as previous or family history of psychiatric disorder, and female sex. Among nurse technicians, work-related factors, such as accidents with biological material, presented the strongest association with CMD. CONCLUSION: The mental health of HCWs fighting COVID-19 in Recife was severely affected. It is crucial that healthcare services provide adequate working conditions and psychological support, investing in programs to promote and protect HCWs mental health.

Anticipated Stigma and Social Barriers to Communication Between Transgender Women Newly Diagnosed with HIV and Health Care Providers: A Mediation Analysis.

Purpose: We assessed whether anticipated stigma (i.e., fear of public mistreatment due to gender identity) impacts communication between transgender women (TGW) living with HIV and health care providers. Methods: This is a secondary analysis of baseline data from Trans Amigas, a study conducted in Brazil, 2018. The study population consisted of TGW living with HIV, older than 18 years, residing in the São Paulo metropolitan area. We used multivariable logistic regression (α = 0.05), mediation, and bootstrapping for the analysis. Results: One hundred and thirteen participants completed the study. Fear of public mistreatment had an adjusted odds ratio (aOR) of 7.42 (p = 0.003) for difficulty reporting new symptoms to providers. Concerning fear of public mistreatment, we found that unemployment had an aOR of 3.62 (p = 0.036); sex work, an aOR of 2.95 (p = 0.041); and issues related to name change in documents, an aOR of 2.71 (p = 0.033). For the indirect effect on difficulty reporting new symptoms, mediated by fear of public mistreatment, unemployment had an aOR of 1.52 (confidence interval [CI] = 0.88-2.24); sex work, an aOR of 1.48 (CI = 0.81-2.52); and name change issues, an aOR of 1.47 (CI = 0.96-2.43). Conclusions: Anticipated stigma was associated with communication difficulties between TGW living with HIV and providers. Our data suggest that structural factors associated with anticipated stigma could indirectly impact on difficulty reporting new symptoms. These findings indicate the importance of considering social contexts that intersect with individual experiences when analyzing communication barriers between providers and patients, and the need to strengthen social policies for TGW in Brazil. Clinical Trial Registration number: R34MH112177.

Prevalence of HIV infection among transgender women and travestis in Brazil: data from the TransOdara study.

OBJECTIVE: The aim of this study was to investigate the prevalence of human immunodeficiency virus (HIV) infection among transgender women and travestis and to analyze factors associated with HIV infection in Brazil. METHODS: TransOdara was a cross-sectional study on sexually transmitted infections among transgender women and travestis in five Brazilian cities between 2019 and 2021. Self-identified transgender women and travestis aged ≥18 years were recruited using respondent-driven sampling, completed an interviewer-led questionnaire, and provided samples to detect HIV. The outcome was the result of the rapid antigen testing for HIV. Adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI) were obtained using Poisson regression with robust variance. RESULTS: Overall, this population was found to be especially vulnerable, with high levels of unstable housing and engagement in informal work. They usually resort to transactional sex as their main working activity. Half of them earned less than the Brazilian minimum wage, which characterizes a poor population living in dire conditions. The overall HIV prevalence was 34.40%. In the final model, the variables associated with the HIV prevalence were as follows: to be 31 years old or older, not studying at the moment they were interviewed, to be unemployed, and engaged in lifetime transactional sex. CONCLUSION: We found disproportionately high HIV prevalence among transgender women and travestis, compared with a low prevalence among respective segments of Brazil's general population, which highlights the context of vulnerability in this population. The data point to the urgency for intensification and expansion of access to HIV prevention and strategies to stop discrimination in health care (among other services and contexts) and provide comprehensive services for this population.

Multiple substance use and associated factors in transgender women and travestis: findings from the TransOdara Study, Brazil.

OBJECTIVE: To estimate the prevalence of concomitant substance consumption and analyze associated risk factors in a non-probabilistic sample of the Brazilian population of transgender women and travestis. METHODS: A cross-sectional study was conducted with recruitment via respondent-driven sampling. The sample included transgender women and travestis residing in São Paulo, Porto Alegre, Salvador, Manaus, and Campo Grande, aged 18 years or older, between 2019 and 2021. The outcome was the concomitant use of licit and illicit substances. The association between sociodemographic/behavioral factors and the outcome was analyzed through Poisson regression with mixed effects. Adjusted prevalence ratios (confidence interval of 95% - 95%CI) were estimated. RESULTS: The prevalence in the last 12 months of multiple substance use was 49.3%, of which 65.5% were alcohol, 52.9% tobacco, and 40.1% marijuana. Transgender women and travestis who use multiple substances face more violence (1.71; 95%CI 1.14-2.55), unemployment (1.58; 95%CI 1.05-2.37) and pervasive unstable work status (1.52; 95%CI 1.08-2.14), transactional sex (1.51; 95%CI 1.21-1.88) which can be their sole option to make a living, and are aged 18 to 24 years (1.37; 95%CI 1.14-1.65). CONCLUSION: The use of multiple substances may be an attempt to cope with distress and marginalization. Substance use has been associated with multiple harms and medical conditions. Comprehensive management and care should be provided, as defined by the key principles of the Brazilian Unified Health System. Health care should be integrated into structural interventions.

Difficulties and advances in access to and use of health services by transgender women and travestis in Brazil.

OBJECTIVE: To understand the narratives of transgender women and travestis (TGW) from four Brazilian cities regarding access to and use of health services. METHODS: Qualitative study carried out within the scope of the TransOdara project, cross-sectional multicenter mixed methods research conducted between 2019-2021. Fifty-two in-depth interviews with TGW in Manaus, Campo Grande, Porto Alegre and São Paulo were analyzed. The analysis was guided by philosophical hermeneutics. RESULTS: Reports of discrimination, stigmatization and pathologization reiterate the difficulties faced by TGW in seeking healthcare. The recurrence of disrespect for the social/corrected name reveals obstacles to the recognition of transgender identities and, in some cases, the intention of inhibiting transsexuality-travestilidade. Other difficulties arise from actions that disregard the health specificities of TGW or the precarious social conditions that affect some of them. On the other hand, based on experiences of respect and adequate care, participants identify an ongoing change, which is expressed in greater availability of services and improved assistance. There is an expectation of continued expansion of services, technologies and training of health professionals. CONCLUSIONS: The identified change has been undertaken at the interface of public health policies with LGBT+ activism and the production of knowledge about TGW health needs. Although the identified advances are insufficient to change the scenario of the historical exclusion experienced by TGW in health services, they point to promising ways to improve their health conditions.

Physical examination for the detection of sexually transmitted infections among transgender women and travestis in Brazil: acceptability and associated factors.

OBJECTIVE: This study aimed to determine the acceptability and factors associated with uptake of a physical examination for the detection of symptomatic sexually transmitted infections (STIs) by transgender women and travestis in Brazil. METHODS: TransOdara was a multi-centric, cross-sectional STI prevalence study conducted among transgender women and travestis in five capital cities (Campo Grande, Manaus, Porto Alegre, Salvador and São Paulo) representing all Brazilian regions, between December 2019 and July 2021. A total of 1,317 self-identified transgender women and travestis aged ≥18 years were recruited using respondent-driven sampling and responded to a standard questionnaire. A medical consultation was offered including a physical examination and collection of samples from multiple sites to detect various STIs. Factors associated with uptake were investigated by reviewing demographic characteristics of participants who gave permission for physical examination (general, genital, and anorectal). RESULTS: Most participants (65.4%, 95% confidence interval - 95%CI 62.7-68.0) gave permission for a general examination (including oropharyngeal), with fewer permitting genital (42.3%, 95%CI 39.6-46.0) or anorectal (42.1%, 95%CI 39.4-44.9) examinations. Overall, 34.4% (95%CI 31.8-37.0) of participants refused all examinations. Participants with STI symptoms were significantly more likely to give permission for full examination than asymptomatic participants (64.3 vs. 37.4%, adjusted odds ratio - AOR=3.6, 95%CI 2.4-5.5). Other factors significantly associated with uptake of a full examination in multivariate analysis included age (AOR=1.5 for ≥25 years), religion (AOR=1.7 for Afro-Brazilian, AOR=1.9 for other religions compared to no religion), and education (AOR=2.0 for higher-level). CONCLUSION: In the context of STI management, this study found limited acceptance of anogenital examinations among transgender women and travestis, with higher acceptance among those with STI symptoms.

Discrimination based on gender identity against transgender women and travestis in Brazil: a latent class analysis and associated factors.

OBJECTIVE: To identify groups of transgender women and travestis (TGW) with specific patterns of gender-based discrimination (GBD) and analyze the factors associated with GBD. METHODS: A cross-sectional study was conducted with TGW recruited through respondent-driven sampling in five Brazilian cities (2019-2021). Latent class analysis was used to characterize GBD (low, medium, and high) using 14 observable variables. Descriptive analysis was performed, and associations between predictor variables and GBD were estimated by adjusted odds ratios (aOR) using ordinal logistic regression. RESULTS: Out of a total of 1,317 TGW, 906 (68.8%) answered questions about GBD. Most were under 34 years old, single, and had a Brown race/skin color. GBD was classified as "low," "medium," and "high," with estimates of 41.7, 44.5, and 13.8%, respectively. Variables positively associated with higher intensity of GBD included living in Manaus compared to São Paulo, being ≤34 years old compared to >34, being homeless compared to living in one's own house or rented apartment, not having legally changed one's name compared to those who had, and reporting physical or sexual violence compared to those who did not report. Variables negatively associated with higher intensity of GBD included having a Brown or Asian race/skin color compared to White and a monthly income ≥1 minimum wage compared to ³1. CONCLUSION: A high proportion of GBD was observed in Brazilian TGW, with this outcome associated with more vulnerable sociodemographic characteristics and a history of violence.

Factors associated with prior testing for HIV, Syphilis, and Hepatitis B and C among transgender women and travestis in Brazil.

OBJECTIVE: To investigate the prior testing for HIV, syphilis, hepatitis B (HBV), and hepatitis C (HCV) among transgender women and travestis (TGW) in five Brazilian cities and identify factors associated with each of these previous tests. METHODS: This is a cross-sectional study with the recruitment of TGW through respondent-driven sampling (TransOdara Study). The investigated outcome variable was prior testing for HIV, syphilis, HBV, and HCV in the last 12 months. The association between sociodemographic and behavioral factors with the outcome was analyzed using a binomial logistic regression with mixed effects. Adjusted odds ratios (aOR) and 95% confidence intervals (CI95%) were estimated. RESULTS: The proportions of individuals with prior testing in the past year were as follows: 56.3% for HIV, 58.0% for syphilis, 42.1% for HBV, and 44.7% for HCV. Negative associations with prior testing were observed for individuals aged 35 years or older, whereas positive associations were found for those with high school education, those who experienced verbal or psychological violence in the last 12 months, and those who had commercial or casual partners in the last 6 months. CONCLUSION: There was low frequency of testing in the 12 months preceding the study for HIV, syphilis, HBV, and HCV compared to the guidelines established by the Ministry of Health. Expanding access to and engagement with healthcare and prevention services for TGW is an essential strategy in reducing the transmission chain of HIV and other sexually transmitted infections (STIs).

Bodies of desire: use of nonprescribed hormones among transgender women and travestis in five Brazilian capitals (2019-2021).

OBJECTIVE: To analyze the experiences of transgender women and travestis regarding the use of hormones for body changes without a medical prescription. METHODS: This is a cross-sectional, quantitative and qualitative study, using data from "TransOdara", which estimated the prevalence of Sexually Transmitted Infections in transgender women and travestis recruited through Respondent-Driven Sampling, between December 2019 and July 2021, in São Paulo, Campo Grande, Manaus, Porto Alegre, and Salvador, Brazil. The main outcome was: use of hormones without medical prescription and associated risk factors. Descriptive analysis, mixed univariate logistic regression models, and semi-structured interviews were carried out. RESULTS: Of the 1,317 recruited participants, 85.9% had already used hormones. The current use of hormones was reported by 40.7% (536) of them. Of those who were able to inform the place where they obtained them, 72.6% (381/525) used them without a medical prescription. The variables associated with the outcome were: current full-time sex work (OR 4.59; 95%CI 1.90-11.06) or in the past (OR 1.92; 95%CI 1.10-3.34), not having changed their name (OR 3.59; 95%CI 2.23-5.76), not currently studying (OR 1.83; 95%CI 1.07-3.13), being younger (OR 2.16; 95%CI 1.31-3.56), and having suffered discrimination at some point in life for being a transgender women and travestis (OR 0.40; 95%CI 0.20-0.81). CONCLUSION: The use of nonprescribed hormones is high among transgender women and travestis, especially among those who are younger, did not study, have not changed their name, and with a history of sex work. This use is related to the urgency for gender transition, with excessive use and damage to health.

Prevalence of syphilis in transgender women and travestis in Brazil: results from a national cross-sectional study.

OBJECTIVE: The study aimed to estimate the prevalence of acquired syphilis and associated factors in a national survey. METHODS: TransOdara was a cross-sectional study comprising transgender women and travestis (TGW) in five major cities in Brazil during December of 2019 and July of 2021. The sample was recruited using the respondent-driven sampling (RDS) method. The outcome "active syphilis" was defined as a positive treponemal test and Venereal-Disease-Research-Laboratory (VDRL) title greater than∕ equal to ⅛. Sociodemographic variables were described. Bivariate and multiple logistic regression were performed, and odds ratios (OR) and 95% confidence intervals (95%CI) were estimated. All analyses were performed in R, 4.3.1. RESULTS: A total of 1,317 TGW were recruited, with 1,291 being tested for syphilis, and 294 (22.8%) meeting the criteria for active syphilis. In bivariate analysis, black/mixed race (OR=1.41, 95%CI 1.01-1.97), basic level of education (OR=2.44, 95%CI 1.17-5.06), no name change in documents (OR=1.39, 95%CI 1.00-1.91) and sex work (past only OR= 2.22, 95%CI 1.47-3.32; partial OR=2.75, 95%CI 1.78-4.25; full time OR=3.62, 95%CI 2.36-5.53) were associated with active syphilis. In the multivariate analysis, sex work was the only associated factor, 2.07 (95%CI 1.37-3.13) past sex work, 2.59 (95%CI 1.66-4.05) part-time sex work and 3.16 (95%CI 2.04-4.92) sex work as the main source of income. CONCLUSION: The prevalence of active syphilis in this study was elevated compared with other countries in Latin America. Sex work was an important associated factor with active syphilis, highlighting the impact that this condition of vulnerability may have in the health of TGW, as members of a key, marginalized population.

Prevalence of chlamydia and gonorreheae among transgender women and travestis in five Brazilian capitals, 2019-2021.

OBJECTIVE: To estimate the prevalence and factors associated with the detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in transgender women and travestis in five Brazilian capitals. METHODS: Data were obtained from a cross-sectional study conducted between 2019 and 2021, with participants recruited through Respondent Driven Sampling in São Paulo, Campo Grande, Manaus, Porto Alegre and Salvador. Detection of CT and NG was analyzed at three collection sites (anorectal, oropharyngeal and urethral). Mixed logistic regression models were employed to identify associated factors. RESULTS: A total of 1,297 recruited participants provided biological material to detect these infections. The prevalences of CT, NG and coinfection were 11.5%, 13.3% and 3.6%, respectively. Independent associations with CT infections included past (OR=1.73; 95%CI 1.02-2.95), current (OR=2.13; 95%CI 1.23-3.69), and part-time sex work (OR=2.75; 95%CI 1.60-4.75), as well as lifetime injectable drug use (OR=3.54; 95%CI 1.49-8.40). For NG, associations were observed with lifetime injectable drug use (OR=1.91; 95%CI 1.28-2.84) and sexual orientation, including heterosexual (OR=3.44; 95%CI 1.35-8.82), homosexual (OR=5.49; 95%CI 1.89-15.97), and bisexual (OR=3.21; 95%CI 1.06-9.68). Coinfection was associated with use of illicit drugs in the last 12 months (OR=2.34, 95%CI 1.10-5.00), and younger age was associated with all investigated outcomes. CONCLUSION: Estimated prevalences of CT, NG and co-infection were higher among transgender women and travestis compared to the general population, particularly among younger, individuals engaged in sex work and illicit drug use.

Lifetime sexual violence among transgender women and travestis (TGW) in Brazil: Prevalence and associated factors.

OBJECTIVE: To describe the prevalence, characteristics, and factors associated with sexual violence in transgender women and travestis (TGW) in Brazil. METHODS: This cross-sectional study was conducted in five Brazilian cities (Campo Grande, Manaus, Porto Alegre, Salvador, and São Paulo) between 2019 and 2021. Participants were recruited using the respondent-driven sampling (RDS) technique. The outcome of interest is the self-reported experience of sexual violence throughout the respondents' lifetime. We evaluated the actions taken by victims of sexual violence and how they dealt with the experience. Logistic regression analysis was employed to examine the associations between sociodemographic and behavioral factors (such as race, income, drug use, sex work, and access to healthcare) and the outcome. RESULTS: A total of 1,317 TGW were interviewed. Among them, 53% (n=698) reported experiencing sexual violence. For 64.4% (n=419) of the respondents, sexual violence occurred on more than one occasion. The majority of TGW did not seek health services (93.2%, n=648), disclose the violence (93.9%, n=653), nor seek support from family or friends (86.5%, n=601). A higher prevalence of sexual violence was associated with homelessness (adjusted prevalence ratio - aPR=1.69, 95% confidence interval - 95%CI 1.01-2.84), a history of engaging in sex work (aPR=2.04, 95%CI 1.46-2.85), self-reporting regular, bad, or very bad emotional health (aPR=1.67, 95%CI 1.28-2.19), and experiencing difficulties accessing health services in the previous year (aPR=2.78, 95%CI 1.74-4.43). CONCLUSION: The high prevalence of sexual violence, analyzed together with the actions of the victims, indicates a context of high vulnerability and low institutional support. In this scenario, violence can be exacerbated, resulting in severe health consequences.

TransOdara study: the challenge of integrating methods, settings and procedures during the COVID-19 pandemic in Brazil.

OBJECTIVE: Sexually transmitted infections (STIs) disproportionately affect transgender women and travestis (TGW), who often lack access to healthcare due to stigma and discrimination. We describe the approach and methodology of a study investigating the prevalence of syphilis, HIV, hepatitis A, B, and C, Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), and human papillomavirus (HPV) among TGW, as well as their knowledge and perceptions regarding syphilis, to better inform policies to curb STIs among this vulnerable population. METHODS: TransOdara was a multicentric, cross-sectional study conducted among TGW in five capital cities from major Brazilian regions between December 2019 and July 2021. Self-identified transgender women and travestis aged >18 years were recruited using respondent-driven sampling after a qualitative formative phase, completed an interviewer-led questionnaire, were offered a physical examination, and were also asked to provide samples from multiple sites to detect various STIs, starting vaccination and treatment when indicated. RESULTS: A total of 1,317 participants were recruited from the five study locations: Campo Grande (n=181, 13.7%), Manaus (n=340, 25.8%), Porto Alegre (n=192, 14.6%), Salvador (n=201, 15.3%), and São Paulo (n=403, 30.6%). The recruitment period varied at each study location due to logistic constraints imposed by the COVID-19 pandemic. CONCLUSION: Despite the enormous challenges posed by the co-occurrence of the COVID-19 pandemic and field work targeting a vulnerable, elusive, and scattered population, the TransOdara project has been effectively implemented. Caveats did not preclude 1,300 TGW from being interviewed and tested, amid a significant epidemic that disrupted health services and research projects in Brazil and worldwide.

Hepatitis A, B and C prevalence among transgender women and travestis in five Brazilian capitals between 2019-2021.

OBJECTIVE: To estimate the prevalence and factors associated with hepatitis A, B, and C in transgender women and travestis's networks, in 5 regions of Brazil. METHODS: This cross-sectional study includedtransgender women and travestis in five Brazilian capitals (Campo Grande, Manaus, Porto Alegre, Salvador, and São Paulo), between December/2019 and July/2021. All samples were subjected to detection of serological markers of hepatitis virus A (HAV), B (HBV), and C (HCV) infections through rapid tests and chemiluminescent microparticle immunoassays. Positive samples in the screening tests were submitted to detect HBV DNA and HCV-RNA by real-time PCR and genotyped by Sanger sequencing. RESULTS: Analysis of 1,317 samples showed network prevalence rates of 69.1%, 25.1%, and 1.5% for HAV, HBV, and HCV exposure, respectively. A high susceptibility rate to HBV infection (35.7%) and low prevalence of vaccine response markers (40%) were also observed. Age greater than 26 years, self-declared black/brown skin color, having only primary education, history of incarceration, and use of a condom in the last sexual intercourse with a casual partner were associated with total anti-HAV. Exposure to HBV was associated with age greater than 26 years, self-declared black/brown, history of being a sex worker, and incarceration. Age > 37 years, history of sexual abuse, and frequent alcohol consumption were associated with hepatitis C infection. CONCLUSION: The highest prevalence of HAV in this population was found in the North and Northeast regions, and the prevalence found was higher than that in the general population, suggesting greater vulnerability. The prevalence of HCV infection in our study was similar to that observed in the general population.

Factors associated with the retention of travestis and transgender women living with HIV in a peer navigation intervention in São Paulo, Brazil. / Fatores associados à retenção de travestis e mulheres trans vivendo com HIV em uma intervenção com navegação de pares em São Paulo, Brasil.

Travestis and transgender women (TrTGW) constitute the groups with the highest HIV prevalence in the world, with higher probability of infection compared with the general population and lower adherence to prevention and treatment strategies than other vulnerable groups. Considering these challenges, this study describes the factors associated with the retention of TrTGW with HIV to the TransAmigas project. Participants were recruited from April 2018 to September 2019 in a public health service in São Paulo, Brazil. A total of 113 TrTGW were randomly assigned to either a peer navigation intervention (75) or a control group (38) and followed up for nine months. To analyze the association between the selected variables and the outcome ("retention at nine months", regardless of contact at three months, defined by the "full completion of the final questionnaire"), bivariate and multivariate logistic regression models were used. Peer contact forms were qualitatively assessed to validate and complement the previous selection of quantitative component variables. Of the 113 participants, 79 (69.9%) participated in the interview after nine months, of which 54 (72%) were from the intervention group and 25 (66%) from the control group. In the final multivariate model, contact at three months (adjusted odds ratio - aOR = 6.15; 95% confidence interval - 95%CI: 2.16-17.51) and higher schooling level (≥ 12 years) (aOR = 3.26; 95%CI: 1.02-10.42) remained associated with the outcome, adjusted by race/skin color, age ≤ 35 years, and HIV serostatus disclosure. Future studies with TrTGW should include contact at regular intervals, with additional efforts aimed at participants with lower schooling level.

Travestis e mulheres trans (TrMT) pertencem aos grupos com mais alta prevalência do HIV no mundo, com maior probabilidade de infecção em relação à população geral e menor adesão a estratégias de prevenção e tratamento do que outros grupos vulneráveis. Considerando esses desafios, descrevemos os fatores associados à retenção de TrMT com HIV no projeto TransAmigas. O recrutamento ocorreu entre abril de 2018 e setembro de 2019, em um serviço público de saúde em São Paulo, Brasil. Foram inscritas 113 TrMT, atribuídas aleatoriamente para uma intervenção com navegadora de pares (75) ou um grupo controle (38) e seguidas durante nove meses. Para analisar a associação entre as variáveis selecionadas e o desfecho ("retenção aos nove meses" independentemente do contato aos três meses, definido pela "resposta completa ao questionário final"), foram empregados modelos de regressão logística bi e multivariados. Uma exploração qualitativa dos formulários de contato de pares foi realizada para validar e complementar a seleção prévia de variáveis do componente quantitativo. Das 113 participantes, 79 (69,9%) responderam à entrevista de nove meses, sendo 54 (72%) do grupo intervenção e 25 (66%) do grupo controle. No modelo multivariado final, o contato aos três meses (odds ratio ajustado - ORa = 6,15; intervalo de 95% de confiança - 95%CI: 2,16-17,51) e a maior escolaridade (≥ 12 anos) (ORa = 3,26; IC95%: 1,02-10,42) permaneceram associados ao desfecho, ajustados por raça/cor, idade < 35 anos e revelação do status sorológico para HIV. Pesquisas futuras com TrMT devem incluir contato em intervalos regulares, com esforços adicionais voltados a participantes com menor escolaridade.

La población de travestis y mujeres trans (TrMT) está en los grupos con mayor prevalencia de VIH en el mundo, con mayor probabilidad de infección en comparación con la población general y menor adherencia a las estrategias de prevención y tratamiento que otros grupos vulnerables. Ante estos desafíos, describimos los factores asociados a la retención de TrMT con VIH en el proyecto TransAmigas. La selección ocurrió entre abril de 2018 y septiembre de 2019, en un servicio público de salud de São Paulo, Brasil. Se inscribieron 113 TrMT, a las cuales se asignaron aleatoriamente a una intervención de navegador de pares (75) o a un grupo control (38) y se les dio seguimiento durante 9 meses. Para analizar la asociación entre las variables seleccionadas y el resultado ("retención a los nueve meses" independientemente del contacto a los 3 meses, definido por "respuesta completa al cuestionario final"), se utilizaron modelos de regresión logística bi- y multivariante. Se realizó una exploración cualitativa de los formularios de contacto de pares para validar y complementar la selección previa de las variables en el componente cuantitativo. De las 113 participantes, 79 (69,9%) respondieron a la entrevista de los 9 meses, de las cuales 54 (72%) pertenecían al grupo intervención y 25 (66%) al grupo control. En el modelo multivariante final, el contacto a los 3 meses (odds ratio ajustado - ORa = 6,15; intervalo de 95% de confianza - IC95%: 2,16-17,51) y un alto nivel de instrucción (≥ 12 años) (ORa = 3,26; IC95%: 1,02-10,42) permanecieron asociados con el resultado, ajustado por etnia/color, edad < 35 años y divulgación del estado serológico respecto al VIH. Los futuros estudios con la población TrMT deberán incluir contacto a intervalos regulares, con esfuerzos adicionales dirigidos a las participantes con menor nivel de instrucción.

[Factors associated with inconsistent condom use among men who have sex with men in Brazil and their commercial sexual partners]. / Fatores associados ao uso inconsistente de preservativo com parceiros comerciais entre homens que fazem sexo com homens no Brasil.

We aimed to analyze the factors associated with inconsistent condom use among men who have sex with men (MSM) and their commercial sexual partners in Brazil. This is a cross-sectional study with adult MSM who were recruited via respondent-driven sampling (RDS) in 12 Brazilian capitals in 2016. MSM answered a sociobehavioral questionnaire which included questions on their sexual behavior. The inconsistent use of condoms with their clientele was measured via insertive and receptive anal sex in the six months prior to our research and in their last sexual intercourse. The association between independent variables and the inconsistent use of condoms was measured via a Poisson regression model with robust variance and estimation of adjusted prevalence ratios (aPR). Data from 461 MSM were analyzed. We found a 26% prevalence of inconsistent condom use with their clientele (95%CI: 19.0-34.3, n = 123). Belonging to the lowest economic classes (D/E), having medium or low knowledge about HIV, having practiced insertive and receptive anal sex, and having never tested for HIV throughout their lives were associated with inconsistent use of condoms with their clientele. The variables associated with inconsistent use indicated that commercial sex is practiced in a context of greater vulnerability to HIV infection, referring to the need for biomedical and behavioral interventions which focus on access to and use of prevention strategies together with public policies to reduce socioeconomic inequalities among MSM who practice commercial sexual.

O objetivo foi analisar os fatores associados ao uso inconsistente de preservativo com parceiros comerciais entre homens que fazem sexo com homens (HSH) no Brasil. Foi feito um estudo transversal, com HSH adultos, recrutados por meio da técnica respondent-driven sampling (RDS), em 12 capitais brasileiras, em 2016. Os HSH responderam a um questionário sociocomportamental, que incluía questões sobre o comportamento sexual. O uso inconsistente de preservativo com parceiros comerciais foi mensurado por meio das relações sexuais anais insertivas e receptivas, ocorridas nos últimos seis meses e na última relação sexual. A associação entre as variáveis independentes e o uso inconsistente de preservativo foi mensurada utilizando o modelo de regressão de Poisson com variância robusta, com estimação de razões de prevalência ajustadas (RPa). Foram analisados dados de 461 HSH. A prevalência de uso inconsistente de preservativo com parceiros comerciais foi de 26% (IC95%: 19,0-34,3, n = 123). Pertencer às classes econômicas mais baixas (D/E), ter médio ou baixo conhecimento sobre HIV, ter praticado sexo anal insertivo e receptivo e nunca ter realizado teste para HIV na vida são fatores que estiveram associados ao uso inconsistente de preservativo com parceiros comerciais. As variáveis associadas ao uso inconsistente indicaram que o sexo comercial está sendo praticado em um contexto de maior vulnerabilidade à infecção pelo HIV. Nesse sentido, são necessárias intervenções biomédicas e comportamentais, com foco no acesso e na utilização de estratégias de prevenção, aliadas a políticas públicas para a redução de desigualdades socioeconômicas entre HSH que praticam sexo comercial.

El objetivo fue analizar los factores asociados al uso inconsistente del preservativo con las parejas comerciales entre los hombres que tienen sexo con hombres (HSH) en Brasil. Estudio transversal, con HSH adultos, reclutados a través de la técnica respondent-driven sampling (RDS), en 12 capitales brasileñas, en 2016. Los HSH respondieron a un cuestionario sociocomportamental que incluía preguntas sobre el comportamiento sexual. El uso inconsistente del preservativo con parejas comerciales se midió por las relaciones anales insertivas y receptivas que se produjeron en los últimos seis meses y por la última relación sexual. La asociación entre las variables independientes y el uso inconsistente del preservativo se midió mediante el modelo de regresión de Poisson con varianza robusta, con estimación de las razones de prevalencia ajustadas (RPa). Se analizaron los datos de 461 HSH. La prevalencia del uso inconsistente del preservativo con las parejas comerciales fue del 26% (IC95%: 19,0-34,3, n = 123). Pertenecer a las clases económicas más bajas (D/E), tener un conocimiento medio o bajo sobre el VIH, haber practicado sexo anal tanto insertivo como receptivo y no haberse sometido nunca a la prueba del VIH en su vida se asociaron con el uso inconsistente del preservativo con las parejas comerciales. Las variables asociadas al uso inconsistente indicaron que el sexo comercial se está practicando en un contexto de mayor vulnerabilidad a la infección por el VIH, refiriendo la necesidad de intervenciones biomédicas y conductuales, con un enfoque en el acceso y uso de estrategias de prevención, junto con políticas públicas para reducir las desigualdades socioeconómicas entre los HSH que practican el sexo comercial.

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.

Social inequalities and COVID-19 mortality in the city of São Paulo, Brazil.

BACKGROUND: Heterogeneity in COVID-19 morbidity and mortality is often associated with a country's health-services structure and social inequality. This study aimed to characterize social inequalities in COVID-19 mortality in São Paulo, the most populous city in Brazil and Latin America. METHODS: We conducted a population-based study, including COVID-19 deaths among São Paulo residents from March to September 2020. Age-standardized mortality rates and unadjusted rate ratios (RRs) [with corresponding 95% confidence intervals (CIs)] were estimated by race, sex, age group, district of residence, household crowding, educational attainment, income level and percentage of households in subnormal areas in each district. Time trends in mortality were assessed using the Joinpoint model. RESULTS: Males presented an 84% increase in COVID-19 mortality compared with females (RR = 1.84, 95% CI 1.79-1.90). Higher mortality rates were observed for Blacks (RR = 1.77, 95% CI 1.67-1.88) and mixed (RR = 1.42, 95% CI 1.37-1.47) compared with Whites, whereas lower mortality was noted for Asians (RR = 0.63, 95% CI 0.58-0.68). A positive gradient was found for all socio-economic indicators, i.e. increases in disparities denoted by less education, more household crowding, lower income and a higher concentration of subnormal areas were associated with higher mortality rates. A decrease in mortality over time was observed in all racial groups, but it started earlier among Whites and Asians. CONCLUSION: Our results reveal striking social inequalities in COVID-19 mortality in São Paulo, exposing structural inequities in Brazilian society that were not addressed by the governmental response to COVID-19. Without an equitable response, COVID-19 will further exacerbate current social inequalities in São Paulo.