Modeling the epidemiological impact of the UNAIDS 2025 targets to end AIDS as a public health threat by 2030.

BACKGROUND: UNAIDS has established new program targets for 2025 to achieve the goal of eliminating AIDS as a public health threat by 2030. This study reports on efforts to use mathematical models to estimate the impact of achieving those targets. METHODS AND FINDINGS: We simulated the impact of achieving the targets at country level using the Goals model, a mathematical simulation model of HIV epidemic dynamics that includes the impact of prevention and treatment interventions. For 77 high-burden countries, we fit the model to surveillance and survey data for 1970 to 2020 and then projected the impact of achieving the targets for the period 2019 to 2030. Results from these 77 countries were extrapolated to produce estimates for 96 others. Goals model results were checked by comparing against projections done with the Optima HIV model and the AIDS Epidemic Model (AEM) for selected countries. We included estimates of the impact of societal enablers (access to justice and law reform, stigma and discrimination elimination, and gender equality) and the impact of Coronavirus Disease 2019 (COVID-19). Results show that achieving the 2025 targets would reduce new annual infections by 83% (71% to 86% across regions) and AIDS-related deaths by 78% (67% to 81% across regions) by 2025 compared to 2010. Lack of progress on societal enablers could endanger these achievements and result in as many as 2.6 million (44%) cumulative additional new HIV infections and 440,000 (54%) more AIDS-related deaths between 2020 and 2030 compared to full achievement of all targets. COVID-19-related disruptions could increase new HIV infections and AIDS-related deaths by 10% in the next 2 years, but targets could still be achieved by 2025. Study limitations include the reliance on self-reports for most data on behaviors, the use of intervention effect sizes from published studies that may overstate intervention impacts outside of controlled study settings, and the use of proxy countries to estimate the impact in countries with fewer than 4,000 annual HIV infections. CONCLUSIONS: The new targets for 2025 build on the progress made since 2010 and represent ambitious short-term goals. Achieving these targets would bring us close to the goals of reducing new HIV infections and AIDS-related deaths by 90% between 2010 and 2030. By 2025, global new infections and AIDS deaths would drop to 4.4 and 3.9 per 100,000 population, and the number of people living with HIV (PLHIV) would be declining. There would be 32 million people on treatment, and they would need continuing support for their lifetime. Incidence for the total global population would be below 0.15% everywhere. The number of PLHIV would start declining by 2023.

Ending AIDS as a public health threat by 2030: Time to reset targets for 2025.

Paul De Lay and co-authors introduce a Collection on the design of targets for ending the AIDS epidemic.

Exploring relationships between HIV programme outcomes and the societal enabling environment: A structural equation modeling statistical analysis in 138 low- and middle-income countries.

Countries worldwide have attempted to reduce the incidence of HIV and AIDS associated deaths with varying success, despite significant progress in antiretroviral treatment (ART) and condom use. A chief obstacles is that key populations affected face high levels of stigma, discrimination and exclusion, limiting the successful response to HIV. However, a gap exists in studies demonstrating the moderation effects of societal enablers on overall programme effectiveness and HIV outcomes using quantitative methods.Structural Equation Modeling was used for 138 countries covering a 12-year period to examine how the unfavorable societal enabling environment, including stigma and discrimination, unfavorable legal environment and lack of access to societal justice, gender inequality and other unfavorable development situations affect the effectiveness of HIV programmes and HIV outcomes, while controlling for potentially confounding variables. The results only showed statistical significance when all four societal enablers were modeled as a composite. The findings show the direct and indirect standardized effects of unfavorable societal enabling environments to AIDS-related mortality among PLHIV are statistically significant and positive (0.26 and 0.08, respectively). We hypothesize that this may be because an unfavorable societal enabling environment can negatively affect adherence to ART, quality of healthcare and health seeking behavior. Higher ranked societal environments increase the effect of ART coverage on AIDS related mortality by about 50% in absolute value, that is -0.61 as against -0.39 for lower ranked societal environments. However, mixed results were obtained on the impact of societal enablers on changes in HIV incidence through condom use. Results indicate that countries with better societal enabling environments had fewer estimated new HIV infections and fewer AIDS-related deaths. The failure to include societal enabling environments in HIV response undermines efforts to achieve the 2025 HIV targets, and the related 2030 Sustainable Development indicator to end AIDS, even if sufficient resources are mobilized.

Removing the societal and legal impediments to the HIV response: An evidence-based framework for 2025 and beyond.

Societal and legal impediments inhibit quality HIV prevention, care, treatment and support services and need to be removed. The political declaration adopted by UN member countries at the high-level meeting on HIV and AIDS in June 2021, included new societal enabler global targets for achievement by 2025 that will address this gap. Our paper describes how and why UNAIDS arrived at the societal enabler targets adopted. We conducted a scoping review and led a participatory process between January 2019 and June 2020 to develop an evidence-based framework for action, propose global societal enabler targets, and identify indicators for monitoring progress. A re-envisioned framework called the '3 S's of the HIV response: Society, Systems and Services' was defined. In the framework, societal enablers enhance the effectiveness of HIV programmes by removing impediments to service availability, access and uptake at the societal level, while service and system enablers improve efficiencies in and expand the reach of HIV services and systems. Investments in societal enabling approaches that remove legal barriers, shift harmful social and gender norms, reduce inequalities and improve institutional and community structures are needed to progressively realize four overarching societal enablers, the first three of which fall within the purview of the HIV sector: (i) societies with supportive legal environments and access to justice, (ii) gender equal societies, (iii) societies free from stigma and discrimination, and (iv) co-action across development sectors to reduce exclusion and poverty. Three top-line and 15 detailed targets were recommended for monitoring progress towards their achievement. The clear articulation of societal enablers in the re-envisioned framework should have a substantial impact on improving the effectiveness of core HIV programmes if implemented. Together with the new global targets, the framework will also galvanize advocacy to scale up societal enabling approaches with proven impact on HIV outcomes.

Peer- and community-led responses to HIV: A scoping review.

INTRODUCTION: In June 2021, United Nations (UN) Member States committed to ambitious targets for scaling up community-led responses by 2025 toward meeting the goals of ending the AIDS epidemic by 2030. These targets build on UN Member States 2016 commitments to ensure that 30% of HIV testing and treatment programmes are community-led by 2030. At its current pace, the world is not likely to meet these nor other global HIV targets, as evidenced by current epidemiologic trends. The COVID-19 pandemic threatens to further slow momentum made to date. The purpose of this paper is to review available evidence on the comparative advantages of community-led HIV responses that can better inform policy making towards getting the world back on track. METHODS: We conducted a scoping review to gather available evidence on peer- and community-led HIV responses. Using UNAIDS' definition of 'community-led' and following PRISMA guidelines, we searched peer-reviewed literature published from January 1982 through September 2020. We limited our search to articles reporting findings from randomized controlled trials as well as from quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. The overall goals of this scoping review were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to quickly inform policy, practice, and research. FINDINGS: Our initial search yielded 279 records. After screening for relevance and conducting cross-validation, 48 articles were selected. Most studies took place in the global south (n = 27) and a third (n = 17) involved youth. Sixty-five percent of articles (n = 31) described the comparative advantage of peer- and community-led direct services, e.g., prevention and education (n = 23) testing, care, and treatment programs (n = 8). We identified more than 40 beneficial outcomes linked to a range of peer- and community-led HIV activities. They include improved HIV-related knowledge, attitudes, intentions, self-efficacy, risk behaviours, risk appraisals, health literacy, adherence, and viral suppression. Ten studies reported improvements in HIV service access, quality, linkage, utilization, and retention resulting from peer- or community-led programs or initiatives. Three studies reported structural level changes, including positive influences on clinic wait times, treatment stockouts, service coverage, and exclusionary practices. CONCLUSIONS AND RECOMMENDATIONS: Findings from our scoping review underscore the comparative advantage of peer- and community-led HIV responses. Specifically, the evidence from the published literature leads us to recommend, where possible, that prevention programs, especially those intended for people living with and disproportionately affected by HIV, be peer- and community-led. In addition, treatment services should strive to integrate specific peer- and community-led components informed by differentiated care models. Future research is needed and should focus on generating additional quantitative evidence on cost effectiveness and on the synergistic effects of bundling two or more peer- and community-led interventions.

[Advances and challenges for the prevention and control of AIDS in Mexico]. / Avance y retos de la prevención y el control del SIDA en México.

This document aims to give an epidemiological overview of HIV and AIDS in Mexico, to highlight some aspects of both the governmental and nongovernmental response, and to emphasize important challenges in the fight against the epidemic. The HIV and AIDS epidemic in Mexico is confined to specific groups such as men who have sex with men and intravenous drug users. It has low prevalence among general population, a percentage we aim to maintain. Universal access to retroviral treatment in Mexico is an achievement that is sustainable only if a constant reduction of new cases is accomplished. This can only be obtained by preventive measures that are based on evidence. It is necessary to strengthen nongovernmental associations that are working on prevention. In 2009, the number of nongovernmental associations that received official financing was relatively low. It is necessary to improve the epidemic vigilance and evaluation systems. This would allow better follow-up of the activities that confront the epidemic, and to obtain better feedback for the procedures.

Direct and indirect effects of enablers on HIV testing, initiation and retention in antiretroviral treatment and AIDS related mortality.

BACKGROUND: An enabling environment is believed to have significant and critical effects on HIV and AIDS program implementation and desired outcomes. This paper estimates the paths, directionality, and direct and indirect associations between critical enablers with antiretroviral treatment (ART) coverage and to AIDS-related mortality. METHODS: Frameworks that consider the role of enablers in HIV and AIDS programs were systematically reviewed to develop a conceptual model of interaction. Measurements for constructs of the model were pooled from the latest publicly available data. A hypothetical model, including latent/unobserved factors and interaction of enablers, program activities and outcomes, was analyzed cross-sectionally with structural equation modeling. Coefficients of the model were used to estimate the indirect associations of enablers to treatment coverage and the subsequent associated impact on AIDS related mortality. FINDINGS: The model's fit was adequate (RMSEA = 0·084, 90% CI [0·062, 0·104]) and the indirect effects of enablers on outcomes were measured. Enablers having significant associations with increased ART coverage were social/financial protection, governance, anti-discrimination, gender equality, domestic AIDS spending, testing service delivery, and logistics. INTERPRETATION: Critical enablers are significantly correlated to outcomes like ART coverage and AIDS related mortality. Even while this model does not allow inference on causality, it provides directionality and magnitude of the significant associations.

CD4 Counts at Entry to HIV Care in Mexico for Patients under the "Universal Antiretroviral Treatment Program for the Uninsured Population," 2007-2014.

In Mexico, public health services have provided universal access to antiretroviral therapy (ART) since 2004. For individuals receiving HIV care in public healthcare facilities, the data are limited regarding CD4 T-lymphocyte counts (CD4e) at the time of entry into care. Relevant population-based estimates of CD4e are needed to inform strategies to maximize the impact of Mexico's national ART program, and may be applicable to other countries implementing universal HIV treatment programs. For this study, we retrospectively analyzed the CD4e of persons living with HIV and receiving care at state public health facilities from 2007 to 2014, comparing CD4e by demographic characteristics and the marginalization index of the state where treatment was provided, and assessing trends in CD4e over time. Our sample included 66,947 individuals who entered into HIV care between 2007 and 2014, of whom 79% were male. During the study period, the male-to-female ratio increased from 3.0 to 4.3, reflecting the country's HIV epidemic; the median age at entry decreased from 34 years to 32 years. Overall, 48.6% of individuals entered care with a CD4≤200 cells/µl, ranging from 42.2% in states with a very low marginalization index to 52.8% in states with a high marginalization index, and from 38.9% among individuals aged 18-29 to 56.5% among those older than 50. The adjusted geometric mean (95% confidence interval) CD4e increased among males from 135 (131,142) cells/µl in 2007 to 148 (143,155) cells/µl in 2014 (p-value<0.0001); no change was observed among women, with a geometric mean of 178 (171,186) and 171 (165,183) in 2007 and 2014, respectively. There have been important gains in access to HIV care and treatment; however, late entry into care remains an important barrier in achieving optimal outcomes of ART in Mexico. The geographic, socioeconomic, and demographic differences observed reflect important inequities in timely access to HIV prevention, care, and treatment services, and highlight the need to develop contextual and culturally appropriate prevention and HIV testing strategies and linkage programs.

[Teaching and including HIV/AIDS in the curricula of a medical school sample in Mexico]. / La enseñanza del VIH/SIDA y su integración en la curricula en una muestra de escuelas de medicina en México.

BACKGROUND: The HIV/AIDS epidemic is apublic health problem that has had an impact on all health systems around the world. Mexico is no exception. Although it has been acknowledged that we have a concentrated epidemic, the problem continues to grow. OBJECTIVE: The objective of this study was to evaluate if the medical school curricula in Mexico included the topic of HIV/AIDS and to assess the level of knowledge medical students have about this disease. MATERIAL AND METHODS: Descriptive study of eight medical schools interviewing pre-graduate medical students. RESULTS: Only 15% of the curricula of private medical schools and 21.7% of public schools included the subject of HIV/AIDS. Although it is difficult to standardize this finding, an average of 8.8 hours was assigned to the study of HIV/AIDS. 90% of the professors involved in teaching the topic of HIV/AlDS hadno clinical experience in thefield CONCLUSION: HIV/AIDS is a low priority subject in our medical school curricula. Efforts must be placed to standardize and reinforce this highly important topic.

Country response to HIV/AIDS: national health accounts on HIV/AIDS in Brazil, Guatemala, Honduras, Mexico and Uruguay.

National expenditures on HIV/AIDS were estimated as summary indicators to assess the country's response to HIV/AIDS. The methodology is based on a matrix system describing the level and flow of health expenditures on HIV/AIDS: an adaptation of the National Health Accounts methods. The expenditures were classified by source (public, private, international), by the use of funds (prevention, care), by object, and by type of provider institution. The results are reported in US dollars using the official exchange rate for the year of estimation. For international comparisons monetary units were adjusted by the purchasing power parity (US dollars PPP). National HIV/AIDS total expenditures were: Guatemala US dollars PPP29.5 million, Uruguay US dollars PPP 32.5 million, Mexico US dollars PPP 257 million, and Brazil US dollars PPP 587.4 million during 1998, and Honduras US dollars PPP 33.9 million for 1999. The total HIV/AIDS expenditures per capita for 1998 were: Brazil US dollars 2.69, Mexico US dollars 1.25, Guatemala US dollars 1.08, Uruguay US dollars 6.63, and Honduras US dollars 3.6 for 1999. The 1998 distribution of the total HIV/AIDS expenditures in prevention and care were, respectively, Brazil 10 and 80%, Guatemala 15 and 70%, Mexico 29 and 66%, Uruguay 36 and 51%, and Honduras 28 and 65% for 1999. The share of total expenditures on antiretroviral drugs ranged from 52% in Guatemala to 75% in Brazil, even when the estimated coverage of antiretroviral therapy was close to 10% in Guatemala and universal in Brazil. The estimated flow from international sources per capita in 1998 was Uruguay US dollars 0.03, Brazil US dollars 0.24, Guatemala US dollars 0.11, Mexico US dollars 0.01, and Honduras US dollars 1.04 in 1999. The data allow international comparisons and provide critical information to improve equity and efficiency in the allocation of scarce resources. The National HIV/AIDS Accounts also constitute a powerful tool to describe the country's response to HIV/AIDS.

Study raises questions about measurement of 'additionality,'or maintaining domestic health spending amid foreign donations.

Donor nations and philanthropic organizations increasingly require that funds provided for a specific health priority such as HIV should supplement domestic spending on that priority-a concept known as "additionality." We investigated the "additionality" concept using data from Honduras, Rwanda, and Thailand, and we found that the three countries increased funding for HIV in response to increased donor funding. In contrast, the study revealed that donors, faced with increased Global Fund resources for HIV in certain countries, tended to decrease their funding for HIV or shift funds for use in non-HIV health areas. More broadly, we found many problems in the measurement and interpretation of additionality. These findings suggest that it would be preferable for donors and countries to agree on how best to use available domestic and external funds to improve population health, and to develop better means of tracking outcomes, than to try to develop more sophisticated methods to track additionality.

Levels of spending and resource allocation to HIV programs and services in Latin America and the Caribbean.

BACKGROUND: An estimated 1.86 million people are living with HIV in Latin America and the Caribbean (LAC). The region is comprised of mainly middle-income countries with steady economic growth while simultaneously there are enormous social inequalities and several concentrated AIDS epidemics. This paper describes HIV spending patterns in LAC countries including analysis of the levels and patterns of domestic HIV spending from both public and international sources. METHODS AND FINDINGS: We conducted an extensive analysis of the most recently available data from LAC countries using the National AIDS Spending Assessment tool. The LAC countries spent a total of US$ 1.59 billion on HIV programs and services during the latest reported year. Countries providing detailed information on spending showed that high percentages are allocated to treatment and care (75.1%) and prevention (15.0%). Domestic sources accounted for 93.6 percent of overall spending and 79 percent of domestic funds were directed to treatment and care. International funds represented 5.4 percent of total HIV funding in the region, but they supplied the majority of the effort to reach most-at-risk-populations (MARPs). However, prevalence rates among men who have sex with men (MSM) still reached over 25 percent in some countries. CONCLUSIONS: Although countries in the region have increasingly sustained their response from domestic sources, still there are future challenges: 1) The growing number of new HIV infections and more people-living-with-HIV (PLWH) eligible to receive antiretroviral treatment (ART); 2) Increasing ART coverage along with high prices of antiretroviral drugs; and 3) The funding for prevention activities among MARPs rely almost exclusively on external donors. These threats call for strengthened actions by civil society and governments to protect and advance gains against HIV in LAC.

Financing the response to HIV in low-income and middle-income countries.

OBJECTIVES: To describe levels of national HIV spending and examine programmatic allocations according to the type of epidemic and country income. METHODS: Cross-sectional analysis of HIV expenditures from 50 low-income and middle-income countries. Sources of information included country reports of domestic spending by programmatic activity and HIV services. These HIV spending categories were cross tabulated by source of financing, stratified by type of HIV epidemic and income level of the country and reported in international dollars (I$). RESULTS: Fifty low-income and middle-income countries spent US $ 2.6 billion (I$ 5.8 billion) on HIV in 2006; 87% of the funding among the 17 low-income countries came from international donors. Average per capita spending was I$ 2.1 and positively correlated with Gross National Income. Per capita spending was I$ 1.5 in 9 countries with low-level HIV epidemics, I$ 1.6 in 27 countries with concentrated HIV epidemics and I$ 9.5 in 14 countries with generalized HIV epidemics. On average, spending on care and treatment represented 50% of AIDS spending across all countries. The treatment-to-prevention spending ratio was 1.5:1, 3:1, and 2:1 in countries with low-level, concentrated and generalized epidemics, respectively. Spending on prevention represented 21% of total AIDS spending. However, expenditures addressing most-at-risk populations represented less than 1% in countries with generalized epidemics and 7% in those with low-level or concentrated epidemics. CONCLUSIONS: The most striking finding is the mismatch between the types of HIV epidemics and the allocation of resources. The current global economic recession will force countries to rethink national strategies, especially in low-income countries with high aid dependency. Mapping HIV expenditures provides crucial guidance for reallocation of resources and supports evidence-based decisions. Now more than ever, countries need to know and act on their epidemics and give priority to the most effective programmatic services.

Sex between men in the context of HIV: The AIDS 2008 Jonathan Mann Memorial Lecture in health and human rights.

Gay, bisexual, and other men who have sex with men (MSM) have been among the most affected populations by HIV since the AIDS pandemic was first identified in the 1980s. Evidence from a wide range of studies show that these men remain at the highest risk for HIV acquisition in both developed and developing countries, and that despite three decades of evidence of their vulnerability to HIV, they remain under-served and under-studied. Prevention strategies targeted to MSM are markedly under-funded in most countries, leading to limited access to health services including prevention, treatment, and care. We explore the global epidemic among MSM in 2008, the limited funding available globally to respond to these epidemics, and the human rights contexts and factors which drive HIV spread and limit HIV responses for these men.What do we mean by the term MSM? MSM is a construct from the 1990s that tries to capture behavior and not identity. It was crafted to avoid stigmatizing and culturally laden terms such as gay or bisexual, which do not capture the wide diversity of orientations, sexual practices, cultures, and contextual settings in which male same-sex behaviors occur, and where HIV transmission and acquisition risks are centered. MSM includes both gay and non-gay identified men, bisexual men, and MSM who identify themselves as heterosexuals. It also includes men engaging in "situational" sex between men, such as can occur in prisons, schools, militaries or other environments; and it includes male sex workers who may be of any orientation but are often at very high risk for HIV. MSM may include some biologically male transgender persons, though some do not identify as male. And MSM includes a wide array of traditional and local terms worldwide-with enormous cultural diversity in Asia, Africa, Latin America and elsewhere. We use the term MSM here at its most inclusive.

Sexual behavior patterns and HIV risks in bisexual men compared to exclusively heterosexual and homosexual men.

OBJECTIVE: To compare patterns of sexual behavior among bisexual, heterosexual and homosexual men. MATERIAL AND METHODS: A household probability survey was carried out in Mexico City in 1992-1993 using the national health surveys sampling frame. Information from 8,068 men was obtained; however, the main analysis of this paper refers only to men sexually active in the previous 5 years. RESULTS: Bisexuals reported more prevalent anal intercourse with women (16% vs. 3%, p = 0.01), and more sexual encounters with female sex workers than exclusive heterosexuals (10% vs. 4%; p = 0.04). Bisexuals used condoms more often with sex workers than did heterosexuals (p = 0.01). Most of the bisexuals (79%) did not engage in anal receptive or insertive intercourse with males in the previous year, practicing instead oral insertive sex or only masturbation; 35% of homosexuals did not report practicing anal sex. Bisexuals who engaged in anal intercourse had less anal receptive behavior than homosexuals (13% vs. 60%, p < 0.01); of these, due to condom use, only 7% of bisexuals and 18% of homosexuals had unprotected anal receptive sex in the last intercourse with a male. CONCLUSIONS: Bisexuals practice less risky sexual behavior with males than exclusive homosexuals. This finding may imply that bisexual men in Mexico are an ineffective epidemiological bridge for HIV transmission. The English version of this paper is available too at:http://www.insp.mx/salud/index.html.

La enseñanza del VIH/SIDA y su integración en la currícula en una muestra de escuelas de medicina en México / Teaching and including HIV/AIDS in the curricula of a medical school sample in Mexico

Antecedentes: El problema de salud pública de la infección por el VIH/SIDA ha impactado todos los sistemas de salud del mundo. Nuestro país no es ajeno a este problema y aunque se reconoce que México tiene una epidemia concentrada, el problema ha ido creciendo. Objetivo: El objetivo de este trabajo fue conocer si en los contenidos temáticos de las currícula de las escuelas de medicina en México está incluido el estudio del VIH/SIDA, así como evaluar el nivel de conocimientos que los alumnos de medicina tienen respecto a la enfermedad Material y métodos: Se realizó un estudio descriptivo de ocho escuelas de medicina. La unidad de observación fueron los estudiantes de pregrado. Resultados: El porcentaje de materias que incluyen en su currícula conceptos sobre el tema de VIH/SIDA es de 15% en las escuelas privadas y en las públicas de 21.7%. Aunque es difícil de estandarizar, en promedio se imparten 8.8 horas sobre el tema. 90% de los profesores que participan en la enseñanza del VIH/SIDA, no tienen experiencia clínica. Conclusiones: La enseñanza del tema en nuestras escuelas de medicina tiene una prioridad baja, por lo que consideramos que es necesario reforzar y estandarizar los contenidos temáticos sobre VIH/SIDA.

Background: The HIV/AIDS epidemic is a public health problem that has had an impact on all health systems around the world. Mexico is no exception. Although it has been acknowledged that we have a concentrated epidemic, the problem continues to grow. Objective: The objective of this study was to evaluate if the medical school curricula in Mexico included the topic of HIV/AIDS and to assess the level of knowledge medical students have about this disease. Material and Methods: Descriptive study of eight medical schools interviewing pre graduate medical students. Results: Only 15% of the curricula of private medical schools and 21.7% of public schools included the subject of HIV/AIDS. Although it is difficult to standardize this finding, an average of 8.8 hours was assigned to the study of HIV/AIDS. 90% of the professors involved in teaching the topic of HIV/AIDS had no clinical experience in the field. Conclusion: HIV/AIDS is a low priority subject in our medical school curricula. Efforts must be placed to standardize and reinforce this highly important topic.

Sexual behavior patterns and HIV risks in bisexual men compared to exclusively heterosexual and homosexual men

OBJETIVO: Comparar los patrones de comportamiento sexual entre hombres bisexuales, heterosexuales y homosexuales. MATERIAL Y MÉTODOS: Se llevó a cabo una encuesta probabilística en hogares de la Ciudad de México en 1992-1993, utilizando el marco muestral de las Encuestas Nacionales de Salud; se obtuvo información de 8 068 hombres entre 15 y 60 años de edad. El análisis principal de este trabajo se centra en hombres sexualmente activos en los cinco años previos a la encuesta. RESULTADOS: Los hombres bisexuales notificaron con mayor frecuencia relaciones sexuales anales con mujeres (16% vs. 3%, p=0.01), y mayor frecuencia de relaciones sexuales con trabajadoras sexuales que los heterosexuales exclusivos (10% vs. 4%, p=0.04). Los bisexuales usaron condones más frecuentemente con trabajadoras sexuales que los heterosexuales (p=0.01). La mayoría de los bisexuales (79%) no mantuvieron relaciones sexuales anales (receptivas o insertivas) con otros hombres en el año previo al estudio; en su lugar, llevaron a cabo sexo oral insertivo o sólo masturbación; 35% de los homosexuales exclusivos no reportó llevar a cabo ninguna práctica anal durante sus relaciones sexuales. Los bisexuales que mantuvieron coito anal tuvieron comportamientos receptivos con menor frecuencia que los homosexuales exclusivos (13% vs. 60%, p<0.01); de éstos, debido al uso de condón, sólo 7% de los bisexuales y 18% de los homosexuales tuvieron coito anal receptivo no protegido en la última relación sexual con otro hombre. CONCLUSIONES: Los bisexuales mantuvieron comportamientos sexuales con otros hombres de menor riesgo que los homosexuales exclusivos. Este hallazgo podría implicar que los hombres bisexuales en México no son un puente epidemiológico efectivo para la transmisión del VIH.

Uso del condón en hombres con parejas no estables en la Ciudad de México / Condom use among men with non-stable partners in Mexico City

Objetivo. Analizar la asociación de variables sociodemográficas en la utilización del condón durante prácticas sexuales vaginales con parejas no estables. Material y métodos. Los datos provienen de una encuesta probabilística sobre comportamiento sexual aplicada en 1992-1993 a una muestra de hogares en la Ciudad de México y su área conurbada. De 8 068 hombres de 15 a 60 años de edad que proporcionaron información, se seleccionaron 1 535 cuya última relación sexual -con penetración vaginal- había sido con una pareja no estable. Primero se realizó un análisis por componentes principales, para agrupar aquellas variables con dimensiones subyacentes comunes y, a partir de ellos y de algunas variable individuales, se efectuó una regresión logística. Resultados. Las variables que midieron conocimientos sobre el SIDA y sus mecanismos de transmisión y prevención, no tuvieron una relación estadísticamente significativa (p< 0.05) con haber usado condón en la última relación sexual vaginal con una pareja no estable (variable dependiente). En su lugar, las variables que sí presentaron una relación estadísticamente significativa con la variable dependiente, fueron: visión del placer del sexo con condón o sin penetración; autoeficacia para realizar sexo sin penetración; autocompulsión en el uso del condón asociado al SIDA como enfermedad de mayor temor; percepción sobre el carácter evitable de la infección y sobre la efectividad del condón; estado civil; escolaridad; y número de episodios de enfermedades de transmisión sexual (ETS) en toda la vida: Conclusiones: Aunque la provisión de información es importante en las estrategias educacionales de prevención sobre VIH/SIDA, el fomento de una percepción individual y colectiva favorable (placentera) sobre el condón, el sexo seguro y la autoeficacia para poner en práctica medidas preventivas contra la infección por VIH, puede ser de mayor importancia para adoptar el uso de condón como práctica de prevención

Factores de riesgo asociados a infeccion por VIH en hombres homoxesuales y bisexuales: el caso de la Ciudad de Mexico / Risk factors associated with HIV infections in male homosexuals and bisexuals: the case of Mexico City

El primer caso de SIDA en stéxico se diagnosticó en el instituto Nacional de la Nutrición "Salvador Zubirdn" en 1983, y hasta el primero de enero de 1988 se hablan atendido 127 enfermos en lo institución. Se informan los resultados clinicos y demográficos de los primeros 107 pacientes (106 hombres y una mujer). La edad promedio fue de 35.3 alias. De los varones, 94(88%) refirieron homosexuallidad y 33 (35%) de ellos se declararon bisexuales: La serología por EUSA fue positiva en todos los pacientes en quienes se efecluó. La manifestación inicial en 81 pacientes fue positiva infección oportunista (76%), sarcoma de Kaposi en 21 (20%) y ambos en cinco (5%). Cincuenta por ciento de los pacientes habla fallecido a la semana 22 después de establecido el diagnostico, tras un promedio de hospitalización de 47. 7 dios por año, con un costo de 19 millones de pesas por paciente-año. Los gérmenes más frecuentemente identificados fueron: C. albicans en 69 pacientes (65%), citomegalovirus en 36(34%), micobacteria en 32(30%), Cryptosporidiurn en 27(23%), y P. carinii Y virus del herpes simple en 23 (22%). De las neoplasias, se encontró sarcoma de Kaposi en 50 pacientes (47%) y linfomas en cinco (5%). El estudio de seroprevalencia mostró que aproximadamente 30% de los homosexuales asintomaticos de la ciudad de México ha adquirido la infección por VlH. Las manifestaciones de SIDA en nuestros. pacientes fueron semejantes a /as informadas en otros paises, pero fue más frecuente el antecedente de bisexualidad y las infecciones por Cryptosporidiurn, y menos frecuente el antecedente de drogadicción por vía endovenosa y las infecciones por P. carinü