Lifestyle changes during the COVID-19 pandemic in Brazil: results from three consecutive cross-sectional web surveys.

OBJECTIVE: The importance of a healthy lifestyle in preventing morbidity and mortality is well-established. The COVID-19 pandemic brought about significant lifestyle changes globally, but the extent of these changes in the Brazilian population remains unclear. The objective of this study was to evaluate changes in lifestyle among the Brazilian general population during the first year of the pandemic. DESIGN: Three consecutive anonymous web surveys were carried out: survey 1 (S1)-April 2020, S2-August 2020 and S3-January 2021. SETTING: Brazil. PARTICIPANTS: The study included 19 257 (S1), 1590 (S2) and 859 (S3) participants from the general population, who were ≥18 years, of both sexes, with access to the internet, self-reporting living in Brazil and who agreed to participate after reading the informed consent. PRIMARY OUTCOME: Lifestyle changes were assessed using the Short Multidimensional Instrument for Lifestyle Evaluation-Confinement (SMILE-C). The SMILE-C assesses lifestyle across multiple domains including diet, substance use, physical activity, stress management, restorative sleep, social support and environmental exposures. We used a combination of bootstrapping and linear fixed-effect modelling to estimate pairwise mean differences of SMILE-C scores overall and by domain between surveys. RESULTS: In all the surveys, participants were mostly women and with a high education level. Mean SMILE-C scores were 186.4 (S1), 187.4 (S2) and 190.5 (S3), indicating a better lifestyle in S3 as compared with S1. The pairwise mean differences of the overall SMILE-C scores were statistically significant (p<0.001). We also observed a better lifestyle over time in all domains except for diet and social support. CONCLUSIONS: Our findings indicate that individuals from a large middle-income country, such as Brazil, struggled to restore diet and social relationships after 1 year of the pandemic. These findings have implications for monitoring the long-term consequences of the pandemic, as well as future pandemics.

Predictors of illicit substance abuse/dependence during young adulthood: A machine learning approach.

Prior studies have found an especially high prevalence of illicit substance use among adolescents and young adults in Brazil. The current study aimed to employ machine learning techniques to identify predictors of illicit substance abuse/dependence among a large community sample of young adults followed for 5 years. This prospective, population-based cohort study included a sample of young adults between the ages of 18-24 years from Pelotas, Brazil at baseline (T1). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was used to assess illicit substance abuse/dependence. A clinical interview was conducted to collect data on sociodemographic characteristics and psychopathology. Elastic net was used to generate a regularized linear model for the machine learning component of this study, which followed standard machine learning protocols. A total of 1560 young adults were assessed at T1, while 1244 were reassessed at the 5-year follow-up period (T2). The strongest predictors of illicit substance abuse/dependence at baseline (AUC of 0.83) were alcohol abuse/dependence, tobacco abuse/dependence, being in a current major depressive episode, history of a lifetime manic episode, current suicide risk, and male sex. The strongest predictors for illicit substance abuse/dependence at the 5-year follow-up (AUC: 0.79) were tobacco abuse/dependence at T1, history of a lifetime manic episode at T1, male sex, alcohol abuse/dependence at T1, and current suicide risk at T1. Our findings indicate that machine learning techniques hold the potential to predict illicit substance abuse/dependence among young adults using sociodemographic/clinical characteristics, with relatively high accuracy.

Understanding alcohol-related indicators from population surveys: answering the "Five W's of Epidemiology".

The harmful use of alcohol is a major risk factor for the global burden of disease, and public policies are the most effective strategies to prevent it. Population-based surveys are milestones for planning, implementing, and monitoring those policies. However, there are numerous ways to measure alcohol consumption which may result in different indicators. Researchers and stakeholders should find common ground in the understanding of these measures to avoid misinterpretation and confusion in the field. Answering to the "Five W's Epidemiology", when interpreting alcohol-related information, may improve the communication, as well as reproducibility and comparability of research findings. This paper aims to exemplify this approach by describing some indicators from the World Health Organization's Global Information System on Alcohol and Health (GISAH) and the corresponding data available from the latest Brazilian household surveys. Notably, none of the Brazilian surveys reports on all the nine selected GISAH indicators, and only two provided the necessary methodological details to be fully reproducible. A stronger agenda is of the utmost importancefor advancing in the monitoring and prevention of alcohol-related harms in Brazil.

Underage drinking in Brazil: findings from a community household survey

Objectives: Previous studies have estimated the 30-day prevalence of alcohol use to be approximately 21% among youth in Brazil, despite the legal drinking age of 18 years. The present study aimed to determine the prevalence of underage drinking and its associated factors among adolescents in Brazil. Methods: The 3rd National Survey on Drug Use by the Brazilian Population (III Levantamento Nacional sobre o Uso de Drogas pela População Brasileira) is a nationwide, multi-stage, probability-sample household survey. Herein, youth between the ages of 12-17 years were included. Lifetime and 12-month alcohol use prevalence were estimated. Factors associated with 12-month alcohol use were evaluated through multivariate analysis considering survey weights and design. Results: Overall, 628 youth were interviewed. Estimated lifetime and 12-month alcohol use were 34.3% (standard error [SE] = 1.9) and 22.2% (SE = 1.7), respectively. Factors associated with 12-month drinking were: other/no religion vs. Christianity; living in rural vs. urban areas; self-reported diagnosis of depression vs. no self-reported depression; lifetime tobacco use vs. no history of tobacco use; and any illicit drug use vs. no history of illicit drug use. Conclusion: Considering that alcohol use is a major risk factor for early death among Brazilian youth, our findings highlight the importance of preventative measures to reduce underage drinking.

Underage drinking in Brazil: findings from a community household survey.

OBJECTIVES: Previous studies have estimated the 30-day prevalence of alcohol use to be approximately 21% among youth in Brazil, despite the legal drinking age of 18 years. The present study aimed to determine the prevalence of underage drinking and its associated factors among adolescents in Brazil. METHODS: The 3rd National Survey on Drug Use by the Brazilian Population (III Levantamento Nacional sobre o Uso de Drogas pela População Brasileira) is a nationwide, multi-stage, probability-sample household survey. Herein, youth between the ages of 12-17 years were included. Lifetime and 12-month alcohol use prevalence were estimated. Factors associated with 12-month alcohol use were evaluated through multivariate analysis considering survey weights and design. RESULTS: Overall, 628 youth were interviewed. Estimated lifetime and 12-month alcohol use were 34.3% (standard error [SE] = 1.9) and 22.2% (SE = 1.7), respectively. Factors associated with 12-month drinking were: other/no religion vs. Christianity; living in rural vs. urban areas; self-reported diagnosis of depression vs. no self-reported depression; lifetime tobacco use vs. no history of tobacco use; and any illicit drug use vs. no history of illicit drug use. CONCLUSION: Considering that alcohol use is a major risk factor for early death among Brazilian youth, our findings highlight the importance of preventative measures to reduce underage drinking.

Depression, Anxiety, and Lifestyle Among Essential Workers: A Web Survey From Brazil and Spain During the COVID-19 Pandemic.

BACKGROUND: Essential workers have been shown to present a higher prevalence of positive screenings for anxiety and depression during the COVID-19 pandemic. Individuals from countries with socioeconomic inequalities may be at increased risk for mental health disorders. OBJECTIVE: We aimed to assess the prevalence and predictors of depression, anxiety, and their comorbidity among essential workers in Brazil and Spain during the COVID-19 pandemic. METHODS: A web survey was conducted between April and May 2020 in both countries. The main outcome was a positive screening for depression only, anxiety only, or both. Lifestyle was measured using a lifestyle multidimensional scale adapted for the COVID-19 pandemic (Short Multidimensional Inventory Lifestyle Evaluation-Confinement). A multinomial logistic regression model was performed to evaluate the factors associated with depression, anxiety, and the presence of both conditions. RESULTS: From the 22,786 individuals included in the web survey, 3745 self-reported to be essential workers. Overall, 8.3% (n=311), 11.6% (n=434), and 27.4% (n=1027) presented positive screenings for depression, anxiety, and both, respectively. After adjusting for confounding factors, the multinomial model showed that an unhealthy lifestyle increased the likelihood of depression (adjusted odds ratio [AOR] 4.00, 95% CI 2.72-5.87), anxiety (AOR 2.39, 95% CI 1.80-3.20), and both anxiety and depression (AOR 8.30, 95% CI 5.90-11.7). Living in Brazil was associated with increased odds of depression (AOR 2.89, 95% CI 2.07-4.06), anxiety (AOR 2.81, 95%CI 2.11-3.74), and both conditions (AOR 5.99, 95% CI 4.53-7.91). CONCLUSIONS: Interventions addressing lifestyle may be useful in dealing with symptoms of common mental disorders during the strain imposed among essential workers by the COVID-19 pandemic. Essential workers who live in middle-income countries with higher rates of inequality may face additional challenges. Ensuring equitable treatment and support may be an important challenge ahead, considering the possible syndemic effect of the social determinants of health.

An Internet-Based HIV Self-Testing Program to Increase HIV Testing Uptake Among Men Who Have Sex With Men in Brazil: Descriptive Cross-Sectional Analysis.

BACKGROUND: Approximately 30% of people living with HIV worldwide are estimated to be unaware of their infection. HIV self-testing (HIVST) is a strategy recommended by the World Health Organization to increase access to and uptake of testing among key populations who are at high risk for HIV infection. OBJECTIVE: This study aimed to describe the development and feasibility of a free, anonymous, internet-based HIVST strategy designed for men who have sex with men in Curitiba, Brazil (electronic testing [e-testing]). METHODS: The project was developed under the scope of the "A Hora é Agora" (The Time is Now) program. Individuals aiming to request an HIVST package (two tests each) answered an anonymous 5-minute questionnaire regarding inclusion criteria and sexual risk behavior. Eligible individuals could receive one package every 6 months for free. Website analytics, response to online questionnaires, package distribution, and return of test results were monitored via a platform-integrated system. RESULTS: Between February 2015 and January 2016, the website documented 17,786 unique visitors and 3218 completed online questionnaires. Most individuals self-reported being white (77.0%), young (median age: 25 years, interquartile range: 22-31 years), educated (87.3% completed secondary education or more), and previously tested for HIV (62.5%). Overall, 2526 HIVST packages were delivered; of those, 542 (21.4%) reported a result online or by mail (23 reactive and 11 invalid). During the study period, 37 individuals who reported using e-testing visited the prespecified health facility for confirmatory testing (30 positive, 7 negative). CONCLUSIONS: E-testing proved highly feasible and acceptable in this study, thus supporting scale-up to additional centers for men who have sex with men in Brazil.

Awareness of Prevention Strategies and Willingness to Use Preexposure Prophylaxis in Brazilian Men Who Have Sex With Men Using Apps for Sexual Encounters: Online Cross-Sectional Study.

BACKGROUND: Geosocial networking (GSN) smartphone apps are becoming the main venue for sexual encounters among Brazilian men who have sex with men (MSM). To address the increased HIV incidence in this population, preexposure prophylaxis (PrEP) was recently implemented in the Brazilian public health system in the context of combined HIV prevention. OBJECTIVE: This study aimed to describe the characteristics of MSM using GSN apps for sexual encounters, their awareness of prevention strategies, and willingness to use PrEP. METHODS: This study was an online cross-sectional study conducted in 10 Brazilian state capitals from July 1 to July 31, 2016. The questionnaire was programmed on SurveyGizmo and advertised in two GSN apps used by MSM to find sexual partners (Hornet and Grindr). Inclusion criteria were >18 years of age, cisgender men, with an HIV-negative status. Eligible individuals answered questions on: demographics; behavior; and knowledge, preferences, and willingness to use PrEP, nonoccupational postexposure prophylaxis (nPEP), HIV self-testing (HIVST), and condoms. Logistic regression modeling was performed to assess the factors associated with daily oral PrEP willingness. RESULTS: During the study period, 8885 individuals provided consent and started the questionnaire. Of these, 23.05% (2048/8885) were ineligible, 6837 (6837/8885, 76.94%) initiated, and 5065 (5065/8885, 57.00%) completed the entire questionnaire and were included in the present analysis. Median age was 30 years (interquartile range: 25-36), most self-declared as MSM (4991/5065, 98.54%), white (3194/5065, 63.06%), middle income (2148/5065, 42.41%), and had 12 or more years of schooling (3106/5062, 61.36%). The majority of MSM (3363/5064, 66.41%) scored >10 points (high risk) on The HIV Incidence Risk for MSM Scale, but only 21.39% (1083/5064) had a low perceived likelihood of getting HIV in the next year. Daily use of apps for sex was reported by 35.58% (1798/5054). Most MSM (4327/5065, 85.43%) reported testing for HIV at least once in their lifetime and 9.16% (464/5065) used nPEP in the previous year. PrEP, nPEP, and HIVST awareness was reported by 57.89% (2932/5065), 57.39% (2907/5065), and 26.57% (1346/5065) of participants, respectively. Half of all respondents (2653/5065, 52.38%) were willing to use daily oral PrEP, and this finding was associated with higher numbers of male sexual partners (adjusted odds ratio [AOR] 1.26, 95% CI 1.09-1.47), condomless receptive anal intercourse (AOR 1.27, 95% CI 1.12-1.44), sex with HIV-positive partner versus no HIV-positive partner (one HIV-positive partner: AOR 1.36, 95% CI 1.11-1.67), daily use of apps for sexual encounters (AOR 1.48, 95% CI 1.17-1.87), high and unknown perceived likelihood of getting HIV in the next year (AOR 1.72, 95% CI 1.47-2.02 and AOR 1.39, 95% CI 1.13-1.70), sexually transmitted infection diagnosis (AOR 1.25, 95% CI 1.03-1.51), stimulant use (AOR 1.24, 95% CI 1.07-1.43), PrEP awareness (AOR 1.48, 95% CI 1.30-1.70), and unwillingness to use condoms (AOR 1.16, 95% CI 1.00-1.33). CONCLUSIONS: Our results evidenced high-risk scores in the studied population, suggesting the importance of PrEP use. Those individuals presenting risky sexual behaviors were more willing to use PrEP. Nonetheless, only 58% (2932/5065) of individuals had heard about this prevention strategy. Efforts to increase awareness of new prevention strategies are needed, and mobile health tools are a promising strategy to reach MSM.

Unprotected sexual practices among men who have sex with women and men who have sex with men living with HIV/AIDS in Rio de Janeiro.

Combined antiretroviral therapy is now acknowledged for preventing new HIV infections, besides decreasing mortality and morbidity. However, in many Latin America countries the epidemic is still driven by unprotected sexual intercourse. This study aims to describe sexual practices related to HIV/STD and to evaluate factors associated to unprotected sex among men who have sex with women (MSW) and men who have sex with men (MSM) under care at a reference center for HIV in Rio de Janeiro, Brazil. A cross-sectional study, nested in a Brazilian clinical cohort, evaluated the sexual practices of 404 sexually active HIV-positive MSW and men who have MSM. Approximately 30 % of them reported unprotected sexual practices during the 6 months prior to the interview. Most frequent risky practices reported were unprotected vaginal sex among MSW and unprotected receptive anal sex among MSM. Factors increasing the chance of unprotected sexual practices among MSW were the partner's desire of becoming pregnant (OR 2.81; CI 95 %: 1.36-5.95). To have received comments about excessive consumption of alcohol (OR 2.43; CI 95 %: 1.01-5.83), illicit drug use (OR 4.41; CI 95 %: 1.75-11.60) and lived in marital situation (OR 2.10; CI 95 %: 1.09-4.08) were significantly associated with unsafe sexual practices among MSM. The results highlight that health care of men living with HIV, as well as the prevention strategies, must consider the particularities of sexual behavior practiced by people who differ in sexual orientation.

Factors associated with tobacco smoking and cessation among HIV-infected individuals under care in Rio de Janeiro, Brazil.

Worldwide the prevalence of smoking among people living with HIV/AIDS is elevated compared to the general population. This probably reflects the cluster of individual characteristics that have shared risk factors for HIV infection and smoking. A cross-sectional study, enrolling a convenience sample from a Brazilian HIV clinical cohort was conducted to evaluate the prevalence of tobacco smoking and the factors associated with current smoking and abstinence. A total of 2,775 HIV-infected individuals were interviewed: 46.2% have never smoked, 29.9% were current smokers and 23.9% were former smokers. Current smokers had a higher prevalence of alcohol and illicit drug use when compared to the other two groups. A higher proportion of heterosexual individuals were former smokers or never smokers while among men who have sex with men (MSM) a higher proportion were current smokers. Former smokers had been more frequently diagnosed with high blood pressure, diabetes mellitus, cardiovascular diseases and depression, while for current smokers lung diseases were more frequent. Former smokers and current smokers were more likely to have had any hospital admission (42.0% and 41.2%, respectively) than participants who never smoked (33.5%) (p<0.001). Multivariate model results showed that current smokers (versus never smokers) were more likely to be less educated, to report the use of alcohol, crack and cocaine and to present clinical comorbidities. Former smokers (versus current smokers) were more likely to be older, to have smoked for a shorter amount of time and to have smoked >31 cigarettes/day. MSM (compared to heterosexuals) and cocaine users (versus non-users) had lower odds of being former smokers. Considering our results, smoking cessation interventions should be tailored to younger individuals, MSM and substance users.

Unrecorded alcohol in Rio de Janeiro: assessing its misusers through Respondent Driven Sampling.

BACKGROUND: Around 20-30% of alcohol use in low and middle-income countries is estimated to come from unrecorded sources, but little is known about the characteristics of its consumers. The aim of this study was to obtain information about users of unrecorded alcohol and describe factors associated with its frequent use. METHOD: A cross-sectional study, using Respondent Driven Sampling (RDS), was conducted in Rio de Janeiro, Brazil in 2010. Individuals aged 18-65 who reported binge drinking in the last 12 months were recruited to participate in a structured interview. Three sources of unrecorded alcohol use were assessed: home-made/unrecorded; perfumes/lotions; and "medicinal" products (compounds made of herbs and local spirits). RESULTS: 343 individuals were recruited and 303 were interviewed. The sample comprised mostly of men (n=256) from low socioeconomic strata, with a mean age of 38.8 (±12). Most individuals (71.8%) reported to have used more than one variety of unrecorded alcohol, which was found to be associated with: being older than 31 (OR 2.21; CI 95% 1.05-4.80), an AUDIT score >20 (OR 11.21; CI 95% 4.56-30.96), having used crack/cocaine (OR 2.29; CI 95% 1.02-5.21), and having received treatment for alcohol addiction in the last 12 months (OR 3.64; CI 95% 1.25-13.49). CONCLUSION: Most unrecorded alcohol users were disadvantaged polysubstance users. Assessing unrecorded alcohol use has important clinical implications and should be screened for among crack/powder cocaine and alcohol-dependent patients.

Unprotected sex among men who have sex with men living with HIV in Brazil: a cross-sectional study in Rio de Janeiro.

BACKGROUND: Many countries are facing concentrated HIV epidemics among vulnerable populations, including men who have sex with men (MSM). Unprotected anal intercourse (UAI) is the main HIV transmission route among them and its understanding in the different cultures and how it relates to HIV transmission, re-infection and development of HIV antiretroviral resistance has important public health implications. Data on UAI among Brazilian MSM are scarce. This study aims to evaluate the prevalence and associated factors of UAI among HIV-infected MSM who had sex with seronegative or male partners with an unknown serostatus. METHOD: A cross-sectional study nested in a cohort was conducted in Rio de Janeiro, Brazil. The one hundred and fifty five MSM included in the study answered an ACASI interview and provided biological samples. Generalized linear models were used to identify variables associated with UAI. RESULTS: Overall, UAI with an HIV-negative or unknown serostatus male partner was reported by 40.6% (63/155) of MSM. Lifetime sexual abuse or domestic violence was reported by 35.9%, being more frequent among MSM who reported UAI compared to those who did not (P = 0.001). Use of stimulants before sex was reported by 20% of the MSM, being slightly higher among those who reported UAI (27.0% vs. 15.2%; P = 0.072). Commercial sex was frequent among all MSM (48.4%). After multivariate modeling, the report of sexual abuse or domestic violence (OR = 2.70; 95% CI: 1.08-7.01), commercial sex (OR = 2.28; 95% CI: 1.04- 5.10), the number of male sexual partners (p = 0.039) and exclusively receptive anal intercourse (OR = 0.21; 95% CI: 0.06-0.75) remained associated with UAI. CD4 levels, HIV viral load and antiretroviral therapy were not associated with UAI. CONCLUSION: The UAI prevalence found with negative or unknown HIV status partners points out that other interventions are needed as additional prevention tools to vulnerable MSM. The main factors associated with UAI were a lifetime history of violence, commercial sex and the number of male sexual partners. This clustering of different behavioral, health and social problems in this population reinforce the need of a comprehensive approach on treating and preventing HIV among MSM.

Fenproporex and amphetamine pharmacokinetics in oral fluid after controlled oral administration of fenproporex.

BACKGROUND: Fenproporex hydrochloride (FEN) is an anorectic drug used in the treatment of obesity, and its major metabolite is amphetamine (AMP), another central nervous system stimulant. The concentration versus time profile of FEN and its metabolite AMP has been described in classic biological matrices such as plasma and urine; however, there are no reports of such data in oral fluid. OBJECTIVE: The aim of this study is to describe the pharmacokinetics of FEN and AMP in oral fluid after intake of FEN. METHODS: Twenty-five milligrams of FEN (1 capsule of Desobesi-m) was orally administered to 6 male volunteers, and oral fluid samples were collected with a Quantisal device during 24.00 hours after drug ingestion. These samples were submitted to solid-phase microextraction before analysis by gas chromatography-mass spectrometry in the selected-ion-monitoring mode, using deuterium-labeled AMP as internal standard. RESULTS: After FEN administration, both analytes could be detected in oral fluid of all volunteers with an initial detection time varying from 0.50 to 1.00 hour. FEN peak concentrations occurred between 1.00 and 1.50 hours after administration and were between 70.7 and 227.5 µg/L. For AMP, peak concentration occurred between 1.50 and 4.00 hours, reaching 33.0-150.9 µg/L. CONCLUSION: The authors observed that oral administration of FEN resulted in significant amounts of FEN and AMP in oral fluid, showing that oral fluid could be a biological matrix suitable for pharmacokinetic studies for both analytes. Using a compartmental approach, FEN data were best fitted by 1-compartment model with first-order input and output, whereas AMP followed a 2-compartment model with first-order input and output.