HIV Vertical transmission in Rio de Janeiro, Brazil - does the distance matter?

Mother-to-child transmission (MTCT) is the main route of transmission for HIV among under 5 children in Brazil. National data indicate that missed opportunities for HIV prevention of MTCT are still common in antenatal care (ANC). We studied variables related to target process indicators in a cohort of HIV exposed children. We used data from 1996 to 2013 related to HIV exposed uninfected and HIV-infected children attended in an HIV reference hospital in Rio de Janeiro, Brazil. Data were collected from baseline questionnaires applied to all children followed-up in the hospital. Gestational and perinatal history were extracted from the mother's ANC card. Infants were categorized according to dates of first HIV care at the unit (1996-2000, 2001-2006 and 2007-2013). Distances between recorded addresses and the nearest maternity/hospital were measured by Euclidean distance, the shortest car route calculated in Google Maps and the route of the available bus line. Of the 599 children who fulfilled the inclusion criteria, 178 (29.7%) were HIV-infected. Approximately 70% of infants exposed to the virus from 1996-2000 were infected, dropping to 15.2% from 2001-2006 and rebounding to 30.1% from 2007-2013. Birth cohort was associated with ANC, and mothers from 2007-2013 had a lower chance of attending ANC (OR = 0.16; 95%CI 0.08-0.30). In addition, when the distance home-birthplace was higher than 9.5 km, there was a lower chance that the mother had attended ANC (OR = 0.35; 95%CI 0.18-0.68). Birth cohort was associated to HIV and ANC, and our data showed that a reduction of ANC might be related to rebound in HIV cases. There seems to have an association between larger distances from home to the birthplace and absence of ANC, which suggests that ANC was being performed in the tertiary units instead of in the primary care facilities as recommended.

Improvement of HAART in Brazil, 1998-2008: a nationwide assessment of survival times after AIDS diagnosis among men who have sex with men.

BACKGROUND: In 1996, Brazil became the first developing country to provide free, universal access to HAART, laboratory monitoring, and clinical care to any eligible patient. As of June 2014, approximately 400,000 patients were under treatment, making it the most comprehensive HIV treatment initiative implemented thus far in a middle-income country, worldwide. The Brazilian epidemic is highly concentrated among men who have sex with men (MSM). METHODS: Four national information systems were combined and Cox regression was used to conduct retrospective cohort analysis of HAART availability/access on all-cause mortality among MSM diagnosed with AIDS reported to the information systems between 1998-2008, adjusting for demographic, clinical, and behavioral factors and controlling for spatially-correlated survival data by including a frailty effect. Multiple imputation by chained equations was used to handle missing data. RESULTS: Among 50,683 patients, 10,326 died during the 10 year of period. All-cause mortality rates declined following introduction of HAART, and were higher among non-white patients and those starting HAART with higher viral load and lower CD4 counts. In multivariable analysis adjusted for race, age at AIDS diagnosis, and baseline CD4 cell count, MSM diagnosed in latter periods had almost a 50% reduction in the risk of death, compared to those diagnosed between 1998-2001 (2002-2005 adjHR: 0.54, 95% CI:0.51-0.57; 2006-2008 adjHR: 0.51, 95% CI:0.48-0.55). After controlling for spatially correlated survival data, mortality remained higher among those diagnosed in the earliest diagnostic cohort and lower among non-white patients and those starting HAART with higher viral load and lower CD4 lymphocyte counts. CONCLUSIONS: Universal and free access to HAART has helped achieve impressive declines in AIDS mortality in Brazil. However, after a 10-years follow-up, differential AIDS-related mortality continue to exist. Efforts are needed to identify and eliminate these health disparities, therefore improving the Brazilian response towards HIV/AIDS epidemic.

Acceptability of self-conducted home-based HIV testing among men who have sex with men in Brazil: data from an on-line survey.

The Brazilian HIV/AIDS epidemic is concentrated among men who have sex with men (MSM), however HIV testing rates among MSM are not commensurate with their risk. Strategies to expand early diagnosis may include use of self-conducted home-based testing kits, which are now available for purchase in the US. In April 2011 we conducted a survey with Brazilian MSM using Facebook to assess HIV testing preferences and acceptability of home-based testing. Among 356 previously tested, HIV-negative MSM, 47% reported a preference for home-based testing, 27% preferred clinic-based testing, and 26% had no preference. Less frequent testers and those who had considered testing but failed to test were more likely to prefer home-based testing. Close to 90% reported that they would use self-test kits; 62% and 54% said they would use home-based testing to make choices about unprotected sex with regular and new partners, respectively. Concerns included difficulty to understand the tests (32%) and receiving results alone (23%). Overall, home-based testing may appeal to MSM and result in increased testing frequency. Research on feasibility and utilization of self-tests in practice is needed.

Acceptability of self-conducted home-based HIV testing among men who have sex with men in Brazil: data from an on-line survey / Aceitabilidade da autotestagem domiciliar para o HIV entre homens que fazem sexo com homens no Brasil: dados de uma enquete na Internet / Aceptabilidad del examen de VIH autoadministrado en casa con hombres que practican sexo con hombres en Brasil: datos de una encuesta por internet

The Brazilian HIV/AIDS epidemic is concentrated among men who have sex with men (MSM), however HIV testing rates among MSM are not commensurate with their risk. Strategies to expand early diagnosis may include use of self-conducted home-based testing kits, which are now available for purchase in the US. In April 2011 we conducted a survey with Brazilian MSM using Facebook to assess HIV testing preferences and acceptability of home-based testing. Among 356 previously tested, HIV-negative MSM, 47% reported a preference for home-based testing, 27% preferred clinic-based testing, and 26% had no preference. Less frequent testers and those who had considered testing but failed to test were more likely to prefer home-based testing. Close to 90% reported that they would use self-test kits; 62% and 54% said they would use home-based testing to make choices about unprotected sex with regular and new partners, respectively. Concerns included difficulty to understand the tests (32%) and receiving results alone (23%). Overall, home-based testing may appeal to MSM and result in increased testing frequency. Research on feasibility and utilization of self-tests in practice is needed.

A epidemia de HIV/AIDS no Brasil é concentrada em homens que fazem sexo com homens (HSH), mas suas taxas de testagem são incompatíveis com seus riscos. Estratégias para expandir o diagnóstico precoce entre HSH podem incluir kits de autotestagem em ambiente doméstico (AAD), como os disponíveis para compra nos Estados Unidos. Em abril de 2011, realizamos uma pesquisa com HSH brasileiros recrutados em Facebook para conhecer preferências de testagem e aceitabilidade da AAD. Entre 356 HSH HIV(-) testados previamente, 47% preferiam a AAD, 27% testagem em clínicas e 26% sem preferência. HSH com menos testagem ou que consideraram a testagem sem fazê-la tinham maior probabilidade de preferir a AAD (p < 0,05). Quase 90% usariam a AAD, 62 e 54% para decidir sobre ter sexo desprotegido com parceiros regulares e novos, respectivamente. Dificuldade de entender os testes (32%) e receber os resultados sozinhos (23%) foram preocupações referidas. Testes anti-HIV de AAD podem ser atrativos para HSH e resultar em aumento de testagem. Pesquisas com foco na viabilidade e utilização dos kits AAD na prática são necessárias.

La epidemia de VIH/SIDA en Brasil se concentra en hombres que practican sexo con hombres (HSH), pero los índices de exámenes clínicos para conocer si están infectados son incompatibles con sus riesgos. Las estrategias para expandir el diagnóstico precoz entre HSH pueden incluir kits de autoanálisis para el hogar, como los que están a disposición del público en Estados Unidos. En abril de 2011, realizamos una investigación con HSH brasileños, captados en Facebook, para conocer preferencias de exámenes y la aceptabilidad del autoanálisis en un ambiente doméstico. Entre los 356 HSH VIH(-) analizados previamente, un 47% preferían un autoanálisis en un ambiente doméstico, un 27% pruebas en clínicas y un 26% no tenían preferencias. HSH que menos exámenes se realizaron o quienes los consideraron, pero no se los hicieron, tenían mayor probabilidad de preferir el autoanálisis en un ambiente doméstico. Casi un 90% usarían autoanálisis en su hogar, un 62% y 54% con el fin de decidir sobre tener sexo sin protección con parejas regulares y nuevas, respectivamente. La dificultad de entender los análisis (32%) y recibir los resultados a solas (23%) fueron las preocupaciones a las que se refirieron. Los análisis anti-VIH de autoadministración en el hogar pueden ser atractivos para HSH y resultar en un aumento de exámenes. Las investigaciones centradas en la viabilidad y utilización de los test de autoanálisis en la práctica son necesarias.

Outcomes among HIV-1 infected individuals first starting antiretroviral therapy with concurrent active TB or other AIDS-defining disease.

BACKGROUND: Tuberculosis (TB) is common among HIV-infected individuals in many resource-limited countries and has been associated with poor survival. We evaluated morbidity and mortality among individuals first starting antiretroviral therapy (ART) with concurrent active TB or other AIDS-defining disease using data from the "Prospective Evaluation of Antiretrovirals in Resource-Limited Settings" (PEARLS) study. METHODS: PARTICIPANTS WERE CATEGORIZED RETROSPECTIVELY INTO THREE GROUPS ACCORDING TO PRESENCE OF ACTIVE CONFIRMED OR PRESUMPTIVE DISEASE AT ART INITIATION: those with pulmonary and/or extrapulmonary TB ("TB" group), those with other non-TB AIDS-defining disease ("other disease"), or those without concurrent TB or other AIDS-defining disease ("no disease"). Primary outcome was time to the first of virologic failure, HIV disease progression or death. Since the groups differed in characteristics, proportional hazard models were used to compare the hazard of the primary outcome among study groups, adjusting for age, sex, country, screening CD4 count, baseline viral load and ART regimen. RESULTS: 31 of 102 participants (30%) in the "TB" group, 11 of 56 (20%) in the "other disease" group, and 287 of 1413 (20%) in the "no disease" group experienced a primary outcome event (p = 0.042). This difference reflected higher mortality in the TB group: 15 (15%), 0 (0%) and 41 (3%) participants died, respectively (p<0.001). The adjusted hazard ratio comparing the "TB" and "no disease" groups was 1.39 (95% confidence interval: 0.93-2.10; p = 0.11) for the primary outcome and 3.41 (1.72-6.75; p<0.001) for death. CONCLUSIONS: Active TB at ART initiation was associated with increased risk of mortality in HIV-1 infected patients.

Egocentric network data provide additional information for characterizing an individual's HIV risk profile.

OBJECTIVE: We investigated the hypothesis that partner-specific characteristics are important to improve an individual's risk characterization. DESIGN: It has been shown that the egocentric network structure is important to establish a person's risk for infection. METHODS: The study was cross-sectional in its design and enrolled 1231 volunteers at one HIV testing site in Rio de Janeiro, Brazil, and applied an adapted ego-network questionnaire. Each individual was interviewed about their own risk factors and those related to up to 10 sex partners. We used the dyadic data analysis method in which each relationship forms a record. Two receiver operator characteristic curves were generated, and the ability to correctly predict volunteers' HIV serostatus based on a model with characteristics of volunteers and sex partners and another with only volunteers' characteristics was evaluated. RESULTS: Partner-related variables were associated with HIV serostatus both for men and women. The model with volunteer/sex partners' characteristics performed better in discriminating between HIV-positive and negative volunteers only for men but not for women. The c statistic for men volunteers was 0.82 [95% confidence interval (CI) 0.77-0.87] for the volunteer alone model and 0.88 (95% CI 0.86-0.91) for the combined model (P = 0.03). The values for women were 0.75 (95% CI 0.65-0.86) and 0.78 (95% CI 0.71-0.85), respectively (P = 0.71). CONCLUSION: Ego-network theory-based approaches provide additional information for characterizing risk for HIV infection among men.

Usefulness of clinical algorithm as screening process to detected malaria in low-to-moderate transmission areas of scarce health related resources.

INTRODUCTION: In areas of low-to-moderate risk of malaria transmission, the World Health Organization recommends parasitic confirmation before treatment. Such areas have usually low budget for health care and malaria diagnosis is mostly based on clinical assumption. Algorithms have been developed to improve health care providers' identification of clinical malaria and could be used as screening to reduce the number of individuals requiring parasitic confirmation before treating. METHODS: Prospective clinical and parasitological data were collected from inhabitants of four villages from March 1984 through March 1985. Symptoms and signs recorded by physicians were used in multivariate models to test the best predictors of malaria. Sensitivity and specificity were calculated for various cut-offs of scores and compared to clinical diagnosis. RESULTS: A total of 8.941 individuals were evaluated during the 1-year period of data collection. The overall prevalence of malaria parasitemia was 19.7% (n=1762). Of the 4280 people evaluated during the high season period, 24% (n=1024) presented any parasitemia, 55.3% (566/1024) due to Plasmodium falciparum. The final clinical algorithm included history of fever, rigors, headache, absence of myalgia, backache or cough, nausea or vomiting, and splenomegaly on examination as predictable variables. At a cut-off score of 2.0, the sensitivity of the algorithm was higher for the entire sample (57% vs. 43%), for high season period (70% vs. 53%), for children less than 6 years of age (59% vs. 40%), for individuals with parasitemia due to P. falciparum (65% vs. 48%), and for high P. falciparum parasitemic individuals at high season (84% vs. 68%). However, specificity was usually lower unless a higher cut off was used, in which case the gain in sensitivity by using the algorithm was reduced. CONCLUSION: In low-to-moderate transmission areas in which health related resources are scarce, a clinical algorithm increases the identification of real cases of malaria and could be used as screening for further parasitic identification.

The use of supplementary techniques to increase recall of sex partners in a network-based research study in Rio de Janeiro, Brazil.

OBJECTIVE: To evaluate supplementary cueing as a technique to increase recall of sex partners in the year before the interview. GOAL: Recall of partners beyond those freely recalled. STUDY DESIGN: We asked volunteers at a clinic in Brazil to freely recall all regular and casual sex partners in the year before the interview. Then, we used a name generator developed by Brewer et al. in the United States, in which volunteers were prompted with 4 types of cues: location, alphabetic, social role, and network. We calculated different measures to evaluate the technique and analyzed the associations between reporting any additional partner and demographic characteristics. RESULTS: Among volunteers reporting 2 or more sexual partners (n = 590), 41 (7%) recalled 1 or more additional partners by using the supplementary technique, with 105 partners of 2090 (5%) recalled only after using the cues. For volunteers reporting 4 or more sexual partners (n = 193), 34 (18%) recalled 1 or more additional partners by using the supplementary technique, and 98 of 1177 (8%) of their sexual partners were recalled after using the cues. Men were less likely than women to report sex partners after prompting with the social role cues (OR 0.09), and overall the combined techniques were slightly less effective for older individuals (OR 0.95). CONCLUSION: The cue technique can improve sexual partners' recall in cultural contexts different than the United States, mainly for individuals already reporting several partners before the cue.

Support for emergency department screening for intimate partner violence depends on perceived risk.

Emergency department (ED) screening for intimate partner violence (IPV) faces logistic difficulties and has uncertain efficacy. We surveyed 146 ED visitors and 108 ED care providers to compare their support for ED IPV screening in three hypothetical scenarios of varying IPV risk. Visitor support for screening was 5 times higher for the high-risk (86%) than for the low-risk (17%) scenario. Providers showed significantly more support for the need for ED IPV screening than visitors. Controlling for confounding by gender, race, experience with IPV, hospital, and marital status did not affect comparisons between groups. These responses indicate greater support for IPV screening in the ED for high-risk than for low-risk cases, particularly among visitors.

Perceptions of help resources for victims of intimate partner violence.

Intimate partner violence (IPV) constitutes a major public health problem in the United States. This cross-sectional survey of 108 emergency department (ED) care providers and 146 ED visitors at three metropolitan EDs compared the beliefs of ED health care providers with those of community members about the relative benefits of the helpfulness of resources for IPV victims using hypothetical case scenarios. Although providers generally indicated that help resources were helpful in all scenarios, visitors were more discriminating, showing less support for resources in the lower-risk scenario. Regarding differences between groups, visitors selected police and attorneys more frequently than providers as a helpful resource, whereas providers selected shelters and counselors more frequently than visitors. Adjustment for previous experience with IPV did not change these results. Understanding the differences between health care providers' and community members' perceptions of resources for victims of IPV may improve the effectiveness of referral to IPV resources.

Severity-of-illness markers as predictors of nosocomial infection in adult intensive care unit patients.

BACKGROUND: Patients admitted to intensive care units (ICUs) are at high risk for acquiring nosocomial infections. We examined the association between markers of severity of illness at ICU admission and the development of ICU-attributable nosocomial infections. METHODS: Retrospective cohort study of 851 patients admitted to the medical or surgical ICU in an urban teaching hospital from January 1997 to January 1998. Logistic regression analysis was used to identify predictors of nosocomial infection, including the Acute Physiology, Age, Chronic Health Evaluation III severity-of-illness scoring system. RESULTS: Patients receiving mechanical ventilation on day 1 of ICU admission (OR, 1.99; 95% CI, 1.29-3.06) and patients transferred to the ICU from another unit within the same hospital (OR, 2.04; 95% CI, 1.24-3.34) were twice as likely to acquire an ICU-attributable nosocomial infection compared with patients admitted from other sources. The day-1 Acute Physiology, Age, Chronic Health Evaluation III score was not a significant predictor of nosocomial infection. CONCLUSION: The need for mechanical ventilation on ICU day 1 and transfer to the ICU from another unit are independent predictors of ICU-attributable nosocomial infections. Up to 50% of ICU patients who develop nosocomial infections could be easily identified at ICU admission, allowing for targeted use of preventive strategies to reduce the risk of nosocomial infections.