Recent dynamics in Neisseria gonorrhoeae genomic epidemiology in Brazil: antimicrobial resistance and genomic lineages in 2017-20 compared to 2015-16.

OBJECTIVES: Regular quality-assured WGS with antimicrobial resistance (AMR) and epidemiological data of patients is imperative to elucidate the shifting gonorrhoea epidemiology, nationally and internationally. We describe the dynamics of the gonococcal population in 11 cities in Brazil between 2017 and 2020 and elucidate emerging and disappearing gonococcal lineages associated with AMR, compare to Brazilian WGS and AMR data from 2015 to 2016, and explain recent changes in gonococcal AMR and gonorrhoea epidemiology. METHODS: WGS was performed using Illumina NextSeq 550 and genomes of 623 gonococcal isolates were used for downstream analysis. Molecular typing and AMR determinants were obtained and links between genomic lineages and AMR (determined by agar dilution/Etest) examined. RESULTS: Azithromycin resistance (15.6%, 97/623) had substantially increased and was mainly explained by clonal expansions of strains with 23S rRNA C2611T (mostly NG-STAR CC124) and mtr mosaics (mostly NG-STAR CC63, MLST ST9363). Resistance to ceftriaxone and cefixime remained at the same levels as in 2015-16, i.e. at 0% and 0.2% (1/623), respectively. Regarding novel gonorrhoea treatments, no known zoliflodacin-resistance gyrB mutations or gepotidacin-resistance gyrA mutations were found. Genomic lineages and sublineages showed a phylogenomic shift from sublineage A5 to sublineages A1-A4, while isolates within lineage B remained diverse in Brazil. CONCLUSIONS: Azithromycin resistance, mainly caused by 23S rRNA C2611T and mtrD mosaics/semi-mosaics, had substantially increased in Brazil. This mostly low-level azithromycin resistance may threaten the recommended ceftriaxone-azithromycin therapy, but the lack of ceftriaxone resistance is encouraging. Enhanced gonococcal AMR surveillance, including WGS, is imperative in Brazil and other Latin American and Caribbean countries.

Evidence of Zika Virus Reinfection by Genome Diversity and Antibody Response Analysis, Brazil.

We generated 238 Zika virus (ZIKV) genomes from 135 persons in Brazil who had samples collected over 1 year to evaluate virus persistence. Phylogenetic inference clustered the genomes together with previously reported ZIKV strains from northern Brazil, showing that ZIKV has been remained relatively stable over time. Temporal phylogenetic analysis revealed limited within-host diversity among most ZIKV-persistent infected associated samples. However, we detected unusual virus temporal diversity from >5 persons, uncovering the existence of divergent genomes within the same patient. All those patients showed an increase in neutralizing antibody levels, followed by a decline at the convalescent phase of ZIKV infection. Of interest, in 3 of those patients, titers of neutralizing antibodies increased again after 6 months of ZIKV infection, concomitantly with real-time reverse transcription PCR re-positivity, supporting ZIKV reinfection events. Altogether, our findings provide evidence for the existence of ZIKV reinfection events.

Detection and persistence of Zika virus in body fluids and associated factors: a prospective cohort study.

This study aimed to analyze the detection and duration of the Zika virus (ZIKV) in plasma, urine, saliva, sweat, rectal swabs, vaginal secretions, breast milk, and semen and to explore risk factors associated with prolonged viral persistence. A prospective cohort study of symptomatic patients and their household contacts was conducted in Brazil from July 2017 to June 2019. A total of 260 individuals (184 women and 76 men) with confirmed ZIKV infection were enrolled and followed up for 12 months. ZIKV RNA was present in all body fluid specimens and detectable for extended periods in urine, sweat, rectal swabs, and semen. The longest detection duration was found in semen, with high viral loads in the specimens. ZIKV RNA clearance was associated with several factors, including age, sex, education level, body mass index, non-purulent conjunctivitis, joint pain, and whether the participant had a history of yellow fever vaccination. The influence of each of these factors on the low or fast viral clearance varied according to the specific body fluid under investigation. Recurrent ZIKV detection events after total viral clearance were observed in the cohort. Our findings provide valuable insights into the persistence and potential recurrence of ZIKV infection, highlighting the need for continued monitoring and follow-up of individuals infected with ZIKV and for effective prevention measures to reduce the risk of transmission.

Subnational certification of elimination of mother-to-child transmission of HIV and/or syphilis: a Brazilian experience report.

OBJECTIVE: to describe the subnational implementation process of the certification for elimination of mother-to-child transmission of HIV and/or syphilis, its main barriers, challenges and opportunities. METHODS: in 2022, indicators from the last full year for impact targets and the last two full years for process targets, available in national information systems, were evaluated; descriptive reports were analyzed and actions were acknowledged within four thematic axes, according to PAHO/WHO recommendations. RESULTS: 43 municipalities ≥ 100,000 inhabitants were certified, covering 24.6 million inhabitants; one municipality achieved dual elimination (HIV-syphilis), 28 municipalities achieved elimination of HIV and 10 received silver tiers; regarding syphilis, one elimination was observed, along with 4 gold tiers, 13 silver tiers and 4 bronze tiers; a higher number of certifications was identified in the Southeast and South regions. CONCLUSION: barriers and challenges of the process were overcome through tripartite collaboration; the experience provided better integration of surveillance with care and improved actions aimed at preventing mother-to-child transmission. MAIN RESULTS: First experience of the sub-national process of certification of elimination of mother-to-child transmission (MTCT) of HIV and/or syphilis at a global level. In 2022, 43 municipalities ≥ 100,000 inhabitants were certified, covering 24.6 million inhabitants. IMPLICATIONS FOR SERVICES: The experience of sub-national certification of the EMTCT was important in mobilizing the municipalities that engaged in its initiatives, worked to improve the quality of care and surveillance and emerging as the main proponents in the process. PERSPECTIVES: Through this ongoing and dynamic initiative, there is an anticipation of over 100 municipalities and states joining in 2023. Sub-national certification aims to enhance comprehensive care for pregnant women, in order to achieve national certification of EMTCT.

Gonorrhea prevalence in adults in Brazil: Spectrum-STI trend estimation, 2000-2020.

BACKGROUND: Gonorrhea is not a notifiable disease in Brazil, and the national health information system does not collect data on reported cases or infection prevalence. METHODS: We compiled published data on gonorrhea prevalence in Brazil from cross-sectional surveys and clinical trials between 2000 and 2020. The study entry criteria included a sample size of 50 or more, and Neisseria gonorrhoeae infection detected in urine, urethral, anal, or cervicovaginal specimens using either Nucleic Acid Amplification Test or culture. Gonorrhea prevalence trends between 2000 and 2020 were generated using Spectrum-STI, a statistical trend-fitting model. RESULTS: Forty-five studies with 59 gonorrhea prevalence data points were identified. Fifty data points were for women and represented 21,815 individuals, eight for men encompassing a total of 4,587 individuals, and one for transgender people comprising 345 individuals. The Spectrum-STI estimate for the prevalence of urogenital infection with gonorrhea in women 15-49 in 2020 was 0.63% (95% confidence interval (CI): 0.13-2.23) and was lower than the 1.05% estimated value for 2000 (95% CI: 0.36-2.79). The corresponding figures for men were 0.70% (95% CI: 0.16-2.44) and 1.14% (95% CI: 0.34-3.15). Anal prevalence estimates could not be generated because of insufficient data (three data points). CONCLUSIONS: These results suggest that the overall prevalence of genitourinary gonococcal infections in Brazil is less than 1%. Data on gonorrhea prevalence in men and in populations at increased STI vulnerability are limited.

Adequacy of prenatal care and associated factors in the State of Rio Grande do Sul, Brazil.

OBJECTIVE: This study aims to assess the degree of adequacy of prenatal care (PNC) in the state of Rio Grande do Sul (RS) and in its 7 macro-regions considering the time of PNC initiation and the number of appointments attended. It also aims to verify the mode of delivery prevalence and the factors associated with PNC adequacy by mode of delivery. METHODS: Sub analysis from a cross-sectional study conducted among 13,432 childbearing women aged 15-49 years assisted in 66 maternity hospitals of the Unified Health System (SUS) and private associated facilities from September 2017 to October 2019. A standardized form was used to collect sociodemographic data, and information about PNC and delivery from the childbearing women's prenatal cards, hospital records, and medical reports. RESULTS: The PNC coverage was (98.4%), but only 57.5% of the participants had an adequate PNC defined as the one initiated until the 12th gestational week, with attendance of at least 6 appointments. The cesarean rate was 57.2%. Among women who performed vaginal delivery, multivariate analysis showed that for each 1-year increase in the age of the parturient, the chance of having an adequate PNC increased by 5%. White parturients with higher education and fewer deliveries residing in the macro-region of Valleys were more likely to have an adequate PNC when compared with non-white parturients, who were illiterate and/or had incomplete elementary school, with 3 or more deliveries and who resided in other macro-regions. During pregnancy, 96.0% of the women performed at least one anti-HIV test, 55.8% a rapid test for syphilis, and 75.0% a Venereal Disease Research Laboratory test (VDRL). CONCLUSIONS: Despite the almost universal PNC coverage in RS, the PNC offered by the SUS was adequate for just half of the population, therefore public health policies targeted at women receiving care in this setting shall be revisited.

Detection of HPV DNA in vaginal samples self-collected by women living with HIV treated through the Brazilian public health system: Prevalence and analysis of risk factors.

BACKGROUND: Women living with human immunodeficiency virus (HIV) (WLWH) are more likely to be infected with the oncogenic human papillomavirus (HPV). We assessed the prevalence of high-risk (HR) (16/18/31/33/35/39/45/51/52/56/58/59/68/73/82), probable high-risk (pHR) (26/53/66), and low-risk (LR) (6/11/40/42/43/44/54/61/70) HPV types and their associated risk factors. METHODS: This cross-sectional study of WLWH aged 18-64 years included one laboratory and eight HIV-specialty healthcare facilities in the pilot network. Descriptive statistics were used to assess sociodemographic and behavioral characteristics. Adjusted analyses were conducted to evaluate risk factors associated with HR and/or pHR HPV infection in WLWH. RESULTS: From May/2021 to May/2022, 1,914 (92.5%) WLWH participated in the pilot study and had valid HPV-DNA results of self-collected vaginal samples. The median age of the participants was 45 years, 60.1% had ≥ 9 years of schooling, 80.5% were ≤ 18 years at first sexual intercourse, and 51.7% had > 4 sexual partners throughout life. The prevalence of any HPV type, HR HPV, pHR HPV, and LR HPV was 65.8%, 49.6%, 16.7%, and 40.0%, respectively. Age was inversely associated with pHR and/or HR-HPV (p < 0.001), and education level was inversely associated with HR-HPV (p = 0.003) types. Any HR or pHR was associated with being single (p = 0.029) and exchanging sex for drugs (p = 0.037). CONCLUSIONS: The prevalence of HPV, especially HR HPV, among WLWH is high in Brazil, highlighting the need for HPV screening in this population. Self-collection of vaginal samples is an important strategy for increasing testing access.

Perspectives and challenges for mother-to-child transmission of HIV, hepatitis B, and syphilis in Brazil.

Background: Eliminating mother-to-child transmission (MTCT) of HIV, hepatitis B, and syphilis is a challenge in Brazil. Many policies have been implemented since 1986, but important gaps remain. This study aimed to describe the trends of MTCT in Brazil and evaluate the gaps and perspectives in this scenario. Methods: This is a descriptive study conducted with secondary data publicly available in the information systems of the Brazilian Ministry of Health regarding data on HIV, syphilis, and hepatitis B in pregnant women and children from 2011 to 2021. Results: HIV and hepatitis B have had constant rates over the years in pregnant women, with the detection rates around 2.5/1,000 live birth (LB) and 0.5/1.000LB, respectively. The same did not happen with syphilis, which has shown an increasing line in the last decade. In 2011, the detection rate of syphilis in pregnancy was 4.7/1,000LB, and in 2021 it reached 27.1/1,000LB. Regarding the trends in children, an important decrease was observed in HIV/AIDS (incidence rate from 0.18/1,000 in 2011 to 0.04/1,000 in 2021) and Hepatitis B (incidence rate from 0.9/1,000LB in 2011 to 0.5/1,000LB in 2021). For congenital syphilis, there is a continuous increase, being 3.3/1,000LB in 2011 and 9.9/1,000LB in 2021. Data from the HIV clinical monitoring showed that antiretroviral treatment coverage among pregnant women identified increased slightly between 2011 and 2021, in Brazil, from 92.3% to 94.3%. For syphilis, 82.5% of pregnant women were treated with benzathine penicillin, and 88.7% in 2011. The historical series of hepatitis B vaccination coverage in children has decreased over the years; it was 96% in 2013 and 76% in 2021. Conclusion: These data show many gaps and some perspectives in the MTCT program in Brazil. The country is close to reaching MTCT HIV elimination, but there are many challenges regarding HBV and syphilis. These data can be used to organize the strategies to improve the Brazilian response to MTCT elimination of HIV, hepatitis B, and syphilis.

Disparities in HIV continuum of care in the paediatric population: A real-life study in Brazil.

INTRODUCTION: Paediatric HIV follow-up is challenging, and treatment indicators are markedly far from Joint United Nations Programme on HIV/AIDS (UNAIDS) goals. In this study, we describe the 2019 Brazilian HIV cascade according to age categories and sociodemographic variables and address temporal trends between 2009 and 2019. METHODS: We obtained data from the Brazilian Ministry of Health monitoring database. Cascade outcomes included retention in care, antiretroviral use, and viral suppression. We assessed the effect of age on timely initiation of antiretroviral treatment (ART; initiation with CD4+ T-cell count ≥350 cells/mm3 or a first ART dispensation ≤30 days after the first CD4+ T-cell measurement) and detectable HIV viral load (>50 copies/mL) in univariable and multivariable analysis adjusted for sex, race, and social vulnerability index (SVI). Temporal trends in timely ART initiation and viral suppression were evaluated graphically. RESULTS: Among 771 774 people living with HIV, those in the youngest age categories had poorer indicators in the care cascade. Those in younger age groups, those with higher SVI, and those declaring Black and native Brazilian race/ethnicity had higher odds of having detectable viral load and delayed ART initiation. Although children living with HIV tend to start ART with higher CD4+ T-cell counts, time-series analysis suggests that improvements in treatment indicators seen in the adult population are not observed in the paediatric population. CONCLUSION: Our results highlight the challenges faced by children and adolescents living with HIV in achieving UNAIDS goals. Lower access to ART among children is a central barrier to improved paediatric care.

Subnational certification of elimination of mother-to-child transmission of HIV and/or syphilis: a Brazilian experience report / Certificação subnacional da eliminação da transmissão vertical de HIV e/ou sífilis: relato da experiência brasileira / Certificación subnacional de la eliminación de la trasmisión vertical de VIH y/o sífilis: relato de la experiencia brasileña

Abstract Objective: to describe the subnational implementation process of the certification for elimination of mother-to-child transmission of HIV and/or syphilis, its main barriers, challenges and opportunities. Methods: in 2022, indicators from the last full year for impact targets and the last two full years for process targets, available in national information systems, were evaluated; descriptive reports were analyzed and actions were acknowledged within four thematic axes, according to PAHO/WHO recommendations. Results: 43 municipalities ≥ 100,000 inhabitants were certified, covering 24.6 million inhabitants; one municipality achieved dual elimination (HIV-syphilis), 28 municipalities achieved elimination of HIV and 10 received silver tiers; regarding syphilis, one elimination was observed, along with 4 gold tiers, 13 silver tiers and 4 bronze tiers; a higher number of certifications was identified in the Southeast and South regions. Conclusion: barriers and challenges of the process were overcome through tripartite collaboration; the experience provided better integration of surveillance with care and improved actions aimed at preventing mother-to-child transmission.

Resumo Objetivo: descrever o processo de implantação subnacional da certificação da eliminação da transmissão vertical de HIV e/ou sífilis, suas principais barreiras, desafios e oportunidades. Métodos: em 2022, foram avaliados indicadores do último ano completo para meta de impacto, e dos dois últimos anos completos para metas de processo, disponíveis nos sistemas nacionais de informações; foram analisados relatórios descritivos e reconhecidas ações em quatro eixos temáticos, conforme recomendações da OPAS/OMS. Resultados: 43 municípios ≥ 100 mil habitantes foram certificados, abrangendo 24,6 milhões de habitantes; um município alcançou dupla eliminação (HIV-sífilis), 28 alcançaram eliminação para HIV e 10, selos prata; para sífilis, houve uma eliminação, 4 selos ouro, 13 prata e 4 bronze; identificou-se maior número de certificações nas regiões Sudeste e Sul. Conclusão: barreiras e desafios do processo foram superados pela colaboração tripartite; a experiência proporcionou melhor integração da vigilância com a assistência e qualificação das ações para prevenção da transmissão vertical.

Resumen Objetivo: describir el proceso de implementación subnacional de la certificación de eliminación de la transmisión vertical (TV) de sífilis y/o VIH, barreras, oportunidades y desafíos. Métodos: en 2022, se evaluaron indicadores del último año completo para la meta de impacto y de los dos últimos años para las de proceso en los sistemas de información; se analizaron informes descriptivos y se reconocieron acciones de cuatro ejes, según las recomendaciones de la OPS/OMS. Resultados: se certificaron 43 municipios ≥ 100.000 mil habitantes, cubriendo 24,6 millones de habitantes; un municipio logró la doble eliminación (VIH-sífilis), 28 la eliminación del VIH y 10 sellos plata; para sífilis, hubo una eliminación, 4 sellos oro, 13 plata y 4 bronce; las regiones Sudeste y Sur obtuvieron más certificaciones. Conclusión: barreras y desafíos fueron superados mediante la colaboración tripartita; la experiencia permitió la integración de la vigilancia con la atención y la cualificación de acciones para la prevención de la TV.

Detection of HPV DNA in vaginal samples self-collected by women living with HIV treated through the Brazilian public health system: Prevalence and analysis of risk factors

ABSTRACT Background: Women living with human immunodeficiency virus (HIV) (WLWH) are more likely to be infected with the oncogenic human papillomavirus (HPV). We assessed the prevalence of high-risk (HR) (16/18/31/33/35/39/45/51/52/56/58/59/68/73/82), probable high-risk (pHR) (26/53/66), and low-risk (LR) (6/11/40/42/43/44/54/61/70) HPV types and their associated risk factors. Methods: This cross-sectional study of WLWH aged 18-64 years included one laboratory and eight HIV-specialty healthcare facilities in the pilot network. Descriptive statistics were used to assess sociodemographic and behavioral characteristics. Adjusted analyses were conducted to evaluate risk factors associated with HR and/or pHR HPV infection in WLWH. Results: From May/2021 to May/2022, 1,914 (92.5%) WLWH participated in the pilot study and had valid HPV-DNA results of self-collected vaginal samples. The median age of the participants was 45 years, 60.1% had ≥ 9 years of schooling, 80.5% were ≤ 18 years at first sexual intercourse, and 51.7% had > 4 sexual partners throughout life. The prevalence of any HPV type, HR HPV, pHR HPV, and LR HPV was 65.8%, 49.6%, 16.7%, and 40.0%, respectively. Age was inversely associated with pHR and/or HR-HPV (p < 0.001), and education level was inversely associated with HR-HPV (p = 0.003) types. Any HR or pHR was associated with being single (p = 0.029) and exchanging sex for drugs (p = 0.037). Conclusions: The prevalence of HPV, especially HR HPV, among WLWH is high in Brazil, highlighting the need for HPV screening in this population. Self-collection of vaginal samples is an important strategy for increasing testing access.

Adequacy of prenatal care and associated factors in the State of Rio Grande do Sul, Brazil

ABSTRACT OBJECTIVE This study aims to assess the degree of adequacy of prenatal care (PNC) in the state of Rio Grande do Sul (RS) and in its 7 macro-regions considering the time of PNC initiation and the number of appointments attended. It also aims to verify the mode of delivery prevalence and the factors associated with PNC adequacy by mode of delivery. METHODS Sub analysis from a cross-sectional study conducted among 13,432 childbearing women aged 15-49 years assisted in 66 maternity hospitals of the Unified Health System (SUS) and private associated facilities from September 2017 to October 2019. A standardized form was used to collect sociodemographic data, and information about PNC and delivery from the childbearing women's prenatal cards, hospital records, and medical reports. RESULTS The PNC coverage was (98.4%), but only 57.5% of the participants had an adequate PNC defined as the one initiated until the 12th gestational week, with attendance of at least 6 appointments. The cesarean rate was 57.2%. Among women who performed vaginal delivery, multivariate analysis showed that for each 1-year increase in the age of the parturient, the chance of having an adequate PNC increased by 5%. White parturients with higher education and fewer deliveries residing in the macro-region of Valleys were more likely to have an adequate PNC when compared with non-white parturients, who were illiterate and/or had incomplete elementary school, with 3 or more deliveries and who resided in other macro-regions. During pregnancy, 96.0% of the women performed at least one anti-HIV test, 55.8% a rapid test for syphilis, and 75.0% a Venereal Disease Research Laboratory test (VDRL). CONCLUSIONS Despite the almost universal PNC coverage in RS, the PNC offered by the SUS was adequate for just half of the population, therefore public health policies targeted at women receiving care in this setting shall be revisited.

Gonorrhea prevalence in adults in Brazil: Spectrum-STI trend estimation, 2000-2020

ABSTRACT Background: Gonorrhea is not a notifiable disease in Brazil, and the national health information system does not collect data on reported cases or infection prevalence. Methods: We compiled published data on gonorrhea prevalence in Brazil from cross-sectional surveys and clinical trials between 2000 and 2020. The study entry criteria included a sample size of 50 or more, and Neisseria gonorrhoeae infection detected in urine, urethral, anal, or cervicovaginal specimens using either Nucleic Acid Amplification Test or culture. Gonorrhea prevalence trends between 2000 and 2020 were generated using Spectrum-STI, a statistical trend-fitting model. Results: Forty-five studies with 59 gonorrhea prevalence data points were identified. Fifty data points were for women and represented 21,815 individuals, eight for men encompassing a total of 4,587 individuals, and one for transgender people comprising 345 individuals. The Spectrum-STI estimate for the prevalence of urogenital infection with gonorrhea in women 15-49 in 2020 was 0.63% (95% confidence interval (CI): 0.13-2.23) and was lower than the 1.05% estimated value for 2000 (95% CI: 0.36-2.79). The corresponding figures for men were 0.70% (95% CI: 0.16-2.44) and 1.14% (95% CI: 0.34-3.15). Anal prevalence estimates could not be generated because of insufficient data (three data points). Conclusions: These results suggest that the overall prevalence of genitourinary gonococcal infections in Brazil is less than 1%. Data on gonorrhea prevalence in men and in populations at increased STI vulnerability are limited.

Sexual practices and HPV infection in unvaccinated young adults.

The present study aimed to evaluate the association of genital and oral HPV infection among different sexual practices in both sexes. In total, 6388 unvaccinated men and women aged 16-25 years from all state capitals of Brazil were enrolled in through primary care services between September 2016 and November 2017. Genital and oral HPV genotyping was performed using the Roche Linear Array. Poisson regression analysis with robust variance was conducted to examine factors associated with overall HPV infection. A higher prevalence of genital HPV was found in women who practiced oral sex (57.85%) and in men who practiced all types of sex (65.87%). However, having more sexual partners and being younger were more important than the type of sex practiced. HPV 6 (7.1%) and 16 (10.5%) were significantly more prevalent in women who practiced oral sex, while HPV 6 (23.96%) and 11 (21.49%) were more prevalent in men who practiced anal sex. The type of sex was not associated with oral HPV prevalence. Genital and oral HPV infection were not associated by different sexual practices in the studied population.

National surveillance of Neisseria gonorrhoeae antimicrobial susceptibility and epidemiological data of gonorrhoea patients across Brazil, 2018-20.

Objectives: To (i) describe the nationwide antimicrobial susceptibility of Neisseria gonorrhoeae (NG) isolates cultured across Brazil in 2018-20 and compare it with NG antimicrobial resistance data from 2015-16, and (ii) present epidemiological data of the corresponding gonorrhoea patients in 2018-20. Methods: Twelve representative sentinel sites cultured NG isolates from men with urethral discharge. Susceptibility to eight antimicrobials was examined using agar dilution method, according to WHO standards. The consenting participants were invited to provide epidemiological data. Results: In total, 633 NG isolates (one isolate per participant) were analysed, and 449 (70.9%) questionnaires were answered. Heterosexual (68.2%) and homosexual (23.1%) sexual orientations were common, and most prevalent types of unprotected sexual intercourse were vaginal insertive (69.9%), oral giving (56.6%) and anal insertive (47.4%). The levels of in vitro NG resistance to ciprofloxacin, tetracycline, benzylpenicillin, azithromycin, cefixime, gentamicin, spectinomycin and ceftriaxone were 67.3%, 40.0%, 25.7%, 10.6%, 0.3%, 0%, 0% and 0%, respectively. Compliance with the recommended first-line ceftriaxone 500 mg plus azithromycin 1 g therapy was high (90.9%). Conclusions: Compared with 2015-16, ciprofloxacin resistance has remained high and azithromycin and cefixime resistance rates have increased in Brazil. Resistance remained lacking to ceftriaxone, gentamicin and spectinomycin, which all are gonorrhoea treatment options. The increasing azithromycin resistance in Brazil and internationally may threaten the future use of azithromycin in dual regimens for treatment of gonorrhoea. Consequently, continued and enhanced quality-assured surveillance of gonococcal AMR, and ideally also treatment failures and including WGS, is imperative in Brazil and worldwide.

Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis of the Implementation of Public Health Policies on HTLV-1 in Brazil.

Human T lymphotropic virus 1 (HTLV-1) is a public health issue for most countries and imposes important consequences on patients' health and socioeconomic status. Brazil is one of the global leaders of the public health response to these viruses. The country has challenges to overcome to implement meaningful policies aiming to eliminate HTLV-1/2. An analysis of strengths, weaknesses, opportunities, and threats (SWOT) for the implementation of public health policies on HTLV-1/2 was performed. The strengths identified were the Brazilian Unified Health System (SUS); Brazilian expertise in public health programs successfully implemented; currently available policies targeting HTLV; and strong collaboration with researchers and patient's representative. Lack of awareness about HTLV, insufficient epidemiological data, lack of reference centers for patient care, insufficient availability of confirmatory tests, lack of universal antenatal screening, and absence of cost-effectiveness studies were identified as weaknesses. Some interesting opportunities included the increased interest from international organizations on HTLV, possibility of integrating HTLV into other programs, external funding for research, available online platforms, opportunity to acquire data from HTLV-1/2 surveillance to gather epidemiological information, and HTLV policies that were implemented independently by states and municipalities. In addition to the COVID-19 pandemic, existing demands from different diseases, the country's demography and its marked sociocultural diversity and the volatility of the technical team working with HTLV-1/2 at the Brazilian Ministry of Health are threats to the implementation of public policies on HTLV-1/2. This SWOT analysis will facilitate strategic planning to allow continuous progress of the Brazilian response to HTLV-1/2 infection.

The fight against sexually transmitted infections cannot stop in the COVID-19 era: a brazilian experience in online training for sexually transmitted infections guidelines / A luta contra as infecções sexualmente transmissíveis não pode parar na era COVID-19: experiência brasileira em treinamento on-line para diretrizes em infecções sexualmente transmissíveis

Introduction: The Brazilian Ministry of Health had planned face-to-face workshops for professional training about the Clinical Protocols and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections for the year 2020. Due to the COVID-19 pandemic, the workshops were cancelled, and a new strategy was adopted: virtual meetings, called Webinars ­ Clinical Protocols and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections 2020. Objective: To report the experience at the Ministry of Health in online training about the clinical protocol and therapeutic guidelines for comprehensive care for people sexually transmitted infections for health professionals in 2020. Methods: The webinars were held in partnership with the Brazilian Society of Sexually Transmitted Diseases and the Pan American Health Organization. Each chapter of the Clinical Protocols and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections ­ 2020 was converted into a webinar, with the participation of at least three experts, two speakers, and a moderator. Results: In total, 16 webinars were presented, covering topics such as sexually transmitted infections surveillance, prevention, diagnosis, treatment, public policies, and sexual violence. The initiative had more than 77,000 hits, with an average of 4,900 hits per webinar and the topic "syphilis" being the most accessed. The event reached all 27 federative units of Brazil, as well as 27 other countries. About 500 questions were received from the audience and answered during the sessions and/or through a document published later on by the Ministry of Health. Conclusion: Given the high number of hits and inquiries received, we can conclude that health professionals remained engaged in the topic of sexually transmitted infections during the pandemic. This experience shows the great potential of innovative methods for distance learning to promote continuing education, including a series of webinars aimed at strengthening the fight against sexually transmitted infections.

Introdução: O Ministério da Saúde do Brasil planejou para o ano de 2020 oficinas presenciais para capacitação profissional sobre o Protocolo Clínico e Diretrizes Terapêuticas para Atenção Integral às Pessoas com Infecções Sexualmente Transmissíveis. Em função da pandemia de COVID-19, as oficinas foram canceladas, optando-se pela estratégia de encontros virtuais, denominados Webinares ­ Protocolo Clínico e Diretrizes Terapêuticas para Atenção Integral às Pessoas com Infecções Sexualmente Transmissíveis ­ 2020. Objetivo: Descrever a experiência do Ministério da Saúde em capacitações on-line para profissionais de saúde no contexto dos Webinares ­ Protocolo Clínico e Diretrizes Terapêuticas para Atenção Integral às Pessoas com Infecções Sexualmente Transmissíveis ­ 2020. Métodos: Os webinares foram realizados em parceria com a Sociedade Brasileira de Doenças Sexualmente Transmissíveis e Organização Pan-Americana da Saúde. Cada capítulo do Protocolo Clínico e Diretrizes Terapêuticas para Atenção Integral às Pessoas com Infecções Sexualmente Transmissíveis ­ 2020 foi convertido em um webinar, com a participação de pelo menos três especialistas, sendo dois palestrantes e um moderador. Resultados: No total, foram apresentados 16 webinares, que abordaram temas como vigilância, prevenção, diagnóstico, tratamento das infecções sexualmente transmissíveis, políticas públicas e violência sexual. Foram mais de 77 mil acessos, com média de 4.900 acessos por webinar, sendo a que a sífilis foi a temática mais acessada. O evento alcançou todos as 27 unidades federativas do Brasil, bem como outros 27 países. Cerca de 500 perguntas foram recebidas, as quais foram respondidas durante as sessões e/ou por meio de um documento publicado pelo Ministério da Saúde. Conclusão: Dado o elevado número de acessos e questionamentos recebidos, conclui-se que os profissionais da saúde permaneceram engajados no tema infecções sexualmente transmissíveis durante a pandemia. Essa experiência demonstrou o grande potencial de métodos inovadores de ensino à distância para promoção da educação permanente, como a realização de uma série de webinares, visando ao fortalecimento do combate às infecções sexualmente transmissíveis.

[Barriers and facilitators for access to PrEP by vulnerable populations in Brazil: the ImPrEP Stakeholders Study]. / Barreiras e facilitadores do acesso de populações vulneráveis à PrEP no Brasil: Estudo ImPrEP Stakeholders.

HIV preexposure prophylaxis (PrEP) has been considered a fundamental strategy for controlling the HIV/AIDS epidemic, and since 2018 it has been the object of an implementation study (ImPrEP Stakeholders Study), conducted in Brazil, México, and Peru. A qualitative component of this study was developed with the objective of identifying the social and structural contexts that involve and organize the supply of PrEP services in Brazil, the stakeholders' subjectivities, and the different perceptions that can impact the strategy's implementation. The current article's focus was to analyze access by vulnerable populations to PrEP services from the perspective of managers, health professionals, leaders or activists, and users of PrEP. This was a qualitative study using a comprehensive methodology, conducted in six Brazilian state capitals, interviewing 71 key actors from November 2018 to May 2019. The analysis was based on access analysis models as proposed by Giovanella & Fleury, McIntyre et al. and Penchansky & Thomas. The results are presented along three lines: "perceptions of combined prevention and PrEP", "availability and adequacy: profile and structure of services in the context of ImPrEP", and "acceptability: attitudes and practices of health professionals and users".

A profilaxia pré-exposição ao HIV (PrEP) tem sido considerada uma estratégia fundamental para o controle da epidemia de HIV/aids, e desde 2018 tem sido objeto de estudo de implementação (Estudo ImPrEP Stakeholders), realizado no Brasil, no México e no Peru. Um componente qualitativo desse estudo foi desenvolvido com o objetivo de identificar os contextos sociais e estruturais que envolvem e organizam a oferta de serviços de PrEP no Brasil, as subjetividades dos atores envolvidos e as diferentes percepções que podem impactar a efetivação dessa estratégia. O presente artigo teve como foco de análise o acesso das populações vulneráveis aos serviços de PrEP, na perspectiva de gestores, profissionais de saúde, lideranças ou ativistas e usuários de PrEP. É um estudo qualitativo com o uso de metodologia compreensiva, realizado em seis capitais brasileiras, em que foram entrevistados 71 atores-chave no período de novembro de 2018 a maio de 2019. A análise foi pautada pelos modelos analíticos sobre acesso propostos por Giovanella & Fleury, McIntyre et al. e Penchansky & Thomas. Os resultados são apresentados com base em três eixos: "percepções sobre prevenção combinada e PrEP"; "disponibilidade e adequação: perfil e estrutura dos serviços no contexto do ImPrEP"; e "aceitabilidade: atitudes e práticas dos profissionais de saúde e usuários".

La profilaxis preexposición al VIH (PrEP) ha sido considerada una estrategia fundamental para el control de la epidemia de VIH/sida y desde 2018 ha sido objeto de estudio de implementación (Estudio ImPrEP Stakeholders), realizado en Brasil, México y Perú. Un componente cualitativo de este estudio se desarrolló con el objetivo de identificar los contextos sociales y estructurales que engloban y organizan la oferta de servicios de PrEP en Brasil, las subjetividades de los actores implicados y las diferentes percepciones que pueden impactar en hacer efectiva esa estrategia. El objetivo de este artículo es el análisis del acceso de las poblaciones vulnerables a los servicios de PrEP, desde la perspectiva de los gestores, profesionales de salud, líderes o activistas y usuarios de la PrEP. Se trata de un estudio cualitativo con uso de metodología comprensiva, realizado en seis capitales brasileñas, en las que fueron entrevistados 71 actores-clave, durante el período de noviembre de 2018 a mayo de 2019. El análisis se pautó mediante modelos analíticos sobre acceso, propuestos por Giovanella & Fleury, McIntyre et al. y Penchansky & Thomas. Los resultados se presentan a partir de tres ejes: "percepciones sobre prevención combinada y PrEP", "disponibilidad y adecuación: perfil y estructura de los servicios en el contexto de la ImPrEP" y "aceptabilidad: actitudes y prácticas de los profesionales de salud y usuarios".

Barreiras e facilitadores do acesso de populações vulneráveis à PrEP no Brasil: Estudo ImPrEP Stakeholders / Barriers and facilitators for access to PrEP by vulnerable populations in Brazil: the ImPrEP Stakeholders Study / Barreras y facilitadores de acceso de poblaciones vulnerables a la PrEP en Brasil: Estudio ImPrEP Stakeholders

Resumo: A profilaxia pré-exposição ao HIV (PrEP) tem sido considerada uma estratégia fundamental para o controle da epidemia de HIV/aids, e desde 2018 tem sido objeto de estudo de implementação (Estudo ImPrEP Stakeholders), realizado no Brasil, no México e no Peru. Um componente qualitativo desse estudo foi desenvolvido com o objetivo de identificar os contextos sociais e estruturais que envolvem e organizam a oferta de serviços de PrEP no Brasil, as subjetividades dos atores envolvidos e as diferentes percepções que podem impactar a efetivação dessa estratégia. O presente artigo teve como foco de análise o acesso das populações vulneráveis aos serviços de PrEP, na perspectiva de gestores, profissionais de saúde, lideranças ou ativistas e usuários de PrEP. É um estudo qualitativo com o uso de metodologia compreensiva, realizado em seis capitais brasileiras, em que foram entrevistados 71 atores-chave no período de novembro de 2018 a maio de 2019. A análise foi pautada pelos modelos analíticos sobre acesso propostos por Giovanella & Fleury, McIntyre et al. e Penchansky & Thomas. Os resultados são apresentados com base em três eixos: "percepções sobre prevenção combinada e PrEP"; "disponibilidade e adequação: perfil e estrutura dos serviços no contexto do ImPrEP"; e "aceitabilidade: atitudes e práticas dos profissionais de saúde e usuários".

Abstract: HIV preexposure prophylaxis (PrEP) has been considered a fundamental strategy for controlling the HIV/AIDS epidemic, and since 2018 it has been the object of an implementation study (ImPrEP Stakeholders Study), conducted in Brazil, México, and Peru. A qualitative component of this study was developed with the objective of identifying the social and structural contexts that involve and organize the supply of PrEP services in Brazil, the stakeholders' subjectivities, and the different perceptions that can impact the strategy's implementation. The current article's focus was to analyze access by vulnerable populations to PrEP services from the perspective of managers, health professionals, leaders or activists, and users of PrEP. This was a qualitative study using a comprehensive methodology, conducted in six Brazilian state capitals, interviewing 71 key actors from November 2018 to May 2019. The analysis was based on access analysis models as proposed by Giovanella & Fleury, McIntyre et al. and Penchansky & Thomas. The results are presented along three lines: "perceptions of combined prevention and PrEP", "availability and adequacy: profile and structure of services in the context of ImPrEP", and "acceptability: attitudes and practices of health professionals and users".

Resumen: La profilaxis preexposición al VIH (PrEP) ha sido considerada una estrategia fundamental para el control de la epidemia de VIH/sida y desde 2018 ha sido objeto de estudio de implementación (Estudio ImPrEP Stakeholders), realizado en Brasil, México y Perú. Un componente cualitativo de este estudio se desarrolló con el objetivo de identificar los contextos sociales y estructurales que engloban y organizan la oferta de servicios de PrEP en Brasil, las subjetividades de los actores implicados y las diferentes percepciones que pueden impactar en hacer efectiva esa estrategia. El objetivo de este artículo es el análisis del acceso de las poblaciones vulnerables a los servicios de PrEP, desde la perspectiva de los gestores, profesionales de salud, líderes o activistas y usuarios de la PrEP. Se trata de un estudio cualitativo con uso de metodología comprensiva, realizado en seis capitales brasileñas, en las que fueron entrevistados 71 actores-clave, durante el período de noviembre de 2018 a mayo de 2019. El análisis se pautó mediante modelos analíticos sobre acceso, propuestos por Giovanella & Fleury, McIntyre et al. y Penchansky & Thomas. Los resultados se presentan a partir de tres ejes: "percepciones sobre prevención combinada y PrEP", "disponibilidad y adecuación: perfil y estructura de los servicios en el contexto de la ImPrEP" y "aceptabilidad: actitudes y prácticas de los profesionales de salud y usuarios".