Clinical and epidemiological features of mpox in a Brazilian reference center for HIV and sexually transmitted infections: A cross-sectional study.

Background: The 2022 mpox outbreak has affected disproportionately people living with HIV (PLWH) and pre-exposure prophylaxis (PrEP) users. Methods: We conducted a cross-sectional study to evaluate factors associated with laboratory diagnosis of mpox among suspected cases, and access differences between PrEP users and PLWH with confirmed diagnostic. Results: 394 mpox suspected cases were analyzed, 309 (78.4%) confirmed. Most patients with mpox were PLWH (54.4%) and 99 (32%) PrEP users. Mpox cases were likely to be between 25 and 39 years old (aOR=2.8; p=0.042), men who have sex with men/bisexual or transgender women (aOR=17.2; p< 0.001) and to have fever (aOR=4.7; p< 0.001), adenomegaly (aOR=7.2; p< 0.001) and multiple vesicular lesions (aOR=4.2; p< 0.001). Comparing PrEP users to PLWH with confirmed mpox, PrEP users had lesions predominantly with exclusive genital involvement (p=0.016); while PLWH had higher extragenital involvement (p=0.018). Conclusions: PrEP users and PLWHA were the main epidemiological groups in our cohort. Recognizing the differences between vulnerable populations can contribute to the development public policies to control mpox in settings with reduced access to vaccines.

Mpox in a Couple Living with HIV: Relapse or Reinfection?

Mpox is caused by a zoonotic orthopoxvirus capable of infecting several animal species, including humans. The analysis of cases in the current outbreak showed that, differently from what happens in the classical disease, mpox has mostly affected men who have sex with men (MSM) and bisexuals, including a high proportion of people living with HIV/AIDS. The role of the immune system in fighting mpox has been discussed in literature and experts believe that immunity conferred by natural infection may be lifelong, advocating against the possibility of reinfection by monkeypox virus. This report presents a MSM couple living with HIV with cycles of mpox lesions after two different risk exposures. The clinical course of both cases, as well as the temporal and anatomical relationship between the second cycle of monkeypox virus lesions and the second exposure, suggests the occurrence of reinfection. The genomic surveillance of monkeypox virus, a better understanding of its interaction with the human host, and knowledge of the postinfection and postvaccine protection correlation are more relevant at this moment, when we observe an intersection of the mpox multicountry outbreak with the HIV/AIDS epidemic, considering the immunosenescence and other immune system issues caused by HIV.

Acceptability of teleconsultation in a public service specialized in the prevention and care of HIV infection and other sexually transmitted infections / Aceitabilidade da teleconsulta em um serviço público especializado na prevenção e cuidado da infecção pelo HIV e outras infecções sexualmente transmissíveis

Introduction: Telemedicine was leveraged for its contribution to mitigate the impact of COVID-19 in Brazil and worldwide. Objective: We aim to evaluate the acceptability of incorporating teleconsultation through synchronized videoconference by users and professionals in a service specialized in the prevention and treatment of the human immunodeficiency virus and other sexually transmitted infections, and to identify associated factors. Methods: This is a cross-sectional study with 410 users and 57 professionals who answered a category-standardized questionnaire. Predictors of acceptability were assessed using logistic regression model. Results: A total of 364 (88.8%) users said they would accept the modality. The factors positively associated with the odds of acceptance were the self-assessment of having favorable conditions to participate in a teleconsultation (aOR 54.8; 95%CI 12.4­242.1; p<0.001), the perception of saving money (aOR 5.2; 95%CI 1.9­14.0; p=0.001), and perceived convenience of the modality (aOR 6.7; 95%CI 2.9­15.9; p<0.001). Factors associated with reduced odds of acceptance were the fear of not being evaluated well (aOR 0.2; 95%CI 0.1­0.4; p<0.001), or remaining long without seeing the professional (aOR 0.2; 95%CI 0.1­0.5; p<0.001). The acceptance of the modality among professionals was 75.4% and the perception of its convenience (aOR 16.8; 95%CI 2.6­108.4; p=0.003) and that the institution has appropriated conditions (aOR 7.7; 95%CI 1.5­40.6; p=0.016) were associated with increased odds of accepting its incorporation in their routine. Conclusion: Governance should invest in infrastructure and support, secure protocols, digital literacy, and training of its users and employees for video teleconsultation. (AU)

Introdução: A telemedicina foi alavancada por sua contribuição para mitigar o impacto da COVID-19 no Brasil e no mundo. Objetivo: Pretendemos avaliar a aceitabilidade da incorporação da teleconsulta por videoconferência síncrona por usuários e profissionais de um serviço especializado na prevenção e tratamento da infecção pelo vírus da imunodeficiência humana (HIV) e outras infecções sexualmente transmissíveis, bem como identificar fatores associados. Métodos: Estudo transversal com 410 usuários e 57 profissionais, que responderam a um questionário padronizado por categoria. Os preditores de aceitabilidade foram avaliados utilizando-se um modelo de regressão logística. Resultados: O total de 364 (88,8%) usuários disseram que aceitariam a modalidade. Os fatores positivamente associados à probabilidade de aceitação foram a autoavaliação quanto a ter condições favoráveis para participar de uma teleconsulta (razão de chances ajustada ­ aOR 54,8; intervalo de confiança de 95% ­ IC95% 12,4­242,1; p<0,001), a percepção de poupar dinheiro (aOR 5,2; IC95% 1,9­14,0; p=0,001) e a percepção de conveniência da modalidade (aOR 6,7; IC95% 2,9­15,9; p<0,001). As menores probabilidades de aceitação foram o medo de não ser bem avaliado (aOR 0,2; IC95% 0,1­0,4; p<0,001) e de permanecer muito tempo sem ver o profissional (aOR 0,2; IC95% 0,1­0,5; p<0,001). A aceitação da modalidade pelos profissionais foi de 75,4% e a percepção de sua conveniência (aOR 16,8; IC95% 2,6­108,4; p=0,003) e a de que a instituição possui condições favoráveis (aOR 7,7; IC95% 1,5­40,6; p=0,016) foram associadas com a maior probabilidade de aceitar a incorporação da modalidade em sua rotina. Conclusão: A governança deve investir em infraestrutura e apoio, protocolos seguros, literacia digital e treinamento de seus usuários e funcionários para a videoconsulta. (AU)

Improving the continuum of care monitoring in Brazilian HIV healthcare services: An implementation science approach.

OBJECTIVE: To evaluate the impact of an intervention improving the continuum of care monitoring (CCM) within HIV public healthcare services in São Paulo, Brazil, and implementing a clinical monitoring system. This system identified three patient groups prioritized for additional care engagement: (1) individuals diagnosed with HIV, but not receiving treatment (the treatment gap group); (2) individuals receiving treatment for >6 months with a detectable viral load (the virologic failure group); and (3) patients lost to follow-up (LTFU). METHODS: The implementation strategies included three training sessions, covering system logistics, case discussions, and development of maintenance goals. These strategies were conducted within 30 HIV public healthcare services (May 2019 to April 2020). After each training session, professionals shared their experiences with CCM at regional meetings. Before and after the intervention, providers were invited to answer 23 items from the normalization process theory questionnaire (online) to understand contextual factors. The mean item scores were compared using the Mann-Whitney U test. The RE-AIM implementation science framework (evaluating reach, effectiveness, adoption, implementation, and maintenance) was used to evaluate the integration of the CCM. RESULTS: In the study, 47 (19.3%) of 243 patients with a treatment gap initiated treatment, 456 (49.1%) of 928 patients with virologic failure achieved suppression, and 700 of 1552 (45.1%) LTFU patients restarted treatment. Strategies for the search and reengagement of patients were developed and shared. Providers recognized the positive effects of CCM on their work and how it modified existing activities (3.7 vs. 4.4, p<0.0001, and 3.9 vs. 4.1, p<0.05); 27 (90%) centers developed plans to sustain routine CCM. CONCLUSION: Implementing CCM helped identify patients requiring more intensive attention. This intervention led to changes in providers' perceptions of CCM and care and management processes, which increased the number of patients engaged across the care continuum and improved outcomes.

An intervention for the implementation of clinical monitoring in specialized care services to people living with HIV/AIDS. / Intervenção para a implementação do monitoramento clínico em serviços especializados de atenção às pessoas vivendo com HIV/aids.

The clinical monitoring of people living with HIV/AIDS (PLWHA) contributes to identifying and managing cases of individuals who have not begun treatment (gap), those experiencing treatment failure or who have abandoned treatment. This article sought to present and discuss the development of a methodology to implement the clinical monitoring of PLWHA in the services of the Brazilian Unified National Health System (SUS). The methodology used since 2014 by the CRT-STI/AIDS-Coordination of the STI/AIDS Program, São Paulo State, Brazil, was re-structured in three meetings between June and August 2018. The new methodology retained the axes of presentation of number of users in treatment failure, gap or abandonment in the participant services, as well as the discussion of individual, social and programmatic vulnerabilities. A new axis was added which directs the discussion of the possibilities of reorganizing service care flows and management practices. Additionally, the intervention started to be carried out in health services, with the participation of a higher number of professionals from the multi-professional team, discussion of cases, workflows and processes, and regional meetings to exchange clinical monitoring experiences between services. The re-structuring of the methodology contributed to a reduction in treatment gap, a reorganization of care flows and the inclusion of clinical monitoring as a management tool in services specialized in providing care to PLWHA. This methodology can be implemented by other state programs, municipalities and services, since all have access to the same information sources used in this intervention.

Intervenção para a implementação do monitoramento clínico em serviços especializados de atenção às pessoas vivendo com HIV/aids / Intervención para la implementación del monitoreo clínico en servicios especializados de atención a personas afectadas por el VIH/SIDA / An intervention for the implementation of clinical monitoring in specialized care services to people living with HIV/AIDS

O monitoramento clínico de pessoas vivendo com HIV/aids (PVHA) contribui para a identificação e gestão de caso das pessoas sem início de tratamento (gap), em falha terapêutica e em abandono de tratamento. O objetivo deste artigo é apresentar e discutir o desenvolvimento de uma metodologia para a implementação do monitoramento clínico das PVHA em serviços do Sistema Único de Saúde (SUS). A metodologia utilizada desde 2014 pelo Centro de Referência e Treinamento DST/AIDS-SP-Coordenação do Programa Estadual de IST/AIDS do Estado de São Paulo, Brasil, foi reestruturada em três reuniões, no período de junho a agosto de 2018. Foram mantidos os eixos de apresentação do número de usuários com falha terapêutica, em gap e em abandono de tratamento nos serviços participantes, e a discussão de vulnerabilidades individuais, sociais e programáticas. Foi adicionado um novo eixo que direciona a discussão das possibilidades de reorganização de fluxos assistenciais e práticas gerenciais do serviço. Adicionalmente, a intervenção passou a ser feita nos serviços de saúde, com a participação de um número maior de profissionais da equipe multiprofissional, discussão de casos, fluxos e processos de trabalho e encontros regionais para a troca de experiências em monitoramento clínico entre os serviços. A reestruturação da metodologia contribuiu para a diminuição do gap de tratamento, reorganização de fluxos assistenciais e inclusão do monitoramento clínico como ferramenta de gestão nos serviços de assistência especializada às PVHA. Essa metodologia pode ser implementada por outros programas estaduais, municípios e serviços, uma vez que todos têm acesso às mesmas fontes de informação usadas nesta intervenção.

El monitoreo clínico de personas afectadas por el VIH/SIDA (PVHA) contribuye a la identificación y gestión de caso de personas sin inicio de tratamiento (gap), con fallos en la parte terapéutica y abandono del tratamiento. El objetivo de este artículo es presentar y discutir el desarrollo de una metodología para la implementación del monitoreo clínico de las PVHA en servicios del Sistema Único de Salud (SUS). La metodología utilizada desde 2014 por el CRT-ETS/SIDA-Coordinación del Programa Estatal de ETS/SIDA del Estado de São Paulo, Brasil, fue reestructurada en tres reuniones, durante el período de junio a agosto de 2018. Se mantuvieron los ejes de presentación del número de usuarios con fallos en la parte terapéutica, gap y con abandono de tratamiento en los servicios participantes estudiados, así como la discusión de vulnerabilidades individuales, sociales y programáticas. Se añadió un nuevo eje que vertebra la discusión sobre las posibilidades de reorganización de los flujos asistenciales y prácticas de gestión del servicio. Asimismo, la intervención pasó a realizarse en los servicios de salud, con la participación de un mayor número de profesionales del equipo multiprofesional, discusión de casos, flujos y procesos de trabajo, así como encuentros regionales para el intercambio de experiencias en el monitoreo clínico entre los servicios. La reestructuración de la metodología contribuyó a la disminución del gap en el tratamiento, la reorganización de flujos asistenciales, así como la inclusión del monitoreo clínico como herramienta de gestión en los servicios de asistencia especializada a las PVHA. Esta metodología puede ser implementada en otros programas estatales, municipios y servicios, ya que todos tienen acceso a las mismas fuentes de información usadas en esta intervención.

The clinical monitoring of people living with HIV/AIDS (PLWHA) contributes to identifying and managing cases of individuals who have not begun treatment (gap), those experiencing treatment failure or who have abandoned treatment. This article sought to present and discuss the development of a methodology to implement the clinical monitoring of PLWHA in the services of the Brazilian Unified National Health System (SUS). The methodology used since 2014 by the CRT-STI/AIDS-Coordination of the STI/AIDS Program, São Paulo State, Brazil, was re-structured in three meetings between June and August 2018. The new methodology retained the axes of presentation of number of users in treatment failure, gap or abandonment in the participant services, as well as the discussion of individual, social and programmatic vulnerabilities. A new axis was added which directs the discussion of the possibilities of reorganizing service care flows and management practices. Additionally, the intervention started to be carried out in health services, with the participation of a higher number of professionals from the multi-professional team, discussion of cases, workflows and processes, and regional meetings to exchange clinical monitoring experiences between services. The re-structuring of the methodology contributed to a reduction in treatment gap, a reorganization of care flows and the inclusion of clinical monitoring as a management tool in services specialized in providing care to PLWHA. This methodology can be implemented by other state programs, municipalities and services, since all have access to the same information sources used in this intervention.

Transmitted Drug Resistance among People Living with HIV/Aids at Major Cities of Sao Paulo State, Brazil.

Human immunodeficiency virus type 1 (HIV-1) transmitted drug resistance (TDR) is an important public health issue. In Brazil, low to intermediate resistance levels have been described. We assessed 225 HIV-1 infected, antiretroviral naïve individuals, from HIV Reference Centers at two major metropolitan areas of Sao Paulo (Sao Paulo and Campinas), the state that concentrates most of the Brazilian Aids cases. TDR was analyzed by Stanford Calibrated Population Resistance criteria (CPR), and mutations were observed in 17 individuals (7.6%, 95% CI: 4.5%-11.9%). Seventy-six percent of genomes (13/17) with TDR carried a nonnucleoside reverse transcriptase inhibitor (NNRTI) resistance mutation, mostly K103N/S (9/13, 69%), potentially compromising the preferential first-line therapy suggested by the Brazilian HIV Treatment Guideline that recommends efavirenz-based combinations. Moreover, 6/17 (35%) had multiple mutations associated with resistance to one or more classes. HIV-1 B was the prevalent subtype (80%); other subtypes include HIV-1 F and C, mosaics BC, BF, and single cases of subtype A1 and CRF02_AG. The HIV Reference Center of Campinas presented more cases with TDR, with a significant association of TDR with clade B infection (P < 0.05).