Adriana A. Pinho

HIV among MSM in a large middle-income country.

Objective:To conduct the first national biological and behavioral surveillance survey for HIV among MSM in Brazil. Design:A cross-sectional surveillance study utilizing Respondent Driven Sampling (RDS) in 10 cities, following formative research. Planned sample: 350 MSM reporting sex with another man in the last 12 months, at least 18 years of age, and residing in the city of the study. Methods:Conventional RDS recruitment. Results were calculated for each city using RDSAT 5.6. For the national estimate, a new individual weight using a novel method was calculated. The 10 cities were aggregated, treated as strata and analyzed using STATA11.0. Self-reported HIV status and logistic regression was used to impute missing values for serostatus, an important issue for RDSAT. Results:A total of 3859 MSM were interviewed. Sample was diverse, most self-identified as mulatto or black, were social class C or below, and had relatively low levels of education. More than 80% reported more than one partner in the last 6 months. Only 49% had ever tested for HIV. HIV prevalence among MSM ranged from 5.2 to 23.7% in the 10 cities (3.7–16.5% without imputation) and was 14.2% for all cities combined with imputation. The overall prevalence was two and three times higher than that estimated for female sex workers and drug users, respectively, in Brazil. Half of those who tested HIV positive were not aware of their infection. Conclusion:The AIDS epidemic in Brazil is disproportionately concentrated among MSM, as has been found in other countries. Renewed efforts to encourage testing, prevention and treatment are required.

Contexts of HIV vulnerability among Brazilian women

This article aims to identify contexts of vulnerability related to HIV among Brazilian women. From November 2003 to December 2004, a cross-sectional study was conducted in 13 municipalities in the five Brazilian regions. The study included 1,777 women with a positive HIV diagnosis and 2,045 women attending public health care services. There were no significant differences between the two groups concerning number of sexual partners. However, HIV-positive women had a history of earlier sexual initiation and lower frequency of condom use. Higher proportions of HIV-positive women had used drugs, had a history of previous STDs, and had been victims of sexual violence some time in their life. The findings suggest the importance of considering strategies for HIV prevention focused on womens empowerment as a whole, and not focused only on their individual behaviors.

Home-based self-sampling and self-testing for sexually transmitted infections: Acceptable and feasible alternatives to provider-based screening in low-income women in Sao Paulo Brazil.

Objective: The objective of this study was to determine whether home-based screening for sexually transmitted infections (STIs) is acceptable, feasible, and increases the proportion of women screened among low-income women in São Paulo, Brazil. Study Design: Eight hundred eighteen women were randomized to receive a clinic appointment or a kit for home-based STI self-collection and testing. All participants collected 2 vaginal swabs, one for polymerase chain reaction detection of chlamydia, gonorrhea, and trichomoniasis and another for a self-conducted rapid test for trichomoniasis. Results: Slightly more women responded to the initiative within 2 weeks in the home group (80%) than in the clinic group (76%) with younger women showing improved response to home-based screening. Ninety-four percent of home group participants successfully completed self-collection and self-testing on their first attempt. Conclusions: Home-based self-collection and self-testing was acceptable, feasible, and resulted in a slightly higher response rate. Home sampling and testing provide promising alternatives to clinic-based STI screening across diverse contexts.

Induced abortion in women of reproductive age living with and without HIV/Aids in Brazil

This study aimed to identify and compare the characteristics of women living (WLHA) and not living with HIV/AIDS (WNLHA) regarding the report of lifetime induced abortion. Data from 1,777 MVHA and 2,045 MNVHA were collected between November 2003 and December 2004 during a cross-sectional study carried out in 13 municipalities of Brazil. After adjustment for confounding variables, 13.3% of MVHA versus 11.0% of MNVHA reported induced abortion in their lifetime (p>0.05). In multivariate analysis, independent correlates of lifetime induced abortion for both groups were: age, with older women reporting greater proportions of reporting induced abortion, living in the North region of Brazil, age at sexual debut (up to 17 years old), having three or more lifetime sexual partners, having ever used drugs and self-reporting occurrence of sexually transmitted diseases. The results suggest that, in general, the characteristics of women who reported induced abortion in both groups were similar, and that the contexts associated to HIV infection and to reproductive practices and decisions among women might share similarities.

Factors Associated with Low Levels of HIV Testing among Men Who Have Sex with Men (MSM) in Brazil

The aim of this study was to assess risk factors associated with low levels of HIV testing among MSM recruited through respondent driven sampling (RDS) in Brazil. Of 3,617 participants, 48.4% had never tested previously for HIV. A logistic model indicated that younger age, lower socioeconomic class, education, poor HIV/AIDS knowledge, no history of cruising, and having been tested during the study were characteristics independently associated with low levels of previous HIV testing. The HIV testing rate among MSM in Brazil is still low in spite of the availability of a large number services providing universal and free access to HIV/AIDS diagnosis and treatment. To respond to low utilization, the authors propose a higher priority for testing for key populations such as MSM, expanded education, expanding testing sites and a welcoming and nonjudgmental environment in health services.

Early diagnosis and correlations of sexually transmitted infections among women in primary care health services

INTRODUCTION Sexually Transmitted Infections (STIs) in women remain a public health challenge due to high prevalence, difficulties to implement early diagnosis strategies and high rates of complications. OBJECTIVE Identify the prevalence of STIs among users of a primary health care clinic in São Paulo. METHODS Women, 18 to 40 years of age, were invited to self-collect vaginal specimens to be tested for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis by Polymerase Chain Reaction (PCR). Women were also invited to answer a demographic and sexual history questionnaire, either on the computer or face-to-face. RESULTS The prevalence of STIs obtained from the 781 women included in the study was: Chlamydia trachomatis: 8.4%, Neisseria gonorrhoeae: 1.9%, and Trichomonas vaginalis: 3.2%. Thirteen percent tested positive for at least one out of the three STIs. The variables associated independently with a higher risk of STIs were: age under 20-years-old, more than two lifetime sexual partners, and self-perception of STI risk. The use of condoms as a contraceptive method proved to be a protective factor. CONCLUSION The high prevalence found among these women indicates the need for the implementation of STI screening strategies in primary care settings in Brazil.

HIV-1, HBV, HCV, HTLV, HPV-16/18, and Treponema pallidum infections in a sample of Brazilian men who have sex with men

Background Men who have sex with men (MSM) are more vulnerable to blood-borne infections and/or sexually-transmitted infections (STI). This study was conducted to estimate the prevalences of mono and co-infections of HIV-1 and other blood-borne/STIs in a sample of MSM in Campinas, Brazil. Methods Responding Driven Sampling (RDS) was used for recruitment of MSM. Serum samples collected from 558 MSM were analyzed for the presence of serological markers for HIV-1, HBV, HCV, HTLV, HPV-16/18, and T. pallidum infections. Results The highest prevalences of infection in serum samples were found for HPV-16 and 18 (31.9% and 20.3%, respectively). Approximately 8% of the study population showed infection with HIV-1, and within that group, 27.5% had recently become infected with HIV-1. HBV infection and syphilis were detected in 11.4% and 10% of the study population, respectively, and the rates of HTLV and HCV infection were 1.5% and 1%, respectively. With the exception of HTLV, all other studied infections were usually found as co-infections rather then mono-infections. The rates of co-infection for HCV, HPV-18, and HIV-1 were the highest among the studied infections (100%, 83%, and 85%, respectively). Interestingly, HTLV infection was usually found as a mono-infection in the study group, whereas HCV was found only as a co-infection. Conclusions The present findings highlight the need to educate the MSM population concerning their risk for STIs infections and methods of prevention. Campaigns to encourage vaccination against HBV and HPV could decrease the rates of these infections in MSM.

Exploring the relationship between induced abortion and HIV infection in Brazil

Abstract The impact of HIV on the decision to interrupt pregnancy remains an understudied topic in Brazil and the world. The technical means to implement HIV prevention and treatment interventions are widely available in Brazil. Although Brazil has restrictive abortion laws, induced abortion occurs frequently. This qualitative study investigates the extent to which Brazilian women are motivated to seek abortion as a consequence of having HIV disease, and the extent to which the decision is part of a larger reproductive decision-making context. Researchers interviewed 30 women who were living with HIV and had terminated pregnancies or attempted to do so. Many women identified their HIV status as an important aspect of their decision-making regarding abortion. Women also took into account issues such as the stage of life when the pregnancy occurred and the absence of support from partners and families. Contraceptive practices, pregnancy and abortion in this population are influenced by multiple factors that act on the structural, social, interpersonal and individual levels. We hypothesize that HIV infection and abortion are sometimes associated with similar contexts of vulnerability. Health services therefore should address HIV and reproductive issues together, with reproductive and sexual rights serving as the fundamental basis of health care. Résumé L’impact du VIH sur la décision d’interrompre une grossesse demeure un sujet sous-étudié au Brésil et dans le monde. Les moyens techniques pour mettre en łuvre des interventions de prévention et de traitement du VIH sont largement disponibles au Brésil. Même si ce pays a une législation restrictive en matière d’avortement, les interruptions volontaires de grossesse y sont fréquentes. Cette étude qualitative examine dans quelle mesure les Brésiliennes sont incitées à avorter du fait de leur séropositivité et dans quelle mesure cette décision s’inscrit dans un contexte plus large de prise de décision. Les chercheurs ont interrogé 30 femmes qui vivaient avec le VIH et avaient avorté ou tenté de le faire. Beaucoup de ces femmes identifiaient leur séropositivité comme un aspect important de leur décision d’avorter. Elles avaient aussi tenu compte de questions comme le stade de la vie où la grossesse s’était produite et l’absence de soutien du partenaire et de la famille. Dans cette population, les pratiques contraceptives, la grossesse et l’avortement sont influencés par de multiples facteurs qui agissent aux niveaux individuel, interpersonnel, social et structurel. Nous supposons que l’infection à VIH et l’avortement sont parfois associés à des contextes similaires de vulnérabilité. Les services de santé devraient donc aborder ensemble le VIH et les questions génésiques, les droits sexuels et génésiques servant de base fondamentale aux soins de santé. Resumen El impacto del VIH en la decisión de interrumpir un embarazo continúa siendo un tema poco estudiado a nivel mundial y específicamente en Brasil, donde los medios técnicos para la prevención del VIH y la implementación de intervenciones de tratamiento están disponibles de manera extendida. Aunque en Brasil existen leyes restrictivas referentes al aborto, el aborto inducido ocurre con frecuencia. En este estudio cualitativo se investiga hasta qué grado las mujeres brasileñas están motivadas para buscar servicios de aborto como consecuencia de tener VIH y hasta qué grado la decisión es parte de un contexto más amplio de toma de decisiones sobre la salud reproductiva. Los investigadores entrevistaron a 30 mujeres que estaban viviendo con VIH y habían interrumpido su embarazo o intentando hacerlo. Muchas mujeres identificaron su estado de VIH como un aspecto importante de su toma de decisiones respecto al aborto. Las mujeres tomaron en cuenta asuntos como la etapa de la vida cuando ocurrió el embarazo y la falta de apoyo de su pareja y familia. Múltiples factores que actúan a nivel estructural, social, interpersonal e individual, influyen en las prácticas anticonceptivas, el embarazo y el aborto en esta población. Planteamos como hipótesis que la infección por VIH y el aborto a veces están asociados con similares contextos de vulnerabilidad. Por lo tanto, los servicios de salud deben tratar los asuntos relacionados con el VIH y la salud reproductiva de manera conjunta, y los derechos sexuales y reproductivos deben servir como la base fundamental de los servicios de salud.

Dual Protection and Dual Methods in Women Living with HIV: The Brazilian Context.

The cooccurrence of HIV and unintended pregnancy has prompted a body of work on dual protection, the simultaneous protection against HIV and unintended pregnancy. This study examines dual protection and dual methods as a risk-reduction strategy for women living with HIV. Data are from a cross-sectional sample of HIV-positive women attended in Specialized STI/AIDS Public Health Service Clinics in 13 municipalities from all five regions of Brazil 2003-2004 (N = 834). Descriptive techniques and logistic regression were used to examine dual protection among women living with HIV. We expand the definition of dual protection to include consistent condom use and reversible/irreversible contraceptive methods, we test the dual methods hypothesis that women who use dual methods will use condoms less consistently than women who use only condoms, and we identify predictors of dual protection. Dual protection is common in our sample. Women who use dual methods have lower odds of consistent condom use than women who only use condoms. Among dual method users, we find that women who use an irreversible method use condoms more consistently than women who use a reversible method. Women on ART and with an HIV-serodiscordant partner have greater odds of consistent condom use than their counterparts.

Prevalence and factors associated with HSV-2 and hepatitis B infections among truck drivers crossing the southern Brazilian border

Objectives The authors estimate the prevalence of HIV, syphilis, hepatitis B virus (HBV) and herpes simplex virus type-2 (HSV-2) infection and correlates of HBV and HSV-2 infection among truck drivers crossing the southern Brazilian border at Foz do Iguaçu. Methods Between October 2003 and March 2005, 1945 truck drivers were sampled while accessing voluntary counselling and testing services; 1833 (94.2%) were tested for HIV (ELISA and confirmatory immunofluorescence assay) and syphilis (non-treponemal (VDRL) and treponemal tests (FTA-ABS)). From these, 799 stored sera were tested for HSV-2 (type-specific ELISA test for detection of IgG) and HBV (core antibodies (anti-HBc) with positives tested for surface antigen (HBsAg)). The authors estimate HIV, syphilis, HSV-2 and HBV prevalence and determine socio-demographic and behavioural correlates of HSV-2 infection and HBV exposure. Results HIV prevalence was 0.3% (95% CI 0.1 to 0.6) and syphilis 4.5% (95% CI 3.6 to 5.4). Among those tested for HBV and HSV-2, 32.3% (95% CI 28.9 to 35.6) had serological evidence of exposure to HBV and 26.6% (95% CI 23.5 to 29.7) tested positive for HSV-2. Factors independently associated with HBV exposure included increasing age, Brazilian nationality and unprotected anal sex. Increasing age and reporting an unknown number of lifetime partners were associated with HSV-2 infection. Conclusions In this sample of truck drivers in southern Brazil, HIV prevalence was lower than national population estimates; exposure to HBV was higher than population estimates, while per cent positive for HSV-2 was similar to population estimates. The low prevalence of HIV in truck drivers indicates prevention successes; however, future HIV prevention programming should incorporate HBV vaccination and sexually transmitted infection prevention.