Ana Gabriela Travassos

Prevalence of human Papilloma Virus in HIV-positive and HIV-negative patients in the State of Bahia: a pilot study.

Human Papilloma Virus (HPV) plays a central role in the development of cervical cancer. However, other coexisting factors, such as HIV infection, must be present for this to occur. We evaluated the prevalence of HPV in HIV-positive and HIV-negative patients in the city of Salvador, Bahia, Brazil, and determined the most prevalent types of HPV in these patients. Fifty-five cases were selected from among patients attending three institutions providing cervical pathology services in the city of Salvador. HIV testing (Elisa/WB), HPV-DNA testing by PCR, colposcopy, cytology and biopsy were carried out in all patients. The histopathological results were classified as follows: 11 cases were normal/negative for neoplasia, 15 were diagnosed as cervical intraepithelial neoplasia grade 1 (CIN 1), 10 were CIN 2, 15 cases were CIN 3 and there were four cases of invasive squamous cell carcinoma. Among the 55 patients studied, 43 tested positive for HPV-DNA and 20 for HIV. All HIV-positive patients were positive for HPV-DNA. The most prevalent types of HPV were HPV 16, 52, 58, 53, 54, 33 and 51, and there was little difference between the groups of HIV-positive and HIV-negative patients with respect to the type of HPV encountered. The HIV-positive patients were found to be infected with a greater number of types of HPV than the HIV-negative patients. This study corroborates the existence of regional variations in the distribution of certain types of HPV, which is probably due to the particular ethnic constitution found in this region of Brazil.

Predictors of HPV incidence and clearance in a cohort of Brazilian HIV-infected women

Persistent infection with high-risk human papillomavirus (HR-HPV) is necessary for the development of precursor lesions and cervical cancer. HPV infection among women living with HIV/AIDS (WLHA) occurs more frequently, presents a higher rate of persistent infections and an earlier progression to cancer. We aimed to evaluate HR-HPV prevalence, incidence and clearance, and its association with HIV viral suppression, immunological response and other risk factors among WLHA followed at an STD/HIV reference center. This was a cohort study conducted at a reference center for STD/AIDS in Northeastern Brazil from September 2013 to September 2015. Follow-up visits were conducted at 6 and 12 months after enrolment, where socio-epidemiological data were obtained. Cervical samples were collected for conventional cytology and HPV DNA research (PCR COBAS® Roche) in addition to blood samples for CD4+ T lymphocyte count and HIV viral load. We prospectively evaluated 333 women. HR-HPV DNA prevalence was 33.3% at baseline. HPV-16 was present in 5.1%, HPV-18 in 3.9% and 29.4% WLHA had other HR-HPV (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68). The HR-HPV incidence during the follow-up was 10.8%, at the 6-month visit was 7.7% and at the 12-month visit was 3.7%. Variables associated with HR-HPV incidence were: nulliparity, combined oral contraceptive use and detectable HIV viral load. The HR-HPV clearance rate was 41.7% and was associated with age >30 years and lymphocyte T CD4 count >500 cells/mm3 at enrolment. These findings contribute to the knowledge about a group of women that need more careful HPV screening and describe the association between an efficient immunological response and HIV viral suppression with lower incidence and increased clearance of HR-HPV.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhea and associated factors among women living with Human Immunodeficiency Virus in Brazil: a multicenter study

BACKGROUND Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) cause infections in the female genital tract, increasing susceptibility to and infectiousness of HIV. The objectives of the present study were to determine the prevalence and associated factors of CT and GC infection among HIV-infected women in Brazil. METHODS Cross-sectional study conducted from March to December 2015, including HIV-infected women attending referral centers in nine states of Brazil, aged 18-49 years, nonpregnant. An interview was conducted including socio-demographic, epidemiological and clinical characteristics. After the interview, gynecological examination was conducted to collect cervical cytology and vaginal secretion to C. trachomatis and N. gonorrhoeae tests through molecular biology. RESULTS A total of 802 (89.1%) women participated. The prevalence of CT was 2.1% (17/802) and CG was 0.9% (7/802). The prevalence of a positive test for both CT and/or GC was 2.7%. The factors associated with positive CT/GC test in the multivariate logistic regression analysis were abnormal Papanicolau smear (OR 4.1; 95% CI: 1.54-11.09) and the presence of abnormal cervical discharge (OR 2.6; 95% CI: 1.02-6.71). Among 377 women who reported previous STI 245 (65.0%) reported using condom more frequently after being diagnosed. 62 (16.4%) discovered the STI after the partner told he was infected; 157 (41.6%) had STI symptoms and looked for care, and 158 (41.9%) discovered it in a routine consultation for another reason. CONCLUSIONS The control of STI represents a unique opportunity to improve reproductive health of women living with HIV. STI diagnosis can change their behavior and reduce the sexual transmission of HIV and bacterial STI.

Adesão à dupla contracepção entre mulheres infectadas pelo HIV

EBMSP – Escola Bahiana de Medicina e Saude Publica; CEDAP – Centro Estadual Especializado em Diagnostico, Assistencia e Pesquisa; SESAB – Secretaria Estadual de Saude do Estado da Bahia.

P3.185 Chlamydia Trachomatis in the Genital Tract of HIV-Infected Women, Pregnant and Non-Pregnant, Followed in a Reference Centre in Bahia, Northeast Brazil

Background Genital tract infection by Chlamydia trachomatis(CT) is associated with complications such as pelvic pain, infertility and ectopic pregnancy, besides increased risk of HIV sexual transmission. Its occurrence during gestation worsens perinatal morbidity and mortality. In HIV-infected pregnant women also increases the risk of HIV mother-to-child transmission despite the use of HAART. In Brazil, there are few data on the prevalence of HIV/CT co-infection and associated risk factors. Methods Cross-sectional study of HIV-infected women attending in a reference outpatient clinic for gynaecology and prenatal care between October 2010 and September 2011 was conducted, evaluating laboratory and clinical data. The search of CT was performed using Hybrid Capture II collected from endocervix, and clinical data were obtained from standard questionnaire and survey data in medical records. Results 112 HIV-infected women were enrolled, of whom 52 non-pregnant and 60 pregnant. In this population, mean age was 32.3 years (SD = 8.2), 62.5% had a previous history of sexually transmitted diseases, 46.4% began sex life with 15 years or less, 33.1% reported having less than 3 sexual partners throughout life, 45.8% had undetectable HIV viral load. We found a prevalence of 5.4% of Chlamydia trachomatis infection in HIV-infected women followed. There was an association of CT with the presence of pregnancy (10.0% versus 0.0%; p = 0.019), HIV viral load > 10,000 copies (p < 0.001) and the mean time of HIV diagnosis (21.0 versus 69.2 months; p = 0.032). We found no association with other risk factors studied (ethnicity, marital status, education, use of alcohol and drugs, CD4+ T Lymphocyte count). Conclusion Early access to diagnosis and treatment of infection by HIV and Chlamydia trachomatis is an important preventive action. In pregnant women infected with HIV, the prevalence of Chlamydia appears to be greater and this is a period where treatment can improve maternal and neonatal outcome.

Raltegravir versus lopinavir/ritonavir for treatment of HIV-infected late-presenting pregnant women

Background Late-presenting pregnant women pose a challenge in the prevention of HIV-1 mother-to-child-transmission. We compared the safety and efficacy of raltegravir and lopinavir/ritonavir for this population. Methods We did a single-center, pilot, open-label, randomized trial in Brazil (N = 44). We randomly allocated late-presenting HIV-infected pregnant women (older than 18 years with a plasma HIV-1 RNA >1000 copies/mL) to receive raltegravir 400 mg twice a day or lopinavir/ritonavir 400/100 mg twice a day plus zidovudine and lamivudine (1:1). The primary endpoint was virological suppression at delivery (HIV-1 RNA <50 copies per mL), in all patients who received at least one dose of study drugs (modified intention-to-treat analysis). Missing information was treated as failure. We assessed safety in all patients. Results We enrolled and randomly assigned treatment to 33 patients (17 in raltegravir group) between June 2015 and June 2017. The study was interrupted by the IRB because a significant difference between arms was detected in an interim analysis. All patients completed follow up at delivery. At delivery, virological suppression was achieved by 13/17 (76.5%) of patients in raltegravir group, versus 4/16 (25.0%) in lopinavir/ritonavir group (RR 3.1, 95% CI: 1.3–7.4). Patients in raltegravir group had significantly higher proportion of virological suppression at 2, 4, and 6 weeks than lopinavir/ritonavir group. Adverse events were most of mild intensity, but patients in lopinavir/ritonavir group had significantly more gastrointestinal adverse events. There was neither discontinuation nor deaths in this trial. Conclusion Raltegravir might be a first-line option for treatment of HIV-infected late-presenting pregnant women.

P3.83 Antimicrobial resistance of ureaplasma urealyticum and mycoplasma hominis researched at a reference centre in salvador, bahia

Introduction: Ureaplasma urealyticum (UU) and Mycoplasma hominis (MH) are potentially pathogenic organisms commonly found in the urogenital tract, with colonisation rates up to 80% and 40% worldwide, respectively. The aim of this study was to estimate antimicrobial resistance by UU and MH, and identify the antimicrobial agents involved in bacterial resistance. Methods A cross-sectional study, with data obtained retrospectively through medical records review. We analysed 140 patients whose women’s endocervical samples and men’s urine tested positive for MH and UU. The test used for the diagnosis and evaluation of antimicrobial resistance was the MYCOFAST Screening EvolutioN 3 kit. Results The majority of patients were female (90.7%), 57.9% of the patients had >29 years of age and 84.3% did not have a stable union. About 70.0% of the patients tested positive for UU, 3.0% for MH, and 27.0% for both. HIV co-infection was seen in 32.1% and HPV in 30.0%. Absence of current history of Chlamydia trachomatis was a protective factor for the acquisition of azithromycin resistance (p=0.04). As for the antimicrobials, doxycycline showed sensitivity rates higher than 96% for both infections, while azithromycin showed 86.8% of sensitivity for UU, but resistance of 75% for MH. Ciprofloxacin showed sensitivity rates lower than 15% for both infections, while less than 35% were strains sensible to ofloxacin. Erythromycin resistance rates ranged over 65% for the UU-MH coinfection, while over 90% of sample was sensible to tetracycline and clarithromycin resistance rates ranged from 7.1% for UU to 100% for MH. Conclusion The use of ciprofloxacin and ofloxacin is highly debatable considering the high rates of total and intermediate resistance. In our population, doxycycline showed high efficiency and is therefore recommended for the treatment of UU and MH infections. Monitoring antimicrobial resistance is ?fundamental for the adequacy of the therapeutic recommendations.

P3.75 Viral suppression in late presenting hiv-infected pregnant women

Introduction The maternal HIV viral load (VL) is a major predictor of mother to child transmission (MTCT). Therefore, it is necessary a rapid decrease of VL among late-presenting (LP) (after 28 weeks) pregnant women living with HIV (PWLH) aiming viral suppression (VS). We aimed to identify the population of LP-PWLH and compare the VS to the group who had earlier access (EA) to prenatal care. Methods A retrospective cohort carried out at the major HIV reference centre in Bahia, Brazil. Medical records of PWLH attended at prenatal care were reviewed from January 2011 to December 2013. HIV VL and TCD4+ count data were obtained from the national database. Statistical analyses were performed with SPSS 20.0. Results A total of 235 PWLH enrolled in the study, of which 29.4% were LP. Among the latter, the mean age was 28.3 (±6.9) years, similar to the EA group. Thirty four percent of the LP had <8 schooling years (p=0.16), 40.7% were single (p=0.64), 24.6% reported alcohol use (p=0.15), 1.6% drug use (p=0.44) and only 16.7% regular condom use (p=0.92). The majority of LP (62.9%) had partners with unknown serological status, 25.7% had seroconcordant and 11.4% had serodiscordant partners (p<0.01). LP predominantly had HIV diagnosis during pregnancy (60.9%; p<0.01) and were ARV naïve (78.3%; p<0.01), while only 14.5% were on ART at conception (p<0.01). As for the initial ART regimen during pregnancy, 89.9% of LP were using a protease inhibitor based regimen and 11.6% had had regimen changes during pregnancy (p=0.36). LP had a higher initial VL (log10 3.4; p<0.01) and those with recent diagnosis also had higher VL (log10 3.8; p=0.02). LP were more likely to not have a second VL during pregnancy or early peripartum (33.3%; p<0.01). VS was less achieved (34.8% vs 71.8%; p<0.01; OR 4.7, CI95% 2.36–9.66) by the LP group. Conclusion LP showed an increased risk of MTCT, with recent HIV diagnosis, higher VL at prenatal onset and a lower rate of VS. Thus, the use of integrase inhibitors would be a better choice for this population, since it promotes a quickly decrease of VL.

P3.185 Adolescents with hpv: the profile of young people attending a sti and hiv reference centre in salvador/bahia

Introduction The adolescence is a period marked by intense vulnerability, with a high prevalence of HPV, mostly of transient infections. We aimed to identify the population of adolescents infected with HPV and risk factors associated. Methods A cross-sectional study evaluating adolescents (from 10 to 19 years of age) carried out from January to August 2012 at the major Sexually Transmitted Infections (STI) Reference Centre in Bahia, Brazil. Sociodemographic and clinical data were obtained by reviewing charts and analysed through SPSS 20.0. Results Of the adolescents evaluated, 324 had the diagnosis of HPV, evidencing an HPV prevalence of 62.5%. Among those, the mean age was 16.8 (±1.5) years and the sexual debut occurred at 13.2 (±3.5) years of age. There was an association between the female gender and the diagnosis of HPV (p<0.01; OR 3.22, 95% CI 2.18–4.77), as well as to being 16 years old or older (p<0.01; OR 3.44, 95% CI 2.28–5.19). Regarding lifestyle, 25.6% (42/164) of HPV patients reported alcohol use, 8.1% (16/197) illicit drugs use and 2.2% (3/138) were smokers. There was a statistical correlation between having ≥8 years of schooling and HPV (p=0.02; OR 1.76, 95% CI 1.10–2.79), as well as working and the infection (p=0.01; OR 2.54, 95% CI 1.17–5.53). As for clinical characteristics, 15.8% (40/253) of HPV patients were pregnant during the study, with a significant association between pregnancy and the virus (p=0.02; OR 2.69, 95% CI 1.10–6.58). There was 91.9% (295/321) of clinical diagnosis of HPV, and 61.9% (199/321) of genital warts among the infected population. 90.9% (280/308) of the infected adolescents underwent treatment for HPV. Conclusion The clinical and epidemiological profile of these adolescents revealed the need for prevention campaigns against STIs with accessible language, promoting access to information. Access to HPV vaccine is now possible, and it is still necessary to stimulate follow-up and treatment in order to reduce this infection and its associated diseases.

P3.32 Adolescents infected by syphilis – a retrospective cohort in a reference service

Introduction Syphilis persists as a major and ascendant health issue. However, the impact of this disease during the adolescence, a period of behavioural, sexual and psychologic vulnerabilities, is still underexplored. We aimed to evaluate the follow-up of syphilis infected adolescents attended at a reference service of sexually transmitted infections (STI). Methods A retrospective cohort study using data from medical records of adolescents (10 to 19 years old) with diagnosis of syphilis attended at the states STI reference centre, from January to August 2012. Results Among 776 adolescents attending the service, 58 had a diagnosis of syphilis (7.47%). The majority was male (51.7%), mean age was 16.8 (±1.35) years, 92.3% attended school, and 58.1% had ≤8 years of schooling; 39.4% referred drinking alcohol and 39.5% drug use. Among the adolescents, 98.3% had already initiated sexual life, with the mean age of sexual debut of 14.2 (±1.48) years, with an average of 2.33 (±2.55) lifetime sexual partners. About 14.0% declared to be homosexual, 85.4% referred irregular condom use, 22.2% of the girls were pregnant, with mean age at first gestation of 16.0 (±1.09) years. A parcel of 4.8% of the adolescents were HIV-infected, 31.0% reported a previous STI (p=0.02, OR 2.68, 95% CI 1.16–6.17), and 52.3% had another current STI. The mean number of medical visits was 2.33, 22.8% had primary syphilis, 17.5% had the secondary phase of the disease and 59.6% had latent or late syphilis. The social and demographic variables were not statistically different among the adolescents in the different stages of syphilis. The genital ulcer complaint was related to the diagnosis of primary or secondary syphilis (p=0.01, OR 8.53, 95% CI 1.61–45.1). 91.4% of adolescents received treatment for syphilis and 56.6% performed a cure control. Conclusion The high prevalence of other STIs associated with syphilis in adolescents demonstrates the limited knowledge of this population to care and prevention strategies, and remains a challenge for specialised services in the diagnosis and treatment of STI/HIV.