Mariana A. Hacker

Consumo de álcool e drogas: principais achados de pesquisa de âmbito nacional, Brasil 2005

OBJETIVO: Analisar os padroes de consumo de alcool e drogas de uma amostra representativa da populacao urbana brasileira na sua inter-relacao com a saude sexual e reprodutiva. METODOS: Dados de inquerito de base populacional, de abrangencia nacional, com plano amostral complexo, realizado em 2005. Foram entrevistados 5.040 individuos de ambos os sexos, na faixa etaria de 16 a 65 anos. Analisaram-se questoes relativas consumo de alcool e drogas e comportamento sexual. Utilizou-se analise bivariada e multivariada. RESULTADOS: O alcool foi a substância mais frequentemente utilizada, com relato de uso regular, na vida, por 18% dos entrevistados. O consumo de drogas ilicitas foi referido por 9% dos entrevistados, especialmente, maconha e cocaina aspirada, com uso de drogas injetaveis infrequente. Observou-se declinio do consumo de cocaina aspirada e incremento do uso de maconha (nos ultimos 12 meses), comparados a resultados de pesquisa similar realizada em 1998. Historico de abuso sexual constituiu fator de risco do consumo de drogas e uso regular de alcool. A referencia por parte do entrevistado ao papel da religiao na sua formacao, ser branco e do sexo feminino se mostraram protetores frente ao consumo regular de alcool, particularmente prevalente entre homens mais velhos. As opcoes de lazer e a ausencia de praticas religiosas atuais se mostraram associadas ao consumo de drogas. CONCLUSOES: O consumo de alcool, regular ou nao, e prevalente na populacao urbana brasileira, enquanto o uso de drogas injetaveis se mostrou raro. Ao longo da ultima decada observou-se declinio no consumo de cocaina. Historico de abuso sexual se mostrou central ao consumo posterior de drogas e alcool.

The first ten years: achievements and challenges of the Brazilian program of universal access to HIV/AIDS comprehensive management and care, 1996-2006

A review was carried out of papers published between 1996 and 2006, documenting the introduction of highly active anti-retroviral therapy (HAART) in Brazil. Papers indexed in the MEDLINE and SciELO databases were retrieved using different combinations of keywords related to the management and care of AIDS in the post-HAART era: opportunistic diseases and co-infections, adherence to therapy, survival in the pre- and post-HAART eras, adverse events and side-effects, emergence and possible transmission of resistant viral strains, metabolic and cardiovascular disorders, and issues related to access to care and equity. The review documents the dramatic changes in HIV/AIDS disease progression in the post-HAART era, including an increase in survival and quality of life and a pronounced decrease in the episodes of opportunistic diseases. Notwithstanding such major achievements, new challenges have emerged, including slow evolving co-infections (such as hepatitis C, metabolic and cardiovascular disorders), the emergence of viral resistance, with consequences at the individual level (virological failure) and the community level (primary/secondary resistance at the population level), and impacts on the cost of new therapeutic regimens.

Highly active antiretroviral therapy in Brazil: the challenge of universal access in a context of social inequality.

OBJECTIVE To investigate trends in AIDS mortality and incidence in Brazil over the period of 1984 to 2000 and to assess the impact of the introduction of universal access to highly active antiretroviral therapy (HAART) in the country in 1996. METHODS Data from the Brazilian disease notification system and the national mortality information system were used to calculate annual region-specific and sex-specific AIDS incidence and mortality rates. We also calculated sex- and region-specific ratios of the number of AIDS deaths in one year to the number of AIDS cases notified two years earlier. RESULTS AIDS mortality rates for both men and women and in all five of the geographic regions of Brazil declined following introduction of HAART, despite continued growth in AIDS incidence. The ratio of the number of AIDS deaths in one year to the number of AIDS cases notified two years earlier for men equalized rapidly with the ratio for women following introduction of HAART. More recently, AIDS incidence declined for both sexes and in most of the regions of Brazil. CONCLUSIONS Despite Brazils resource limitations and disparities in wealth between men and women and among the countrys regions, the introduction of universal access to HAART in Brazil has helped achieve impressive declines in AIDS mortality, and it may also be contributing to declines in AIDS incidence.

Leprosy among Patient Contacts: A Multilevel Study of Risk Factors

Background This study aimed to evaluate the risk factors associated with developing leprosy among the contacts of newly-diagnosed leprosy patients. Methodology/Principal Findings A total of 6,158 contacts and 1,201 leprosy patients of the cohort who were diagnosed and treated at the Leprosy Laboratory of Fiocruz from 1987 to 2007 were included. The contact variables analyzed were sex; age; educational and income levels; blood relationship, if any, to the index case; household or non-household relationship; length of time of close association with the index case; receipt of bacillus Calmette-Guérin (BGG) vaccine and presence of BCG scar. Index cases variables included sex, age, educational level, family size, bacillary load, and disability grade. Multilevel logistic regression with random intercept was applied. Among the co-prevalent cases, the leprosy-related variables that remained associated with leprosy included type of household contact, [odds ratio (OR) = 1.33, 95% confidence interval (CI): 1.02, 1.73] and consanguinity with the index case, (OR = 1.89, 95% CI: 1.42–2.51). With respect to the index case variables, the factors associated with leprosy among contacts included up to 4 years of schooling and 4 to 10 years of schooling (OR = 2.72, 95% CI: 1.54–4.79 and 2.40, 95% CI: 1.30–4.42, respectively) and bacillary load, which increased the chance of leprosy among multibacillary contacts for those with a bacillary index of one to three and greater than three (OR = 1.79, 95% CI: 1.19–2.17 and OR: 4.07–95% CI: 2.73, 6.09), respectively. Among incident cases, household exposure was associated with leprosy (OR = 1.96, 95% CI: 1.29–2.98), compared with non-household exposure. Among the index case risk factors, an elevated bacillary load was the only variable associated with leprosy in the contacts. Conclusions/Significance Biological and social factors appear to be associated with leprosy among co-prevalent cases, whereas the factors related to the infectious load and proximity with the index case were associated with leprosy that appeared in the incident cases during follow-up.

The role of "long-term" and "new" injectors in a declining HIV/AIDS epidemic in Rio de Janeiro, Brazil.

Background. A substantial decline of HIV prevalence has been observed in injection drug users (IDUs) from Rio de Janeiro, in recent years. Differential characteristics and behaviors of new (injecting for <6 years) and long-term (>=6 y) injectors may help to understand recent changes and to implement appropriate preven-tion strategies. Methods. Between October 1999 and December 2001, 609 active/ex-IDUs were recruited from different communities, interviewed, and tested for HIV. Contingency table analysis and t-tests were used to assess differences between new and long-term injectors. Multiple logistic regression was used to identify independent predictors of HIV serostatus for long-term and new injectors. Results. HIV prevalence was 11.7% for 309 long-term injectors (95% CI 8.1–15.3) and 4.3% for 300 new injectors (95% CI 2.0–6.6). New injectors reported having engaged in treatment and having received syringes from needle exchange programs (NEPs) more frequently than long-term injectors in the last 6 months, but sharing behaviors remained frequent and even increased vis-à-vis long-term injectors. For male new injectors, “sexual intercourse with another man” was found to be the sole significant risk factor for HIV infection (Adj OR = 8.03; 95% CI 1.52–42.48). Among male long-term injectors, “to have ever injected with anyone infected with HIV” (Adj OR = 3.91; 95% CI 1.09–14.06) and to have “ever been in prison” (Adj OR = 2.56; 95% CI 1.05–6.24) were found to be significantly associated with HIV infection. Discussion. New injectors are seeking help in drug treatment centers or needle exchange programs. They differ from long-term injectors in terms of their risk factors for HIV infection and have lower prevalence levels for HIV. Such differences may help to understand the recent dynamics of HIV/AIDS in this population and highlight the need to reinforce new injectors’ help-seeking behavior and to reduce current unacceptably high levels of unprotected sex and syringe sharing in new injectors despite attendance of prevention/treatment programs.

Poverty, bridging between injecting drug users and the general population, and “interiorization” may explain the spread of HIV in southern Brazil

The aim of this paper is to study how structural determinants and the role of injecting drug users (IDUs) as a bridging population to the general population affected the AIDS subepidemic in southern Brazil during 1986-2000. Data from 288 southernmost Brazilian municipalities were analyzed. Using hierarchical modeling and inputs from a Geographic Information System, a multilevel model was constructed. The dependent variable was the logged AIDS standardized incidence rate (among the heterosexual population aged 15-69-years-old); independent variables included indicators for education, water provision, sewage, and garbage collection, per capita income, Gini coefficient (on income), Human Development Index, indicators of accessibility, and AIDS rate among IDUs. Significant predictors included AIDS rate among IDUs, distance from/to highways/railways, the Human Development Index and the ratio of residents who have access to sanitary installations. Poverty (as measured by socioeconomic indicators) and bridging from IDUs contribute to the spread of HIV/AIDS in Brazilian southern municipalities.

Adherence to antiretroviral therapy in a context of universal access, in Rio de Janeiro, Brazil

Abstract Adherence is integral to improving and maintaining the health and quality of life of people living with HIV. Two-hundred HIV-positive adults recruited from teaching hospitals and non-governmental organizations (NGOs) in Rio de Janeiro City were assessed on socio-demographic factors, adherence to antiretroviral therapy (ART) and psychosocial factors hypothesized to be associated with ART. Predictors of non-adherence were analyzed using bivariate and multivariate analyses. Self-reported medication adherence was high (82% had adherence >90%). Non-adherence was associated with personal factors (i.e. sexual orientation, self-efficacy), physical factors (i.e. loss of appetite) and interpersonal factors (i.e. doctor-patient relationship). Adherence in Brazil is as good, if not better, than that seen in the US and western Europe, which is noteworthy since the sample was derived predominantly from public healthcare settings. It is possible that the connection to NGOs in Rio de Janeiro City played a helpful role in achieving high levels of adherence in this sample of people living with HIV and AIDS. Recommendations, based on study findings, include enhancing and sustaining supportive services for NGOs, promoting patient self-efficacy and behavioral skills for adherence, increasing social network support and having healthcare providers directly address patients’ medication beliefs, attitudes and experience with side effects.

Statins Increase Rifampin Mycobactericidal Effect

ABSTRACT Mycobacterium leprae and Mycobacterium tuberculosis antimicrobial resistance has been followed with great concern during the last years, while the need for new drugs able to control leprosy and tuberculosis, mainly due to extensively drug-resistant tuberculosis (XDR-TB), is pressing. Our group recently showed that M. leprae is able to induce lipid body biogenesis and cholesterol accumulation in macrophages and Schwann cells, facilitating its viability and replication. Considering these previous results, we investigated the efficacies of two statins on the intracellular viability of mycobacteria within the macrophage, as well as the effect of atorvastatin on M. leprae infections in BALB/c mice. We observed that intracellular mycobacteria viability decreased markedly after incubation with both statins, but atorvastatin showed the best inhibitory effect when combined with rifampin. Using Shepards model, we observed with atorvastatin an efficacy in controlling M. leprae and inflammatory infiltrate in the BALB/c footpad, in a serum cholesterol level-dependent way. We conclude that statins contribute to macrophage-bactericidal activity against Mycobacterium bovis, M. leprae, and M. tuberculosis. It is likely that the association of statins with the actual multidrug therapy effectively reduces mycobacterial viability and tissue lesion in leprosy and tuberculosis patients, although epidemiological studies are still needed for confirmation.

Epidemiological and genetic analyses of Hepatitis C virus transmission among young/short- and long-term injecting drug users from Rio de Janeiro, Brazil

BACKGROUND Injecting drug users (IDU) have a key role in Hepatitis C Virus (HCV) epidemiology. Young/short-term IDUs constitute a target group for preventive/harm reduction interventions. OBJECTIVES To investigate HCV transmission among young/short-term (ST) and long-term (LT) IDUs, from the perspective of epidemiology and molecular biology. STUDY DESIGN Cross-sectional study assessing the prevalence of HCV infection/genotypes, as well as risk behaviours/practices among IDUs from Rio de Janeiro. Phylogenetic analyses were performed and the extent of segregation between sequences was quantified by the Association Index. RESULTS ST were more likely to engage into needle-sharing (p=.021) and LT to attend Needle Exchange Programs (p=.006). HCV prevalence was 10.1% vs. 23.4% among initiates and LT, respectively (p<.001). Older age vs. imprisonment and longer duration of IDU career were independent predictors for HCV infection among ST and LT, respectively. Among the latter, NEP attendance was inversely associated with viral infection. HCV3a infections were the most prevalent. A moderate extent of phylogenetic segregation between sequences was found, suggestive of transmission between IDU subgroups. CONCLUSIONS The lower HCV prevalence among young/short-term IDUs cannot be viewed with complacency, due to their frequent engagement into direct/indirect sharing practices and the ongoing transmission between IDU subsets. To avert new infections, preventive/harm reduction policies must be tailored to empirical findings.

Human immunodeficiency virus, AIDS, and drug consumption in South America and the Caribbean: epidemiological evidence and initiatives to curb the epidemic

OBJECTIVE The paper reviews data on drug use in relation to the spread of human immunodeficiency virus and AIDS in South America and the Caribbean. METHODS Information was gathered by thoroughly reviewing major bibliographic databanks, web sites of international institutions and regional networks working with substance misuse or human immunodeficiency virus and AIDS, and abstracts from conferences and meetings. RESULTS Although some gaps remain, a growing body of evidence documents the significant role of injected cocaine in the Brazilian and Southern Cone epidemics. The Caribbean and the Andean areas have thus far been spared in large part from the spread of injection drug use and its consequences, but the situation has been changing in Southern Cone countries towards a higher prevalence of harmful injection habits. Additional challenges have been posed by the increasing availability of heroin in the Andean Area and the abuse of crack cocaine and its impact on the sexual transmission of human immunodeficiency virus in many cities. Harm reduction strategies have been established in most areas of Brazil and are gaining momentum in Argentina. Other countries in the Region still face serious limitations due to restrictive legislation and lack of broader support. CONCLUSION Greater participation of Latin American and Caribbean countries in research protocols and continued debate on both successful and failed experiences should be encouraged in order to minimize existing barriers to the full adoption of effective measures to curb the human immunodeficiency virus and AIDS epidemic in this Region.