Raquel Silva Pinheiro

Outreach hepatitis B vaccination of female sex workers in central-west Brazil: immunization status, compliance, and immune response.

OBJECTIVES To evaluate the hepatitis B immunization status of female sex workers (FSWs) in Central-West Brazil and to evaluate their compliance with and immune response to hepatitis B vaccination delivered using outreach strategies. METHODS A total of 721 FSWs recruited in 2 large cities in Central-West Brazil were interviewed and screened for the presence of hepatitis B virus (HBV) markers. Hepatitis B vaccine was offered to all women susceptible to HBV, using outreach strategies. The immune response of FSWs who received a full course of vaccine was assessed following the final vaccine dose. RESULTS We found that 27.6% of FSWs, the majority of whom were aged 18 to 25 years, had serological evidence of previous hepatitis B vaccination. A total of 434 FSWs were eligible for vaccination, 389 (89.6%) of whom accepted the first hepatitis B vaccine dose. Of those, 64% received a second dose and 37.5% received all three doses. Through the outreach strategy, there was a 52.2% increase in the number of women who received the second dose and a 67% increase in the number who received the third dose. Of the 146 women who received a full course of vaccine, 105 accepted testing for quantitative anti-HBs (hepatitis B surface antibody) following the final vaccine dose, and 92.4% of those tested had developed protective levels of anti-HBs. Lower education level, workplace, and length of prostitution were predictors of full-vaccine acceptance. CONCLUSIONS The present findings illustrate the benefits of using outreach strategies to overcome the difficulties of vaccinating hard-to-reach populations such as FSWs.

INTERMEDIATE ENDEMICITY OF HEPATITIS A VIRUS INFECTION IN RURAL SETTLEMENT PROJECTS OF SOUTHWEST GOIAS, BRAZIL.

BACKGROUND Rural populations present an elevated risk of exposure to hepatitis A virus. OBJECTIVE The objective of this study was to estimate the prevalence and risk factors associated with hepatitis A virus infection among residents of rural settlement projects of southwest Goiás, Central Brazil. METHODS A total of 466 residents were interviewed and tested for the detection of anti- hepatitis A virus antibodies by ELISA. RESULTS The global prevalence of anti- hepatitis A virus was 82.2%. In individuals aged 5-9 years and 10-19 years, the prevalence was 15% and 58.8%, respectively. Persons in the 10-19 age group, with a history of life in encampments, with more than five people per residence consuming well water, were predictors for exposure to hepatitis A virus. CONCLUSION Our results suggest that the hepatitis A virus endemicity in rural settlements in southwest Goiás similar to that found in the urban population of the Midwest Region, confirming the implementation of universal hepatitis A vaccination in children.

Vulnerability to Sexually Transmitted Infections in women who sell sex on the route of prostitution and sex tourism in Central Brazil

OBJECTIVE: to investigate knowledge on sexually transmitted diseases (STDs), STD-related risk behaviors, and signs/symptoms of STDs among female sex workers (FSWs). METHODS: a cross-sectional study was conducted with a probabilistic sample comprising 395 women recruited using a respondent-driven sampling method between 2009 and 2010. The data were collected during face-to-face interviews. RESULTS: most of the participants were young adults, had a low educational level, and had poor knowledge on the transmission paths of the human immunodeficiency virus (HIV). Over one-third of the participants were not able to describe the signs/symptoms of STDs. The prevalence rates of vaginal discharge and wounds/ulcers were 49.0% and 8.6%, respectively, but 41.7% of the women had not sought treatment. CONCLUSION: the results indicate the need for public health policies focusing on the control and prevention of STDs in this population, especially for the FSWs who are active in an important prostitution and sex tourism route in central Brazil.OBJECTIVE to investigate knowledge on sexually transmitted diseases (STDs), STD-related risk behaviors, and signs/symptoms of STDs among female sex workers (FSWs). METHODS a cross-sectional study was conducted with a probabilistic sample comprising 395 women recruited using a respondent-driven sampling method between 2009 and 2010. The data were collected during face-to-face interviews. RESULTS most of the participants were young adults, had a low educational level, and had poor knowledge on the transmission paths of the human immunodeficiency virus (HIV). Over one-third of the participants were not able to describe the signs/symptoms of STDs. The prevalence rates of vaginal discharge and wounds/ulcers were 49.0% and 8.6%, respectively, but 41.7% of the women had not sought treatment. CONCLUSION the results indicate the need for public health policies focusing on the control and prevention of STDs in this population, especially for the FSWs who are active in an important prostitution and sex tourism route in central Brazil.

Low prevalence, low immunization and low adherence to full hepatitis B vaccine scheme and high-risk behaviors among crack cocaine users in central Brazil

Crack cocaine users represent a target group for hepatitis B vaccination. We evaluate the HBV epidemiology, immunization status and compliance with a super-accelerated vaccination schedule among in-treatment crack cocaine users in central Brazil. Six hundred in-treatment crack cocaine users were interviewed, and serum samples were tested for HBV markers. A super-accelerated vaccination schedule of HBV vaccine was offered to all susceptible crack cocaine users. In total, 7.0% of those tested had at least one positive marker of HBV exposure. Age, use of crack cocaine through improvised pipe, exchange of sex for money/drugs and previous sexually transmitted infections (STIs) were predictors of HBV exposure. One hundred six (17.7%) individuals showed a serological profile of hepatitis B vaccination. Of these, 54.7% were less than 25 years old, and only 13% of individuals were more than 35 years old. Although 91.8% of crack users accepted the first vaccine dose, only 21.7% received all three doses. Of the 23 crack cocaine users who agreed to have their vaccine response evaluated, 78.3% developed protective anti-HBs titers. Premature termination of treatment was the most common reason for not receiving the full vaccine series. Despite the low prevalence of HBV exposure among in-treatment crack cocaine users in central Brazil, the low rate of immunization and the high frequency of high-risk behaviors highlight the potential for crack users to acquire and disseminate this infection and therefore maintain the viral reservoir. Health practitioners need to keep this in mind, taking advantage of all opportunities to access this population and vaccinate against HBV.

Hepatitis B, HIV, and Syphilis in Female Crack Cocaine Users in Central Brazil

Raquel S. Pinheiro, BSN, MSN, is a Doctoral student, Faculdade de Enfermagem, Goiânia, Brasil. Megmar A. S. Carneiro, BPharm, MSc, PhD, is a Professor, Instituto de Patologia Tropical e Sa ude P ublica, Goiânia, Brasil. Regina M. B. Martins, BPharm, MSc, PhD, is a Professor, Instituto de Patologia Tropical e Sa ude P ublica, Goiânia, Brasil. Karlla A. A. Caetano, BSN, MSN, PhD, is a Professor, Faculdade de Enfermagem, Goiânia, Brasil. Paulie M. R. S. Carvalho, BSN, MSN, is a Doctoral student, Faculdade de Enfermagem, Goiânia, Brasil. Camila C. Ferreira, BSN, is a Master’s student, Faculdade de Enfermagem, Goiânia, Brasil. Marcos A. Matos, BSN, MSN, PhD, is a Professor, Faculdade de Enfermagem, Goiânia, Brasil. Sheila A. Teles, BSN, MsC, PhD, is a Professor, Faculdade de Enfermagem, Universidade Federal de Goi as, Goiânia, Goi as, Brazil. (*Correspondence to: sheila.fen@gmail.com). Hepatitis B virus (HBV) is a widespread global problem, with an estimated 240 million individuals experiencing chronic infection (Ott, Stevens, Groeger, & Wiersma, 2012). HBV is an important contributor to cases of acute and chronic hepatitis, cirrhosis, and hepatocellular carcinoma. HIV, the etiologic agent of AIDS, affected approximately 36.7 million people worldwide and caused 1.1 million deaths in 2015 (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2016). Syphilis (Treponema pallidum) was estimated by the World Health Organization to affect 36.4 million individuals in 2008, with approximately 10.6 million new cases occurring annually (World Health Organization [WHO], 2008). Syphilis infection can cause a range of clinical features, affecting practically any system or organ (Antal, Lukehart, & Meheus, 2002). These micro-organisms are efficiently spread by both sexual and vertical transmission (UNAIDS, 2013; WHO, 2012; Zoni, Gonzalez, & Sj€ogren, 2013). Therefore, women play an important role in the spread of HBV, HIV, and T. pallidum. Women often become infected during their childbearing years, allowing them to transmit these agents to their children perinatally (Dionne-Odom, Tita, & Silverman, 2016; Ham, Lin, Newman, Wijesooriya,

La vulnerabilidad a las enfermedades de transmisión sexual en mujeres que venden sexo en ruta de prostitución y turismo sexual en Brasil Central

OBJECTIVE: to investigate knowledge on sexually transmitted diseases (STDs), STD-related risk behaviors, and signs/symptoms of STDs among female sex workers (FSWs). METHODS: a cross-sectional study was conducted with a probabilistic sample comprising 395 women recruited using a respondent-driven sampling method between 2009 and 2010. The data were collected during face-to-face interviews. RESULTS: most of the participants were young adults, had a low educational level, and had poor knowledge on the transmission paths of the human immunodeficiency virus (HIV). Over one-third of the participants were not able to describe the signs/symptoms of STDs. The prevalence rates of vaginal discharge and wounds/ulcers were 49.0% and 8.6%, respectively, but 41.7% of the women had not sought treatment. CONCLUSION: the results indicate the need for public health policies focusing on the control and prevention of STDs in this population, especially for the FSWs who are active in an important prostitution and sex tourism route in central Brazil.OBJECTIVE to investigate knowledge on sexually transmitted diseases (STDs), STD-related risk behaviors, and signs/symptoms of STDs among female sex workers (FSWs). METHODS a cross-sectional study was conducted with a probabilistic sample comprising 395 women recruited using a respondent-driven sampling method between 2009 and 2010. The data were collected during face-to-face interviews. RESULTS most of the participants were young adults, had a low educational level, and had poor knowledge on the transmission paths of the human immunodeficiency virus (HIV). Over one-third of the participants were not able to describe the signs/symptoms of STDs. The prevalence rates of vaginal discharge and wounds/ulcers were 49.0% and 8.6%, respectively, but 41.7% of the women had not sought treatment. CONCLUSION the results indicate the need for public health policies focusing on the control and prevention of STDs in this population, especially for the FSWs who are active in an important prostitution and sex tourism route in central Brazil.

P3.144 Evaluating the prevalence and knowledge of sexually transmitted infection among homeless persons in central brazil

Introduction The objective of this study was to estimate the prevalence of Sexually Transmitted Infections and to explore the general understanding of transmission and prevention of these infections among the homeless in Goiânia, Central Brazil. Methods This is a cross-sectional study. Between August 2014 and June 2015, residents of a public homeless shelter were recruited in Goiânia, Goiás, in Central Brazil. Survey items included demographics and knowledge of STIs. Blood samples were submitted to rapid tests for HIV, syphilis, and hepatitis B (HBV), and a positive result on any one or more of these tests indicated the presence of an STI. This study was approved by the Research Ethics Committee of the Federal University of Goiás. Results The sample included 209 homeless persons. The mean age of participants was 38 years. The prevalence of STI was 27.8% (58/209), for HIV 3.3% (7/209), syphilis 24.9% (52/209) and hepatitis B 1.0% (2/209). When asked about transmission of HIV, syphilis, and hepatitis B in public restrooms, 4.8%, 8.6% and 10.5% reported that this can occur, respectively. On syringe sharing as an IST transmission route, 78%, 11.5% and 23.9% believe that HIV, syphilis and hepatitis B can be acquired through this parenteral media, respectively. The male condom was investigated as a method of prevention for these sexual infections, and 73.7%, 38.3% and 14.4% affirmed the efficacy of condom use for protection against HIV, syphilis and hepatitis B, respectively. It was found that age (PR: 1.01; 95% CI: 1.00–1.03) and confirming HIV transmission through syringe sharing (PR: 0.47; 95% CI: 0.27–0.81) were statistically significant associated with STI positivity (p≤0.05). Conclusion The dissemination of knowledge about STIs is an important tool for breaking the chain of transmission of sexual infections. In Brazil, access of the homeless population to health and sexuality education services can be improved using mobile health teams, known as Street Outreach Offices.

P3.188 Risk behaviours in homeless persons based on hiv status in central brazil

Introduction Mortality rates among the homeless are greater than the general population, presenting a high prevalence of comorbidities and exposure to risk factors. Housing insecurity has been associated with a high risk of sexual and physical exploitation and involvement in illicit activities as means of survival, contributing to the acquisition of sexually transmitted infections (STI), such as human immunodeficiency virus (HIV). The aim of this study, cross sectional, was to identify risk behaviours for infection by HIV among the homeless in Goiás, Central Brazil. Methods Between September 2014 to August 2015, 356 individuals served by a public shelter in the City of Goiânia, Central Brazil, were interviewed and tested for HIV. Multivariable logistic regression model was used to identify variables associated with HIV infection. Results Of the 356 recruited individuals, 81.2% were male, young (median: 36 years), with a low level of education (median: 7 years of study), self-reported mixed race (60.4%), single (59.6%) and religious (82.3%). Of the total, 3.9% (95% CI: 2.2%–6.4%) were HIV positive. Individuals infected by HIV reported greater risk behaviours, such as: homosexuality/bisexuality (35.7%), consumption of illicit drugs (92.9%), sexual relations with HIV carriers (45.5%), and a history of STI (61.5%) (all p≤0,05). Logistic regression analysis revealed that the number of sexual partners (adjusted odds ratio [AOR]: 6.49; p=0.02) and a history of sexual relations with HIV carriers (AOR: 7.40; p=0.00) were predictors for HIV infection. Conclusion The results of this study support high rates of risk behaviours for HIV infection among the homeless, evidence of the necessity of actions involving the prevention and treatment of STI on the streets and in temporary and permanent housing. Furthermore, it is extremely important to reach out to intersectoral networks (education, justice, culture and health), with the goal of reintegrating an individual into the job market, supporting the restoration of family and social ties, as well as autonomous living.

P3.203 Epidemiology of hiv among crack users in goiás, brazilian midwestern region

Introduction Midwestern Brazil is a significant route and market for cocaine in South America. The consumption of illicit drugs has contributed to HIV dissemination worldwide. Despite this scenario there is little information on the epidemiology of HIV among crack cocaine users in this region. The aims of this study were to estimate the prevalence, risk factors and HIV-1 subtypes among crack users in Goiania, a city in Midwestern Brazil. Methods A total of 600 crack users were interviewed and blood samples were collected for detection of anti-HIV-1. HIV-RNA was detected in positive samples, the HIV-1 protease (PR) and reverse transcriptase (RT) regions were sequenced; subtypes were assigned by REGA/phylogenetic analysis. HIV-subtypes were assigned by REGA. Univariate and multivariate analysis were carried out to identify predictors of HIV infection. This study was analysed and approved by the Committee on Ethics in Human Research of Hospital das Clínicas, Universidade Federal de Goiás. Results The median age of participants was 30 years old, and the majority were male, mixed race, single, and unemployed. Of the total, 2.8% were HIV-positive. Having sex with an HIV carrier, irregular condom use during sexual intercourse, and experience of living on the streets were predictors of HIV positivity (p<0.05). In 12 out of 17 crack users RNA HIV-1 were amplified and sequenced. Seven isolates were subtype B, one subtype F1 and one subtype C. Conclusion A high HIV prevalence was observed among crack users in Midwestern Brazil, a region far from the epicentre of HIV epidemiology. The predictors of HIV infection identified are concerning, and necessitate preventive strategies for HIV infection specifically directed toward this population. HIV-1 subtype C seems to have emerged over the last few years in this population at the centre of the country. Support: This work was supported by Conselho Nacional de Desenvolvimento Cientifico e Tecnologico – CNPq, and Fundação de Amparo a Pesquisa do Estado de Goiás – FAPEG

Low Immunogenicity of Recombinant Hepatitis B Vaccine Derived from Hansenula polymorpha in Adults Aged Over 40 Years

The Brazilian recombinant hepatitis B vaccine (VrHB-IB) is based on the expression of the recombinant antigen in Hansenula polymorpha yeast cells. Currently, data on the immunogenicity of this vaccine in older adults are nonexistent. This study aimed to evaluate the immunogenicity of VrHB-IB in adults over 40 years of age. From May to October 2011, 235 rural settlers between 2 and 93 years of age from the State of Goias in Brazil were eligible for vaccination. Of these, 180 accepted the first dose of the vaccine and 106 (58.9%) completed the vaccination schedule. Multivariate analysis revealed that individuals ≥ 40 years of age responded significantly less well to vaccination than younger adults. Also, a greater proportion of male nonresponders was observed (versus women; P = 0.02). These results point to the need for better evaluation of the immunogenicity of VrHB-IB in older adults.