Cost-effectiveness of adult circumcision in a resource-rich setting for HIV prevention among men who have sex with men

Background.  We examined the effects and cost‐effectiveness of 4 strategies of circumcision in a resource‐rich setting (Australia) in a population of men who have sex with men (MSM).

Method.  We created a dynamic mathematical transmission model and performed an economic analysis to estimate the costs, outcomes, and cost‐effectiveness of different strategies, compared with those of the status quo. Strategies included circumcision of all MSM at age 18 years, circumcision of all MSM aged 35–44 years, circumcision of all insertive MSM aged 18 years, and circumcision of all MSM aged 18 years . All costs are reported in US dollars, with a cost‐effectiveness threshold of $42,000 per quality‐adjusted life‐year.

Results.  We find that 2%–5% of human immunodeficiency virus (HIV) infections would be averted per year, with initial costs ranging from $3.6 million to $95.1 million, depending on the strategy. The number of circumcisions needed to prevent 1 HIV infection would range from 118 through 338. Circumcision of predominately insertive MSM would save $21.7 million over 25 years with a $62.2 million investment. Strategies to circumcise 100% of all MSM and to circumcise MSM aged 35–44 years would be cost‐effective; the latter would require a smaller investment. The least cost‐effective approach is circumcision of young MSM close to their sexual debut. Results are very sensitive to assumptions about the cost of circumcision, the efficacy of circumcision, sexual preferences, and behavioral disinhibition.

Conclusions.  Circumcision of adult MSM may be cost‐effective in this resource‐rich setting. However, the intervention costs are high relative to the costs spent on other HIV prevention programs.

Reconstructing the incidence of human immunodeficiency virus (HIV) in Hong Kong by using data from HIV positive tests and diagnoses of acquired immune deficiency syndrome

The human immunodeficiency virus–acquired immune deficiency syndrome (HIV–AIDS) epidemic in Hong Kong has been under surveillance in the form of voluntary reporting since 1984. However, there has been little discussion or research on the reconstruction of the HIV incidence curve. This paper is the first to use a modified back-projection method to estimate the incidence of HIV in Hong Kong on the basis of the number of positive HIV tests only. The model proposed has several advantages over the original back-projection method based on AIDS data only. First, not all HIV-infected individuals will develop AIDS by the time of analysis, but some of them may undertake an HIV test; therefore, the HIV data set contains more information than the AIDS data set. Second, the HIV diagnosis curve usually has a smoother pattern than the AIDS diagnosis curve, as it is not affected by redefinition of AIDS. Third, the time to positive HIV diagnosis is unlikely to be affected by treatment effects, as it is unlikely that an individual receives medication before the diagnosis of HIV. Fourth, the induction period from HIV infection to the first HIV positive test is usually shorter than the incubation period which is from HIV infection to diagnosis of AIDS. With a shorter induction period, more information becomes available for estimating the HIV incidence curve. Finally, this method requires the number of positive HIV diagnoses only, which is readily available from HIV–AIDS surveillance systems in many countries. It is estimated that, in Hong Kong, the cumulative number of HIV infections during the period 1979–2000 is about 2600, whereas an estimate based only on AIDS data seems to give an underestimate.

Effectiveness of an HIV / AIDS prevention approach across three countries

The study examined the effectiveness of one community based HIV / AIDS prevention approach, Community Counselling, in PNG, India and Zambia. Results indicated the three countries differed along cultural dimensions. Differences on behaviour, attitude, knowledge and risk perceptions associated with HIV / AIDS were noted within each country that reflected exposure to the approach. The professional portfolio examines the curent situations in which cultural guidelines have been developed to assist clinicians in considering indigenous cultural differences in increasingly multicultural societies. Four case studies are presented in which aspects of these issues are identified and discussed.

HIV vaccines : brief review and discussion of future directions

This article reviews data relevant to the development of cocktail vaccines for HIV which have been designed to elicit a wide range of envelope glycoprotein-specific B- and T-cell responses.

HIV-1 down-modulates γ signaling chain of FcγR in human macrophages : a possible mechanism for inhibition of phagocytosis

HIV-1 infection impairs a number of macrophage effector functions, thereby contributing to development of opportunistic infections and the pathogenesis of AIDS. FcγR-mediated phagocytosis by human monocyte-derived macrophages (MDM) is inhibited by HIV-1 infection in vitro, and the underlying mechanism was investigated in this study. Inhibition of phagocytosis directly correlated with the multiplicity of HIV-1 infection. Expression of surface FcγRs was unaffected by HIV-1 infection, suggesting that inhibition of phagocytosis occurred during or after receptor binding. HIV-1 infection of MDM markedly inhibited tyrosine phosphorylation of the cellular proteins, which occurs following engagement of FcγRs, suggesting a defect downstream of initial receptor activation. FcγR-mediated phagocytosis in HIV-infected MDM was associated with inhibition of phosphorylation of tyrosine kinases from two different families, Hck and Syk, defective formation of Syk complexes with other tyrosine-phosphorylated proteins, and inhibition of paxillin activation. Down-modulation of protein expression but not mRNA of the γ signaling subunit of FcγR (a docking site for Syk) was observed in HIV-infected MDM. Infection of MDM with a construct of HIV-1 in which nef was replaced with the gene for the γ signaling subunit augmented FcγR-mediated phagocytosis, suggesting that down-modulation of γ-chain protein expression in HIV-infected MDM caused the defective FcγR-mediated signaling and impairment of phagocytosis. This study is the first to demonstrate a specific alteration in phagocytosis signal transduction pathway, which provides a mechanism for the observed impaired FcγR-mediated phagocytosis in HIV-infected macrophages and contributes to the understanding of how HIV-1 impairs cell-mediated immunity leading to HIV-1 disease progression.

Granulocyte-macrophage colony-stimulating factor augments phagocytosis of mycobacterium avium complex by human immunodeficiency virus type 1-infected monocytes/macrophages in vitro and in vivo

The role of human immunodeficiency virus type 1 (HIV-1) infection on the ability of human monocytes/macrophages to phagocytose Mycobacterium avium complex (MAC) in vivo and in vitro and the effect of granulocyte-macrophage colony-stimulating factor (GM-CSF) on this function were investigated. By use of a flow cytometric assay to quantify phagocytosis, HIV-1 infection was found to impair the ability of monocyte-derived macrophages to phagocytose MAC in vitro, whereas GM-CSF significantly improved this defect. Phagocytosis was not altered by exposure to a mutant form of GM-CSF (E21R) binding only to the α chain of the GM-CSF receptor, suggesting that signaling by GM-CSF that leads to augmentation of phagocytosis is via the β chain of the receptor. In a patient with AIDS and disseminated multidrug-resistant MAC infection, GM-CSF treatment improved phagocytosis of MAC by peripheral blood monocytes and reduced bacteremia. These results imply that GM-CSF therapy may be useful in restoring antimycobacterial function by human monocytes/macrophages.

Expression and purification of soluble recombinant full length HIV-1 Pr55(Gag) protein in Escherichia coli

The HIV-1 Gag precursor protein, Pr55(Gag), is a multi-domain polyprotein that drives HIV-1 assembly. The morphological features of HIV-1 suggested Pr55(Gag) assumes a variety of different conformations during virion assembly and maturation, yet structural determination of HIV-1 Pr55(Gag) has not been possible due to an inability to express and to isolate large amounts of full-length recombinant Pr55(Gag) for biophysical and biochemical analyses. This challenge is further complicated by HIV-1 Gag's natural propensity to multimerize for the formation of viral particle (with ∼2500 Gag molecules per virion), and this has led Pr55(Gag) to aggregate and be expressed as inclusion bodies in a number of in vitro protein expression systems. This study reported the production of a recombinant form of HIV-1 Pr55(Gag) using a bacterial heterologous expression system. Recombinant HIV-1 Pr55(Gag) was expressed with a C-terminal His×6 tag, and purified using a combination of immobilized metal affinity chromatography and size exclusion chromatography. This procedure resulted in the production of milligram quantities of high purity HIV-1 Pr55(Gag) that has a mobility that resembles a trimer in solution using size exclusion chromatography analysis. The high quantity and purity of the full length HIV Gag will be suitable for structural and functional studies to further understand the process of viral assembly, maturation and the development of inhibitors to interfere with the process.

Acquired immunodeficiency syndrome in Brazil

Aim. To describe the acquired immunodeficiency syndrome (AIDS) epidemic in Brazil and analyze the impact of federal government measures addressing the problem since its onset.Method. Retrospective review of AIDS epidemic data from its onset in 1980 up to the last published data in June 2001.Results. AIDS was first reported in Brazil in 1980. By 1988, all 27 Brazilian states had diagnosed cases, and until June 2000 more than half of Brazilian municipalities had recorded at least one case of the disease. The AIDS incidence reached its peak between 1996 and 1997 (14.7 per 100,000 population), and then declined between 1998 and 2000 to 9 per 100,000 population. In the last two decades, the proportion of deaths has been also significantly reduced. These were not random events, but reflected the efficiency of the program implemented by the Brazilian Health Ministry's Coordination on Sexually Transmitted Diseases and AIDS. The program includes an epidemiological surveillance modeling system, which records cases from several regular epidemiological bulletins; national network of diagnosis and monitoring of HIV-infected individuals (ill or not); highly active antiretroviral therapy available free to all patients; mother-infant protection program; educational programs on condom use; the introduction of the female condom; development of AIDS studies in different areas to provide practical solutions; constant preoccupation about drug costs accounting for the patent breaking; and national production of many drugs currently in use.Conclusion. Well-planned and implemented national program against AIDS can significantly reduce the burden of this disease to the population.

Medidas contraceptivas e de proteção da transmissão do HIV por mulheres com HIV/Aids

OBJETIVO: Atualmente, entre as mulheres, a relação sexual é a forma de transmissão que mais tem contribuído para a feminização da epidemia de HIV/Aids. Na busca constante de se estabelecer padrões mais adequados de orientação para saúde, investigou-se o uso de medidas contraceptivas, que também sirvam de proteção da transmissão do HIV, entre mulheres portadoras de HIV/Aids. MÉTODOS: Estudo exploratório desenvolvido em um serviço público ambulatorial de um hospital universitário, referência aos portadores de HIV/Aids da região centro-sul do Estado de São Paulo, no período de cinco meses (2000 a 2001). Foram estudadas 73 mulheres portadoras da infecção pelo HIV, ou com Aids. Os dados foram obtidos por meio de um formulário que investigava a caracterização sociodemográfica, as formas de anticoncepção utilizada e a situação sorológica do parceiro sexual. Os dados foram analisados descritivamente e os conteúdos das respostas abertas, agrupados em temas. Foi aplicado o teste exato de Fisher para análise de algumas variáveis, em nível de 5%. Para a análise de conteúdo utilizou-se a proposta de Bardin. RESULTADOS: A maioria das mulheres estava em fase de vida reprodutiva, eram casadas e foram contaminadas quase exclusivamente por meio da relação heterossexual. Entre elas, 35,4% referiam parceiro sexual discordante quanto à sorologia anti-HIV, e 13,7% utilizavam formas inadequadas de anticoncepção que também não protegiam da transmissão do HIV. CONCLUSÕES: Os resultados alertam para a necessidade de ações educativas continuadas quanto a experiências sexuais mais seguras entre portadoras de HIV/Aids, para que elas possam discutir com seus parceiros outras formas de exercerem sua sexualidade, sendo capazes de estabelecer opção contraceptiva mais consciente, de maneira a zelar pela sua saúde, do parceiro e até do concepto.

Avaliação de serviços de assistência ambulatorial em aids, Brasil: estudo comparativo 2001/2007

OBJETIVO: Avaliar os serviços do Sistema Único de Saúde brasileiro de assistência ambulatorial a adultos vivendo com aids em 2007 e comparar com a avaliação de 2001. MÉTODOS: Os 636 serviços cadastrados no Ministério da Saúde em 2007 foram convidados a responder a um questionário previamente validado (Questionário Qualiaids) com 107 questões de múltipla escolha sobre a organização da assistência prestada. Analisaram-se as frequências das respostas de 2007 comparando-as com as obtidas em 2001 na forma de variação percentual (VP). RESULTADOS: Responderam o questionário 504 (79,2%) serviços. Cerca de 100,0% dos respondentes relataram ter pelo menos um médico, suprimento sem falhas de antirretrovirais e de exames CD4 e carga viral. Vários aspectos mostraram melhor desempenho em 2007 comparados a 2001: registro de número de faltas à consulta médica (de 18,3 para 27,0%, VP: 47,5%), agendamento de consulta em menos de 15 dias no início da terapia antirretroviral (de 55,3 para 66,2%, VP: 19,7%) e participação organizada do usuário (de 5,9 para 16,7%, VP: 183,1%). Houve manutenção de dificuldades: pequena variação na disponibilidade de exames especializados em até 15 dias, como endoscopia (31,9 para 34,5%, VP: 8,1%), e a piora de indicadores como tempo ideal de acesso a consultas especializadas (55,9 para 34,5% em cardiologia, VP negativa de 38,3%). O tempo médio despendido nas consultas médicas de seguimento manteve-se baixo: 15 minutos ou menos (52,5 para 49,5%, VP negativa de 5,8%). CONCLUSÕES: A avaliação de 2007 mostrou que os serviços contam com os recursos essenciais para a assistência ambulatorial. Houve melhoras em muitos aspectos em relação a 2001, mas persistem desafios. Pouco tempo dedicado à consulta médica pode estar vinculado ao número insuficiente de médicos e/ou à baixa capacidade de escuta e diálogo. A acessibilidade prejudicada a consultas especializadas mostra a dificuldade das infraestruturas locais do Sistema Único de Saúde.

The deep mycoses in HIV infection

The deep mycoses are uncommon infections, usually acquired from the inhalation or ingestion of fungal spores, sometimes from the soil in areas of endemicity, such as in the Americas and south-east Asia, or from decaying vegetable matter. They are also seen in immunocompromised persons and, increasingly, in HIV-infected persons. Respiratory involvement is frequent, with granuloma formation, and mucocutaneous involvement may be seen. Oral lesions of the deep mycoses are typically chronic but non-specific, though nodular or ulcerative appearances are common. Person-to-person transmission is rare. In HIV disease, the most common orofacial involvement of deep mycoses has been in histoplasmosis, cryptococcosis, aspergillosis and zygomycosis. Diagnosis is usually confirmed by lesional biopsy although culture may also be valuable. Treatment is with amphotericin or an azole.

HIV attitudes and practices among professors in a Brazilian dental school.

Although there is considerable published research on Acquired Immunodeficiency Syndrome (AIDS), individual biases persist because of lack of information regarding HIV virus transmission. As a result, both infected patients and health care professionals suffer. The objective of this study was to determine if there is prejudice among university professors at the School of Dentistry at Aracatuba's Sao Paulo State University (FOA-UNESP) concerning HIV-positive patients or HIV-positive health care professionals. Out of the seventy-seven professors who responded to the questionnaire, 62.3 percent (forty-eight) stated that they advise their students not to refuse to treat a patient with HIV. Although 96.2 percent (fifty-two) of the fifty-four professors who treat patients have reported that they treat patients who are HIV-positive, only 65.3 percent of them were aware of infection control precautions, and only 32.7 percent reported that they would treat an HIV-positive patient like any other patient. There is also prejudice regarding HIV-positive professionals because only 48.1 percent (thirty-seven) of the professors responded that they would be willing to be treated by an infected professional. It can be concluded that there is prejudice among some of the FOA-UNESP university professors regarding individuals who are HIV-positive.

Atividade física e lipodistrofia em portadores de HIV/AIDS submetidos à terapia anti-retroviral

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Utilização so ácido graxo ômega-3 na hipertrigliceridemia de indivíduos com HIV/Aids: relação com níveis de citocinas

Pós-graduação em Doenças Tropicais - FMB

Vulnerability of women living with HIV/aids

OBJETIVO:traçar o perfil de mulheres vivendo com o vírus da imunodeficiência humana/Aids em municípios do interior do Estado de São Paulo, buscando-se identificar características relacionadas à vulnerabilidade individual, social e programática e analisar as condições em que tiveram conhecimento de seu status sorológico.MÉTODO:entre outubro de 2008 e dezembro de 2010, foi realizado estudo transversal, envolvendo 184 mulheres atendidas em serviço especializado. Os dados foram obtidos por entrevista e exame ginecológico, com coleta de amostras para diagnóstico etiológico de doenças sexualmente transmissíveis.RESULTADOS:predominaram mulheres brancas, entre 30 e 49 anos de idade, com companheiro, baixo nível escolar, múltiplos parceiros sexuais durante a vida e prática de sexo inseguro. A prevalência de doenças sexualmente transmissíveis foi de 87,0%.CONCLUSÃO:o estudo sugere a necessidade de ofertar assistência ginecológica em serviços especializados e realização de ações multiprofissionais que reforcem a autonomia feminina na tomada de decisões protetoras.