��reas de vulnerabilidade para co-infec����o HIV-aids/TB em Ribeir��o Preto, SP

OBJETIVO: Identificar ��reas de vulnerabilidade para os casos novos de co-infec����o HIV/tuberculose (TB). M��TODOS: Estudo descritivo ecol��gico realizado por meio do georreferenciamento dos casos novos de HIV/TB notificados em Ribeir��o Preto, SP, em 2006. Os dados foram obtidos do sistema de informa����o estadual paulista de notifica����o de TB. Os casos novos de co-infec����o HIV/TB foram analisados conforme caracter��sticas sociodemogr��ficas e cl��nicas e, posteriormente, georreferenciados na base cartogr��fica do munic��pio segundo endere��o residencial. Os setores do munic��pio foram categorizados em tr��s n��veis socioecon��micos: inferior, intermedi��rio e superior, com base na an��lise de componentes principais das vari��veis do censo demogr��fico de 2000 (renda, instru����o e percentagem de domic��lios com cinco ou mais moradores). Foi calculada a incid��ncia da co-infec����o HIV/TB para cada n��vel socioecon��mico. RESULTADOS: A co-infec����o HIV/TB acometeu mais adultos do sexo masculino em idade economicamente ativa e a forma pulmonar da TB foi a mais comum. A distribui����o espacial mostrou que as incid��ncias nas ��reas com n��veis socioecon��micos intermedi��rios e inferiores (8,3 e 11,5 casos por 100 mil habitantes, respectivamente) foram superiores ��quela (4,8 casos por 100 mil habitantes) de n��vel socioecon��mico superior. CONCLUS��ES: A taxa de incid��ncia de co-infec����o HIV/TB analisada por n��veis socioecon��micos mostrou padra��o espacial de distribui��a��o n��o homog��neo e apresentou valores mais altos em ��reas de maior vulnerabilidade social. O estudo diagnosticou a��reas geogra��ficas priorita��rias para o controle da co-infec����o e a tecnologia do sistema de informa����o geogr��fica pode ser empregada no planejamento das a����es em sa��de pelos gestores municipais.

Preval��ncia de HIV em gestantes e transmiss��o vertical segundo perfil socioecon��mico, Vit��ria, ES

OBJETIVO: Descrever a preval��ncia de infec����o por HIV em gestantes e a taxa de transmiss��o vertical, segundo o perfil socioecon��mico dos bairros de resid��ncia das m��es. M��TODOS: Estudo ecol��gico explorat��rio utilizando a base de dados do Sistema de Informa����o de Agravos de Notifica����o de gestantes HIV-positivas e aids em crian��as notificadas entre 2000 e 2006 em Vit��ria, ES. Para an��lise das informa����es socioecon��micas foi utilizado o ��ndice de Qualidade Urbana. A preval��ncia de HIV em gestantes e a taxa de transmiss��o vertical foram calculadas. A distribui����o espacial dos casos foi realizada no programa Terraview 3.2.0. Para verificar a associa����o entre a qualidade urbana e a preval��ncia de HIV em gestantes utilizou-se o modelo de regress��o de Poisson. RESULTADOS: Um total de 137 gestantes e 14 crian��as infectadas por transmiss��o vertical foi notificado no per��odo. Sete crian��as correspondiam a m��es HIV-positivas sem notifica����o de caso no per��odo analisado. A preval��ncia de infec����o em gestantes no per��odo foi de 0,44% e a taxa de transmiss��o vertical foi de 9,7%. CONCLUS��ES: A preval��ncia de infec����o por HIV em gestantes e a transmiss��o vertical associam-se �� qualidade urbana do bairro de resid��ncia, indicando que os bairros com menor qualidade urbana devem ser priorizados quanto ��s a����es para redu����o da transmiss��o vertical.

Psychiatric patients' return for HIV/STI test results in mental health centers

OBJECTIVE: To assess individual and/or health service factors associated with patients returning for results of HIV or sexually transmitted infection (STI) tests in mental health centers. METHODS: Cross-sectional national multicenter study among 2,080 patients randomly selected from 26 Brazilian mental health centers in 2007. Multilevel logistic regression was used to assess the effect of individual (level 1) and mental health service characteristics (level 2) on receipt of test results. RESULTS: The rate of returning HIV/STI test results was 79.6%. Among health service characteristics examined, only condom distribution was associated with receiving HIV/STI test results, whereas several individual characteristics were independently associated including living in the same city where treatment centers are; being single; not having heard of AIDS; and not having been previously HIV tested. CONCLUSIONS: It is urgent to expand HIV/STI testing in health services which provide care for patients with potentially increased vulnerability to these conditions, and to promote better integration between mental health and health services.

Preval��ncia e vulnerabilidade �� infec����o pelo HIV de moradores de rua em S��o Paulo, SP

OBJETIVO: Analisar a preval��ncia e o perfil de vulnerabilidade ao HIV de moradores de rua. M��TODOS: Estudo transversal com amostra n��o probabil��stica de 1.405 moradores de rua usu��rios de institui����es de acolhimento de S��o Paulo, SP, de 2006 a 2007. Foi realizado teste anti-HIV e aplicado question��rio estruturado. O perfil de vulnerabilidade foi analisado pela frequ��ncia do uso do preservativo, considerando mais vulner��veis os que referiram o uso nunca ou ��s vezes. Foram utilizadas regress��es log��stica e multinomial para estimar as medidas de efeito e intervalos de 95% de confian��a. RESULTADOS: Houve predomin��ncia do sexo masculino (85,6%), m��dia de 40,9 anos, ter cursado o ensino fundamental (72,0%) e cor n��o branca (71,5%). A pr��tica homo/bissexual foi referida por 15,7% e a parceria ocasional por 62,0%. O n��mero m��dio de parcerias em um ano foi de 5,4 e mais da metade (55,7%) referiu uso de drogas na vida, dos quais 25,7% relataram uso frequente. No total, 39,6% mencionaram ter tido uma doen��a sexualmente transmiss��vel e 38,3% relataram o uso do preservativo em todas as rela����es sexuais. A preval��ncia do HIV foi de 4,9% (17,4% dos quais apresentaram tamb��m sorologia positiva para s��filis). Pouco mais da metade (55,4%) tinha acesso a a����es de preven����o. A maior preval��ncia do HIV esteve associada a ser mais jovem (OR 18 a 29 anos = 4,0 [IC95% 1,54;10,46]), hist��ria de doen��a sexualmente transmiss��vel (OR = 3,3 [IC95% 1,87;5,73]); pr��tica homossexual (OR = 3,0 [IC95% 1,28;6,92]) e �� presen��a de s��filis (OR = 2,4 [IC95% 1,13;4,93]). O grupo de maior vulnerabilidade foi caracterizado por ser mulher, jovem, ter pr��tica homossexual, n��mero reduzido de parcerias, parceria fixa, uso de drogas e ��lcool e n��o ter acesso a a����es de preven����o e apoio social. CONCLUS��ES: O impacto da epidemia entre moradores de rua �� elevado, refletindo um ciclo que conjuga exclus��o, vulnerabilidade social e acesso limitado �� preven����o.

Terapia nutricional nas altera����es metab��licas em pessoas vivendo com HIV/aids

OBJETIVO: Analisar o efeito do tratamento nutricional sobre as altera����es metab��licas provocadas pelo uso da terapia antirretroviral em adultos vivendo com HIV/aids. M��TODOS: Revis��o sistem��tica de literatura no PubMed, Lilacs e Cochrane, entre 1996 e 2010, do tipo ensaio cl��nico, controlado, randomizado, crossover, adultos, vivendo com HIV/aids em uso de terapia antirretroviral e sem doen��as oportunistas. A interven����o de interesse foi suplementa����o nutricional via oral e/ou mudan��a de estilo de vida por tratamento dietoter��pico espec��fico: dislipidemia, resist��ncia insul��nica, lipodistrofia e hipertens��o arterial sist��mica. A escala de Jadad foi utilizada para classifica����o qualitativa dos artigos. RESULTADOS: Foram localizados 385 artigos e sete foram inclu��dos. As interven����es utilizadas nesses estudos foram: dieta, dieta mais exerc��cio f��sico, dieta mais suplemento e somente suplementos. Dislipidemia foi desfecho avaliado em todos os estudos. Os estudos que avaliaram suplementa����o com ��mega 3 encontraram redu����o significativa dos triglic��rides. Dieta espec��fica mais suplementa����o de ��mega 3 mostrou aumento de HDL-colesterol. Suplementa����o com nicotinato de cromo n��o teve efeito sobre a dislipidemia. Modifica����o de estilo de vida, incluindo dieta e atividade f��sica, reduziu significativamente a circunfer��ncia da cintura, lipodistrofia e press��o arterial sist��lica. CONCLUS��ES: A redu����o de triglic��rides pela suplementa����o com ��mega 3 foi a interven����o nutricional com maiores evid��ncias cient��ficas. A prescri����o de dieta espec��fica parece ser a interven����o mais adequada para aumentar HDL-colesterol. N��o �� poss��vel fazer infer��ncias sobre o tratamento nutricional do colesterol total, LDL-colesterol e resist��ncia insul��nica. Modifica����es no estilo de vida podem promover melhora da lipodistrofia e press��o arterial.

Coexistencia de variantes HIV-1 com insercao dipeptidica no gene da transcriptase reversa

O objetivo desta comunicação foi descrever a detecção de coexistência de variantes HIV-1 com inserções de dois aminoácidos entre os códons 69 e 70 da transcriptase reversa. Tais variantes foram isoladas de paciente do sexo masculino, 16 anos de idade, em tratamento no interior do estado de São Paulo. Após confirmação de falha terapêutica, foi realizado teste de resistência a antirretrovirais, a partir do qual foram detectadas duas variantes contendo inserções dos aminoácidos Ser-Gly/Ser-Ala no códon 69 da transcriptase reversa, além da mutação T69S. Tais inserções possuem baixa prevalência, não foram relatadas em caráter de coexistência no Brasil e estão relacionadas com a resistência a múltiplas drogas, tornando o achado relevante do ponto de vista epidemiológico.

Direct treatment costs of HIV/AIDS in Portugal

OBJECTIVE To analyze the direct medical costs of HIV/AIDS in Portugal from the perspective of the National Health Service. METHODS A retrospective analysis of medical records was conducted for 150 patients from five specialized centers in Portugal in 2008. Data on utilization of medical resources during 12 months and patients’ characteristics were collected. A unit cost was applied to each care component using official sources and accounting data from National Health Service hospitals. RESULTS The average cost of treatment was 14,277 €/patient/year. The main cost-driver was antiretroviral treatment (€ 9,598), followed by hospitalization costs (€ 1,323). Treatment costs increased with the severity of disease from € 11,901 (> 500 CD4 cells/µl) to € 23,351 (CD4 count ≤ 50 cells/ µl). Cost progression was mainly due to the increase in hospitalization costs, while antiretroviral treatment costs remained stable over disease stages. CONCLUSIONS The high burden related to antiretroviral treatment is counterbalanced by relatively low hospitalization costs, which, however, increase with severity of disease. The relatively modest progression of total costs highlights that alternative public health strategies that do not affect transmission of disease may only have a limited impact on expenditure, since treatment costs are largely dominated by constant antiretroviral treatment costs.

Enfrentamento e percep����o da mulher em rela����o �� infec����o pelo HIV

OBJETIVO Analisar o enfrentamento e as percepções das mulheres em relação à descoberta da infecção pelo HIV. MÉTODOS Estudo qualitativo em Serviço de Assistência Especializada em HIV/aids em Recife, PE, de janeiro a setembro de 2010. Participaram oito mulheres entre 27 e 37 anos de idade vivendo com HIV, assintomáticas, sem critérios de diagnóstico de aids, infectadas por meio de relação sexual, e acompanhadas no serviço há pelo menos um ano. Foram utilizados formulário para caracterizar o quadro clínico e entrevista semiestruturada para compreender as percepções e sentimentos relacionados à trajetória pessoal após o diagnóstico e as diferentes maneiras de enfrentar o diagnóstico no meio familiar e social. Foi realizada análise de conteúdo na modalidade temática segundo Bardin. RESULTADOS A categoria temática emergente foi estigma e discriminação. As mulheres apresentavam trajetórias de vida marcadas pelo estigma, percebido como discriminação desde o diagnóstico e nas vivências do cotidiano. A revelação da infecção foi sentida como limitante para uma vida normal, levando à necessidade de ocultação do diagnóstico. As posturas discriminatórias por parte de alguns profissionais dos serviços de saúde não especializados em HIV/aids repercutiram negativamente nas experiências futuras em outros serviços de saúde. Além dos efeitos do estigma institucional, o serviço especializado não contemplou espaço para a expressão de outras necessidades para além da doença, o que poderia ajudar no enfrentamento da infecção. CONCLUSÕES A convivência com o HIV esteve fortemente ligada ao estigma. É importante fortalecer as abordagens educativas e o apoio emocional no momento do diagnóstico para favorecer o enfrentamento da condição de soropositividade.

HIV/AIDS knowledge among men who have sex with men: applying the item response theory

OBJECTIVE To evaluate the level of HIV/AIDS knowledge among men who have sex with men in Brazil using the latent trait model estimated by Item Response Theory. METHODS Multicenter, cross-sectional study, carried out in ten Brazilian cities between 2008 and 2009. Adult men who have sex with men were recruited (n = 3,746) through Respondent Driven Sampling. HIV/AIDS knowledge was ascertained through ten statements by face-to-face interview and latent scores were obtained through two-parameter logistic modeling (difficulty and discrimination) using Item Response Theory. Differential item functioning was used to examine each item characteristic curve by age and schooling. RESULTS Overall, the HIV/AIDS knowledge scores using Item Response Theory did not exceed 6.0 (scale 0-10), with mean and median values of 5.0 (SD = 0.9) and 5.3, respectively, with 40.7% of the sample with knowledge levels below the average. Some beliefs still exist in this population regarding the transmission of the virus by insect bites, by using public restrooms, and by sharing utensils during meals. With regard to the difficulty and discrimination parameters, eight items were located below the mean of the scale and were considered very easy, and four items presented very low discrimination parameter (< 0.34). The absence of difficult items contributed to the inaccuracy of the measurement of knowledge among those with median level and above. CONCLUSIONS Item Response Theory analysis, which focuses on the individual properties of each item, allows measures to be obtained that do not vary or depend on the questionnaire, which provides better ascertainment and accuracy of knowledge scores. Valid and reliable scales are essential for monitoring HIV/AIDS knowledge among the men who have sex with men population over time and in different geographic regions, and this psychometric model brings this advantage.

HIV risk practices by female sex workers according to workplace

OBJECTIVE To investigate differences in HIV infection- related risk practices by Female Sex Workers according to workplace and the effects of homophily on estimating HIV prevalence. METHODS Data from 2,523 women, recruited using Respondent-Driven Sampling, were used for the study carried out in 10 Brazilian cities in 2008-2009. The study included female sex workers aged 18 and over. The questionnaire was completed by the subjects and included questions on characteristics of professional activity, sexual practices, use of drugs, HIV testing, and access to health services. HIV quick tests were conducted. The participants were classified in two groups according to place of work: on the street or indoor venues, like nightclubs and saunas. To compare variable distributions by place of work, we used Chi-square homogeneity tests, taking into consideration unequal selection probabilities as well as the structure of dependence between observations. We tested the effect of homophily by workplace on estimated HIV prevalence. RESULTS The highest HIV risk practices were associated with: working on the streets, lower socioeconomic status, low regular smear test coverage, higher levels of crack use and higher levels of syphilis serological scars as well as higher prevalence of HIV infection. The effect of homophily was higher among sex workers in indoor venues. However, it did not affect the estimated prevalence of HIV, even after using a post-stratification by workplace procedure. CONCLUSIONS The findings suggest that strategies should focus on extending access to, and utilization of, health services. Prevention policies should be specifically aimed at street workers. Regarding the application of Respondent-Driven Sampling, the sample should be sufficient to estimate transition probabilities, as the network develops more quickly among sex workers in indoor venues.

Healthcare-associated infections: challenges to public health in Brazil

This study presents a critical evaluation of the scientific literature related to this subject, aiming to assess the policies and administrative issues regarding the prevention and magnitude of healthcare-associated infections and discuss the challenges for their prevention in Brazil. The topics discussed included historical and administrative issues, challenges imposed by the characteristics of the healthcare system and the territorial dimension, laboratorial support limitations, costs, institutional culture, professional qualification, and patient engagement. It is urgent to hold a nationwide discussion among government representatives, institutions, and healthcare workers and users to overcome these challenges.

Dentistry and HIV/AIDS related stigma

OBJECTIVE To analyze HIV/AIDS positive individual&#8217;s perception and attitudes regarding dental services.METHODS One hundred and thirty-four subjects (30.0% of women and 70.0% of men) from Nuevo Le��n, Mexico, took part in the study (2014). They filled out structured, analytical, self-administered, anonymous questionnaires. Besides the sociodemographic variables, the perception regarding public and private dental services and related professionals was evaluated, as well as the perceived stigma associated with HIV/AIDS, through a Likert-type scale. The statistical evaluation included a factorial and a non-hierarchical cluster analysis.RESULTS Social inequalities were found regarding the search for public and private dental professionals and services. Most subjects reported omitting their HIV serodiagnosis and agreed that dentists must be trained and qualified to treat patients with HIV/AIDS. The factorial analysis revealed two elements: experiences of stigma and discrimination in dental appointments and feelings of concern regarding the attitudes of professionals or their teams concerning patients&#8217; HIV serodiagnosis. The cluster analysis identified three groups: users who have not experienced stigma or discrimination (85.0%); the ones who have not had those experiences, but feel somewhat concerned (12.7%); and the ones who underwent stigma and discrimination and feel concerned (2.3%).CONCLUSIONS We observed a low percentage of stigma and discrimination in dental appointments; however, most HIV/AIDS patients do not reveal their serodiagnosis to dentists out of fear of being rejected. Such fact implies a workplace hazard to dental professionals, but especially to the very own health of HIV/AIDS patients, as dentists will not be able to provide them a proper clinical and pharmaceutical treatment.

Strategies for price reduction of HIV medicines under a monopoly situation in Brazil

ABSTRACT OBJECTIVE To analyze Government strategies for reducing prices of antiretroviral medicines for HIV in Brazil. METHODS Analysis of Ministry of Health purchases of antiretroviral medicines, from 2005 to 2013. Expenditures and costs of the treatment per year were analyzed and compared to international prices of atazanavir. Price reductions were estimated based on the terms of a voluntary license of patent rights and technology transfer in the Partnership for Productive Development Agreement for atazanavir. RESULTS Atazanavir, a patented medicine, represented a significant share of the expenditures on antiretrovirals purchased from the private sector. Prices in Brazil were higher than international references, and no evidence was found of a relationship between purchase volume and price paid by the Ministry of Health. Concerning the latest strategy to reduce prices, involving local production of the 200 mg capsule, the price reduction was greater than the estimated reduction. As for the 300 mg capsule, the amounts paid in the first two years after the Partnership for Productive Development Agreement were close to the estimated values. Prices in nominal values for both dosage forms remained virtually constant between 2011 (the signature of the Partnership for Productive Development Agreement), 2012 and 2013 (after the establishment of the Partnership). CONCLUSIONS Price reduction of medicines is complex in limited-competition environments. The use of a Partnership for Productive Development Agreement as a strategy to increase the capacity of local production and to reduce prices raises issues regarding its effectiveness in reducing prices and to overcome patent barriers. Investments in research and development that can stimulate technological accumulation should be considered by the Government to strengthen its bargaining power to negotiate medicines prices under a monopoly situation.

Characteristics of HIV patients who missed their scheduled appointments

ABSTRACT OBJECTIVE: To analyze whether sociodemographic characteristics, consultations and care in special services are associated with scheduled infectious diseases appointments missed by people living with HIV. METHODS: This cross-sectional and analytical study included 3,075 people living with HIV who had at least one scheduled appointment with an infectologist at a specialized health unit in 2007. A secondary data base from the Hospital Management & Information System was used. The outcome variable was missing a scheduled medical appointment. The independent variables were sex, age, appointments in specialized and available disciplines, hospitalizations at the Central Institute of the Clinical Hospital at the Faculdade de Medicina of the Universidade de S&#227;o Paulo, antiretroviral treatment and change of infectologist. Crude and multiple association analysis were performed among the variables, with a statistical significance of p &#8804; 0.05. RESULTS: More than a third (38.9%) of the patients missed at least one of their scheduled infectious diseases appointments; 70.0% of the patients were male. The rate of missed appointments was 13.9%, albeit with no observed association between sex and absences. Age was inversely associated to missed appointment. Not undertaking anti-retroviral treatment, having unscheduled infectious diseases consultations or social services care and being hospitalized at the Central Institute were directly associated to missed appointments. CONCLUSIONS: The Hospital Management & Information System proved to be a useful tool for developing indicators related to the quality of health care of people living with HIV. Other informational systems, which are often developed for administrative purposes, can also be useful for local and regional management and for evaluating the quality of care provided for patients living with HIV.