Pregnancy rates and predictors in women with HIV/AIDS in Rio de Janeiro, Southeastern Brazil

OBJECTIVE: To assess incidence and predictors of first pregnancy among women with HIV/AIDS. METHODS: Prospective cohort study was conducted in Rio de Janeiro, southeastern Brazil, between 1996 and 2003. This study comprised 225 women with HIV/AIDS followed up until their first pregnancy or first censored event (hysterectomy, tubal ligation, menopause, 50 years of age, loss to follow-up, death or the end of December 2003). Pregnancy and abortion rates were estimated, and Cox proportional hazards models were used to identify baseline characteristics associated with pregnancy risk. RESULTS: The women were followed up for 565 person/years with a median follow-up of 3 years per women. The mean age was 32 years (SD: 7), and 54.7% were white. There were 60 pregnancies in 39 women, and 18 were terminated (induced abortions), accounting for a rate of 6.9% and 2.1% women/year, respectively. Repeated pregnancies occurred in 33.3% of the women (13/39). Higher pregnancy risk was seen among younger women (HR=3.42; 95%CI: 1.69;6.95) and those living with their partners (HR=1.89; 95%CI: 1.00;3.57). Lower pregnancy risk was associated with higher education level (HR=0.43; 95%CI: 0.19;0.99) and use of antiretroviral therapy (HR=061; 95%CI: 0.31;1.17). CONCLUSIONS: Lower pregnancy rates were found in our cohort than in the general population. Sociodemographic characteristics should be taken into consideration in the management of reproductive health in HIV-positive childbearing age women. Reproductive and family planning counseling must be incorporated into HIV/AIDS programs for women to help preventing HIV transmission to their partners and offspring.

Subnotifica����o da comorbidade tuberculose e aids: uma aplica����o do m��todo de linkage

OBJETIVO: Analisar a subnotifica����o da comorbidade tuberculose (TB) e aids. M��TODOS: Estudo de vigil��ncia utilizando os registros do Sistema de Informa����o de Agravos de Notifica����o de Tuberculose e de aids no Brasil de 2000 a 2005. Registros de TB sem informa����o da presen��a de aids foram considerados subnotifica����es da comorbidade quando pareados a registros de aids que apresentassem ano de diagn��stico de aids igual ou anterior ao ano de notifica����o da TB, assim como os registros de um mesmo paciente cujos registros anteriores apresentavam essa informa����o. Criou-se um indicador: comorbidade TB-aids reconhecida, a partir dos registros de TB com a informa����o de presen��a de aids. RESULTADOS: A subnotifica����o de TB-aids foi de 17,7%. Esse percentual variou entre estados. A incorpora����o dos registros subnotificados aos previamente reconhecidos elevou a propor����o de TB-aids no Brasil de 6,9% para 8,4%. As maiores propor����es de subnotifica����o foram observadas no Acre, Alagoas, Maranh��o e Piau�� (mais de 35% cada) e as menores em S��o Paulo e Goi��s (cerca de 10% cada). CONCLUS��ES: A subnotifica����o da comorbidade TB-aids encontrada no Brasil deve deflagrar modifica����es no sistema de vigil��ncia para prover informa����es aos programas nacionais.

��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.

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.

Tend��ncia da epidemia de casos de aids no Sul do Brasil no per��odo de 1986 a 2008

OBJETIVO: Descrever a tend��ncia dos casos de aids por sexo e faixa et��ria de 1986 a 2008. M��TODOS: Foi analisada a tend��ncia da aids por faixa et��ria e por sexo, em Londrina, PR, em dois per��odos: 1986-1995 e 1996-2008. Dentre os modelos polinomiais, o de primeiro grau explicou melhor a tend��ncia da epidemia da aids nos dois per��odos. Foram calculadas as taxas de incid��ncia para homens que fazem sexo com homens (HSH), usu��rios de drogas injet��veis (UDI), homens heterossexuais e mulheres. RESULTADOS: No primeiro per��odo, de 1986 a 1995, houve incremento das taxas de incid��ncia em quase todas as faixas et��rias e crescimento da epidemia em ambos os sexos (p < 0,001), mais acentuado em homens de 14 a 39 anos. O segundo per��odo (1996-2008) n��o apresentou incremento estat��stico positivo ou negativo, indicando estabiliza����o da epidemia. Verificou-se que ocorreu queda significativa na faixa de 14 a 29 anos no sexo masculino, com incremento de 0,88 no primeiro per��odo e 0,87 no segundo. Mulheres de 50 anos e mais apresentaram aumento significativo (p = 0,019). Os grupos UDI e HSH predominaram como categorias de exposi����o e HSH ultrapassou UDI no ��ltimo tri��nio do estudo. A partir de 2000, a taxa de incid��ncia entre mulheres de 15 a 49 anos superou a de homens heterossexuais. CONCLUS��ES: Houve queda nas taxas de incid��ncia nas faixas et��rias mais jovens e estabiliza����o nas demais idades. O aumento da propor����o de mulheres e do predom��nio de HSH entre as categorias de exposi����o aponta para necessidade de estrat��gias diferenciadas para atingir grupos com caracter��sticas diversas.

Avalia����o de servi��os de assist��ncia ambulatorial em aids, Brasil: estudo comparativo 2001/2007

OBJETIVO: Avaliar os servi��os do Sistema ��nico de Sa��de brasileiro de assist��ncia ambulatorial a adultos vivendo com aids em 2007 e comparar com a avalia����o de 2001. M��TODOS: Os 636 servi��os cadastrados no Minist��rio da Sa��de em 2007 foram convidados a responder a um question��rio previamente validado (Question��rio Qualiaids) com 107 quest��es de m��ltipla escolha sobre a organiza����o da assist��ncia prestada. Analisaram-se as frequ��ncias das respostas de 2007 comparando-as com as obtidas em 2001 na forma de varia����o percentual (VP). RESULTADOS: Responderam o question��rio 504 (79,2%) servi��os. Cerca de 100,0% dos respondentes relataram ter pelo menos um m��dico, suprimento sem falhas de antirretrovirais e de exames CD4 e carga viral. V��rios aspectos mostraram melhor desempenho em 2007 comparados a 2001: registro de n��mero de faltas �� consulta m��dica (de 18,3 para 27,0%, VP: 47,5%), agendamento de consulta em menos de 15 dias no in��cio da terapia antirretroviral (de 55,3 para 66,2%, VP: 19,7%) e participa����o organizada do usu��rio (de 5,9 para 16,7%, VP: 183,1%). Houve manuten����o de dificuldades: pequena varia����o na disponibilidade de exames especializados em at�� 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 m��dio despendido nas consultas m��dicas de seguimento manteve-se baixo: 15 minutos ou menos (52,5 para 49,5%, VP negativa de 5,8%). CONCLUS��ES: A avalia����o de 2007 mostrou que os servi��os contam com os recursos essenciais para a assist��ncia ambulatorial. Houve melhoras em muitos aspectos em rela����o a 2001, mas persistem desafios. Pouco tempo dedicado �� consulta m��dica pode estar vinculado ao n��mero insuficiente de m��dicos e/ou �� baixa capacidade de escuta e di��logo. A acessibilidade prejudicada a consultas especializadas mostra a dificuldade das infraestruturas locais do Sistema ��nico de Sa��de.

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&#8217; 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 &#8364;/patient/year. The main cost-driver was antiretroviral treatment (&#8364; 9,598), followed by hospitalization costs (&#8364; 1,323). Treatment costs increased with the severity of disease from &#8364; 11,901 (> 500 CD4 cells/&#181;l) to &#8364; 23,351 (CD4 count &#8804; 50 cells/ &#181;l). 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.

The AIDS epidemic in the Amazon region: a spatial case-control study in Rondonia, Brazil

OBJECTIVE To analyze spatial changes in the risk of AIDS and the relationship between AIDS incidence and socioeconomic variables in the state of Rondonia, Amazon region. METHODS A spatial, population case-control study in Rondonia, Brazil, based on 1,780 cases reported to the Epidemiological Surveillance System and controls based on demographic data from 1987 to 2006. The cases were grouped into five consecutive four-year periods. A generalized additive model was adjusted to the data; the dependent variable was the status of the individuals (case or control), and the independent variables were a bi-dimensional spline of the geographic coordinates and some municipality-level socioeconomic variables. The observed values of the Moran&#8217;s I test were compared to a reference distribution of values generated under conditions of spatial randomness. RESULTS AIDS risk shows a marked spatial and temporal pattern. The disease incidence is related to socioeconomic variables at the municipal level in Rond&#244;nia, such as urbanization and human capital. The highest incidence rates of AIDS are in municipalities along the BR-364 highway and calculations of the Moran&#8217;s I test show positive spatial correlation associated with proximity of the municipality to the highway in the third and fourth periods (p = 0.05). CONCLUSIONS Incidence of the disease is higher in municipalities of greater economic wealth and urbanization, and in those municipalities bisected by Rond&#244;nia&#8217;s main roads. The rapid development associated with the opening up of once remote regions may be accompanied by an increase in these risks to health.

Seroprevalence of Toxoplasma gondii IgG antibody in HIV/AIDS-infected individuals in Maputo, Mozambique

OBJECTIVE To analyze the prevalence of IgG antibodies to Toxoplasma gondii in patients infected with HIV/AIDS and the association of demographic and social variables. METHODS Descriptive cross-sectional study that included the analysis of sociodemographic data and laboratory findings of 200 patients infected with HIV/AIDS treated in a laboratory unit in Maputo, Mozambique, in 2010. Individual data for all participants were collected with a self-administered questionnaire. Plasma samples were tested for IgG testing of anti- T. gondii using hemagglutination for the analysis of antibodies. RESULTS The seroprevalence of IgG anti- T. gondii was 46.0% (95%CI 39.2;52.9), 39.3% (95%CI 29.5;50.0) in men and 50.9% (95%CI 41.9;59.8) in women, with no difference between sex (OR 1.30; 95%CI 0.95;1.77; p = 0.12). Ages ranged from 10 to 60 years, with a higher prevalence of infection in older age groups, but with no significant difference between them. Regularly consuming cattle meat (OR 1.74; 95%CI 1.04;2.89, p = 0.05), breeding cats/dogs (OR 6.18; 95%CI 3.60;10.62, p < 0.000) and having regular contact with soil (OR 3.38; 95%CI 2.19;5.21; p < 0.000) were significantly associated with risk of latent infection. CONCLUSIONS Toxoplasmosis is an infection with high prevalence in Mozambique. Cultural and behavioral aspects increase the risk. Toxoplasmosis can be responsible in our environment by the great burden of morbidity and mortality associated with meningoencephalic injuries in patients with HIV/AIDS.

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.

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.

Specialized care for people with AIDS in the state of Ceara, Brazil

OBJECTIVE To analyze if the distribution of specialized care services for HIV/AIDS is associated with AIDS rates. METHODS Ecological study, for which the distribution of 10 specialized care services in the Ceara state, Northeastern Brazil, was obtained, and the mean rates of the disease were estimated per mesoregion. We evaluated 7,896 individuals who had been diagnosed with AIDS, were aged 13 years or older, lived in Ceara, and had been informed of their condition between 2001 and 2011. Maps were constructed to verify the relationship between the distribution of AIDS cases and institutionalized support networks in the 2001-2006 and 2007-2011 periods. BoxMap and LisaMap were used for data analysis. The Voronoi diagram was applied for the distribution of the studied services. RESULTS Specialized care services concentrated in AIDS clusters in the metropolitan area. The Noroeste Cearense and west of the Sertoes Cearenses had high AIDS rates, but a low number of specialized care services over time. Two of these services were implemented where clusters of the disease exist in the second period. The application of the Voronoi diagram showed that the specialized care services located outside the metropolitan area covered a large territory. We identified one polygon that had no services. CONCLUSIONS The scenario of AIDS cases spread away from major urban areas demands the creation of social support services in areas other than the capital and the metropolitan area of the state; this can reduce access barriers to these institutions. It is necessary to create specialized care services for HIV/AIDS in the Noroeste Cearense and north of Jaguaribe.

Dengue vaccines: what we know, what has been done, but what does the future hold?

Dengue, a disease caused by any of the four serotypes of dengue viruses, is the most important arthropod-borne viral disease in the world in terms of both morbidity and mortality. The infection by these viruses induces a plethora of clinical manifestations ranging from asymptomatic infections to severe diseases with involvement of several organs. Severe forms of the disease are more frequent in secondary infections by distinct serotypes and, consequently, a dengue vaccine must be tetravalent. Although several approaches have been used on the vaccine development, no vaccine is available against these viruses, especially because of problems on the development of a tetravalent vaccine. Here, we describe briefly the vaccine candidates available and their ability to elicit a protective immune response. We also discuss the problems and possibilities of any of the vaccines in final development stage reaching the market for human use.

Padr��o lesional da medula ��ssea na imunodefici��ncia adquirida (AIDS)

O estudo da medula ��ssea em 20 casos de necr��psia de pacientes portadores da S��ndrome da Imunodefici��ncia Adquirida sugere que as altera����es medulares s��o freq��entes e de valor diagn��stico no reconhecimento da S��ndrome. �� admitida a exist��ncia de um padr��o lesional diagn��stico onde predominam os seguintes elementos: hipercelularidade, aus��ncia ou redu����o da granulopoiese, plasmocitose, histiocitose e displasia megacarioc��tica.

Cryptosporidiosis among patients with acquired immunodeficiency syndrome (AIDS) in the county of S��o Paulo, Brazil

Stool samples of 157 patients with AIDS, living in the county of S��o Paulo, were submitted to several techniques in the search for Cryptosporidium sp.. Among the various techniques tested for slide preparation (direct smear, spontaneous sedimentation method, and formol-ether concentration), the latter, formol-ether concentration, offered the best results, clearly outdoing all the others. Nineteen samples out of 157 prepared by this technique, after dyeing by the Kinyoun method or by carbol fuchsin dimethyl sulfoxide, were found to be positive for Cryptosporidium sp..