Exit ventriculoperitoneal shunt; enter endoscopic third ventriculostomy (ETV): contemporary views on hydrocephalus and their implications on management

Hydrocephalus has been known to affect humans since the birth of human medicine as it is described by Hippocrates. The management of this condition is however still dodged by challenges due to a poor understanding of its pathophysiology. The ventriculoperitoneal shunt presents considerable problems especially with respect to infection and shunt malfunction. Low income countries, that currently face the greater burden of paediatric hydrocephalus. experience an increased challenge with ventriculoperitoneal shunts due to a shortage of qualified personnel to handle shunt complications. Recent advances in neuro-endoscopic surgery have presented opportunities for alternative treatment options for hydrocephalus such as endoscopic third ventriculostomy (ETV). This paper explores the alternative views in the pathophysiology of hydrocephalus and how they explain the effectiveness of ETV in treating hydrocephalus arising from a variety of causes.

The prevalence of tympanic membrane and related middle ear pathology in children:a large longitudinal cohort study followed from birth to age ten

OBJECTIVE: To record with video-otoscopy the appearance of the tympanic membranes of a cross section of children aged 9 to 10 years. STUDY DESIGN: Cross-sectional study nested within an established longitudinal study of childhood development, the Avon Longitudinal Study of Parents and Children. SETTING: South West England, U.K. PARTICIPANTS: Approximately 6908 of 7261 children with ages ranging from 105 to 140 months born between April 1, 1991, and December 31, 1992, were examined by trained technicians with video-otoscopy. MAIN OUTCOME MEASURES: Two photographs were taken of each child's tympanic membranes to show the features of the pars tensa and the pars flaccida. RESULTS: In just less than three quarters of the children, both ears were normal. Retraction of the pars flaccida was present in 9.6% of children, and that of the pars tensa was present in 7.9%. Most of these changes were mild with few severe retractions. There were 15 cases of overt or suspected cholesteatoma. CONCLUSION: The tympanic membrane changes reflect most of the middle ear disease seen in 9- to 10-year-old children. The prevalence is low, and few children have serious disease at this stage.

NEW DATA ON THE CHRONOLOGY OF THE VALE DO FORNO SEDIMENTARY SEQUENCE (LOWER TAGUS RIVER TERRACE STAIRCASE) AND ITS RELEVANCE AS FLUVIAL ARCHIVE OF THE MIDDLE PLEISTOCENE IN WESTERN IBERIA

NEW DATA ON THE CHRONOLOGY OF THE VALE DO FORNO SEDIMENTARY SEQUENCE (LOWER TAGUS RIVER TERRACE STAIRCASE) AND ITS RELEVANCE AS FLUVIAL ARCHIVE OF THE MIDDLE PLEISTOCENE IN WESTERN IBERIA Pedro P. Cunha 1, António A. Martins 2, Jan-Pieter Buylaert 3,4, Andrew S. Murray 4, Luis Raposo 5, Paolo Mozzi 6, Martin Stokes 7 1 MARE - Marine and Environmental Sciences Centre, Department of Earth Sciences, University of Coimbra, Portugal: pcunha@dct.uc.pt 2 MARE - Marine and Environmental Sciences Centre, Dep. Geociências, University of Évora, Portugal; aam@uevora.pt 3 Centre for Nuclear Technologies, Technical University of Denmark, Risø Campus, Denmark; jabu@dtu.dk 4 Nordic Laboratory for Luminescence Dating, Aarhus University, Risø DTU, Denmark; anmu@dtu.dk 5 Museu Nacional de Arqueologia, Lisboa, Portugal; 3raposos@sapo.pt 6 Department of Geosciences, University of Padova, Italy; paolo.mozzi@unipd.it 7 School of Geography, Earth and Environmental Sciences, University of Plymouth, UK; m.stokes@plymouth.ac.uk The stratigraphic units that record the evolution of the Tagus River in Portugal (study area between Vila Velha de Ródão and Porto Alto villages; Fig. 1) have different sedimentary characteristics and lithic industries (Cunha et al., 2012): - a culminant sedimentary unit (the ancestral Tagus, before the drainage network entrenchment) – SLD13 (+142 to 262 m above river bed – a.r.b.; with probable age ca. 3,6 to 1,8 Ma), without artefacts; - T1 terrace (+84 to 180 m; ca. 1000? to 900 ka), without artefacts; - T2 terrace (+57 to 150 m; top deposits with a probable age ca. 600 ka), without artefacts; - T3 terrace (+43 to 113 m; ca. 460 to 360? ka), without artefacts; - T4 terrace (+26 to 55 m; ca. 335 a 155 ka), Lower Paleolithic (Acheulian) at basal and middle levels but early Middle Paleolithic at top levels; - T5 terrace (+5 to 34 m; 135 to 73 ka), Middle Paleolithic (Mousterian; Levallois technique); - T6 terrace (+3 to 14 m; 62 to 32 ka), late Middle Paleolithic (late Mousterian); - Carregueira Sands (aeolian sands) and colluvium (+3 a ca. 100 m; 32 to 12 ka), Upper Paleolithic to Epipaleolithic; - alluvial plain (+0 to 8 m; ca. 12 ka to present), Mesolithic and more recent industries. The differences in elevation (a.r.b.) of the several terrace staircases results from differential uplift due to active faults. Longitudinal correlation with the terrace levels indicates that a graded profile ca. 200 km long was achieved during terrace formation periods and a strong control by sea base level was determinant for terrace formation. The Neogene sedimentary units constituted the main source of sediments for the fluvial terraces (Fig. 2). Geomorphological mapping, coupled with lithostratigraphy, sedimentology and luminescence dating (quartz-OSL and K-feldspar post-IRIR290) were used in this study focused on the T4 terrace, which comprises a Lower Gravels (LG) unit and an Upper Sand (US) unit. The thick, coarse and dominantly massive gravels of the LG unit indicate deposition by a coarse bed-load braided river, with strong sediment supply, high gradient and fluvial competence, during conditions of rapidly rising sea level. Luminescence dating only provided minimum ages but it is probable that the LG unit corresponds to the earlier part of the MIS9 (ca. 335 to 325 ka), immediately postdating the incision promoted by the very low sea level (reaching ca. -140 m) during MIS10 (362 to 337 ka), a period of relatively cold climate conditions with weak vegetation cover on slopes and low sea level. Fig. 1. Main Portuguese reaches in which the Tagus River can be divided (Lower Tagus Basin): I – from the Spanish border to Arneiro (a general E–W trend, mainly consisting of polygonal segments); II – from Arneiro to Gavião (NE–SW); III – from Gavião to Arripiado (E–W); IV – from Arripiado to Vila Franca de Xira (NNE-SSW); V – from Vila Franca de Xira to the Atlantic shoreline. The faults considered to be the limit of the referred fluvial sectors are: F1 – Ponsul-Arneiro fault (WSW-ENE); F2 – Gavião fault (NW-SE); F3 – Ortiga fault (NW-SE); F4 – Vila Nova da Barquinha fault (W-E); F5 – Arripiado-Chamusca fault (NNE-SSW). 1 – estuary; 2 – terraces; 3 – faults; 4 – Tagus main channel. The main Iberian drainage basins are also represented (inset). The lower and middle parts of the US unit, comprising an alternation of clayish silts with paleosols and minor sands to the east (flood-plain deposits) and sand deposits to the west (channel belt), have a probable age of ca. 325 to 200 ka. This points to formation during MIS9 to MIS7, under conditions of high to medium sea levels and warm to mild conditions. The upper part of the US unit, dominated by sand facies and with OSL ages of ca. 200 to 154 ka, correlates with the early part of the MIS6. During this period, progradation resulted from climate deterioration and relative depletion of vegetation that promoted enhanced sediment production in the catchment, coupled with initiation of sea-level lowering that increased the longitudinal slope. The Vale do Forno and Vale da Atela archaeological sites (Alpiarça, central Portugal) document the earliest human occupation in the Lower Tagus River, well established in geomorphological and environmental terms, within the Middle Pleistocene. The Lower Palaeolithic sites were found on the T4 terrace (+26 m, a.r.b.). The oldest artefacts previously found in the LG unit, display crude bifacial forms that can be attributed to the Acheulian, with a probable age of ca. 335 to 325 ka. The T4 US unit has archaeological sites stratigraphically documenting successive phases of an evolved Acheulian, that probably date ca. 325 to 300 ka. Notably, these Lower Palaeolithic artisans were able to produce tools with different sophistication levels, simply by applying different strategies: more elaborated reduction sequences in case of bifaces and simple reduction sequences to obtain cleavers. Fig. 2. . Simplified geologic map of the Lower Tagus Cenozoic basin, adapted from the Carta Geológica de Portugal, 1/500000, 1992). The study area (comprising the Vale do Forno and Vale de Atela sites) is located on the more upstream sector of the Lower Tagus River reach IV, between Arripiado and Chamusca villages. 1 – alluvium (Holocene); 2 – terraces (Pleistocene); 3 – sands, silts and gravels (Paleogene to Pliocene); 4 – Sintra Massif (Cretaceous); 5 – limestones, marls, silts and sandstones (Mesozoic); 6 – quartzites (Ordovician); 7 – basement (Proterozoic to Palaeozoic); 8 – main fault. The main Portuguese reaches of the Tagus River are identified (I to V). The VF3 site (Milharós), containing a Final Acheulian industry, with fine and elaborated bifaces) found in a stratigraphic level located between the T4 terrace deposits and a colluvium associated with Late Pleistocene aeolian sands (32 to 12 ka), has an age younger than ca. 154 ka but much older than 32 ka. In the study area, the sedimentary units of the T4 terrace seem to record the river response to sea-level changes and climatically-driven fluctuations in sediment supply. REFERENCES Cunha P. P., Almeida N. A. C., Aubry T., Martins A. A., Murray A. S., Buylaert J.-P., Sohbati R., Raposo L., Rocha L., 2012, Records of human occupation from Pleistocene river terrace and aeolian sediments in the Arneiro depression (Lower Tejo River, central eastern Portugal). Geomorphology, vol. 165-166, pp. 78-90.

Treadmill Training Increases Sirt-1 And Pgc-1 α Protein Levels And Ampk Phosphorylation In Quadriceps Of Middle-aged Rats In An Intensity-dependent Manner.

The present study investigated the effects of running at 0.8 or 1.2 km/h on inflammatory proteins (i.e., protein levels of TNF- α , IL-1 β , and NF- κ B) and metabolic proteins (i.e., protein levels of SIRT-1 and PGC-1 α , and AMPK phosphorylation) in quadriceps of rats. Male Wistar rats at 3 (young) and 18 months (middle-aged rats) of age were divided into nonexercised (NE) and exercised at 0.8 or 1.2 km/h. The rats were trained on treadmill, 50 min per day, 5 days per week, during 8 weeks. Forty-eight hours after the last training session, muscles were removed, homogenized, and analyzed using biochemical and western blot techniques. Our results showed that: (a) running at 0.8 km/h decreased the inflammatory proteins and increased the metabolic proteins compared with NE rats; (b) these responses were lower for the inflammatory proteins and higher for the metabolic proteins in young rats compared with middle-aged rats; (c) running at 1.2 km/h decreased the inflammatory proteins and increased the metabolic proteins compared with 0.8 km/h; (d) these responses were similar between young and middle-aged rats when trained at 1.2 km. In summary, the age-related increases in inflammatory proteins, and the age-related declines in metabolic proteins can be reversed and largely improved by treadmill training.

[gait Speed, Grip Strength And Self-rated Health Among The Elderly: Data From The Fibra Campinas Network, São Paulo, Brazil].

The article seeks to investigate patterns of performance and relationships between grip strength, gait speed and self-rated health, and investigate the relationships between them, considering the variables of gender, age and family income. This was conducted in a probabilistic sample of community-dwelling elderly aged 65 and over, members of a population study on frailty. A total of 689 elderly people without cognitive deficit suggestive of dementia underwent tests of gait speed and grip strength. Comparisons between groups were based on low, medium and high speed and strength. Self-related health was assessed using a 5-point scale. The males and the younger elderly individuals scored significantly higher on grip strength and gait speed than the female and oldest did; the richest scored higher than the poorest on grip strength and gait speed; females and men aged over 80 had weaker grip strength and lower gait speed; slow gait speed and low income arose as risk factors for a worse health evaluation. Lower muscular strength affects the self-rated assessment of health because it results in a reduction in functional capacity, especially in the presence of poverty and a lack of compensatory factors.

Access and Affordability of Electricity in Developing Countries

A key objective of developing countries is to provide affordable access to modern energy services in order to support economic and social development. The paper presents a number of arguments for why and in which way energy access and affordability can play a key role in national development programs and in achieving the Millennium Development Goals. Approaches for measuring accessibility and affordability are presented, drawing on case studies of Bangladesh. Brazil, and South Africa, countries with different rates of electrification. Affordability of using electricity is examined in relation to the energy expenditure burden for households and time consumption. Conclusions focus on lessons learned and recommendations for implementing policies, instruments, and regulatory measures to tackle the challenge of affordability. (C) 2011 Elsevier Ltd. All rights reserved.

Depressive symptoms in old age: relations among sociodemographic and self-reported health variables

Background: Depression in old age is a complex multifactorial phenomenon that is influenced by several biopsychosocial variables. Depressive symptoms are associated with the presence of chronic diseases, with being female, with low education and low income levels, and with poor perceived health assessment. In impoverished areas, older adults may have more physical disability, as they may have less access to health services. Therefore, they may be more likely to report depressive symptoms. Methods: Population-based cross-sectional research was undertaken using data from the FIBRA study conducted in Ermelino Matarazzo, a poor subdistrict of the city of Sao Paulo, Brazil. The participants comprised 303 elderly people, aged 65 years and over, who attended a single-session data collection effort carried out at community centers. The protocol comprised sociodemographic and self-reported health variables, and the Geriatric Depression Scale. Results: The majority of the subjects reported five or fewer symptoms of depression (79.21%), reported one or two self-reported chronic diseases (56.86%), declared themselves to have one or two self-reported health problems (46.15%), and had good perceived health assessment (40.27%). The presence of depressive symptoms was associated with a higher number of self-reported health problems, poor perceived health assessment, and lower schooling levels, in the total sample and in analyses including men only. For women, depressive symptoms were associated with the number of self-reported health problems and family income. Conclusion: The presence of health problems, such as falls and memory problems, lower perceived health, and low education (and low family income for women) were associated with a higher presence of depressive symptoms among elderly people in this poor area of Sao Paulo.

Acute high-intensity exercise with low energy expenditure reduced LDL-c and total cholesterol in men

A reduction in LDL cholesterol and an increase in HDL cholesterol levels are clinically relevant parameters for the treatment of dyslipidaemia, and exercise is often recommended as an intervention. This study aimed to examine the effects of acute, high-intensity exercise (similar to 90% VO(2max)) and varying carbohydrate levels (control, low and high) on the blood lipid profile. Six male subjects were distributed randomly into exercise groups, based on the carbohydrate diets (control, low and high) to which the subjects were restricted before each exercise session. The lipid profile (triglycerides, VLDL, HDL cholesterol, LDL cholesterol and total cholesterol) was determined at rest, and immediately and 1 h after exercise bouts. There were no changes in the time exhaustion (8.00 +/- A 1.83; 7.82 +/- A 2.66; and 9.09 +/- A 3.51 min) and energy expenditure (496.0 +/- A 224.8; 411.5 +/- A 223.1; and 592.1 +/- A 369.9 kJ) parameters with the three varying carbohydrate intake (control, low and high). Glucose and insulin levels did not show time-dependent changes under the different conditions (P > 0.05). Total cholesterol and LDL cholesterol were reduced after the exhaustion and 1 h recovery periods when compared with rest periods only in the control carbohydrate intake group (P < 0.05), although this relation failed when the diet was manipulated. These results indicate that acute, high-intensity exercise with low energy expenditure induces changes in the cholesterol profile, and that influences of carbohydrate level corresponding to these modifications fail when carbohydrate (low and high) intake is manipulated.

Regulating industrial forest concessions in Central Africa and South America

Tropical countries face special specific problems in implementing sustainable forest management (SFM). In many countries, questions are raised on whether tropical forests should be publicly, commonly or privately owned and managed in order to enhance sustainability. Other debates also focus on whether small-scale enterprises are better positioned than large-scale industrial concessions to reduce poverty and attain sustainable management. In countries where large tracts of forest are state-owned, concessions are viewed as a means of delivering services of public and collective interest through an association of private investment and public regulation. However, the success of an industrial concession model in countries with large forest resource endowment to achieve multiple goals such as sustainable forest management and local/regional development depends on two critical assumptions. First, forest functions and services should be managed and maintained as public goods. In many cases, additional uses - and corresponding rights - can take place alongside logging activities. Industrial concessions can be more efficient than other tenure models (such as community-based forest management and small-scale enterprises) in achieving SFM, add value to raw material and comply with growing environmental norms. This is especially the case in market-remote areas with low population density and poor infrastructure. Secondly, to achieve these different outcomes, any concession system needs to be monitored and regulated, especially in contexts dominated by asymmetrical information between regulating authorities and concessionaires. New institutional responses have recently been put forward in several countries, providing valuable materials to design a renewed policy mix which associates public and private incentives. This paper provides a survey of the experience of forest concessions in several Central African and South American countries. The concession system is examined in order to clarify the issues involved, the problems encountered, and what can be learned from the shared experience of these countries in the last decade. This paper argues that despite a sometimes patchy record, concessions can help promote SFM so long as they are packaged with a certain number of specific measures. (C) 2008 Elsevier B.V. All rights reserved.

Guidance for the implementation of best practice for the care of patients with tuberculosis

The first two chapters of Best practice for the care of patients with tuberculosis: a guide for low-income countries include an introduction and guidance regarding implementation of best practice. The background to how the guide was developed is significant, as it was developed in collaboration with nurses and other health workers working in the most challenging settings. It therefore provides realistic and practical guidance for best practice where patient loads are large and resources are stretched. Guidance regarding standard setting and clinical audit is an important part of enabling people to recognise the strengths that already exist in their practice and approach those areas that require change in a systematic and practical way. The guide itself consists of a series of standards covering different aspects of patient care, from the moment they seek health care with symptoms to their diagnosis to early stages of treatment, directly observed treatment, the continuation phase and transfer of treatment. There are also standards relating specifically to HIV testing and the care of patients co-infected with tuberculosis and HIV. The standards themselves will appear in full in the subsequent chapters of this series.

What is a healthy weight for middle aged women?

OBJECTIVE: To explore associations between body mass index (BMI) and selected indicators of health and well-being and to suggest a healthy weight range (based on BMI) for middle aged Australian women. DESIGN: population based longitudinal study (cross-sectional baseline data). SUBJECTS: 13431 women aged 45-49 y who participated in the baseline survey for the Australian Longitudinal Study on Women's Health. RESULTS: Forty-eight percent of women had a BMI>25kg/m(2). Prevalence of medical problems (for example, hypertension, diabetes), surgical procedures (cholescystectomy, hysterectomy) and symptoms (for example, back pain) increased monotonically with BMI, while indicators of health care use (for example, visits to doctors) showed a 'J' shaped relationship with BMI. Scores for several sub-scales of the MOS short form health survey (SF36) (for example, general health, role limitations due to emotional difficulties, social function, mental health and vitality) were optimal when BMI was around 19-24 kg/m(2). After adjustment for area of residence, education, smoking, exercise and menopausal status, low BMI was associated with fewer physical health problems than mid-level or higher BMI, and the nationally recommended BMI range of 20-25 was associated with optimum mental health, lower prevalence of tiredness and lowest use of health services. CONCLUSIONS: Acknowledging the limitations of the cross-sectional nature of these data, the results firmly support the benefits of leanness in terms of reducing the risk of cardiovascular disease, diabetes and gall bladder disease. The findings are moderated, however, by the observation that both low and high BMI are associated with decreased vitality and poorer mental health. The optimal range for BMI appears to be about 19-24 kg/m(2). From a public health perspective this study provides strong support for the recommended BMI range of 20-25 as an appropriate target for the promotion of healthy weight in middle aged Australian women.

The food business environment and the role of China and Brazil building a ""food bridge""

Purpose - The purpose of this paper is to discuss the economic crisis of 2008/2009 and the major impacts on developing nations and food-producing countries Within this macro-environment of food chains, there is concern that food inflation might come back sooner than expected The role of China as one of the major food consumers in the future, and Brazil, as the major food producer, is described as the food bridge, and an agenda of common development of these countries suggested. Design/methodology/approach - This paper reviews literature on muses of food inflation, production shortages, and investigation of programs to solve the problem in the future, it is also based on author`s personal insights and experience of working on this field in the last 15 years, and recent discussions in forums and interviews Findings - The major factors that jointly caused food prices increase in 2007/2008 were population growth, Income distribution, urbanization, dollar devaluations, commodity funds, social programs, production shortages, and bionic`s A list of ten policies is suggested. horizontal expansion of food production, vertical expansion, reduction in transaction costs, in protectionism and other taxes, investment in logistics, technology and better coordination, contracts, new generation of fertilizers and to use the best sources of biofuels. Originality/value - Two major outputs from this paper are the ""food demand model"" that inserts in one model the trends and muses of food inflation and the solutions, and the ""food bridge concept"" that also aligns in one box the imminent major food chain cooperation between China and Brazil

Distribution of HDL-cholesterol and non-HDL-cholesterol in Brazilian children and adolescents - The Floripa study

Background and aims: HDL-cholesterol (HDL-C) and non-HDL-cholesterol (nHDL-C) are involved in atherosclerosis. The aim of this study was to determine the distribution of HDL-C and nHDL-C and its association with cardiovascular and socio-cultural variables in a pediatric Brazilian sample. Methods and results: Children and adolescents from Florianopolis were randomly selected and a structured questionnaire was administered, a physical examination was performed and a blood sample was collected. Enzymatic and Direct methods in vitro were used to determine the total cholesterol and HDL-cholesterol levels. The associations among HDL-C and nHDL-C and the described variables were tested by odds ratio and logistic regression. A total of 1009 individuals were examined. Based on the Brazilian criteria, 23% were classified with low levels of HDL-C and 25% with high levels of non-HDL-C. After multivariate analysis there were significant associations among low HDL-C and high C-reactive protein (OR, 3.3; 95% CI, 2.1-5.2), paternal tobacco use (OR, 1.5; 95% CI, 1.1-2.1), and high triceps-to-subscapular index (OR, 1.5; 95% CI, 1.1-2.2). There were also significant associations among high nHDL-C and high waist circumference (OR, 1.95; 95% CI, 1.16-3.29), black skin color (OR, 1.78; 95% CI, 1.06-3.06), and high income (OR, 1.48; 95% CI, 1.09-2.02). Conclusions: In this sample, low levels of HDL-C were associated with other clinical variables such as a centripetal fat pattern and C-reactive protein, and n-HDL-C was associated with abdominal obesity, skin color and economic class. (C) 2009 Elsevier B. V. All rights reserved.

Comparative epidemiology of chronic fatigue syndrome in Brazilian and British primary care: prevalence and recognition

Background Although fatigue is a ubiquitous symptom across countries, clinical descriptions of chronic fatigue syndrome have arisen from a limited number of high-income countries. This might reflect differences in true prevalence or clinical recognition influenced by sociocultural factors. Aims To compare the prevalence, physician recognition and diagnosis of chronic fatigue syndrome in London and Sao Paulo. Method Primary care patients in London (n=2459) and Sao Paulo n=3914) were surveyed for the prevalence of chronic fatigue syndrome. Medical records were reviewed for the physician recognition and diagnosis. Results The prevalence of chronic fatigue syndrome according to Centers for Disease Control 1994 criteria was comparable in Britain and Brazil, 2.1% v. 1.6% (P=0.20). Medical records review identified 11 diagnosed cases of chronic fatigue syndrome in Britain, but none in Brazil (P<0.001). Conclusions The primary care prevalence of chronic fatigue syndrome was similar in two Culturally and economically distinct nations. However, doctors are unlikely to recognise and label chronic fatigue syndrome as a discrete disorder in Brazil. The recognition of this illness rather than the illness itself may be culturally induced.

AIDS in Latin America: assessing the current status of the epidemic and the ongoing response

Background This article provides a summary of the current status of the HIV/AIDS epidemic in Latin America, as well as an outline of the diverse responses to it. Methods A search of international databases (Pubmed and ISI-Web of Science), regional databases (Scielo and Lilacs), regional and national documents and UNAIDS reports. Data are presented according to subregion. Results In Mexico HIV remains concentrated among urban men who have sex with men (MSM), and has been growing among injecting drug users (IDU) and in rural areas in relation to migration. An increasing proportion of women among those affected is observed in all countries in Central America, the most affected region, as well as increasing the impact on other vulnerable groups, such as indigenous populations. The Andean Countries have urban epidemics concentrated among MSM. In Peru, non-traditional vulnerable populations were identified. In the Southern Cone heterosexual transmission became more relevant, probably in connection with IDU epidemics and is increasingly affecting lower income groups. Incidence rates have been declining since 2002 in Brazil, the first country to guarantee free, universal access to antiretrovirals, where one-third of drug-nave patients are still initiating treatment at an advanced stage. Generally, access to treatment has improved as a result of support from the Global Fund and other initiatives, but there are concerns regarding coverage, equity and sustainability. Conclusions HIV is still concentrated among MSM in Latin America. Non-traditional vulnerable groups such as migrants and lower income populations, usually considered part of the general population, deserve attention. Programmes confronting sexual exclusion are still needed. Access to treatment has improved over time, but inequalities persist.