Articles tagged as "Brazil"

High HIV prevalence among men who have sex with men

HIV among MSM in a large middle-income country.

Kerr LR, Mota RS, Kendall C, Pinho AD, Mello MB, Guimarães MD, Dourado I, de Brito AM, Benzaken A, McFarland W, Rutherford G; The HIVMSM Surveillance Group. AIDS. 2013 Jan 28;27(3):427-435.

To conduct the first national biological and behavioral surveillance survey for HIV among MSM in Brazil, a cross-sectional surveillance study utilized respondent driven sampling (RDS) in 10 cities, following formative research. MSM reporting sex with another man in the last 12 months, at least 18 years of age, and residing in the city of the study were recruited. Results were calculated for each city using RDSAT 5.6. For the national estimate, a new individual weight using a novel method was calculated. The 10 cities were aggregated, treated as strata and analyzed using STATA11.0. Self-reported HIV status and logistic regression was used to impute missing values for serostatus, an important issue for RDSAT. A total of 3859 MSM were interviewed. Sample was diverse, most self-identified as mulatto or black, were social class C or below, and had relatively low levels of education. More than 80% reported more than one partner in the last 6 months. Only 49% had ever tested for HIV. HIV prevalence among MSM ranged from 5.2 to 23.7% in the 10 cities (3.7-16.5% without imputation) and was 14.2% for all cities combined with imputation. The overall prevalence was two and three times higher than that estimated for female sex workers and drug users, respectively, in Brazil. Half of those who tested HIV positive were not aware of their infection. The AIDS epidemic in Brazil is disproportionately concentrated among MSM, as has been found in other countries. Renewed efforts to encourage testing, prevention and treatment are required.

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Editor’s notes: Key populations at particular risk of HIV infection need to be understood in a country-specific context. Terminology such as ‘generalized epidemic’ and ‘concentrated epidemic’ may have some utility, but are insufficient for understanding risks for specific populations, and for decision making for resource allocation and tailoring of prevention messaging. In addition, even in concentrated epidemics, HIV prevalence in specific key populations can approach or surpass epidemic proportions.

Men who have sex with men have HIV prevalence rates in many countries that are extraordinarily high: in Brazil this study finds HIV prevalence rates up to 27%, significantly higher than in a number of other key populations. Despite focused HIV prevention and testing campaigns almost half of men who have sex with men in Brazil do not know their infection status. This study was conducted before HIV testing was available outside of government facilities, and concern about stigma and confidentiality was raised by those who hadn’t tested. This study supports the value of NGO-based testing among key populations.

Latin America
Brazil
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Adverse events associated with nevirapine use in pregnancy

Adverse events associated with nevirapine use in pregnancy: a systematic review and meta-analysis.

Ford N, Calmy A, Andrieux-Meyer I, Hargreaves S, Mills EJ, Shubber Z. AIDS. 2013 Jan 5. [Epub ahead of print]

The risk of adverse drug events associated with nevirapine is suggested to be greater in pregnant women. The authors conducted a systematic review and meta-analysis of severe adverse events in HIV-positive women who initiated NVP while pregnant. Six databases were searched for studies reporting adverse events among HIV-positive pregnant women who had received nevirapine-based antiretroviral therapy for at least seven days. Data were pooled by the fixed-effects method. Twenty studies (3582 pregnant women) from 14 countries were included in the final review. The pooled proportion of patients experiencing a severe hepatotoxic event was 3.6% (95%CI 2.4-4.8%), severe rash was experienced by 3.3% of patients (95%CI 2.1-4.5%), and 6.2% (95%CI 4.0-8.4%) of patients discontinued nevirapine due to an adverse event. These results were comparable to frequencies observed in the general adult patient population, and to frequencies reported in non-pregnant women within the same cohort. For pregnant women with a CD4 cell count >250 cells/mm there was a non-significant tendency towards an increased likelihood of cutaneous events overall (OR 1.1, 95%CI 0.8-1.6) and severe cutaneous adverse events (OR 1.4, 95%CI 0.8-2.4) and consequently an increased risk of toxicity-driven regimen substitution (OR 1.7, 95%CI 1.1-2.6). These results suggest that the frequency of adverse events associated with nevirapine use in pregnant women, while high, is no higher than reported for nevirapine in the general adult population. Pregnant women with a high CD4 count may be at increased risk of adverse events, but evidence supporting this association is weak.

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Editor’s notes: The selection of antiretroviral drug regimens has been particularly challenging for HIV-positive pregnant women. Adverse events are less frequent for men and women with efavirenz use compared to nevirapine, and increasingly efavirenz is a preferred choice. However, due to concerns about the safety of efavirenz in pregnancy, nevirapine continues to be widely used as a component of antiretroviral treatment for pregnant women. However, there have been suggestions that HIV-positive pregnant women have higher rates of nevirapine-associated adverse events, especially for those women with high CD4, compared to non-pregnant women on nevirapine. This meta-analysis of 20 studies did demonstrate a relatively high frequency of adverse events in women who use nevirapine, but not at rates higher than among non-pregnant women on HIV treatment with nevirapine. The data about efavirenz safety for the fetus is being carefully reviewed to elucidate if widespread use of efavirenz is preferable to nevirapine during pregnancy.

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Persons left behind: transgender women

Worldwide burden of HIV in transgender women: a systematic review and meta-analysis.

Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Lancet Infect Dis. 2012 Dec 20. pii: S1473-3099(12)70315-8. [Epub ahead of print]

Background: Previous systematic reviews have identified a high prevalence of HIV infection in transgender women in the USA and in those who sell sex (compared with both female and male sex workers). However, little is known about the burden of HIV infection in transgender women worldwide. We aimed to better assess the relative HIV burden in all transgender women worldwide.

Methods: We did a systematic review and meta-analysis of studies that assessed HIV infection burdens in transgender women that were published between Jan 1, 2000, and Nov 30, 2011. Meta-analysis was completed with the Mantel-Haenszel method, and random-effects modelling was used to compare HIV burdens in transgender women with that in adults in the countries for which data were available.

Findings: Data were only available for countries with male-predominant HIV epidemics, which included the USA, six Asia-Pacific countries, five in Latin America, and three in Europe. The pooled HIV prevalence was 19·1% (95% CI 17·4-20·7) in 11 066 transgender women worldwide. In 7197 transgender women sampled in ten low-income and middle-income countries, HIV prevalence was 17·7% (95% CI 15·6-19·8). In 3869 transgender women sampled in five high-income countries, HIV prevalence was 21·6% (95% CI 18·8-24·3). The odds ratio for being infected with HIV in transgender women compared with all adults of reproductive age across the 15 countries was 48·8 (95% CI 21·2-76·3) and did not differ for those in low-income and middle-income countries compared with those in high-income countries.

Interpretation: Our findings suggest that transgender women are a very high burden population for HIV and are in urgent need of prevention, treatment, and care services. The meta-analysis showed remarkable consistency and severity of the HIV disease burden among transgender women.

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Editor’s notes: This paper systematically reviews studies on the prevalence of HIV infection among transgender women in different countries from three continents. Results unfortunately show that there is a dramatic consistency in HIV prevalence data, which reach peaks often above 20%, irrespective of the financial context of the countries where transgenders live. In addition, there is a common theme: risk factors including stigma, discrimination and marginalisation are all factors which dramatically increase the risk of becoming infected by HIV. Not only are transgender women probably the group with the highest risk of acquiring the infection, but they are also in urgent need of prevention, possibly including pre- and post-exposure prophylaxis, and of tailored support and care. But these might not be enough, if marginalisation is supported in some countries with a legal environment contradicting international human rights frameworks.

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Nutrition and People Living with HIV

Dietary intervention prevents dyslipidemia associated with highly active antiretroviral therapy in human immunodeficiency virus type 1-infected individuals: a randomized trial

Lazzaretti RK, Kuhmmer R, Sprinz E, Polanczyk CA, Ribeiro JP. J Am Coll Cardiol. 2012 Mar 13;59(11):979-88

The purpose of this study was to evaluate the efficacy of dietary intervention on blood lipids of human immunodeficiency virus (HIV)-1-infected patients who are started on highly active antiretroviral therapy. Current guidelines recommend diet as first-step intervention for HIV-1-infected individuals with antiretroviral treatment-related dyslipidemia, but there is no evidence from randomized trials to support this recommendation. Eighty-three HIV-1-infected patients, naive from antiretroviral treatment, were randomly assigned to antiretroviral treatment with dietary intervention (diet group, n = 43) or antiretroviral treatment without dietary intervention (control group, n = 40) for 12 months. Diet, according to the National Cholesterol Education Program, was given every 3 months. Before and after intervention, 24-h food records and lipid profile were obtained. Data were analysed by intention to treat, using mixed-effects models. Diet resulted in reduction of percentage of fat intake (from 31 ± 7% to 21 ± 3% of calories), while controls presented no change in percentage of fat intake. Plasma cholesterol (from 151 ± 29 mg/dl to 190 ± 33 mg/dl) and low-density lipoprotein cholesterol (from 85 ± 24 mg/dl to 106 ± 31 mg/dl) increased in the control group and were unchanged in the diet group. Plasma triglycerides were reduced by diet (from 135 ± 67 mg/dl to 101 ± 42 mg/dl) and increased in the control group (from 134 ± 70 mg/dl to 160 ± 76 mg/dl). After 1-year follow-up, 21% of patients who received diet had lipid profile compatible with dyslipidemia compared with 68% (p < 0.001) of controls. Among HIV-1-positive individuals naive of previous treatment, diet prevents dyslipidemia associated with antiretroviral treatment.

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Editor’s note: Weight gain, fat redistribution, high triglycerides, and high cholesterol have replaced malnutrition as new nutritional challenges for people living with HIV on antiretroviral treatment. The striking results of this Brazilian trial should be shared with patients starting on HIV treatment and should inform nutritional counselling. The intervention was simple: quarterly nutritional guidance from a registered dietician focused on preventing lipid abnormalities. Diets were planned individually, based on nutritional needs, socioeconomic status, and dietary habits, to maintain or reduce weight as needed. Caloric intake was divided between lipids (5% saturated, 10% monounsaturated, and 10% polyunsaturated fatty acids), proteins (15%), and carbohydrates (60%, including 30 grams of fibre and 200 mg of dietary cholesterol). Trans fatty acids were to be avoided completely. Dietary recall for food and beverages consumed during the previous 24 hours helped tailor the counselling. At the start of the study, both groups were instructed about nutrition and lifestyle, focusing on the benefits of having a healthy diet, and neither group received advice on physical activity. The intervention group reduced their total calorie intake, cholesterol, and per cent fat intake, including reduced saturated fats, and increased their carbohydrate and fibre consumption. The result was reduced weight gain, fat redistribution, and lipid abnormalities in the first year on antiretroviral treatment. This should translate into lower risk of cardiovascular events and serve as good advice for us all.

Brazil
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