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      The HIV epidemic in Latin America: accomplishments and challenges on treatment and prevention

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          Abstract

          Purpose of review

          To describe how countries in Latin America and the Caribbean are (or are not) meeting 2016 WHO guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, that is, their progress on the adoption of ‘Treat All’ and of preexposure prophylaxis (PrEP) as an additional prevention tool for people at substantial risk of HIV infection.

          Recent findings

          The HIV epidemic in the region continues largely concentrated in vulnerable populations with MSM and transgender women (TGW) suffering the highest burden. On treatment, the challenges of late initiation as well as suboptimal adherence persist. On prevention, recent studies on PrEP willingness in key populations show promising results, meanwhile PrEP implementation projects as well as actual PrEP adoption by national health systems is expanding. A glimpse of real-world PrEP uptake is shown through Brazil's first-year experience of offering PrEP in multiple cities in all regions of the country.

          Summary

          In conclusion, accomplishments have been made though challenges for fully addressing the HIV epidemic persist. The impact of both treatment and PrEP will be limited by the availability and prompt use of all services, including HIV testing.

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          Most cited references41

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          The increase in global HIV epidemics in MSM.

          Epidemics of HIV in MSM continue to expand in most low, middle, and upper income countries in 2013 and rates of new infection have been consistently high among young MSM. Current prevention and treatment strategies are insufficient for this next wave of HIV spread. We conducted a series of comprehensive reviews of HIV prevalence and incidence, risks for HIV, prevention and care, stigma and discrimination, and policy and advocacy options. The high per act transmission probability of receptive anal intercourse, sex role versatility among MSM, network level effects, and social and structural determinants play central roles in disproportionate disease burdens. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiologic data show marked clustering of HIV in MSM networks, and high proportions of infections due to transmission from recent infections. Prevention strategies that lower biological risks, including those using antiretrovirals, offer promise for epidemic control, but are limited by structural factors including, discrimination, criminalization, and barriers to healthcare. Subepidemics, including among racial and ethnic minority MSM in the United States and UK, are particularly severe and will require culturally tailored efforts. For the promise of new and combined bio-behavioral interventions to be realized, clinically competent healthcare is necessary and community leadership, engagement, and empowerment are likely to be key. Addressing the expanding epidemics of HIV in MSM will require continued research, increased resources, political will, policy change, structural reform, community engagement, and strategic planning and programming, but it can and must be done.
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            HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling

            Abstract This paper reports human immuno-deficiency virus (HIV) prevalence in the 2nd National Biological and Behavioral Surveillance Survey (BBSS) among men who have sex with men (MSM) in 12 cities in Brazil using respondent-driven sampling (RDS). Following formative research, RDS was applied in 12 cities in the 5 macroregions of Brazil between June and December 2016 to recruit MSM for BBSS. The target sample size was 350 per city. Five to 6 seeds were initially selected to initiate recruitment and coupons and interviews were managed online. On-site rapid testing was used for HIV screening, and confirmed by a 2nd test. Participants were weighted using Gile estimator. Data from all 12 cities were merged and analyzed with Stata 14.0 complex survey data analysis tools in which each city was treated as its own strata. Missing data for those who did not test were imputed HIV+ if they reported testing positive before and were taking antiretroviral therapy. A total of 4176 men were recruited in the 12 cities. The average time to completion was 10.2 weeks. The longest chain length varied from 8 to 21 waves. The sample size was achieved in all but 2 cities. A total of 3958 of the 4176 respondents agreed to test for HIV (90.2%). For results without imputation, 17.5% (95%CI: 14.7–20.7) of our sample was HIV positive. With imputation, 18.4% (95%CI: 15.4–21.7) were seropositive. HIV prevalence increased beyond expectations from the results of the 2009 survey (12.1%; 95%CI: 10.0–14.5) to 18.4%; CI95%: 15.4 to 21.7 in 2016. This increase accompanies Brazil's focus on the treatment to prevention strategy, and a decrease in support for community-based organizations and community prevention programs.
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              Changing Mortality Profile among HIV-Infected Patients in Rio de Janeiro, Brazil: Shifting from AIDS to Non-AIDS Related Conditions in the HAART Era

              Introduction We describe temporal trends in the mortality rates and factors associated with AIDS and non-AIDS related mortality at the Evandro Chagas Clinical Research Institute (IPEC), Oswaldo Cruz Foundation (FIOCRUZ). Methods Adult patients enrolling from 1986 through 2009 with a minimum follow up of 60 days were included. Vital status was exhaustively checked using patients’ medical charts, through active contact with individuals and family members and by linkage with the Rio de Janeiro Mortality database using a previously validated algorithm. The CoDe protocol was used to establish the cause of death. Extended Cox proportional hazards models were used for multivariate modeling. Results A total of 3530 individuals met the inclusion criteria, out of which 868 (24.6%) deceased; median follow up per patient was 3.9 years (interquartile range 1.7–9.2 years). The dramatic decrease in the overall mortality rates was driven by AIDS-related causes that decreased from 9.19 deaths/100PYs n 1986–1991 to 1.35/100PYs in 2007–2009. Non-AIDS related mortality rates remained stable overtime, at around 1 death/100PYs. Immunodeficiency significantly increased the hazard of both AIDS-related and non-AIDS-related causes of death, while HAART use was strongly associated with a lower hazard of death from either cause. Conclusions Our results confirm the remarkable decrease in AIDS-related mortality as the HIV epidemic evolved and alerts to the conditions not traditionally related to HIV/AIDS which are now becoming more frequent, needing careful monitoring.
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                Author and article information

                Journal
                Curr Opin HIV AIDS
                Curr Opin HIV AIDS
                COHIV
                Current Opinion in HIV and AIDS
                Lippincott Williams & Wilkins
                1746-630X
                1746-6318
                September 2019
                12 July 2019
                : 14
                : 5
                : 366-373
                Affiliations
                Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
                Author notes
                Correspondence to Beatriz Grinsztejn, MD, PhD, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365, Rio de Janeiro 21040-360, Brazil. Tel/. fax: +55 21 2270 7064; e-mail: gbeatriz@ 123456ini.fiocruz.br
                Article
                COH140506 00005
                10.1097/COH.0000000000000564
                6688714
                31219888
                144ec4a2-e684-4562-9720-2b40b38a3f05
                Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

                History
                Categories
                CONCENTRATED EPIDEMICS: Edited by Sheena McCormack, Rachel Baggaley and Kevin M. DeCock
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                epidemiology,hiv/aids,latin america,preexposure prophylaxis,treatment as prevention

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