Publications by authors named "Sheila Araújo Teles"

61 Publications

Travestis and transsexual women: who are at higher risk for sexually transmitted infections?

Rev Bras Epidemiol 2021 3;24:e210017. Epub 2021 May 3.

Faculdade de Enfermagem, Universidade Federal de Goiás - Goiânia (GO), Brazil.

Objective: To compare social characteristics, risk behaviors, and sexually transmitted infections among travestis and transsexual women.

Methodology: A cross-sectional study was carried out in three cities in Goiás, Central Brazil. Trans women were interviewed on sociodemographic characteristics, discrimination, prejudice, sexual behavior, illicit drugs, and previous testing for HIV and syphilis between April 2018 and August 2019.

Results: A total of 166 travestis and 249 transsexual women were investigated. Although sexual, physical, and verbal violence were common to both groups, sexual behavior, use of illicit drugs, prison, and previous positive HIV and syphilis testing were more frequent among travestis than in transsexual women.

Conclusion: The present findings confirm that Brazilian travestis are at greater risk for sexually transmitted infections (STI), indicating that health services should take this imbalance into account in terms of health intervention proportions.
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http://dx.doi.org/10.1590/1980-549720210017DOI Listing
May 2021

Epidemiological and Molecular Characteristics of HIV-1 Infection in a Sample of Men Who Have Sex With Men in Brazil: Phylogeography of Major Subtype B and F1 Transmission Clusters.

Front Microbiol 2020 27;11:589937. Epub 2020 Nov 27.

Institute of Tropical Pathology and Public Health, Federal University of Goiás, Goiânia, Brazil.

This study describes human immunodeficiency virus 1 (HIV-1) prevalence, associated factors, viral genetic diversity, transmitted drug resistance (TDR), and acquired drug resistance mutations (DRM) among a population of 522 men who have sex with men (MSM) recruited by the respondent-driven sampling (RDS) method, in Goiânia city, the capital of the State of Goiás, Central-Western Brazil. All serum samples were tested using a four-generation enzyme-linked immunosorbent assay (ELISA), and reactive samples were confirmed by immunoblotting. Plasma RNA or proviral DNA was extracted, and partial () gene including the protease/reverse transcriptase (PR/RT) region was amplified and sequenced. HIV-1 subtypes were identified by phylogenetic inference and by bootscan analysis. The time and location of the ancestral strains that originated the transmission clusters were estimated by a Bayesian phylogeographic approach. TDR and DRM were identified using the Stanford databases. Overall, HIV-1 prevalence was 17.6% (95% CI: 12.6-23.5). Self-declared black skin color, receptive anal intercourse, sex with drug user partner, and history of sexually transmitted infections were factors associated with HIV-1 infection. Of 105 HIV-1-positive samples, 78 (74.3%) were sequenced and subtyped as B (65.4%), F1 (20.5%), C (3.8%), and BF1 (10.3%). Most HIV-1 subtype B sequences (67%; 34 out of 51) branched within 12 monophyletic clusters of variable sizes, which probably arose in the State of Goiás between the 1980s and 2010s. Most subtype F1 sequences ( = 14, 88%) branched in a single monophyletic cluster that probably arose in Goiás around the late 1990s. Among 78 samples sequenced, three were from patients under antiretroviral therapy (ART); two presented DRM. Among 75 ART-naïve patients, TDR was identified in 13 (17.3%; CI 95%: 9.6-27.8). Resistance mutations to non-nucleoside reverse transcriptase inhibitors (NNRTI) predominated (14.7%), followed by nucleoside reverse transcriptase inhibitor (NRTI) mutations (5.3%) and protease inhibitor (PI) mutations (1.3%). This study shows a high prevalence of HIV-1 associated with sexual risk behaviors, high rate of TDR, and high genetic diversity driven by the local expansion of different subtype B and F1 strains. These findings can contribute to the understanding about the dissemination and epidemiological and molecular characteristics of HIV-1 among the population of MSM living away from the epicenter of epidemics in Brazil.
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http://dx.doi.org/10.3389/fmicb.2020.589937DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732656PMC
November 2020

Human immunodeficiency virus infection and syphilis among homeless people in a large city of Central-Western Brazil: prevalence, risk factors, human immunodeficiency virus-1 genetic diversity, and drug resistance mutations.

Braz J Infect Dis 2021 Jan-Feb;25(1):101036. Epub 2020 Nov 25.

Universidade Federal de Goiás (UFG), Faculdade de Enfermagem, Goiânia, GO, Brazil. Electronic address:

Homeless people are at high risk for sexually transmitted infections (STIs), such as human immunodeficiency virus (HIV) infection and syphilis. We investigated the epidemiology of HIV-1 infection and syphilis among homeless individuals in a large city in Central-Western Brazil. In this cross-sectional study, we interviewed and tested 355 individuals from September 2014 to August 2015. Rapid test samples positive for syphilis were retested using the Venereal Disease Research Laboratory (VDRL) test. Blood samples from HIV-infected participants were collected for POL sequencing using HIV-1 RNA extracted from plasma, reverse transcription, and nested polymerase chain reaction. Anti-HIV-1-positive samples were subtyped by sequencing the nucleotides of HIV-1 protease and part of the HIV-1 reverse transcriptase genes. Transmitted and acquired drug resistance mutations and susceptibility to antiretroviral drugs were also analyzed. Anti-HIV was positive in 14 patients (3.9%; 95% confidence interval [CI]: 2.3-6.4). HIV-1 RNA was detected in 8 of the 14 samples. Two of the eight (25%) isolates showed HIV-1 drug resistance mutations. Furthermore, 78 (22%; 95% CI: 17.9-26.5) and 29 (8.2%; 95% CI: 5.6-11.4) homeless individuals tested positive for syphilis using the rapid test and VDRL test, respectively. Two individuals were anti-HIV-1 and VDRL test positive. Daily alcohol use (adjusted odds ratio [AOR]: 3.2, 95% CI: 1.0-10.4), sex with people living with HIV (PLWH) infection (AOR: 6.8, 95% CI: 1.9-25.0), and sex with people of the same sex (AOR: 5.4, 95% CI: 1.7-17.5) were predictors of HIV infection. Age ≤35 years (AOR: 3.8, 95% CI: 1.4-10.8), previous syphilis testing (AOR: 3.5, 95% CI: 1.4-8.4), history of genital lesions (AOR: 4.9, 95% CI: 1.3-19.1), and crack use in the last six months (AOR: 3.1, 95% CI: 1.3-7.6) were predictors of syphilis. Our findings highlight the importance of STI prevention and control strategies among the homeless.
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http://dx.doi.org/10.1016/j.bjid.2020.11.001DOI Listing
March 2021

Factors associated with the use and reuse of face masks among Brazilian individuals during the COVID-19 pandemic.

Rev Lat Am Enfermagem 2020 Sep 7;28:e3360. Epub 2020 Sep 7.

Universidade Federal da Paraíba, Departamento de Enfermagem Clinica, João Pessoa, PB, Brazil.

Objective: to identify the factors associated with the use and reuse of masks among Brazilian individuals in the context of the COVID-19 pandemic.

Method: cross-sectional study conducted in the five Brazilian regions, among adult individuals, via an electronic form disseminated in social media, addressing general information and the use of masks. Bivariate analysis and binary logistic regression were used to identify the factors associated with the use and reuse of masks.

Results: 3,981 (100%) individuals participated in the study. In total, 95.5% (CI 95%: 94.8-96.1) reported using masks. Fabric masks were more frequently reported (72.7%; CI 95%: 71.3-74.1), followed by surgical masks (27.8%; CI 95%: 26.5-29.2). The percentage of reuse was 71.1% (CI 95%: 69.7-72.5). Most (55.8%; CI 95%: 51.7-60.0) of those exclusively wearing surgical masks reported its reuse. Being a woman and having had contact with individuals presenting respiratory symptoms increased the likelihood of wearing masks (p≤0.001). Additionally, being a woman decreased the likelihood of reusing surgical masks (p≤0.001).

Conclusion: virtually all the participants reported the use of masks, most frequently fabric masks. The findings draw attention to a risky practice, that of reusing surgical and paper masks. Therefore, guidelines, public policies, and educational strategies are needed to promote the correct use of masks to control and prevent COVID-19.
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http://dx.doi.org/10.1590/1518-8345.4604.3360DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478877PMC
September 2020

High prevalence of Hepatitis C Virus infection among people who use crack cocaine in an important international drug trafficking route in Central-West Region Brazil.

Infect Genet Evol 2020 11 31;85:104488. Epub 2020 Jul 31.

Federal University of Mato Grosso do Sul, Avenida Senador Filinto Mueller, s/n, Laboratório de Imunologia Clínica, FACFAN, Campo Grande, MS 79070-900, Brazil; Oswaldo Cruz Foundation, Rua Gabriel Abrão, 92 - Jardim das Nações, Campo Grande, MS 79081-746, Brazil.

In this study, the prevalence rate, associated risk factors and genetic diversity of hepatitis C virus (HCV) infection were determined among people who use crack from an international drug trafficking route in Central-West, Brazil. Blood samples were collected from 700 users of crack from Campo Grande and two border cities of Mato Grosso do Sul State and tested for HCV infection using serological and molecular testing methodologies. Anti-HCV was detected in 31/700 (4.5%, 95% CI: 2.9-6.0%) and HCV RNA in 26/31 (83.9%) of anti-HCV positive samples. Phylogenetic analysis of three HCV sub-genomic regions (5'UTR, NS5B and HVR-1) revealed the circulation of 1a (73.9%), 1b (8.7%) and 3a (17.4%) genotypes. Next-generation sequencing and phylogenetic analysis of intra-host viral populations of HCV HVR-1 showed a significant variation in intra-host genetic diversity among infected individuals, with 58.8% composed of more than one sub-population. Bayesian analysis estimated that the most recent common HCV ancestor for strains identified here was introduced to this region after 1975 following expansion of intravenous drug use in Brazil. Multivariate analyses showed that only 'ever having injected drugs' was independently associated with HCV infection. These results indicate an increasing spread of multiple HCV strains requiring public health intervention, such as harm reduction, testing services and treatment among crack users in this important border region of Central Brazil.
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http://dx.doi.org/10.1016/j.meegid.2020.104488DOI Listing
November 2020

Factors associated with sexually transmitted infections in sugarcane cutters: subsidies to caring for.

Rev Lat Am Enfermagem 2020 19;28:e3306. Epub 2020 Jun 19.

Universidade Federal da Paraíba, Departamento de Enfermagem Clínica, João Pessoa, PB, Brazil.

Objective: to estimate the prevalence of Sexually Transmitted Infections (STIs) and associated factors in sugarcane cutters.

Method: a cross-sectional, analytical study with 937 sugarcane cutters from Paraíba and Goiás, states of Brazil, respectively. An outcome variable was the positive results in some rapid tests for HIV, syphilis, hepatitis B and C. Bivariate and multiple analyses were performed to identify the association between these infections and sociodemographic and behavioral variables.

Results: all participants were male, most were young adults and had low schooling. Prevalence of STI was estimated at 4.1% (95% CI: 3.0-5.5). According to multiple regression analysis, the variables age over 40 years (OR 5.0; CI 95%: 1.8-14), alcohol consumption (OR 3.9; CI 95%: 1.3-11.9), and illicit drugs (OR 2.9; CI 95%: 1.3-6.3) were factors associated with the STIs investigated. On the other hand, having some religion (OR 0.4; CI 95%: 0.2-0.8), and work in the Midwest Region (OR 0.4; CI 95%: 0.2-0.9) were factors negatively associated with these infections.

Conclusion: presence of risk behaviors for STI among sugarcane cutters. Screening for these infections in groups of rural workers is essential for early diagnosis and breaking the chain of transmission.
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http://dx.doi.org/10.1590/1518-8345.3425.3306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7304989PMC
June 2020

Human papillomavirus and Chlamydia trachomatis infections in adolescents and young women: Prevalence and risk factors.

Diagn Cytopathol 2020 Aug 7;48(8):736-744. Epub 2020 May 7.

Institute of Tropical Pathology and Public Health, Federal University of Goiás, Goiânia, Brazil.

Background: The objective of this study was to estimate the prevalence of Human papillomavirus (HPV) genotypes and Chlamydia trachomatis (CT) infections among adolescents and young adult women and to identify the risk factors associated.

Methods: This study included 276 sexually active participants, classified as adolescents (15-19 years) and young adult women (20-24 years) that realized conventional cytology and were tested for 27 HPV genotypes and for CT. Bivariate and multivariate analyses were performed to evaluate the factors associated with both infections.

Results: The prevalence of HPV infection was 50.7% in adolescents and 43.0% in young adult women. The HPV-16 was the most prevalent (27.7%), followed by HPV-68 (6.9%), HPV-52 (6.2%), HPV-39 (4.6%), and HPV-73 (4.6%). The prevalence of CT infection was 11.5% among adolescents and 6.2% among young adult women. Cytological abnormalities were found in 14.2% among adolescents, of which 80.9% were positive for HPV and 10% of young adult women of which 84.6% were positive for HPV infection. HPV16 and HPV 68 were detected in 35.7% and 32.1% of cases with cytological abnormalities. Factors independently associated with HPV infection obtained by multivariate analysis were unmarried or divorced marital status and the presence of cytological abnormalities. The same variables were analyzed for the association with CT infection, and the association with cytological abnormalities remained significant.

Conclusion: HPV and CT infections are very prevalent in adolescent and young adult women; these findings reinforce the need of early vaccination, prior to the onset of sexual activity, and justify implementation of molecular screening tests.
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http://dx.doi.org/10.1002/dc.24460DOI Listing
August 2020

Molecular and epidemiological aspects of hepatitis C virus infection among crack cocaine users.

J Med Virol 2020 08 2;92(8):1239-1245. Epub 2019 Dec 2.

Institute of Tropical Pathology and Public Health, Federal University of Goiás (UFG), Goiás, Brazil.

The aim is to investigate the prevalence, risk factors, and hepatitis C virus (HCV) genotypes/subtypes among crack users in-treatment in Central Brazil. A cross-sectional survey in which 600 in-treatment crack users were interviewed and tested for anti-HCV Ab by enzyme-linked immunosorbent assay was conducted between August 2012 and April 2013. Anti-HCV-positive samples were also submitted for HCV RNA detection by polymerase chain reaction. Positive HCV RNA samples were genotyped by direct sequencing analysis of the NS5B region of the viral genome, followed by phylogenetic analysis. Of the total, 3.7% (95.0% CI, 2.4%-5.6%) were anti-HCV positive. Age over 40 years and history of injecting drugs were risk factors for HCV, while snorting cocaine was a protector variable. HCV RNA was detected in 14 of 22 anti-HCV-positive samples, and the genotypes 1 (n = 10) and 3 (n = 2), subtypes 1a (n = 7), 1b (n = 3), and 3a (n = 2) were identified. The HCV prevalence found among crack users is almost threefold that observed in the general population in Brazil supporting that this population is at higher risk for HCV. The findings of cocaine insufflation as a protective behavior for HCV infection in this population should be explored.
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http://dx.doi.org/10.1002/jmv.25632DOI Listing
August 2020

Screening for HBV, HCV, HIV and syphilis infections among bacteriologically confirmed tuberculosis prisoners: An urgent action required.

PLoS One 2019 22;14(8):e0221265. Epub 2019 Aug 22.

Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil.

Viral hepatitis, syphilis, HIV, and tuberculosis infections in prisons have been identified globally as a public health problem. Tuberculosis (TB) and viral hepatitis co-infection may increase the risk of anti-tuberculosis treatment-induced hepatotoxicity, leading to the frequent cause of discontinuation of the first-line anti-tuberculosis drugs. Therefore, the aim of this cross-sectional study was to investigate the epidemiological features of HCV, HBV, syphilis and HIV infections among bacteriologically confirmed tuberculosis prisoners in Campo Grande (MS), Central Brazil. The participants who agreed to participate (n = 279) were interviewed and tested for the presence of active or current HCV, HBV, syphilis and HIV infections. The prevalence of HCV exposure was 4.7% (13/279; 95% CI 2.2-7.1). HCV RNA was detected in 84.6% (11/13) of anti-HCV positive samples. Out of 279 participants, 19 (6.8%; 95% CI 4.4-10.4) were HIV co-infected, 1.4% (4/279, 95% CI 0.5-3.8) had chronic hepatitis B virus (HBsAg positive) and 9.3% (26/279, 95% CI 6.4-13.4) had serological marker of exposure to hepatitis B virus (total anti-HBc positive). The prevalence of lifetime syphilis infection (anti-T. pallidum positive) was 10% (28/279, 95% CI 7.0-14.2) and active syphilis (VDRL ≥ 1/8 titre) was 5% (14/279, 95% CI 2.9-8.3). The prevalence of TB/HCV co-infection among prisoners with HIV (15.8%) was higher than among HIV-non-infected prisoners (3.8%; P<0.05). These results highlight the importance of hepatitis testing among prisoners with bacteriologically confirmed case of TB who can be more effectively and safely treated in order to reduce the side effects of hepatotoxic anti-TB drugs.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221265PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6705821PMC
March 2020

Factors Associated with Marital Satisfaction and Quality of Life in Family Caregivers of Patients with Mental Disorders.

Int J Environ Res Public Health 2019 08 8;16(16). Epub 2019 Aug 8.

Faculty of Nursing, Federal University of Goias, Goiânia 74605-080, Brazil.

(1) Background: The aim of this research was to analyze factors associated with quality of life (QoL) and marital satisfaction in married family caregivers of patients with mental disorders. (2) Methods: A cross-sectional study was conducted in all community mental health services in Goiania municipality, Brazil, in 2016-2017. Married family caregivers of patients with severe and persistent mental disorders were recruited and their QoL and marital satisfaction was assessed by using the World Health Organization Quality of Life Instrument Abbreviated version (WHOQOL-BREF) and Marital Satisfaction Scale. Multiple linear regressions were performed to identify factors associated with QoL and marital satisfaction. (3) Results: For 163 family caregivers, the psychological and environmental QoL domains presented the best and the worst scores, respectively. Factors independently associated with better QoL for caregivers were male caregiver, the younger age of a caregiver, >8 years of schooling, ≥5 years as a caregiver who performed physical activities, caregiver without chronic disease, and no patient's crisis in the last 30 days. Factors independently associated with marital satisfaction of the caregiver were male caregiver, caregiver with >8 years of schooling, caregiver who received support by relatives to care for the patient, caregiver who performed physical activities, no patient's crisis in the last 30 days, and patient hospitalization in the last six months; (4) Conclusions: The main predictor for marital satisfaction was support by relatives, and for QoL it was no patient's crisis in the last 30 days.
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http://dx.doi.org/10.3390/ijerph16162825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6719212PMC
August 2019

Hepatitis C prevalence among men who have sex with men in Central Brazil.

Braz J Infect Dis 2019 Jul - Aug;23(4):271-273. Epub 2019 Jul 22.

Federal University of Goiás, Institute of Tropical Pathology and Public Health, Goiânia, GO, Brazil. Electronic address:

To assess the prevalence of hepatitis C virus infection among men who have sex with men (MSM) in Central Brazil, a cross-sectional study was conducted in the City of Goiânia, Central Brazil, using Respondent-Driven Sampling (RDS). All serum samples were tested for anti-HCV and also for alanine aminotransferase (ALT). Anti-HCV positive samples and/or those with elevated ALT were tested for HCV RNA and genotyped. Of the 522 participants, four were found to be anti-HCV positive, and one was also HCV RNA positive (active HCV infection). Elevated ALT was found in 14 individuals. Of these, one showed evidence of acute HCV infection (HCV RNA positive and anti-HCV negative). Therefore, five MSM were positive for either anti-HCV and/or HCV RNA, giving a crude overall HCV prevalence of 1.0%; 1.3% (95% CI: 0.3-5.5) after being weighted by RDSAT. All five individuals reported high-risk sexual behaviors, including two who showed evidence of active HCV infection (genotype 1, subtypes 1a and 1b). Although the study population reported high-risk sexual practices, HCV infection was not more frequent in MSM than in the general Brazilian population.
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http://dx.doi.org/10.1016/j.bjid.2019.06.008DOI Listing
October 2019

Hepatitis B virus infection among oncohematologic disease patients in Central Brazil: prevalence, risk factors and immunization.

Hematol Transfus Cell Ther 2019 Jul - Sep;41(3):199-204. Epub 2019 Mar 28.

Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil. Electronic address:

Introduction: Carriers of oncohematological diseases are at high risk for hepatitis B virus (HBV) infection.

Objective And Method: To investigate the epidemiology of HBV infection in Goiânia, Central Brazil, 322 individuals with oncohematological diseases (leukemias, Hodgkin lymphoma and non-Hodgkin lymphoma) were interviewed and blood samples were collected for the detection of serological markers of HBV-DNA by polymerase chain reaction (PCR). Medical records of participants were also reviewed.

Results: Non-Hodgkin's lymphomas (n=99) and chronic myeloid leukemia (n=108) were the most frequent oncohematological diseases. The overall prevalence of HBV was 13.97% (45/322). Of the total participants, 8.69% (28/322) presented isolated positivity for anti-HBs, suggesting low vaccine coverage. HBV-DNA was detected in 25% (1/4) of HBsAg positive samples and in 25% (3/12) of anti-HBc isolated, suggesting HBV occult infection. All samples were identified as subgenotype A1. Entries in patient records and the findings of this investigation suggest anti-HBc seroconversion during oncologic treatment. Age 50 years or over and use of a central catheter during therapy were associated with HBV exposure.

Conclusion: The low frequency of hepatitis B immunized individuals, detection of HBV DNA in HBsAg negative samples, and the suggestion of HBV exposure during treatment evidenced the potential for health-related viral dissemination in people with oncohematological diseases in our region, reinforcing the importance of serological monitoring, vaccination against hepatitis B, and adoption of strict infection control measures in these individuals.
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http://dx.doi.org/10.1016/j.htct.2018.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732398PMC
March 2019

Epidemiology of HIV, syphilis, and hepatitis B and C among manual cane cutters in low-income regions of Brazil.

BMC Infect Dis 2018 Nov 3;18(1):546. Epub 2018 Nov 3.

Faculty of Nursing, Federal University of Goias/Universidade Federal de Goiás, Goiânia, GO, Brazil.

Background: In recent decades the epidemic of asymptomatic sexually transmitted infections has extended deep into Brazil, including small towns and rural areas. The purpose of this study was to investigate the epidemiology of HIV, syphilis, and hepatitis B (HBV) and hepatitis C viruses (HCV), and to evaluate immunization coverage against hepatitis B in a group of rural workers in Brazil.

Methods: In 2016, a cross-sectional study was conducted with 937 manual sugarcane cutters of the Midwest and Northeast Regions of Brazil. All individuals were interviewed and screened for HIV, syphilis, HBV and HCV. Correlating factors with lifetime HBV infection were investigated using logistic regression. Positive Predictive Values, Negative Predictive Values, sensitivity and specificity were also calculated relative to vaccination against Hepatitis B, comparing anti-HBs titers to vaccination reports.

Results: Most reported previous hospitalization (55%), occupational injuries (54%), sharing of personal items (45.8%), alcohol consumption (77.2%), multiple sexual partners in previous 12 months (39.8%), and no condom use during sexual intercourse in last 12 months (46.5%). Only 0.2% reported using injection drugs. Anti-HIV-1 was detected in three individuals (0.3%). Serological markers of lifetime syphilis (treponemal test) were detected in 2.5% (95% CI: 1.6-3.6) of participants, and active syphilis (treponemal test and VDRL) present in 1.2%. No samples were positive for anti-HCV. The prevalence of lifetime HBV infection (current or past infection) was 15.9%, and 0.7% (95% CI 0.4 to 1.5) were HBsAg-positive. Previous hospitalization (OR 1.53, CI 1.05-2.24, p < 0.01) and multiple sexual partners in the last 12 months (OR 1.80, CI 1.25-2.60, p < 0.01) were predictors for lifetime HBV infection. Although 46.7% (95% CI 43.4-49.9) of individuals reported having been vaccinated against hepatitis B, only 20.6% (95% CI 18.1-23.3) showed serological evidence of previous hepatitis B vaccination (positive for anti-HBs alone).

Conclusions: The high prevalence of syphilis and HBV compared to the general population and the high frequency of risk behaviors show the potential for sexual and parenteral dissemination of these agents in this rural population. In addition, the low frequency of hepatitis B vaccinated individuals suggests a need for improved vaccination services.
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http://dx.doi.org/10.1186/s12879-018-3439-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6215621PMC
November 2018

Symptomatic Sexually Transmitted Infections in Brazil's Emerging Rural Populations.

J Assoc Nurses AIDS Care 2018 Nov - Dec;29(6):942-948. Epub 2018 May 26.

We used a cross-sectional study in 2011 to estimate prevalence and risk behaviors for self-reported symptomatic sexually transmitted infections (STI) in rural settlers in Midwestern Brazil. There were 353 individuals recruited who had been living in the settlement for more than 6 months. The endpoint variable was having reported vaginal discharge, urethral discharge, genital ulcers, or anogenital warts in the previous 12 months. Univariate and multivariate Poisson regressions were performed to identify STI correlates. A prevalence of 22.4% of self-reported symptomatic STI was found. Being female, homosexual, and/or having lived in camps were associated with self-report of STI (p < .05). The high prevalence of self-reported symptomatic STI among settlers suggested that this was a key population in the epidemiology of STI in rural regions and demands the strengthening of health promotion actions in this vulnerable population, especially for women, homosexuals, and those who previously lived in camps.
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http://dx.doi.org/10.1016/j.jana.2018.05.004DOI Listing
August 2019

Decline in hepatitis B and C prevalence among hemodialysis patients in Tocantins, Northern Brazil.

Rev Inst Med Trop Sao Paulo 2018 Jul 30;60:e36. Epub 2018 Jul 30.

Universidade Federal de Goiás, Instituto de Patologia Tropical e Saúde Pública, Goiânia, Goiás, Brazil.

Infection control measures have been responsible for a decline in the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in hemodialysis patients. In Brazil, these measures have been in place since 1996. The aim of this study was to evaluate the current HBV and HCV epidemiology among hemodialysis patients in the State of Tocantins comparing them with those found 14 years ago. There was a significant decline in hepatitis B surface antigen (HBsAg) and anti-HCV prevalence from 4% and 13% in 2001 to 0.8% and 2.8% in 2014-2015, respectively (p < 0.05). Variables related to hemodialysis environment such as working shift and length of time on hemodialysis treatment were no longer associated to HCV and HBV exposure in 2014-2015. A high prevalence of self-reported hepatitis B vaccination was observed in both periods, but only 30% of the individuals showed serological profile of effective previous immunization, suggesting a low compliance with surveillance of hepatitis B immunization in hemodialysis centers. The significant decline in viral hepatitis B and C prevalence in hemodialysis patients in Tocantins underscores the importance of infection control measures, but the low frequency of protective serological profile after immunization against hepatitis B points to the need for greater vigilance of the patients' vaccination.
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http://dx.doi.org/10.1590/S1678-9946201860036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069268PMC
July 2018

HIV-1 infection among crack cocaine users in a region far from the epicenter of the HIV epidemic in Brazil: Prevalence and molecular characteristics.

PLoS One 2018 17;13(7):e0199606. Epub 2018 Jul 17.

Faculty of Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil.

Brazil has the largest cocaine market in South America, and crack cocaine use is closely associated with HIV-1 infection. This study investigated the prevalence, risk factors, and HIV-1 subtypes, including recombinant forms and mutations associated with drug resistance, among crack cocaine users in Central-West Brazil. We recruited 600 crack cocaine users admitted to a referral hospital in Goiânia for psychiatric disorders. The participants were interviewed; blood samples were collected for anti-HIV-1/2 serological screening. HIV-1 pol gene sequences (entire protease [PR] and partial reverse transcriptase [RT]) were obtained from plasma RNA. HIV-1 subtypes, recombinant viruses, transmitted drug resistance (TDR), and secondary drug resistance mutations were investigated. The median participant age was 30 years (range, 18-68 years); most were male, single, unemployed, and of mixed races. Among them, 2.8% (17/600) were HIV-1 positive: 2.2% of men (11/507) and 6.5% of women (6/93). The main predictors of HIV-1 seropositivity were a sexual partner with HIV infection, irregular condom use, and previous homelessness. HIV-1 pol sequences (12/17) indicated the predominance of subtype B (n = 7), followed by recombinant forms FPR/BRT (n = 1) and BPR/FRT (n = 2) and subtypes F1 (n = 1) and C (n = 1). TDR prevalence was 58.3% (7/12). Isolates from two participants showed mutations associated with resistance to nucleoside reverse transcriptase inhibitors (NRTI) only (M41L, T125C, T125F, M184V), while an isolate from one patient who had received antiretroviral therapy (ART) since 2008 had a mutation associated with resistance to non-NRTI (G190S). Five isolates had secondary mutations to protease inhibitors (K20M, L10V, L33I, A71T, A71V). In conclusion, the findings of HIV-1 circulation, TDR to NRTI, and secondary mutations to protease inhibitors in ART-naïve crack cocaine users support the importance of monitoring this population in regions far from the epicenter of the HIV epidemic.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199606PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6049907PMC
January 2019

High-risk behaviors for hepatitis B and C infections among female sex workers.

Rev Soc Bras Med Trop 2018 Mar-Apr;51(2):198-202

Laboratório de Imunologia Clínica, Faculdade de Ciências Farmacêuticas, Alimentos e Nutrição, Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brasil.

Introduction: The prevalence of hepatitis B and hepatitis C and risk behaviors among 402 female sex workers in Central Brazil were investigated by respondent-driven sampling.

Methods: Blood samples were tested for hepatitis B and C markers by enzyme-linked immunosorbent assay. Two hepatitis B vaccination schedules were performed.

Results: The prevalence of hepatitis B and C infections were 9.3% and 0.5%, respectively. Susceptibility to hepatitis B infection was observed in 61.5% of subjects. There was no significant difference in adherence index (p=0.52) between vaccination schedules and all participants had protective antibody titers.

Conclusions: This hard-to-reach population requires hepatitis B and C surveillance.
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http://dx.doi.org/10.1590/0037-8682-0231-2017DOI Listing
May 2018

Use of illicit drugs by adolescents and young adults of an urban settlement in Brazil.

Rev Assoc Med Bras (1992) 2018 Feb;64(2):114-118

Faculty of Nursing, Universidade Federal de Goiás, Goiânia, GO, Brazil.

Objective: To estimate the prevalence and factors associated with illicit drug use by adolescents and young adults of a formal urban settlement.

Method: Cross-sectional study including adolescents and young adults 12-24 years of an urban settlement in the Midwest Region of Brazil. Data were collected using a structured questionnaire and analyzed using Stata, version 12.0. We used Poisson regression model to estimate the factors associated with illicit drug use.

Results: Of the total participants (n=105), 27.6% (95CI 20.0-36.9%) had used illicit drugs such as marijuana, cocaine, crack, LSD and inhalants. The consumption of these substances was associated with male gender, use of body piercing and/or tattoos, licit drug use and self-report of signs and/or symptoms of sexually transmitted infections.

Conclusion: High prevalence of illicit drug use was found in the individuals investigated, ratifying the presence of risk factors to the vulnerability of the settlers to use these substances in the urban settlement population.
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http://dx.doi.org/10.1590/1806-9282.64.02.114DOI Listing
February 2018

Prevalence of hepatitis E virus RNA and antibodies in a cohort of kidney transplant recipients in Central Brazil.

Int J Infect Dis 2018 Apr 10;69:41-43. Epub 2018 Feb 10.

Institute of Tropical Pathology and Public Health, Federal University of Goiás, Goiânia, Goiás, Brazil. Electronic address:

Objective: To assess the prevalence of hepatitis E virus (HEV) RNA and antibodies among kidney transplant recipients (KTR) in Central Brazil. The presence of chronic HEV infection was also investigated.

Methods: A cohort study was conducted among 316 KTR treated at a referral center for kidney transplantation in Goiânia, Brazil. All serum samples were tested for the presence of HEV RNA (real-time PCR) and anti-HEV IgG/IgM (ELISA). Anti-HEV-positive samples were confirmed using an immunoblot test. HEV chronicity was investigated in a subgroup of patients with elevated alanine aminotransferase (ALT >40IU/l) through HEV RNA detection in additional serum samples collected 3 and 6 months apart.

Results: A seroprevalence of 2.5% (95% confidence interval 1.2-5.1%) was found for anti-HEV IgG. There was no difference in characteristics between the anti-HEV IgG seropositive and seronegative KTR groups. Anti-HEV IgM was detected in only one patient (0.3%). All KTR were negative for HEV RNA.

Conclusions: These results show that HEV infection is infrequent in KTR in Central Brazil, with low seroprevalence rates of past and recent infection, and also an absence of active and chronic HEV infections.
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http://dx.doi.org/10.1016/j.ijid.2018.01.032DOI Listing
April 2018

Gender differences in patterns of drug use and sexual risky behaviour among crack cocaine users in Central Brazil.

BMC Psychiatry 2017 12 28;17(1):412. Epub 2017 Dec 28.

Faculty of Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil.

Background: The aim of this study was to compare sociodemographic characteristics, patterns of drug use, and risky sexual behaviour among female and male users of crack cocaine.

Methods: Between 2012 and 2013, we conducted a cross-sectional study of 919 crack cocaine users (783 men and 136 women) in Central Brazil using face-to-face interviews. Blood samples were collected to test for syphilis. The Chi-Square Automatic Interaction Detector (CHAID) was used to explore the differences between genders. We implemented two models: the first model included previous incarceration and variables related to patterns of drug use, and the second model included variables related to sexual risky behaviours and syphilis exposure.

Results: Women consumed more crack cocaine than men on a regular basis; however, poly-drug use was more common among men. More women than men reported exchanging sex for money and/or drugs and inconsistent condom use during sexual intercourse; women also reported more sexual partners. In addition, the frequency of sexual violence was higher for women than men. A higher proportion of women than men were positive for syphilis (27.2% vs. 9.2%; p < 0.001). The CHAID decision tree analysis identified seven variables that differentiated the genders: previous incarceration, marijuana use, daily crack cocaine consumption, age at first illicit drug use, sexual violence, exchange of sex for money and/or drugs, and syphilis exposure.

Conclusion: Our findings demonstrate a difference in patterns of crack cocaine consumption and sexual risky behaviours between genders, thus indicating a need for gender-specific interventions in this population.
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http://dx.doi.org/10.1186/s12888-017-1569-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5745789PMC
December 2017

Factors associated with HIV prevalence in a prison population.

Rev Esc Enferm USP 2017 Dec 18;51:e03274. Epub 2017 Dec 18.

Universidade Federal do Piauí, Teresina, Piauí, Brasil.

Objective: To analyze HIV prevalence and associated factors in inmates in a prison in a state in the Northeast region of Brazil.

Method: Epidemiological, cross-sectional study carried out with prisoners. Interviews were conducted using a form and a rapid test for the diagnosis. Bivariate and multivariate hypothesis testing, with a simple logistic ratio (unadjusted odds ratio) and multiple ratio (adjusted odds ratio) were applied. Significance level was set at p≤0.05.

Results: A total of 2,131 inmates participated in the study. The HIV prevalence was 1.0%. Seropositive individuals were mostly Afro-American; their marital status was predominantly single/separated/widower. The mean age was of 31.3 years, and the mean educational level was 6.29 years. There was a link between the HIV virus and the variables: selection of partners based on physical attributes and vaginal sexual intercourse.

Conclusion: Tackling the HIV infection represents a major challenge for prison and sanitary authorities, considering that the issues related to the HIV context inside and outside the prison environment are interconnected and, therefore, demands coordinated action.
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http://dx.doi.org/10.1590/S1980-220X2016040903274DOI Listing
December 2017

Hepatitis E seroprevalence and associated factors in rural settlers in Central Brazil.

Rev Soc Bras Med Trop 2017 Sep-Oct;50(5):675-679

Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goiás, Goiânia, GO, Brasil.

Introduction: Prevalence of hepatitis E virus (HEV) infection and associated factors were investigated in rural settlements in Central Brazil.

Methods: A total of 464 settlers were interviewed, and serum samples were tested for anti-HEV IgG/IgM. Positive samples were tested for HEV RNA.

Results: Sixteen participants (3.4%; 95% CI 2.0-5.7) were positive for anti-HEV IgG. None was positive for anti-HEV IgM. HEV RNA was not detected. Dwelling in a rural settlement for >5 years was associated with HEV seropositivity.

Conclusions: The results revealed the absence of acute infection and a low prevalence of previous exposure to HEV.
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http://dx.doi.org/10.1590/0037-8682-0105-2017DOI Listing
December 2017

Factors related to the perceived stigmatization of people living with HIV.

Rev Esc Enferm USP 2017 Oct 9;51:e03248. Epub 2017 Oct 9.

Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Ribeirão Preto, SP, Brazil.

Objective: Analyzing the factors related to perceived stigmatization of people living with HIV.

Method: A cross-sectional study conducted from September of 2014 to December 2015 with users from a specialized service in Minas Gerais. Data were collected through individual instrument application, organized in Microsoft Office Excel(r) 2010 spreadsheets and processed on IBM(r) SPSS 23.0. Descriptive statistics and multiple linear regression method were used for data analysis, adopting statistical significance set at 5.0% (p≤0.05). The study development met research ethics standards.

Results: 258 users participated in the study. Most were males between 40 and 49 years of age, single, with low educational level and income. Being between 40 and 49 years of age and having been hospitalized for complications related to HIV were positively associated predictors to increased stigmatization; while not having comorbidities and not being aware of exposure to HIV were predictors associated to reduced stigmatization.

Conclusion: Given these results, we highlight that stigmatization can have an impact on the lives of people living with HIV, strengthening their feelings of guilt and shame, which can lead to depression, social isolation and abandoning treatment and clinical follow-up.
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http://dx.doi.org/10.1590/S1980-220X2016046703248DOI Listing
October 2017

Prevalence, risk factors and hepatitis B immunization: helping fill the gap on hepatitis B epidemiology among homeless people, Goiânia, Central Brazil.

Cad Saude Publica 2017 Aug 7;33(7):e00109216. Epub 2017 Aug 7.

Faculdade de Enfermagem, Universidade Federal de Goiás, Goiânia, Brasil.

Data are limited in Brazil on hepatitis B infection among homeless individuals, a marginalized population with high risk of sexually transmissible infections (STI), including hepatitis B. The aim of this study was to investigate hepatitis B epidemiology in homeless persons lodged in a public shelter in Goiânia, Central Brazil. From August 2014 to June 2015, 353 individuals were interviewed and tested for markers of HBV infection. Overall HBV prevalence was 21.8% (95%CI: 17,82-26,41), and 19,5% (95%CI: 15,75-24,0) showed a serological profile of previous HBV vaccination. Older individuals (> 50 years), blacks, and homosexuals or bisexuals showed increased exposure to HBV. The low frequency of individuals immunized against HBV, high social vulnerability, and risk behaviors emphasize the need for health services administrators to provide more opportunities for HBV vaccination in this target population.
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http://dx.doi.org/10.1590/0102-311X00109216DOI Listing
August 2017

Viral hepatitis in female sex workers using the Respondent-Driven Sampling.

Rev Saude Publica 2017 Jun 26;51:65. Epub 2017 Jun 26.

Faculdade de Enfermagem. Universidade Federal de Goiás. Goiânia, GO, Brasil.

Objective: To estimate the prevalence of hepatitis B virus and C virus infections and their genotypes and analyze the risk factors for the markers of exposure to hepatitis B virus in female sex workers in a region of intense sex trade.

Methods: This is a cross-sectional study performed with four hundred and two female sex workers in Goiânia, Brazil. Data have been collected using the Respondent-Driven Sampling. The women have been interviewed and tested for markers of hepatitis B and C viruses. Positive samples have been genotyped. The data have been analyzed using the Respondent-Driven Sampling Analysis Tool, version 5.3, and Stata 11.0.

Results: The adjusted prevalence for hepatitis B virus and C virus were 17.1% (95%CI 11.6-23.4) and 0.7% (95%CI 0.1-1.5), respectively. Only 28% (95%CI 21.1-36.4) of the participants had serological evidence of vaccination against hepatitis B virus. Being older (> 40 years), being single, having a history of blood transfusion and use of cocaine, and ignoring the symptoms of sexually transmitted infections were associated with positivity for hepatitis B virus (p < 0.05). We have detected the subgenotype A1 of hepatitis B virus (n = 3) and the subtypes of hepatitis C virus 1a (n = 3) and 1b (n = 1).

Conclusions: We can observe a low prevalence of infection of hepatitis B and C viruses in the studied population. However, the findings of the analysis of the risk factors show the need for more investment in prevention programs for sexual and drug-related behavior, as well as more efforts to vaccinate this population against hepatitis B. The genotypes of the hepatitis B virus and C virus identified are consistent with those circulating in Brazil.
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http://dx.doi.org/10.1590/S1518-8787.2017051006540DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5477708PMC
June 2017

Low completion rate of hepatitis B vaccination in female sex workers.

Rev Bras Enferm 2017 May-Jun;70(3):489-494

Universidade de São Paulo, Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil.

Objective:: to assess predictive factors for noncompletion of the hepatitis B vaccination schedule in female sex workers in the city of Teresina, Northeastern Brazil.

Method:: 402 women were interviewed and, for those who did not wish to visit specialized sites, or did not know their hepatitis B vaccination status, the vaccine was offered at their workplaces. Bi- and multivariate analyses were performed to identify potential predictors for noncompletion of the vaccination schedule.

Results:: of the 284 women eligible for vaccination, 258 (90.8%) received the second dose, 157/258 (60.8%) and 68/258 (26.3%) received the second and third doses, respectively. Working at clubs and consuming illicit drugs were predictors for noncompletion of the vaccination schedule.

Conclusion:: the high acceptability of the vaccine's first dose, associated with low completion rates of the vaccination schedule in sex workers, shows the need for more persuasive strategies that go beyond offering the vaccine at their workplaces.

Objetivo:: avaliar fatores preditores de não completude do esquema vacinal contra hepatite B em mulheres que se prostituem em Teresina, Nordeste do Brasil.

Método:: Um total de 402 mulheres foi entrevistado e, para as que se negaram a irem a lugares especializados, ou desconheciam sua situação vacinal contra hepatite B, a vacina foi oferecida no local do trabalho. Análises bi e multivariadas foram realizadas para identificar potenciais preditores de não completude do esquema vacinal.

Resultados:: Das 284 mulheres elegíveis para vacinação, 258 (90,8%) receberam a primeira dose, 157/258 (60,8%) e 68/258 (26,3%) receberam a segunda e terceira doses. Trabalhar em boates e consumir drogas ilícitas foram preditores de não completude do esquema vacinal (p<0,05).

Conclusão:: A elevada aceitabilidade da primeira dose da vacina, associada à baixa completude do esquema vacinal em profissionais do sexo, evidencia a necessidade de estratégia mais persuasiva que vá além da oferta da vacina no local de trabalho.
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http://dx.doi.org/10.1590/0034-7167-2016-0567DOI Listing
April 2018

Viral hepatitis: a challenge for nursig.

Rev Bras Enferm 2017 04;70(2):231-232

School of Nursing, Universidade Federal de Goiás, Goiânia, Goiás, Brazil.

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http://dx.doi.org/10.1590/0034-7167.2017700201DOI Listing
April 2017

Prevalence and Incidence of HCV Infection among Prisoners in Central Brazil.

PLoS One 2017 6;12(1):e0169195. Epub 2017 Jan 6.

Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil.

The aim of this multicenter, cross sectional study was to assess the prevalence, incidence and associated risk factors among incarcerated populations from twelve Brazilian prisons. The total of 3,368 individuals from twelve prisons was randomly recruited between March 2013 and March 2014. Participants were interviewed, and provided blood samples which were tested for antibodies to Hepatitis C (HCV ab). One year after the first investigation, a cohort study was conducted with 1,656 inmates who participated the cross sectional study. Positive samples were tested for the presence of HCV RNA. Out of 3,368 inmates, 520 (15.4%) were females, and 2,848 (84.6%) were males. The overall prevalence of HCV was 2.4% (95% CI: 1.9 to 2.9), with 0.6% (95% CI: 0.4 to 0.8) in females, and 2.7% (95% CI: 2.1 to 3.3) in males (p<0.01). HCV RNA was detected in 51/80 (63.7%) samples. Among men prisoners, multivariate analysis of associated factors showed independent associations between HCV exposure and increasing age, inject drug use, length of incarceration, smoking hashish, sharing needle and syringe and HIV positivity. During the cohort study, 7/1,656 new cases of HCV infection were detected, and the incidence rate was 0.4/100 person-year. Once high frequency rates of specific HCV risk behaviors and new HCV infections have been identified inside prisons, effective interventions strategies such as screening, clinical evaluation and treatment to reduce the spread of HCV infection are essential.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0169195PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5218405PMC
August 2017

SEROPREVALENCE OF HTLV IN A POPULATION OF HIV1-INFECTED PATIENTS IN MIDWESTERN BRAZIL.

Rev Inst Med Trop Sao Paulo 2016 Nov 3;58:80. Epub 2016 Nov 3.

Universidade Federal de Goiás (UFG), Instituto de Patologia Tropical e Saúde Pública. Goiânia, GO, Brasil.

Human T-cell lymphotropic virus (HTLV) may affect the clinical course of human immunodeficiency virus 1 (HIV1). Both infections are common in endemic areas because these viruses share similar routes of transmission. The aim of this study was to estimate the seroprevalence of HTLV1/2 in a population of HIV1-infected patients in the state of Goiás, Midwestern Brazil. Of the 505 studied patients, four (0.79%) were positive for anti-HTLV1/2 by enzyme-linked immunosorbent assay (ELISA), with HTLV1 infection confirmed by line immunoassay (LIA) and polymerase chain reaction (PCR) in all of the ELISA-positive samples. No cases of HTLV2 infection were observed. The prevalence of HTLV1/HIV1 coinfection was 0.79% (4/505; 95% CI: 0.25-2.16). All the coinfected patients reported sexual risk behaviors and only one reported intravenous drug use. Sequencing of the viral long terminal repeat (LTR) region and phylogenetic analysis revealed that the four HTLV1 isolates belonged to the Transcontinental a subgroup of the Cosmopolitan (1a) subtype, the most frequent subgroup detected in Brazil. This study shows a low prevalence of HTLV1/2 in HIV1-infected patients in Midwestern Brazil.
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http://dx.doi.org/10.1590/S1678-9946201658080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5096634PMC
November 2016

Low Immunogenicity of Recombinant Hepatitis B Vaccine Derived from Hansenula polymorpha in Adults Aged Over 40 Years.

Am J Trop Med Hyg 2017 Jan 31;96(1):118-121. Epub 2016 Oct 31.

Nursing School, Federal University of Goias, Goiania, Brazil.

The Brazilian recombinant hepatitis B vaccine (VrHB-IB) is based on the expression of the recombinant antigen in Hansenula polymorpha yeast cells. Currently, data on the immunogenicity of this vaccine in older adults are nonexistent. This study aimed to evaluate the immunogenicity of VrHB-IB in adults over 40 years of age. From May to October 2011, 235 rural settlers between 2 and 93 years of age from the State of Goias in Brazil were eligible for vaccination. Of these, 180 accepted the first dose of the vaccine and 106 (58.9%) completed the vaccination schedule. Multivariate analysis revealed that individuals ≥ 40 years of age responded significantly less well to vaccination than younger adults. Also, a greater proportion of male nonresponders was observed (versus women; P = 0.02). These results point to the need for better evaluation of the immunogenicity of VrHB-IB in older adults.
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http://dx.doi.org/10.4269/ajtmh.16-0475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5239676PMC
January 2017