Articles - Latin America

Same-day initiation of oral pre-exposure prophylaxis among gay, bisexual, and other cisgender men who have sex with men and transgender women in Brazil, Mexico, and Peru (ImPrEP)

Summary Background Although gay, bisexual, and other cisgender men who have sex with men (MSM) and transgender women have the highest HIV burden in Latin America, pre-exposure prophylaxis (PrEP) implementation is poor. We aimed to assess the feasibility of same-day oral PrEP delivery in Brazil, Mexico, and Peru. Methods Implementation PrEP (ImPrEP) was a prospective, single-arm, open-label, multicentre PrEP implementation study conducted in Brazil (14 sites), Mexico (four sites), and Peru (ten sites). MSM and transgender women were eligible to participate if they were aged 18 years or older, HIV-negative, and reported one or more prespecified criteria. Enrolled participants received same-day initiation of daily oral PrEP (tenofovir disoproxil fumarate [300 mg] coformulated with emtricitabine [200 mg]). Follow-up visits were scheduled at week 4 and quarterly thereafter. We used logistic regression models to identify factors associated with early loss to follow-up (not returning after enrolment), PrEP adherence (medication possession ratio ≥0·6), and long-term PrEP engagement (attending three or more visits within 52 weeks). This study is registered at the Brazilian Registry of Clinical Trials, U1111-1217-6021. Findings From Feb 6, 2018, to June 30, 2021, 9979 participants were screened and 9509 were enrolled (Brazil n=3928, Mexico n=3288, and Peru n=2293). 543 (5·7%) participants were transgender women, 8966 (94·3%) were cisgender men, and 2481 (26·1%) were aged 18–24 years. There were 12 185·25 person-years of follow-up. 795 (8·4%) of 9509 participants had early loss to follow-up, 6477 (68·1%) of 9509 were adherent to PrEP, and 5783 (70·3%) of 8225 had long-term PrEP engagement. Transgender women (adjusted odds ratio 1·60, 95% CI 1·20–2·14), participants aged 18–24 years (1·80, 1·49–2·18), and participants with primary education (2·18, 1·29–3·68) had increased odds of early loss to follow-up. Transgender women (0·56, 0·46–0·70), participants aged 18–24 years (0·52, 0·46–0·58), and those with primary education (0·60, 0·40–0·91) had lower odds of PrEP adherence. Transgender women (0·56, 0·45–0·71), participants aged 18–24 years (0·56, 0·49–0·64), and those with secondary education (0·74, 0·68–0·86) had lower odds of long-term PrEP engagement. HIV incidence was 0·85 per 100 person-years (95% CI 0·70–1·03) and was higher for transgender women, participants from Peru, those aged 18–24 years, Black and mixed-race participants, and participants who were non-adherent to PrEP. Interpretation Same-day oral PrEP is feasible for MSM and transgender women in Latin America. Social and structural determinants of HIV vulnerability need to be addressed to fully achieve the benefits of PrEP. Funding Unitaid, WHO, and Ministries of Health in Brazil, Mexico, and Peru. Translations For the Portuguese and Spanish translations of the abstract see Supplementary Materials section.

Ambulatory and hospitalized patients with suspected and confirmed mpox: an observational cohort study from Brazil

Summary Background By October 30, 2022, 76,871 cases of mpox were reported worldwide, with 20,614 cases in Latin America. This study reports characteristics of a case series of suspected and confirmed mpox cases at a referral infectious diseases center in Rio de Janeiro, Brazil. Methods This was a single-center, prospective, observational cohort study that enrolled all patients with suspected mpox between June 12 and August 19, 2022. Mpox was confirmed by a PCR test. We compared characteristics of confirmed and non-confirmed cases, and among confirmed cases according to HIV status using distribution tests. Kernel estimation was used for exploratory spatial analysis. Findings Of 342 individuals with suspected mpox, 208 (60.8%) were confirmed cases. Compared to non-confirmed cases, confirmed cases were more frequent among individuals aged 30–39 years, cisgender men (96.2% vs. 66.4%; p < 0.0001), reporting recent sexual intercourse (95.0% vs. 69.4%; p < 0.0001) and using PrEP (31.6% vs. 10.1%; p < 0.0001). HIV (53.2% vs. 20.2%; p < 0.0001), HCV (9.8% vs. 1.1%; p = 0.0046), syphilis (21.2% vs. 16.3%; p = 0.43) and other STIs (33.0% vs. 21.6%; p = 0.042) were more frequent among confirmed mpox cases. Confirmed cases presented more genital (77.3% vs. 39.8%; p < 0.0001) and anal lesions (33.1% vs. 11.5%; p < 0.0001), proctitis (37.1% vs. 13.3%; p < 0.0001) and systemic signs and symptoms (83.2% vs. 64.5%; p = 0.0003) than non-confirmed cases. Compared to confirmed mpox HIV-negative, HIV-positive individuals were older, had more HCV coinfection (15.2% vs. 3.7%; p = 0.011), anal lesions (45.7% vs. 20.5%; p < 0.001) and clinical features of proctitis (45.2% vs. 29.3%; p = 0.058). Interpretation Mpox transmission in Rio de Janeiro, Brazil, rapidly evolved into a local epidemic, with sexual contact playing a crucial role in its dynamics and high rates of coinfections with other STI. Preventive measures must address stigma and social vulnerabilities. Funding Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz).

Ethnoracial inequalities and child mortality in Brazil: a nationwide longitudinal study of 19 million newborn babies

Background Racism is a social determinant of health inequities. In Brazil, racial injustices lead to poor outcomes in maternal and child health for Black and Indigenous populations, including greater risks of pregnancy-related complications; decreased access to antenatal, delivery, and postnatal care; and higher childhood mortality rates. In this study, we aimed to estimate inequalities in childhood mortality rates by maternal race and skin colour in a cohort of more than 19 million newborns in Brazil. Methods We did a nationwide population-based, retrospective cohort study using linked data on all births and deaths in Brazil between Jan 1, 2012, and Dec 31, 2018. The data consisted of livebirths followed up to age 5 years, death, or Dec 31, 2018. Data for livebirths were extracted from the National Information System for livebirths, SINASC, and for deaths from the Mortality Information System, SIM. The final sample consisted of complete data for all cases regarding maternal race and skin colour, and no inconsistencies were present between date of birth and death after linkage. We fitted Cox proportional hazard regression models to calculate the crude and adjusted hazard ratios (HRs) and 95% CIs for the association between maternal race and skin colour and all-cause and cause-specific younger than age 5 mortality rates, by age subgroups. We calculated the trend of HRs (and 95% CI) by time of observation (calendar year) to indicate trends in inequalities. Findings From the 20 526 714 livebirths registered in SINASC between Jan 1, 2012, and Dec 31, 2018, 238 436 were linked to death records identified from SIM. After linkage, 1 010 871 records were excluded due to missing data on maternal race or skin colour or inconsistent date of death. 19 515 843 livebirths were classified by mother's race, of which 224 213 died. Compared with children of White mothers, mortality risk for children younger than age 5 years was higher among children of Indigenous (HR 1·98 [95% CI 1·92–2·06]), Black (HR 1·39 [1·36–1·41]), and Brown or Mixed race (HR 1·19 [1·18–1·20]) mothers. The highest hazard ratios were observed during the post-neonatal period (Indigenous, HR 2·78 [95% CI 2·64–2·95], Black, HR 1·54 [1·48–1·59]), and Brown or Mixed race, HR 1·25 [1·23–1·27]) and between the ages of 1 year and 4 years (Indigenous, HR 3·82 [95% CI 3·52–4·15]), Black, HR 1·51 [1·42–1·60], and Brown or Mixed race, HR 1·30 [1·26–1·35]). Children of Indigenous (HR 16·39 [95% CI 12·88–20·85]), Black (HR 2·34 [1·78–3·06]), and Brown or Mixed race mothers (HR 2·05 [1·71–2·45]) had a higher risk of death from malnutrition than did children of White mothers. Similar patterns were observed for death from diarrhoea (Indigenous, HR 14·28 [95% CI 12·25–16·65]; Black, HR 1·72 [1·44–2·05]; and Brown or Mixed race mothers, HR 1·78 [1·61–1·98]) and influenza and pneumonia (Indigenous, HR 6·49 [95% CI 5·78–7·27]; Black, HR 1·78 [1·62–1·96]; and Brown or Mixed race mothers, HR 1·60 [1·51–1·69]). Interpretation Substantial ethnoracial inequalities were observed in child mortality in Brazil, especially among the Indigenous and Black populations. These findings demonstrate the importance of regular racial inequality assessments and monitoring. We suggest implementing policies to promote ethnoracial equity to reduce the impact of racism on child health. Funding MCTI/CNPq/MS/SCTIE/Decit/Bill & Melinda Gates Foundation's Grandes Desafios Brasil, Desenvolvimento Saudável para Todas as Crianças, and Wellcome Trust core support grant awarded to CIDACS-Center for Data and Knowledge Integration for Health.   Full Text

Younger Brazilians hit by COVID-19 – What are the implications?

By the first week of June, Brazil had reached almost 17 million cases and a little more than 472,000 deaths. A notable demographic change has been observed within this period, in which young and middle-aged adults representing an increasing share of patients in wards and intensive care units (ICU).

Epidemiology, Biodiversity, and Technological Trajectories in the Brazilian Amazon: From Malaria to COVID-19

The Amazon biome is under severe threat due to increasing deforestation rates and loss of biodiversity and ecosystem services while sustaining a high burden of neglected tropical diseases. Approximately two thirds of this biome are located within Brazilian territory. There, socio-economic and environmental landscape transformations are linked to the regional agrarian economy dynamics, which has developed into six techno-productive trajectories (TTs).

Trust, attitudes, information: a study on the perception of the COVID-19 pandemic in 12 Brazilian cities

In this study, we analyze the perception of Brazilians about COVID-19 in 12 cities in the country. Issues about the severity and dangers of the disease, sources of information and reliability, checking information, attitudes, precautions and priorities for coping and trusting relationships in science were addressed. 

Comments and recommendations for regulating the Nagoya Protocol in Brazil

Abstract Brazil deposited at the UN Secretariat its ratification of Nagoya Protocol on March 4, 2021. 90 (ninety) days from this date, the country becomes a member of the Nagoya Protocol, assuming rights and duties. This paper aims to contribute to the challenge that the country will have in harmonizing the Nagoya Protocol and its internal legal framework (Law 13.123/2015 regulated by Decree 8.772 /2016)

Covid-19 pandemic implications for food and nutrition security in Brazil

The emergence of COVID-19 in Brazil further explained the massive discrepancy between different social realities coexisting in the country, rekindling the discussions about food and nutrition security, similarly to what has been happening in other countries facing the same pandemic situation. In this paper, we argue that the risks to hunger and food security in Brazil have been present since 2016 and are now being exacerbated due to the emergence of the COVID-19 epidemic. 

Genetic Evidence and Host Immune Response in Persons Reinfected with SARS-CoV-2, Brazil

The dynamics underlying severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reinfection remain poorly understood. We identified a small cluster of patients in Brazil who experienced 2 episodes of coronavirus disease (COVID-19) in March and late May 2020. In the first episode, patients manifested an enhanced innate response compared with healthy persons, but neutralizing humoral immunity was not fully achieved. The second episode was associated with different SARS-CoV-2 strains, higher viral loads, and clinical symptoms. Our finding that persons with mild COVID-19 may have controlled SARS-CoV-2 replication without developing detectable humoral immunity suggests that reinfection is more frequent than supposed, but this hypothesis is not well documented.

Você conhece os impactos do vírus Zika sobre as famílias?

*Portuguese content* Com objetivo de avaliar como as famílias dessas crianças foram impactadas, a pesquisa Impactos econômicos e sociais do vírus Zika foi realizada no IFF-Fiocruz, hospital público federal situado no Rio de Janeiro, que atua em ensino, pesquisa e atendimento a mulheres, crianças e adolescentes.

COVID-19 en América Latina y Caribe: Determinación de prioridades en investigación y llamado a la acción

The Global Health Network (www.tghn.org) established in January 2020 a community of practice to address research on COVID-19 in low/middle-income countries.

Emerging complexities and rising omission: Contrasts among socio-ecological contexts of infectious diseases, research and policy in Brazil

  In this article, we explore elements that highlight the interdependent nature of demands for knowledge production and decision-making related to the appearance of emerging diseases. To this end, we refer to scientific production and current contextual evidence to verify situations mainly related to the Brazilian Amazon, which suffers systematic disturbances and is characterized as a possible source of pathogenic microorganisms.