HIV and syphilis infections and associated factors among patients in treatment at a Specialist Alcohol, Tobacco, and Drugs Center in São Paulo's "Cracolândia"

Intervention diversity predicts social rehabilitation indicators at discharge in Therapeutic Communities

INTRODUCTION

The Therapeutic Community Model narrows the gap in substance use disorder's network of assistance in Brazil by offering residential treatment to socially vulnerable populations. Due to a historical lack of evidence-based approaches, the government has established treatment guidelines and has been trying to implement training and monitoring methods.

METHOD

This study analysed real-world data from the monitoring system implemented in the largest network of institutions receiving public funds in the State of Sao Paulo. Data came from 8109 records of individuals admitted between 2014 and 2016 in 48 institutions.

RESULTS

Results showed that less than half of the sample was exposed to at least one therapeutic activity from each of the recreational, spiritual, educational and selfcare intervention domains, as proposed by the national guidelines. Social rehabilitation outcome (SRO) defined by housing and self-support at discharge was reported by 21 % of the sample, who stayed in residential treatment for 82.6 days in average. More than half completed the therapeutic programme while 27.3 % dropout. Treatment duration and the diversity of the interventions offered were significantly associated with SRO when mutually adjusted. Chances of SRO increased nearly 5 times when residents were offered the full range of intervention domains, even when controlling for treatment duration. Treatment duration increased chances of SRO in a dose-response manner with a threefold increase for stays up to 90 days and over 9 times for stays longer than 90 days.

CONCLUSION

Our findings offer evidence to promote treatment guidelines compliance and to pave the way for the implementation of monitoring systems for this modality of treatment in Brazil and abroad.

Can Contingency Management Solve the Problem of Adherence to Antiretroviral Therapy in Drug-Dependent Individuals?

Drug misuse among people living with HIV (human immunodeficiency virus) is associated with higher mortality. It is a frequently observed reason for treatment abandonment, with people who misuse drugs showing a 10 to 25 times higher risk of HIV than the general population. The authors conducted a systematic review and meta-analysis to assess the efficacy of contingency management (CM) to improve adherence to antiretroviral therapy in people living with HIV and substance use disorder (SUD). The inclusion criteria consisted of studies written in English, Italian, Spanish, German, and French; studies conducted with humans; and clinical trials that combined SUD treatment with CM for people living with HIV. Two hundred twenty-two articles were identified, five met all inclusion criteria, and three provided enough data to perform the meta-analysis. We considered treatment adherence by measuring the increase in the CD4 count as our primary outcome. We found a significant increase in treatment adherence in the patient group compared with the control groups during the intervention phase. Positive findings did not persist after the cessation of the incentives. The meta-analysis showed that the intervention improved patient adherence by 2.69 (95% confidence interval: [0.08, 0.51]; p = .007) compared with the control group during the intervention period. All short-term CM studies converged on a positive result for adherence to antiretroviral therapy.

The Interactions Between Vulnerabilities for HIV and Syphilis among Cisgender and Transgender People Who Use Drugs

In Brazil, transgender people are most affected by HIV, and crack cocaine addiction may contribute to social vulnerability and exposure to sexual and violence-related risks. This cross-sectional study comprised 2393 individuals seeking addiction treatment, consisting of 43 trans women, 1995 cisgender men, and 355 cisgender women. Records of rapid test results for HIV and syphilis and screening responses of trans women were compared to both cisgender groups using a logistic regression model to identify associated risk factors. HIV prevalence was higher in the transgender group (39.5%) than in cis women and men (5.9% and 3.6%, respectively). Our study showed an eightfold higher chance of a positive HIV test among transgender individuals who used drugs (OR: 8.79, p < .01, 95% CI: 3.90-19.78) compared to cisgender people who used drugs. A lifetime history of syphilis infection was more common in transgender people (60.0%) and cis women (32.8%) than in cis men (9.5%). Active syphilis was also more common in the transgender population (OR: 5.46, p < .01, 95% CI: 2.63 11.32). In our sample, 44.2% of transgender individuals had a history of at least one suicide attempt in their lifetime. Our results showed that transgender women were at higher risk of crack cocaine use (OR: 5.51, p < .01, 95% CI: 2.16-14.06) than cisgender men and women. The study showed that trans women had a higher prevalence of syphilis and HIV, and a greater chance of being homeless. The synergy of these vulnerabilities may have led to our findings of high psychotic symptoms and a history of suicide attempts in transgender individuals.

Syphilis and Co-Infections with HIV-1, HBV, and HCV among People Who Use Crack-Cocaine in Northern Brazil

The rates of syphilis and viral co-infections among people who use crack-cocaine (PWUCC) were assessed in this study. This cross-sectional study relied on biological and self-reported socio-behavioral data from a convenience sample of 990 PWUCC from twenty-six municipalities in the states of Amapá and Pará, northern Brazil. Blood samples were collected to assess the presence of Treponema pallidum using the Rapid Qualitative Test (RQT) and the Venereal Disease Research Laboratory (VDRL). Reactive samples by RQT were used to assess the presence of HBV, HCV, and HIV-1 using Enzyme Immunoassay (EIA) and Polymerase Chain Reaction (PCR). Logistic regression models were used to determine the association of variables assessed with syphilis. In total, 287 (29.0%) of the PWUCC sample had reactive results for syphilis. HBV (15.7%), HCV (5.9%), and HIV-1 (9.8%) were detected among PWUCC with syphilis. Young age, low monthly income and education level, long duration of crack-cocaine use, condomless sex, multiple sex partners, and exchange of sex for money/drugs were associated with syphilis. The present study provides unique insights on the epidemiological status of syphilis among PWUCC in northern Brazil, with multiple implications for improving urgent interventions for diagnosis, prevention, and treatment.

HIV and Substance Use in Latin America: A Scoping Review

This scoping review aims to explore the interplay between substance use (SU) and HIV in Latin America (LA). Database searches yielded 3481 references; 196 were included. HIV prevalence among people who used substances (PWUS) ranged from 2.8–15.2%. SU definitions were variable throughout studies, and thus data were not easily comparable. In 2019, only 2% of new HIV infections were attributed to injection drug use (IDU) in LA. Factors associated with HIV among PWUS included being female, IDU and homelessness, and PWUS were likely to engage in risky sexual behaviors, start antiretroviral treatment late, have poor adherence, have treatment failure, be lost to follow-up, have comorbidities, and experience higher mortality rates and lower quality of life, as has been reported in PLWH with SU in other regions. Five intervention studies were identified, and only one was effective at reducing HIV incidence in PWUS. Interventions in other regions have varying success depending on context-specific characteristics, highlighting the need to conduct more research in the LA region. Though progress has been made in establishing SU as a major concern in people living with HIV (PLWH), much more is yet to be done to reduce the burden of HIV and SU in LA.

Determinants of syphilis infection among pregnant women attending antenatal care in hospitals of Wolaita zone, Southern Ethiopia, 2020

Objective of the study

The objective of this study was to identify determinants of syphilis infection among pregnant women attending antenatal care in hospitals in the Wolaita zone, Southern Ethiopia,2020.

Methods

An unmatched facility-based case-control study was conducted among pregnant women who received antenatal care at four randomly selected hospitals from September 1 to October 30, 2020. A two-stage sampling technique was used in the selection of hospitals and study participants. The data were collected from the participants using a pre-tested structured questionnaire and analyzed using STATA Release 15. Bivariate and multivariate logistic regression analyses were used to determine syphilis infection determinants. Crude and adjusted odds ratios were used for each explanatory variable with a 95% confidence level. A statistically significant association was declared when a p-value was less than 0.05.

Results

A total of 296 (74 cases and 222 controls) pregnant women participated, with a recruitment rate of 97.4%. In multivariate logistic regression, the likelihood of developing a maternal syphilis infection was higher in pregnant women who had more than one-lifetime sexual partner [AOR = 3.59, 95% CI (1.09–11.71)]; a history of sexually transmitted infections [AOR = 3.46, 95%CI (1.32–9.08)] and used a substance [AOR = 3.39, 95%CI (1.31–8.77)].

Conclusion

Sexual-related factors continued to be a major determinant of syphilis in pregnant women. The results suggest that there is a need to promote safe sexual behavior, raise awareness about the risk of STIs, and early diagnosis and treatment of STIs to control syphilis infection, and necessary to make the antenatal care service comprehensive for pregnant women.

Sociodemographic and clinical profile of crack cocaine treatment-seeking individuals living in “Crackland”, Brazil

ABSTRACT Objective: São Paulo‘s Crackland is the biggest and oldest open drug use scene in Brazil, yet little is known about the profile of crack cocaine treatment-seeking individuals living in this region. The aim of this crossectional study was to describe the demographics and clinical characteristics of treatment-seeking crack users living in the Crackland region. Methods: A sample of nighty eight individuals were screened for DSM-V substance use disorders, including substance use, impulsiveness, and psychiatric symptoms. Recent crack cocaine use was also tested using biologic specimens. Results: Results indicated severe social vulnerability, as participants experienced high rates of homelessness (46.9%), unstable housing (50%), unemployment (60.4%) and early school drop-out (27.5%). The average age of crack use onset was 20 years (SD = 6.9) and the mean duration of continuous crack use was 15 years (SD = 9.7). Most participants presented with concomitant mental health disorders, particularly alcohol use disorder (87.8%), as well high rates of psychiatric symptomatology and impulsiveness. More than half of the sample reported at least one previous inpatient (73.5%) and outpatient (65.3%) addiction treatment attempt. Conclusion: This population profile should inform mental healthcare services, promoting the provision of tailored assistance by targeting specific demands at all levels of treatment.

SOCIAL INTERACTION OF WOMEN EXPOSED TO HIV/AIDS: A REPRESENTATIVE MODEL

ABSTRACT Objective: to present the representative model of the social interaction of women exposed to the Human Immunodeficiency Virus and AIDS based on the meanings attributed by them. Method: an interpretative and qualitative research study carried out in Rio de Janeiro, Brazil, from 2017 to 2018, through semi-structured interviews with 17 women who made up four sample groups, in the period between June 2017 and January 2018. The framework for data analysis is the Grounded Theory and Symbolic Interactionism, and the study was ethically approved as required by the National Health Council. Results: for women, the representative model of the social interaction process of exposure to the Human Immunodeficiency Virus and AIDS means “not protecting themselves” and “not being protected by the other”. It is seen as a sloppy, irresponsible and reckless act. The women know the measures to prevent exposure; however, they do not use condoms and acknowledge that they are both exposed and exposing others simultaneously. The central category entitled “Neglecting one's own life although being aware of exposure to the Human Immunodeficiency Virus and AIDS” stands out. Conclusion: understanding this social interaction can contribute to the apprehension of the main factors that influence the construction of these meanings by women, thus helping them to give a new meaning to this exposure and allowing them to modify their actions to protect themselves and others against AIDS. Consequently, effective assistance based on preservation of life is encouraged, with a view to comprehensive care to women and reducing their exposure to infection.

Effectiveness of incorporating contingency management into a public treatment program for people who use crack cocaine in Brazil. A single-blind randomized controlled trial

BACKGROUND

Smoked cocaine (i.e., crack use) is a severe health problem in Brazil, with the country being reported as having the largest crack market in the world. The objective of this study was to evaluate the effectiveness of incorporating Contingency Management targeting cocaine abstinence into a public treatment program in Brazil.

METHODS

Single-blind randomized controlled trial conducted at Unidade Recomeço Helvétia (URH), a public ambulatory treatment program for persons who use crack and live in the "Crackland" region in downtown São Paulo, Brazil. In total, 98 treatment-seeking individuals who use crack were randomized to one of two treatment conditions. Participants allocated to the control condition (n = 48) received 12 weeks of the standard treatment provided at URH. Participants allocated to the experimental condition (n = 50) received the same treatment in combination with Contingency Management (URH+CM). In URH+CM, participants were provided with vouchers with monetary value for submission of negative cocaine urinalysis twice weekly.

RESULTS

Compared to the URH group, the URH+CM group was significantly more likely to submit a negative cocaine urinalysis during treatment, with odds ratios ranging from 4.17 to 6.78, depending on how missing data was accounted for (p<0.01). Participants receiving Contingency Management also had higher odds of achieving three or more weeks of continuous abstinence (OR= 8.07; 95% CI [2.48, 26.24]), achieved longer durations of abstinence (B = 2.14; 95% CI [0.67, 3.61]), submitted a higher percentage of negative urinalysis (B = 19.85; 95% CI [6.89, 32.82]), and were retained in treatment for a longer period (B = 3.00; 95% CI [1.04, 4.97]), compared to those receiving URH alone (p<0.01 for all).

CONCLUSIONS

The incorporation of Contingency Management was effective in promoting cocaine abstinence and treatment retention. The large-scale dissemination of Contingency Management may be an effective strategy to treat Brazilians with cocaine use disorders.