Concerns have been raised that universal availability of antiretroviral agents in resource-limited settings might lead to the emergence and spread of resistant strains. We present the largest survey on human immunodeficiency virus type 1 (HIV-1) resistance among treatment-naïve and experienced patients followed in small, relatively underprivileged cities in Brazil with universal availability to standard of care antiretroviral combinations. Samples were collected between 2004 and 2006 from 95 patients followed in the cities of Saquarema and Santo Antonio de Pádua, state of Rio de Janeiro. A proviral fragment encompassing protease and reverse transcriptase (RT) regions was generated and drug susceptibility level was inferred. Among 50 strains from drug-naïve subjects, one (2%) had intermediate-level resistance to RT inhibitors. Among 38 patients on therapy as of sampling, 28 (73.7%) had plasma viral load (PVL) below detection limit (26 of whom without evidence of resistance mutations) and 11 (28.9%) harbored strains with reduced susceptibility. Only two strains harbored both protease and RT inhibitor mutations. Among seven patients who were off-treatment as of sampling, two (28.5%) harbored strains with reduced susceptibility to RT inhibitors. The relatively high frequency of undetectable PVL among patients on treatment and the overall low prevalence of resistance-associated mutations are reassuring. Continued surveillance, however, is necessary.

As part of an ongoing study on the features of AIDS spread towards small cities and rural areas, we present a molecular survey of human immunodeficiency virus type 1 (HIV-1) polymerase sequences recovered between 2004 and 2006 from 71 patients receiving care in the city of Saquarema, inner state of Rio de Janeiro. Phylogenetic reconstructions found the two prevalent lineages in the state (subtypes B [59 strains, 83.1%], F1 [6 strains; 8.4%], and BF1 recombinants [four strains; 5.6%]), as well as two (2.8%) CRF02_AG strains, which seems to be an emerging lineage in the capital. These CRF02_AG sequences were recovered from a married heterosexual couple who never traveled abroad, thus providing the first molecular evidence of autochthonous horizontal transmission of this lineage of major global importance. Also, three phylogenetic clusters of strains recovered from a total of 18.3% of the cohort were uncovered. Their close genetic relatedness suggests they were recovered from patients who probably took part in the same chain of viral spread. In conjunction with our previous surveys from inner Rio de Janeiro, these results suggest that although small cities harbor unique molecular features of HIV-1 infection, they also clearly reflect and may rapidly absorb the diversity recorded in large urban centers.

No Brasil, relativamente pouca atenção vem sendo dispensada ao estudo das características do avanço da epidemia de Aids em direção aos pequenos municípios e áreas rurais. Apresentamos um estudo descritivo sobre as características epidemiológicas da infecção pelo HIV entre 208 pacientes adultos atendidos entre julho de 1999 e maio de 2006 pelos Programas Municipais de HIV/Aids de três municípios do interior do Estado do Rio de Janeiro: Saquarema, Santo Antonio de Pádua, e Miracema. Os resultados delineiam uma epidemia de perfil heterossexual, com uma razão de sexos homem-mulher de 1,1. Mais de 90% eram residentes das cidades estudadas, demonstrando uma demanda local por assistência relacionada ao HIV e a importância dos Programas Municipais de HIV/Aids. Um quarto dos pacientes referiu antecedentes de uso de cocaína inalada. Variáveis idade e gênero masculino mostraram-se independentemente associadas a um diagnóstico de Aids quando da apresentação. Esta última mostra-se de acordo com um mais recente avanço da epidemia em direção às mulheres. Registramos uma baixa freqüência de circuncisão masculina, um importante determinante da transmissão heterossexual do HIV. Quase 60% dos pacientes se apresentaram em estágios avançados de infecção HIV, o que sugere a existência de um grande reservatório de casos não diagnosticados na comunidade.

In Brazil relatively little attention is being paid to the study of the features of the spread of the AIDS epidemic towards small cities and rural areas. We report a descriptive study on the epidemiological features of HIV infection among 208 adult patients seen between July 1999 and May 2006 in the municipal HIV/AIDS Programs of three cities of inner Rio de Janeiro State: Saquarema, Santo Antonio de Pádua and Miracema. A portrait of a heterosexual epidemic emerged, with an overall male to female ratio of 1.1. More than 90% were residents of the studied cities, demonstrating a local demand for HIV-related assistance and the importance of municipal HIV/AIDS Programs. Past or current use of snorted cocaine was reported by a quarter of the patients. Older age and male gender were independent predictors of having a diagnosis of AIDS at presentation. The latter is in accordance with a more recent wave of epidemic spread towards female gender. A low frequency of male circumcision, an important determinant of heterosexual HIV transmission, was recorded. Almost 60% of the patients first presented in advanced stages of HIV infection, suggesting the existence of a large pool of undiagnosed cases in the community.

We recently performed a molecular epidemiology survey of human immunodeficiency virus type 1 (HIV-1) infection in Miracema, a small city in Southeast Brazil, and found multiple monophyletic clusters, consistent with independent introductions and spread of different viral lineages in the city. Here we apply Bayesian coalescent-based methods to the two largest subtype B clusters and estimate that the most recent common ancestors that gave rise to these two transmission chains were in circulation around 1991-1992. The finding that HIV-1 spread in this Brazilian small city was already taking place at a time Aids was considered a problem restricted to large urban centers may have important public health implications.

O presente trabalho objetivou avaliar a prevalência e o papel de um tratamento em massa das helmintíases intestinais em Santa Isabel do Rio Negro, Estado do Amazonas, Brasil. Foi realizado em 2002 um estudo seccional, incluindo inquérito copro-parasitológico, objetivando a obtenção das prevalências das parasitoses intestinais e dados sobre as condições sanitárias do local, estudando-se uma amostra de 308 indivíduos. Em 2003 foi realizada intervenção para tratamento em massa das helmintíases intestinais com administração de albendazol (ou mebendazol para crianças entre 12 e 24 meses) na sede do município, alcançando-se 83% de cobertura. Novo inquérito copro-parasitológico foi realizado em 2004, para comparação das prevalências antes a após o tratamento. As prevalências das infecções por Ascaris lumbricoides, Trichuris trichiura e ancilostomídeos foram 48%, 27% e 21%, respectivamente em 2002. Em 2004 observou-se redução significativa das infecções por Ascaris lumbricoides (p < 0,05; OR / 95% IC = 0,44 / 0,30 - 0,65), Trichuris trichiura (p < 0,05; OR / 95% IC = 0,37 / 0,22 - 0,62), ancilostomídeos (p < 0,05; OR / 95% IC = 0,03 / 0,01 - 0,15) e poliparasitismo por helmintos intestinais (p < 0,05; OR / 95% IC = 0,16 / 0,08 - 0,32). Foi também observada redução da prevalência de infecção por Entamoeba histolytica/dispar (p < 0,05; OR / 95% CI = 0,30 / 0,19 - 0,49). Concluiu-se que o tratamento em massa pode auxiliar o controle das helmintíases intestinais, porém ações governamentais em infraestrutura urbana e educação são essenciais para uma redução sustentada das prevalências destas infecções.

The objective of the present study was to estimate the prevalence of soil-transmitted helminthiasis and evaluate the sanitary conditions and the role of a mass treatment campaign for control of these infections in Santa Isabel do Rio Negro. A cross-sectional survey was carried out in 2002, to obtain data related to the sanitary conditions of the population and fecal samples for parasitological examination in 308 individuals, followed by a mass treatment with albendazole or mebendazole with coverage of 83% of the city population in 2003. A new survey was carried out in 2004, involving 214 individuals, for comparison of the prevalences of intestinal parasitosis before and after the mass treatment. The prevalences of ascariasis, trichuriasis and hookworm infection were 48%; 27% and 21% respectively in 2002. There was a significant decrease for the frequency of infections by Ascaris lumbricoides (p < 0.05; OR / 95% CI = 0.44 / 0.30 - 0.65), Trichuris trichiura (p < 0.05; OR / 95% CI = 0.37 / 0.22 - 0.62), hookworm (p < 0.05; OR / 95% CI = 0.03 / 0.01 - 0.15) and helminth poliparasitism (p < 0.05; OR / 95% CI = 0.16 / 0.08 - 0.32). It was also noticed a decrease of prevalence of infection by Entamoeba histolytica / dispar (p < 0.05; OR / 95% CI = 0.30 / 0.19 - 0.49) and non-pathogenic amoebas. It was inferred that a mass treatment can contribute to the control of soil-transmitted helminthiasis as a practicable short-dated measure. However, governmental plans for public health, education and urban infrastructure are essential for the sustained reduction of prevalences of those infections.

In Brazil, surveillance studies on antiretroviral drug resistance among drug-naïve and treatment-experienced patients have focused primarily on patients living in large urban centers. As the epidemic spreads towards small municipalities and the innermost parts of the country, it will be essential to monitor the prevalence of antiretroviral drug resistance in these areas. We report the first survey on the prevalence of antiretroviral drug resistance in a small Brazilian municipality. Between July 1999 and March 2005, 72 adult human immunodeficiency virus type-1(HIV-1)-infected patients received care at the Municipal HIV/AIDS Program of the small, southeastern municipality of Miracema, state of Rio de Janeiro. A genotyping study of antiretroviral drug resistance was performed in 54 patients. Among 27 samples from treatment-experienced patients, 9 (33.3%) harbored strains with reduced drug susceptibility. Among these, 6 had reduced susceptibility to reverse transcriptase (RT) inhibitors and 3 to both RT and protease inhibitors. No primary antiretroviral drug resistance was recorded among 27 drug-naïve subjects. The relatively low prevalence of resistance mutations in the Miracema cohort argues against the concern that resource-poor settings should not implement widespread accessibility to standard of care antiretroviral combinations due to the possibility of sub-optimal adherence leading to the emergence and spread of drug-resistant strains.

OBJETIVO: Estudos sobre as características da infecção pelo HIV em pequenos municípios brasileiros são de grande importância para o desenho de estratégias de intervenção, para a alocação apropriada de recursos e melhoria da assistência. O objetivo foi investigar as características clínicas e epidemiológicas da infecção pelo HIV em um pequeno município. MÉTODOS: Foi realizado estudo descritivo em Miracema, município do noroeste do Estado do Rio de Janeiro, entre julho de 1999 e dezembro de 2003. Foram analisados todos os pacientes adultos com diagnóstico de infecção pelo HIV atendidos no Programa Municipal de HIV/Aids. Dados clínicos e epidemiológicos foram coletados prospectivamente por meio de questionário padronizado. RESULTADOS: Foram analisados no total 65 pacientes adultos que receberam atendimento no Programa Municipal de HIV/Aids. A maioria (34) eram mulheres (razão de sexos homem-mulher de 0,9). Encontrou-se preponderância absoluta de pacientes que nasceram em Miracema ou municípios vizinhos (94%), moravam em Miracema (90,7%), eram solteiros (70,8%), atribuíam a aquisição da infecção ao contato heterossexual desprotegido (72,3%) e tinham antecedentes de uso de cocaína inalada (27,7%). Desordens do sistema nervoso central (incluindo cinco casos de neurocriptococose) e insuficiência respiratória aguda semelhante à pneumocistose pulmonar foram as principais causas de morbidade. A maioria dos pacientes (56,9%) iniciou acompanhamento em estágios avançados de infecção pelo HIV. CONCLUSÕES: A preponderância de pacientes em estágios avançados de infecção pelo HIV sugere a existência de um grande reservatório de casos não diagnosticados na comunidade. Uma característica marcante da casuística foi a inversão da razão de sexos homem-mulher. Investigações adicionais cobrindo áreas geográficas maiores são urgentemente necessárias para o melhor entendimento do espectro clínico e epidemiológico da infecção pelo HIV em pequenos municípios brasileiros e áreas rurais.

OBJECTIVE: Studies on the aspects of HIV infection in small Brazilian municipalities are invaluable to appropriately design control strategies, better allocate resources, and improve health care services. The objective of the study was to assess the clinical and epidemiological aspects of HIV infection in a small municipality. METHODS: A descriptive study was carried out in Miracema, a small municipality in the northwestern area of the state of Rio de Janeiro, Brazil, between July 1999 and December 2003. All HIV-infected adult patients followed up at the local HIV/AIDS Program were included. Clinical and epidemiologic characteristics were prospectively assessed through standardized questionnaires. RESULTS: A total of 65 adult patients who attended the local HIV/AIDS Program were analyzed. Most (34) were women (male to female ratio: 0.9). An absolute predominance of patients who were born in Miracema or neighboring municipalities (94%), lived in Miracema (90.7%), were single (70.8%), attributed the acquisition of HIV infection to unprotected heterosexual intercourse (72.3%) and had a past history of snorting cocaine (27.7) was found Central nervous system disorders (including five cases of cryptococcal meningitis) and acute pulmonary pneumocystosis-like respiratory failure were major causes of morbidity. Most patients (56.9%) were at presented in advanced stages of HIV infection. CONCLUSIONS: The predominance of patients on advanced stages of HIV infection suggest the existence of a large pool of undiagnosed cases in the community. A major feature of the cohort was an inverted male to female ratio. Further investigations over a broader geographic area are urgently needed for better understanding the clinical and epidemiological characteristics of HIV infection in small Brazilian municipalities and rural areas.

OBJETIVO: Estudos sobre as características da infecção pelo HIV em pequenos municípios brasileiros são de grande importância para o desenho de estratégias de intervenção, para a alocação apropriada de recursos e melhoria da assistência. O objetivo foi investigar as características clínicas e epidemiológicas da infecção pelo HIV em um pequeno município. MÉTODOS: Foi realizado estudo descritivo em Miracema, município do noroeste do Estado do Rio de Janeiro, entre julho de 1999 e dezembro de 2003. Foram analisados todos os pacientes adultos com diagnóstico de infecção pelo HIV atendidos no Programa Municipal de HIV/Aids. Dados clínicos e epidemiológicos foram coletados prospectivamente por meio de questionário padronizado. RESULTADOS: Foram analisados no total 65 pacientes adultos que receberam atendimento no Programa Municipal de HIV/Aids. A maioria (34) eram mulheres (razão de sexos homem-mulher de 0,9). Encontrou-se preponderância absoluta de pacientes que nasceram em Miracema ou municípios vizinhos (94%), moravam em Miracema (90,7%), eram solteiros (70,8%), atribuíam a aquisição da infecção ao contato heterossexual desprotegido (72,3%) e tinham antecedentes de uso de cocaína inalada (27,7%). Desordens do sistema nervoso central (incluindo cinco casos de neurocriptococose) e insuficiência respiratória aguda semelhante à pneumocistose pulmonar foram as principais causas de morbidade. A maioria dos pacientes (56,9%) iniciou acompanhamento em estágios avançados de infecção pelo HIV. CONCLUSÕES: A preponderância de pacientes em estágios avançados de infecção pelo HIV sugere a existência de um grande reservatório de casos não diagnosticados na comunidade. Uma característica marcante da casuística foi a inversão da razão de sexos homem-mulher. Investigações adicionais cobrindo áreas geográficas maiores são urgentemente necessárias para o melhor entendimento do espectro clínico e epidemiológico da infecção pelo HIV em pequenos municípios brasileiros e áreas rurais.

OBJECTIVE: Studies on the aspects of HIV infection in small Brazilian municipalities are invaluable to appropriately design control strategies, better allocate resources, and improve health care services. The objective of the study was to assess the clinical and epidemiological aspects of HIV infection in a small municipality. METHODS: A descriptive study was carried out in Miracema, a small municipality in the northwestern area of the state of Rio de Janeiro, Brazil, between July 1999 and December 2003. All HIV-infected adult patients followed up at the local HIV/AIDS Program were included. Clinical and epidemiologic characteristics were prospectively assessed through standardized questionnaires. RESULTS: A total of 65 adult patients who attended the local HIV/AIDS Program were analyzed. Most (34) were women (male to female ratio: 0.9). An absolute predominance of patients who were born in Miracema or neighboring municipalities (94%), lived in Miracema (90.7%), were single (70.8%), attributed the acquisition of HIV infection to unprotected heterosexual intercourse (72.3%) and had a past history of snorting cocaine (27.7) was found Central nervous system disorders (including five cases of cryptococcal meningitis) and acute pulmonary pneumocystosis-like respiratory failure were major causes of morbidity. Most patients (56.9%) were at presented in advanced stages of HIV infection. CONCLUSIONS: The predominance of patients on advanced stages of HIV infection suggest the existence of a large pool of undiagnosed cases in the community. A major feature of the cohort was an inverted male to female ratio. Further investigations over a broader geographic area are urgently needed for better understanding the clinical and epidemiological characteristics of HIV infection in small Brazilian municipalities and rural areas.

Formas altamente agressivas de carcinoma cutâneo de células escamosas vêm sendo reconhecidas como uma importante complicação da infecção pelo HIV. Descrevemos o caso de um paciente do sexo masculino, de 59 anos, que se apresentou com uma lesão altamente agressiva de SCC na região do couro cabeludo, com destruição do osso parietal subjacente e curso clínico fulminante.

Unusually aggressive forms of cutaneous squamous cell carcinoma are being increasingly recognized as a complication of HIV infection. We report the case of a 59-year-old male patient with advanced HIV infection who presented with a highly aggressive SCC lesion over the scalp area with destruction of the underlying parietal bone and fulminant clinical progression.

Desde os primeiros anos da epidemia de Aids, grandes diferenças geográficas na prevalência de infecção pelo HIV foram registradas entre países vizinhos e regiões vizinhas dentro de um mesmo país na África subsaariana. Tais diferenças não podiam ser completamente explicadas por fatores como o comportamento sexual e o uso de preservativos. Um acúmulo de dados epidemiológicos vem mostrando que a circuncisão masculina desempenha um efeito protetor contra a aquisição heterossexual do HIV pelo homem na África subsaariana e provavelmente contribui para as acentuadas diferenças de prevalência de HIV. Assim, realizou-se uma atualização dos estudos conduzidos em solo africano sobre a associação entre circuncisão masculina e infecção pelo HIV, as origens da prática da circuncisão entre as populações humanas, os mecanismos pelos quais a presença do prepúcio aumentaria a susceptibilidade de aquisição heterossexual do HIV pelo homem, sua associação com outras doenças infecciosas e também neoplásicas, o debate sobre a conveniência da adoção de práticas de circuncisão como estratégia de controle da epidemia de HIV na África, a escassa literatura brasileira sobre circuncisão masculina e as perspectivas de investigações futuras.

Since the early years of the AIDS epidemic significant geographic differences in HIV prevalence were reported within neighboring countries and neighboring regions within the same country in sub-Saharan Africa. These differences could not be fully explained by factors such as sexual behavior and condom use. Mounting epidemiological data have demonstrated that male circumcision is a major protective factor against male heterosexual HIV infection in sub-Saharan Africa and probably contributes to these significant differences in HIV prevalence. This is a review of African studies on the association between male circumcision and HIV infection, the origin of circumcision practices in human societies, potential prepuce mechanisms for increasing male vulnerability to heterosexual HIV infection, its association with other infectious and neoplastic diseases, controversies on the convenience of male circumcision as an HIV control strategy in Africa, the scarce Brazilian literature on male circumcision and perspectives of future research.

Desde os primeiros anos da epidemia de Aids, grandes diferenças geográficas na prevalência de infecção pelo HIV foram registradas entre países vizinhos e regiões vizinhas dentro de um mesmo país na África subsaariana. Tais diferenças não podiam ser completamente explicadas por fatores como o comportamento sexual e o uso de preservativos. Um acúmulo de dados epidemiológicos vem mostrando que a circuncisão masculina desempenha um efeito protetor contra a aquisição heterossexual do HIV pelo homem na África subsaariana e provavelmente contribui para as acentuadas diferenças de prevalência de HIV. Assim, realizou-se uma atualização dos estudos conduzidos em solo africano sobre a associação entre circuncisão masculina e infecção pelo HIV, as origens da prática da circuncisão entre as populações humanas, os mecanismos pelos quais a presença do prepúcio aumentaria a susceptibilidade de aquisição heterossexual do HIV pelo homem, sua associação com outras doenças infecciosas e também neoplásicas, o debate sobre a conveniência da adoção de práticas de circuncisão como estratégia de controle da epidemia de HIV na África, a escassa literatura brasileira sobre circuncisão masculina e as perspectivas de investigações futuras.

Since the early years of the AIDS epidemic significant geographic differences in HIV prevalence were reported within neighboring countries and neighboring regions within the same country in sub-Saharan Africa. These differences could not be fully explained by factors such as sexual behavior and condom use. Mounting epidemiological data have demonstrated that male circumcision is a major protective factor against male heterosexual HIV infection in sub-Saharan Africa and probably contributes to these significant differences in HIV prevalence. This is a review of African studies on the association between male circumcision and HIV infection, the origin of circumcision practices in human societies, potential prepuce mechanisms for increasing male vulnerability to heterosexual HIV infection, its association with other infectious and neoplastic diseases, controversies on the convenience of male circumcision as an HIV control strategy in Africa, the scarce Brazilian literature on male circumcision and perspectives of future research.

The term schistosomiasis encompasses a group of infectious disorders caused by five species of the genus Schistosoma, a blood trematode of outstanding importance in tropical areas. Some of these disorders have long been associated with malignant neoplasia, the most striking association being between disease caused by Schistosoma haematobium, the predominant etiological agent of urinary schistosomiasis, and squamous cell carcinoma of the bladder, a relatively uncommon vesical cancer in non-endemic areas. Four cases of simultaneous adenocarcinoma and schistosomiasis of the prostate have been previously reported (S. haematobium in three and S. mansoni in one). We report a fifth case of concomitant adenocarcinoma and schistosomiasis of the prostate in a 68-year-old Brazilian patient infected with S. mansoni. We also review the medical literature on the association between schistosomiasis and cancer.

O desenvolvimento de piora clínica paradoxal como resposta ao início do tratamento da tuberculose pode complicar a evolução de pacientes com e sem infecção pelo HIV. Apresentamos uma grave manifestação da chamada reação paradoxal ao tratamento da tuberculose, que revelou doença meníngea previamente silenciosa em um paciente HIV-positivo de 34 anos.

The development of paradoxical clinical worsening following initiation of tuberculosis treatment may complicate the clinical course of both HIV-infected and uninfected patients. We report a severe manifestation of the so called paradoxical reaction to the treatment of tuberculosis that unmasked previously silent meningeal disease in a 34-year-old HIV-infected male patient.