Este artigo apresenta como estudo de caso os aspectos mais controversos de pesquisa conduzida na Guate mala (1946-1948), patrocinada pelo Serviço de Saúde Pública dos Estados Unidos e envolvendo participantes infectados intencionalmente pelo Treponema pallidum. Analisando as alterações de 2008 na Declaração de Helsinque e a ainda pequena adesão a outros instrumentos internacionais, como a Declaração Universal sobre Bioética e Direitos Humanos, da Unesco, a discussão enfatiza a importância da implantação de diretrizes éticas internacionalmente aceitas para impedir que voluntários humanos sejam envolvidos em pesquisas não éticas. Conclui considerando que é indispensável o envolvimento de cientistas e ativistas para alcançar padrões éticos universalmente aceitos e aplicáveis, visando evitar duplo standard. Além disso, que a participação igualitária em pesquisas e distribuição justa de seus benefícios será importante passo para atingir o acesso universal a cuidados de saúde de qualidade para todos.

This manuscript presents as a case study the most controversial aspects of a research conducted in Guatemala (1946-1948), sponsored by the United States Public Health Service in which participants were intentionally infected with Treponema pallidum. The analysis of changes in the 2008 Declaration of Helsinki and the still insufficient adherence to UNESCO´s Universal Declaration on Bioethics and Human Rights emphasizes the importance of applying internationally accepted ethical standards for human volunteers to prevent unethical research. It concludes that the involvement of scientists and activists is crucial to achieve internationally accepted ethical standards to be equally applied throughout the world, avoiding the risks of double standards, and also that egalitarian participation in research and fair distribution of its benefits will be an important step towards universal access to good quality healthcare for all people.

Este artículo presenta como estudio de caso los aspectos más controvertidos de la investigación realizadas en Guatemala (1946-1948), patrocinada por el Servicio de Salud Pública de los Estados Unidos e involucrando participantes infectados por el Treponema pallidum por todo el mundo. Analizando los cambios en la Declaración de Helsinki de 2008 y la pequeña adhesión, en aquel entonces, a directrices internacionales como la Declaración Universal sobre Bioética y Derechos Humanos de UNESCO la discusión enfatiza la importancia de aplicar normas éticas aceptadas internacionalmente para impedir que voluntarios humanos participen de investigaciones no éticas y concluye considerando que es indispensable la participación de científicos y activistas para alcanzar las normas éticas universalmente aceptados y aplicables, para evitar el doble estándar. Además, que la participación igualitaria en investigaciones y la distribución justa de sus beneficios será un importante paso para lograr el acceso universal a cuidados de una salud de calidad para todos.

O surgimento da Aids e o aumento da incidência da infecção pelo HIV continuam como um dos grandes desafios mundiais para o século XXI. A maneira como esse enfrentamento vem se dando e como será nos próximos anos será de importância fundamental para a discussão geral sobre saúde pública, ética e direitos humanos. Os diversos aspectos relacionados à epidemia da Aids são aqui discutidos, incluindo as possíveis intervenções para seu controle. Mudanças nas decisões sobre a alocação de recursos, tanto para a saúde pública quanto para as pesquisas, bem como a expansão da discussão ética, dos direitos humanos e a necessidade de melhorar o padrão de vida da população são condições indispensáveis para enfrentar esse grave problema de saúde pública.

The emergence of the Aids epidemic and the increase in the incidence of HIV infection are still a health challenge for the 21st century. The way the epidemic is being confronted and how it will be in the years to come will be of fundamental importance on the discussion of public health, ethics and human rights. The diverse aspects of the epidemic are here discussed, including the possible interventions necessary to its control. Changes in the decision-making process for the allocation of resources, both for public health care and research, as well the expansion of the ethical debate and the need to improve the standard of living of all individuals, are imperative conditions in order to face this very serious public health problem.

OBJETIVO: Descrever o comportamento bissexual masculino quanto à identidade sexual, uso de preservativo, freqüência de relações sexuais e tipos de parceria e verificar diferenças entre práticas protegidas nas suas relações com homens e mulheres. MÉTODOS: Estudo transversal aninhado em coorte de homossexuais e bissexuais HIV negativos implantada em 1994 em Belo Horizonte (Projeto Horizonte). Dos 1.025 voluntários recrutados entre 1994 e 2005, foram selecionados 195 que relataram, na admissão, ter tido relações sexuais com homens e mulheres nos seis meses anteriores à entrevista. Foi criado índice de risco comportamental, designado Índice de Risco Horizonte, que incorpora uma constante para cada prática sexual não protegida, ajustada segundo o número de encontros sexuais. RESULTADOS: Houve predomínio de atividade sexual com homens; a maioria se auto-referiu como bissexual (55%) e homossexual (26%). A mediana do número de parceiros homens ocasionais nos últimos seis meses (4) foi superior ao de parceiras ocasionais (2) e de parceiros fixos de ambos os sexos (1). No sexo vaginal com parceira fixa, o uso inconsistente do preservativo foi de 55%, comparado com 35% e 55% no sexo anal insertivo e receptivo com parceiros fixos. O índice foi maior para os que relataram terem tido sexo com homens e mulheres comparado com os que tiveram sexo exclusivamente com mulheres ou homens. CONCLUSÕES: As situações de risco para HIV foram mais freqüentes entre os homens que relataram atividade sexual com homens e mulheres. Os comportamentos sexuais e de proteção dos bissexuais diferem conforme gênero e estabilidade da parceria, havendo maior desproteção com parceiras fixas mulheres.

OBJECTIVE: To describe bisexual men's behavior in terms of sexual identity, condom use, frequency of sexual intercourse and types of partners and to determine rates of inconsistent condom according to partner's gender. METHODS: Cross-sectional study nested in a cohort of HIV-negative homosexual and bisexual men in the city of Belo Horizonte, Southeastern Brazil, followed up since 1994 (Horizonte Project). Of 1,025 subjects enrolled between 1994 and 2005, 195 volunteers who reported at admission having sexual relations with men and women during the previous six months were selected. A behavioral risk index, called Horizonte Risk Index, was estimated. It incorporates a constant assigned to each type of unprotected sexual act, adjusted for the number of sexual encounters. RESULTS: Sexual activity with men predominated; most considered themselves as bisexual (55%) and homosexual (26%). During the six months prior to the study, median number of casual male partners (4) was higher than both casual female partners (2) and steady male or female partners (1). During vaginal sex with a steady partner, the rate of inconsistent condom use was 55%, compared to 35% and 55% in anal insertive and anal receptive sex, respectively, with steady male partners. The index was higher for those having sex with men and women compared to those having sex either exclusively with women or men (p=0.004). CONCLUSIONS: HIV risk behavior was more frequent among men who reported sexual activity both with men and women. Bisexual men display different sexual and protective behavior according to gender and steadiness of relationships, and female steady partners had more unprotected encounters.

OBJETIVO: Descrever o comportamento bissexual masculino quanto à identidade sexual, uso de preservativo, freqüência de relações sexuais e tipos de parceria e verificar diferenças entre práticas protegidas nas suas relações com homens e mulheres. MÉTODOS: Estudo transversal aninhado em coorte de homossexuais e bissexuais HIV negativos implantada em 1994 em Belo Horizonte (Projeto Horizonte). Dos 1.025 voluntários recrutados entre 1994 e 2005, foram selecionados 195 que relataram, na admissão, ter tido relações sexuais com homens e mulheres nos seis meses anteriores à entrevista. Foi criado índice de risco comportamental, designado Índice de Risco Horizonte, que incorpora uma constante para cada prática sexual não protegida, ajustada segundo o número de encontros sexuais. RESULTADOS: Houve predomínio de atividade sexual com homens; a maioria se auto-referiu como bissexual (55%) e homossexual (26%). A mediana do número de parceiros homens ocasionais nos últimos seis meses (4) foi superior ao de parceiras ocasionais (2) e de parceiros fixos de ambos os sexos (1). No sexo vaginal com parceira fixa, o uso inconsistente do preservativo foi de 55%, comparado com 35% e 55% no sexo anal insertivo e receptivo com parceiros fixos. O índice foi maior para os que relataram terem tido sexo com homens e mulheres comparado com os que tiveram sexo exclusivamente com mulheres ou homens. CONCLUSÕES: As situações de risco para HIV foram mais freqüentes entre os homens que relataram atividade sexual com homens e mulheres. Os comportamentos sexuais e de proteção dos bissexuais diferem conforme gênero e estabilidade da parceria, havendo maior desproteção com parceiras fixas mulheres.

OBJECTIVE: To describe bisexual men's behavior in terms of sexual identity, condom use, frequency of sexual intercourse and types of partners and to determine rates of inconsistent condom according to partner's gender. METHODS: Cross-sectional study nested in a cohort of HIV-negative homosexual and bisexual men in the city of Belo Horizonte, Southeastern Brazil, followed up since 1994 (Horizonte Project). Of 1,025 subjects enrolled between 1994 and 2005, 195 volunteers who reported at admission having sexual relations with men and women during the previous six months were selected. A behavioral risk index, called Horizonte Risk Index, was estimated. It incorporates a constant assigned to each type of unprotected sexual act, adjusted for the number of sexual encounters. RESULTS: Sexual activity with men predominated; most considered themselves as bisexual (55%) and homosexual (26%). During the six months prior to the study, median number of casual male partners (4) was higher than both casual female partners (2) and steady male or female partners (1). During vaginal sex with a steady partner, the rate of inconsistent condom use was 55%, compared to 35% and 55% in anal insertive and anal receptive sex, respectively, with steady male partners. The index was higher for those having sex with men and women compared to those having sex either exclusively with women or men (p=0.004). CONCLUSIONS: HIV risk behavior was more frequent among men who reported sexual activity both with men and women. Bisexual men display different sexual and protective behavior according to gender and steadiness of relationships, and female steady partners had more unprotected encounters.

Rickettsial diseases except those belonging to spotted fever group rickettsioses are poorly studied in South America particularly in Brazil where few epidemiological reports have been published. We describe a serosurvey for Rickettsia rickettsii, R. typhi, Coxiella burnetii, Bartonella henselae, B. quintana, and Ehrlichia chaffeensis in 437 healthy people from a Brazilian rural community. The serum samples were tested by indirected micro-immunoflourescence technique and a cutoff titer of 1:64 was used. The seroprevalence rates for R. rickettsii, R. typhi, C. burnetii, B. henselae, B. quintana, and E. chaffeensis were respectively 1.6% (7 samples); 1.1% (5 samples); 3.9% (17 samples); 13.7% (60 samples); 12.8% (56 samples), and 10.5% (46 samples). Frequent multiple/cross-reactivity was observed in this study. Age over 40 years old, urban profession, and rural residence were significantly associated with some but not all infections rate. Low seropositivity rates for R. rickettsii, R. typhi, and C. burnetii contrasted with higher rates of seropositivity for B. quintana, B. henselae, and E. chaffeensis. These results show that all tested rickettsial species or antigenically closely related possible exist in this particular region.

INTRODUÇÃO: Os níveis de RNA do HIV-1 no plasma refletem a replicação viral sistêmica e a replicação no sistema nervoso central pode ocorrer independentemente da infecção sistêmica, mas a utilidade da medida destes níveis no líquido cefalorraqueano (LCR) permanece indefinida. OBJETIVO: Comparar os níveis de RNA do HIV-1 no LCR e plasma de pacientes sem doenças neurológicas e com diferentes doenças neurológicas, bem como correlacionar estes níveis com a sua evolução e o uso de antiretrovirais. MÉTODO: Foram avaliados 97 pacientes com suspeita de doença neurológica que realizaram punção lombar e que foram divididos em dois grupos: sem doenças neurológicas (23) e com doenças neurológicas (74). Metodologia NASBA foi usada para quantificação do RNA do HIV-1. RESULTADOS: A mediana da carga viral do LCR foi maior em pacientes com neurotoxoplasmose, neurocriptococose, demência pelo HIV e doença neurológica sem etiologia definida quando comparada aos pacientes sem doenças neurológicas. Não houve diferença da carga viral do plasma entre os pacientes com e sem doença neurológica. A mediana da carga viral do plasma e LCR foi maior nos pacientes que faleceram em relação aos tratados com sucesso. A carga viral do LCR e plasma foi menor nos pacientes com doenças oportunísticas que usavam HAART em relação aos que não a usavam. CONCLUSÃO: A carga viral no LRC foi maior nos pacientes com qualquer doença neurológica em relação aos sem doenças neurológicas, mas isto não ocorreu no plasma, sugerindo que doença neurológica influencia mais o compartimento do LCR que o do plasma, mas não foi possível diferenciar as doenças neurológicas pelos níveis de RNA do HIV-1 do LCR.

BACKGROUND: Plasma HIV RNA levels reflect systemic viral replication but in CNS it may occur relatively independent of systemic infection, yet clinical application of CSF HIV-1 RNA levels is less clear. OBJECTIVE: to compare CSF and plasma HIV-1 RNA levels of patients with different opportunistic neurological diseases to those without neurological disease, as well as to correlate these levels with the outcome of the disease and use of HAART. METHOD: 97 patients who had lumbar puncture for routine work up of suspected neurological diseases, were divided in 2 groups: without neurological disease (23) and with neurological disease (74). NASBA was used for plasma and CSF HIV RNA. RESULTS: Median CSF viral load was higher in toxoplasmic encephalitis, cryptococcal meningitis, HIV dementia and neurological diseases without a defined etiology when compared to patients without neurological disease. There was no difference between plasma viral load in patients with and without neurological diseases. Median viral load was higher in plasma and CSF among patients who died when compared to those successfully treated. CSF and plasma viral load were lower in patients with opportunistic diseases on HAART than without HAART. CONCLUSION: CSF viral load was higher in patients with any neurological disease, but this difference was not present in plasma viral load, suggesting that neurological disease influences more the CSF than plasma compartments. Notwithstanding different neurological diseases were not possible to be diferentiated by the levels of CSF HIV-1.

Hepatitis B and C constitute important public health problems worldwide. In Brazil, studies on prevalence of viral hepatitis have local and regional characteristics; consequently it is difficult to define the national epidemiological situation. Our objective was to evaluate the seroprevalence of hepatitis B and C in conscripts of the Brazilian Army. A transversal study among males aged 17 to 22 years was conducted nationwide. After informed consent, each volunteer filled in a social-behavioral questionnaire and had blood drawn to test for HBsAg and anti-HCV. A total of 7,372 volunteers were evaluated in the second half of 2002. The prevalence of HBsAg was 2.6% (95% confidence interval: 2.2, 3.0) and that of anti-HCV was 1.5% (95% confidence interval: 1.2, 1.8). A wide variation among macro regions and states in the same region was observed for both markers. In conclusion, although this population theoretically had a low risk for HBV and HCV infection, these results are higher than expected for this age range. These findings may indicate a change in the pattern of HBV and HCV transmission in Brazil. Due to the different dynamics of these epidemics, further studies are warranted to confirm these apparent trends.

Combined antiretroviral therapy results in sustained viral suppression and a decrease in mortality and morbidity due to HIV infection. Intrinsic strength, durability and absence of cross-resistance are key factors in the selection of antiretrovirals. Failure with nelfinavir has been associated with two protease gene mutations, D30N and L90M. The D30N mutation does not result in cross-resistance with other protease inhibitors, and it decreases viral fitness. In order to check for this mutation after failure with nelfinavir, the 246 HIV-1 genotyping test was performed on virus samples from 55 patients with failure of nelfinavir as the first protease inhibitor. Most (84%) of the viral strains were of subtype B. Nucleosides associated with mutations (NAM) were observed in 80% of the tests; no INS69, complex 151, K65R and L74V mutations, which give multi-resistance to nucleoside analogue reverse transcriptase inhibitors to tenofovir and DDI, respectively, were observed. In the tests for protease gene mutations, the D30N mutation was found in 57%, L90M in 18% and the wild-type virus in 25%. These data are similar to published reports, showing that alternative therapies used after failure with nelfinavir may be more successful, as the D30N mutation does not cause cross-resistance to other protease inhibitors.

Os objetivos deste trabalho são avaliar risco ocupacional de exposição ao HIV entre estudantes de medicina, avaliar o conhecimento e o uso das medidas de biossegurança e a cobertura da vacinação contra hepatite B. Questionário específico foi aplicado a 136 estudantes de medicina da Universidade Federal de Minas Gerais. A maioria da população avaliada, 87 (64%) estudantes relataram participar de procedimentos cirúrgicos, 68 (50%) já sofreram algum tipo de exposição a sangue, 90 (66,2%) afirmaram conhecer as medidas universais de biossegurança e 33 (24,3%) relataram conhecer os procedimentos em caso de exposição a sangue contaminado. A população avaliada apresenta alto risco de exposição a material biológico e cerca de um terço desta tem baixo nível de conhecimento das medidas de biossegurança, apesar de fazer uso delas. Torna-se necessário a utilização de estratégias como ensino formal, treinamento em serviço e criação de serviços especializados em biossegurança para a modificação desta realidade.

The objectives of this study were to evaluate the occupational risk of medical students, their knowledge and practice of universal biosafety measures and hepatitis B immunization coverage. A specific questionnaire was applied to 136 medical students of the Universidade Federal de Minas Gerais: 87 (64%) students were involved in surgical procedures, 68 (50%) had been exposed to blood, 90 (66.2%) knew the universal biosafety measures and 33 (24.3%) knew the procedure in case of blood exposure. Thus, this population has a high risk of blood exposure and although there is a low formal knowledge about universal biosafety measures, most of these were generally used. New strategies, such as formal teaching of universal biosafety measures, in loco supervision, and biosafety teams, are necessary to change this situation.

Foram estudadas as alterações clínicas e radiológicas pulmonares da fase inicial da esquistossomose mansoni em 30 indivíduos previamente sadios, que se infectaram simultaneamente. Os achados foram comparados aos de um grupo - controle e relacionados a possíveis fatores patogenéticos como carga parasitária, eosinofilia sangüínea e área de reação intradérmica imediata, esta como estimativa de IgE ligada a mastócito. As manifestações pulmonares foram de intensidade leve ou moderada, sendo a tosse seca o sintoma mais comum. As alterações radiológicas significativas constaram de espessamento de paredes brônquicas, micronodulação em rosário e micronodulação esparsa, localizadas predominantemente nas porções inferiores dos campos pulmonares. Verificou-se associação significativa de sibilos e área da reação intradérmica imediata, bem como entre o número de eosinófilos sangüíneos e a ocorrência de alterações radiológicas tomadas em conjunto. Houve correlação entre a carga parasitária, expressa pelo número de ovos eliminados nas fezes, e a presença de sibilos, dor torácica e micronodulação em rosário.

The clinical and radiological pulmonary manifestations in the initial phase of schistosomiasis mansoni were studied in thirty previously healthy individuals who were simultaneously infected. The findings were compared with those concerning a control group and related to possible pathogenetic factors. The respiratory manifestations were of light or of moderate intensity, the dry cough being the most common symptom. The significant radiological alterations were: thickening of bronchial walls and beaded micronodulation, predominantly localized in the lower pulmonary fields. It was observed significant association between wheezing and IgE levels, estimated by the area of immediate intradermal reaction, as well as between the number of blood eosinophils and the occurrence of radiological changes. Moreover, there was correlation between the worm burden and the presence of wheezing, thoracic pain and beaded micronodulation. Thus, the clinical and radiological pulmonary manifestations described are significant part of the initial phase of schistosomiasis mansoni and present the worm burden, eosinophilia and levels of IgE as probable pathogenetic factors.

The post-treatment pulmonary alterations were evaluated in patients (Study 1) and in mice (Study 2) infected with Schistosoma mansoni. Study 1: the patients were examined pre and post-treatment (with ora oxamniquine) and the following exams were performed: sputum for eosinophils and chest x-ray. Study 2: four groups of mice (total = 64) were studied; Group I (infected and treated with oxamniquine); II (infected and not treated); III (not infected and treated) and IV (not infected and not treated). All were x-rayed to check for pulmonary abnormalities pre and post-treatment and lung specimens were studied by optical microscopy and immunofluorescence. We have found abnormalities in the parameters checked in both studies and the results suggest an immunological reaction, probably due to deposition of immune complexes in the lungs, with subsequent activation of the complement system. The experimental study showed that the alterations are not dependent of the presence of eggs and/or worms of S. mansoni in the lungs, thus corroborating the hypothesis of deposition of circulating material.