OBJECTIVES: Comprehensive care for people living with human immunodeficiency virus (HIV) (PLH) includes the promotion of healthier habits, including physical activity (PA). This study aimed to describe a multicomponent pragmatic trial protocol to assess the effect of PA in preventing body changes and metabolic disturbances, improving the quality of life of PLH starting antiretroviral therapy (ART) and present cohort characteristics. METHODS: PLH undergoing ART for ≤4 months were recruited for a randomized trial. The intervention comprised three cardiorespiratory and/or strength training sessions per week at the clinic or in public spaces for 6 months under on-site or remote supervision, and educational sessions. Participants’ PA levels, cardiorespiratory fitness, anthropometric measures, strength, flexibility, quality of life, and laboratory monitoring (blood glucose and lipids, CD4 counts) at baseline and post-intervention will be compared. The pragmatic design aims to enable the assessment of intervention effectiveness in real-life conditions. RESULTS: At baseline, our cohort of 38 recently diagnosed patients (mean time since HIV diagnosis and duration of ART were 3 and 2.58 months, respectively) were predominantly male, young, with high schooling and good immune status (median CD4 count=498 cells/mm3). Twenty-two (57.9%) patients reported a PA below the World Health Organization recommendations. We found baseline normal anthropometric measures and metabolic parameters: below-average trunk flexion and elbow extension strength, poor handgrip strength and flexibility, and high quality of life scores in all except the physical domain. CONCLUSIONS: Understanding how effective PA is in preventing body changes and metabolic disturbances, and in improving the quality of PLH starting ART may help establish guidelines to better incorporate PA in HIV care.

ABSTRACT This study describes difficulties in the monitoring of a child born during an oral outbreak of Chagas disease, in which there are several indications that the transmission occurred through the congenital route: 1. the mother was in the third trimester of pregnancy when she was infected; 2. She presented high parasitemia at the time of delivery; 3. In both, the mother and her daughter, T. cruzi was classified as DTU TcIV. The parasites were not found in the blood at birth and the infection was detected only three months later in an asymptomatic infant. As the mother and her child live in a highly endemic area, vector transmission could not be excluded during this period.

ABSTRACT Background: Antiretroviral therapy (ART) has decreased AIDS incidence and mortality, rendering comorbidities, such as hepatitis B more relevant for people living with human immunodeficiency virus (HIV). Since antiretroviral drugs may also inhibit hepatitis B virus (HBV) replication, analyzing the impact of ART on management of hepatitis B in this population is important. Objective: To assess HBV viremia among HIV/HBV coinfected individuals on ART and its associated factors. Method: For this cross-sectional study, HIV/HBV-coinfected individuals, aged over 18 years, who were on ART for over six months and receiving care at an outpatient clinic in São Paulo were recruited. Sociodemographic characteristics, information about viral exposure, clinical and laboratory data, including evaluation of liver fibrosis were obtained. Plasma HBV DNA was measured by polymerase chain reaction. Viral genome sequencing was conducted for genotyping and identification of drug resistance-conferring mutations if viral load exceeded 900 IU/mL. Results: Out of 2,946 patients who attended the clinic in 2015, 83 were eligible and 56 evaluated. Plasma HBV DNA was detected in 16 (28.6%) (95% CI: 18.0-41.3%), all on lamivudine and tenofovir treatment. HBV DNA detection was associated with lower education (p = 0.015), higher international normalized ratios (p = 0.045), history of an AIDS-defining illness [OR: 3.43 (95% CI: 1.10-11.50)], and HBeAg detection [OR: 6.60 (95% CI: 1.84-23.6)]. In contrast, a last CD4+ count above 500 cells/mm3 in the year prior to inclusion [OR: 0.18 (95% CI: 0.04-0.71)] and detection of anti-HBe [OR: 0.21 (95% CI: 0.04-0.99)] were negatively associated. Patients with HBV DNA above 900 IU/mL were infected with subgenotypes A1 (n = 3) and D2 (n = 1), and exhibited viral mutations associated with total resistance to lamivudine and partial resistance to entecavir. Conclusions: Despite being on ART, a significant proportion of HIV/HBV-coinfected individuals present HBV viremia. Characterization of factors that are associated with this finding may help professionals provide better management to these patients.

ABSTRACT Background: HIV-infected children surviving until adulthood have been transitioning to adult outpatient health care service in Brazil since the late 2000's. Deterioration of clinical condition is expected during this period, as reported among youths with non-communicable chronic diseases. Despite their young age, they are long-term hosts of the virus, have prolonged exposure to antiretroviral therapy and have suffered from the social determinants and stigma of HIV infection since early childhood. Objectives: This study aimed to 1) describe demographic and clinical characteristics at the first appointment at adult care service following pediatric care of a cohort of Brazilian youths living with HIV since childhood; and 2) retrospectively address adherence and clinical variables in the last two years of pediatric follow-up. Methods: Descriptive study. Results: 41 consecutive patients referred to adult outpatient care from a pediatric HIV unit were enrolled, median age 19 years, and median lifetime CD4 + nadir 117 cell/mm3; 89% reported previous AIDS-defining conditions. At first laboratory assessment in adult care, only 46% had undetectable (<400 copies/ml) HIV viral load and the median CD4 + count was 250 cell/mm3. Conclusion: Youths living with HIV at the transition from pediatric to adult care had poor treatment adherence, low lifetime CD4 + cell nadir, low CD4 cell count and detectable HIV viral load. Health care providers should closely monitor these adolescents in a youth friendly environment, prepared for open communication about all aspects of their health.

OBJECTIVE: To evaluate the impact of a complex-care-based medical school in the context of the Brazilian health care system on students’ career choices. METHODS: This was a retrospective cross-sectional study based on medical regulatory organization records. It included records for 7,419 physicians who graduated from FMUSP. Geographic data were analyzed using Kernel maps, and the statistical analysis was performed with SPSS® version 24.0. A p-value less than 0.05 was considered significant. RESULTS: Of the 7,419 physicians, 68.6% (95% CI 67.5-69.7) were male, and 20.7% (95% CI 19.8%-21.7%) had no medical specialty, compared to 46.4% nationwide. Internal medicine and surgery-based specialties were more popular, accounting for 39.4% (95% CI 38.3%-40.5%) and 16.8% (95% CI 15.5%-17.6%) of our study group, compared to the Brazilian averages of 25.9% and 13.5%. Our graduates also had a higher probability of staying in São Paulo City, especially when born outside the city. CONCLUSION: We believe that FMUSP remains an interesting model for studying the impact of a highly specialized center on the education and career choices of medical students.

ABSTRACT Zika virus (ZIKV) clinical presentation and frequency/duration of shedding need further clarification. Symptomatic ZIKV-infected individuals identified in two hospitals in Sao Paulo State, Brazil, were investigated regarding clinical characteristics, shedding in body fluids, and serodynamics. Ninety-four of 235 symptomatic patients (Site A: 58%; Site B: 16%) had Real-Time PCR-confirmed ZIKV infection; fever, headache and gastrointestinal symptoms were less frequent, and rash was more frequent compared to ZIKV-negative patients. Real-Time PCR in serum had worse performance compared to plasma, while urine had the highest sensitivity. Shedding in genital fluids and saliva was rare. IgM positivity was the highest <14 days after the symptoms onset (86%), decreasing >28 days (24%); IgG positivity increased >14 days (96%) remaining positive in 94% of patients >28 days. ZIKV prevalence varied importantly in two neighboring cities during the same transmission season. Urine Real-Time PCR can improve diagnostic sensitivity; serum testing is less useful. Accurate serological tests are needed to improve diagnosis and surveillance.

ABSTRACT Background: Zika virus (ZIKV) sexual transmission and prolonged viral shedding in semen have been previously reported, suggesting a strong viral affinity for genital tissues. A transient impact of ZIKV on male fertility was shown in animal and human studies. Methods: Adult male patients with confirmed ZIKV infection diagnosed in the city of Araraquara, Brazil during the epidemic season of 2016 were invited one year after the acute infection to respond to a questionnaire of genital symptoms and to provide a semen sample for molecular ZIKV testing and spermogram analysis, as well as a serum sample for hormonal testing. Results: 101 of 187 tested patients had positive ZIKV RT-PCR in plasma and/or urine samples (54%, 72 women and 29 men). Of 15 adult male participants for whom telephone contact was successful, 14 responded to the questionnaire of genital symptoms and six consented to provide a semen sample at a median of 12 months after the acute infection. We report abnormal spermogram results from patients one year after confirmed ZIKV infection. Conclusions: Our findings suggest a possible long-term detrimental effect of ZIKV infection on human male fertility that has to be further explored in well-characterized samples from cohort studies conducted in ZIKV-endemic areas.

Abstract Background The infectious diseases specialist is a medical doctor dedicated to the management of infectious diseases in their individual and collective dimensions. Objectives The aim of this paper was to evaluate the current profile and distribution of infectious diseases specialists in Brazil. Methods This is a cross-sectional study using secondary data obtained from institutions that register medical specialists in Brazil. Variables of interest included gender, age, type of medical school (public or private) the specialist graduated from, time since finishing residency training in infectious diseases, and the interval between M.D. graduation and residency completion. Maps are used to study the geographical distribution of infectious diseases specialists. Results A total of 3229 infectious diseases specialist registries were counted, with 94.3% (3045) of individual counts (heads) represented by primary registries. The mean age was 43.3 years (SD 10.5), and a higher proportion of females was observed (57%; 95% CI 55.3–58.8). Most Brazilian infectious diseases specialists (58.5%) practice in the Southeastern region. However, when distribution rates were calculated, several states exhibited high concentration of infectious diseases specialists, when compared to the national rate (16.06). Interestingly, among specialists working in the Northeastern region, those trained locally had completed their residency programs more recently (8.7 yrs; 95% CI 7.9–9.5) than physicians trained elsewhere in the country (13.6 yrs: 95% CI 11.8–15.5). Conclusion Our study shows that Brazilian infectious diseases specialists are predominantly young and female doctors. Most have concluded a medical residency training program. The absolute majority practice in the Southeastern region. However, some states from the Northern, Northeastern and Southeastern regions exhibit specialist rates above the national average. In these areas, nonetheless, there is a strong concentration of infectious diseases specialists in state capitals and in metropolitan areas.

A urbanização é um processo irreversível em escala mundial e estima-se que o número de pessoas que vivem em cidades deverá atingir 67% da população do planeta até 2050. Os países de baixa ou média renda, por sua vez, possuem 30% a 40% da população urbana vivendo atualmente em favelas, em situação de risco para diversos agravos de saúde. No Brasil, embora 84,3% da população residissem em áreas urbanas já em 2010, não se verificam no momento ações consistentes voltadas ao enfrentamento das questões de saúde urbana. Neste artigo discute-se a situação epidemiológica de agravos infecciosos de interesse para a saúde pública (dengue, infecção por HIV/aids, leptospirose, hanseníase e tuberculose) a partir do ano 2000 nas 17 metrópoles do país, de modo a esclarecer o papel atual das doenças infecciosas no contexto da saúde urbana brasileira.

Urbanization is an irreversible global process and the number of people living in cities is estimated to reach 67% of the world population by 2050. In low- and middle-income countries, 30% to 40% of the population currently lives in slum areas, under risk of several diseases. Even though 84.3% of the Brazilian population already lived in urban areas in 2010, no consistent initiatives have been implemented to address urban health issues. We discuss here the epidemiological features of communicable diseases that are relevant to public health (dengue, HIV/aids, leptospirosis, leprosy and tuberculosis) in Brazil's 17 metropolitan areas since 2000 to help clarify the current role of infections in the context of Brazilian urban health.

OBJETIVO Analisar as características clínicas e laboratoriais de indivíduos infectados pelo HIV na admissão em serviço de referência em saúde.MÉTODOS Estudo transversal realizado entre 1999 e 2010, com 527 indivíduos com diagnóstico sorológico confirmado de infecção pelo HIV, matriculados em serviço de saúde ambulatorial, em Santarém, PA, Brasil. Foram coletadas informações de prontuários referentes à população estudada sobre o motivo de realização da testagem anti-HIV, estadio clínico e número de linfócitos T CD4+ periféricos, no ato da matrícula. Os dados foram distribuídos em três grupos, segundo ano de admissão do paciente: 1999 a 2002 (P1), 2003 a 2006 (P2) e 2007 a 2010 (P3), para a análise comparativa das variáveis de interesse.RESULTADOS Do total estudado, 62,0% dos pacientes foram admitidos no grupo P3. O motivo de realização da testagem anti-HIV diferiu entre os sexos. Houve preponderância da realização do teste por presença de sintomas sugestivos da infecção na população masculina e pelo conhecimento da soropositividade do parceiro entre as mulheres nos grupos P1 e P2. A maior proporção de mulheres testadas por apresentarem sintomas de infecção pelo HIV/aids fez desaparecer essa diferença entre os gêneros no período mais recente. Observou-se maior participação de matriculados em fase mais avançada da doença no grupo P3.CONCLUSÕES Apesar do maior reconhecimento de casos de HIV/aids, os pacientes seguem descobrindo seu status sorológico tardiamente e apresentando-se à admissão no serviço de saúde com doença em atividade. A epidemia de HIV/aids no Pará apresenta especificidades em evolução que compõem o complexo mosaico da epidemia na região Norte e no Brasil.

OBJECTIVE To analyze the clinical and laboratory characteristics of HIV-infected individuals upon admission to a reference health care center.METHODS This cross-sectional study was conducted between 1999 and 2010 on 527 individuals with confirmed serological diagnosis of HIV infection who were enrolled in an outpatient health care service in Santarém, PA, Northern Brazil. Data were collected from medical records and included the reason for HIV testing, clinical status, and count of peripheral CD4+ T lymphocytes upon enrollment. The data were divided into three groups, according to the patient’s year of admission – P1 (1999-2002), P2 (2003-2006), and P3 (2007-2010) – for comparative analysis of the variables of interest.RESULTS In the study group, 62.0% of the patients were assigned to the P3 group. The reason for undergoing HIV testing differed between genders. In the male population, most tests were conducted because of the presence of symptoms suggesting infection. Among women, tests were the result of knowledge of the partner’s seropositive status in groups P1 and P2. Higher proportion of women undergoing testing because of symptoms of HIV/AIDS infection abolished the difference between genders in the most recent period. A higher percentage of patients enrolling at a more advanced stage of the disease was observed in P3.CONCLUSIONS Despite the increased awareness of the number of HIV/AIDS cases, these patients have identified their serological status late and were admitted to health care units with active disease. The HIV/AIDS epidemic in Pará presents specificities in its progression that indicate the complex characteristics of the epidemic in the Northern region of Brazil and across the country.

OBJETIVO Analisar as características clínicas e laboratoriais de indivíduos infectados pelo HIV na admissão em serviço de referência em saúde.MÉTODOS Estudo transversal realizado entre 1999 e 2010, com 527 indivíduos com diagnóstico sorológico confirmado de infecção pelo HIV, matriculados em serviço de saúde ambulatorial, em Santarém, PA, Brasil. Foram coletadas informações de prontuários referentes à população estudada sobre o motivo de realização da testagem anti-HIV, estadio clínico e número de linfócitos T CD4+ periféricos, no ato da matrícula. Os dados foram distribuídos em três grupos, segundo ano de admissão do paciente: 1999 a 2002 (P1), 2003 a 2006 (P2) e 2007 a 2010 (P3), para a análise comparativa das variáveis de interesse.RESULTADOS Do total estudado, 62,0% dos pacientes foram admitidos no grupo P3. O motivo de realização da testagem anti-HIV diferiu entre os sexos. Houve preponderância da realização do teste por presença de sintomas sugestivos da infecção na população masculina e pelo conhecimento da soropositividade do parceiro entre as mulheres nos grupos P1 e P2. A maior proporção de mulheres testadas por apresentarem sintomas de infecção pelo HIV/aids fez desaparecer essa diferença entre os gêneros no período mais recente. Observou-se maior participação de matriculados em fase mais avançada da doença no grupo P3.CONCLUSÕES Apesar do maior reconhecimento de casos de HIV/aids, os pacientes seguem descobrindo seu status sorológico tardiamente e apresentando-se à admissão no serviço de saúde com doença em atividade. A epidemia de HIV/aids no Pará apresenta especificidades em evolução que compõem o complexo mosaico da epidemia na região Norte e no Brasil.

OBJECTIVE To analyze the clinical and laboratory characteristics of HIV-infected individuals upon admission to a reference health care center.METHODS This cross-sectional study was conducted between 1999 and 2010 on 527 individuals with confirmed serological diagnosis of HIV infection who were enrolled in an outpatient health care service in Santarém, PA, Northern Brazil. Data were collected from medical records and included the reason for HIV testing, clinical status, and count of peripheral CD4+ T lymphocytes upon enrollment. The data were divided into three groups, according to the patient’s year of admission – P1 (1999-2002), P2 (2003-2006), and P3 (2007-2010) – for comparative analysis of the variables of interest.RESULTS In the study group, 62.0% of the patients were assigned to the P3 group. The reason for undergoing HIV testing differed between genders. In the male population, most tests were conducted because of the presence of symptoms suggesting infection. Among women, tests were the result of knowledge of the partner’s seropositive status in groups P1 and P2. Higher proportion of women undergoing testing because of symptoms of HIV/AIDS infection abolished the difference between genders in the most recent period. A higher percentage of patients enrolling at a more advanced stage of the disease was observed in P3.CONCLUSIONS Despite the increased awareness of the number of HIV/AIDS cases, these patients have identified their serological status late and were admitted to health care units with active disease. The HIV/AIDS epidemic in Pará presents specificities in its progression that indicate the complex characteristics of the epidemic in the Northern region of Brazil and across the country.

OBJECTIVE:To characterize the findings of behavioral hearing assessment in HIV-positive individuals who received and did not receive antiretroviral treatment.METHODS:This research was a cross-sectional study. The participants were 45 HIV-positive individuals (18 not exposed and 27 exposed to antiretroviral treatment) and 30 control-group individuals. All subjects completed an audiological evaluation through pure-tone audiometry, speech audiometry, and high-frequency audiometry.RESULTS:The hearing thresholds obtained by pure-tone audiometry were different between groups. The group that had received antiretroviral treatment had higher thresholds for the frequencies ranging from 250 to 3000 Hz compared with the control group and the group not exposed to treatment. In the range of frequencies from 4000 through 8000 Hz, the HIV-positive groups presented with higher thresholds than did the control group. The hearing thresholds determined by high-frequency audiometry were different between groups, with higher thresholds in the HIV-positive groups.CONCLUSION:HIV-positive individuals presented poorer results in pure-tone and high-frequency audiometry, suggesting impairment of the peripheral auditory pathway. Individuals who received antiretroviral treatment presented poorer results on both tests compared with individuals not exposed to antiretroviral treatment.

OBJECTIVES: To assess the virologic and immunological response of darunavir/ritonavir plus optimized background therapy in highly antiretroviral-experienced HIV-infected patients in Brazil. METHODS: Prospective cohort study carried out in a tertiary center in Sao Paulo, Brazil. Three-class antiretroviral-experienced patients with confirmed virologic failure began darunavir/ritonavir plus optimized background therapy (nucleoside/tide reverse transcriptase inhibitors ± raltegravir ± enfuvirtide ± maraviroc) after performing a genotypic resistance assay. Clinical evaluation and laboratory tests were collected at baseline and at weeks 12, 24, and 48. Multivariate analysis was performed to identify predictors of virologic response at 48 weeks. RESULTS: Ninety-two patients were included. The median of darunavir resistant mutation was 1 (range 0-6). The median genotypic sensitivity score in the optimized background therapy was 2 (interquartile range 1-2). At week 48, 83% (95% CI: 75-90%) had an HIV RNA level <50 copies/mL and the median CD4 cell count was 301 (interquartile range 224-445) cells/mm³. Baseline HIV RNA >100 000 copies/mL was inversely associated with virologic success at week 48 (HR: 0.22, 95% CI: 0.06-0.85, p = 0.028). CONCLUSIONS: Darunavir/ritonavir plus optimized background therapy was a highly effective salvage regimen under clinical routine conditions in a referral center in Brazil, which is similar to the reported in high-income countries.