Travestis, transgender women and young MSM are at high risk for PrEP early loss to follow-up in Rio de Janeiro, Brazil

Abstract Introduction Oral pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir (FTC/TDF) is highly effective in preventing HIV infection. This study aimed to identify factors associated with PrEP early loss to follow-up (ELFU) among gay, bisexual and other men who have sex with men (MSM), travestis and transgender women (TGW). Methodology This was a prospective cohort study evaluating TGW and MSM who initiated PrEP at the Evandro Chagas National Institute of Infectious Diseases (INI-Fiocruz) from 2014 to 2020. ELFU was defined as not returning for a PrEP visit within 180 days after first dispensation. Exposure variables included age, gender, race, education, transactional sex, condomless anal intercourse [CAI] (both in the past six months), binge drinking and substance use (both in past three months) and syphilis diagnosis at baseline. Multilevel logistic regression models with random intercepts and fixed slopes were used to identify factors associated with ELFU accounting for clustering of participants according to their PrEP initiation study/context (PrEP Brasil, PrEParadas, ImPrEP and PrEP SUS). Results Among 1,463 participants, the median age was 29 years (interquartile range 24-36), 83% self-identified as MSM, 17% as TGW, 24% were black, 37% mixed-black/pardo and 30% had < 12 years of education. Fifteen percent reported transactional sex, 59% reported CAI, 67% binge drinking, 33% substance use, and 15% had a syphilis diagnosis. Overall, 137 participants (9.7%) had ELFU. Younger age (18-24 years) (adjusted odds ratio [aOR] 1.9, 95%CI:1.2-3.2), TGW (aOR 2.8, 95%CI:1.6-4.8) and education < 12 years (aOR 1.9, 95%CI:1.2-2.9) were associated with greater odds of ELFU. Conclusion TGW, young individuals and those with lower education were at higher risk of PrEP ELFU. Our results suggest that the development of specific strategies targeting these populations should be a priority, through policies that aim to reduce the incidence of HIV infection.

Mortality rates by gender and sexual orientation reveal a disproportionally high mortality among cisgender men of unknown sexual orientation and men who have sex with women in a cohort of people living with HIV in Rio de Janeiro, Brazil

ABSTRACT Background: Antiretroviral therapy use has led to a decline in HIV-related mortality yet disparities by gender and/or sexual orientation may exist. In this study, we estimated hazards of death in people living with HIV (PLWH) according to gender and sexual orientation. Methods: We included PLWH ≥ 18 years enrolled between 2000 and 2018 at INI/Fiocruz, Rio de Janeiro, Brazil. Participants were grouped as cisgender or transgender women, cisgender men who have sex with men (MSM) or men who have sex with women, or cisgender men with unknown sexual orientation. We assessed disparities in the hazard of death using Cox proportional hazards models. Results: Among 5,576 PLWH, median age at enrollment was 35 years, 39% were MSM, 28% cisgender women, 23% men who have sex with women, 5% transgender women, and 5% men with unknown sexual orientation. A total of 795 deaths occurred in 39,141 person-years of follow-up. Mortality rates per 1,000 person-years were: 82.4 for men with unknown sexual orientation, 24.5 for men who have sex with women, 18.3 for cisgender, 16.6 for transgender women, and 15.1 for MSM. Compared to MSM, men with unknown sexual orientation had the highest death hazard ratio (adjusted hazard ratio [aHR] 2.93, 95% confidence interval [CI] 2.35-3.81), followed by men who have sex with women (aHR 1.17, 95%CI 0.96, 1.43); death hazard ratios for cisgender and transgender women were not statistically different. Conclusion: We observed disparities in the hazard of death for men with unknown sexual orientation and men who have sex with women despite universal access to antiretroviral therapy in Brazil. Future work should characterize and assist men with unknown sexual orientation with tailored policies and interventions. Increased hazard of death was not observed for transgender women, which probably results from interventions implemented in our service to reach, engage, retain, and support this population.

Pregnancy rates and predictors in women with HIV/AIDS in Rio de Janeiro, Southeastern Brazil / Incidência e preditores de gestação em mulheres com HIV/Aids no Rio de Janeiro / Incidencia y predictores de gestación en mujeres con VIH/SIDA en Rio de Janeiro, Sureste de Brasil

OBJECTIVE: To assess incidence and predictors of first pregnancy among women with HIV/AIDS. METHODS: Prospective cohort study was conducted in Rio de Janeiro, southeastern Brazil, between 1996 and 2003. This study comprised 225 women with HIV/AIDS followed up until their first pregnancy or first censored event (hysterectomy, tubal ligation, menopause, 50 years of age, loss to follow-up, death or the end of December 2003). Pregnancy and abortion rates were estimated, and Cox proportional hazards models were used to identify baseline characteristics associated with pregnancy risk. RESULTS: The women were followed up for 565 person/years with a median follow-up of 3 years per women. The mean age was 32 years (SD: 7), and 54.7% were white. There were 60 pregnancies in 39 women, and 18 were terminated (induced abortions), accounting for a rate of 6.9% and 2.1% women/year, respectively. Repeated pregnancies occurred in 33.3% of the women (13/39). Higher pregnancy risk was seen among younger women (HR=3.42; 95%CI: 1.69;6.95) and those living with their partners (HR=1.89; 95%CI: 1.00;3.57). Lower pregnancy risk was associated with higher education level (HR=0.43; 95%CI: 0.19;0.99) and use of antiretroviral therapy (HR=061; 95%CI: 0.31;1.17). CONCLUSIONS: Lower pregnancy rates were found in our cohort than in the general population. Sociodemographic characteristics should be taken into consideration in the management of reproductive health in HIV-positive childbearing age women. Reproductive and family planning counseling must be incorporated into HIV/AIDS programs for women to help preventing HIV transmission to their partners and offspring.

OBJETIVO: Identificar incidência e preditores incidência da primeira gestação entre mulheres com HIV/Aids. MÉTODOS: Estudo prospectivo de coorte conduzido entre 1996 e 2003 no Rio de Janeiro, RJ, com 225 mulheres acompanhadas até a primeira gestação ou até o primeiro evento considerado censura (histerectomia, ligadura tubárea, menopausa, 50 anos de idade, perda de acompanhamento, óbito ou final de dezembro de 2003). Taxas de incidência de gestação e de aborto foram estimadas e modelos de riscos proporcionais de Cox foram usados para identificar as características da visita de inclusão associadas com o risco de gestação. RESULTADOS: As mulheres foram acompanhadas por 565 pessoas/ano, com média de acompanhamento de 3 anos por mulher. A idade média foi de 32 anos (DP: 7) e 54,7% eram brancas. Sessenta gestações foram observadas em 39 mulheres e 18 resultaram em abortos induzidos (taxas de incidência de 6,9% e 2,1% mulheres/ano, respectivamente). Gestações repetidas ocorreram em 33,3% das mulheres (13/39). Maior risco de gestação foi observado entre mulheres jovens (HR = 3,42; IC95%:1,69;6,95) e entre aquelas vivendo com seus parceiros (HR = 1,89; IC95%:1,00;3,57). Menor risco de gestação esteve associado à maior escolaridade (HR = 0,43; IC95%:0,19;0,99) e ao uso de terapia anti-retroviral (HR = 0,61; IC95%:0,31;1,17). CONCLUSÕES: A incidência de gestação na coorte foi menor se comparada àquela observada na população geral. Características sociodemográficas devem ser consideradas no manejo dos desejos reprodutivos de mulheres HIV-positivas em idade reprodutiva. Os programas de HIV/Aids devem incluir aconselhamento reprodutivo e contraceptivo para prevenir a transmissão do HIV para seus parceiros e prole.

OBJETIVO: Identificar incidencia y predictores de la primera gestación entre mujeres con VIH/Sida. MÉTODOS: Estudio prospectivo de cohorte conducido en Rio de Janeiro, Sureste de Brasil, entre 1996 y 2003. El estudio incluyó 225 mujeres acompañadas hasta la primera gestación o hasta el primer evento considerado censura (histerectomía, ligadura tubárica, menopausia, 50 años de edad, pérdida de acompañamiento, óbito o final de diciembre de 2003). Se estimaron las tasas de incidencia de gestación y de aborto, y se usaron modelos de riesgos proporcionales de Cox para identificar las características de la visita de inclusión asociadas con el riesgo de gestación. RESULTADOS: Las mujeres fueron acompañadas por 565 persona/años, con promedio de acompañamiento de 3 años por mujer. La edad promedio fue de 32 años (DP:7), y 54,7 por ciento eran blancas. Sesenta gestaciones fueron observadas en 39 mujeres y 18 resultaron en abortos inducidos (tasas de incidencia de 6,9 por ciento y 2,1 por ciento mujeres/año, respectivamente). Las gestaciones repetidas ocurrieron en 33,3 por ciento de las mujeres (13/39). Fue observado el mayor riesgo de gestación entre mujeres jóvenes (HR=3,42; IC 95 por ciento:1,69;6,95) y entre aquellas que vivían con sus parejas (HR=1,89; IC 95 por ciento: 1,00;3,57). El menor riesgo de gestación estuvo asociado a la mayor escolaridad (HR=0,43; IC95 por ciento:0,19;0,99) y al uso de terapia antirretroviral (HR=0,61; IC95 por ciento:0,31;1,17). CONCLUSIONES: La incidencia de gestación en la cohorte fue menor al compararse con aquella observada en la población general. Características sociodemográficas deben ser consideradas en el manejo de los deseos reproductivos de mujeres VIH-positivas en edad reproductiva. Los programas de VIH/SIDA deben incluir consejos reproductivos y contraceptivos para prevenir la transmisión del VIH para sus parejas y prole.