Correlation between gender-based violence and poor treatment outcomes among transgender women living with HIV in Brazil.

BACKGROUND: Transgender women are disproportionately affected by both HIV and gender-based violence (GBV), defined as physical, sexual, or emotional violence perpetrated against an individual based on their gender identity/expression. While a growing body of evidence demonstrates that GBV leads to poor HIV care and treatment outcomes among cisgender women, less research has examined this association among transgender women. We assessed the impact of lifetime experiences of GBV on subsequent retention in HIV care and laboratory confirmed viral suppression among a sample of transgender women living with HIV (TWH) in Brazil. METHODS: A pilot trial of a peer navigation intervention to improve HIV care and treatment among TWH was conducted in São Paulo, Brazil between 2018 and 2019. TWH were recruited and randomized into the intervention or control arm and participated in a baseline and 9-month follow-up survey and ongoing extraction of clinical visit, prescribing, and laboratory data. Generalized linear model regressions with a Poisson distribution estimated the relative risk (RR) for the association of lifetime physical and sexual violence reported at baseline with treatment outcomes (retention in HIV care and viral suppression) at follow-up, adjusting for baseline sociodemographic characteristics. RESULTS: A total of 113 TWH participated in the study. At baseline, median age was 30 years, and the prevalence of lifetime physical and sexual violence was 62% and 45%, respectively. At follow-up, 58% (n = 66/113) were retained in care and 35% (n = 40/113) had evidence of viral suppression. In adjusted models, lifetime physical violence was non-significantly associated with a 10% reduction in retention in care (aRR: 0.90, 95% CI: 0.67, 1.22) and a 31% reduction in viral suppression (aRR: 0.69; 95% CI: 0.43, 1.11). Lifetime sexual violence was non-significantly associated with a 28% reduction in retention in HIV care (aRR: 0.72, 95% CI: 0.52, 1.00) and significantly associated with a 56% reduction in viral suppression (aRR: 0.44; 95% CI: 0.24, 0.79). CONCLUSION: Our findings are among the first to demonstrate that lifetime experiences with physical and sexual violence are associated with poor HIV outcomes over time among transgender women. Interventions seeking to improve HIV treatment outcomes should assess and address experiences of GBV among this population. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03525340.

Factors associated with the retention of travestis and transgender women living with HIV in a peer navigation intervention in São Paulo, Brazil. / Fatores associados à retenção de travestis e mulheres trans vivendo com HIV em uma intervenção com navegação de pares em São Paulo, Brasil.

Travestis and transgender women (TrTGW) constitute the groups with the highest HIV prevalence in the world, with higher probability of infection compared with the general population and lower adherence to prevention and treatment strategies than other vulnerable groups. Considering these challenges, this study describes the factors associated with the retention of TrTGW with HIV to the TransAmigas project. Participants were recruited from April 2018 to September 2019 in a public health service in São Paulo, Brazil. A total of 113 TrTGW were randomly assigned to either a peer navigation intervention (75) or a control group (38) and followed up for nine months. To analyze the association between the selected variables and the outcome ("retention at nine months", regardless of contact at three months, defined by the "full completion of the final questionnaire"), bivariate and multivariate logistic regression models were used. Peer contact forms were qualitatively assessed to validate and complement the previous selection of quantitative component variables. Of the 113 participants, 79 (69.9%) participated in the interview after nine months, of which 54 (72%) were from the intervention group and 25 (66%) from the control group. In the final multivariate model, contact at three months (adjusted odds ratio - aOR = 6.15; 95% confidence interval - 95%CI: 2.16-17.51) and higher schooling level (≥ 12 years) (aOR = 3.26; 95%CI: 1.02-10.42) remained associated with the outcome, adjusted by race/skin color, age ≤ 35 years, and HIV serostatus disclosure. Future studies with TrTGW should include contact at regular intervals, with additional efforts aimed at participants with lower schooling level.

Travestis e mulheres trans (TrMT) pertencem aos grupos com mais alta prevalência do HIV no mundo, com maior probabilidade de infecção em relação à população geral e menor adesão a estratégias de prevenção e tratamento do que outros grupos vulneráveis. Considerando esses desafios, descrevemos os fatores associados à retenção de TrMT com HIV no projeto TransAmigas. O recrutamento ocorreu entre abril de 2018 e setembro de 2019, em um serviço público de saúde em São Paulo, Brasil. Foram inscritas 113 TrMT, atribuídas aleatoriamente para uma intervenção com navegadora de pares (75) ou um grupo controle (38) e seguidas durante nove meses. Para analisar a associação entre as variáveis selecionadas e o desfecho ("retenção aos nove meses" independentemente do contato aos três meses, definido pela "resposta completa ao questionário final"), foram empregados modelos de regressão logística bi e multivariados. Uma exploração qualitativa dos formulários de contato de pares foi realizada para validar e complementar a seleção prévia de variáveis do componente quantitativo. Das 113 participantes, 79 (69,9%) responderam à entrevista de nove meses, sendo 54 (72%) do grupo intervenção e 25 (66%) do grupo controle. No modelo multivariado final, o contato aos três meses (odds ratio ajustado - ORa = 6,15; intervalo de 95% de confiança - 95%CI: 2,16-17,51) e a maior escolaridade (≥ 12 anos) (ORa = 3,26; IC95%: 1,02-10,42) permaneceram associados ao desfecho, ajustados por raça/cor, idade < 35 anos e revelação do status sorológico para HIV. Pesquisas futuras com TrMT devem incluir contato em intervalos regulares, com esforços adicionais voltados a participantes com menor escolaridade.

La población de travestis y mujeres trans (TrMT) está en los grupos con mayor prevalencia de VIH en el mundo, con mayor probabilidad de infección en comparación con la población general y menor adherencia a las estrategias de prevención y tratamiento que otros grupos vulnerables. Ante estos desafíos, describimos los factores asociados a la retención de TrMT con VIH en el proyecto TransAmigas. La selección ocurrió entre abril de 2018 y septiembre de 2019, en un servicio público de salud de São Paulo, Brasil. Se inscribieron 113 TrMT, a las cuales se asignaron aleatoriamente a una intervención de navegador de pares (75) o a un grupo control (38) y se les dio seguimiento durante 9 meses. Para analizar la asociación entre las variables seleccionadas y el resultado ("retención a los nueve meses" independientemente del contacto a los 3 meses, definido por "respuesta completa al cuestionario final"), se utilizaron modelos de regresión logística bi- y multivariante. Se realizó una exploración cualitativa de los formularios de contacto de pares para validar y complementar la selección previa de las variables en el componente cuantitativo. De las 113 participantes, 79 (69,9%) respondieron a la entrevista de los 9 meses, de las cuales 54 (72%) pertenecían al grupo intervención y 25 (66%) al grupo control. En el modelo multivariante final, el contacto a los 3 meses (odds ratio ajustado - ORa = 6,15; intervalo de 95% de confianza - IC95%: 2,16-17,51) y un alto nivel de instrucción (≥ 12 años) (ORa = 3,26; IC95%: 1,02-10,42) permanecieron asociados con el resultado, ajustado por etnia/color, edad < 35 años y divulgación del estado serológico respecto al VIH. Los futuros estudios con la población TrMT deberán incluir contacto a intervalos regulares, con esfuerzos adicionales dirigidos a las participantes con menor nivel de instrucción.

Fatores associados à retenção de travestis e mulheres trans vivendo com HIV em uma intervenção com navegação de pares em São Paulo, Brasil / Factores asociados con la retención de travestis y mujeres transgénero que viven con el VIH en una intervención consultada por pares en São Paulo, Brasil / Factors associated with the retention of travestis and transgender women living with HIV in a peer navigation intervention in São Paulo, Brazil

Travestis e mulheres trans (TrMT) pertencem aos grupos com mais alta prevalência do HIV no mundo, com maior probabilidade de infecção em relação à população geral e menor adesão a estratégias de prevenção e tratamento do que outros grupos vulneráveis. Considerando esses desafios, descrevemos os fatores associados à retenção de TrMT com HIV no projeto TransAmigas. O recrutamento ocorreu entre abril de 2018 e setembro de 2019, em um serviço público de saúde em São Paulo, Brasil. Foram inscritas 113 TrMT, atribuídas aleatoriamente para uma intervenção com navegadora de pares (75) ou um grupo controle (38) e seguidas durante nove meses. Para analisar a associação entre as variáveis selecionadas e o desfecho ("retenção aos nove meses" independentemente do contato aos três meses, definido pela "resposta completa ao questionário final"), foram empregados modelos de regressão logística bi e multivariados. Uma exploração qualitativa dos formulários de contato de pares foi realizada para validar e complementar a seleção prévia de variáveis do componente quantitativo. Das 113 participantes, 79 (69,9%) responderam à entrevista de nove meses, sendo 54 (72%) do grupo intervenção e 25 (66%) do grupo controle. No modelo multivariado final, o contato aos três meses (odds ratio ajustado - ORa = 6,15; intervalo de 95% de confiança - 95%CI: 2,16-17,51) e a maior escolaridade (≥ 12 anos) (ORa = 3,26; IC95%: 1,02-10,42) permaneceram associados ao desfecho, ajustados por raça/cor, idade < 35 anos e revelação do status sorológico para HIV. Pesquisas futuras com TrMT devem incluir contato em intervalos regulares, com esforços adicionais voltados a participantes com menor escolaridade.

La población de travestis y mujeres trans (TrMT) está en los grupos con mayor prevalencia de VIH en el mundo, con mayor probabilidad de infección en comparación con la población general y menor adherencia a las estrategias de prevención y tratamiento que otros grupos vulnerables. Ante estos desafíos, describimos los factores asociados a la retención de TrMT con VIH en el proyecto TransAmigas. La selección ocurrió entre abril de 2018 y septiembre de 2019, en un servicio público de salud de São Paulo, Brasil. Se inscribieron 113 TrMT, a las cuales se asignaron aleatoriamente a una intervención de navegador de pares (75) o a un grupo control (38) y se les dio seguimiento durante 9 meses. Para analizar la asociación entre las variables seleccionadas y el resultado ("retención a los nueve meses" independientemente del contacto a los 3 meses, definido por "respuesta completa al cuestionario final"), se utilizaron modelos de regresión logística bi- y multivariante. Se realizó una exploración cualitativa de los formularios de contacto de pares para validar y complementar la selección previa de las variables en el componente cuantitativo. De las 113 participantes, 79 (69,9%) respondieron a la entrevista de los 9 meses, de las cuales 54 (72%) pertenecían al grupo intervención y 25 (66%) al grupo control. En el modelo multivariante final, el contacto a los 3 meses (odds ratio ajustado - ORa = 6,15; intervalo de 95% de confianza - IC95%: 2,16-17,51) y un alto nivel de instrucción (≥ 12 años) (ORa = 3,26; IC95%: 1,02-10,42) permanecieron asociados con el resultado, ajustado por etnia/color, edad < 35 años y divulgación del estado serológico respecto al VIH. Los futuros estudios con la población TrMT deberán incluir contacto a intervalos regulares, con esfuerzos adicionales dirigidos a las participantes con menor nivel de instrucción.

Travestis and transgender women (TrTGW) constitute the groups with the highest HIV prevalence in the world, with higher probability of infection compared with the general population and lower adherence to prevention and treatment strategies than other vulnerable groups. Considering these challenges, this study describes the factors associated with the retention of TrTGW with HIV to the TransAmigas project. Participants were recruited from April 2018 to September 2019 in a public health service in São Paulo, Brazil. A total of 113 TrTGW were randomly assigned to either a peer navigation intervention (75) or a control group (38) and followed up for nine months. To analyze the association between the selected variables and the outcome ("retention at nine months", regardless of contact at three months, defined by the "full completion of the final questionnaire"), bivariate and multivariate logistic regression models were used. Peer contact forms were qualitatively assessed to validate and complement the previous selection of quantitative component variables. Of the 113 participants, 79 (69.9%) participated in the interview after nine months, of which 54 (72%) were from the intervention group and 25 (66%) from the control group. In the final multivariate model, contact at three months (adjusted odds ratio - aOR = 6.15; 95% confidence interval - 95%CI: 2.16-17.51) and higher schooling level (≥ 12 years) (aOR = 3.26; 95%CI: 1.02-10.42) remained associated with the outcome, adjusted by race/skin color, age ≤ 35 years, and HIV serostatus disclosure. Future studies with TrTGW should include contact at regular intervals, with additional efforts aimed at participants with lower schooling level.

Acceptability of self-sampling for etiological diagnosis of mucosal sexually transmitted infections (STIs) among transgender women in a longitudinal cohort study in São Paulo, Brazil.

This study conducted among transgender women in São Paulo, Brazil assessed the acceptability and suitability of screening sexually transmitted infections (STIs), such as Chlamydia trachomatis and Neisseria gonorrhoeae, by sampling multiple anatomical sites (i.e. urethral, anorectal, oropharyngeal, and neovaginal), and utilizing self- or provider-collection methods. First, a convenience sample of 23 cohort participants were recruited during a scheduled study visit between October and November 2018. Data collection was through a short investigator-led quantitative survey in Portuguese, and included presentation of investigator-designed, gender-neutral instructional diagrams to guide self-sampling. Three supplemental focus group discussions (FGDs) with a total of 30 participants guided by semi-structured script were conducted in Portuguese between September and October 2019. All participants reported being assigned male sex at birth and self-identified with a feminine gender identity at time of study. All survey respondents (100%; n = 23) indicated willingness to provide samples for STI screening during a future study visit. Preference was for self-collection of urine samples (83%; n = 19), urethral swabs (82%; n = 18), and anorectal swabs (77%; n = 17). A lower preference for self-collection of oropharyngeal swabs (48%; n = 11) was observed. Most respondents (78%; n = 18) indicated that they would not prefer specimens to be collected by a health professional, mainly due to 'more privacy' (72%; n = 13). All respondents indicated that they would feel comfortable to provide a self-collected sample based on instructional diagrams shown. In FGDs, although the collection by a health professional was described as a technically safer option for some participants, there was a preference for self-collection to avoid discomfort and embarrassment in exposing the body. Overall, this sub-study suggested acceptability among transgender women of introducing self-sampling for etiological diagnosis of STIs from potential infection sites. Uptake and usability will be explored further in a cross-sectional STI prevalence study of transgender women in Brazil.

Acceptability of self-sampling for etiological diagnosis of mucosal sexually transmitted infections (STIs) among transgender women in a longitudinal cohort study in São Paulo, Brazil

ABSTRACT This study conducted among transgender women in São Paulo, Brazil assessed the acceptability and suitability of screening sexually transmitted infections (STIs), such as Chlamydia trachomatis and Neisseria gonorrhoeae, by sampling multiple anatomical sites (i.e. urethral, anorectal, oropharyngeal, and neovaginal), and utilizing self- or provider-collection methods. First, a convenience sample of 23 cohort participants were recruited during a scheduled study visit between October and November 2018. Data collection was through a short investigator-led quantitative survey in Portuguese, and included presentation of investigator-designed, gender-neutral instructional diagrams to guide self-sampling. Three supplemental focus group discussions (FGDs) with a total of 30 participants guided by semi-structured script were conducted in Portuguese between September and October 2019. All participants reported being assigned male sex at birth and self-identified with a feminine gender identity at time of study. All survey respondents (100%; n = 23) indicated willingness to provide samples for STI screening during a future study visit. Preference was for self-collection of urine samples (83%; n = 19), urethral swabs (82%; n = 18), and anorectal swabs (77%; n = 17). A lower preference for self-collection of oropharyngeal swabs (48%; n = 11) was observed. Most respondents (78%; n = 18) indicated that they would not prefer specimens to be collected by a health professional, mainly due to 'more privacy' (72%; n = 13). All respondents indicated that they would feel comfortable to provide a self-collected sample based on instructional diagrams shown. In FGDs, although the collection by a health professional was described as a technically safer option for some participants, there was a preference for self-collection to avoid discomfort and embarrassment in exposing the body. Overall, this sub-study suggested acceptability among transgender women of introducing self-sampling for etiological diagnosis of STIs from potential infection sites. Uptake and usability will be explored further in a cross-sectional STI prevalence study of transgender women in Brazil.

Conhecimentos, percepções e itinerários terapêuticos de travestis e mulheres trans no cuidado a infecções sexualmente transmissíveis em Salvador, Brasil / Knowledge, perceptions and therapeutic itineraries of travestis and transgender woman in the care of sexually transmitted infections in Salvador, Brazil / Conocimientos, percepciones e rutas terapéuticas de travestis y mujeres trans en la atención de enfermedades de transmisión sexual en Salvador, Brasil

Resumo O artigo objetivou analisar conhecimentos, percepções, práticas de cuidado e Itinerrários Terapêuticos (IT) para o diagnóstico e tratamento das Infecções Sexualmente Transmissíveis (IST), com destaque para sífilis, entre Travestis e Mulheres Trans (TrMT) em Salvador, Brasil. Foram realizados 05 grupos focais e 06 entrevistas semiestruturadas com 30 TrMT. Os achados apontam amplo desconhecimento e percepções contraditórias sobre as IST, especialmente a sífilis; identificação de duas importantes trajetórias de cuidado às IST e o destaque para IT marcados por estigmas e discriminação nos serviços de saúde. Sugere-se a ampliação das ações de saúde para essa população reconhecendo suas necessidades e a construção de novas estratégias de prevenção e tratamento para IST, dialogadas com as TrMT, e garantia de autonomia, ética e sigilo na produção do cuidado.

Abstract The article aimed to analyze knowledge, perceptions, care practices and Therapeutic Itineraries (TI) for the diagnosis and treatment of Sexually Transmitted Diseases (STD), with emphasis on syphilis, among travesti and transgender women (TGW) in Salvador, Brazil. 05 focus groups and 06 semi-structured interviews with travesti/TGW were carried out with a total of 30 participants. The findings point to a wide lack of knowledge and contradictory perceptions about STD, especially syphilis; identification of two important trajectories of care for STD and the emphasis on TI marked by stigma and discrimination in health services. The expansion of health actions for this population is suggested, recognizing their needs and the construction of new prevention and treatment strategies for STD, in dialogue with the travesti/TGW, and guaranteeing autonomy, ethics and confidentiality in the production of care.

Resumen El artículo tuvo como objetivo analizar conocimientos, percepciones, prácticas de atención y Rutas Terapêuticas (RT) para el diagnóstico y tratamiento de las Enfermedades de Transmisión Sexual (ETS), con énfasis en la sífilis, entre las travestidas y mujeres trans (TrMT) en Salvador, Brasil. Se realizaron 05 grupos focales y 06 entrevistas semiestructuradas con 30 TrMT. Los hallazgos apuntan a una amplia falta de conocimiento y percepciones contradictorias sobre las ETS, especialmente la sífilis; identificación de dos importantes trayectorias de atención a las ETS y el énfasis en las RT marcadas por el estigma y la discriminación en los servicios de salud. Se sugiere ampliar las acciones de salud para esta población, reconociendo sus necesidades y la construcción de nuevas estrategias de prevención y tratamiento de las ETS, en diálogo con el TrMT, y garantizando la autonomía, ética y confidencialidad en la producción de cuidados.

A cross-sectional study of mental health and suicidality among trans women in São Paulo, Brazil.

BACKGROUND: Trans women have been shown to experience disproportionately poor outcomes in physical and mental health. Although it is common to talk about the violence against trans people, little is still known about mental health outcomes and experiences of suicidality among trans women, particularly in developing countries. This study aims to investigate risk factors and associations with mental health, suicide ideation and suicide attempts among trans women in the largest metropolitan area in Brazil. METHODS: Trans women living in São Paulo were recruited between May 2017 and July 2019 using the long-chain peer referral method Respondent-Driven Sampling. Multivariate regression models were used to investigate the associations with K10 score classification (logistic) and suicidal ideation/suicide attempt (ordinal logistic). RESULTS: A total of 763 trans women were included in the study. Over one quarter (26.5%) of trans women had been diagnosed with anxiety in the past, and close to one in five (19.1%) trans women had received a diagnosis of depression. More than two in five (41.9%) trans women had moderate to severe psychological distress. More than half of all participating trans women reported having previously either experienced suicidal ideation or attempted to take their own lives (25.0 and 31.2% respectively). In multivariate regression, moderate to severe psychological distress was associated with homelessness, income, current sex work, use of stimulant drugs, history of physical abuse, depression diagnosis and access to mental health treatment. Suicidal ideation and suicide attempts were associated with race/skin color, living arrangements, marital status, current sex work, history of sexual violence, depression and PTSD diagnoses, access to mental health treatment and psychological distress. CONCLUSIONS: This study showed that there is a significant association between mental health conditions, lack of treatment for these conditions and suicidality among trans gender women. Findings point to the need for a structural transformation in Brazil that enables a reduction in the social inequality and violence that impact the mental health of trans women. A number of recommendations to achieve this are provided.

'We are not infertile': challenges and limitations faced by women in same-sex relationships when seeking conception services in São Paulo, Brazil.

The use of reproductive technologies has expanded beyond cases of infertility, and opportunities for individuals of different sexual orientations to use such technologies for conception have increased. The authors examined the challenges and limitations faced by women in same-sex relationships seeking conception services in São Paulo, Brazil. They interviewed 16 women in same-sex relationships who conceived children using reproductive technologies. Access to public health services for conception remains limited and exclusive to infertile heterosexual couples. Women in same-sex relationships are forced to select between costly medical treatments in the private sector, or self-insemination with sperm from a known donor. In this study, individuals reported that they experienced adverse effects of treatments; were treated with technologies for infertility when they were, in fact, fertile; and were exposed to unnecessary and invasive interventions. Growing political conservatism and the reduction of investment in public health services are factors that can directly affect sexual and reproductive health, including that of lesbians. Public policies that enable same-sex couples to conceive have yet to be developed in many countries, and a clearer articulation of the right to evidence-informed, rights-based care, consistent with national and international guidelines is a much-needed next step.

Homoparentalidade feminina: nuances da assistência à saúde durante concepção, gravidez, parto e pós-parto / Female homoparentality health care during conception, pregnancy, childbirth and postpartum

Com a possibilidade de acesso a tecnologias reprodutivas cresce o número de mulheres em relação homoafetiva que engravidam e buscam o sistema de saúde. Estudos mostram que a qualidade do atendimento pode ser afetada por questionamentos inadequados, homofobia e comunicação heteronormativa. O objetivo deste trabalho é compreender a percepção de mulheres em relação homoafetiva sobre a assistência à saúde recebida durante concepção, gravidez, parto e pós-parto em serviços públicos e privados na região metropolitana de São Paulo. Neste estudo qualitativo foram entrevistadas de forma individual 19 mulheres que tiveram filhos biológicos durante uma relação homoafetiva, totalizando a história de dez casais. Os resultados apontam que o acesso aos serviços públicos de concepção permanece exclusivo aos casais inférteis heterossexuais. Os casais homoafetivos precisam escolher entre tratamentos médicos caros e invasivos no sistema privado ou uso de inseminação caseira com esperma de doador conhecido, técnica não regulamentada no Brasil e que pode acarretar problemas legais futuros caso o doador decida requerer direitos de paternidade. Mais do que apenas eventos biológicos, a concepção, gestação, o parto e a amamentação possuem dimensões sociais e relacionais importantes de vínculo da parceira que não gesta com o bebê, e também com a companheira que está grávida. No entanto, a reprodução ainda requer a legitimação e o reconhecimento das especificidades de casais homoafetivos por diversos atores envolvidos nesse processo, entre eles os profissionais da saúde. Após a gravidez, a maioria das participantes foi atendida no sistema suplementar de saúde e, apesar da avaliação positiva em geral, foram relatadas situações de desconforto com a postura dos profissionais em diversos momentos, incluindo suposição de heterossexualidade; formulários e orientações voltadas para pai/mãe, questionamento da legitimidade do casal e algumas situações de discriminação e privação de direitos. Os avanços e limites do reconhecimento desse momento para ambas as mulheres, com ênfase na inclusão da parceira que não está biologicamente grávida, foram aspectos destacados pelas participantes deste estudo como determinantes na qualidade dessa experiência de parentalidade. Mesmo com a conquista de direitos legais, como a aprovação do casamento entre pessoas do mesmo sexo, entre outras, muitas instituições e profissionais de saúde continuam despreparados para oferecer assistência adequada para casais homoafetivos. Diferentes intervenções podem melhorar a qualidade dos cuidados prestados aos casais homossexuais, incluindo a implementação de leis e políticas públicas; mudanças estruturais dentro do sistema de saúde; e melhor treinamento para profissionais de saúde. A reivindicação é por uma mudança cultural que exige a participação ativa dos profissionais de saúde, gestores e responsáveis por sua formação

With improved access to reproductive technologies, more women in same-sex relationships are choosing to plan pregnancies and are accessing the health system for care during conception, pregnancy, delivery and postpartum. Studies show the affect that homophobia, heteronormative communication, and inappropriate questioning by healthcare practitioners can have on the quality of care that is given. The objective of this study is to understand the perceptions of women in a same-sex relationship on the quality of healthcare received throughout conception, pregnancy, delivery and postpartum while using public and private health services in the metropolitan region of São Paulo. In this qualitative study, 19 women who had biological children while in a same-sex relationship were interviewed, amounting to the shared histories and experiences of ten couples. Access to conception services provided by the public health system in Brazil remains exclusive to infertile heterosexual couples, leaving many homosexual women to choose between two primary options. They can purchase costly medical treatments and services from the private health system or they can perform self-insemination using donated sperm. The latter technique is not regulated in Brazil and could expose women to potential legal problems associated with the possible decision of sperm donors to pursue paternity rights. More than just its biological impact, conception, gestation, childbirth, and breastfeeding have important social and relational effects on attachment for both the partner who is carrying the pregnancy as well as for the partner who is not pregnant with the baby. The legitimation and recognition of the specificities of samesex couples is required by several actors involved in this process, chief among them being health professionals. After pregnancy, the majority of the participants were attended to in the public health system. Despite predominantly positive evaluations overall, participants also reported some discomforting situations involving the behavior of health professionals including assumptions of heterosexuality; forms and orientations addressing parents as only father / mother, doubts or questions cast on the legitimacy of the couples\' relationships, and a few instances of discrimination and violated rights. Participants of this study highlighted how the acknowledgement of this moment for both women, with particular emphasis on the inclusion of the partner who is not biologically pregnant, is a large determinant of their perceptions on the quality of that parenting experience. Even with the advancement of legal rights such as the federal approval of same-sex marriage, among other civil rights achievements, many institutions and health professionals remain unprepared to provide adequate assistance and care that addresses the specific needs of homosexual couples. Different types of interventions can improve the quality of care provided to homosexual couples, include incorporating changes in laws/policies; structural changes within the health system; and better training for health workers. The aim is for a cultural change that requires the active participation of health professionals, managers, and those responsible for their training

Abuse and disrespect in childbirth care as a public health issue in Brazil: origins, definitions, impacts on maternal health, and proposals for its prevention / Violência obstétrica como questão para a saúde pública no Brasil: origens, definições, tipologia, impactos sobre a saúde materna, e propostas para sua prevenção

Disrespect and abuse (in Brazil called obstetric violence), described by different terms, is increasingly used in social activism, in academic research and public policy formulation, and was recently recognized as a public health issue by the World Health Organization. As an innovative theme, it requires a mapping its origins, definitions, typology, impacts on maternal health and proposals for its preventing and remedy. We present a critical-narrative review about this issue, including academic literature, productions of social movements and institutional documents, in Brazil and internationally. After a short historical overview, we map the definitions and types of violence. The complex causation of these forms of violence is discussed, including the role of professional training, the organization of health services, and the implications for maternal morbidity and mortality. Finally we present interventions in public health that have been used or proposed to prevent and mitigate obstetric violence, and an agenda for innovation and research in this area.(AU)

A violência obstétrica, descrita por diferentes termos, cada vez mais é utilizada no ativismo social, em pesquisas acadêmicas e na formulação de políticas públicas, sendo recentemente reconhecida como questão de saúde pública pela Organização Mundial da Saúde. Como tema inovador, requer um mapeamento de suas origens, definições, tipologia, impactos na saúde materna e propostas de prevenção e superação.Apresentamos esta revisão crítico-narrativasobre o tema, abarcandoliteratura acadêmica, produções dos movimentos sociais e documentos institucionais, do Brasil e exterior. Após breve recuperação histórica do tema,mapeiam-se as definições e as tipologias de violência identificadas. Discute-se a complexa causalidade destas formas de violência, incluindo o papel da formação dos profissionais e da organização dos serviços de saúde e as implicações na morbimortalidade materna. Finaliza-se com intervenções em Saúde Pública que têm sido utilizadas ou propostas para prevenir e mitigar a violência obstétrica, e uma agenda de pesquisa de inovação nesta área.(AU)

Violência obstétrica como questão para a saúde pública no Brasil: origens, definições, tipologia, impactos sobre a saúde materna, e propostas para sua prevenção / Abuse and disrespect in childbirth care as a public health issue in Brazil: origins, definitions, impacts on maternal health, and proposals for its prevention

Disrespect and abuse (in Brazil called obstetric violence), described by different terms, is increasingly used in social activism, in academic research and public policy formulation, and was recently recognized as a public health issue by the World Health Organization. As an innovative theme, it requires a mapping its origins, definitions, typology, impacts on maternal health and proposals for its preventing and remedy. We present a critical-narrative review about this issue, including academic literature, productions of social movements and institutional documents, in Brazil and internationally. After a short historical overview, we map the definitions and types of violence. The complex causation of these forms of violence is discussed, including the role of professional training, the organization of health services, and the implications for maternal morbidity and mortality. Finally we present interventions in public health that have been used or proposed to prevent and mitigate obstetric violence, and an agenda for innovation and research in this area...

A violência obstétrica, descrita por diferentes termos, cada vez mais é utilizada no ativismo social, em pesquisas acadêmicas e na formulação de políticas públicas, sendo recentemente reconhecida como questão de saúde pública pela Organização Mundial da Saúde. Como tema inovador, requer um mapeamento de suas origens, definições, tipologia, impactos na saúde materna e propostas de prevenção e superação.Apresentamos esta revisão crítico-narrativa sobre o tema, abarcando literatura acadêmica, produções dos movimentos sociais e documentos institucionais, do Brasil e exterior. Após breve recuperação histórica do tema,mapeiam-se as definições e as tipologias de violência identificadas. Discute-se a complexa causalidade destas formas de violência, incluindo o papel da formação dos profissionais e da organização dos serviços de saúde e as implicações na morbimortalidade materna. Finaliza-se com intervenções em Saúde Pública que têm sido utilizadas ou propostas para prevenir e mitigar a violência obstétrica, e uma agenda de pesquisa de inovação nesta área...

Concanavalin-A induces IL-17 production during the course of Candida albicans infection.

In a previous study, our group verified that 100% of mice survived to a lethal dose of Candida albicans following pretreatment with concanavalin-A (Con-A) for 3 days. This work proposed to investigate whether treatment could mediate an adaptative immune response involving T(H) 17 cells. A significant increase in IL-17 levels at 6 h postinfection was observed and was maintained up to 18 h in the Con-A group, whereas in control mice, a reduction in this cytokine was verified. In addition, T(H) 17 cells develop in the presence of TGF-ß, IL-1 ß, and IL-6 that were increased significantly 2 h postinfection in Con-A-treated mice. Macrophages were involved in the process, engulfing greater numbers of yeast cells, and were activated through TNF-α and interferon-γ produced at significant levels at 2 h postinfection. A significant increase in IL-12 levels was also observed at 2 h postinfection. Thus, activated macrophages were probably more capable of killing and processing Candida antigens, signalizing an adaptative immune response. Macrophages from controls did not prevent yeast-to-hyphae transition and were partially destroyed, as shown in scanning microscopy. These results suggest that treatment with Con-A facilitated the triggering of T(H) 17 and T(H) 1 responses via IL-17 and IFN-γ production, leading to the resolution of C. albicans infection.

Artin M enhances TNF-α production and phagocytosis of Candida albicans mediated by dectin-1 and mannose receptors.

The activities of dectin-1 and mannose receptors on phagocytosis of Candida albicans and the production of TNF-α by macrophages from mice pretreated for 3 days with extract of Artocarpus intergrifolia seeds (jack extract), Artin M or jacalin were studied. Macrophages from these mice were coincubated with C. albicans CR15 (yeast), in the presence of mannose (50mM) plus mannan (100 µg) or laminarin (1mg). Phagocytosis was significantly enhanced to 52% in macrophages from mice pretreated intraperitoneally for 3 days with jack extract (500 µg/250 µl PBS). Reduction in phagocytosis from 52% to 34% (P<0.05) occurred in the presence of mannose receptor inhibitors and from 52% to 16% (P<0.01) in the presence of dectin-1 inhibitor laminarin, whereas only 20% of control macrophages phagocytosed blastoconidia. Similar results were verified for pretreatment of mice with Artin M (2.5 µg/250 µl PBS), but not for jacalin (25 µg/250 µl PBS). Macrophages from mice pretreated 3 days previously with jack extract or Artin M and then coincubated for 2h with C. albicans presented a significant increase in TNF-α production, correlating with significantly less transition of yeast to filamentous forms compared to pretreatment with jacalin. These results suggest that Artin M, but not jacalin present in jack extract significantly increased TNF-α production and the activity of mannose and dectin-1 receptors.

[Enteropathogens relating to diarrhea in HIV patients on antiretroviral therapy]. / Enteropatógenos relacionados à diarréia em pacientes HIV que fazem uso de terapia anti-retroviral.

The etiology of the diarrheic process in AIDS may be caused by viruses, bacteria, fungi, protozoa or helminths, as well as HIV itself. This study evaluated enteropathogens relating to diarrhea in HIV patients who were on antiretroviral therapy. The parasitological methods used were Faust, Hoffmann and Kinyoun. Isolation and culturing of fungi were carried out in accordance with the methodology recommended by the NCCLS M27-A standard. The yeast species were identified using the polymerase chain reaction (PCR). Bacteria were isolated on MacConkey and SS agar and the species were identified using Enterokit B (Probac do Brasil) and biochemical methods. Forty-nine patients were evaluated: 44.89% presented enteroparasites and 48.1% presented Candida sp, of which 61.5% were Candida albicans, 7.6% were Candida sp and 30.7% were Candida non-albicans. Bacteria were isolated from 72% of the patients, of which 49% were Escherichia coli, 13% Salmonella parathyphi, Klebsiella sp or Proteus and 6% Citrobacter freundii or Yersinia sp. There was high prevalence of Candida sp in HIV patients with diarrhea and non-albicans species were isolated. Their presence could be taken to mean that they were accomplices in or causes of the infection.

Enteropatógenos relacionados à diarréia em pacientes HIV que fazem uso de terapia anti-retroviral / Enteropathogens relating to diarrhea in HIV patients on antiretroviral therapy

A etiologia do processo diarréico na AIDS pode ser causada por vírus, bactérias, fungos, protozoários e helmintos, assim como pelo próprio HIV. Este trabalho avaliou enteropatogenos relacionados à diarréia em pacientes HIV que fazem uso de terapia anti-retroviral. Os métodos parasitológicos utilizados foram Faust, Hoffmann e Kinyoun. O isolamento e cultura dos fungos foram realizados conforme metodologia recomendada por NCCLS M27-A standard. A identificação das espécies de leveduras foi realizada através da reação em cadeia da polimerase. O isolamento de bactérias, foi feito em agar Mac Conkey e agar SS, a identificação das espécies através do Enterokit B (Probac do Brasil) e métodos bioquímicos. Foram avaliados 49 pacientes, 44,9 por cento apresentaram enteroparasitas, 48,1 por cento Candida sp com 61,5 por cento Candida albicans, 7,6 por cento Candida sp e 30,7 por cento Candida não- albicans. Foram isoladas bactérias de 72 por cento dos pacientes, 49 por cento Escherichia coli, 13 por cento Salmonella parathyphi, Klebsiella sp ou Proteus e 6 por cento Citrobacter freundii ou Yersinia sp. Houve alta prevalência de Candida sp nos pacientes HIV com diarréia e foram isoladas espécies não albicans cuja presença pode ser entendida como cúmplice ou causa da infecção.

The etiology of the diarrheic process in AIDS may be caused by viruses, bacteria, fungi, protozoa or helminths, as well as HIV itself. This study evaluated enteropathogens relating to diarrhea in HIV patients who were on antiretroviral therapy. The parasitological methods used were Faust, Hoffmann and Kinyoun. Isolation and culturing of fungi were carried out in accordance with the methodology recommended by the NCCLS M27-A standard. The yeast species were identified using the polymerase chain reaction (PCR). Bacteria were isolated on MacConkey and SS agar and the species were identified using Enterokit B (Probac do Brasil) and biochemical methods. Forty-nine patients were evaluated: 44.89 percent presented enteroparasites and 48.1 percent presented Candida sp, of which 61.5 percent were Candida albicans, 7.6 percent were Candida sp and 30.7 percent were Candida non-albicans. Bacteria were isolated from 72 percent of the patients, of which 49 percent were Escherichia coli, 13 percent Salmonella parathyphi, Klebsiella sp or Proteus and 6 percent Citrobacter freundii or Yersinia sp. There was high prevalence of Candida sp in HIV patients with diarrhea and non-albicans species were isolated. Their presence could be taken to mean that they were accomplices in or causes of the infection.