Fundação Oswaldo Cruz Epidemiology on a Shoestring Francisco

Fundação Oswaldo Cruz Epidemiology on a Shoestring Francisco Inácio Bastos with Mônica Malta and coworkers & On behalf of the “Grupo de Estudos em População, Sexualidade e Aids”

Overview: Obtaining additional information from available resources on HIV/AIDS in Brazil * Integrating existing databases - national databases - international databases * Integrating assessment of alcohol and substance use/misuse into large surveys Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Challenges on monitoring HIV morbidity and mortality in Brazil • Many administrative bases designed for different purposes, especially the management of the largest ARV program (free access to the point of delivery of ARVs) in any middle-income country • Until recently not linked for research purposes (missed opportunity) Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Brazil - Databases on HIV/AIDS n SINAN-AIDS: Reported AIDS cases n n Demographics and exposure categories SISCEL (Lab monitoring system) n CD 4, Cd 8 and viral load SICLOM (Monitoring of ARV dispensation) n SIM (All causes mortality) n n Date of death, basic and underlying causes Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Inclusion criteria for the analysis AIDS cases among adults (≥ 18 y old); n Reported between 2000 – 2006 n Exposure categories: n IDUs: Simple and multiple n MSM: Simple (gay or bisexual) and multiple n n Only males n ♀ - < 3% of AIDS cases among IDUs Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

MERGE SINAN/AIDS SICLOM SISCEL LINKAGE DATABANK 1 DATABANK 2 Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ SIM

Linkage n Aim: To inter-relate information from different databases, related to a single individual n n n Probabilities defined a priori; Use of common fields, such as name of the patient and his/her mother’s name; Pairing (A: no match; B: perfect match; C: imperfect match [gray zone]) n Final decision after consulting four fields: the patient’s name, his/her mother’s name, birthday; place of residence. n Software Reclink® 3. 0 Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Survival analysis 1. Kaplan-Meier curves and log rank tests for: «IDU» vs. «MSM » n 1 st CD 4 count (unknown, >200, 200 -350, 350 -500, >500) n 1 st viral load (in log 10 copies/ml) (unknown, >5. 00, 4. 00 -5. 00, <4. 00) n Age bracket n Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Survival analysis (cont. ) n Wald test to assess covariates; n Schoenfeld’s residuals analysis to evaluate the adjustment; n Inclusion of a frailty term (random effects model, to adjust for overdispersion/ unmeasured variables). n Cox Proportional Hazard Model. Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Kaplan-Meier curve by exposure category Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Main findings: n n IDUs had a shorter survival time, compared to MSM (two times smaller); Survival time was shorter after AIDS diagnosis among those patients without a CD 4/viral load result, followed by those from strata with worse results; Non-white patients and older patients have a shorter suvival time; The inclusion of a random term did not change the main findings, but reduced the magnitude of the effects. Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Integrating assessment of substance misuse into national surveys n Regular surveys, repeated annually/biannually: n a) Brazilian Army Conscripts Surveys - one supplement (1999) addressing substance use/misuse; n b) PCAP-BR (Survey of Knowledge, Attitudes and Practices of the Brazilian Population) – regular assessment of substance use/misuse; Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

National Survey Sexual Behavior and Perceptions of the Brazilian Population concerning HIV/AIDS, 2005 n By: “Grupo de Estudos em População, Sexualidade e Aids” “ n A probabilistic plan was designed with 5, 040 sampling units obtained from the Brazilian population, with individuals aged between 16 -65 years living in Brazilian urban centers. n Complex sampling plan distributed over eight main estimation domains, designed in multiple stages. n Inclusion of a comprehensive module on alcohol and illicit substance use/misuse Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Available as a supplement at: n http: //www. scielosp. org/scielo. php? script=sci_i ssuetoc&pid=0034891020080008&lng=en&nrm=iso n n Findings from one of the papers: Bastos, FI; Cunha, CB; Bertoni, N; Grupo de Estudos em População, Sexualidade e Aids. Use of psychoactive substances and contraceptive methods by the Brazilian urban population, 2005. Rev. Saúde Pública 42(suppl. 1): 118 -126. Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Discriminatory analysis of interviewees using CHAID Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

The variable of greatest relevance in discriminating between use and nonuse of a condom was whether this last sexual intercourse was with a stable or with a casual partner. Among the individuals whose last sexual intercourse was with a stable partner, those from the youngest age group (16 -24 years) reported the most frequent use of condoms (85. 0%). Regular use of alcohol or illegal drugs modulates the use of condoms among individuals in stable relationships, for men and women aged 25 -44 years, and men aged 16 -24 years. Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Younger women (16 -34 years) reported more frequent use of at least one of these methods (59. 8%), in comparison with women aged 35 -49 years (41. 7%). Among the women who used substances, 48. 8% of the ones aged 16 -34 years did so, as well as 25. 7% of the ones aged 35 -49 years used contraceptive methods other than condoms. ► The use of substances are associated with a decrease in the use of contraceptive methods other than condoms Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ

Ongoing research n PROSUL project (linkage of international data); please take a look at the poster: Vulnerability Associated with HIV Transmission among Drug U in Three Countries in South America: Argentina, Brazil, and Uru (1998 -2004) , by Ralón, G et al. Monday, 4 August 2008 Poster Exhibition, Hall D Ministério da Saúde Fundação Oswaldo Cruz - FIOCRUZ