Paula Mendes Luz

Introduction: Despite an overall recent decline of 28% in the region, AIDS‐related deaths have increased among women in some Latin American countries. Low HIV risk perception among women may contribute to late diagnosis. We compared advanced HIV disease (AHD) at care enrolment between males and females in Latin America and the Caribbean. Methods: Adults (≥18 years old) from clinical sites in the Central and South America network for HIV epidemiology who enrolled between 2003 and 2022 were stratified by sex‐at‐birth/HIV acquisition group as females, males with male‐to‐male sexual contact and heterosexual males (HMs). We classified location as within a generalized epidemic (GE: Haiti) or a concentrated epidemic (CE: Argentina, Brazil, Chile, Honduras and Mexico). We estimated the probability of AHD (AIDS diagnosis or CD4<200 cells/µL) at enrolment in care using logistic regression models, stratifying by sex‐at‐birth/acquisition group and CE/GE setting, adjusting for age, education level and calendar year of enrolment. Results: Of 47,548 people living with HIV, 51% were from GE sites (58% females), and 49% were from CE sites (20% females, 22% HMs and 58% males with male‐to‐male sexual contact). In GE, 27.7% of persons presented with AHD (23.5% of females; 33.3% of males), while in CE, 44.9% of persons presented with AHD (37.4% of males with male‐to‐male sexual contact, 47.8% of females and 61.8% of HMs). Males in GE had higher odds of AHD compared with females (aOR: 1.48 [95% CI: 1.40–1.57]). The odds of AHD decreased from 2003 to 2022 (aOR: 0.29 [95% CI: 0.26–0.33] in GE and aOR: 0.32 [95% CI: 0.29–0.36] in CE). In sex‐at‐birth/acquisition stratified models, in CE sites, odds decreased more in males with male‐to‐male sexual contact (aOR: 0.22 [95% CI: 0.19–0.25]) than in females (aOR: 0.57 [95% CI: 0.46–0.79]) and HMs (aOR: 0.47 [95% CI: 0.38–0.58]) in 2022 versus 2003. Conclusions: In CE sites, the slight decreasing trend of AHD at enrolment among females and HMs contrasts with the steeper decline among males with male‐to‐male sexual contact. In the GE site, risk of AHD at enrolment decreased in both males and females over time. Interventions to increase awareness, improve HIV testing, and hasten linkage to care among females and HMs are needed in CE settings in addition to addressing structural and social barriers.

Introduction: Since the onset of the 2022 multinational mpox outbreak, Brazil has reported one of the highest case burdens globally, disproportionately affecting sexual and gender diverse populations. Mpox vaccination efforts in Brazil have been limited by delayed procurement, restricted eligibility criteria and structural access barriers. Understanding vaccination use, correlates of uptake and characteristics of individuals previously diagnosed with mpox is essential to guide equitable prevention strategies. Methods: We conducted an online cross‐sectional survey between August and December 2024 among individuals recruited through social media and dating apps. Eligible participants were aged ≥18 years, identified as a sexual and gender diverse person, and residing in Brazil. Primary outcomes were previous mpox vaccination and mpox diagnosis. Sociodemographic, behavioural, internalized LGBTQIAPN+phobia and HIV/sexually transmitted infections (STIs) variables were collected. Adjusted logistic regression models identified independent factors associated with both outcomes. Results: Of 9546 respondents, most were cisgender men (91.8%), aged >30 years (81.5%) and residing in capital cities (77.2%). Overall, mpox vaccination coverage was 4.9%; nearly half received only one dose, and one quarter were vaccinated outside Brazil. Previous mpox diagnosis was reported by 2.1% of respondents, with 76.5% seeking healthcare and 7.0% requiring hospitalization. Factors associated with previous mpox vaccination were self‐identification as White (aOR = 1.36; 95% CI: 1.10−1.69), more than five sex partners (aOR = 1.29; 95% CI: 1.03–1.62), living with HIV (aOR = 3.40; 95% CI: 2.59–4.47), current/prior HIV pre‐exposure prophylaxis (PrEP) use (aOR = 1.88; 95% CI: 1.41–2.53) and internalized LGBTQIAPN+phobia score (aOR = 0.80; 95% CI: 0.71−0.90). Factors associated with previous mpox diagnosis were living in capital cities (aOR = 1.88; 95% CI: 1.17–3.20), more than five sex partners (aOR = 1.93; 95% CI: 1.35−2.79), stimulant drug use (aOR = 1.61; 95% CI: 1.14–2.25), any STI diagnosis (aOR = 2.41; 95% CI: 1.74–3.33), living with HIV (aOR = 3.73; 95% CI: 2.31–6.25) and current/prior PrEP use (aOR = 2.35; 95% CI: 1.43−4.01). Conclusions: Mpox vaccination among sexual and gender diverse populations in Brazil remains critically low. Findings highlight structural barriers, including vaccine scarcity, delayed rollout and stigma, that hinder equitable vaccine access. Integrating mpox vaccination into combined HIV/STI prevention services, adopting differentiated care delivery models and partnering with community‐led organizations are essential to expanding reach, improving dose completion and reducing health inequities during ongoing and future outbreaks.

Suppression of HIV with antiretrovirals eliminates HIV transmission risk, summarized as Undetectable = Untransmittable (U = U). However, U = U literacy remains unevenly understood and shared, and stigmas persist. Equitable and accurate awareness of U = U requires culturally tailored interventions, improved provider education, and supportive policy environments beyond biomedical evidence alone.

Introduction: In Brazil, men who have sex with men (MSM) and transgender women (TGW) remain heavily affected by HIV. Long‐acting pre‐exposure prophylaxis (LA PrEP) with injectable cabotegravir (CAB‐LA) or lenacapavir (LEN‐LA) is more effective at preventing HIV acquisition than oral PrEP. Our objective was to assess the potential clinical and economic impact of offering CAB‐LA or LEN‐LA to MSM and TGW with high vulnerability to HIV acquisition in Brazil and determine the maximum cost at which they would be cost‐effective. Methods: We used the CEPAC microsimulation model of HIV prevention and treatment to evaluate two strategies for MSM and TGW aged 18−49: (1) SOC : standard‐of‐care oral PrEP at current coverage, and (2) SOC+LA : offering oral and LA PrEP (either CAB‐LA or LEN‐LA). Input parameters are derived from Brazil‐based data from 2010 to 2024 and published studies: HIV incidence (%/year, MSM: 3.4 [age 18−29 years], 1.1 [30−49 years]; TGW: 5.0 [18−29 years], 1.7 [30−49 years]), relative risk reduction, LA versus oral PrEP (66% [CAB‐LA]; 89% [LEN‐LA]), PrEP coverage (20% [oral PrEP]; 20% [LA PrEP]) and oral PrEP cost (programmatic+drug = $207/year). Outcomes include lifetime HIV risk, life expectancy (LE) and incremental cost‐effectiveness ratio (ICER) of SOC+LA versus SOC in 2024 USD/year of life saved (YLS). We identified the maximum LA PrEP cost with ICER below the established Brazilian willingness‐to‐pay threshold of $8740/YLS. Results: Compared to SOC, SOC+CAB‐LA would decrease MSM lifetime HIV risk from 21.4% to 16.8%, increase undiscounted LE from 39.0 to 39.4 years. For TGW, SOC+CAB‐ LA would decrease lifetime HIV risk from 29.5% to 23.4%, increase LE from 36.0 to 36.9 years. Results for SOC+LEN‐LA would be similar to SOC+CAB‐LA . SOC+LA would remain cost‐effective for MSM at cost below $710/year for CAB‐LA and $740/year for LEN‐LA. Findings are most sensitive to LA PrEP cost, HIV incidence, and whether and by how much LA PrEP increases coverage. Conclusions: Offering LA PrEP with cabotegravir or lenacapavir in addition to oral PrEP for MSM and TGW in Brazil could markedly improve clinical outcomes and be cost‐effective at ∼$700/year. Cost agreements are critical to ensure these prevention options are accessible in high‐incidence settings.

Despite documented increases in food insecurity (FI) during the COVID-19 pandemic, the specific impact on highly vulnerable households within distinct urban contexts, as well as the interplay of various household-level factors in exacerbating this vulnerability, remain understudied. This study investigated FI prevalence and household-level factors associated with moderate/severe FI in Complexo de Manguinhos , a complex of slums in Rio de Janeiro, Brazil, during the COVID-19 pandemic. The Comvida-1 survey was conducted between September/2020 and February/2021 and included individuals aged ≥1 year. FI was measured using the Brazilian Food Insecurity Scale. Multiple Correspondence Analysis (MCA) identified associations between household variables (family composition, income, welfare benefits, job/income losses). Multilevel logistic regression assessed associations between the dimensions identified by the MCA and moderate/severe FI. Among 3864 households, moderate/severe FI prevalence was 14.7% (95% confidence interval [CI]: 13.5-15.9) and ranged from 4 to 28% across the 16 slums comprised in the Complexo de Manguinhos . Two MCA dimensions were associated with FI: Dimension 1 represented chronic socioeconomic vulnerability, with highest contributions from Bolsa Família benefit (10.73%), multiple children in Bolsa Família (9.56%), and presence of children in the household (6.84%). Dimension 4 captured acute COVID-19 economic impacts, including job/income loss (17.24%), reduced working hours (11.44%), and reduced family income (11.30%). Each dimension increased the odds of moderate/severe FI by approximately three-fold (Dimension 1 adjusted odds ratio [aOR]=2.72, 95%CI: 2.19-3.38; Dimension 4 aOR=3.32, 95%CI: 2.42-4.55, both p < 0.001). Both chronic socioeconomic vulnerability and acute COVID-19 economic shocks significantly predicted moderate/severe FI through distinct pathways. Dimension 1 reflected structural inequities from long-term poverty; Dimension 4 captured sudden economic instability. Effective interventions require layered approaches: strengthening social protections for chronic vulnerability (e.g., enhanced Bolsa Família benefits for families with children) while implementing rapid-response mechanisms for economic crises (e.g., emergency cash transfers and job retention programs).

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy yet use and persistence among populations at high vulnerability to HIV in Brazil remains suboptimal. We sought to quantify internalized homonegativity and discrimination using multi-item validated instruments and to estimate their associations with PrEP use and discontinuation among gay, bisexual, and other men who have sex with men (MSM). A cross-sectional, web-based survey was conducted from November 2021 to January 2022, recruiting a convenience sample of MSM through dating apps and social media. The survey assessed sociodemographic characteristics, sexual behavior, substance use, HIV transmission knowledge (using the HIV Knowledge Assessment tool), internalized homonegativity (using the Reactions to Homosexuality Scale), and experiences of discrimination (using the Explicit Discrimination Scale). PrEP use was assessed with response options “I have never used PrEP” (henceforth “never used”), “I am currently using PrEP” (henceforth “current use”), and “I used PrEP in the past but stopped” (henceforth “discontinuation”). Unadjusted and adjusted associations between internalized homonegativity and discrimination and the outcomes a) “current use” of PrEP compared to “never use”, and b) “discontinuation” compared to “current use”, were estimated using logistic regression models. The analytic sample consisted of 2,840 participants, with PrEP use patterns distributed as follows: 71.3% had never used PrEP, 22.8% were current users, and 5.9% had discontinued use. Unadjusted analyses indicated negative associations between internalized homonegativity and discrimination scores with current PrEP use (with higher scores leading to decreased odds of “current use”), and positive associations with PrEP discontinuation (higher scores leading to increased odds of “discontinuation”). After adjusting for potential confounders, higher internalized homonegativity was associated with decreased odds of “current use” (adjusted odds ratio [aOR] = 0.88, 95% confidence interval [CI] = 0.78–0.99) per 1 standard deviation [SD] increase in score) and more experiences of discrimination was associated with increased odds of “discontinuation” (aOR = 1.24, 95% CI: 1.03–1.50 per 1 SD increase in score). Our findings support the hypothesis that psychological distress from self-stigmatization and discrimination undermines PrEP use and persistence. Public health strategies need to integrate stigma-reduction and culturally competent, LGBTQIAPN+-affirming services to support PrEP as an effective prevention strategy.

Background: Approximately 30% of people living with HIV in Brazil have suboptimal adherence to antiretroviral therapy (ART). Theoretical models of health behaviors and objective evidence support the role of perceived barriers in hindering health behaviors. Objective: We aimed to evaluate the psychometric properties of the perceived barriers to ART adherence (PEDIA) scale among gay, bisexual, and other men who have sex with men (MSM) and transgender and nonbinary (TGNB) persons in Brazil. Methods: Using a cross-sectional study design, we evaluated the factor structure, construct validity, convergent and discriminant factorial validity, and internal reliability of the PEDIA scale using 2 convenience samples of participants aged 18 years or older living in Brazil. Sample 2020 was recruited through an internet-based survey between February and March 2020 and Sample 2021 between May 2021 and January 2022. The study instrument included sociodemographic information, ART use, and the 3 measures of ART adherence. Using Sample 2020, we performed exploratory factor analysis (EFA) with parallel analysis to evaluate PEDIA’s factor structure. Based on the goodness of fit measures and theoretical relevance, we developed a reduced version of PEDIA (PEDIAr). Using Sample 2021, we performed a psychometric evaluation of PEDIAr, which included confirmatory factor analysis (CFA), examination of modification indexes and item-item and item-total correlations, and an assessment of its correlation with different measures of adherence to ART. Goodness of fit was evaluated based on multiple indices. Results: EFA conducted on Sample 2020 (n=1692) revealed a 2-factor structure with 3 factor loadings P=.94 and P=.55, respectively). Conclusions: PEDIAr, the 10-item reduced version of PEDIA, proved to be valid among gay, bisexual, and other MSM and TGNB persons in Brazil. This shorter instrument was able to capture 2 distinguished dimensions of the perceived barriers to adherence to ART (practical aspects and psychological aspects). By proactively identifying individuals struggling with adherence to ART, PEDIAr can facilitate timely interventions and improve personalized care.