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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

SINAN-AIDS: Reported AIDS cases


SISCEL (Lab monitoring system)



Demographics and exposure categories
CD4, Cd8 and viral load
SICLOM (Monitoring of ARV dispensation)
SIM (All causes mortality)

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);
Reported between 2000 – 2006
Exposure categories:
IDUs: Simple and multiple
 MSM: Simple (gay or bisexual) and multiple


Only males

♀ - < 3% of AIDS cases among IDUs
Ministério da Saúde
Fundação Oswaldo Cruz - FIOCRUZ
MERGE
SINAN/AIDS
SICLOM
SISCEL
LINKAGE
DATABANK 1
SIM
DATABANK 2
Ministério da Saúde
Fundação Oswaldo Cruz - FIOCRUZ
Linkage

Aim: To inter-relate information from different databases,
related to a single individual



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])

Final decision after consulting four fields: the patient’s name,
his/her mother’s name, birthday; place of residence.

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 »
 1st CD4 count (unknown, >200, 200-350, 350-500,
>500)
 1st viral load (in log10 copies/ml) (unknown, >5.00,
4.00-5.00,<4.00)
 Age bracket

Ministério da Saúde
Fundação Oswaldo Cruz - FIOCRUZ
Survival analysis (cont.)
Wald test to assess covariates;
 Schoenfeld’s residuals analysis to evaluate
the adjustment;
 Inclusion of a frailty term (random effects
model, to adjust for overdispersion/
unmeasured variables).


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:




IDUs had a shorter survival time, compared to MSM (two
times smaller);
Survival time was shorter after AIDS diagnosis among
those patients without a CD4/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

Regular surveys, repeated annually/biannually:

a) Brazilian Army Conscripts Surveys - one
supplement (1999) addressing substance
use/misuse;

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

By: “Grupo de Estudos em População, Sexualidade e Aids”

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.

Complex sampling plan distributed over eight main
estimation domains, designed in multiple stages.

Inclusion of a comprehensive module on alcohol and
illicit substance use/misuse
Ministério da Saúde
Fundação Oswaldo Cruz - FIOCRUZ



Available as a supplement at:
http://www.scielosp.org/scielo.php?script=sci_
issuetoc&pid=0034891020080008&lng=en&nrm=iso
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

PROSUL project (linkage of international data); please
take a look at the poster:
Vulnerability Associated with HIV Transmission among
Drug Users in Three Countries in South America:
Argentina, Brazil, and Uruguay (1998-2004) , by Ralón, G
et al.
Monday, 4 August 2008
Poster Exhibition, Hall D
Ministério da Saúde
Fundação Oswaldo Cruz - FIOCRUZ

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