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A scoping review of prevalence, incidence and risk factors for HIV infection amongst young people in Brazil

A scoping review of prevalence, incidence and risk factors for HIV infection amongst young people... Background: Despite young people being a key population for HIV prevention, the HIV epidemic amongst young Brazilians is perceived to be growing. We therefore reviewed all published literature on HIV prevalence and risk factors for HIV infection amongst 10-25 year olds in Brazil. Methods: We searched Embase, LILACS, Proquest, PsycINFO, PubMed, Scopus and Web of Science for studies published up to March 2017 and analyzed reference lists of relevant studies. We included published studies from any time in the HIV epidemic which provided estimates specific to ages 10-25 (or some subset of this age range) for Brazilians on either: (a) HIV prevalence or incidence; or (b) the association between HIV and socio-demographic or behavioral risk factors. Results: Forty eight publications met the inclusion criteria: 44 cross-sectional, two case-control, two cohort. Four studies analysed national data. Forty seven studies provided HIV prevalence estimates, largely for six population subgroups: Counselling and Testing Center attendees; blood donors; pregnant women; institutional individuals; men-who-have-sex-with-men (MSM) and female sex workers (FSW); four provided HIV incidence estimates. Twelve studies showed HIV status to be associated with a wide range of risk factors, including age, sexual and reproductive history, infection history, substance use, geography, marital status, mental health and socioeconomic status. Conclusions: Few published studies have examined HIV amongst young people in Brazil, and those published have been largely cross-sectional and focused on traditional risk groups and the south of the country. Despite these limitations, the literature shows raised HIV prevalence amongst MSM and FSW, as well as amongst those using drugs. Time trends are harder to identify, although rates appear to be falling for pregnant women, possibly reversing an earlier de-masculinization of the epidemic. Improved surveillance of HIV incidence, prevalence and risk factors is a key component of efforts to eliminate HIV in Brazil. Keywords: Brazil, HIV, Adolescents, Young adults, Review Background sexually transmitted infections (STIs) are elevated Young people, especially young women, are considered a amongst young people, such as being in the beginning of key population for HIV prevention interventions world- their sexual life, experimenting with high-risk behaviors wide [1]. However, targeting interventions is difficult and feeling invulnerable [2]. Although Brazil is world- when information on HIV prevalence and risk factors is renowned for its leadership in the fight against AIDS patchy or missing altogether. Several risk factors for [3–5], and even as AIDS rates are declining in many other places, Brazil is perceived to be facing a sharp in- crease in HIV infections among young people [6]. * Correspondence: g.harling@ucl.ac.uk Institute for Global Health, University College London, Mortimer Market AIDS has been a reportable condition in Brazil Centre, London WC1E 6JB, UK throughout the epidemic. Over the past 10 years the Department of Global Health and Population, Harvard T.H. Chan School of AIDS detection rate has averaged 20.5 cases per 100,000 Public Health, Boston, USA Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 2 of 13 persons per year [7]. Between 2004 and 2013, reported The aim of this study is therefore to review all pub- AIDS cases in Brazil rose by 53.2% among those aged lished evidence on HIV prevalence and incidence, and 15-19 and 10.3% among those aged 20-24 [8]. These in- how they relate to risk behaviors among different popu- creases were greater in men than in women: between lations of Brazilian adolescents between 1982 and 2015. 2005 and 2014 reported AIDS case rates per 100,000 Such information should help identify gaps in the litera- persons per year rose from 2.1 to 6.7 for 15-19 year old ture, and provide a scientific basis for the development males and from 3.4 to 4.2 among 15-19 year old females; of preventive strategies for this age group. for 20-24 year olds the rate rose from 16.0 to 30.3 among men but decreased from 15.3 to 12.0 among Methods women [7]. These differences in case rate trends are We performed a systematic search on seven electronic reflected in the changing ratio of male to female AIDS databases – PubMed, Embase, PsycINFO, LILACS, Web notifications: among 13-19 year olds this ratio fell from of Science, Scopus and ProQuest – to identify poten- 2.7:1 in 1990 to a low of 0.6:1 in 2005, before rebound- tially relevant analyses. The keywords we used for this ing to reach 1.6:1 in 2014. Notably, these rising rates are search were the MeSH terms [“HIV” or “HIV infection”], in contrast to older ages: AIDS notification rates fell in “Adolescents” and “Brazil” or similar non-MeSH terms all five-year age ranges from 30 to 49 years old between outside of PubMed. The search was conducted between 2005 and 2014. March 25th and March 31st 2017. Reference lists In contrast, HIV has not historically been a reportable were also analyzed for any potentially relevant articles condition. From 2007 to June 2015, 93,260 HIV infec- not included in the original search. We included any tions were notified in Brazil [7], however, mandatory no- conference proceedings (within Web of Science and tification of HIV infection began only in June 2014. Scopus) and dissertations (ProQuest) found in our Additionally, health service providers can notify both database searches. newly-identified and existing known cases, which makes One author analyzed all articles found by title to select epidemiologic analysis of national HIV case reports diffi- those that were potentially relevant, with a strong bias to- cult. In 2015, approximately 830,000 people were esti- wards retention. The abstracts of all studies selected based mated to be living with HIV in Brazil, a prevalence of on their titles were independently evaluated by two au- 0.40% [8]. Between 2007 and 2015, the proportion of thors (IPS and GH) and any discrepancies were kept in HIV-positive individuals reported to be the age groups the analysis. For all studies selected at the abstract stage, 10-14, 15-19 and 20-24 years old rose from 0.3%, 4.3% data were extracted using an instrument designed for this and 13.4% of all notifications to 0.3%, 6.1% and 18.2%, study, covering sociodemographic characteristics (gender, respectively. Across all ages, the male to female ratio of age group, location, race and social categories), method- notified HIV infections increased slightly from 1.9 in ology (study design, study population, data source, time 2007 to 2.2 in 2014. period of data collection, baseline sample size and loss to Given these epidemiological patterns, a review of the follow up), and outcomes (HIV prevalence or HIV inci- literature on HIV in young people in Brazil seems dence, risk behaviors). timely. Past literature reviews have discussed specific The final decision to include studies was made based aspects of HIV in adolescents and young people in on this data extraction and whether it met the inclusion/ Brazil. These studies have shown the difficulty of tran- exclusion criteria, based on independent evaluation by sitioning from childhood to adult life for adolescents two authors (IPH and GH), and a discussion of any dis- living with AIDS [9], the efficacy of preventive inter- crepancies; the third author (HK) was available for con- ventions focusing on this population [10], the situation sultation if agreement could not be reached. Our of orphans and vulnerable children [11] and the rela- inclusion criteria were that studies: (i) contained either tionship between STIs, AIDS and abuse of psycho- (a) HIV prevalence or incidence data or (b) analysis of active substances in adolescence [12]. In addition, risk factors for HIV infection; (ii) either focused on indi- several articles have analyzed risk behavior and HIV viduals aged between 10 and 25 years, or stratified their infection among adolescents in Brazil in specific popu- results by the age group of interest; (iii) included data on lations, such as users of anonymous Counselling and the Brazilian population. Conversely, our exclusion cri- Testing Centers (CTA), interns of the correctional sys- teria were: (i) lack of stratification by age, if covering a tem, pregnant women, men-who-have-sex-with-men broader age group than 10-25 years; (ii) lack of stratifica- (MSM) and others. However, there is no comprehen- tion by country, if a multinational study; (iii) lack of sive literature review putting together the results of quantitative presentation of data on prevalence, inci- these studies amongst young people, and it is difficult dence or risk factors; (iv) reporting only AIDS cases in- to see trends over time in the adolescent HIV epi- stead of HIV infections; (v) reporting only on HIV demic in Brazil. positive individuals. Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 3 of 13 Analysis Results First, we evaluated HIV prevalence in different popula- Of the 2180 unique articles identified by database tion groups. The analysis started with broader groups, searches, 470 studies were selected as potentially rele- closer to the national population level, such as users of vant for this analysis based on their titles (Fig. 1). We CTAs, blood donors and pregnant women. We then retained 128 of these based on their abstracts, although progressed to more specific groups such as residents at we were unable to obtain the full text of four of these correctional institutions, sex workers, MSM and people (all four were published before 1995). Sixty two studies who inject drugs (PWID). Second, we analyzed the asso- that otherwise met our inclusion criteria were excluded ciation between various exposures and HIV prevalence. because they did not stratify their results by age group These exposures included sociodemographic characteris- so we could extract data specific to young people, and tics – such as age, place of living and marital status – 14 other articles did not meet other inclusion criteria. and behavioral characteristics such as age of sexual de- This left 48 studies which reported either HIV preva- but, drug use, sexual preferences and sex in exchange lence or risk factors for our age group of interest and for money. were published in English, Portuguese or French We presented all crude HIV prevalence and incidence (note, we kept one study with an age range 15-26). rates reported in the studies, so long as they provided a Thirty-six of these 48 articles provided an age-specific number specific to the age range of interest. For risk fac- HIV prevalence, but not HIV risk factors; we there- tors, we presented any exposure reported to be signifi- fore report results separately for prevalence and risk cantly associated with HIV infection in the relevant age exposures. We summarize all studies included in the range. We preferentially reported adjusted measures of final analyses in Table 1. association and confidence intervals when provided. Fi- nally, when no risk factors were significantly associated, Prevalence and incidence we noted this. Forty-seven studies provided age-specific HIV preva- We did not appraise the methodological quality or risk lence or incidence estimates. of bias of the included articles, which is consistent with guidance on scoping review conduct [13]. All authors Counselling and testing Center attendees contributed to the elaboration of the discussion of the Fifteen studies studied counselling and testing center article through bibliographic search and their expertise. (CTA) attendees without focusing only on pregnant Fig. 1 Flow diagram of systematic review process Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 4 of 13 Table 1 Summary of all studies included in the systematic review First Author Location Sample (N) Data Design Main Results Reference collection Pechansky Porto Alegre RS CTA attendees 1995; 1997 Repeated HIV prevalence for <25 year [14] (1026; 390 aged <25) cross-section olds: 11.5% Alves Santos, SP CTA attendees (7794; 1996-1999 Cross-section HIV prevalence for <25 year [15] 2769 aged <25) olds: 3.1% Recent HIV infection for <25 year olds: 0.3% (based on STARHS algorithm) Bassols Porto Alegre RS Adolescent CTA 2000-2001 Cross-section HIV prevalence among boys: 4.8% [16] attendees (287) HIV prevalence among girls: 7.4% de Araújo Campos dos CTA attendees 2001-2002 Cross-section HIV prevalence for 13-19 year olds: [17] Goytacazes RJ (7386; 1129 aged non-pregnant women: 0%; 13-19; 1878 pregnant women: 0.5%; men: 12.1% aged 20-24) HIV prevalence for 20-24 year olds: non-pregnant women: 5.8%; pregnant women: 0.47%; men: 6.4% Bassols Porto Alegre RS Female adolescent CTA 2000-2001 Cross-section HIV prevalence: 7.4% [18] attendees (258) Risk factors: Composite drug risk: using illicit drugs & visiting drug using/selling places (aOR: 4.18, 95%CI: 1.47-11.8) Bassols Porto Alegre RS Adolescent CTA Not reported Cross-section HIV prevalence: 6.2% [19] attendees (402) Risk factors: SCL-90-R psychiatric score (aOR: 1.88, 95%CI: 1.06-3.34); Composite sexual behavior risk (aOR: 1.63, 95%CI: 0.98-2.70) Cook Rio de Janeiro RJ Women attending CTA 2001 Cross-section HIV prevalence for 14-19 year [20] (200; 44 aged 14-19; olds: 6.8% 97 aged 20-24) HIV prevalence for 20-24 year olds: 9.3% Bassichetto Sao Paulo SP Attendees of 4 CTAs who 2002-2004 Cross-section Risk factors: Recent infection not [21] tested positive for HIV-1 associated with age: (14-19 years (485; 14 aged 14-19.9; 82 old: 28.6%; 20-24 years old: 24.4%) aged 20-24.9) de Souza Goias state and Attendees of 15 CTAs 2003-2004 Cross-section HIV prevalence for males aged [22] Federal District (16,991; 784 male and 13-19: 1.1% 1652 females aged 13-19) HIV prevalence for females aged 13-19: 0.2% Monteiro Feira de Santana, BA Attendees of the municipal 2003-2012 Cross-section HIV prevalence for males: 1.08% [23] CTA aged 11-18 (3482; 664 HIV prevalence for non-pregnant male, 1183 non-pregnant females: 1.05% female, 1635 pregnant HIV prevalence for pregnant female) women: 0.31% de Castro Rio de Janeiro, RJ Attendees of 3 CTAs 2004-2005 Cross-section HIV prevalence for <25 year [24] (9008; 2525 aged <25) olds: 2.6% HIV incidence for <25 year olds: 0.6%/year (based on BED-CEIA test) Scheineder Santa Catarina state Attendees of 14 CTAs 2005 Cross-section HIV prevalence for females [25] (22,846; 2416 aged 10-19) aged 10-19: 0.9% HIV prevalence for males aged 10-19: 2.1% Cavalcanti Recife PE Attendees of 5 CTAs 2007-2009 Cross-section HIV prevalence for <25 year olds: [26] (32,256; 16,161 aged <25) 0.82% (95%CI: 0.68-0.97%) Recent infection for <25 year olds: 12/27 prevalent cases (based on BED-CEIA test) Pereira Feira de Santana BA Attendees of the municipal 2007-2011 Cross-section HIV prevalence for males: 3.0% [27] CTA (3768) HIV prevalence for females: 1.6% Risk factors for females: drug use (PrR = 2.1, 95%CI: 1.15-3.82); alcohol use (PrR = 2.1, 95%CI: Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 5 of 13 Table 1 Summary of all studies included in the systematic review (Continued) First Author Location Sample (N) Data Design Main Results Reference collection 1.16-3.91); married (PrR = 2.02, 95%CI: 1.09-3.75) Risk factors for males: use of drugs other than alcohol (PrR: 13.25, 95%CI: 5.12-34.28); MSM (PrR: 5.21, 95%CI: 2.57-10.57) Andrade Curitiba PR Blood Donors (213,666; 1992-1999 Cross-section HIV prevalence for <18 year olds: [28] Neto 177 aged <18, 51,670 0.56% aged 18-25) HIV prevalence for 18-25 year olds: 0.14% Kupek Santa Catarina state Blood Donors (293,725; 2007-2013 Cross-section; HIV prevalence for 16-24 year olds: [29] 95,797 aged 16-24) Cohort 1.22% (95%CI: 1.01-1.46) HIV incidence for 16-24 year olds: 0.28 per 100PY (95%CI: 0.20-0.37) Seroprevalence rose throughout the study period for males but for females it rose only until 2012, then declined. Souza Recife PE Pregnant women seeking 1993 Cross-Section 0 pregnant women aged <21 [30] antenatal care (1000; 0.9% out of ~325 were HIV+ aged <15, 31.6% aged 15-20) de Freitas Sao Paulo SP HIV-positive pregnant women 1991-2002 Cross-section Recent HIV infection for 15-19 [31] Oliveira seeking antenatal care (106; year olds: 10% 10 aged 15-19, 28 aged 20-24) Recent HIV infection for 20-24 year olds: 17.9% (based on STARHS algorithm) No significant association between age and recent infection status Reiche Londrina PR Pregnant women at a 1996-1998 Cross-section HIV prevalence for 10-20 year [32] teaching hospital (1473; olds: 1.0% 290 aged 10-20) Souza Campina Grande PB Pregnant women at prenatal 2001 Cross-section HIV prevalence for 14-19 year [33] services (386; 127 aged olds: 0.0% 14-19; 140 aged 20-25) HIV prevalence for 20-25 year olds: 0.07% de Macedo Cuiabá MT Postpartum women (1607; 2001-2002 Cross-section HIV prevalence for 15-20 year [34] Orione 575 aged 15-20; 525 aged olds: 0.5% 21-25) HIV prevalence for 21-25 year olds: 0.4% Figueiró-Filho Campo Grande, MS Pregnant women at prenatal 2002-2003 Cross-section HIV prevalence for <21 years [35] services (35,512; 9906 old: 0.2% aged 11-20) No significant association between age and HIV serostatus Cardoso 27 Southern Brazil Pregnant women attending 2003 Cross-section HIV prevalence for 12-25 year [36] cities CTAs (8002; 4630 aged 12-25) olds: 0.5% Costa Goiania GO Pregnant women at prenatal 2004-2005 Cross-section HIV prevalence for 12-19 year [37] services (28,561, 6664 olds: 0.03% aged 12-19) Costa Feira de Santana BA Pregnant women aged <25 2004 - 2008 Cross-section HIV prevalence for ≤16 year [38] at prenatal services (3030) olds: 0.3% HIV prevalence for 17-19 year olds: 0.5% HIV prevalence for 20-24 year olds: 0.1% Pinho- Campinas, SP Pregnant women at prenatal 2005-2013 Cross-section HIV prevalence for 10-19 year [39] Pompeu services (458 aged 10-19) olds: 1.97% There was a positive association between anemia and HIV infection (p = 0.02) Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 6 of 13 Table 1 Summary of all studies included in the systematic review (Continued) First Author Location Sample (N) Data Design Main Results Reference collection de Melo Sergipe state Pregnant women at prenatal 2007 Cross-section HIV prevalence for [40] Inagaki services (9550; 24.9% aged 10-19 year olds: 0.09% 10-19) Moura Maceió, AL Pregnant women at prenatal 2007-2012 Cross-section HIV prevalence for [41] services (54,616; 17,231 <19 year olds: 0.3% aged <19) Miranda National Women in labor at public 2009 Cross-section HIV prevalence: 0.7% [42] hospitals (2071) Risk factors: Living in the North region (aOR: 2.0 95%CI: 1.07-3.73); STI history (aOR: 42.5, 95%CI: 1.89-168.49) Ferezin 29 cities in Paraná Pregnant women at a 2010 Cross-section HIV prevalence for 14-19 year [43] state teaching hospital (1534; olds: 0.3% 354 aged 14-19) Domingues National Pregnant women (23,894; 2011-2012 Cross-section HIV prevalence for 12-19 year [44] 4570 aged 12-19) olds: 0.14% Pinto Belo Horizonte MG Inmates in a youth 1989-1991 Case-control HIV prevalence for street-based [45] correctional institute (394; youth: 2% 195 previously street-based, HIV prevalence for home-based 199 previously home-based) youth: 0% Risk factors: 2 of 3 HIV-positive males reported using injection drugs; all HIV-positive youths reported heterosexual activity Zanetta Sao Paulo SP Inmates in a youth 1994 Cross-section HIV prevalence for females: 10.3% [46] correctional institute (1215) HIV prevalence for males: 2.6% Risk factors for females: Commercial sex work (OR = 5.98 (95%CI: 1.04-34.30) Risk factors for males: HCV seropositivity [OR = 26.5 (95%CI: 8.83-79.70)]; age > 18 [OR = 3.45 (95%CI: 1.21-9.86)]; PWID [OR = 3.39 (95%CI: 1.10-10.4) Coelho Ribeirão Preto, SP Inmates in a correctional 2003 Cross-section HIV prevalence for 19-24 year [47] institute (333; 96 aged <25) olds: 0.09% Fialho Salvador BA Incarcerated youth aged 2004-2005 Cross-section HIV prevalence: 0.34% [48] 11-18 (297) Harrison Rio de Janeiro, RJ High-risk HIV- MSM recruited 1995-1997 Cohort HIV incidence for <20 year olds: [49] at HIV testing sites and MSM 8.4 (95%CI: 1.7-15) per 100PY venues (750; 242 aged <25) HIV incidence for 20-24 year olds: 3.9 (95%CI: 1.7-6.1) per 100PY Age < 25 was associated with HIV seroconversion (aRR = 2.6, 95%CI: 1.3-5.6) Szwarcwald National Military conscripts (1997: 1997-2002 Cross-section HIV prevalence (2002): 0.09% [50] 9844; 1998: 30,318; 1999: Risk factors: positive syphilis test 29,373; 2000: 23,659; 2002: OR = 5.72 (95%CI: 1.32-24.9), MSM 30,970) OR = 4.06 (95%CI: 1.29-12.8), At least 1 STI related problem OR = 2.76 (95%CI: 1.18-6.45), More than 10 lifetime sexual partners OR = 2.33 (95%CI: 1.05-5.18), Resident of Southern Brazil OR = 2.77 (95%CI: 1.10-6.99) Soares Campinas SP MSM (658; 167 aged 2005-2006 Cross-section HIV prevalence for 14-19 year [51] 14-19, 190 aged 20-24) olds: 2.9% HIV prevalence for 20-24 year olds: 5.9% Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 7 of 13 Table 1 Summary of all studies included in the systematic review (Continued) First Author Location Sample (N) Data Design Main Results Reference collection Szwarcwald National Military conscript personnel 2007 Cross-section HIV prevalence overall: 0.1% [52] aged 17-21 (35,432, of HIV prevalence for MSM: 1.2% whom ~800 report being Risk factors: being MSM MSM) OR = 11.16 (95%CI: 4.90-25.39); having at least one STI-related problem OR = 2.53 (95%CI: 1.20-5.36); >10 lifetime partners OR = 2.52 (95%CI: 1.21-5.25) Guimarães Belo Horizonte, MG MSM (272; 113 aged <24) 2010 Cross-section HIV prevalence for <24 year [53] olds: 2.8% de Souza São Paulo, SP MSM (771; number aged 2011-2012 Cross-section HIV prevalence for 18-24 year [54] <25 not reported) olds: 6.4% (95%CI: 3.5-11.5%) Trevisol Imbituba SC Female sex workers (90; 44 2003-2004 Cross-section HIV prevalence for <26 year [55] aged <26) olds: 6.8% Schuelter- Santa Catarina state Sex workers (147; 57 aged 2009 Cross-section HIV prevalence for 18-24 year [56] Trevisol 18-24) olds: 5.3% Costa Porto Alegre, RS Male to Female transsexuals 1998-2014 Cross-section HIV prevalence for 18-26 year [57] (284; 128 aged 15-26) olds: 14.8% Freitas- Rio Branco, AC Attendees of immunization 1999 Cross-section HIV prevalence: 0% [58] Carvalho campaign (390; 118 aged 12-21) Codes Salvador, BA Women attending a public Not reported Cross-section HIV prevalence for <21 year [59] family planning clinic (202; olds: 0% 70 aged <22; 77 aged 22-25) HIV prevalence for 22-25 year olds: 4% Szwarcwald Recife, PE and General population (902 in 2013 Cross-section HIV incidence for 13-24 year [60] Curitiba, PR Recife; 1013 in Curitiba) olds in Curitiba, PR: 0.060%/year (18.8% of all HIV-positive) HIV incidence for 13-24 year olds in Recife, PE: 0.059% (19.4% of all HIV-positive) Silveira Pelotas RS HIV-positive women (144; 11 1999-2000 Case-control Risk factors: Odds of being [61] aged 15-19, 39 aged 20-24); (controls); HIV-positive were higher for AIDS-diagnosed women 2003-2004 15-19 year olds (OR: 3.0, 95%CI: (130; 7 aged 15-19, 13 aged (cases) 1.4-6.6) and for 20-24 year olds 20-24); door-to-door (OR: 6.2, 95%CI: 1.4-11.4) than interviewed controls (1537; for those aged ≥40 151 aged 15-19, 240 aged 20-24) All sample sizes cited are analytic, and thus do not include non-respondents. CTA Counselling and testing center, MSM Men who have sex with men, PWID People Who Inject Drugs, STI Sexually Transmitted Infection, STARHS Serologic Testing Algorithm for Recent HIV Seroconversion, OR Odds Ratio, aOR Adjusted Odds Ratio, PrR Prevalence Ratio, 100PY 100 person-years women. The HIV seroprevalence of individuals attending Campos dos Goytacazes, RJ aged 13 to 19 had a sero- CTAs in Porto Alegre in 1995 and 1997 was 11.5% prevalence of 0% among non-pregnant women, 0,50% amongst under 25 year olds [14]. Young age was found among pregnant women and 12,1% among men [17]. In to be protective for HIV infection (adjusted Odds Ratio addition, amongst 20 to 24 years old, non-pregnant [aOR] for 25-60 vs <25: 1.7; 95%CI: 1.1-2.7), however women had a prevalence of 5,8%, pregnant women this study was not stratified by gender. The HIV preva- 0,47% and men 6,4%. Female members of an expanded lence among clients aged under 25 years old in a CTA sample of 13-20 year old females attending this CTA in Santos, SP between 1996 and 1999 was 3.1%, of which over the same period had an HIV prevalence of 7.4% 0.3% were diagnosed as recently infected based on the [18]. The same authors report an HIV prevalence of serologic testing algorithm for recent HIV seroconver- 6.2% in another overlapping group of adolescents visit- sion (STARHS) [15]. Adolescents aged 13-20 attending a ing the clinic [19], although they did not report when CTA in Porto Alegre, RS in 2000-01 had an overall HIV the data was collected within the article. Women attend- seroprevalence of 6.4%: 4.8% among males; 7.2% among ing a CTA in Rio de Janeiro in 2001 had an HIV preva- females [16]. Between 2001 and 2002, users of a CTA in lence of 6.8% amongst 14-19 year olds and 9.3% Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 8 of 13 amongst 20-24 year olds [20]. Between 2002 and 2004, Pregnant women Bassichetto et al. found that among HIV-positive adoles- Sixteen studies reported HIV prevalence amongst preg- cents and young adults, 28.6% of 14-19 year olds and nant women. In 1993, none of approximately 325 preg- 24.4% of 20-24 year olds were diagnosed as recently in- nant women aged 20 years or younger seen in an fected based on STARHS, and that these proportions antenatal service in Recife were found to be HIV- were higher than in older age groups [21]. positive [30]. One study measured HIV incidence In 2003-04 HIV prevalence in CTAs in Goiás and amongst 106 women living with HIV seeking antenatal Federal District states in Central Brazil was 1.1% care in Sao Paulo, SP from 1991 to 2002 [31]. The au- among males and 0.2% among females aged 13- thors estimated, based on STARHS, that 10% of those 19 years [22]. From 2003 to 2012, HIV prevalence aged between 15 and 19, and 17.9% of those aged 20-24, amongst 11-18 year olds attending CTAs in Feira de years old had been infected within the past 6 months; Santana, BA was 1.08% for males and 1.05% for non- however, this difference was not statistically significant. pregnant women [23].Between 2004 and 2005, the From 1996 to 1998, HIV prevalence for 10-20 year old prevalence of HIV infection among people aged under pregnant females attending a teaching hospital in north- 25 years old testing in a CTA in Rio de Janeiro, RJ, ern Parana was 1% [32]. In Campina Grande, PB in was 2.6% (95%CI: 1.9-3.2) and the estimated incidence 2001, women testing for HIV during antenatal care, had (based on IgG BED capture enzyme immunoassay an HIV prevalence of 0% amongst 14-19 year-olds and [BED-CEIA]) was between 0.56 and 0.87%, depending 0.07% amongst those aged 20-25 [33]. Between 2001 and on the estimation method used [24]. In 2005, females 2002, postpartum women aged 15-20 in three public and males aged 10-19 years old attending CTAs in hospitals in Cuiabá, MS had an HIV prevalence of 0.5%, SantaCatarinahad an HIVprevalenceof0.9%(95%CI: while those aged 21-25 had a prevalence of 0.4% [34]. 0.5-2.3) and 2.1% (95%CI: 1.1-3.1), respectively [25]. In Mato Grosso do Sul state between 2002 and 2003, Adolescents represented 16.3% of females and 9.5% of HIV prevalence among pregnant women aged 11- males who accessed these services, and their preva- 20 years old was 0.2% [35]. A prevalence of 0.5% lence was lower than the overall prevalence of 2.0% (95%CI: 0.3–0.6) was seen in pregnant women aged 12- among women and 5.6% among men. In 2007-2009, 25 attending CTAs in southern Brazil in 2003 [36]. From HIV prevalence among users of CTAs under 25 years 2003 to 2012, HIV prevalence amongst pregnant 11- in Recife, PE was 0.82% (95%CI: 0.68-0.97) [26]. In 18 year olds attending CTAs in Feira de Santana, BA addition, this study found that of the 27 individuals was 0.31% [23]. In 2004-2005, a prevalence of 0.03% was aged under 25 who tested positive for HIV, 12 were found among pregnant women aged 12-19 who were classified as recent infections based on BED-CEIA. seeking antenatal care in Goiania, GO [37]. Between From 2007 to 2011, in a study of adolescents and 2004 and 2008 in Feira de Santana, BA, HIV prevalence young adults aged between 13 and 24 years old at- among pregnant women testing for HIV during ante- tending a CTA in Feira de Santana, BA was found an natal care aged <16, 17-19 and 20-24, was 0,3, 0,5 and overall HIV prevalence of 1.94% in the population, 0,1% respectively [38]. Data from 2005 to 2013 found a specifically 3.0% among males and 1.6% among HIV prevalence of 1.97% among pregnant teenagers females [27]. aged between 10 and 19 with maternal anemia receiving prenatal care in Campinas, SP [39]. HIV prevalence in Blood donors women during antenatal care in 2007 in Sergipe state Two articles studied the prevalence of HIV among blood was found to be 0.09% amongst women aged 10-19 donors. Between 1992 to 1999, the HIV prevalence in blood (95%CI: 0.01-0.3) [40]. In Maceio, AL between 2007 and donors aged 18-25 in Curitiba, PR was 0.14% [28]. This age 2012, the HIV prevalence amongst pregnant women group presented the highest number of donations and the aged 15-26 years was 0.3% [41]. A nationwide analysis of highest number of HIV cases (although HIV prevalence 15-24 year-old women in labor in 2009 found a preva- rates were higher amongst 26-35 year old donors). Between lence of 0.7% (95%CI: 0.4–1.1) [42]. 2007 to 2013, after the implantation of NAT screening, In the northwestern region of Parana, in 2010, there HIV prevalence amongst blood donors aged 16-24 in Santa was a prevalence of 0.3% among 14-19 year old women Catarina was 1.22% (95%CI: 1.01–1.46); an analysis of re- attending a teaching hospital [43]. A national study con- peat donors in this age group showed an HIV incidence of ducted in 2011-2012 found a HIV prevalence of 0.14% 0.28 (95%CI: 0.20–0.37) per 1000 person-years [29]. The among pregnant women aged 12-19 [44]. same article reported a sharp increase in HIV prevalence over time among 16-24 year old male donors; a similar rise Institutional settings was observed for young women until 2012, followed by a Four articles focused in youth in institutional settings. sharp decline. Between 1989 and 1991, HIV prevalence among 10- Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 9 of 13 18 year olds admitted to a state-run shelter for homeless 25 year-olds were HIV-positive [59]. In 2013, a study es- and youth offenders in Belo Horizonte, MG was 2% [45]. timated the HIV incidence for 13-24 year olds in the In 1994, a sample of 12-21 year old youths in a similar general population in the cities of Recife, PE and Curi- institution in São Paulo had an HIV prevalence of 10.3% tiba, PR to be 0.06% in both cities, using Sedia™ HIV- for females and 2.6% for males [46]. In 2003, the preva- 1LAg-Avidity tests [60]. lence of HIV infection amongst 19-24 years old in an in- stitutional setting in Ribeirão Preto, SP was 0.09% [47]. Risk exposures In 2004-2005, only one case was found among 297 in- Twelve studies provided information on risk exposures carcerated youth in Salvador, BA, representing a preva- in age groups falling entirely within our inclusion criteria lence of 0.34% (95%CI: 0.02–2.16) [48]. (i.e. 10–25 years old). Men-who-have-sex-with-men Counseling and testing center attendees Six articles studied MSM. In a cohort of 18-50 year old Four of the articles studying CTA attendees reported as- MSM in Rio de Janeiro between 1995 and 1997, 18- sociations between risk factors and HIV infection. First, 19 year olds had an incidence rate of 8.4 (95%CI: 1.7-15) Bassols and colleagues reported in two articles that sev- per 100 person-years, and 20-24 year olds had rate of eral sexual and drug behaviours were positively associ- 3.9 (95%CI: 1.7-6.1) per 100 person-years [49]. The same ated with HIV infection amongst CTA attendees in study found 18-24 year olds were significantly more Porto Alegre [18, 19]. In the earlier study, HIV seroposi- likely to seroconvert than those aged 25-50 [adjusted In- tivity was also positively associated with early sexual ini- cidence Rate Ratio (aIRR) = 2.6 (95%CI: 1.3–5.6)]. In a tiation (<12 years old) and unprotected sexual stratified random sample of 30,970 literate 2002 Brazil- intercourse with a male partner (whether the respondent ian military conscripts, overall HIV prevalence was was male or female). Second, Bassichetto et al. showed 0.09% (95%CI: 0.05-0.12%), while that amongst MSM that in Sao Paulo 78.9% of CTA users testing positive was 0.56% (95%CI: 0.00-1.12%) [50]. In 2005 and 2006in and aged 14-25 were single, and that sexual exposure the Campinas, SP metropolitan area HIV prevalence was was responsible for 98.7% of cases [21]. Although 40% of 2.9% amongst 14-19 year-old MSM, and 5.9% in 20- seropositive subjects were PWID, blood-to-blood trans- 24 year old MSM [51]. In a second sample of 2007 Bra- mission was not thought to be responsible for any infec- zilian military conscripts, HIV prevalence among MSM tions in this sample. Third, Pereira et al. found the was 1.23% (95%CI: 0.34-2.13) compared to 0.11% association between HIV infection and marital status to (95%CI: 0.07-0.16) in the overall sample [52]. In 2010, vary by gender for CTA attendees in Feira de Santana: prevalence amongst 18-24-year-old MSM in Belo Hori- 78.6% of HIV positive men were unmarried while 61.9% zonte, MG was 2.8% [53]. Data from late 2011 and early of infected women were married or in a stable relation- 2012 reports a prevalence of 6.4% in MSM 18-24 year- ship [27]. Among females, drug use, alcohol use, less olds in São Paulo, SP [54]. than 8 years of schooling, reporting multiple partners and being married were associated with HIV infection. Female sex workers Among males, use of drugs other than alcohol, having Two studies considered female sex workers (FSW). In more than 8 years of schooling and identifying as MSM 2003 and 2004, there were 3 HIV-positive FSW in a were positively associated with HIV infection. sample of 44 FSW aged under 26 (6.8%) in Imbituba, SC [55], while a 2009 study of predominantly-female sex Pregnant women workers in the southern cities of Santa Catarina state, in- One study in Campinas, SP found HIV-positive pregnant cluding Imbituba, reported a prevalence of 5.3% amongst adolescents to have higher rates of anemia than their the 57 individuals aged 18-24 [56]. HIV-negative peers [39]. One national study found that among pregnant women in labor, living in the North re- Other groups gion and an STI history were positively associated with Male to female transsexuals aged 15 to 26 seeking sex HIV infection [42]. A third study found no significant reassignment surgery between 1998 and 2014 in from association between age at pregnancy and HIV- Porto Alegre, RS had an HIV prevalence of 14.8% [57]. seropositivity within 11-20 year olds in Mato Grosso do In 1999, in Rio Branco, AC, a northern city in the Ama- Sul state [35]. zonian region with many indigenous citizens, no 12- 21 year old attending an immunization campaign tested Institutional settings positive for HIV [58]. In 2002, none of the 70 women Two studies studied associations between risk behaviors aged 18-21 attending a public family planning clinic in and HIV infection among adolescents in institutional Salvador, BA were HIV seropositive; however 4% of 22- settings. In Belo Horizonte, all three HIV-positive males Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 10 of 13 in a study of street- and home-based youth between 1989 reported AIDS rates (Florianópolis SC, Manaus AM, São and 1991 reported heterosexual activity, and two of them Luís MA and Belém PA) have no published studies re- reported injection drug use [45]. Amongst street-involved garding young people and HIV. The literature’s focus in youth in São Paulo, HIV infection was associated with sex the South is supported by two of the three states of this work for women, and history of STIs, Hepatitis C sero- region having the second- and third-highest reported positivity and use of illegal drugs among men [46]. AIDS rates in the country, and by the fact that almost 75% of the AIDS cases identified in Brazil from 1980 Other groups until June of 2015 were in the South and Southeast re- Several predictors for HIV infection were reported gions [7]. While these higher reporting rates may reflect among military conscripts in 2002: a positive syphilis these regions wealth, and therefore ability to diagnose test; identifying as MSM; any STI-related problem; more AIDS cases, it may also reflect that the body of literature than 10 lifetime sexual partners; or residence in the reflects past history of the HIV epidemic, rather than South region [50]. By 2007, syphilis positivity and resi- the current situation. It is also notable that many studies dence in the South region had ceased to be significant were conducted in state capital cities, and even those predictors, but the others remained [52]. Finally, 15- studies conducted elsewhere were often conducted in 19 year olds had 2.4 times the odds of being HIV- university campus cities, such as Campos dos Goyta- infected compared to those aged 20-24 in a case-control cazes [17], Feira de Santana [27, 38], Londrina [32] or study of HIV-positive women in Pelotas, RS [61]. Campina Grande [33]. All these trends highlight a clear need for additional research in non-traditional risk areas Discussion of Brazil. In this study, we reviewed all published evidence on HIV Second, a large proportion of infections amongst both prevalence and risk factors for infection amongst 10- adolescents and young people were recent: 9.6% of HIV- 25 year olds in Brazil. A key finding of our review is the positive individuals aged under 25 in Santos [15]; 17.9% lack of comprehensive data regarding risk behaviors for of HIV-positive 20-24 year olds attending antenatal care HIV infection either through studies specifically in Sao Paulo [31]; 18.8% and 19.4% of HIV-positive 18- amongst adolescents, or stratified for this age group. 24 year olds Recife and Curitiba respectively in 2013 Most of the studies we identified covered a broad age [60]; 25% of HIV-positive 15-24 year olds in Sao Paulo range, from adolescence up to senior ages, and in most CTAs [21]; and 44.4% of HIV-positive adolescents seek- cases HIV prevalence, but not risk factors, were strati- ing care in Recife CTAs [26]. While unsurprising, fied by age group. In some cases, the stratification given the briefer sexual history of younger people and grouped young and middle-aged adults in the same age the predominantly sexual transmission route for HIV group (e.g. 20 to 40 years old), which limited their use- in Brazil, these data highlight the importance of de- fulness for understanding risks amongst young people. veloping preventive strategies focusing this age group, While analyses of wider age ranges and the conditions of based on the behavioral risk factors to which they are already-infected individuals appear quite common, fo- more susceptible. cused evidence of the extent, and predictors, of young Third, the literature highlights some groups of young Brazilians’ risk of HIV infection remains limited. As a re- people at increased risk of HIV infection. HIV infection sult, we were not able to conduct a quantitative assess- rates are high among MSM, and are rising relative to the ment of any outcome using meta-analysis. general population. Two nationwide studies of military Despite its limitations, some important themes can be conscripts in 2002 and 2007 reported HIV prevalence seen in the literature reviewed. First, the geographic among MSM of 0.56% and 1.23% respectively, while the coverage of the literature was limited. Of the 48 articles overall population prevalence remained stable [50, 52]. included in the final analysis, 14 were conducted in the HIV prevalence was even higher amongst sex workers, South region and 14 in the Southeast region, while ten with an HIV prevalence of 6.8% [55] and 5.3% [56] were in the Northeast, four in the Center-West and one amongst sex workers aged under 26 in two studies in in the North region of Brazil (four were national and Santa Catarina state. Sex workers are well-recognized as one covered cities in both the South and Northeast). Ac- being at higher risk of HIV infection; HIV prevention cording to the last HIV Epidemiological Bulletin released policies focused on younger sex workers may be particu- by the Brazilian Ministry of Health in 2015, AIDS cases larly important. Finally, there may be a downward trend are increasing in the Center-West, North, and Northeast in decreasing the infection rates amongst pregnant regions in the general population, and two of the four women, at least in one setting: HIV prevalence among states with the highest AIDS reporting rates (Amazonas pregnant women aged between 10 and 20 in Paraná in and Roraima) are in the North [62]. At the municipal 1996-98 was 1% [32], but had fallen to 0.3% among 14- level, the state capitals with the second to fifth highest 19 year old pregnant women by 2010 [43]. Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 11 of 13 Fourth, several behaviors were reported as predictors HIV prevalence since self-perceived risk for STI infection of HIV infection. Use of illicit drugs or attending drug- is a key predictor of attendance. using/selling places was consistently associated with in- creased HIV risk [18, 27, 46, 61]. In addition, a history Conclusion of STIs was also associated with HIV infection in more Our review of the literature on HIV prevalence, inci- than one study [42, 46, 50]. Interestingly, being in a dence and risk factors in Brazil suggests that there is an stable relationship was associated with HIV infection unmet need for research into HIV risk patterns in the among women while being unmarried was associated country. This is particularly true given suggestions in the with infection among men [27]. This may reflect the literature that HIV prevalence may have been increasing higher risk for HIV amongst MSM. Somewhat surpris- among adolescents in recent years. The 2014 change in ingly, in no study was past condom use associated with the law to require medical staff to notify the government infection rates; this may reflect low interest amongst re- of HIV infections may act as a spur to action for such searchers, inaccurate reporting by respondents (due to research, by providing standardized nationwide data. recall bias or intentional mis-reporting) or truly no asso- However, given the relatively low national HIV preva- ciation in the populations studied. lence, and thus relatively low HIV testing rates, amongst One topic of concern within Brazil in recent years has young Brazilians, the use of targeted, nationally repre- been the “feminization” of the HIV epidemic. This was sentative surveys of young people using biological testing reflected in research highlighting that the male to female for HIV and STIs may well also be justified. ratio of reported AIDS cases among adolescents in Rio Abbreviations de Janeiro city fell from 4.7 in the period 1984-1989 to AC: Acre state; AIDS: Acquired immunodeficiency syndrome; aIRR: Adjusted 0.5 in 2005-2009 [63], and from 24 to two nationally be- incidence rate ratio; AL: Alagoas state; aOR: Adjusted odds ratio; BA: Bahia state; BED-CEIA: BED capture enzyme immunoassay; CTA: Counselling and tween 1985 and 1999 [64]. HIV prevalence rates testing center; FSW: Female sex worker; GO: Goiás state; HIV: Human amongst 14-20 year olds were reported to have equalized immunodeficiency virus; MG: Minas Gerais state; MS: Mato Grosso do Sul by 2002 [65]. This led to the launch of a national cam- state; MSM: Men-who-have-sex-with-men; NAT: Nucleic acid testing; OR: Odds ratio; PB: Paraíba state; PE: Pernambuco state; PR: Paraná state; paign to combat the feminization of the epidemic in PrR: Prevalence ratio; PWID: People who inject drugs; RJ: Rio de Janeiro; 2007, particularly through combatting women’s vulner- RS: Rio Grande do Sul state; SC: Santa Catarina state; SP: Sao Paolo state; abilities [66]. More recently the ratio of male to female STARHS: Serologic testing algorithm for recent HIV seroconversion; STI: Sexually transmitted infection AIDS cases has again risen [7], however, young women living with HIV appear to be particularly vulnerable, Acknowledgements even amongst all women living with HIV [67]. Not applicable. Funding Strengths and limitations This work was not supported by any funders. Our analysis has the strength of considering any study published on young people and HIV since the beginning Availability of data and materials of the epidemic. Furthermore, we considered studies in All data generated or analysed during this study are included in this published article. English, French or Portuguese. Nevertheless, there were some limitations to our work. First, we considered only Authors’ contributions published literature, and it is quite possible that other un- GH conceptualized the study. IPS conducted the initial literature search and summarized the results in tables and graphs. IPS wrote the first draft of the published studies exist. We were also unable to access paper. All authors contributed to the study design, data interpretation and four of the 124 potentially relevant articles based on ab- final revisions to the text. All authors read and approved the final manuscript. stract review; however all of these were over 20 years old, Ethics approval and consent to participate and thus should not affect our review of recent epidemic Not applicable. trends. Second, our ability to make comparisons across time and space was limited by the highly varied study Consent for publication methodologies used; only when authors repeated their Not applicable. methods could we make direct comparisons. Furthermore, Competing interests almost all studies grouped together wide age ranges, mak- The authors declare that they have no competing interests. ing it difficult to stratify our findings into the typically used five-year age categories (e.g. 15-19, 20-24). Generaliz- Publisher’sNote ing beyond Brazil is also particularly difficult due to the Springer Nature remains neutral with regard to jurisdictional claims in published unique history of HIV infection and care in this country. maps and institutional affiliations. Finally, several of the studies used methods that are likely Author details make it difficult even to generalize to the whole Brazilian 1 Department of Epidemiology, Fluminense Federal University, Niterói, Brazil. population. For example CTAs are likely to have higher Institute for Global Health, University College London, Mortimer Market Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 12 of 13 Centre, London WC1E 6JB, UK. Department of Global Health and Population, 22. de Souza SM, Teles SA, Rezza G, Pezzotti P, Gir E. Epidemiology of HIV Harvard T.H. Chan School of Public Health, Boston, USA. infection in central Brazil: data from voluntary counseling and testing centers. J Assoc Nurses AIDS Care. 2013;24:503–11. Received: 6 June 2017 Accepted: 4 October 2017 23. Monteiro MdOP, Costa MCO, Vieira GO, da Silva CAL. Fatores associados à ocorrência de sífilis em adolescentes do sexo masculino, feminino e gestantes de um Centro de Referência Municipal/CRM-DST/HIV/AIDS de Feira de Santana, Bahia. Adolescencia e Saude 2015, 12:21-32. 24. de Castro CAV, Grinsztejn B, Veloso VG, Bastos FI, Pilotto JH, Morgado MG. References Prevalence, estimated HIV-1 incidence and viral diversity among people 1. Joint United Nations Programme on HIV/AIDS (UNAIDS). The gap report. seeking voluntary counseling and testing services in Rio de Janeiro, Brazil. UNAIDS: Geneva, Switzerland; 2014. BMC Infect Dis. 2010;10:224. 2. Camargo BV, Giacomozzi AI, Wachelke JFR, Aguiar A. Romantic relationships, 25. Schneider IJC, Ribeiro C, Breda D, Skalinski LM, d’Orsi E. Perfil sexual behavior and vulnerability of African-descending and white epidemiológico dos usuários dos Centros de Testagem e Aconselhamento adolescents towards HIV/AIDS. Saude Soc. 2010;19:36–50. do Estado de Santa Catarina, Brasil, no ano de 2005 epidemiological profile 3. Bastos FIPM, Kerrigan D, Malta MS. Cunha CCd, Strathdee SA. Treatment for of the clientele in HIV testing and Counseling Centers in Santa Catarina. HIV/AIDS in Brazil: strengths, challenges, and opportunities for operations Cad Saude Publica. 2008, 24:1675-1688. research. AIDScience. 2001;1:15. 26. Cavalcanti AM, Brito AM, Salustiano DM, Lima KO, Silva SP, Lacerda HR. 4. Oliveira-Cruz V, Kowalski J, McPake B. Viewpoint: the Brazilian HIV/AIDS Recent HIV infection rates among HIV positive patients seeking voluntary ‘success story’–can others do it? Tropical Med Int Health. 2004;9:292–7. counseling and testing centers in the metropolitan region of Recife – PE, 5. Greco DB, Simao M. Brazilian policy of universal access to AIDS treatment: Brazil. Braz J Infect Dis. 2012;16:157–63. sustainability challenges and perspectives. AIDS. 2007;21(Suppl 4):S37–45. 27. Pereira BS, Costa MC, Amaral MT, da Costa HS, da Silva CA, Sampaio VS. 6. Associated Press. HIV infections rise, thwart Brazil's AIDS efforts. 2014. Factors associated with HIV/AIDS infection among adolescents and young [http://www.dailymail.co.uk/wires/ap/article-2720485/HIV-infections-rise- adults enrolled in a Counseling and testing Center in the State of Bahia, thwart-Brazils-AIDS-efforts.html]. Brazil. Cien Saude Colet. 2014;19:747–58. 7. Department of Health. Boletim Epidemiológico de AIDS e DST. Brasília: 28. Andrade Neto JL, Pintarelli VL, Felchner PCZ, Morais RL, Nishimoto FL. HIV Department of STI, AIDS and Viral Hepatitis, Ministry of Health; 2015. prevalence among blood donors in a blood bank in Curitiba (Brazil). Braz J 8. Department of Health. The Brazilian response to HIV and AIDS: global AIDS Infect Dis. 2002;6:15–21. response progress reporting narrative report. Brasília, DF: Department of STI, 29. Kupek E, Petry A. Changes in the prevalence, incidence and residual risk for AIDS and Viral Hepatitis, Ministry of Health; 2015. HIV and hepatitis C virus in southern Brazilian blood donors since the 9. Machado DM, Succi RC, Turato ER. Transitioning adolescents living with HIV/ implementation of NAT screening. Rev Soc Bras Med Trop. 2014;47:418–25. AIDS to adult-oriented health care: an emerging challenge. J Pediatr. 2010; 30. Souza ES, Figueira FS, Da Silva G, Vilarim J, De Souza A, Pessoa V, et al. 86:465–72. Seroprevalence of HIV-1 among pregnant women at Recife, northeastern 10. DiClemente RJ, Salazar LF, Crosby RA. A review of STD/HIV preventive Brazil. J Acquir Immune Defic Syndr. 1995;10:486–7. interventions for adolescents: sustaining effects using an ecological 31. de Freitas Oliveira CA, Ueda M, Yamashiro R, Rodrigues R, Sheppard HW, de approach. J Pediatr Psychol. 2007;32:888–906. Macedo Brigido LF. Rate and incidence estimates of recent human 11. Franca-Junior I, Doring M, Stella IM. Crianças órfãs e vulneráveis pelo HIV no immunodeficiency virus type 1 infections among pregnant women in Sao Brasil: onde estamos e para onde vamos? Rev Saude Publica. 2006; Paulo, Brazil, from 1991 to 2002. J Clin Microbiol. 2005;43:1439–42. 40(Suppl):23–30. 32. Reiche EMV, Morimoto HK, Farias GN, Hisatsugu KR, Geller L, Gomes ACLF, 12. Morais VO, Moura MV, Costa MC, Patel BN. Sexually transmitted diseases, et al. Prevalência de tripanossomíase americana, sífilis, toxoplasmose, AIDS, and use/abuse of psychoactive substances in adolescence. J Pediatr. rubéola, hepatite B, hepatite C e da infecção pelo vírus da imunodeficiência 2001;77(Suppl 2):S190–204. humana, avaliada por intermédio de testes sorológicos, em gestantes 13. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. atendidas no período de 1996 a 1998 no Hospital Universitário Regional Guidance for conducting systematic scoping reviews. Int J Evid Based Norte do Paraná (Universidade Estadual de Londrina, Paraná, Brasil). Rev Soc Healthc. 2015;13:141–6. Bras Med Trop. 2000;33:519–27. 14. Pechansky F, Kessler F, Von Diemen L, Inciardi JA, Surratt H. Uso de 33. Souza SMB, Andrade J. Soroprevalência para HIV em gestantes substâncias, situações de risco e soroprevalência em indivíduos que buscam acompanhadas pelo Programa Saúde da Família de Campina Grande, testagem gratuita para HIV em Porto Alegre, Brasil. Rev Panam Salud Paraíba. Rev Baiana Saude Publica. 2003;27:28–37. Publica. 2005;18:249–55. 34. de Macedo Orione MA, Assis SB, Souto FJD. Perfil epidemiológico de 15. Alves K, Shafer KP, Caseiro M, Rutherford G, Falcao ME, Sucupira MC, et puérperas e prevalência de anticorpos para infecção pelo HIV e vírus da al. Risk factors for incident HIV infection among anonymous HIV testing hepatite C em Cuiabá, Mato Grosso. Rev Soc Bras Med Trop. 2006;39:163–8. site clients in Santos, Brazil: 1996–1999. J Acquir Immune Defic Syndr. 35. Figueiró-Filho EA, Senefonte FRA, Lopes AHA, Morais OO, Souza Júnior VG, 2003;32:551–9. Maia TL, et al. Frequency of HIV-1, rubella, syphilis, toxoplasmosis, 16. Bassols AM, Pechansky F, Dieder AL, Correia AG, Toniolo DP, Fabian A, et al. cytomegalovirus, simple herpes virus, hepatitis B, hepatitis C, Chagas disease Gênero, sexualidade e uso de drogas e adolescentes que realizaram o teste and HTLV I/II infection in pregnant women of state of Mato Grosso do Sul. anti-HIV em um centro de testagem gratuita de Porto Alegre. Rev Psiquiatr Rev Soc Bras Med Trop. 2007;40:181–7. Rio Grande Do Sul. 2002;24:77–84. 36. Cardoso AJ, Griep RH, Carvalho HB, Barros A, Silva SB, Remien RH. Infecção 17. de Araújo LC, Fernandes RCSC, Coelho MCP, Medina-Acosta E. Prevalência pelo HIV entre gestantes atendidas nos centros de testagem e da infecção pelo HIV na demanda atendida no Centro de Testagem e aconselhamento em Aids. Rev Saude Publica. 2007;41(Suppl 2):101–8. Aconselhamento da Cidade de Campos dos Goytacazes, Estado do Rio de 37. Costa ZB, Machado GC, Avelino MM, Gomes Filho C, Macedo Filho JV, Minuzzi Janeiro, Brasil, 2001-2002. Epidemiol Serv Saude. 2005;14:85–90. AL, et al. Prevalence and risk factors for hepatitis C and HIV-1 infections among 18. Bassols AM, Boni R, Pechansky F. Alcohol, drugs, and risky sexual behavior pregnant women in Central Brazil. BMC Infect Dis. 2009;9:116. are related to HIV infection in female adolescents. Rev Bras Psiquiatr. 2010; 32:361–8. 38. Costa MCO, Santos BC, Peixoto de Souza KE, Cruz NLA, Cajaseira Santana M, Cunha do Nascimento O. HIV/AIDS e sífilis entre gestantes adolescentes e 19. Bassols AM, Santos RA, Rohde LA, Pechansky F. Exposure to HIV in Brazilian adultas jovens: fatores de exposição e risco dos atendimentos de um adolescents: the impact of psychiatric symptomatology. Eur Child Adolesc programa de DST/HIV/AIDS na rede pública de saúde/SUS, Bahia, Brasil. Rev Psychiatry. 2007;16:236–42. Baiana Saude Publica. 2011;35:179. 20. Cook RL, May S, Harrison LH, Moreira RI, Ness RB, Batista S, et al. High 39. Pinho-Pompeu M, Surita FG, Pastore DA, Paulino DSM, Pinto e Silva JL. prevalence of sexually transmitted diseases in young women seeking HIV Anemia in pregnant adolescents: impact of treatment on perinatal testing in Rio de Janeiro, Brazil. Sex Transm Dis. 2004;31:67–72. outcomes. J Matern Fetal Neonatal Med. 2017;30(10):1158-62. 21. Bassichetto KC, Bergamaschi DP, Oliveira SM, Deienno MC, Bortolato R, de 40. de Melo Inagaki AD, de Oliveira LAR, de Oliveira MFB, Santos RCS, Araújo Rezende HV, et al. Elevated risk for HIV-1 infection in adolescents and RM, Alves JAB, et al. Soroprevalência de anticorpos para toxoplasmose, young adults in Sao Paulo, Brazil. PLoS One. 2008;3:e1423. Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 13 of 13 rubéola, citomegalovírus, sífilis e HIV em gestantes sergipanas. Rev Soc Bras 63. Taquette SR, Matos HJ, Rodrigues Ade O, Bortolotti LR, Amorim E. A epidemia Med Trop. 2009;42:532–6. de AIDS em adolescentes de 13 a 19 anos, no município do Rio de Janeiro: 41. Moura AA, de Mello MJG, Correia JB. Prevalence of syphilis, human descrição espaço-temporal. Rev Soc Bras Med Trop. 2011;44:467–70. immunodeficiency virus, hepatitis B virus, and human T-lymphotropic virus 64. Brito AM, Castilho EA, Szwarcwald CL. AIDS e infecção pelo HIV no Brasil: infections and coinfections during prenatal screening in an urban uma epidemia multifacetada. Rev Soc Bras Med Trop. 2001;34:207–17. Northeastern Brazilian population. Int J Infect Dis. 2015;39:10–5. 65. Osava M. Health-Brazil: AIDS grows dramatically among young women. Global Information Network: New York, NY; 2002. [https://search.proquest. 42. Miranda AE, Pinto VM, McFarland W, Page K. HIV infection among young pregnant women in Brazil: prevalence and associated risk factors. AIDS com/docview/457568113]. 66. Ministry of Health. Integrated plan to combat the feminization of the AIDS Behav. 2014;18(Suppl 1):S50–2. epidemic and other STDs. Brasília: National Ministry of Health; 2007. 43. Ferezin RI, Bertolini DA, Demarchi IG. Prevalência de sorologia positiva para 67. Teixeira LB, Pilecco FB, Vigo A, Knauth DR. Sexual and reproductive HIV, hepatite B, toxoplasmose e rubéola em gestantes do noroeste health of women living with HIV in southern Brazil. Cad Saude Publica. paranaense. Rev Bras Ginecol Obstet. 2013;35:66–70. 2013;29:609–20. 44. Domingues RMSM, Szwarcwald CL, Souza PRB, do Carmo Leal M. Prenatal testing and prevalence of HIV infection during pregnancy: data from the “birth in Brazil” study, a national hospital-based study. BMC Infect Dis. 2015;15:100. 45. Pinto JA, Ruff AJ, Paiva JV, Antunes CM, Adams IK, Halsey NA, et al. HIV risk behavior and medical status of underprivileged youths in Belo Horizonte, Brazil. J Adolesc Health. 1994;15:179–85. 46. Zanetta DM, Strazza L, Azevedo RS, Carvalho HB, Massad E, Menezes RX, et al. HIV infection and related risk behaviours in a disadvantaged youth institution of Sao Paulo, Brazil. Int J STD AIDS. 1999;10:98–104. 47. Coelho HC, Perdoná GC, Neves FR, Passos ADC. HIV prevalence and risk factors in a Brazilian penitentiary. Cad Saude Publica. 2007;23:2197–204. 48. Fialho M, Messias M, Page-Shafer K, Farre L, Schmalb M, Pedral-Sampaio D, et al. Prevalence and risk of blood-borne and sexually transmitted viral infections in incarcerated youth in Salvador, Brazil: opportunity and obligation for intervention. AIDS Behav. 2008;12:S17–24. 49. Harrison LH, do Lago RF, Friedman RK, Rodrigues J, Santos EM, de Melo MF, et al. Incident HIV infection in a high-risk, homosexual, male cohort in Rio de Janeiro, Brazil. J Acquir Immune Defic Syndr. 1999;21:408–12. 50. Szwarcwald CL, de Carvalho MF, Barbosa Junior A, Barreira D, Speranza FA, de Castilho EA. Temporal trends of HIV-related risk behavior among Brazilian military conscripts, 1997-2002. Clinics (Sao Paulo). 2005;60:367–74. 51. Soares CC, Georg I, Lampe E, Lewis L, Morgado MG, Nicol AF, et al. HIV-1, HBV, HCV, HTLV, HPV-16/18, and Treponema pallidum infections in a sample of Brazilian men who have sex with men. PLoS One. 2014;9:e102676. 52. Szwarcwald CL, Andrade CLT, Pascom ARP, Fazito E, Pereira GFM, Penha IT. HIV-related risky practices among Brazilian young men, 2007. Cad Saude Publica. 2011;27:s19–26. 53. Guimarães MDC, Ceccato MGB, Gomes R, Rocha GM, Camelo LV, Carmo RA, et al. Vulnerabilidade e fatores associados a HIV e sífilis em homens que fazem sexo com homens, Belo Horizonte, MG. Rev Assoc Med Minas Gerais. 2013;23:412–26. 54. Veras MA, Calazans GJ, de Almeida Ribeiro MC, de Freitas Oliveira CA, Giovanetti MR, Facchini R, França IL, McFarland W. High HIV prevalence among men who have sex with men in a time-location sampling survey, Sao Paulo, Brazil. AIDS Behav. 2015;19:1589–98. 55. Trevisol FS, Silva MV. HIV frequency among female sex workers in Imbituba, Santa Catarina, Brazil. Braz J Infect Dis. 2005;9:500–5. 56. Schuelter-Trevisol F, Custodio G, Silva AC, Oliveira MB, Wolfart A, Trevisol DJ. HIV, hepatitis B and C, and syphilis prevalence and coinfection among sex workers in southern Brazil. Rev Soc Bras Med Trop. 2013;46:493–7. 57. Costa AB, Fontanari AMV, Jacinto MM,da SilvaDC, Lorencetti EK,da Rosa Filho HT, et al. Population-based HIV prevalence and associated factors in male-to-female transsexuals from southern Brazil. Arch Sex Behav. 2015;44:521–4. Submit your next manuscript to BioMed Central 58. Freitas-Carvalho J, Viana S, Darub T, Farias E, Rocha G, Galvão-Castro B, et al. Soroprevalência para retrovírus em uma amostra da população de Rio and we will help you at every step: Branco (Acre). Rev Baiana Saude Publica. 2002;26:9–18. • We accept pre-submission inquiries 59. Codes JS, Cohen DA, Melo NA, Santos AB, Codes JJG, Silva JC Jr, et al. Detecção de doenças sexualmente transmissíveis em clínica de � Our selector tool helps you to find the most relevant journal planejamento familiar da rede pública no Brasil. Rev Bras Ginecol Obstet. � We provide round the clock customer support 2002;24:101–6. � Convenient online submission 60. Szwarcwald CL, Ferreira OC Jr, Brito AM, Luhm KR, Ribeiro CEL, Silva AM, et al. Estimation of HIV incidence in two Brazilian municipalities, 2013. Rev � Thorough peer review Saude Publica. 2016;50:55. � Inclusion in PubMed and all major indexing services 61. Silveira MF, Santos IS, Victora CG. Poverty, skin colour and HIV infection: a � Maximum visibility for your research case-control study from southern Brazil. AIDS Care. 2008;20:267–72. 62. Department of Health. Boletim Epidemiológico HIV/AIDS de 2016. 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A scoping review of prevalence, incidence and risk factors for HIV infection amongst young people in Brazil

BMC Infectious Diseases , Volume 17 (1) – Oct 11, 2017

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Springer Journals
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Copyright © 2017 by The Author(s).
Subject
Medicine & Public Health; Infectious Diseases; Parasitology; Medical Microbiology; Tropical Medicine; Internal Medicine
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1471-2334
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10.1186/s12879-017-2795-9
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29020929
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Abstract

Background: Despite young people being a key population for HIV prevention, the HIV epidemic amongst young Brazilians is perceived to be growing. We therefore reviewed all published literature on HIV prevalence and risk factors for HIV infection amongst 10-25 year olds in Brazil. Methods: We searched Embase, LILACS, Proquest, PsycINFO, PubMed, Scopus and Web of Science for studies published up to March 2017 and analyzed reference lists of relevant studies. We included published studies from any time in the HIV epidemic which provided estimates specific to ages 10-25 (or some subset of this age range) for Brazilians on either: (a) HIV prevalence or incidence; or (b) the association between HIV and socio-demographic or behavioral risk factors. Results: Forty eight publications met the inclusion criteria: 44 cross-sectional, two case-control, two cohort. Four studies analysed national data. Forty seven studies provided HIV prevalence estimates, largely for six population subgroups: Counselling and Testing Center attendees; blood donors; pregnant women; institutional individuals; men-who-have-sex-with-men (MSM) and female sex workers (FSW); four provided HIV incidence estimates. Twelve studies showed HIV status to be associated with a wide range of risk factors, including age, sexual and reproductive history, infection history, substance use, geography, marital status, mental health and socioeconomic status. Conclusions: Few published studies have examined HIV amongst young people in Brazil, and those published have been largely cross-sectional and focused on traditional risk groups and the south of the country. Despite these limitations, the literature shows raised HIV prevalence amongst MSM and FSW, as well as amongst those using drugs. Time trends are harder to identify, although rates appear to be falling for pregnant women, possibly reversing an earlier de-masculinization of the epidemic. Improved surveillance of HIV incidence, prevalence and risk factors is a key component of efforts to eliminate HIV in Brazil. Keywords: Brazil, HIV, Adolescents, Young adults, Review Background sexually transmitted infections (STIs) are elevated Young people, especially young women, are considered a amongst young people, such as being in the beginning of key population for HIV prevention interventions world- their sexual life, experimenting with high-risk behaviors wide [1]. However, targeting interventions is difficult and feeling invulnerable [2]. Although Brazil is world- when information on HIV prevalence and risk factors is renowned for its leadership in the fight against AIDS patchy or missing altogether. Several risk factors for [3–5], and even as AIDS rates are declining in many other places, Brazil is perceived to be facing a sharp in- crease in HIV infections among young people [6]. * Correspondence: g.harling@ucl.ac.uk Institute for Global Health, University College London, Mortimer Market AIDS has been a reportable condition in Brazil Centre, London WC1E 6JB, UK throughout the epidemic. Over the past 10 years the Department of Global Health and Population, Harvard T.H. Chan School of AIDS detection rate has averaged 20.5 cases per 100,000 Public Health, Boston, USA Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 2 of 13 persons per year [7]. Between 2004 and 2013, reported The aim of this study is therefore to review all pub- AIDS cases in Brazil rose by 53.2% among those aged lished evidence on HIV prevalence and incidence, and 15-19 and 10.3% among those aged 20-24 [8]. These in- how they relate to risk behaviors among different popu- creases were greater in men than in women: between lations of Brazilian adolescents between 1982 and 2015. 2005 and 2014 reported AIDS case rates per 100,000 Such information should help identify gaps in the litera- persons per year rose from 2.1 to 6.7 for 15-19 year old ture, and provide a scientific basis for the development males and from 3.4 to 4.2 among 15-19 year old females; of preventive strategies for this age group. for 20-24 year olds the rate rose from 16.0 to 30.3 among men but decreased from 15.3 to 12.0 among Methods women [7]. These differences in case rate trends are We performed a systematic search on seven electronic reflected in the changing ratio of male to female AIDS databases – PubMed, Embase, PsycINFO, LILACS, Web notifications: among 13-19 year olds this ratio fell from of Science, Scopus and ProQuest – to identify poten- 2.7:1 in 1990 to a low of 0.6:1 in 2005, before rebound- tially relevant analyses. The keywords we used for this ing to reach 1.6:1 in 2014. Notably, these rising rates are search were the MeSH terms [“HIV” or “HIV infection”], in contrast to older ages: AIDS notification rates fell in “Adolescents” and “Brazil” or similar non-MeSH terms all five-year age ranges from 30 to 49 years old between outside of PubMed. The search was conducted between 2005 and 2014. March 25th and March 31st 2017. Reference lists In contrast, HIV has not historically been a reportable were also analyzed for any potentially relevant articles condition. From 2007 to June 2015, 93,260 HIV infec- not included in the original search. We included any tions were notified in Brazil [7], however, mandatory no- conference proceedings (within Web of Science and tification of HIV infection began only in June 2014. Scopus) and dissertations (ProQuest) found in our Additionally, health service providers can notify both database searches. newly-identified and existing known cases, which makes One author analyzed all articles found by title to select epidemiologic analysis of national HIV case reports diffi- those that were potentially relevant, with a strong bias to- cult. In 2015, approximately 830,000 people were esti- wards retention. The abstracts of all studies selected based mated to be living with HIV in Brazil, a prevalence of on their titles were independently evaluated by two au- 0.40% [8]. Between 2007 and 2015, the proportion of thors (IPS and GH) and any discrepancies were kept in HIV-positive individuals reported to be the age groups the analysis. For all studies selected at the abstract stage, 10-14, 15-19 and 20-24 years old rose from 0.3%, 4.3% data were extracted using an instrument designed for this and 13.4% of all notifications to 0.3%, 6.1% and 18.2%, study, covering sociodemographic characteristics (gender, respectively. Across all ages, the male to female ratio of age group, location, race and social categories), method- notified HIV infections increased slightly from 1.9 in ology (study design, study population, data source, time 2007 to 2.2 in 2014. period of data collection, baseline sample size and loss to Given these epidemiological patterns, a review of the follow up), and outcomes (HIV prevalence or HIV inci- literature on HIV in young people in Brazil seems dence, risk behaviors). timely. Past literature reviews have discussed specific The final decision to include studies was made based aspects of HIV in adolescents and young people in on this data extraction and whether it met the inclusion/ Brazil. These studies have shown the difficulty of tran- exclusion criteria, based on independent evaluation by sitioning from childhood to adult life for adolescents two authors (IPH and GH), and a discussion of any dis- living with AIDS [9], the efficacy of preventive inter- crepancies; the third author (HK) was available for con- ventions focusing on this population [10], the situation sultation if agreement could not be reached. Our of orphans and vulnerable children [11] and the rela- inclusion criteria were that studies: (i) contained either tionship between STIs, AIDS and abuse of psycho- (a) HIV prevalence or incidence data or (b) analysis of active substances in adolescence [12]. In addition, risk factors for HIV infection; (ii) either focused on indi- several articles have analyzed risk behavior and HIV viduals aged between 10 and 25 years, or stratified their infection among adolescents in Brazil in specific popu- results by the age group of interest; (iii) included data on lations, such as users of anonymous Counselling and the Brazilian population. Conversely, our exclusion cri- Testing Centers (CTA), interns of the correctional sys- teria were: (i) lack of stratification by age, if covering a tem, pregnant women, men-who-have-sex-with-men broader age group than 10-25 years; (ii) lack of stratifica- (MSM) and others. However, there is no comprehen- tion by country, if a multinational study; (iii) lack of sive literature review putting together the results of quantitative presentation of data on prevalence, inci- these studies amongst young people, and it is difficult dence or risk factors; (iv) reporting only AIDS cases in- to see trends over time in the adolescent HIV epi- stead of HIV infections; (v) reporting only on HIV demic in Brazil. positive individuals. Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 3 of 13 Analysis Results First, we evaluated HIV prevalence in different popula- Of the 2180 unique articles identified by database tion groups. The analysis started with broader groups, searches, 470 studies were selected as potentially rele- closer to the national population level, such as users of vant for this analysis based on their titles (Fig. 1). We CTAs, blood donors and pregnant women. We then retained 128 of these based on their abstracts, although progressed to more specific groups such as residents at we were unable to obtain the full text of four of these correctional institutions, sex workers, MSM and people (all four were published before 1995). Sixty two studies who inject drugs (PWID). Second, we analyzed the asso- that otherwise met our inclusion criteria were excluded ciation between various exposures and HIV prevalence. because they did not stratify their results by age group These exposures included sociodemographic characteris- so we could extract data specific to young people, and tics – such as age, place of living and marital status – 14 other articles did not meet other inclusion criteria. and behavioral characteristics such as age of sexual de- This left 48 studies which reported either HIV preva- but, drug use, sexual preferences and sex in exchange lence or risk factors for our age group of interest and for money. were published in English, Portuguese or French We presented all crude HIV prevalence and incidence (note, we kept one study with an age range 15-26). rates reported in the studies, so long as they provided a Thirty-six of these 48 articles provided an age-specific number specific to the age range of interest. For risk fac- HIV prevalence, but not HIV risk factors; we there- tors, we presented any exposure reported to be signifi- fore report results separately for prevalence and risk cantly associated with HIV infection in the relevant age exposures. We summarize all studies included in the range. We preferentially reported adjusted measures of final analyses in Table 1. association and confidence intervals when provided. Fi- nally, when no risk factors were significantly associated, Prevalence and incidence we noted this. Forty-seven studies provided age-specific HIV preva- We did not appraise the methodological quality or risk lence or incidence estimates. of bias of the included articles, which is consistent with guidance on scoping review conduct [13]. All authors Counselling and testing Center attendees contributed to the elaboration of the discussion of the Fifteen studies studied counselling and testing center article through bibliographic search and their expertise. (CTA) attendees without focusing only on pregnant Fig. 1 Flow diagram of systematic review process Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 4 of 13 Table 1 Summary of all studies included in the systematic review First Author Location Sample (N) Data Design Main Results Reference collection Pechansky Porto Alegre RS CTA attendees 1995; 1997 Repeated HIV prevalence for <25 year [14] (1026; 390 aged <25) cross-section olds: 11.5% Alves Santos, SP CTA attendees (7794; 1996-1999 Cross-section HIV prevalence for <25 year [15] 2769 aged <25) olds: 3.1% Recent HIV infection for <25 year olds: 0.3% (based on STARHS algorithm) Bassols Porto Alegre RS Adolescent CTA 2000-2001 Cross-section HIV prevalence among boys: 4.8% [16] attendees (287) HIV prevalence among girls: 7.4% de Araújo Campos dos CTA attendees 2001-2002 Cross-section HIV prevalence for 13-19 year olds: [17] Goytacazes RJ (7386; 1129 aged non-pregnant women: 0%; 13-19; 1878 pregnant women: 0.5%; men: 12.1% aged 20-24) HIV prevalence for 20-24 year olds: non-pregnant women: 5.8%; pregnant women: 0.47%; men: 6.4% Bassols Porto Alegre RS Female adolescent CTA 2000-2001 Cross-section HIV prevalence: 7.4% [18] attendees (258) Risk factors: Composite drug risk: using illicit drugs & visiting drug using/selling places (aOR: 4.18, 95%CI: 1.47-11.8) Bassols Porto Alegre RS Adolescent CTA Not reported Cross-section HIV prevalence: 6.2% [19] attendees (402) Risk factors: SCL-90-R psychiatric score (aOR: 1.88, 95%CI: 1.06-3.34); Composite sexual behavior risk (aOR: 1.63, 95%CI: 0.98-2.70) Cook Rio de Janeiro RJ Women attending CTA 2001 Cross-section HIV prevalence for 14-19 year [20] (200; 44 aged 14-19; olds: 6.8% 97 aged 20-24) HIV prevalence for 20-24 year olds: 9.3% Bassichetto Sao Paulo SP Attendees of 4 CTAs who 2002-2004 Cross-section Risk factors: Recent infection not [21] tested positive for HIV-1 associated with age: (14-19 years (485; 14 aged 14-19.9; 82 old: 28.6%; 20-24 years old: 24.4%) aged 20-24.9) de Souza Goias state and Attendees of 15 CTAs 2003-2004 Cross-section HIV prevalence for males aged [22] Federal District (16,991; 784 male and 13-19: 1.1% 1652 females aged 13-19) HIV prevalence for females aged 13-19: 0.2% Monteiro Feira de Santana, BA Attendees of the municipal 2003-2012 Cross-section HIV prevalence for males: 1.08% [23] CTA aged 11-18 (3482; 664 HIV prevalence for non-pregnant male, 1183 non-pregnant females: 1.05% female, 1635 pregnant HIV prevalence for pregnant female) women: 0.31% de Castro Rio de Janeiro, RJ Attendees of 3 CTAs 2004-2005 Cross-section HIV prevalence for <25 year [24] (9008; 2525 aged <25) olds: 2.6% HIV incidence for <25 year olds: 0.6%/year (based on BED-CEIA test) Scheineder Santa Catarina state Attendees of 14 CTAs 2005 Cross-section HIV prevalence for females [25] (22,846; 2416 aged 10-19) aged 10-19: 0.9% HIV prevalence for males aged 10-19: 2.1% Cavalcanti Recife PE Attendees of 5 CTAs 2007-2009 Cross-section HIV prevalence for <25 year olds: [26] (32,256; 16,161 aged <25) 0.82% (95%CI: 0.68-0.97%) Recent infection for <25 year olds: 12/27 prevalent cases (based on BED-CEIA test) Pereira Feira de Santana BA Attendees of the municipal 2007-2011 Cross-section HIV prevalence for males: 3.0% [27] CTA (3768) HIV prevalence for females: 1.6% Risk factors for females: drug use (PrR = 2.1, 95%CI: 1.15-3.82); alcohol use (PrR = 2.1, 95%CI: Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 5 of 13 Table 1 Summary of all studies included in the systematic review (Continued) First Author Location Sample (N) Data Design Main Results Reference collection 1.16-3.91); married (PrR = 2.02, 95%CI: 1.09-3.75) Risk factors for males: use of drugs other than alcohol (PrR: 13.25, 95%CI: 5.12-34.28); MSM (PrR: 5.21, 95%CI: 2.57-10.57) Andrade Curitiba PR Blood Donors (213,666; 1992-1999 Cross-section HIV prevalence for <18 year olds: [28] Neto 177 aged <18, 51,670 0.56% aged 18-25) HIV prevalence for 18-25 year olds: 0.14% Kupek Santa Catarina state Blood Donors (293,725; 2007-2013 Cross-section; HIV prevalence for 16-24 year olds: [29] 95,797 aged 16-24) Cohort 1.22% (95%CI: 1.01-1.46) HIV incidence for 16-24 year olds: 0.28 per 100PY (95%CI: 0.20-0.37) Seroprevalence rose throughout the study period for males but for females it rose only until 2012, then declined. Souza Recife PE Pregnant women seeking 1993 Cross-Section 0 pregnant women aged <21 [30] antenatal care (1000; 0.9% out of ~325 were HIV+ aged <15, 31.6% aged 15-20) de Freitas Sao Paulo SP HIV-positive pregnant women 1991-2002 Cross-section Recent HIV infection for 15-19 [31] Oliveira seeking antenatal care (106; year olds: 10% 10 aged 15-19, 28 aged 20-24) Recent HIV infection for 20-24 year olds: 17.9% (based on STARHS algorithm) No significant association between age and recent infection status Reiche Londrina PR Pregnant women at a 1996-1998 Cross-section HIV prevalence for 10-20 year [32] teaching hospital (1473; olds: 1.0% 290 aged 10-20) Souza Campina Grande PB Pregnant women at prenatal 2001 Cross-section HIV prevalence for 14-19 year [33] services (386; 127 aged olds: 0.0% 14-19; 140 aged 20-25) HIV prevalence for 20-25 year olds: 0.07% de Macedo Cuiabá MT Postpartum women (1607; 2001-2002 Cross-section HIV prevalence for 15-20 year [34] Orione 575 aged 15-20; 525 aged olds: 0.5% 21-25) HIV prevalence for 21-25 year olds: 0.4% Figueiró-Filho Campo Grande, MS Pregnant women at prenatal 2002-2003 Cross-section HIV prevalence for <21 years [35] services (35,512; 9906 old: 0.2% aged 11-20) No significant association between age and HIV serostatus Cardoso 27 Southern Brazil Pregnant women attending 2003 Cross-section HIV prevalence for 12-25 year [36] cities CTAs (8002; 4630 aged 12-25) olds: 0.5% Costa Goiania GO Pregnant women at prenatal 2004-2005 Cross-section HIV prevalence for 12-19 year [37] services (28,561, 6664 olds: 0.03% aged 12-19) Costa Feira de Santana BA Pregnant women aged <25 2004 - 2008 Cross-section HIV prevalence for ≤16 year [38] at prenatal services (3030) olds: 0.3% HIV prevalence for 17-19 year olds: 0.5% HIV prevalence for 20-24 year olds: 0.1% Pinho- Campinas, SP Pregnant women at prenatal 2005-2013 Cross-section HIV prevalence for 10-19 year [39] Pompeu services (458 aged 10-19) olds: 1.97% There was a positive association between anemia and HIV infection (p = 0.02) Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 6 of 13 Table 1 Summary of all studies included in the systematic review (Continued) First Author Location Sample (N) Data Design Main Results Reference collection de Melo Sergipe state Pregnant women at prenatal 2007 Cross-section HIV prevalence for [40] Inagaki services (9550; 24.9% aged 10-19 year olds: 0.09% 10-19) Moura Maceió, AL Pregnant women at prenatal 2007-2012 Cross-section HIV prevalence for [41] services (54,616; 17,231 <19 year olds: 0.3% aged <19) Miranda National Women in labor at public 2009 Cross-section HIV prevalence: 0.7% [42] hospitals (2071) Risk factors: Living in the North region (aOR: 2.0 95%CI: 1.07-3.73); STI history (aOR: 42.5, 95%CI: 1.89-168.49) Ferezin 29 cities in Paraná Pregnant women at a 2010 Cross-section HIV prevalence for 14-19 year [43] state teaching hospital (1534; olds: 0.3% 354 aged 14-19) Domingues National Pregnant women (23,894; 2011-2012 Cross-section HIV prevalence for 12-19 year [44] 4570 aged 12-19) olds: 0.14% Pinto Belo Horizonte MG Inmates in a youth 1989-1991 Case-control HIV prevalence for street-based [45] correctional institute (394; youth: 2% 195 previously street-based, HIV prevalence for home-based 199 previously home-based) youth: 0% Risk factors: 2 of 3 HIV-positive males reported using injection drugs; all HIV-positive youths reported heterosexual activity Zanetta Sao Paulo SP Inmates in a youth 1994 Cross-section HIV prevalence for females: 10.3% [46] correctional institute (1215) HIV prevalence for males: 2.6% Risk factors for females: Commercial sex work (OR = 5.98 (95%CI: 1.04-34.30) Risk factors for males: HCV seropositivity [OR = 26.5 (95%CI: 8.83-79.70)]; age > 18 [OR = 3.45 (95%CI: 1.21-9.86)]; PWID [OR = 3.39 (95%CI: 1.10-10.4) Coelho Ribeirão Preto, SP Inmates in a correctional 2003 Cross-section HIV prevalence for 19-24 year [47] institute (333; 96 aged <25) olds: 0.09% Fialho Salvador BA Incarcerated youth aged 2004-2005 Cross-section HIV prevalence: 0.34% [48] 11-18 (297) Harrison Rio de Janeiro, RJ High-risk HIV- MSM recruited 1995-1997 Cohort HIV incidence for <20 year olds: [49] at HIV testing sites and MSM 8.4 (95%CI: 1.7-15) per 100PY venues (750; 242 aged <25) HIV incidence for 20-24 year olds: 3.9 (95%CI: 1.7-6.1) per 100PY Age < 25 was associated with HIV seroconversion (aRR = 2.6, 95%CI: 1.3-5.6) Szwarcwald National Military conscripts (1997: 1997-2002 Cross-section HIV prevalence (2002): 0.09% [50] 9844; 1998: 30,318; 1999: Risk factors: positive syphilis test 29,373; 2000: 23,659; 2002: OR = 5.72 (95%CI: 1.32-24.9), MSM 30,970) OR = 4.06 (95%CI: 1.29-12.8), At least 1 STI related problem OR = 2.76 (95%CI: 1.18-6.45), More than 10 lifetime sexual partners OR = 2.33 (95%CI: 1.05-5.18), Resident of Southern Brazil OR = 2.77 (95%CI: 1.10-6.99) Soares Campinas SP MSM (658; 167 aged 2005-2006 Cross-section HIV prevalence for 14-19 year [51] 14-19, 190 aged 20-24) olds: 2.9% HIV prevalence for 20-24 year olds: 5.9% Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 7 of 13 Table 1 Summary of all studies included in the systematic review (Continued) First Author Location Sample (N) Data Design Main Results Reference collection Szwarcwald National Military conscript personnel 2007 Cross-section HIV prevalence overall: 0.1% [52] aged 17-21 (35,432, of HIV prevalence for MSM: 1.2% whom ~800 report being Risk factors: being MSM MSM) OR = 11.16 (95%CI: 4.90-25.39); having at least one STI-related problem OR = 2.53 (95%CI: 1.20-5.36); >10 lifetime partners OR = 2.52 (95%CI: 1.21-5.25) Guimarães Belo Horizonte, MG MSM (272; 113 aged <24) 2010 Cross-section HIV prevalence for <24 year [53] olds: 2.8% de Souza São Paulo, SP MSM (771; number aged 2011-2012 Cross-section HIV prevalence for 18-24 year [54] <25 not reported) olds: 6.4% (95%CI: 3.5-11.5%) Trevisol Imbituba SC Female sex workers (90; 44 2003-2004 Cross-section HIV prevalence for <26 year [55] aged <26) olds: 6.8% Schuelter- Santa Catarina state Sex workers (147; 57 aged 2009 Cross-section HIV prevalence for 18-24 year [56] Trevisol 18-24) olds: 5.3% Costa Porto Alegre, RS Male to Female transsexuals 1998-2014 Cross-section HIV prevalence for 18-26 year [57] (284; 128 aged 15-26) olds: 14.8% Freitas- Rio Branco, AC Attendees of immunization 1999 Cross-section HIV prevalence: 0% [58] Carvalho campaign (390; 118 aged 12-21) Codes Salvador, BA Women attending a public Not reported Cross-section HIV prevalence for <21 year [59] family planning clinic (202; olds: 0% 70 aged <22; 77 aged 22-25) HIV prevalence for 22-25 year olds: 4% Szwarcwald Recife, PE and General population (902 in 2013 Cross-section HIV incidence for 13-24 year [60] Curitiba, PR Recife; 1013 in Curitiba) olds in Curitiba, PR: 0.060%/year (18.8% of all HIV-positive) HIV incidence for 13-24 year olds in Recife, PE: 0.059% (19.4% of all HIV-positive) Silveira Pelotas RS HIV-positive women (144; 11 1999-2000 Case-control Risk factors: Odds of being [61] aged 15-19, 39 aged 20-24); (controls); HIV-positive were higher for AIDS-diagnosed women 2003-2004 15-19 year olds (OR: 3.0, 95%CI: (130; 7 aged 15-19, 13 aged (cases) 1.4-6.6) and for 20-24 year olds 20-24); door-to-door (OR: 6.2, 95%CI: 1.4-11.4) than interviewed controls (1537; for those aged ≥40 151 aged 15-19, 240 aged 20-24) All sample sizes cited are analytic, and thus do not include non-respondents. CTA Counselling and testing center, MSM Men who have sex with men, PWID People Who Inject Drugs, STI Sexually Transmitted Infection, STARHS Serologic Testing Algorithm for Recent HIV Seroconversion, OR Odds Ratio, aOR Adjusted Odds Ratio, PrR Prevalence Ratio, 100PY 100 person-years women. The HIV seroprevalence of individuals attending Campos dos Goytacazes, RJ aged 13 to 19 had a sero- CTAs in Porto Alegre in 1995 and 1997 was 11.5% prevalence of 0% among non-pregnant women, 0,50% amongst under 25 year olds [14]. Young age was found among pregnant women and 12,1% among men [17]. In to be protective for HIV infection (adjusted Odds Ratio addition, amongst 20 to 24 years old, non-pregnant [aOR] for 25-60 vs <25: 1.7; 95%CI: 1.1-2.7), however women had a prevalence of 5,8%, pregnant women this study was not stratified by gender. The HIV preva- 0,47% and men 6,4%. Female members of an expanded lence among clients aged under 25 years old in a CTA sample of 13-20 year old females attending this CTA in Santos, SP between 1996 and 1999 was 3.1%, of which over the same period had an HIV prevalence of 7.4% 0.3% were diagnosed as recently infected based on the [18]. The same authors report an HIV prevalence of serologic testing algorithm for recent HIV seroconver- 6.2% in another overlapping group of adolescents visit- sion (STARHS) [15]. Adolescents aged 13-20 attending a ing the clinic [19], although they did not report when CTA in Porto Alegre, RS in 2000-01 had an overall HIV the data was collected within the article. Women attend- seroprevalence of 6.4%: 4.8% among males; 7.2% among ing a CTA in Rio de Janeiro in 2001 had an HIV preva- females [16]. Between 2001 and 2002, users of a CTA in lence of 6.8% amongst 14-19 year olds and 9.3% Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 8 of 13 amongst 20-24 year olds [20]. Between 2002 and 2004, Pregnant women Bassichetto et al. found that among HIV-positive adoles- Sixteen studies reported HIV prevalence amongst preg- cents and young adults, 28.6% of 14-19 year olds and nant women. In 1993, none of approximately 325 preg- 24.4% of 20-24 year olds were diagnosed as recently in- nant women aged 20 years or younger seen in an fected based on STARHS, and that these proportions antenatal service in Recife were found to be HIV- were higher than in older age groups [21]. positive [30]. One study measured HIV incidence In 2003-04 HIV prevalence in CTAs in Goiás and amongst 106 women living with HIV seeking antenatal Federal District states in Central Brazil was 1.1% care in Sao Paulo, SP from 1991 to 2002 [31]. The au- among males and 0.2% among females aged 13- thors estimated, based on STARHS, that 10% of those 19 years [22]. From 2003 to 2012, HIV prevalence aged between 15 and 19, and 17.9% of those aged 20-24, amongst 11-18 year olds attending CTAs in Feira de years old had been infected within the past 6 months; Santana, BA was 1.08% for males and 1.05% for non- however, this difference was not statistically significant. pregnant women [23].Between 2004 and 2005, the From 1996 to 1998, HIV prevalence for 10-20 year old prevalence of HIV infection among people aged under pregnant females attending a teaching hospital in north- 25 years old testing in a CTA in Rio de Janeiro, RJ, ern Parana was 1% [32]. In Campina Grande, PB in was 2.6% (95%CI: 1.9-3.2) and the estimated incidence 2001, women testing for HIV during antenatal care, had (based on IgG BED capture enzyme immunoassay an HIV prevalence of 0% amongst 14-19 year-olds and [BED-CEIA]) was between 0.56 and 0.87%, depending 0.07% amongst those aged 20-25 [33]. Between 2001 and on the estimation method used [24]. In 2005, females 2002, postpartum women aged 15-20 in three public and males aged 10-19 years old attending CTAs in hospitals in Cuiabá, MS had an HIV prevalence of 0.5%, SantaCatarinahad an HIVprevalenceof0.9%(95%CI: while those aged 21-25 had a prevalence of 0.4% [34]. 0.5-2.3) and 2.1% (95%CI: 1.1-3.1), respectively [25]. In Mato Grosso do Sul state between 2002 and 2003, Adolescents represented 16.3% of females and 9.5% of HIV prevalence among pregnant women aged 11- males who accessed these services, and their preva- 20 years old was 0.2% [35]. A prevalence of 0.5% lence was lower than the overall prevalence of 2.0% (95%CI: 0.3–0.6) was seen in pregnant women aged 12- among women and 5.6% among men. In 2007-2009, 25 attending CTAs in southern Brazil in 2003 [36]. From HIV prevalence among users of CTAs under 25 years 2003 to 2012, HIV prevalence amongst pregnant 11- in Recife, PE was 0.82% (95%CI: 0.68-0.97) [26]. In 18 year olds attending CTAs in Feira de Santana, BA addition, this study found that of the 27 individuals was 0.31% [23]. In 2004-2005, a prevalence of 0.03% was aged under 25 who tested positive for HIV, 12 were found among pregnant women aged 12-19 who were classified as recent infections based on BED-CEIA. seeking antenatal care in Goiania, GO [37]. Between From 2007 to 2011, in a study of adolescents and 2004 and 2008 in Feira de Santana, BA, HIV prevalence young adults aged between 13 and 24 years old at- among pregnant women testing for HIV during ante- tending a CTA in Feira de Santana, BA was found an natal care aged <16, 17-19 and 20-24, was 0,3, 0,5 and overall HIV prevalence of 1.94% in the population, 0,1% respectively [38]. Data from 2005 to 2013 found a specifically 3.0% among males and 1.6% among HIV prevalence of 1.97% among pregnant teenagers females [27]. aged between 10 and 19 with maternal anemia receiving prenatal care in Campinas, SP [39]. HIV prevalence in Blood donors women during antenatal care in 2007 in Sergipe state Two articles studied the prevalence of HIV among blood was found to be 0.09% amongst women aged 10-19 donors. Between 1992 to 1999, the HIV prevalence in blood (95%CI: 0.01-0.3) [40]. In Maceio, AL between 2007 and donors aged 18-25 in Curitiba, PR was 0.14% [28]. This age 2012, the HIV prevalence amongst pregnant women group presented the highest number of donations and the aged 15-26 years was 0.3% [41]. A nationwide analysis of highest number of HIV cases (although HIV prevalence 15-24 year-old women in labor in 2009 found a preva- rates were higher amongst 26-35 year old donors). Between lence of 0.7% (95%CI: 0.4–1.1) [42]. 2007 to 2013, after the implantation of NAT screening, In the northwestern region of Parana, in 2010, there HIV prevalence amongst blood donors aged 16-24 in Santa was a prevalence of 0.3% among 14-19 year old women Catarina was 1.22% (95%CI: 1.01–1.46); an analysis of re- attending a teaching hospital [43]. A national study con- peat donors in this age group showed an HIV incidence of ducted in 2011-2012 found a HIV prevalence of 0.14% 0.28 (95%CI: 0.20–0.37) per 1000 person-years [29]. The among pregnant women aged 12-19 [44]. same article reported a sharp increase in HIV prevalence over time among 16-24 year old male donors; a similar rise Institutional settings was observed for young women until 2012, followed by a Four articles focused in youth in institutional settings. sharp decline. Between 1989 and 1991, HIV prevalence among 10- Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 9 of 13 18 year olds admitted to a state-run shelter for homeless 25 year-olds were HIV-positive [59]. In 2013, a study es- and youth offenders in Belo Horizonte, MG was 2% [45]. timated the HIV incidence for 13-24 year olds in the In 1994, a sample of 12-21 year old youths in a similar general population in the cities of Recife, PE and Curi- institution in São Paulo had an HIV prevalence of 10.3% tiba, PR to be 0.06% in both cities, using Sedia™ HIV- for females and 2.6% for males [46]. In 2003, the preva- 1LAg-Avidity tests [60]. lence of HIV infection amongst 19-24 years old in an in- stitutional setting in Ribeirão Preto, SP was 0.09% [47]. Risk exposures In 2004-2005, only one case was found among 297 in- Twelve studies provided information on risk exposures carcerated youth in Salvador, BA, representing a preva- in age groups falling entirely within our inclusion criteria lence of 0.34% (95%CI: 0.02–2.16) [48]. (i.e. 10–25 years old). Men-who-have-sex-with-men Counseling and testing center attendees Six articles studied MSM. In a cohort of 18-50 year old Four of the articles studying CTA attendees reported as- MSM in Rio de Janeiro between 1995 and 1997, 18- sociations between risk factors and HIV infection. First, 19 year olds had an incidence rate of 8.4 (95%CI: 1.7-15) Bassols and colleagues reported in two articles that sev- per 100 person-years, and 20-24 year olds had rate of eral sexual and drug behaviours were positively associ- 3.9 (95%CI: 1.7-6.1) per 100 person-years [49]. The same ated with HIV infection amongst CTA attendees in study found 18-24 year olds were significantly more Porto Alegre [18, 19]. In the earlier study, HIV seroposi- likely to seroconvert than those aged 25-50 [adjusted In- tivity was also positively associated with early sexual ini- cidence Rate Ratio (aIRR) = 2.6 (95%CI: 1.3–5.6)]. In a tiation (<12 years old) and unprotected sexual stratified random sample of 30,970 literate 2002 Brazil- intercourse with a male partner (whether the respondent ian military conscripts, overall HIV prevalence was was male or female). Second, Bassichetto et al. showed 0.09% (95%CI: 0.05-0.12%), while that amongst MSM that in Sao Paulo 78.9% of CTA users testing positive was 0.56% (95%CI: 0.00-1.12%) [50]. In 2005 and 2006in and aged 14-25 were single, and that sexual exposure the Campinas, SP metropolitan area HIV prevalence was was responsible for 98.7% of cases [21]. Although 40% of 2.9% amongst 14-19 year-old MSM, and 5.9% in 20- seropositive subjects were PWID, blood-to-blood trans- 24 year old MSM [51]. In a second sample of 2007 Bra- mission was not thought to be responsible for any infec- zilian military conscripts, HIV prevalence among MSM tions in this sample. Third, Pereira et al. found the was 1.23% (95%CI: 0.34-2.13) compared to 0.11% association between HIV infection and marital status to (95%CI: 0.07-0.16) in the overall sample [52]. In 2010, vary by gender for CTA attendees in Feira de Santana: prevalence amongst 18-24-year-old MSM in Belo Hori- 78.6% of HIV positive men were unmarried while 61.9% zonte, MG was 2.8% [53]. Data from late 2011 and early of infected women were married or in a stable relation- 2012 reports a prevalence of 6.4% in MSM 18-24 year- ship [27]. Among females, drug use, alcohol use, less olds in São Paulo, SP [54]. than 8 years of schooling, reporting multiple partners and being married were associated with HIV infection. Female sex workers Among males, use of drugs other than alcohol, having Two studies considered female sex workers (FSW). In more than 8 years of schooling and identifying as MSM 2003 and 2004, there were 3 HIV-positive FSW in a were positively associated with HIV infection. sample of 44 FSW aged under 26 (6.8%) in Imbituba, SC [55], while a 2009 study of predominantly-female sex Pregnant women workers in the southern cities of Santa Catarina state, in- One study in Campinas, SP found HIV-positive pregnant cluding Imbituba, reported a prevalence of 5.3% amongst adolescents to have higher rates of anemia than their the 57 individuals aged 18-24 [56]. HIV-negative peers [39]. One national study found that among pregnant women in labor, living in the North re- Other groups gion and an STI history were positively associated with Male to female transsexuals aged 15 to 26 seeking sex HIV infection [42]. A third study found no significant reassignment surgery between 1998 and 2014 in from association between age at pregnancy and HIV- Porto Alegre, RS had an HIV prevalence of 14.8% [57]. seropositivity within 11-20 year olds in Mato Grosso do In 1999, in Rio Branco, AC, a northern city in the Ama- Sul state [35]. zonian region with many indigenous citizens, no 12- 21 year old attending an immunization campaign tested Institutional settings positive for HIV [58]. In 2002, none of the 70 women Two studies studied associations between risk behaviors aged 18-21 attending a public family planning clinic in and HIV infection among adolescents in institutional Salvador, BA were HIV seropositive; however 4% of 22- settings. In Belo Horizonte, all three HIV-positive males Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 10 of 13 in a study of street- and home-based youth between 1989 reported AIDS rates (Florianópolis SC, Manaus AM, São and 1991 reported heterosexual activity, and two of them Luís MA and Belém PA) have no published studies re- reported injection drug use [45]. Amongst street-involved garding young people and HIV. The literature’s focus in youth in São Paulo, HIV infection was associated with sex the South is supported by two of the three states of this work for women, and history of STIs, Hepatitis C sero- region having the second- and third-highest reported positivity and use of illegal drugs among men [46]. AIDS rates in the country, and by the fact that almost 75% of the AIDS cases identified in Brazil from 1980 Other groups until June of 2015 were in the South and Southeast re- Several predictors for HIV infection were reported gions [7]. While these higher reporting rates may reflect among military conscripts in 2002: a positive syphilis these regions wealth, and therefore ability to diagnose test; identifying as MSM; any STI-related problem; more AIDS cases, it may also reflect that the body of literature than 10 lifetime sexual partners; or residence in the reflects past history of the HIV epidemic, rather than South region [50]. By 2007, syphilis positivity and resi- the current situation. It is also notable that many studies dence in the South region had ceased to be significant were conducted in state capital cities, and even those predictors, but the others remained [52]. Finally, 15- studies conducted elsewhere were often conducted in 19 year olds had 2.4 times the odds of being HIV- university campus cities, such as Campos dos Goyta- infected compared to those aged 20-24 in a case-control cazes [17], Feira de Santana [27, 38], Londrina [32] or study of HIV-positive women in Pelotas, RS [61]. Campina Grande [33]. All these trends highlight a clear need for additional research in non-traditional risk areas Discussion of Brazil. In this study, we reviewed all published evidence on HIV Second, a large proportion of infections amongst both prevalence and risk factors for infection amongst 10- adolescents and young people were recent: 9.6% of HIV- 25 year olds in Brazil. A key finding of our review is the positive individuals aged under 25 in Santos [15]; 17.9% lack of comprehensive data regarding risk behaviors for of HIV-positive 20-24 year olds attending antenatal care HIV infection either through studies specifically in Sao Paulo [31]; 18.8% and 19.4% of HIV-positive 18- amongst adolescents, or stratified for this age group. 24 year olds Recife and Curitiba respectively in 2013 Most of the studies we identified covered a broad age [60]; 25% of HIV-positive 15-24 year olds in Sao Paulo range, from adolescence up to senior ages, and in most CTAs [21]; and 44.4% of HIV-positive adolescents seek- cases HIV prevalence, but not risk factors, were strati- ing care in Recife CTAs [26]. While unsurprising, fied by age group. In some cases, the stratification given the briefer sexual history of younger people and grouped young and middle-aged adults in the same age the predominantly sexual transmission route for HIV group (e.g. 20 to 40 years old), which limited their use- in Brazil, these data highlight the importance of de- fulness for understanding risks amongst young people. veloping preventive strategies focusing this age group, While analyses of wider age ranges and the conditions of based on the behavioral risk factors to which they are already-infected individuals appear quite common, fo- more susceptible. cused evidence of the extent, and predictors, of young Third, the literature highlights some groups of young Brazilians’ risk of HIV infection remains limited. As a re- people at increased risk of HIV infection. HIV infection sult, we were not able to conduct a quantitative assess- rates are high among MSM, and are rising relative to the ment of any outcome using meta-analysis. general population. Two nationwide studies of military Despite its limitations, some important themes can be conscripts in 2002 and 2007 reported HIV prevalence seen in the literature reviewed. First, the geographic among MSM of 0.56% and 1.23% respectively, while the coverage of the literature was limited. Of the 48 articles overall population prevalence remained stable [50, 52]. included in the final analysis, 14 were conducted in the HIV prevalence was even higher amongst sex workers, South region and 14 in the Southeast region, while ten with an HIV prevalence of 6.8% [55] and 5.3% [56] were in the Northeast, four in the Center-West and one amongst sex workers aged under 26 in two studies in in the North region of Brazil (four were national and Santa Catarina state. Sex workers are well-recognized as one covered cities in both the South and Northeast). Ac- being at higher risk of HIV infection; HIV prevention cording to the last HIV Epidemiological Bulletin released policies focused on younger sex workers may be particu- by the Brazilian Ministry of Health in 2015, AIDS cases larly important. Finally, there may be a downward trend are increasing in the Center-West, North, and Northeast in decreasing the infection rates amongst pregnant regions in the general population, and two of the four women, at least in one setting: HIV prevalence among states with the highest AIDS reporting rates (Amazonas pregnant women aged between 10 and 20 in Paraná in and Roraima) are in the North [62]. At the municipal 1996-98 was 1% [32], but had fallen to 0.3% among 14- level, the state capitals with the second to fifth highest 19 year old pregnant women by 2010 [43]. Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 11 of 13 Fourth, several behaviors were reported as predictors HIV prevalence since self-perceived risk for STI infection of HIV infection. Use of illicit drugs or attending drug- is a key predictor of attendance. using/selling places was consistently associated with in- creased HIV risk [18, 27, 46, 61]. In addition, a history Conclusion of STIs was also associated with HIV infection in more Our review of the literature on HIV prevalence, inci- than one study [42, 46, 50]. Interestingly, being in a dence and risk factors in Brazil suggests that there is an stable relationship was associated with HIV infection unmet need for research into HIV risk patterns in the among women while being unmarried was associated country. This is particularly true given suggestions in the with infection among men [27]. This may reflect the literature that HIV prevalence may have been increasing higher risk for HIV amongst MSM. Somewhat surpris- among adolescents in recent years. The 2014 change in ingly, in no study was past condom use associated with the law to require medical staff to notify the government infection rates; this may reflect low interest amongst re- of HIV infections may act as a spur to action for such searchers, inaccurate reporting by respondents (due to research, by providing standardized nationwide data. recall bias or intentional mis-reporting) or truly no asso- However, given the relatively low national HIV preva- ciation in the populations studied. lence, and thus relatively low HIV testing rates, amongst One topic of concern within Brazil in recent years has young Brazilians, the use of targeted, nationally repre- been the “feminization” of the HIV epidemic. This was sentative surveys of young people using biological testing reflected in research highlighting that the male to female for HIV and STIs may well also be justified. ratio of reported AIDS cases among adolescents in Rio Abbreviations de Janeiro city fell from 4.7 in the period 1984-1989 to AC: Acre state; AIDS: Acquired immunodeficiency syndrome; aIRR: Adjusted 0.5 in 2005-2009 [63], and from 24 to two nationally be- incidence rate ratio; AL: Alagoas state; aOR: Adjusted odds ratio; BA: Bahia state; BED-CEIA: BED capture enzyme immunoassay; CTA: Counselling and tween 1985 and 1999 [64]. HIV prevalence rates testing center; FSW: Female sex worker; GO: Goiás state; HIV: Human amongst 14-20 year olds were reported to have equalized immunodeficiency virus; MG: Minas Gerais state; MS: Mato Grosso do Sul by 2002 [65]. This led to the launch of a national cam- state; MSM: Men-who-have-sex-with-men; NAT: Nucleic acid testing; OR: Odds ratio; PB: Paraíba state; PE: Pernambuco state; PR: Paraná state; paign to combat the feminization of the epidemic in PrR: Prevalence ratio; PWID: People who inject drugs; RJ: Rio de Janeiro; 2007, particularly through combatting women’s vulner- RS: Rio Grande do Sul state; SC: Santa Catarina state; SP: Sao Paolo state; abilities [66]. More recently the ratio of male to female STARHS: Serologic testing algorithm for recent HIV seroconversion; STI: Sexually transmitted infection AIDS cases has again risen [7], however, young women living with HIV appear to be particularly vulnerable, Acknowledgements even amongst all women living with HIV [67]. Not applicable. Funding Strengths and limitations This work was not supported by any funders. Our analysis has the strength of considering any study published on young people and HIV since the beginning Availability of data and materials of the epidemic. Furthermore, we considered studies in All data generated or analysed during this study are included in this published article. English, French or Portuguese. Nevertheless, there were some limitations to our work. First, we considered only Authors’ contributions published literature, and it is quite possible that other un- GH conceptualized the study. IPS conducted the initial literature search and summarized the results in tables and graphs. IPS wrote the first draft of the published studies exist. We were also unable to access paper. All authors contributed to the study design, data interpretation and four of the 124 potentially relevant articles based on ab- final revisions to the text. All authors read and approved the final manuscript. stract review; however all of these were over 20 years old, Ethics approval and consent to participate and thus should not affect our review of recent epidemic Not applicable. trends. Second, our ability to make comparisons across time and space was limited by the highly varied study Consent for publication methodologies used; only when authors repeated their Not applicable. methods could we make direct comparisons. Furthermore, Competing interests almost all studies grouped together wide age ranges, mak- The authors declare that they have no competing interests. ing it difficult to stratify our findings into the typically used five-year age categories (e.g. 15-19, 20-24). Generaliz- Publisher’sNote ing beyond Brazil is also particularly difficult due to the Springer Nature remains neutral with regard to jurisdictional claims in published unique history of HIV infection and care in this country. maps and institutional affiliations. Finally, several of the studies used methods that are likely Author details make it difficult even to generalize to the whole Brazilian 1 Department of Epidemiology, Fluminense Federal University, Niterói, Brazil. population. For example CTAs are likely to have higher Institute for Global Health, University College London, Mortimer Market Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 12 of 13 Centre, London WC1E 6JB, UK. Department of Global Health and Population, 22. de Souza SM, Teles SA, Rezza G, Pezzotti P, Gir E. Epidemiology of HIV Harvard T.H. Chan School of Public Health, Boston, USA. infection in central Brazil: data from voluntary counseling and testing centers. J Assoc Nurses AIDS Care. 2013;24:503–11. Received: 6 June 2017 Accepted: 4 October 2017 23. Monteiro MdOP, Costa MCO, Vieira GO, da Silva CAL. Fatores associados à ocorrência de sífilis em adolescentes do sexo masculino, feminino e gestantes de um Centro de Referência Municipal/CRM-DST/HIV/AIDS de Feira de Santana, Bahia. Adolescencia e Saude 2015, 12:21-32. 24. de Castro CAV, Grinsztejn B, Veloso VG, Bastos FI, Pilotto JH, Morgado MG. References Prevalence, estimated HIV-1 incidence and viral diversity among people 1. Joint United Nations Programme on HIV/AIDS (UNAIDS). The gap report. seeking voluntary counseling and testing services in Rio de Janeiro, Brazil. UNAIDS: Geneva, Switzerland; 2014. BMC Infect Dis. 2010;10:224. 2. Camargo BV, Giacomozzi AI, Wachelke JFR, Aguiar A. Romantic relationships, 25. Schneider IJC, Ribeiro C, Breda D, Skalinski LM, d’Orsi E. Perfil sexual behavior and vulnerability of African-descending and white epidemiológico dos usuários dos Centros de Testagem e Aconselhamento adolescents towards HIV/AIDS. Saude Soc. 2010;19:36–50. do Estado de Santa Catarina, Brasil, no ano de 2005 epidemiological profile 3. Bastos FIPM, Kerrigan D, Malta MS. Cunha CCd, Strathdee SA. Treatment for of the clientele in HIV testing and Counseling Centers in Santa Catarina. HIV/AIDS in Brazil: strengths, challenges, and opportunities for operations Cad Saude Publica. 2008, 24:1675-1688. research. AIDScience. 2001;1:15. 26. Cavalcanti AM, Brito AM, Salustiano DM, Lima KO, Silva SP, Lacerda HR. 4. Oliveira-Cruz V, Kowalski J, McPake B. Viewpoint: the Brazilian HIV/AIDS Recent HIV infection rates among HIV positive patients seeking voluntary ‘success story’–can others do it? Tropical Med Int Health. 2004;9:292–7. counseling and testing centers in the metropolitan region of Recife – PE, 5. Greco DB, Simao M. Brazilian policy of universal access to AIDS treatment: Brazil. Braz J Infect Dis. 2012;16:157–63. sustainability challenges and perspectives. AIDS. 2007;21(Suppl 4):S37–45. 27. Pereira BS, Costa MC, Amaral MT, da Costa HS, da Silva CA, Sampaio VS. 6. Associated Press. HIV infections rise, thwart Brazil's AIDS efforts. 2014. Factors associated with HIV/AIDS infection among adolescents and young [http://www.dailymail.co.uk/wires/ap/article-2720485/HIV-infections-rise- adults enrolled in a Counseling and testing Center in the State of Bahia, thwart-Brazils-AIDS-efforts.html]. Brazil. Cien Saude Colet. 2014;19:747–58. 7. Department of Health. Boletim Epidemiológico de AIDS e DST. Brasília: 28. Andrade Neto JL, Pintarelli VL, Felchner PCZ, Morais RL, Nishimoto FL. HIV Department of STI, AIDS and Viral Hepatitis, Ministry of Health; 2015. prevalence among blood donors in a blood bank in Curitiba (Brazil). Braz J 8. Department of Health. The Brazilian response to HIV and AIDS: global AIDS Infect Dis. 2002;6:15–21. response progress reporting narrative report. Brasília, DF: Department of STI, 29. Kupek E, Petry A. Changes in the prevalence, incidence and residual risk for AIDS and Viral Hepatitis, Ministry of Health; 2015. HIV and hepatitis C virus in southern Brazilian blood donors since the 9. Machado DM, Succi RC, Turato ER. Transitioning adolescents living with HIV/ implementation of NAT screening. Rev Soc Bras Med Trop. 2014;47:418–25. AIDS to adult-oriented health care: an emerging challenge. J Pediatr. 2010; 30. Souza ES, Figueira FS, Da Silva G, Vilarim J, De Souza A, Pessoa V, et al. 86:465–72. Seroprevalence of HIV-1 among pregnant women at Recife, northeastern 10. DiClemente RJ, Salazar LF, Crosby RA. A review of STD/HIV preventive Brazil. J Acquir Immune Defic Syndr. 1995;10:486–7. interventions for adolescents: sustaining effects using an ecological 31. de Freitas Oliveira CA, Ueda M, Yamashiro R, Rodrigues R, Sheppard HW, de approach. J Pediatr Psychol. 2007;32:888–906. Macedo Brigido LF. Rate and incidence estimates of recent human 11. Franca-Junior I, Doring M, Stella IM. Crianças órfãs e vulneráveis pelo HIV no immunodeficiency virus type 1 infections among pregnant women in Sao Brasil: onde estamos e para onde vamos? Rev Saude Publica. 2006; Paulo, Brazil, from 1991 to 2002. J Clin Microbiol. 2005;43:1439–42. 40(Suppl):23–30. 32. Reiche EMV, Morimoto HK, Farias GN, Hisatsugu KR, Geller L, Gomes ACLF, 12. Morais VO, Moura MV, Costa MC, Patel BN. Sexually transmitted diseases, et al. Prevalência de tripanossomíase americana, sífilis, toxoplasmose, AIDS, and use/abuse of psychoactive substances in adolescence. J Pediatr. rubéola, hepatite B, hepatite C e da infecção pelo vírus da imunodeficiência 2001;77(Suppl 2):S190–204. humana, avaliada por intermédio de testes sorológicos, em gestantes 13. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. atendidas no período de 1996 a 1998 no Hospital Universitário Regional Guidance for conducting systematic scoping reviews. Int J Evid Based Norte do Paraná (Universidade Estadual de Londrina, Paraná, Brasil). Rev Soc Healthc. 2015;13:141–6. Bras Med Trop. 2000;33:519–27. 14. Pechansky F, Kessler F, Von Diemen L, Inciardi JA, Surratt H. Uso de 33. Souza SMB, Andrade J. Soroprevalência para HIV em gestantes substâncias, situações de risco e soroprevalência em indivíduos que buscam acompanhadas pelo Programa Saúde da Família de Campina Grande, testagem gratuita para HIV em Porto Alegre, Brasil. Rev Panam Salud Paraíba. Rev Baiana Saude Publica. 2003;27:28–37. Publica. 2005;18:249–55. 34. de Macedo Orione MA, Assis SB, Souto FJD. Perfil epidemiológico de 15. Alves K, Shafer KP, Caseiro M, Rutherford G, Falcao ME, Sucupira MC, et puérperas e prevalência de anticorpos para infecção pelo HIV e vírus da al. Risk factors for incident HIV infection among anonymous HIV testing hepatite C em Cuiabá, Mato Grosso. Rev Soc Bras Med Trop. 2006;39:163–8. site clients in Santos, Brazil: 1996–1999. J Acquir Immune Defic Syndr. 35. Figueiró-Filho EA, Senefonte FRA, Lopes AHA, Morais OO, Souza Júnior VG, 2003;32:551–9. Maia TL, et al. Frequency of HIV-1, rubella, syphilis, toxoplasmosis, 16. Bassols AM, Pechansky F, Dieder AL, Correia AG, Toniolo DP, Fabian A, et al. cytomegalovirus, simple herpes virus, hepatitis B, hepatitis C, Chagas disease Gênero, sexualidade e uso de drogas e adolescentes que realizaram o teste and HTLV I/II infection in pregnant women of state of Mato Grosso do Sul. anti-HIV em um centro de testagem gratuita de Porto Alegre. Rev Psiquiatr Rev Soc Bras Med Trop. 2007;40:181–7. Rio Grande Do Sul. 2002;24:77–84. 36. Cardoso AJ, Griep RH, Carvalho HB, Barros A, Silva SB, Remien RH. Infecção 17. de Araújo LC, Fernandes RCSC, Coelho MCP, Medina-Acosta E. Prevalência pelo HIV entre gestantes atendidas nos centros de testagem e da infecção pelo HIV na demanda atendida no Centro de Testagem e aconselhamento em Aids. Rev Saude Publica. 2007;41(Suppl 2):101–8. Aconselhamento da Cidade de Campos dos Goytacazes, Estado do Rio de 37. Costa ZB, Machado GC, Avelino MM, Gomes Filho C, Macedo Filho JV, Minuzzi Janeiro, Brasil, 2001-2002. Epidemiol Serv Saude. 2005;14:85–90. AL, et al. Prevalence and risk factors for hepatitis C and HIV-1 infections among 18. Bassols AM, Boni R, Pechansky F. Alcohol, drugs, and risky sexual behavior pregnant women in Central Brazil. BMC Infect Dis. 2009;9:116. are related to HIV infection in female adolescents. Rev Bras Psiquiatr. 2010; 32:361–8. 38. Costa MCO, Santos BC, Peixoto de Souza KE, Cruz NLA, Cajaseira Santana M, Cunha do Nascimento O. HIV/AIDS e sífilis entre gestantes adolescentes e 19. Bassols AM, Santos RA, Rohde LA, Pechansky F. Exposure to HIV in Brazilian adultas jovens: fatores de exposição e risco dos atendimentos de um adolescents: the impact of psychiatric symptomatology. Eur Child Adolesc programa de DST/HIV/AIDS na rede pública de saúde/SUS, Bahia, Brasil. Rev Psychiatry. 2007;16:236–42. Baiana Saude Publica. 2011;35:179. 20. Cook RL, May S, Harrison LH, Moreira RI, Ness RB, Batista S, et al. High 39. Pinho-Pompeu M, Surita FG, Pastore DA, Paulino DSM, Pinto e Silva JL. prevalence of sexually transmitted diseases in young women seeking HIV Anemia in pregnant adolescents: impact of treatment on perinatal testing in Rio de Janeiro, Brazil. Sex Transm Dis. 2004;31:67–72. outcomes. J Matern Fetal Neonatal Med. 2017;30(10):1158-62. 21. Bassichetto KC, Bergamaschi DP, Oliveira SM, Deienno MC, Bortolato R, de 40. de Melo Inagaki AD, de Oliveira LAR, de Oliveira MFB, Santos RCS, Araújo Rezende HV, et al. Elevated risk for HIV-1 infection in adolescents and RM, Alves JAB, et al. Soroprevalência de anticorpos para toxoplasmose, young adults in Sao Paulo, Brazil. PLoS One. 2008;3:e1423. Saffier et al. BMC Infectious Diseases (2017) 17:675 Page 13 of 13 rubéola, citomegalovírus, sífilis e HIV em gestantes sergipanas. Rev Soc Bras 63. Taquette SR, Matos HJ, Rodrigues Ade O, Bortolotti LR, Amorim E. A epidemia Med Trop. 2009;42:532–6. de AIDS em adolescentes de 13 a 19 anos, no município do Rio de Janeiro: 41. Moura AA, de Mello MJG, Correia JB. Prevalence of syphilis, human descrição espaço-temporal. Rev Soc Bras Med Trop. 2011;44:467–70. immunodeficiency virus, hepatitis B virus, and human T-lymphotropic virus 64. Brito AM, Castilho EA, Szwarcwald CL. AIDS e infecção pelo HIV no Brasil: infections and coinfections during prenatal screening in an urban uma epidemia multifacetada. Rev Soc Bras Med Trop. 2001;34:207–17. Northeastern Brazilian population. Int J Infect Dis. 2015;39:10–5. 65. Osava M. Health-Brazil: AIDS grows dramatically among young women. Global Information Network: New York, NY; 2002. [https://search.proquest. 42. Miranda AE, Pinto VM, McFarland W, Page K. HIV infection among young pregnant women in Brazil: prevalence and associated risk factors. AIDS com/docview/457568113]. 66. Ministry of Health. Integrated plan to combat the feminization of the AIDS Behav. 2014;18(Suppl 1):S50–2. epidemic and other STDs. Brasília: National Ministry of Health; 2007. 43. Ferezin RI, Bertolini DA, Demarchi IG. Prevalência de sorologia positiva para 67. Teixeira LB, Pilecco FB, Vigo A, Knauth DR. Sexual and reproductive HIV, hepatite B, toxoplasmose e rubéola em gestantes do noroeste health of women living with HIV in southern Brazil. Cad Saude Publica. paranaense. Rev Bras Ginecol Obstet. 2013;35:66–70. 2013;29:609–20. 44. Domingues RMSM, Szwarcwald CL, Souza PRB, do Carmo Leal M. Prenatal testing and prevalence of HIV infection during pregnancy: data from the “birth in Brazil” study, a national hospital-based study. BMC Infect Dis. 2015;15:100. 45. Pinto JA, Ruff AJ, Paiva JV, Antunes CM, Adams IK, Halsey NA, et al. HIV risk behavior and medical status of underprivileged youths in Belo Horizonte, Brazil. J Adolesc Health. 1994;15:179–85. 46. Zanetta DM, Strazza L, Azevedo RS, Carvalho HB, Massad E, Menezes RX, et al. HIV infection and related risk behaviours in a disadvantaged youth institution of Sao Paulo, Brazil. Int J STD AIDS. 1999;10:98–104. 47. Coelho HC, Perdoná GC, Neves FR, Passos ADC. HIV prevalence and risk factors in a Brazilian penitentiary. Cad Saude Publica. 2007;23:2197–204. 48. Fialho M, Messias M, Page-Shafer K, Farre L, Schmalb M, Pedral-Sampaio D, et al. Prevalence and risk of blood-borne and sexually transmitted viral infections in incarcerated youth in Salvador, Brazil: opportunity and obligation for intervention. AIDS Behav. 2008;12:S17–24. 49. Harrison LH, do Lago RF, Friedman RK, Rodrigues J, Santos EM, de Melo MF, et al. Incident HIV infection in a high-risk, homosexual, male cohort in Rio de Janeiro, Brazil. J Acquir Immune Defic Syndr. 1999;21:408–12. 50. Szwarcwald CL, de Carvalho MF, Barbosa Junior A, Barreira D, Speranza FA, de Castilho EA. Temporal trends of HIV-related risk behavior among Brazilian military conscripts, 1997-2002. Clinics (Sao Paulo). 2005;60:367–74. 51. Soares CC, Georg I, Lampe E, Lewis L, Morgado MG, Nicol AF, et al. HIV-1, HBV, HCV, HTLV, HPV-16/18, and Treponema pallidum infections in a sample of Brazilian men who have sex with men. PLoS One. 2014;9:e102676. 52. Szwarcwald CL, Andrade CLT, Pascom ARP, Fazito E, Pereira GFM, Penha IT. HIV-related risky practices among Brazilian young men, 2007. Cad Saude Publica. 2011;27:s19–26. 53. Guimarães MDC, Ceccato MGB, Gomes R, Rocha GM, Camelo LV, Carmo RA, et al. Vulnerabilidade e fatores associados a HIV e sífilis em homens que fazem sexo com homens, Belo Horizonte, MG. Rev Assoc Med Minas Gerais. 2013;23:412–26. 54. Veras MA, Calazans GJ, de Almeida Ribeiro MC, de Freitas Oliveira CA, Giovanetti MR, Facchini R, França IL, McFarland W. High HIV prevalence among men who have sex with men in a time-location sampling survey, Sao Paulo, Brazil. AIDS Behav. 2015;19:1589–98. 55. Trevisol FS, Silva MV. HIV frequency among female sex workers in Imbituba, Santa Catarina, Brazil. Braz J Infect Dis. 2005;9:500–5. 56. Schuelter-Trevisol F, Custodio G, Silva AC, Oliveira MB, Wolfart A, Trevisol DJ. HIV, hepatitis B and C, and syphilis prevalence and coinfection among sex workers in southern Brazil. Rev Soc Bras Med Trop. 2013;46:493–7. 57. Costa AB, Fontanari AMV, Jacinto MM,da SilvaDC, Lorencetti EK,da Rosa Filho HT, et al. Population-based HIV prevalence and associated factors in male-to-female transsexuals from southern Brazil. Arch Sex Behav. 2015;44:521–4. Submit your next manuscript to BioMed Central 58. Freitas-Carvalho J, Viana S, Darub T, Farias E, Rocha G, Galvão-Castro B, et al. Soroprevalência para retrovírus em uma amostra da população de Rio and we will help you at every step: Branco (Acre). Rev Baiana Saude Publica. 2002;26:9–18. • We accept pre-submission inquiries 59. Codes JS, Cohen DA, Melo NA, Santos AB, Codes JJG, Silva JC Jr, et al. Detecção de doenças sexualmente transmissíveis em clínica de � Our selector tool helps you to find the most relevant journal planejamento familiar da rede pública no Brasil. Rev Bras Ginecol Obstet. � We provide round the clock customer support 2002;24:101–6. � Convenient online submission 60. Szwarcwald CL, Ferreira OC Jr, Brito AM, Luhm KR, Ribeiro CEL, Silva AM, et al. Estimation of HIV incidence in two Brazilian municipalities, 2013. Rev � Thorough peer review Saude Publica. 2016;50:55. � Inclusion in PubMed and all major indexing services 61. Silveira MF, Santos IS, Victora CG. Poverty, skin colour and HIV infection: a � Maximum visibility for your research case-control study from southern Brazil. AIDS Care. 2008;20:267–72. 62. Department of Health. Boletim Epidemiológico HIV/AIDS de 2016. Brasília, Submit your manuscript at DF: Department of STI, AIDS and Viral Hepatitis, Ministry of Health; 2016. www.biomedcentral.com/submit

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