E lia n a A m a ra l, A n ib a l F a tJn d e s, N e iva S e lla n L o p e s G o n 9 a le s, Jo rd a o P e lle g rin o Jr., C a rm in o A n to n io d e S o u za , Jo a o L u iz P in to e S ilva
P rev alen ce o f H IV an d
Treponema pallidum
in fectio n s in
p reg n an t w o m en in C am p in as an d th eir asso ciatio n w ith
so cio -d em o g rap h ic facto rs
Obstetrics and Gynecology Department,
Medical School, University of Campinas - Campinas, Brazil
T h e a n o n ym o u s se ro p re va le n ce o f H IV a n d syp h ilis w a s stu d ie d b y co lle ctin g u m b ilica l co rd b lo o d sa m p le s fro m 5 ,8 1 5 w o m e n w h o g a ve b irth in C a m p in a s' h o sp ita ls th ro u g h o u t a six-m o n th p e rio d . E L IS A a n d W e ste rn b lo t w e re u se d fo r H IV , a n d V O R L a n d T P H A fo r T re p o n e m a p a llid u m scre e n in g . W h ile m a in ta in in g th e a n o n ym ity o f th e w o m e n , in fo rm a tio n w a s re co rd e d o n th e h o sp ita l o f o rig in , d ivid e d in to u n ive rsity (p u b lic) a n d p riva te h o sp ita ls, a s w e ll a s o n th e fo rm o f p a ym e n t (so cia l se cu rity, p riva te in su ra n ce o r d ire ct p a ym e n t), a g e , m a rita l sta tu s, e d u ca tio n , e m p lo ym e n t a n d p la ce o f re sid e n ce . S e ro p re va le n ce w a s 0 .4 2 p e rce n t fo r H IV a n d 1 .1 6 p e rce n t fo r syp h ilis. T h e re w a s a sig n ifica n t co rre la tio n b e tw e e n a p o sitive re a ctio n to th e tw o in fe ctio n s (p = 0 .0 2 ). A fte r u n iva ria te a n d lo g istic re g re ssio n a n a lysis, o n ly u n ive rsity h o sp ita ls w e re sh o w n to b e a sso cia te d w ith se ro p o sitivity fo r H IV , w h e re a s th e sa m e va ria b le a n d a n o ld e r a g e w e re a sso cia te d w ith syp h ilis. A ll p o sitive re a ctio n s w e re fo u n d e ith e r in p u b lic h o sp ita ls o r a m o n g so cia l se cu rity p a tie n ts tre a te d a t p riva te in stitu tio n s. T h e co n clu sio n w a s th a t H IV in fe ctio n is b e co m in g a lm o st a s p re va le n t a s syp h ilis a m o n g th is p o p u la tio n , a n d a ffe cts p rim a rily th e lo w e r so cio -e co n o m ic stra ta . T h is su g g e sts th a t ro u tin e , vo lu n ta ry H IV se ro lo g y sh o u ld b e co n sid e re d a n d d iscu sse d w ith p a tie n ts d u rin g p re n a ta l o r d e live ry ca re w h e n e ve r a p o p u la tio n sh o w s a se ro p re va le n ce clo se to o r g re a te r th a n 1 p e rce n t.
U N IT E R M S : H u m a n im m u n o d e ficie n cy viru s. H IV , p re va le n ce w o m e n , g e sta tio n . U m b ilica l co rd b lo o d .
IN T R O D U C T IO N
B
b e e n re p o rte d
y m id -1 9 9 1 ,
a to ta l o f 3 7 1 ,8 0 2
w o rld w id e ;
1 8 ,1 1 3 o f th e se w e re in
A ID S
c a se s h a d
B ra z il,
w h ic h
ra n k e d
th ird in n u m b e r
o f c a se s.
5 2T h e sp re a d o f th e e p id e m ic
h a s b e e n v e ry ra p id th ro u g h o u t
th e w o rld , b u t h a s n o t fo llo w e d
th e sa m e m o d e l in e v e ry
c o u n try .
T h e
id e n tific a tio n
o f se v e ra l
e p id e m io lo g ic
A d d re s s fo r c o rre s p o n d e n c e : E lia n a A m a ra l
D ivisa o d e O b ste trfcia d o C A IS M - U N IC A M P R u a A le xa n d e r F le m in g , 1 0 1
C a m p in a s/S P - B ra sil - C E P 1 3 0 8 1 -9 7 0
p a tte rn s
h a s c o n trib u te d
to a b e tte r
u n d e rsta n d in g
o f
w o m e n 's
p a rtic ip a tio n
in th e sp re a d o f th e d ise a se .
E p id e m io lo g ic
p a tte rn
T y p e I, fo u n d
in th e U n ite d
S ta te s a n d in so m e a re a s in L a tin A m e ric a n ,
c o rre sp o n d s
to p o p u la tio n s
in w h ic h
h o m o se x u a l
m e n
a re th e m o st
a ffe c te d g ro u p , fo llo w e d
b y in tra v e n o u s
d ru g u se rs a n d a
sm a ll n u m b e r o f w o m e n . T y p e II p a tte rn is fo u n d in A fric a
a n d
th e
C a rib b e a n ,
w ith
p re d o m in a n tly
h e te ro se x u a l
d isse m in a tio n
a n d n o d iffe re n c e
in p re v a le n c e
b e tw e e n
m e n a n d w o m e n .
P a tte rn
III re fe rs to c o u n trie s
w ith lo w
A ID S
p re v a le n c e
e v e n
a m o n g
g ro u p s
c o n sid e re d
h ig h
risk .
4 0S u c h
p a tte rn s,
h o w e v e r,
c a n
c h a n g e
w ith
tim e ,
g iv in g rise to a n in te rm e d ia ry
p a tte rn
T y p e
IIIl,
fo u n d in
re g io n s
w h e re
in itia l
d isse m in a tio n
w a s
a m o n g
h o m o se x u a ls
a n d d ru g u se rs, b u t w h e re
th e in c id e n c e
o f
1109
th e
d is e a s e
h a s
b e e n
e x p a n d in g
th r o u g h
h e te r o s e x u a l
tr a n s m is s io n .4 1
T h e W o r ld H e a lth
O r g a n iz a tio n
c o n s id e r s
L a tin
A m e r ic a ,
in c lu d in g
B r a z il,
to
b e
p a r t
o f
th is
in te r m e d ia te
g r o u p .3 6 .3 9
A c c o r d in g
to in f o r m a tio n
f r o m th e B r a z ilia n M in is tr y
o f H e a lth ,
th e f ir s t m a le A I D S c a s e in B r a z il w a s r e p o r te d
in
1 9 8 0 ,b u t th e f ir s t f e m a le
c a s e
w a s n o t r e p o r te d
u n til
1 9 8 3 .
I n
1 9 8 4 ,th e r e
w a s o n e in f e c te d
w o m a n
f o r e v e r y
1 2 4
m e n , b u t in
1 9 9 3th e r a tio w a s
1 : 4 .1 2 T h e e v o lu tio n o f
A I D S
d is tr ib u tio n
a m o n g
B r a z ilia n
w o m e n
h a s s h o w n
a
d e c r e a s e
in in f e c tio n
th r o u g h
b lo o d
a n d b lo o d
p r o d u c ts ,
b u t a p r o g r e s s iv e
in c r e a s e
in in f e c tio n
b y h e te r o s e x u a l
c o n ta c t,
w h ic h
to d a y
is th e
m a in
m e c h a n is m
f o r
th e
tr a n s m is s io n
o f H I V
in f e c tio n
( F ig .
I).
1 0 0
____H eterosexual +Iv D rug »I( B lood
80
---60
,,~ ro ro
,,~ ro ~
,,~ ~ I \ j ,,~ ~ " "~ ~ 7,,. ,,~ ~ 'OYEAR
T h e
im m e d ia te
c o n s e q u e n c e
o f
th e
h ig h e r
p r e v a le n c e
a m o n g
w o m e n
is th e
v e r tic a l
tr a n s m is s io n
o f th e
in f e c tio n
to th e ir
c h ild r e n
in a p r o p o r tio n
th a t
v a r ie s
f r o m
1 2 .9to
3 9p e r c e n t.9 .2 4 .2 5 ,4 5 ,4 9
I n B r a z il,
d u r in g
th e f ir s t h a lf o f
1 9 9 3 ,v e r tic a l
tr a n s m is s io n
r e p r e s e n te d
8 7 .9 p e r c e n t
o f a ll p e d ia tr ic
A I D S
c a s e s ,
w h e r e a s
u p
to 1 9 8 6 , 7 8 p e r c e n t
o f H I V
in f e c tio n s
a m o n g
c h ild r e n
h a d
b e e n
a c q u ir e d
th r o u g h
b lo o d .1 2
K n o w le d g e
a b o u t th e d im e n s io n
o f th e e p id e m ic
is
r e q u ir e d
to e d u c a te
th e
p o p u la tio n
to a d o p t
p r e v e n tiv e
m e a s u r e s ,
a n d p r o v id e s
th e b a s is f o r s e n s itiz in g
th o s e w h o
a r e p o litic a lly
r e s p o n s ib le
to m a k e d e c is io n s w h ic h s u p p o r t
c o n tr o l
p r o g r a m s .
T h is k n o w le d g e
is a ls o r e q u ir e d
f o r th e
e v a lu a tio n
o f th e im p a c t c a u s e d
b y c o n tr o l m e a s u r e s .
T h e
in d ic a to r
c o m m o n ly
u s e d to a s s e s s th e d im e n s io n s
o f th e
e p id e m ic
is th e n u m b e r
o f A I D S
c a s e s r e p o r te d
to h e a lth
a u th o r itie s .
N e v e r th e le s s ,
s u c h m e th o d o lo g y
a f f o r d s o n ly
a la te
in s ig h t
in to
th e d y n a m ic s
o f th e in f e c tio n ,
a s th e
n u m b e r s
o b ta in e d
r e f e r
to
in d iv id u a ls
w h o
h a d
b e e n
c o n ta m in a te d
s e v e r a l
y e a r s e a r lie r .6
P r e v a le n c e
s tu d ie s o f H I V in f e c tio n
c o n s titu te
a m o r e
e f f ic ie n t m e th o d to e v a lu a te
th e d im e n s io n
o f th e e p id e m ic
a n d to f o llo w
its d y n a m ic s ,
p r o v id in g
g lo b a l a n d u p d a te d
in f o r m a tio n
o n c o n ta m in a tio n
le v e ls ,
w h ic h
c a n th e n
b e
a p p lie d
to s e v e r a l
p o p u la tio n
g r o u p S .6 ,4 HT h e ir
r e p e titio n
in r e la tiv e ly
s ta b le
p o p u la tio n
g r o u p s
th r o u g h
s o - c a lle d
" s e n tin e l
s u r v e illa n c e ,"
p r o v id e s
a lo n g - te r m
v ie w
o f th e
e v o lu tio n
o f th e
e p id e m ic .
T h e
m u ltip lic a tio n
o f th e s e
" s e n tin e l
s u r v e illa n c e "
s tu d ie s p e r m its
e f f ic ie n t,
s w if t a n d
e c o n o m ic a l
s c r e e n in g ,
a s w e ll
a s a m o n ito r in g
o f th e
in f e c tio n .2 0 ,4 7
T h e p r e v a le n c e
o f th e in f e c tio n
a m o n g
w o m e n
m a y
b e a g o o d
in d ic a tio n
o f th e s itu a tio n
a m o n g
th e g e n e r a l
p o p u la tio n
w h e n n o n - s e le c te d
g r o u p s
a r e e v a lu a te d .
T h e
m o s t c o m p r e h e n s iv e
a n d p r a c tic a l
w a y to r e a c h u n s e le c te d
w o m e n
is to p e r f o r m
s e r o lo g ic
te s ts o n p a tie n ts
a tte n d in g
p r e n a ta l
c lin ic s
o r a t b ir th .2 9 .3 3 .3 H
A n o th e r
r e a s o n
f o r
in v e s tig a tin g
th e
p r e v a le n c e
a m o n g
d e liv e r in g
w o m e n
is th e
r is k
o f c o n ta m in a tio n
f o r h e a lth
p r o f e s s io n a ls .1 5 .1 6
P r o s p e c ti
v e s tu d ie s
o f th e
r is k
f a c e d
b y
h e a lth
p r o f e s s io n a ls
e x p o s e d
to
s e r o p o s itiv e
b lo o d
h a s
s h o w n
a 0 .3
p e r c e n t
r a te
o f
s e r o c o n v e r s io n
a f te r
a c c id e n ts
w ith
c o n ta m in a te d
n e e d le s
o r c u ttin g
in s tr u m e n ts ,
a n d
n o s e r o c o n v e r s io n
a f te r
e x p o s u r e
o f th e m u c o s a .
3 0T h e
p r o f e s s io n a l
a s s is tin g
a t a b ir th
is e x p o s e d
to
m u c h la r g e r q u a n titie s
o f b lo o d a n d o th e r b o d y f lu id s th a n
m o s t
s u r g e o n s
in n o n - o b s te tr ic
p r o c e d u r e s .
T h e r e f o r e ,
p r e v a le n c e
d a ta
o n
s y p h ilis
a n d
H I V
a m o n g
p r e g n a n t
w o m e n
is
a ls o
u s e f u l
to
h ig h lig h t
th e
n e e d
to
ta k e
p r e v e n tiv e
m e a s u r e s . T h is a p p lie s to h o s p ita l m a n a g e m e n t,
to e n s u r e
th e
a d e q u a te
p r o v is io n
o f e q u ip m e n t,
a n d
to
d o c to r s a n d n u r s e s , s o a s to e d u c a te th e m to ta k e p r o t~ c - ti v e
m e a s u r e s .
I n B r a z il, th e m e d ic a l
lite r a tu r e
s h o w s
a p r e v a le n c e
r a n g in g
f r o m
1 .0 p e r c e n t
to
3 .7 5
p e r c e n t
in p r e n a ta l
p a tie n ts /d e liv e r in g
w o m e n
in s p e c if ic
p o p u la tio n
g r o u p s ,
Table 1
Proportion of valid samples to total
births by hospital
H ospitals
S am ples
D eliveries
n/N
n
N
0 /01 7 5 9 1 ,7 4 0 6 6 .5 8
2 1 ,3 8 0 1 ,6 0 2 8 6 .1 4
3 1 ,1 8 6 1 ,5 2 6 7 7 .7 2
4 7 2 5 7 9 4 9 1 .3 1
5 . 1 ,7 6 5 4 ,6 0 8 3 8 .3 0
T otal
5 ,8 1 5 9 ,6 7 0 6 0 .1 3A M A R A L, E .; F A U N D E S , A .; G O N l;A LE S , N .S .L. et al. - P revalence of H IV and Treponema S ao P aulo M edical Journal/R P M 114(2): 1108-1116, 1996
1110
selected fro m w h ere th ere is a h ig h co n cen tratio n
o f w o m en
p resen tin g
h ig h -risk
b eh av io r
fo r H IV in fectio n . 1 9 .2 3 ,4 3
A t
C A IS M ,
th e W o m en 's
H o sp ital
o f th e S tate U n iv ersity
o f
C am p in as
(U N IC A M P ),
H IV
in fectio n
w as d iag n o sed
d u rin g
p reg n an cy
in 0 .4 7
p ercen t
o f w o m en
d eliv erin g
b etw een
S ep tem b er
1 9 8 8 an d D ecem b er
1 9 9 0 . H o w ev er,
th e actu al p rev alen ce
w as u n k n o w n ,
as sero lo g ic tests w ere
p erfo rm ed
o n ly
o n w o m en
w ith k n o w n
risk facto rs
fo r
H IV in fectio n .2
R o u tin e
testin g
creates
o th er
p ro b lem s,
as th e
w o rld w id e
eth ical
n o rm
fo r H IV
in fectio n
screen in g
estab lish es
th at th e in d iv id u als
to b e tested
sh o u ld
g iv e
th eir in fo rm ed
co n sen t
w h en ev er
id en tified
b y th e p erso n
req u estin g
th e test.1 .1 4 .IRP rev alen ce
stu d ies w ith id en tified
su b jects w h o ag ree to b e tested
lead to a u n d erestim atio n
o f u p to
5 0 p ercen t,
as a co n seq u en ce
o f th e
self-ex clu sio n
o f in d iv id u als
at h ig h er
risk .2 2 .3 0 .3 1 .5 0T h e
reco m m en d ed
eth ical
p ro ced u re
fo r co n d u ctin g
ran d o m
sero p rev alen ce
stu d ies
is to
carry
o u t
an o n y m o u s
sero lo g y ,
b o th o n th e p art o f th e in d iv id u al
b ein g tested
an d
o n
th e
p art
th e
research er,
in
a d o u b le-b lin d
stu d y .3 .6 .4 7 ,4 RT h is
stu d y
d esig n
is co n sid ered
eth ical,
b ecau se
th e
b lo o d
sam p le
b eco m es
th e o b ject
o f th e
stu d y ,
as th e id en tity
o f th e p atien ts
is u n k n o w n .
T h is
m eth o d o lo g y
h as
alread y
b een
u sed
in
sev eral
co u n tries,2 7 .3 o .3 3 .5 oan d is reco m m en d ed
b y in tern atio n al
o rg an izatio n s
d ealin g
w ith
A ID S
co n tro l
after carefu l
co n sid eratio n
o f its ad v an tag es
an d d isad v an tag es.3 R ,4 7 ,4 R
T h e m ain ad v an tag e
o f th is m eth o d is th at it p ro v id es
a m o re accu rate
ev alu atio n
o f p rev alen ce.
A t a tim e w h en
few p h y sician s
p ay p ro p er atten tio n
to H IV in fectio n ,
w e
ju d g ed
raisin g aw aren ess
o n th e actu al p rev alen ce
to b e a
p rio rity
th at
req u ires
th e
ad h eren ce
to m eth o d o lo g y
in tern atio n ally
reco m m en d ed
fo r th is p u rp o se.
T h e
d ev elo p m en t
o f th is
stu d y
in C am p in as
w as
ju stified
b ecau se
th e city
w as ran k ed
n in th in ab so lu te
n u m b ers
an d sev en teen th
in A ID S in cid en ce
co efficien t, 1 2
w h ich p laced
th e city in an in term ed iate
situ atio n
am o n g
B razilian
u rb an
cen ters.
A p arallel
stu d y o n
T. pal/idum
in fectio n
w as
ad d ed
w ith
th e
g o al
o f co m p arin g
th e
p rev alen ce
o f th e tw o
d iseases,
co n sid erin g
also th at
sy p h ilis
sero lo g y
is p art o f th e stan d ard
p ren atal
ro u tin e
reco m m en d ed
b y th e M in istry
o f H ealth .lo T h is h as th e
ad d itio n al
p u rp o se
o f stu d y in g
lu es sero p o sitiv ity
as a risk
facto r fo r H IV in fectio n .
S U B J E C T S A N D M E T H O D
,
A cro ss-sectio n al
stu d y w as carried o u t b etw een A p ril
I
an d S ep tem b er
3 0 , 1 9 9 1 . U m b ilical
co rd b lo o d sam p les
w ere
co llected
in all d eliv eries
o ccu rrin g
at th e fiv e
h o sp itals reg isterin g
th e h ig h est n u m b er
o f o b stetric
cases
in C am p in as
(8 3 p ercen t
o f d eliv eries).
T h ree
o f th e
m atern ity
h o sp itals
are p art o f p riv ate
o r p h ilan th ro p ic
o rg an izatio n s,
an d th e o th er tw o are u n iv ersity
h o sp itals,
w h ich
m ak e
u p p art o f S U S
(P u b lic
H ealth
S y stem ).
S am p les
w ere
co llected
d u rin g
all b irth s,
w ith o u t
an y
selectio n
criteria.
T h erefo re,
all ty p es
o f p atien ts
w ere
in clu d ed , fro m th o se w h o se ex p en ses
w ere co v ered b y S U S
to th o se w h o h ad p riv ate h ealth in su ran ce
o r p aid d irectly .
T h e clin ical
b o ard s o f d irecto rs
an d th e h o sp itals'
eth ics
co m m ittees
ap p ro v ed
th e d ev elo p m en t
o f th e stu d y after
ev alu atin g
th e p ro p o sal.
U m b ilical
co rd b lo o d sam p les
(I O m l) w ere co llected
w ith o u t
th e ad d itio n
o f an y an tico ag u lan t,
in all b irth s,
in d ep en d en t
o f th e
fo rm
o f d el i v ery
(v ag i n al o r b y
C aesarean
sectio n ).
T h e p atien ts'
in itials,
d ate an d tim e
o f d eliv ery
w ere w ritten o n ad h esiv e
lab els, w ith sp ecific
serial n u m b ers fo r each h o sp ital p rin ted o n th e sam e lab el.
S am p les
id en tified
o n ly b y th e lab el w ere co llected
d aily
b y a research assistan t fro m th e fiv e h o sp itals an d d eliv ered
fo r sero lo g ic testin g to th e H em o cen tro
- C am p in as,
lo cated
at th e S tate U n iv ersity
o f C am p in as
(U N IC A M P ).
A n E L IS A
test (A b b o t
H IV
IE IA ,
m an u factu red
b y A b b o tt
L ab o rato ries
in B razil)
w as carried
o u t o n
each
sam p le,
fo llo w ed
b y W estern
b lo t
(D u
P o n t)
w h en ev er
E L IS A
resu lts
w ere p o sitiv e
o r in co n clu siv e.
W estern
b lo t
w as
co n sid ered
p o sitiv e
w h en
p o sitiv e
resu lts
w ere fo u n d
fo r b an d s
p 2 4 , P 3 1 , g p 4 1 o r g p
1 2 0 /g p
1 6 0 ,
acco rd in g
to B io tech
d u
P o n t,
criteria
co rro b o rated
b y
th e
U .S .
F o o d
an d
D ru g
A d m in istratio n .'7
S creen in g
fo r
T. pallidu/11
in fectio n
w as co n d u cted
b y V D R L
q u an titativ e
test (B o eh rin g ),
an d all p o sitiv e
sam p les
w ere
tested
fo r co n firm atio n
b y T P H A
(B io lab ).
In th e
m ean tim e,
research
assistan ts
co llected
ep id em io lo g ic
d ata fro m h o sp ital
reco rd s,
rem o v in g
an y
p erso n al
id en tificatio n
w h ich co u ld tie sero lo g y
resu lts to
sp ecific
p atien ts.
T o p ro tect
an o n y m ity ,
o n ly
n u m erical
id en tificatio n
w as k ep t.
D ep en d en t
v ariab les stu d ied w ere: H IV in fectio n
an d
T. pal/idu/11
in fectio n . In d ep en d en t
v ariab les
stu d ied w ere:
ty p e o f h o sp ital
(u n iv ersity
o r o th er);
m o d e
o f p ay m en t
fo r h o sp ital b ill (m ean in g
h o w h o sp ital
an d m ed ical
co sts
w ere co v ered ); ag e; m arital statu s; ed u catio n ;
p ro fessio n al
o ccu p atio n ;
an d city o f resid en ce.
A ll in fo rm atio n
w as reco rd ed
o n a sp ecial fo rm . A ll
fo rm s
w ith o u t
th e sero lo g y
resu lts
w ere
ex clu d ed
fro m
th e
an aly sis.
W h en
sero lo g y
resu lts
d id
n o t h av e
th e
co rresp o n d in g
fo rm w ith in fo rlllatio n
o n th e in d ep en d en t
v ariab les,
th ey
w ere
u sed
o n ly
to estim ate
th e g en eral
p rev alen ce
o f th e tw o in fectio n s
(1 1 3 cases).
R esu lts
o f
1 1 1 1
R E S U L T S
T a b le 2
N u m b e r o f b lo o d s a m p le s lo s t to a n a ly s is , b y re a s o n
s e r o lo g ic a l te s ts w e r e e n te r e d in to a I B M - P C c o m p u te r
u s in g th e D B a s e I I I P lu s p r o g r a m ; s ta tis tic a l a n a ly s is w a s
c a r r ie d o u t o n th e S P S S - P C p r o g r a m . U n iv a r ia te a n a ly s is
w a s c o n c lu d e d u s in g d ic h o to m iz e d v a r ia b le s th r o u g h th e
Q - s q u a r e te s t a n d , w h e n n e c e s s a r y , th r o u g h th e Y a te s a n d
F is h e r c o r r e c tio n p r o c e d u r e s . M u ltip le a n a ly s is w a s c a r r ie d
o u t u s in g th e lo g is tic r e g r e s s io n te c h n iq u e .
T a b le 3
S e ro p re v a le n c e fo r H IV a n d T .
pallidum
b y h o s p ita l
H o s p ita ls H IV
T. pallidum
R a tio H IV /n (% ) n (% )
T.pallidum
1 4 (0 .6 ) 1 3 (1 .9 ) 1 :3
2 1 2 (1 .0 ) 2 4 (2 .0 ) 1 :2
3 3 (0 .3 ) 9 (0 .9 ) 1 :3
4
o
(0 .0 ) 3 (0 .5 )5 2 (0 .1 ) 1 0 (0 .7 ) 1 :5
T o ta l 2 1 (0 .4 ) 5 9 (1 .2 ) 1 :3
H IV
T.pallidum
P o s itiv e N e g a tiv e T o ta l
P o s itiv e 2 (3 0 % ) 1 8 (0 .4 % ) 2 0
N e g a tiv e 5 7 5 ,0 0 4 5 ,0 6 1
T o ta l 5 9 5 ,0 2 2 5 ,0 8 1
T h e 0 .4 p e r c e n t H I V s e r o p r e v a le n c e f o u n d a m o n g
c h ild b e a r in g w o m e n in C a m p in a s c a n b e c o n s id e r e d J o w ,
T a b le 4
C o rre la tio n
b e tw e e n s e ro p o s itiv ity
fo r H IV a n d T .
pallidum
D IS C U S S IO N
T w e n ty - tw o p o s itiv e a n d f iv e in c o n c lu s iv e r e s u lts
w e r e f o u n d b y th e E L I S A m e th o d f o r H I Y . T w e n ty p o s itiv e
a n d o n e in c o n c lu s iv e E L I S A - s a m p le s w e r e c o n f ir m e d a s
p o s itiv e b y th e W e s te r n b lo t te s t. I n th e n o n - s p e c if ic te s t
f o r
T.
pailidum,
6 1 r e a c tin g s a m p le s w e r e f o u n d , w ithq u a n tita tiv e V D R L le s s th a n o r e q u a l to o n e - e ig h t. T h e
s p e c if ic p r o o f c o n f ir m e d th e p o s itiv ity o f 5 9 s a m p le s , w ith
e v id e n c e th a t th e r e m a in in g tw o w e r e f a ls e - p o s itiv e .
T h u s , th e H I V s e r o p r e v a le n c e f o u n d in th e to ta l
c o lle c tio n o f s a m p le s w a s 0 .4 p e r c e n t o r 4 p e r 1 0 0 0 ,
v a r y in g f r o m 0 p e r c e n t to 1 .0 p e r c e n t a m o n g p a r tic ip a tin g
h o s p ita ls . G e n e r a l s e r o p r e v a le n c e f o r
T. pailidum
w a s 1 .2p e r c e n t, v a r y in g f r o m 0 .5 p e r c e n t to 2 .0 p e r c e n t. T h e
h ig h e s t p r e v a le n c e w a s o b s e r v e d in u n iv e r s ity h o s p ita ls ,
a n d n o H I V in f e c tio n w a s d e te c te d a t th e o n e h o s p ita l
w h ic h a tte n d s o n ly p r iv a te p a tie n ts a n d th o s e w ith p r iv a te
h e a lth in s u r a n c e ( T a b le 3 ) .
T h e r e w a s a s ig n if ic a n t c o r r e la tio n ( p < 0 .0 2 ) b e tw e e n
s e r o p o s itiv ity f o r s y p h ilis a n d H I V . H I V in f e c tio n
p r e v a le n c e w a s s e v e n tim e s h ig h e r in p o s itiv e
T. pailie/um
s a m p le s ( 3 .0 p e r c e n t) , th a n in th e n e g a tiv e
T. pailie/um
g r o u p ( 0 .4 p e r c e n t) ( T a b le 4 ) . T h e u n iv a r ia te a n a ly s is
s h o w e d a c o r r e la tio n o f b o th in f e c tio n s w ith u n iv e r s ity
h o s p ita l a n d S U S p a y m e n t m o d e ; th e r e a ls o w a s a
c o r r e la tio n w ith a g e o v e r 2 4 f o r
T. pailie/um,
a n d w ith th ea b s e n c e o f a m a r ita l u n io n f o r H I V ( T a b le 5 ) . N o H I V
s e r o p o s itiv e s a m p le s w e r e f o u n d a m o n g p r iv a te p a tie n ts
o r th o s e w h o h a d p r iv a te h e a lth in s u r a n c e ; th e 2 1
s e r o p o s itiv e s a m p le s w e r e f o u n d a m o n g p a tie n ts u s in g
S U S . M u ltip le r e g r e s s io n s h o w e d , f o r b o th in f e c tio n s , a
c o r r e la tio n w ith u n iv e r s ity h o s p ita l c a r e a n d , f o r s y p h ilis
o n ly , a c o r r e la tio n w ith o ld e r a g e ( T a b le 6 ) .
p = 0 .0 2 (F is h e r's te s t)
V D R L
6 9 3
1 5
1 9
6
7 3 3
5 ,0 8 2
5 ,8 1 5 E L IS A
6 9 3
1 5
o
6
7 1 4
5 ,1 0 1
5 ,8 1 5
D u r in g th e p e r io d o f s a m p le c o lle c tio n th e r e w e r e
9 ,2 0 9 b ir th s . H o w e v e r , b e c a u s e o f f a ilu r e s in s a m p le
c o lle c tio n , o n ly 5 ,8 1 5 b lo o d s a m p le s w e r e o b ta in e d ,
c o r r e s p o n d in g to 6 0 .1 3 p e r c e n t o f a ll d e liv e r ie s . T h e
n u m b e r o f b ir th s , s a m p le s c o lle c te d , a n d r e s u ltin g
p r o p o r tio n b y h o s p ita l a r e s h o w n in T a b le 1 .
M o r e th a n 1 0 p e r c e n t ( 7 1 4 ) o f th e s a m p le s w e r e
r e je c te d f o r d if f e r e n t r e a s o n s . S p o n ta n e o u s f o r m a tio n o f
p la s m a in p la c e o f s e r u m r e n d e r e d 1 9 s a m p le s a d e q u a te
f o r H I V s e r o lo g y , b u t n o t f o r
T. pallidum.
C o n s e q u e n tly ,5 ,1 0 1 v a lid s a m p le s w e r e s e le c te d f o r th e E L I S A te s t a n d
5 ,0 8 2 f o r th e V D R L te s t ( T a b le 2 ) .
T o ta l s a m p le s lo s t
V a lid s a m p le s
T o ta l s a m p le s c o lle c te d R e a s o n
- h e m o ly s is
- in s u ffic ie n t m a te ria l
- p la s m a fo rm a tio n
- b ro k e n v e s s e l
A M A R A L , E .; F A U N D E S , A .; G O N C ;A L E S , N .S .L . e t a l. - P re v a le n c e o f H IV a n d Treponema. S a o P a u lo M e d ic a l J o u rn a l/R P M 1 1 4 (2 ): 1 1 0 8 -1 1 1 6 , 1 9 9 6
1 1 1 2
T. pallidum
< 0 .0 0 0 1
0 .0 1 1 5
H IV0 .0 0 6 4
N .S .
0 .0 4 5
0 .2 4 4
0 .8 0 3
0 .4 9 9
0 .1 4 8
0 .0 0 0 5
T a b le 6 ,
V a lu e fo r fa cto rs a sso cia te d w ith H IV a n d T .
pallidum
in m u ltip le lo g istic
re g re ssio n
F a cto rs
U n ive rsity H o sp ita l
O ld e r A g e
m a le /fe m a le
ra tio
in th e n u m b e r
o f A ID S
c a s e s
re p o rte d
to th e M in is try
o f H e a lth ,
12a n d th e g ro w in g
in fe c tio n
ra te s
a m o n g
th e
.w o m e n d e liv e rin g
a t th e u n iv e rs ity
h o s p ita l
in R ib e ira o
P re to .
2 3A p re v a le n c e
o f 0 .4
to 0 .6 p e rc e n t
in
C a m p in a s ,
a n d o f 1 .0 to
1 .5 (if c o rd
b lo o d
te s tin g
d e te c ts
o n ly
tw o -th ird s
o f m a te rn a l
in fe c tio n s )
in u n iv e rs ity
h o s p ita ls
s h o u ld c a ll
th e a tte n tio n o f m e d ic a l a u th o ritie s
to th e n e e d
fo r H IV s c re e n in g
in p re g n a n t
w o m e n .
T h e c o s t o f H IV
s e ro lo g y
h a s lim ite d
th e
u s e
o f te s tin g
d u rin g
p re n a ta l
c a re
in
C a m p in a s .
O n ly
o n e
u n iv e rs ity
h o s p ita l
o ffe re d
th is te s t, b u t re s tric te d
it to p re g n a n t
w o m e n
w h o
re fe rre d
ris k
fa c to rs
fo r H IV
c o n ta m in a tio n .
In v ie w
o f th e re s u lts
o f th is
s tu d y ,
th is
a ttitu d e
m a y
b e
to o
p a s s iv e
c o n s id e rin g
th e e x p a n s io n
o f th e e p id e m ic
in
th e c ity .
T h e
U .S .
P u b lic
H e a lth
D e p a rtm e n t,
in
1 9 8 7 ,
a n d
th e
A m e ric a n
C o lle g e
o f
O b s te tric ia n s
a n d
G y n e c o lo g is ts ,
in
1 9 8 8 ,
re c o m m e n d e d
th a t
c o u n s e lin g
a n d
s e ro lo g ic
te s ts
s h o u ld
b e
o ffe re d
in
a ll
c e n te rs
a s s is tin g
h ig h -ris k
w o m e n
o r g ro u p s
w ith
in c re a s in g
s e ro p re v a le n c e .
1In
N e w
J e rs e y ,
a H IV
p re v a le n c e
ra te
o f 4 .9 /1 0 0 0
in
u m b ilic a l
c o rd
b lo o d
s a m p le s
(s im ila r
to
w h a t
w a s
fo u n d
in C a m p in a s )
w a s th e ju s tific a tio n
fo r o ffe rin g
v o lu n ta ry
H IV
te s tin g
to a ll c h ild b e a rin g
w o m e n
a n d
th o s e
in te n d in g
to b e c o m e
p re g n a n tY
T h e a d v a n ta g e
o f ro u tin e p re n a ta l
s c re e n in g
fo r H IV
is
th a t
p re -
a n d
p o s tte s t
c o u n s e lin g
m a y
p ro v id e
o p p o rtu n itie s
fo r
a d e q u a te
in fo rm a tio n /e d u c a tio n
a n d
d ia lo g u e le a d in g to g e n u in e b e h a v io r m o d ific a tio n .
D e s p ite
th e s tro n g
e m o tio n a l
im p a c t
o f th e in fe c tio n
d ia g n o s is
d u rin g p re g n a n c y ,
th e re is a b e n e fit
in th e c lo s e r
c lin ic a l
s u rv e illa n c e
o f th e
in fe c te d
p re g n a n t
w o m a n
a n d
h e r
n e w b o rn ,
w h ic h
s e e m s
to im p ro v e
th e
p ro g n o s is
fo r
s e ro p o s itiv e
p a tie n ts .
13T h e s im ila ritie s
o f H IV
a n d
T.
pallidum
in fe c tio n s
in y o u n g w o m e n , a llie d to th e ir c lo s e p re v a le n c e ,
s u g g e s ts
th e n e e d to tre a t th e m in a s im ila r w a y a t th e p ro g ra m m a tic
T. pallidum
P re vl. (% )
p
2 .0
0 .0 0 0 1
7 .0
1 .6
0 .3
0 .9
1 .5
1 .1
1 .6
1 .4
0 .9
1 .1
1 .3
1 .2
1 .1
T a b le 5
S u m m a ry o f u n iva ria te a n a lysis a cco rd in g to va ria b le ca te g o ry
P re vl. = P re va le n ce
w h ile
1 .2
p e rc e n t
fo r
T. pallidum
is c la s s ifie d
a s
in te rm e d ia te .
51T h e
s tu d y
h a s
s h o w n ,
h o w e v e r,
g re a t
in e q u a lity
in th e d is trib u tio n
o f c a s e s ; H IV a n d
T. pallidum
p re v a le n c e
in u n iv e rs ity
h o s p ita ls
w a s tw ic e a s h ig h a s in
th e
to ta l
o f th e
s a m p Ie s
(c lo s e
to
1 a n d
2 p e rc e n t,
re s p e c tiv e ly ).
T h is c la s s ifie d
th e m a s h a v in g in te rm e d ia te
to h ig h
ra te s o f th e s e
in fe c tio n s .
T h e s a m e ra tio o f o n e
H ~ V to th re e
T. pallidum
in fe c tio n s
w a s o b s e rv e d ,
w ith
m in o r
v a ria tio n s ,
in e a c h
h o s p ita l
a n d
in th e
e n tire
c o lle c tio n
o f s a m p le s .
T h e
e v a lu a tio n
o f th e
p re v a le n c e
fo u n d
in th is
s tu d y
s h o u ld
ta k e
in to c o n s id e ra tio n
th a t th e p re c is io n
o f u m b ilic a l
c o rd
b lo o d
s c re e n in g
in th e a s s e s s m e n t
o f
m a te rn a l
s e ro lo g ic
c o n d itio n
is
q u e s tio n a b le .
Its
a c c u ra c y
fo r H IV
in fe c tio n
h a s n o t y e t b e e n
s tu d ie d .
A s
fo r
s y p h ilis ,
R A W S T R O M
a n d
B R O M B E R G
44
c o m p a re d
s e ro lo g y
in
m a te rn a l,
u m b ilic a l
c o rd
a n d
n e o n a te
b lo o d ,
u s in g
th e ra p id
p la s m a
re a g e n t
(R P R ).
T h e s e
a u th o rs
fo u n d
3 3 p e rc e n t
o f fa ls e -n e g a ti
v e re s u lts
in c o rd
b lo o d
c o m p a re d
to m a te rn a l
in fe c tio n .
O n th e
o th e r
h a n d ,
2 p e rc e n t
o f th e c o rd
b lo o d
s a m p le s
w e re
p o s itiv e
w h ile th e m a te rn a l
s a m p le s
w e re n e g a tiv e .
T h e
s a m e
p ro p o rtio n
o f fa ls e -n e g a tiv e
re s u lts
fo r s y p h ilis ,
in c o rd
b lo o d ,
h a d
b e e n
fo u n d
b y M IL L E R
e t a 1 .
37If
th e s a m e
m a rg in
o f e rro r
w e re
v a lid
fo r H IV , th e re a l
m a te rn a l
p re v a le n c e
in o u r
s a m p le
w o u ld
b e 0 .6
a n d
1 .8 p e rc e n t
fo r H IV
a n d
T.
pallidul11,
re s p e c tiv e ly .
T h e s e
re s u lts
a re in a g re e m e n t
w ith o th e r e v id e n c e
o f
in c re a s e d
H IV
in fe c tio n
ra te s
a m o n g
B ra z i Ii a n
w o m e n
o f re p ro d u c tiv e
a g e ,
s u c h
a s th e
in c re a s in g
H IV
V a ria b le s
C a te g o rie s
P re vl. (% )
p
T yp e o f
U n ive rsity
0 .8
0 .0 0 0 1
H o sp ita l
O th e r
0 .2
M o d e o f
S U S
0 .6
0 .0 0 6
P a ym e n t
O th e r
0 .0
A g e
::::;
2 4
0 .4
0 .8 3 1
~ 2 5
0 .4
M a rita l
In u n io n
0 .3
0 .0 3 7
S ta tu s
O th e r
0 .8
E d u ca tio n
4 o r le ss
0 .3
0 .5 8 9
in Y e a rs
5 o r m o re
0 .5
O ccu p a tio n
Y e s
0 .3
0 .5 3 4
N o
0 .5
R e sid e n ce
C a m p in a s
0 .4
0 .8 7 9
O th e r
0 .3
1113
level.
F or
exam ple,
the
populations
at risk
and
the
educational
activities
to prevent
the
tw o
infections
frequently
overlap.
T he crucial
difference
is that H IV
infection is non-treatable
and carries a strong stigm a, w hich
justifies
the requirem ent
of inform ed consent prior to H IV
testing, w hile serologic
diagnosis
of syphilis is routinely
done w ithout ethical conflicts.
In light of our results and the above considerations,
it is suggested
that H IV
testing
should
be included
in
routine prenatal care in C am pinas,
as w ell as in all regions
w here infection
rates have reached
interm ediate
or high
levels, such as S antos, R ibeirao
P reto, S ao P aulo and R io
de Janeiro.21.23.26.46
S tudies of pregnant w om en in the U nited S tates have
show n that acceptance
of H IV testing during the prenatal
period reaches only
7 6percent,4.5 and that infected w om en
are m ore com m on
am ong those w ho refuse to be screened
for H Iy'35
T he
alternative
approach,
selectively
screening
w om en
w ith risk factors for H IV infection,
becom es
less
efficient, because the higher the prevalence
of H I V am ong
the general
fem ale population,
the higher the proportion
of infected
w om en
not
detected
by
risk
behavior
screening.22.34.5o
T hus,
the
clinical-epidem iologic
evaluation
of risk
factors
has
not been
effective
in
identifying
all infected w om en, leaving
5 0 - 6 6
percent of
positive cases undiagnosed.23.28 T herefore,
several authors
conclude
that w ith prevalence
reaching significant
levels,
routine
and
universal
consented
prenatal
testing
is
recom m ended.48
T he need and convenience
of adopting
this strategy
depends
on periodic
reevaluation.
T he
interm ediate
position
of C am pinas
in the scenario of the epidem ic
and
its populational
characteristics
suggest
that it m ay serve
as a sentinel city for national
surveillance
of the disease.
T o
this
end,
repeated
prevalence
studies
am ong
childbearing
w om en should be carried out in C am pinas
at
regular intervals.
T he problem
is that prevalence
studies m ust be blind
and universal
to be accurate.
T he ethics of carrying
out
blind
testing
for H IV
infection
has been
questioned
because it m eans not identifying
H IV positive w om en w ho
w ill deliver
and breastfeed
their babies
w ithout
being
inform ed
of their condition,
or of the precautions
they
should
take w ith their sexual
partner
and the new born.
T he available
alternative
should be considered
for ethical
judgem ent.
T he present situation
in C am pinas,
as w ell as in the
overw helm ing
m ajority of births in B razil, is that w om en
are not given the option ofH IV
testing. T he lim iting factors
are the lack of available
laboratory
facilities,
the cost of
the kits for E L IS A
and, particularly,
of the W estern
B lot
test. A s described
above, at the tim e the present study w as
carried
out, only the laboratory
of one of the university
hospitals w as agreeing to do the E L IS A
test for a selected
group
of high-risk
w om en
attending
a prenatal
clinic,
w hereas
w om en
delivering
in the other hospitals
in the
city did not have access to H IV testing.
If H IV screening
had been available
for all patients
delivering
in C am pinas
at the tim e of the study, it w ould
have been unethical to interrupt their routine for research
purposes. T his w as not the case, as no routine w as altered
during the study period. S till, it could be criticized
from
an ethical
point of view , that as the H IV
test had been
adm inistered, even throughout a short period, those w om en
and their fam ilies could have benefited
from inform ation
about their condition. T his w ould have required identifying
the sam ples
w ith the nam e of each w om an.
F or this, w e
w ould have had to request the patients'
consent, according
to accepted ethical principles.
P revious
experience
show s
that
about
2 5
percent
of the
w om en
w ould
not have
consented,
and that the prevalence
of H IV
infection
is
higher
exactly
in this
group.21.28.31.50T hus,
if w e had
follow ed
the first procedure
w e w ould
have
failed
to
accom plish
the purpose
of the study, nam ely, to evaluate
the real prevalence
of H I V infection am ong w om en giving
birth in C am pinas,
as those w ith the highest
prevalence
m ight not have been tested.
T he
ethics
of blind
surveillance
testing
has been
the subject
of profound
discussions
by w orking
groups
in E urope,
the U nited
S tates,
C anada
and the W orld
H ealth
O rganization.
A n A m erican
Journal
of P ublic
H ealth editorial
recently
concluded
that "seroprevalence
studies are not only ethically perm issible,but
their conduct
is an ethical
resposibility
for those
responsible
for
public health".? T his opinion
w as endorsed
by an editor
ofB ioetica
(ajournal
published
by the B razilian
F ederal
C ouncil
of M edicine),
w ho
review ed
the
article
m entioned
above.8
A nother problem
w ith blind, anonym ous
serology
is
that
it does
not perm it
the
detailed
study
of
socio-dem ographic
factors
potentially
associated
w ith
these
infections.
E ven
considering
such
m ethodologic
restrictions,
the present
data suggest
that there
is a link
betw een
socio-econom ic
situation
and infection,
both for
H IV and
T.
pallidul11,
as all the positive cases w ere w om en
treated
by S U S ; none of them
w ere private
patients
or
w om en
w ith private
health
insurance.
T he correlation
betw een H IV infection and poverty has been described
by
several authors.32.42 In the U nited
S tates, this connection
is indirectly
observed
in the disproportionate
prevalence
of the infection
am ong blacks and H ispanics.
1114
C o n se q u e n tly ,
it a p p e a rs th a t H IV in fe c tio n
is a n o th e r
e x a m p le
o f th e so c ia l d isa d v a n ta g e
o f th e p o o r. T h e c u rre n t
d iffic u lt
situ a tio n
o f th e p u b lic
h e a lth sy ste m
in B ra z il c a n
n o t b e a n e x c u se
to ig n o re
th e p ro g re ssiv e
c o n ta m in a tio n
o f th e p o p u la tio n
w ith H IY . In 1 9 8 8 , th e M in istry
o f H e a lth
(M O H )
re je c te d
a p ro p o sa l
fo r u n iv e rsa l
te stin g
fo r H IV
d u rin g
p re n a ta l
c a re . S in c e th e n , th e M O H
h a s n o t m a d e a
sin g le
sta te m e n t
c o n c e rn in g
th is
issu e .
1IA n y
c h a n g e
in
p o lic y sh o u ld b e b a se d o n c u rre n t
d a ta o n H IV p re v a le n c e ,
su c h a s th a t p ro v id e d
b y th is stu d y . W e h o p e th a t o u r re su lts
m a y h e lp m a n y
w o m e n
in th e fu tu re
if th e se
re su lts,
a n d
th o se o f a la te r se c o n d ro u n d , a re su c c e ssfu l
in c o n v in c in g
h e a lth
a u th o ritie s
o f th e n e e d
fo r ro u tin e
H IV
sc re e n in g
d u rin g
p re n a ta l
c a re .
RESUMO
E s tu d o u -s e s o ro p re v a le n c ia a n o n im a p a ra V iru s d e Im u n o d e fic ie n c ia H u m a n a (H IV ) e s ifilis a tra v e s d e c o le ta d e s a n g u e d e
c o rd a o u m b ilic a l d e 5 .8 1 5 p a rtu rie n te s , e m h o s p ita is d e C a m p in a s , S p ' p o r u m p e rfo d o d e s e is m e s e s . F o ra m u tiliz a d o s te s te s d e E L IS A e "W e s te rn b lo t" p a ra d ia g n 6 s tic o d e in fe c y a o p e lo H IV , e V O R L e T P H A p a ra
Treponema pallidum.
M a n te n d o -s e 0a n o n im a to , c o lh e ra m -s e in fo rm a y o e s s o b re h o s p ita l d e o rig e m , d iv id id o e m u n iv e rs ita rio (p u b lic o ) e p riv a d o , fo rm a d e p a g a m e n to (s e g u ro s o c ia l, s e g u ro p a rtic u la r e p a g a m e n to d ire to ), id a d e , s itu a y a o m a rita l, e s c o la rid a d e , o c u p a y a o e c id a d e d e p ro c e d e n c ia .
A s o ro p re v a le n c ia p a ra H IV fo i 0 ,4 2 p e rc e n t e p a ra s ifilis fo i 1 ,1 6 p e rc e n t. F o i e n c o n tra d a a s s o c ia y a o e n tre a m b a s , is to e , m a io r p re v a le n c ia d a p rim e ira n a s a m o s tra s p o s itiv a s p a ra lu e s (p = 0 ,0 2 ). A p 6 s a n a lis e p o r re g re s s a o lo g is tic a , a p e n a s 0
h o s p ita l u n iv e rs ita rio m o s tro u -s e a s s o c ia d o
a
s o ro p o s itiv id a d e p a ra H IV , e a m e s m a v a ria v e l e m a io re s id a d e s s e re la c io n a ra ma
s ifilis . T o d a s a s re a y o e s p o s itiv a s p a ra H IV fo ra m e n c o n tra d a s e m h o s p ita is u n iv e rs ita rio s o u e m p a c ie n te s c u jo s p a rto s fo ra m p a g o s p e lo S U S e m h o s p ita is p riv a d o s . C o n c lu iu -s e q u e a p re v a le n c ia d e in fe c y a o p e lo H IV e s ta s e a p ro x im a n d od a q u e la e n c o n tra d a a t ra v e s d e s o ro lo g ia p a ra s ifilis , a fe ta n d o p a c ie n te s d e c a m a d a s s o c io e c o n o m ic a s m e n o s fa v o re c id a s . S u g e re -s e c o n s id e ra r a in d ic a y a o d e s o ro lo g ia ro tin e ira e c o n s e n tid a p a ra H IV n o p re -n a ta l, q u a n d o a p o p u la y a o m o s tra r
p re v a le n c ia d e in fe c y a o p r6 x im a o u m a io r q u e 1 p e rc e n t.
REFERENCES
1 . A C O G -C o m m itte e O p in io n : C o m m itte e o n E th ic s. H u m a n
im m u n o d e fic ie n c y v iru s in fe c tio n : p h y sic ia n s'
re sp o n sib ilitie s. In t 1 G y n e c o l O b ste t 1 9 9 1 ;3 6 :3 4 0 -2 .
2 . A m a ra l E , P a ssin i R 1 r, F a u n d e s A , e t a l. In fe c ~ a o p e lo H IV
e m O b ste trfc ia : R e v isa o e re fle x a o so b re a s v a ria s fa c e s d e
u rn p ro b le m a . F e m in a 1 9 9 1 ; 1 9 : 1 0 4 -1 4 .
3 .. A v in s A L , L o B . T o te ll o r n o t to te ll: th e e th ic a l d ile m m a s
o f H IV te st n o tific a tio n in e p id e m io lo g ic a l re se a rc h . A m 1
P u b l H e a lth 1 9 8 9 ;7 9 : 1 5 4 4 -8 .
4 . B a rb a c c i M , R e p k e 1 , C h a isso n R . R o u tin e p re n a ta l sc re e n in g
fo r H IV in fe c tio n . L a n c e t 1 9 9 1 ;3 3 7 :7 0 9 -1 1 .
5 .. B a rto n 1 1 , O 'C o n n o r T M , C a n n o n M 1 , e t a l. P re v a le n c e o f
h u m a n im m u n o d e fic ie n c y v iru s in a g e n e ra l p re n a ta l
p o p u la tio n . A m 1 O b ste t G y n e c o l 1 9 8 9 ; 1 6 0 : 1 3 1 6 -2 4 .
6 . B a y e r R , L u m e y L H , W a n L . T h e A m e ric a n , B ritish a n d
D u tc h re sp o n se s to u n lin k e d a n o n y m o u s H IV se ro p re v a le n c e
stu d ie s: a n in te rn a tio n a l c o m p a riso n . A ID S 1 9 9 0 ;4 :2 8 3 -9 0 .
7 . B a y e r R . T h e e th ic s o f b lin d H IV su rv e illa n c e te stin g . A m 1
o f P u b lic H e a lth 1 9 9 3 ;8 3 :4 9 6 -7 .
8 . B IO E T IC A . A e tic a d a tria g e m so ro l6 g ic a n a o v in c u la d a p a ra
o V iru S d a im u n o d e fic ie n c ia h u m a n a (l'IlV ). B io e tic a
1 9 9 4 ;2 ( I):1 0 8 .
9 . B la n c h e S , R o u z io u x C , M o sc a to M L G , e t a l. A p ro sp e c tiv e
stu d y o f in fa n ts b o rn to w o m e n se ro p o sitiv e fo r h u m a n
im m u n o d e fic ie n c y v iru s ty p e 1 . N E n g l 1 M e d
1 9 8 9 ;3 2 0 : 1 6 4 3 -8 .
1 0 . M in iste rio D a S a u d e , B ra sil. P re -n a ta l d e b a ix o risc o . N o rm a s
e M a n u a is T e c n ic o s. B ra sflia 1 9 8 6 .
1 1 . M in iste rio D a S a u d e , B ra sil. A ID S - R e c o m e n d a ~ 6 e s
T e c n ic a s e A sp e c to s E tic o s. B ra sflia 1 9 8 8 .
1 2 . M in iste rio D a S a u d e , B ra sil. In : B o le tim E p id e m io l6 g ic o
A ID S . A n o V I, N ° 4 , B ra silia , S e m a n a E p id e m io l6 g ic a . M a y
1 4 -1 7 , 1 9 9 3 .
1 3 . B u c h b in d e r S , K a tz M , H e sso l N , e t a l. H e a lth lo n g -te rm
p o sitiv e : m e n in fe c te d w ith H IV fo r m o re th a n 1 0 y e a rs w ith
C D 4 c o u n ts> 5 0 0 c e lls. In : F in a l P ro g ra m & O ra l A b stra c ts
o f th e V III In te rn a tio n a l C o n fe re n c e O n A id s, A m ste rd a m ,
1 9 9 2 :tU 4 1 (tu c 0 5 7 2 ).
1 4 . C e n te r F o r D ise a se C o n tro l. P u b lic h e a lth se rv ic e g u id e lin e s
fo r c o u n se lin g a n d a n tib o d y te stin g to p re v e n t H IV in fe c tio n
a n d A ID S . M M W R 1 9 8 7 ;3 6 :5 0 9 -1 5 .
S a o P a u lo M e d ic a l J o u rn a l/R P M 1 1 4 (2 ): 1 1 0 8 -1 1 1 6 ,1 9 9 6 A M A R A L , E .; F A U N D E S , A .; G O N l;A L E S , N .S L e t a l. - P re v a le n c e o f H I V a n dTreponema
1115
1 5 . C e n te r F o r D ise a se C o n tro l. R e c o m m e n d a tio n s fo r p re v e n tio n o f H IV tra n sm issio n in h e a lth -c a re se ttin g s. M M W R 1 9 8 7 ; 3 6 (su p p l: I S -1 8 S ).
1 6 . C e n te r F o r D ise a se C o n tro l. U p d a te : u n iv e rsa l p re c a u tio n s fo r p re v e n tio n o f h u m a n im m u n o d e fic ie n c y v iru s, h e p a titis B v iru s, a n d o th e r b lo o d -b o rn e p a th o g e n s in h e a lth -c a re se ttin g s. M M W R 1 9 8 8 ;3 7 :3 7 7 .
1 7 . C e n te r F o r D ise a se C o n tro l. In te rp re ta tio n a n d u se o f th e W e ste rn b lo t a ssa y fo r se ro d ia g n o sis o f h u m a n im m u n o d e fic ie n c y v iru s T y p e I in fe c tio n s. M M W R
1 9 8 9 ;3 8 (S -7 ): I.
1 8 . C h a te a u v e rt M , D u ffie A , G ilm o re ' N . H u m a n im m u n o d e fic ie n c y v iru s a n tib o d y te stin g : C o u n se lin g g u id e lin e s fro m th e C a n a d ia n M e d ic a l A sso c ia tio n : O tta w a :C a n . M e d . A sso c . 1 9 9 0 .
1 9 .D in iz E M . A sp e c to s e p id e m io l6 g ic o s e so ro l6 g ic o s d a S ln d ro m e d e Im u n o d e fic ie n c ia A d q u irid a e m p o p u la c ;a o d e a lto risc o p a ra d o e n c ;a s se x u a lm e n te tra n sm isslv e is. S a o P a u lo 1 9 9 0 . (T h e sis - S c h o o l o f M e d ic in e , U n iv e rsid a d e d e S a o P a u lo )
2 0 . D o n d e ro T l, C u rra n lW . S e ro su rv e i Ila n c e o f H u m a n Im m u n o d e fic ie n c y V iru s in fe c tio n . A m 1 P u b l H e a lth
1 9 9 1 ;8 1 :5 6 1 -2 .
2 1 . D u a rte G , P in h a ta M M , P a sti M l, e t a l. P ro b le m a s p n h ic o s n a d e te rm in a c ;a o d a p re v a le n c ia e a ssiste n c ia a s p a rtu rie n te s c o m so ro lo g ia p o sitiv a p a ra H IY . In : X V C o n g re sso B ra sile iro d e G in e c o lo g ia e O b ste trfc ia , S a o P a u lo , 1 9 8 9 .
2 2 . D u a rte G , M u ssi-P in h a ta M M , D e l L a m a 1 ., e t a l. V a lo r d e q u e stio n a rio e sp e c ffic o n a id e n tific a c ;a o d e p a rtu rie n te s d e risc o p a ra in fe c c ;a o p e lo V Iru S d a im u n o d e fic ie n c ia h u m a n a (H IV ). 1 B ra s G in e c o l 1 9 9 I; 1 0 1 : 1 6 9 -7 4 .
2 3 . D u a rte G , Q u in ta n a F M , M a ra n a H R C , e t a l. D o e s th e d ia g n o sis o f o th e r S T D id e n tify p a rtu rie n ts a t risk fo r H IV in fe c tio n ? In : F in a l P ro g ra m & O ra l A b stra c t o f th e V III In te rn a tio n a l C o n fe re n c e O n A id s, A m ste rd a m ,
1 9 9 2 :B 1 7 1 (P o B 3 5 0 8 )
2 4 . E u ro p e a n C o lla b o ra tiv e S tu d y . C h ild re n b o rn to w o m e n w ith H IV -I in fe c tio n : n a tu ra l h isto ry a n d risk o f tra n sm issio n . L a n c e t 1 9 9 1 ;3 3 7 :2 5 3 -6 1 .
2 5 . E u ro p e a n C o lla b o ra tiv e S tu d y . R isk fa c to rs fo r m o th e rto -c h ild tra n sm issio n o f H IV -I. L a n c e t 1 9 9 2 ;3 3 9 : 1 0 0 7 -1 0 1 2 . 2 6 . G ira ld e s P R , S a n to s M C , R iv e tti P S , e t a l. P e sq u isa d e a n tic o rp o s a n ti-H IV p e lo te ste E L IS A n a ro tin a p re -n a ta l. R e v B ra s M e d 1 9 8 9 ;4 6 : 1 0 6 -8 .
2 7 . G w in n M , P a p p a io a n o u M , G e o rg e lR , e t a l. P re v a le n c e o f H IV in fe c tio n in c h ild b e a rin g w o m e n in th e U n ite d S ta te s: S u rv e illa n c e u sin g n e w b o rn b lo o d sa m p le s. lA M A
1 9 9 1 ;2 6 5 : 1 7 0 4 -8 .
2 8 . H a ssig S E , K in k e la N , N sa W , e t a l. P re v e n tio n o f p e rin a ta l H IV tra n sm issio n : a re th e re a lte rn a tiv e s to p re -p re g n a n c y se ro lo g ic a l sc re e n in g in K in sh a sa , Z a ire ? A ID S 1 9 9 0 ;4 :9 1 3 -1 6 .
2 9 . H e n d e rso n O K , F a h e y B l, W illy M , e t a l. R isk o f o c c u p a c io n a l tra n sm issio n o f im m u n o d e fic ie n c y v iru s T y p e I (H IV -I) a sso c ia te d w ith c lin ic a l e x p o su re : a p ro sp e c tiv e e v a lu a tio n . A n n In te rn M e d 1 9 9 0 ; 1 1 3 :7 4 0 -6 .
3 0 . H o ff R , B e ra rd i V P , W e i b ie n B l, e t a l. S e ro p re v a le n c e o f h u m a n im m u n o d e fic ie n c y v iru s a m o n g c h ild b e a rin g w o m e n . E stim a tio n b y te stin g sa m p le s o f b lo o d fro m n e w b o rn s. N E n g l 1 M e d 1 9 8 8 ; 3 1 8 :5 2 5 -3 0 .
3 1 . H u ll H F , B e ttin g e r C l, G a lla h e r M M , e t a l. C o m p a riso n o f H IV -a n tib o d y p re v a le n c e in p a tie n ts c o n se n tin g to a n d d e c lin in g H IV -a n tib o d y te stin g in a n S T D c lin ic . lA M A
1 9 8 8 ;2 6 0 :9 3 5 -8 .
3 2 . K ru e g e r L E , W o o d R W , D ie h r "P H , e t a l. P o v e lty a n d H IV se ro p o sitiv ity : th e p o o r a re m o re lik e ly to b e in fe c te d . A ID S
1 9 9 0 ;4 :8 1 1 -1 4 .
3 3 . L a n d e sm a n S , M in k o ff H , H o lm a n S , e t a l. S e ro su rv e y o f h u m a n im m u n o d e fic ie n c y v iru s in fe c tio n in p a rtu rie n ts. Im p lic a tio n s fo r h u m a n im m u n o d e fic ie n c y v iru s te stin g p ro g ra m s o f p re g n a n t w o m e n . lA M A 1 9 8 7 ;2 5 8 :2 7 0 1 -3 . 3 4 . L in d sa y M K , A d e fris W , P e te rso n H B , e t a l. D e te rm in a n ts
o f a c c e p ta n c e o f ro u tin e v o lu n ta ry H u m a n Im m u n o d e fic ie n c y V iru s te stin g in a n in n e r-c ity p re n a ta l p o p u la tio n . O b ste t G y n e c o l 1 9 9 1 ;7 8 :6 7 8 -8 0 .
3 5 . L in d sa y M K , P e te rso n H B , W illis S , e t a l. In c id e n c e a n d p re v a le n c e o f h u m a n im m u n o d e fic ie n c y v iru s in fe c tio n in a p re n a ta l p o p u la tio n u n d e rg o in g ro u tin e v o lu n ta ry h u m a n im m u n o d e fic ie n c y v iru s sc re e n in g , lu ly 1 9 8 7 to lu n e 1 9 9 0 . A m 1 O b ste t G y n e c o l 1 9 9 1 ; 1 6 5 :9 6 1 -4 .
3 6 . M a n n 1 M . G lo b a l A ID S in th e 1 9 9 0 's. 1 A c q Im m u n D e f S y n d 1 9 9 0 ;3 :3 4 8 .
3 7 . M ille r lL , M e y e rP G , P a tT O tt N A , e t a l. A stu d y o f th e b io lo g ic fa lse ly p o sitiv e re a c tio n s fo r sy p h ilis in c h ild re n . 1 P e d ia tr
1 9 6 0 ;5 7 :5 4 8 -5 2 .
3 8 . O rg a n isa c i6 n P a n a m e ric a n a D e L a S a lu d . R e la t6 rio d a I R e u n ia o L a tin o a m e ric a n a so b re S ID A /A ID S M a te rn o -In fa n til n a R e g ia o d a s A m e ric a s. S a o P a u lo , 1 9 9 0 . 3 9 . O rg a n isa tio n M o n d ia le D e L a S a n te . P a n d e m ie d 'in fe c tio n
a V IH \S ID A : situ a tio n a c tu e lle e t te n d a n c e s fu tu re s. R e c a p itu la tio n . G e n e v a , la n u a ry 1 9 9 2 .
4 0 . P io t P , P lu m m e r F A , M h a lu F S , e t a l. A ID S : A n In te rn a tio n a l P e rsp e c tiv e . S c ie n c e 1 9 8 8 ;2 3 9 :5 7 3 -9 .
4 1 . P io t P , L a g a M , R y d e r R , e t a l. T h e g lo b a l e p id e m io lo g y o f H IV in fe c tio n : c o n tin u ity , h e te ro g e n e ity a n d c h a n g e . 1 A c q Im m u n D e f S y n d 1 9 9 0 ;3 :4 0 3 -1 2 .
4 2 . P io t P . E p id e m io lo g y o f S T D s: S ta te -o f-th e -A rt. In : F in a l P ro g ra m & O ra l A b stra c ts o f th e V III In te rn a tio n a l C o n fe re n c e O n A id s, A m ste rd a m , 1 9 9 2 .
4 3 . P o rto A G M . P re v a le n c e o f a c q u ire d im m u n o d e fic ie n c y sy n d ro m e d e te c te d d u rin g p re n a ta l c a re o f a p o p u la tio n o f lo w so c io -e c o n o m ic sta tu s. A m 1 O b ste t G y n e c o l 1 9 9 1 ; 1 6 4 :7 0 5 -6 .
4 4 . R a w stro n S A , B ro m b e rg K . C o m p a riso n o f m a te rn a l a n d n e w b o rn se ro lo g ic te sts fo r sy p h ilis. A
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0 C1 9 9 1 ; 1 4 5 : 1 3 8 3 -8 .
4 5 . R y d e r R W , N sa W , H a ssig S E , e t a l. P e rin a ta l tra n sm issio n o f th e h u m a n im m u n o d e fic ie n c y v iru s T y p e I to in fa n ts o f se ro p o sitiv e w o m e n in Z a ire . N E n g l 1 M e d
1 9 8 9 ;3 2 0 : 1 6 3 7 -4 2 .
4 6 . S c h e c h te r M . A ID S III - M a l a ta c a 8 e m c a d a m il g e sta n te s. S u m u la R a d is. F io c n Jz . A n o V III, ju n h o , 1 9 9 1 .
A M A R A L , E .; F A U N D E S , A .; G O N < ;::A L E S , N .S .L . e t a l. - P re v a le n c e o f H IV a n d Treponema S a o P a u lo M e d ic a l J o u rn a l/R P M 1 1 4 (2 ): 1 1 0 8 -1 1 1 6 , 1 9 9 6
