Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

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ISSN: 2177-5281 (Online)

Vol. 14 nº 3 - Jul/Sep - 2017

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Páginas 7 a 15


Epidemiological profile of adolescents living in Recife - PE, reported as AIDS cases from 2007 to 2015

Perfil epidemiológico de adolescentes residentes en Recife - PE, notificados como caso de Sida en el período de 2007 a 2015

Perfil epidemiológico de adolescentes residentes em Recife - PE, notificados como caso de Aids no período de 2007 a 2015

Autores: Mirian Domingos Cardoso1; Alisse Maria Chaves de Lima Peixoto2; Ana Carolina Monteiro de Araújo Rolim3

1. PhD in Public Health, Minas Gerais Federal University (UFMG). Belo Horizonte, Minas Gerais State, Brazil. Adjunct Professor, Pernambuco University (UPE). Recife, Pernambuco, Brazil
2. Master's Degree student in Adolescent Medicine. Degree in Nursing, Nossa Senhora das Graças Nursing School, Pernambuco University (UPE). Recife, Pernambuco, Brazil
3. Degree in Nursing, Nossa Senhora das Graças Nursing School, Pernambuco University (UPE). Recife, Pernambuco, Brazil

Mirian Domingos Cardoso
Rua Quinze de março, 298, Torrões
Recife, PE, Brasil. CEP: 50761-070
mirian.domingos@upe.br

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Keywords: Adolescent, Acquired Immunodeficiency Syndrome, health profile.
Palabra Clave: Adolescente, Síndrome de Inmunodeficiencia Adquirida, perfil de salud.
Descritores: Adolescente, Síndrome de Imunodeficiência Adquirida, perfil de saúde.

Abstract:
OBJECTIVE: Describe the epidemiological profile of adolescents with 10-19 years old living in Recife, reported as AIDS cases from 2007 to 2015.
METHODS: A descriptive study with official data from AIDS surveillance system. The selected variables were classified according to the records of the epidemiological investigation.
RESULTS: 84 cases were reported where the age average was 17.4, 67% had brown and black color, 45% were illiterate or had not finished elementary school. The number of cases did not vary between sexes in the analyzed period, where there was an increase in female cases from 2011 (5/1), declining after this year. The average incidence and mortality rates in the period were respectively 6.2 and 0.4 / 100,000 inhabitants.
CONCLUSION: Despite efforts to control the AIDS epidemic, there is still a need to improve the access of this population to prevent infection and control the incidence.

Resumen:
OBJETIVO: Describir el perfil epidemiológico de adolescentes de 10 a 19 años residentes en Recife-PE, notificados como caso de SIDA en el período de 2007 a 2015.
MÉTODOS: Estudio descriptivo con datos del sistema oficial de vigilancia de SIDA. Las variables seleccionadas fueron clasificadas de acuerdo con las fichas de investigación epidemiológica.
RESULTADOS: Fueron notificados 84 casos donde el promedio de edad fue de 17,4, 67% eran de raza/color pardo, 45% analfabetos o tenían enseñanza fundamental incompleta. El número de casos de la enfermedad no varió entre los sexos en el período analizado, donde se observó un aumento de casos en el sexo femenino desde 2011 (5/1) declinando después de este año. Los coeficientes medios de incidencia y mortalidad en el período fueron respectivamente de 6,2 y 0,4/100.000 habitantes.
CONCLUSIÓN: A pesar de los esfuerzos en el control de la epidemia del SIDA, hay necesidad de mejoría en el acceso de esa población a acciones de prevención de la infección y control de incidencia.

Resumo:
OBJETIVO: Descrever o perfil epidemiológico de adolescentes de 10 a 19 anos residentes em Recife-PE, notificados como caso de Aids no período de 2007 a 2015.
MÉTODOS: Estudo descritivo com dados do sistema oficial de vigilância de Aids. As variáveis selecionadas foram classificadas de acordo com as fichas de investigação epidemiológica.
RESULTADOS: Foram notificados 84 casos onde a média de idade foi de 17,4, 67% eram de raça/cor parda, 45% analfabetos ou tinham ensino fundamental incompleto. O número de casos da doença não variou entre os sexos no período analisado, onde observou-se um aumento de casos no sexo feminino a partir de 2011 (5/1) declinando após este ano. Os coeficientes médios de incidência e mortalidade no período foram respectivamente de 6,2 e 0,4/100.000 habitantes.
CONCLUSÃO: Apesar dos esforços no controle da epidemia da Aids, há necessidade de melhorar o acesso dessa população a ações de prevenção da infecção e controle da incidência.

INTRODUCTION

The epidemiological situation of AIDS today in Brazil is characterized by feminization, interiorization and pauperization, while also expanding among the young population. The period between 10 and 19 years of age, adolescence is the stage where feminization is most striking 1.

In Brazil, the prevalence of HIV infection in the young population is on the rise, with HIV percentages even more significant when recalling that AIDS appears only six years after infection on average. Consequently, it may thus be assumed that many notified cases among adults were actually infected during adolescence or early youth 2,3,4.

The first adolescent AIDS case reported in the Recife municipality was male, in 1985, and it was only in 1987 that a female case was diagnosed. Twenty years after this first notification, the number of reports had equaled out by gender in 2005, reflecting the feminization of AIDS during this stage of life. 5

Despite Brazil's proven experience in controlling the AIDS epidemic, this situation still continues to challenge public policies, particularly when related to the young population. There are many AIDS studies in Brazil, but few of them focus on adolescence. Consequently, the purpose of this research project is to describe the epidemiological profile of adolescents living in Recife, Pernambuco State, reported as HIV/AIDS cases between 2007 and 2015.


METHODS

A population-based descriptive study was conducted using the AIDS Case Report Information System (SINAN / AIDS) run by the Municipal Health Bureau (SMS) in the City of Recife, Pernambuco State, with population data from the Brazilian Institute for Geography and Statistics (IBGE) through to 2012, and Population Projection Data in Recife for 2013 to 2015.

The analysis data base was constructed through merging the AIDS databases for children and adults (under and over 13 years of age, respectively). The selective variables were classified as: a) Social and demographic characteristics (age, gender, race/color, schooling, district of residence); b) Epidemiological clinical characteristics (exposure category, probable mode of transmission, lymphocytes T CD4< 350 cel/mm3; AIDS case definition criteria, number of associated opportunistic diseases, case progression).

The data were analyzed through Statistical Package for Social Sciences (SPSS) 20.0 by variable blocks. Core trend measurements were calculated for the continuous variables and the differences in the categorical variable proportions were compared using the chi-square test with statistically significant difference of p less than or equal to 0.05 (p≤; 0.05). The incidence in mortality indicators were calculated by year of diagnosis and age bracket. This project was approved by the Research Ethics Committee under CAAE Nº: 55201016.6.0000.5207.


RESULTS

During the period addressed by the study, 84 cases of AIDS were reported among adolescents between 10 to 19 years of age living in Recife, Pernambuco State. The mean incidence coefficient during the period was 3.2/100,000 inhabitants, peaking in 2014 (6.2). Analyzing the incidence coefficient (IC) by age bracket, a downtrend was noted for youngsters between 10 to 14 years of age, with an uptrend for older adolescents between 15 to 19 years of age (Figure 1).


Figure 1. Incidence coefficient (IC) for AIDS cases among adolescents between 10 and 19 years of age living in Recife, Pernambuco State, notified between 2007 and 2015, classified by age bracket (Source: SINAN- Recife, Pernambuco State).



The mean age was 17.4 years old (±SD 2.2 years) and the median age was 18 years old, with the age bracket between 15 and 19 years of age the most prevalent (89.3%). Males and females presented the same number of cases during the period under study. However, a striking difference was noted in the ratio (%), peaking in 2010 with 500 female cases for each 100 male cases. From 2011 onwards, this feminization began to drop, reversing in 2013. (Figure 2).


Figure 2. Number of AIDS cases presented by gender/year and ratio among adolescents between 10 and 19 years of age reported between 2007 and 2015 (Source: SINAN- Recife, Pernambuco State).



Comparing the co-variable proportions by gender (Table 1), a statistically significant difference was noted in proportion only for categorical variables of exhibition and form of transmission. When analyzing the variables, removing unknown information and comparing the relative values of the co-variables by gender, a higher prevalence was noted in the age bracket between 15 and 19 years of age for both genders. However, girls presented higher proportions of cases for the youngsters between 10 and 14 years of age (16.7 versus 4.8%), mixed race/brown (84.6 versus 63.9%) and illiterate/incomplete primary education (63.2 versus 43.3%).

With regard to distribution by district of residence, it was noted that, despite a higher concentration of cases in Public Health District I, IV and V, there was no statistically significant difference (p≥ 0.05).

Table 2 presents the clinical and epidemiological characteristics of the cases. Sexual transmission prevailed for both genders, although it is noteworthy that 5.6% of these adolescents stated that transmission took place through injectable drugs. For the exposure category, most (77.5%) were heterosexual while 48.4% were homosexuals.

It was noted that a T CD4+ lymphocyte count below 350 cel/mm3 was the highest percentage for both genders, at 76.2% and 66.7% for females and males respectively. In most cases, no opportunistic diseases were registered for either gender. However, among those presenting diseases at diagnosis (47.6%), 79.0% of girls and 61.9% of boys presented more than two opportunistic diseases.

With regard to progression, 13 (15.5%) cases were recorded as deaths, of whom four (30.8%) were female and 9 (69.2%) were male. The mean mortality coefficient per 100,000 inhabitants for the period studied was 0.9/100,000 inhabitants.

For the mortality coefficient (MC), an increase was noted over the years, rising from 0.8 in 2007 to 1.6 in 2014 (Figure 3). By age bracket, the years with the highest figures were 2011 and 2012 for youngsters between 10 and 14 years of age, and 2011 for those between 15 and 19 years of age (Figure 3).


Figure 3. Mortality coefficient (MC) for AIDS in adolescents between 10 and 19 years of age living in Recife, Pernambuco State between 2007 and 2015, by age bracket (Source: SINAN-Recife, Pernambuco State).



DISCUSSION

In this research project, the population of adolescents between 10 and 19 years of age reported as AIDS cases between 2007 and 2015 in Recife was evenly divided by gender, reflecting the level of feminization attained by this epidemic. Compared with the start of the epidemic, when people living with this disease were predominantly male and more than thirty years old, the incidence between genders has now evened out 6.

When analyzing the incidence coefficient (IC) by age, it was noted that the highest coefficient was found among adolescents between 15 and 19 years of age, trending upwards. The higher incidence in this age bracket may be justified that this disease appears an average of six years after infection, for people infected during childhood. Furthermore, it is assumed that this in the age bracket when most adolescents become sexually active and are thus more likely to acquire sexually transmitted diseases. Keeping pace with incidence, mortality was also higher among youngsters in this age bracket2.

Although the period addressed by this study covered less than a decade, which may hamper the trend analyses, the incidence coefficient calculated by year may demonstrate an uptrend in this epidemic among adolescents, which is also seen in other studies, peaking in 2014, with an IC of 6.2 per 100,000 inhabitants. With regard to mortality, the MC rose significantly from 2011 onwards, then plateauing through to 2015.

With regard to the drop in the feminization of AIDS noted from 2013 onwards, these findings may reflect collective actions undertaken by UNAIDS with ten goals to be achieved before 2015. These goals include: eliminating gender inequalities, together with gender-based violence and abuse, while enhancing the ability of women and girls to protect themselves against AIDS. With the drop in feminization of this epidemic, shrinkage may also be achieved in vertical AIDS transmission, with benefits for the entire population in general 7.

Still regarding the social and demographic characteristics of these adolescents, race/color, schooling and age bracket proved predominant for both genders. Largely mixed-race, they had completed their primary education and are between 15 and 19 years of age. It must be borne in mind that the education level of this population is generally low, as they are expected to complete secondary school in this age bracket, or at least be in class. Consequently, studies underscore the influence of social contexts in vulnerability to AIDS, as poor schooling hampers access to correct and reliable information on disease prevention, especially STD/AIDS8,9.

With regard to Public Health Districts, although some of them cluster together people with higher purchasing power than others, when looking at the general distribution of adolescents in these Districts, there are no significant discrepancies among them, reflecting social class heterogeneity. Consequently, an epidemic that previously affected only wealthier people is today clearly affecting people regardless of social class 10.

Regarding the exposure category, the highest percentage of cases was found among female heterosexuals and male homosexuals, converging with the history of the epidemic. This information is historically compatible, as the disease initially affected more male homosexuals, spreading to heterosexual women through sexual contacts between these homosexual and bisexual men. This difference in the predominant category between the genders is confirmed through other research projects conducted with adolescents, confirming that the trend towards female submission and difficulties in negotiating safe sex is still striking9.

Despite efforts by the Ministry of Health to curtail sexual transmission of the AIDS virus, it remains prevalent in this age bracket, particularly among the female segment of the population, with a possible hypothesis being difficulties encountered by these youngsters in ensuring safe sex, as well as the challenges faced by girls in negotiating condom use with their partners. Compared to another research project conducted with adolescents Rio Grande do Sul State in 2008, 61.54% reported vertical transmission, in contrast to this this study where sexual transmission posted the largest percentage of cases, with vertical transmission accounting for only 7.1% among girls and 4.8% among boys. This finding may be related to progress in prophylactic medication technology during pregnancy and birth 11.

The TCD4+ lymphocyte count of less than 350 cel/mm3 was found among most of these adolescents, which might be related to late diagnosis of the disease and the resulting delays in starting treatment, thus worsening the infection. It is thus noted that there is a need for early and timely diagnoses through preventive actions and extended testing. Furthermore, questions may be raised whether there are gaps in the healthcare network, as this population does not live upstate and there are several specialized HIV/AIDS facilities in Recife.

Although most of the adolescents reported with TCD4+ lymphocyte count of less than 350 cel/mm3, more than half the girls and half the boys had no opportunistic infections when reported, followed by the highest percentage of 1 to 5 opportunistic diseases, reaffirming that progression of the disease and the epidemic has not only been modified by antiretroviral (ARV) treatment, but also clinical handling of opportunistic infections is another outcome of alterations to standards for this epidemic 11.

The upsurge in mortality found in this study contradicts the statement issued in 2013 by the Brazilian Ministry of Health, stating that the survival time of people living with AIDS in Brazil had increased from 2007 onwards. These findings demonstrate that, despite efforts underway in Brazil and elsewhere in the world to lower HIV infection rates and extend the survival of people living with AIDS, there are still more vulnerable segments of the population that continue to become infected, then living with the disease that is not controlled in ways that avoid death.


CONCLUSION

This study presented several constraints in terms of gaps in some variables in the SINAN/AIDS database in Recife, hampering a more accurate analysis of the epidemic among adolescents. Late reporting, demonstrated by the number of cases reported at death, indicates an underestimated epidemiological status that may lead to mistaken construals of the progression of the disease. We underscore the importance of investments in case reporting, and the expansion of testing actions through training sessions and awareness-heightening of the importance of completing report sheets. These actions are vital to ensure more complete data and shorter gaps between diagnosis and notification, resulting in a better planning for healthcare actions.

This research project underscores the importance of healthcare for adolescents, as its findings indicate epidemiological clinical data that could be avoided or result in more positive outcomes, such as avoiding sexual transmission of HIV in this age bracket. This stage of life offers many means of obtaining information on safe sex, including better internet access and open dialogs with families and schools, for example. However, the results of this research project show that easy access to information is not minimizing the risk of infection. Consequently, it is vital to create more attractive media, in order to ensure that this age bracket seeks information and closer follow-up from healthcare facilities. In this context, the School Healthcare Program (PSE) may help establish links with the target public.


NOTE OF THANKS

It is vital to thank all those involved in the preparation of this paper, particularly Maria Goretti de Godoy and the entire STD/AIDS and Viral Hepatitis Coordination Unit staff at Recife City Hall, for their warm welcome, goodwill and trust in making the data available for use during the preparation of this study.


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