AIDS Behav (2008) 12:741–747

DOI 10.1007/s10461-008-9407-z

ORIGINAL PAPER

Behavior Surveillance: Prevalence and Factors Associated

with High-Risk Sexual Behavior Among HIV-Infected Men
in Brazil in the Post-HAART Era
Mark D. C. Guimarães Æ Beatriz Grinsztejn Æ Peter V. Chin-Hong Æ
Lorenza N. Campos Æ Valéria R. Gomes Æ Victor H. Melo Æ José Henrique Pilotto Æ
Ricardo A. Carmo Æ Joel M. Palefsky

Published online: 20 May 2008

Ó Springer Science+Business Media, LLC 2008

Abstract A cross-sectional analysis was conducted to
describe unsafe sexual practices among HIV-infected men
under care in two Brazilian urban areas. Data were col-
lected by face-to-face interviews. Twenty-five percent
practiced unprotected sex in the previous year, 16% were
abstinent, 33% had sex with men only, 45% with women
only, 48% had male/female stable partners, 84% were on
HAART and 48% had AIDS. Illicit drug use, number of
female partners, having stable partners, and STD diagnosis
were associated with unsafe sex. Interventions to reduce
risk taking behavior among HIV-positive men under care
M. D. C. Guimarães (&)
L. N. Campos
V. H. Melo
Department of Preventive and Social Medicine,
Faculty of Medicine, Federal University of Minas Gerais,
Av. Prof. Alfredo Balena 190 – 10 andar,
CEP 30130-100 Belo Horizonte, MG, Brazil
e-mail: drew@medicina.ufmg.br
M. D. C. Guimarães
HIV Center for Clinical and Behavioral Studies,
Columbia University, New York, USA
B. Grinsztejn
Evandro Chagas Research Institute/Fiocruz, Rio de Janeiro,
Brazil
P. V. Chin-Hong
J. M. Palefsky
University of California San Francisco, San Francisco, USA
V. R. Gomes
Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
J. H. Pilotto
Nova Iguaçu Hospital, Nova Iguaçu, RJ, Brazil
R. A. Carmo
Eduardo de Menezes Hospital, Belo Horizonte, MG, Brazil
in these settings are urgent, especially among heterosexual
stable couples
Keywords Risk taking
Sexual behavior

HIV-infected men
HAART
Heterosexual
Introduction
Risk-taking sexual behavior has been shown to decrease
among HIV-infected individuals when intervention strate-
gies are implemented in HV health care settings (Johnson
et al. 2006). However, there is evidence that a significant
proportion of these individuals still practice unsafe sex and
this remains a challenge for HIV prevention. The advent of
highly active antiretroviral therapy (HAART) has had a
significant impact on HIV-associated morbidity and mor-
tality with a growing number of people living with AIDS
under care. However, unsafe sexual practices among these
individuals on HAART has raised public health concerns
due to its potential for HIV transmission to uninfected
individuals, including resistant HIV viral strains (Chin-
Hong et al. 2005; Ostrow et al. 2002; Stolte et al. 2004).
Factors associated with unsafe practices include
knowledge of partners’ HIV status, alcohol and illicit drug
consumption, number of partners, gender, and ethnicity
(Bouhnik et al. 2007; Moatii et al. 2003; Wolf et al. 2003).
Stable partnership, especially heterosexual, has also been
shown to be associated with unsafe practices, even after
taking into account HIV seroconcordance. Moatii et al.
(2003) have shown that episodes of unprotected sex occur
in similar proportions with both regular and occasional
partners. However, respondents who declared multiple
sexual partners were more likely to have always used
condom than those who only had one single partner during

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the previous 6 months. In addition, among HIV-infected
patients who lived in a stable relationship, more than two-
thirds had no information about the serostatus of their
partner and this was associated with a greater chance of
unsafe sex (Moatii et al. 2003).
Unprotected anal sex between HIV-positive men and
their female partners is particularly high in Brazil com-
pared with European and USA studies (Guimarães et al.
2001; Halperin 1999). These pre-HAART data indicate that
HIV transmission was almost four times more likely to
occur among those women reporting unprotected vaginal
or anal sex and this continued to be practiced even after the
women learned that their partners were HIV infected
(Guimarães et al. 2001). Furthermore, the longer the time
since learning that the male index case was HIV infected
the higher the proportion of unsafe sex, indicating lower
sustainability of safe sex over time.
Brazil has provided universal access to ARVT since
1996 with results recognized worldwide. However, there
are few post-HAART data on risk-taking practices among
HIV -infected patients in Brazil. In addition, more con-
temporary data are needed especially in settings where
there is a large proportion of heterosexual participants with
stable partners. We were able to assess a population of
HIV-infected men under care in public referral centers
similar to our pre-ARVT study approximately 10 years
later. The main purpose of the current analysis is to assess
factors associated with unsafe sex among HIV-infected
men attending these centers in two urban areas in Brazil in
a post-ARVT era. We hypothesize that these men continue
to have high rates of unprotected sex, especially with their
female partners.
Methods
Participants
This is a multicenter cross-sectional study of HIV-infected
male patients attending six public AIDS referral clinics in
urban Brazil, four in the city of Rio de Janeiro and two in
the city of Belo Horizonte, designed to explore the feasi-
bility of a long-term HPV cohort study. In this analysis we
explore factors associated with unsafe sexual practices.
These are all public units providing AIDS care and have
similar patient clientele. Recruitment occurred from May
thru July 2003 and eligibility criteria included: (1) to be
under care in one of the six clinics; (2) to have a confirmed
HIV diagnosis; and, (3) to be 18 years of age or older.
Patients were selected as they visited the clinics for their
regular medical care and were invited for an interview after
signing the consent form. Participation in the study was
completely voluntary and confidentiality was assured. This
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AIDS Behav (2008) 12:741–747
project was approved by local institutional review boards,
the University of California San Francisco institutional
review board, and the Brazilian National Ethical Com-
mittee Boards.
Sample size was estimated in 577 HIV-infected male
patients and was distributed proportional to the overall
distribution of patients under care in each center, assuming
that the proportion of men with stable partners did not vary
significantly across centers. Systematic random sampling
was used to select patients attending their regular medical
follow-up according to pre-defined lists.
Measures
Data were collected from face-to-face interviews using a
semi-structured questionnaire which were administered by
trained interviewers following detailed instruction proto-
cols. Data were checked for completeness by each center
supervisor and entered in batch format. The questionnaire
provided information on sociodemographics (age, marital
status, skin color, occupation, education and income);
sexual behavior in the past year (sexual activity with men
and/or women, age at first intercourse, stable sexual part-
nership, duration of stable partnership, HIV-status of
sexual partner, condom use, sexual practice and frequency
of sexual contact); and other behavior/exposure character-
istics (history of sexually transmitted diseases, injecting
drug use (IDU), blood transfusion, smoking, alcohol,
cocaine and other illicit drug use, disclosure of HIV-sero-
positivity to the sexual partner and partner HIV-serostatus).
Clinical data were obtained from medical charts and
included HIV testing, current CD4 + T-lymphocyte count,
HIV viral load, ARVT, clinical classification, and STD
diagnoses.
Condom use in the past year was defined as always,
sometimes (i.e., [50%), rarely (i.e., \50%), or never. For
analysis purposes, unsafe sex was defined as not always
using condoms in vaginal or anal sex during the year prior
to the interview. Stable partnership was defined as a male
or female relationship firmly established, as perceived by
the participant, which included a sexual relationship,
regardless of marital status or duration of the relationship.
HIV exposure category and number of male or female
partners in the past year were also reported.
Data Analysis
The prevalence of unsafe sex in the past year among HIV-
infected men was determined by the number of participants
reporting not always using condoms in vaginal or anal sex
during the year prior to the interview by the total number of
men interviewed. Odds ratios (OR) with 95% confidence
interval (CI) were used to estimate the strength of the
AIDS Behav (2008) 12:741–747 743

association between single putative risk factors and unsafe Table 1 Descriptive characteristics among the 545 HIV-infected men, Rio de
Janeiro and Belo Horizonte, Brazil, 2003
sex. Categorical data were analyzed using chi-square and
continuous data were analyzed using Student’s t-test. Characteristic Na %
Multiple logistic regression was fitted to obtain esti- Sociodemographics
mates of the risk of unsafe sex, adjusted for potential Centersb
confounding factors. For this analysis, variables that Belo Horizonte 275 50.5
showed association with unsafe sex in the univariate Rio de Janeiro 267 49.5
analysis with a p-value less than .20 were considered to Age ([35-years-old) 349 64.0
begin modeling. Sequential deletion of variables was Marital status (single) 340 62.4
conducted until a final model was obtained with all vari- Skin color (non-white) 308 56.5
ables showing statistical significance of less than .05. The Schooling (B8 years) 309 56.8
statistical importance of each variable was assessed Monthly family income (\US$ 170) 198 34.7
through the Wald test. Models were compared using the Under social welfare 247 45.9
likelihood ratio test and fitness of final model was assessed Current cigarette smoking 213 39.1
by the Hosmer-Lemeshow test. Ninety-five percent confi- Current alcohol drinking 271 49.7
Illicit drug use in the past 12 months 107 19.8
dence intervals computed on the adjusted odds ratios
Likely source of HIV exposure
(AOR) derived from the coefficients and their respective
Sex with other men 245 45.0
standard errors. SAS SystemÒ version 6.04 was used for
Sex with women 211 38.7
data analysis and Paradox WindowsÒ version 9 for
Othersc 88 16.1
database.
Sexual behavior in the past 12 months
Sexual practice
Abstinent 86 15.9
Results Women only 244 45.2
Men only 179 33.1
Of the 577 male participants initially selected, 32 did not Men and women 31 5.7
participate (eleven refused to participate, four did not show B10 female partners 258 47.8
up for scheduled visits, four could not be contacted, eight B10 male partners 181 33.5
did not have time due to work or travel, and five had other Anal sex with womend 121 44.0
conditions), leaving 545 (94.5%) for the current analysis. Unprotected anal sex with womene 40 33.1
No difference was observed between participants and non- Unprotected vaginal sex with womene 83 30.2
participants regarding age and study center. Any anal sex with mend 205 96.7

Descriptive characteristics of the study population are Insertive anal sex with mend 183 86.3
Unprotected insertive anal sex with mene 46 25.1
shown in Table 1. Most participants were older than 35
Receptive anal sex with mend 177 83.5
years of age (mean = 38.8 years), were single, non-white
Unprotected receptive anal sex with mene 42 23.7
(black or mulato) and had less than 9 years of schooling.
Overall unsafe sexf 137 25.1
These data, along with a low family income and a high
Current female or male stable partner 263 48.3
proportion of patients under social welfare, are similar to
Clinical
the Brazilian AIDS cases reported to the Ministry of Health Diagnosis of any STD in the past 12 months 72 13.3
at the time of recruitment. Current drinking alcohol or Current CD4 + T-lymphocyte (\350 mm3) 242 44.4
smoking cigarettes were reported by 49.7% and 39.1% of Current AIDS diagnosis (CDC C classification) 262 48.1
these men, respectively, while 19.8% reported to have used HIV viral load at interview (400 + copies) 262 48.1
any illicit drug in the past 12 months. Self-reported data Currently on HAART 459 84.2
indicated sex with men followed by sex with women as the a
Total varies due to missing values
main sources of HIV exposure among this population. b
Belo Horizonte: Infectious and Parasitic Diseases Training and Reference Center,
Overall, 25.1% of the 545 male participants reported City Health Department; Eduardo de Menezes Hospital, Minas Gerais State Health
unprotected anal or vaginal sex in the 12 months prior to Department. Rio de Janeiro: Pedro Ernesto University Hospital, State University of
Rio de Janeiro; Evandro Chagas Clinical Research Institute, Oswaldo Cruz Foun-
the interview and 48.3% indicated that they had a stable dation; Clementino Fraga Filho University Hospital, Federal University of Rio de
female or male partner. While 50.1% of the participants Janeiro; Nova Iguaçu General Hospital, Nova Iguaçu City Health Department
c
reported having had sex with both male or female partners Transfusion, Hemophiliac, injection drug use
d
in their lifetime, only 5.7% reported having had sex with Among those reporting sex with women or with men, accordingly
e
both male or female partners in the past year. Sex with Among those reporting the practice
f
women only or sex with men only were the predominant Not always using condoms in vaginal and/or anal sex during 12 months prior
to interview
practices (45.2% and 33.1%, respectively) in the past year.

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744 AIDS Behav (2008) 12:741–747

Among those reporting sex with women, 44.0% practiced Table 2 Univariate analysis of risk factors for unsafe sexa among
anal sex with their female partners, about a third of these HIV-infected men in urban Brazil, 2003
unprotected. Similarly, a high proportion of these men Characteristics Total Unsafe Odds (95% CI)
practiced unprotected vaginal sex with their female part- sex ratio
ners in the past year (30.2%). Although more men n (%)b
practiced insertive or receptive anal intercourse with their Sociodemographics/substance use
male partners, as expected, rates of unprotected sex were 1. Age (years-old)
slightly lower (25.1% and 23.7% respectively, for insertive B35 196 58 (29.6) 1.4 (0.9–2.3)
and receptive) compared with their sexual practices with [35 344 79 (23.0) 1
women. In addition, a higher proportion of the men 2. Marital status
reporting sex with women had from one to ten female Married or in union 203 61 (30.0) 1.5 (1.0–2.2)*
sexual partners in the last year (47.8%) compared with
Single 337 76 (22.6) 1
male partners (33.5%).
3. Skin color
Most of the participants reported having a history of any
White 232 58 (25.0) 1 (0.6–1.5)
STD (67.2 %) in their lifetime and 72 (13.3%) indicated
Non-white 307 79 (25.7) 1
having had an STD diagnosis in the past year. CD4 + T-
4. Schooling (years)
lymphocyte count at the time of the interview was under
B8 307 82 (26.7) 1.2 (0.8–1.7)
350 cells/mm3 for 44.4% (Median = 365.5 cells/mm3) and
[8 232 55 (23.7) 1
a large proportion of the interviewees were symptomatic
5. Family income
for AIDS (48.1%) and had an HIV viral load greater than
BUS$ 170 206 61 (29.6) 1.4 (1.0–2.2)
400 copies/mL (Median HIV-viral load = 9,200 copies/mL
[US$ 170 334 76 (22.7) 1
and median log = 3.96). Approximately 84.0% of the
6. Under social welfare
participants were on ARVT.
Yes 244 62 (25.4) 1 (0.7–1.5)
Univariate Analysis No 289 74 (25.6) 1
7. Current cigarette smoking:
Analysis of sociodemographic variables showed that Yes 213 55 (25.8) 1 (0.7–1.6)
younger men (B35-years-old), those who were married or No 327 82 (25.1) 1
lived with their partners and those with lower family 8. Current alcohol drinking:
income had a greater chance of practicing unprotected sex, Yes 269 71 (26.4) 1.1 (0.8–1.6)
although p-values were only borderline significant No 271 66 (24.3) 1
(Table 2). No difference was found with regard to 9. Any illicit drug use in the past 12 months
recruitment site (p = .92) Yes 107 36 (33.6) 1.7 (1.1–2.6)*
Men whose source of HIV infection was a heterosexual No 433 101 (23.3) 1
contact (OR = 2.0, p = .03), those practicing sex with both Sexual behavior
men and women in the past 12 months (OR = 3.3, p = .002) 12. Likely source of HIV exposure
and those reporting from 1 to 10 (OR = 2.4, p = .001) or Heterosexual contact 210 64 (30.5) 2 (1.1–3.6)*
more than 10 (OR = 5.7, p = .001) female sexual partners in MSM contact 242 57 (23.6) 1.4 (0.8–2.6)
the past 12 months had significantly increased chances of Othersc 88 16 (18.2) 1
practicing unsafe sex. In addition, having a stable partner 14. Sexual practice in the past 12 months
and the practice of anal sex with their female partners also None 86 – – –
significantly increased the chances of practicing unsafe sex Men and women 31 16 (51.6) 3.3 (1.4–7.7)**
among these HIV-infected men (OR = 1.9 and 2.2, Women only 244 77 (31.6) 1.4 (0.9–2.2)
respectively). Number of male partners in the past 12 Men only 179 44 (24.6) 1
months and anal sex with men were not statistically asso- 15. Number of female partners in the past 12 months
ciated with unsafe sexual practice. Finally, men reporting [10 17 9 (52.9) 5.7 (3.0–15.5)**
any diagnosis of STDs in the past 12 months also had a 1–10 258 84 (32.6) 2.4 (1.6–3.7)**
statistically significant association with unsafe sexual None 265 44 (16.6) 1
practice (OR = 1.9, p = .01). Not being on ARVT, having 16. Number of male partners in the past 12 months
lower current CD4 + T-lymphocyte count (\350 cells/ [10 29 8 (27.6) 1.3 (0.5–3.1)
mm3) or higher viral load ([400 copies/mL) and having 1–10 181 52 (28.7) 1.3 (0.9–2.0)
AIDS diagnosis were positively associated with unsafe None 330 77 (23.3) 1
sexual practice, although not statistically significant.

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AIDS Behav (2008) 12:741–747 745

Table 2 continued Table 3 Multivariate logistic regression analysis of unsafe sexa

among HIV-infected men in urban Brazil, 2003
Characteristics Total Unsafe Odds (95% CI)
sex ratio Characteristics OR (95% CI)
n (%)b
Current female or male stable partner
17. Anal sex with women in the past 12 months No 1
Yes 121 46 (38.0) 2.2 (1.4–3.5)** Yes 2.1 (1.1–4.1)*
No 419 91 (21.7) 1 Self reported HIV exposure
18. Anal sex with men in the past 12 months Othersb 1
Yes 205 58 (28.3) 1.3 (0.8–1.9) MSM contact 2 (1.0–3.8)*
No 335 79 (23.6) 1 Heterosexual contact 2.7 (1.3–5.7)*
19. Current female or male stable partner Any illicit drug use past 12 months
Yes 263 83 (31.6) 1.9 (1.3–2.8)** No 1
No 277 54 (19.5) 1 Yes 1.6 (1.0–2.7)*
Clinical Diagnosis of STDs past 12 months
23. Diagnosis of STD in the past 12 months No 1
Yes 72 27 (37.5) 1.9 (1.2–3.3)** Yes 2.1 (1.3–3.4)**
No 468 110 (23.5) 1 Partner HIV status
24. Current CD4 cell count (mm3) Negative 1
\350 242 64 (26.4) 1.2 (0.8–2.8) Positive 1.7 (0.9–3.2)
350+ 275 65 (23.6) 1 Unknown or no stable partner 1.8 (0.9–3.9)
25. Clinical AIDS diagnosis Number of female partners past 12 months
CDC C 125 35 (28.0) 1.2 (0.8–1.9) None 1
CDC A/B 413 101 (24.5) 1 1–10 3.1 (1.7–5.7)**
26. Current viral load: [10 7.9 (2.6–24.3)**
400+ 260 72 (27.7) 1.4 (0.9–2.1) a
Not always using condoms in vaginal and/or anal sex during 12
\400 237 51 (21.5) 1 months prior to interview
27. Currently on HAART b
Transfusion, hemophiliac, injection drug use
No 78 26 (33.3) 1.6 (0.9–2.7) Hosmer-Lemeshow = 10.45; p-value = .235
Yes 455 110 (24.2) 1 * p \ .05; ** p \ .01
a
Not always using condoms in vaginal and/or anal sex during 12
months prior to interview
b
Prevalence of unsafe sex in each category
Those participants who had stable partners, who had any
c
Transfusion, hemophiliac, injection drug use
STD diagnosis or who had reported any illicit drug in the
* p \ .05; ** p \ .01
past 12 months were also more likely to practice unsafe
sex, although illicit drug use was only of borderline sig-
nificance. Because HIV seroconcordance is a potential
Multivariate Analysis marker for unsafe practices among couples, we decided to
fit serostatus of the partner in the final model, although it
The independent association effect of exposure variables was not significantly associated with unsafe practice
with unsafe sexual practice was assessed through logistic (adjusted OR = 1.7, 95% CI = .9–3.2). Finally, goodness of
regression. Table 3 shows the AOR and the 95% CI. All fit was assessed through the Hosmer-Lemeshow test, which
AOR obtained in the multivariate analysis were greater than indicated that the final model provided an adequate fit (p =
the univariate OR, except for illicit drug use in the past 12 .235).
months. Source of HIV exposure indicated that AOR of
heterosexual contact (OR = 2.7, 95% CI = 1.3–5.7) and MSM
contact (OR = 2.0, 95% CI = 1.0–3.8), compared with other Discussion
sources, i.e., transfusion, hemophiliac, injection drug use,
were consistent with the trend shown in the univariate Unsafe sexual practices are still highly prevalent among
analysis. Similarly, the number of female partners in the past HIV-positive men in many countries. In our post-ARVT
12 months, 1–10 (OR = 3.1, 95% CI = 1.7–5.7) and more than data we were able to identify that more than a quarter of
10 female partners (OR = 7.9, 95% CI = 2.6–24.3), also HIV-positive men under care in public health referral
showed independent association with unsafe sex. centers in these two Brazilian cities are not using condoms

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746
consistently in all sexual practices, especially with their
female partners. Unsafe practices were more likely to occur
among those men in stable relationships, among those
reporting more than 10 female partners in the past year and
among those reporting heterosexual contact as a possible
source of their HIV infection. Additionally, anal sex with
women predicted unsafe practices, although its indepen-
dent effect could be not be demonstrated. Our data also
indicated that, overall, HIV-infected men tended to have
more vaginal and anal sex without condoms with their
female partners than either anal receptive or anal insertive
sex with their male partners. Unprotected anal sex among
women and its role in heterosexual HIV transmission is
still a largely undermined public health issue in several
countries, including Brazil (Halperin 1999).
Although our results may only be representative of the
surveyed services in the two cities, this is consistent with
trends in the number of reported AIDS cases in Brazil,
which indicates an increase in heterosexual transmission
among women and a proportional increase in AIDS cases
among men attributed to heterosexual contact. Although,
reporting data is likely to have lower reliability, with
possible risk categories misclassified, the trend over time is
worrisome. Women accounted for 41.0% of new AIDS
cases in 2007, compared with 29.7% in 1996, while het-
erosexual transmission accounted for 64.0% of new
sexually transmitted cases among men in 2007, compared
with 46.0% in 1996 (Brasil 2007).
HIV prevalence among female stable partners of HIV-
positive men in Brazil has been shown to be higher than in
those in more developed countries. One of the main factors
associated with such high prevalence is heterosexual
unprotected anal sex. Despite a decline in the proportion of
unprotected sex when comparing the pre-ARTV estimates
with our post-ARTV data, from 39.9% to 25.0%, respec-
tively, this is still an alarming rate, which should concern
public health officials. The higher rates of heterosexual
unprotected anal sex in Brazil are of concern and public
campaigns should more directly target this issue. So far,
Brazilian campaigns have been generally soft with general
messages such as ‘‘use condoms in all practices’’. Unsafe
anal sex should receive more direct attention and preven-
tion efforts in areas where it is more prevalent.
Unsafe sexual behavior has also been linked to illicit
substance use, most likely due to decreased awareness and/
or perception of risk. This is more common among injec-
tion drug users, but also among other populations. In our
analysis, overall use of illicit drugs was associated with
unsafe practices only at a borderline level. Small numbers
and lower statistical power could partially explain this
finding. However, the trend is clear and supported by the
literature and should, nevertheless, be considered as an
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AIDS Behav (2008) 12:741–747
important marker for risk-taking behavior and be targeted
for intervention programs.
STD diagnoses were also associated with unsafe sex. As
shown by others, the incidence of syphilis is increasing in
several populations, especially among men who have sex
with men and injection drug users. Diagnosis of STDs is an
important marker for unsafe sex. It is well established that
ulcerative STDs may increase infectivity of HIV and thus
the probability of HIV transmission among discordant
couples. In addition to proper diagnosis and treatment of
other STD during medical follow-up, counseling should be
more carefully and routinely carried out in AIDS referral
centers in order to increase safe sex practice among HIV-
positive men under care.
Although none of the clinical or immunological markers
were statistically associated with unsafe practice, those
with lower CD4 count, with symptoms, with higher viral
load and not on ARV treatment showed higher prevalence
of practicing unsafe sex. Although these may not be nec-
essarily causally associated due to the cross-sectional
design of our study, these data indicate that the probability
of HIV transmission will most likely be higher among
these men, given the strong association of higher viral load
and infectivity as shown by others. Advanced stage of
clinical disease and high viral load have been demonstrated
to increase infectivity and the likelihood of HIV trans-
mission. Similarly, patients under ARVT who are not
completely adherent to their treatment may also show
higher levels of viral load in addition to potentially
exposing their partners to resistant virus (Chin-Hong et al.
2005. The high proportion (85.0%) of patients on ARTV
within our study population at the time of interview reflects
the current free universal ARTV policy of the Brazilian
AIDS program. Although we do not have precise data on
adherence, previous reports of similar populations in Brazil
indicate high non-adherence rates (Nemes et al. 2004).
Also of concern for HIV transmission is the delay in
treatment among Brazilian AIDS patients as demonstrated
by Souza et al. (2007). Using data from the Brazilian
national AIDS registry they indicated that a significant
proportion (53.0%) of patients start their treatment with
CD4 cell counts below 350/mm3. In our data, although not
as high, almost one third (29.0%) among those who had not
started their treatment at the time of the interview had
lower CD4 cell count (\350/mm3). The combination of
late treatment start, non-adherence among those on ARTV
and unsafe sex among the HIV-infected population under
care in Brazil may have a significant impact on HIV
transmission and should be of public health concern and a
matter to be further explored in future studies. In addition,
proper interventions to reduce risk taking behavior among
HIV-positive populations under care should be given a
AIDS Behav (2008) 12:741–747
serious and direct approach by public health officials and
care providers.
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