Print version ISSN 1516-4446
Rev. Bras. Psiquiatr. vol.31 no.1 São Paulo Mar. 2009
Prevalência de HIV, sífilis, hepatites B e C entre adultos com transtornos mentais: um estudo multicêntrico no Brasil
Mark Drew Crosland GuimarãesI; Lorenza Nogueira CamposI; Ana Paula Souto MeloI, II; Ricardo Andrade CarmoIII; Carla Jorge MachadoIV; Francisco de Assis AcurcioV; for the PESSOAS Project Network Group1
IDepartment of Preventive and Social Medicine, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
IIRaul Soares Institute and Teaching Hospital, State Health Department, Belo Horizonte (MG), Brazil
IIIEduardo de Menezes Hospital, State Health Department, Belo Horizonte (MG), Brazil
IV Center of Regional Development and Planning, School of Economic Sciences, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
VDepartment of Social Pharmacy, School of Pharmacy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
OBJECTIVE: There is evidence that patients with mental illness have increased prevalence of sexually transmitted infections, but data in Brazil are scarce. The objective of this study was to determine the prevalence of HIV, hepatitis C and B, and syphilis among patients with mental illness in Brazil.
METHOD: A multicenter representative sample of adults with mental illness was randomly selected from 26 mental health institutions throughout Brazil. Sociodemographic, sexual behavior and clinical data were obtained from person-to-person interviews and blood was collected for serology testing. Seroprevalence with 95% confidence limits were obtained correcting for sampling scheme.
RESULTS: Of the 2,475 patients interviewed, 2,238 had blood collected. Most participants were sexually active ever (88.8%) or in the last 6 months (61.6%), female (51.9%), and single (66.6%). Half of the sample had less than 5 years of schooling and the mean monthly individual income was low (US$ 210.00). Condom use was very low either during lifetime (8%) or in the last 6 months (16%). Overall seroprevalence were 1.12%, 0.80%, 1.64%, 14.7% and 2.63% for, respectively, syphilis, HIV, HBsAg, anti-HBc and anti-HCV.
CONCLUSIONS: Seroprevalences found were higher than other populations with representative studies in Brazil, with high rates of sexual risk behavior. This is of public health concern, and prevention and care strategies for sexually transmitted infections among psychiatric patients should urgently be implemented by health authorities.
Descriptors: Mental disorders; HIV seroprevalence; Syphilis; Multicenter study; Hepatitis B
OBJETIVO: Evidências indicam que pacientes com transtornos mentais têm elevada prevalência de infecções sexualmente transmissíveis, mas dados brasileiros são escassos. O objetivo deste estudo foi determinar a prevalência do HIV, hepatites C e B, e sífilis entre pacientes com transtornos mentais no Brasil.
MÉTODO: Uma amostra representativa de pacientes adultos com transtornos mentais foi aleatoriamente selecionada de instituições públicas de saúde mental no Brasil. Dados sociodemográficos, comportamentais e clínicos foram obtidos por entrevista face-a-face e sangue foi coletado para exames sorológicos. Soroprevalências com intervalo de 95% de confiança foram obtidas com correção para o esquema amostral.
RESULTADOS: Dos 2.475 pacientes entrevistados, 2.238 tiveram sangue coletado. A maioria era sexualmente ativa ao longo da vida (88,8%) ou nos últimos seis meses (61,4%), do gênero feminino (51,9%), solteira (66,6%), com metade dos participantes com menos de cinco anos de escolaridade e renda média mensal baixa individual (US$210). Uso de preservativo foi baixo em toda a vida (8%) ou nos últimos seis (16%). As soroprevalências gerais foram 1,12%, 0,80%, 1,64%, 14,7% e 2,63% para, respectivamente, sífilis, HIV, HBsAg, anti-HBc e anti-HCV.
CONCLUSÕES: As soroprevalências encontradas são maiores do que outros estudos com populações representativas no Brasil, com altos índices de comportamento sexual de risco. Isto é preocupante e estratégias de prevenção e cuidado para as infecções sexualmente transmissíveis entre pacientes psiquiátricos devem ser urgentemente implementadas pelos serviços de saúde.
Descritores: Transtornos mentais; Soroprevalência de HIV; Sífilis; Estudo multicêntrico; Hepatite B
The Brazilian National STD/AIDS Program has developed an integral and universal approach, i.e., curative, preventive and promotional aspects, in providing care for those with HIV infection, with widely international recognition1. In addition, the development of surveillance tools for monitoring the dissemination of HIV infection and other sexually transmitted infections (STI) to vulnerable populations has been a priority2. Studies with national representative samples have been conducted among pregnant women3,4, military recruits5, and more recently studies among men who have sex with men, female sex workers and injecting drug users (IDU) are currently under way in 10 major Brazilian metropolitan areas6 .
There is evidence that patients with mental illness have increased prevalence of STI, including HIV, with rates varying from 3% to 22%7. However, most of these seroprevalence studies have been conducted in developed countries among patients with severe mental illness (SMI), i.e., schizophrenia, bipolar disorders and depression with psychotic symptoms8, or in mental health care facilities which over represent populations with substance use disorders and IDU. As a consequence, seroprevalence and behavioral characteristics may either be overestimated or lack representativeness to warrant estimates with more reliable external validity. Therefore, STI seroprevalence studies that target patients with greater variety of psychiatric conditions are highly desirable and much needed.
In Brazil, data on both seroprevalence of STI and risk behavior among patients with mental illness are scarce and there is none with a national representative sample of patients with general psychiatric diagnoses. Consonant with its policy, the Brazilian National STD/AIDS Program, in collaboration with the National Mental Health Coordination and the Universidade Federal de Minas Gerais, launched a study designed to assess risk behavior and STI/HIV prevalence among patients with mental illness under public hospital or outpatient care, namely PESSOAS Project (HIV Seroprevalence Survey in Mental Health). The aim of this brief communication is to describe the seroprevalence of HIV, syphilis, hepatitis B and C from PESSOAS Project and compare these rates to other representative data in Brazil.
This is a cross-sectional national multicenter study conducted in 11 public psychiatric hospitals and in 15 public mental health outpatient clinics (CAPS) in Brazil. Because we aimed at obtaining a wider representation of adult patients with mental illness, participants were randomly selected regardless of their psychiatric diagnosis. In addition, we excluded Alcohol and Drug Addiction CAPS Centers (CAPSAd) due to the possibility of overestimating selected risk behaviors and/or prevalence rates, considering the concentration of substance use diagnoses and/or IDU in these centers, highly correlated with HIV infection. Thus, our eligibility criteria included adult (18+ years old) psychiatric patients under care either at hospitals or adult CAPS, who were capable of providing written informed consent, and were able to answer the questionnaire. Ethical approval was obtained from each site, the Universidade Federal de Minas Gerais (UFMG/ETIC 125/03) and the National Ethical Review Board (CONEP 592/2006). Methodological details can be found elsewhere9.
The sample size was estimated in 2,401 patients and it was proportionally stratified by type of center hospital or CAPS, yielding framing fractions of 38% and 62%, respectively. We anticipated 60% participation rate, resulting in 3,362 patients to be initially recruited. Within each type of center stratum, the sample size was proportionally distributed by the Brazilian geographical Regions according to the number of AIDS cases reported to the Ministry of Health as follows: 2%, 9%, 16%, 69% and 5% for, respectively, the North, Northeast, South, Southeast and Central-West Regions. A two-stage probability sampling frame was used. First, the centers were randomly selected proportionally to the number of beds for the hospital stratum or the number of registered patients for the CAPS stratum within each region. The second sampling stage was carried out by selecting patients using simple random probability frame from each site9.
The protocol, questionnaires and procedures were tested and validated in a pilot study, previously described10. A preliminary assessment was carried out by mental health professionals in order to evaluate the subjects' ability to participate. Seven objective questions (patient's name, three words to be repeated immediately and later, day of the week, month and year, name of the place they were, simple math calculation) adapted from the Mini Mental State Examination were asked. Also, a qualitative assessment was carried out for the presence of delusional symptoms, acute psychosis and degree of mental retardation. Final judgment was based on the overall assessment, and those capable and eligible were invited to participate. A seven-day period was allowed for clinical stabilization of hospitalized patients.
A semi-structured person-to-person interview, tested and previously described10, was conducted for obtaining sociodemographic, clinical and behavioral data. Interviews were administered by experienced mental health care professionals. Psychiatric diagnoses and other medical comorbidities were obtained from medical charts and were grouped according to the International Classification of Diseases (ICD-10).
Serology testing for HIV, hepatitis B and C and syphilis was conducted using standard markers for Hepatitis B Surface Antigen (HBsAg) (ELISA), Hepatitis B Total Antibody (Anti-HBc) (ELISA), Hepatitis C antibody (Anti-HCV) (ELISA), HIV antibody (Anti-HIV 1 e 2) (ELISA) confirmed by Western Blot and Syphilis (VDRL, confirmed with Hemagglutinin). Blood was collected by local health professionals after counseling and frozen sera were referred to Ezequiel Dias Foundation Laboratory, Belo Horizonte-MG, where they were checked for quality control and processed for exams.
The seroprevalence of each infection was estimated by dividing the number of positive tests by the total number of tested participants. These estimates and their corresponding 95% confidence interval were adjusted for within-cluster correlation considering each center as a potential cluster. Point estimates were proportionally weighted by the sample size of each site relative to its total population, i.e. number of beds or number of registered patients. Participants and non-participants were compared with regard to schooling, age, gender, psychiatric diagnosis and type of center (hospital or CAPS) using Pearson's Chi-Square test, and all analyses were carried out using SAS® and Stata®.
Among the 3,255 recruited patients, 492 (15%) were not capable of participating according to the preliminary assessment and 2,763 (85%) were actually invited to participate. Among these, 2,475 were interviewed (90%), 2,300 had blood collected (83%), while 2,238 (81%) had both interviews and blood collected and 288 were non-participants (10%). Reasons for non-participation were refusals (52%), not being located (19%), missed appointments (8%), non-eligible (4%), legally incapable (1%), death (0.7%), only blood collected (0.7%), and others (13%). There was no difference between participant and non-participant with regard to schooling (p = 0.07), age (p = 0.593), gender (p = 0.276) or psychiatric diagnosis (p = 0.551). However, hospital patients had a higher participation rate as compared to CAPS (p < 0.01). Eighty-one percent of the centers (n = 21) were public institutions, while the remaining were private with partial public funding. A detailed description of the centers can be found elsewhere11.
Most participants were 40 or older (55.5%), female (51.9%), single (66.6%), while mean monthly individual income was US$ 210.00. Half of the sample had less than 5 years of schooling and 18.5% were not able to read or write. Ever use of cigarette, alcohol, any illicit drug or injection drug were reported by 71.0%, 64.1%, 24.8% and 3.0% of participants, respectively. Most patients had been sexually active ever (88.8%) or in the last 6 months (61.6%). Only 8.0% and 16.1% reported always using condoms during their lifetime or in the past 6 months, respectively, while 61.5% had more than one sexual partner ever. Schizophrenia and other psychotic disorders were the most common diagnoses (47.3%) followed by depression (13.3%), bipolar disorder (9.0%), substance use (7.0%), and anxiety (3.6%), while 58.1% had at least one previous psychiatric hospitalization. Finally, 22.0% had any medical comorbidity registered in the medical charts, 24.0% had a history of STI, 45.4% had a low level of knowledge regarding HIV/AIDS and 55.9% perceived themselves as not being at risk for HIV/AIDS.
Overall seroprevalence was 0.80% for anti-HIV, 1.1% for syphilis, 1.6% for HBsAg, and 2.63% for anti-HCV, while the prevalence of anti-HBc, a marker for previous exposure to hepatitis B, was much higher (14.7%) (Table 1). Compared to other studies with national samples in Brazil, the prevalence of HIV among our sample was one time higher than pregnant women (0.4%) and almost eight times higher than military recruits (0.09%)3,5,12-18. In addition, HIV prevalence was higher than all other large studies, as well as the national estimate for the adult Brazilian population (0.61%). The prevalence of all hepatitis C and B markers were also higher, including a representative sample of the general population of São Paulo City (HCV = 1.42% and anti-HBc = 5.9%)12.
This is the first known national representative seroprevalence study of STI/HIV among patients with mental illness in Brazil. The point prevalence of HIV, syphilis, hepatitis B and C were shown to be higher when comparing to other Brazilian studies with probability samples of non-psychiatric populations, although some estimates were within the 95% confidence limits. Severe mental health conditions with lower perception of risk and cognitive impairment could partially explain these findings7,19,20. Also, lower socioeconomic conditions, lack of social support and poor access to health care may add to the burden of other medical conditions, including STI, to psychiatric patients7,20. Our rates tended to be lower than those found among SMI patients in developed countries (3%-22%)7, particularly the USA, where studies tend to include younger and more severe mentally ill patients, usually recruited from one or a few psychiatric institutions with no clear geographical or population basis1. Similarly, studies carried out in Brazil among other populations may have been too specific in their age and/or gender definitions or eligibility criteria (i.e., military recruits or pregnant women).
Our sample covered inpatients and outpatients from all five Brazilian Regions with a greater variety of psychiatric diagnoses. However, because these were abstracted from medical records from a variety of services, interpretations should be cautious. We also restricted our sample to patients receiving care at the time of the survey and who were capable of participating and this could potentially underestimate the prevalence and behavior estimates.
Our study population also had similar age and gender distribution, as compared to the general Brazilian population. However, there was a higher proportion of participants who were black (16%), illiterate (18.5%), had less than 4 years of schooling (34.4%) and a lower mean individual income (US$ 210.00), as compared to the Brazilian census (6%, 11.8%, 23.7%, mean = US$ 388.00, respectively)21. This may indicate that social inequality should be addressed by public health authorities in developing STI prevention and care strategies for this population in Brazil. More studies are needed to further explore potential causal relationships with STI among patients with mental illness.
Finally, we indicate that adults with mental illness in Brazil are at increased risk for STI compared to other population groups. There is an urgent need of developing public health policies towards providing a more comprehensive and integrated health care and prevention strategies for these patients. However, more representative studies worldwide are needed to improve and generate more precise risk behavior and STI prevalence rates for cross-country comparisons among mentally ill patients.
Financing: Brazilian National STD/AIDS Program, Ministry of Health (Financial Support: UNESCO/DST-Aids 914/BRA/1101 Project 086/05). Dr. Guimarães was granted a Visiting Scholar Fellowship from CAPES (Brazilian Graduate Coordination, Ministry of Education).
The authors state no conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject of their manuscript.
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Mark Drew Crosland Guimarães
Av. Alfredo Balena, 190 - Bairro Santa Efigênia
30130-100 Belo Horizonte, MG, Brazil
Phone/Fax: (55 31) 3409-9109
Submitted: July 21, 2008
Accepted: October 22, 2008
1 We are deeply indebted to all PESSOAS Project Network Group:
Ana Maria Amaral Ragazzi, CERSAM César Campos, Betim, MG
Ana Maria Damian Souto, CAPS Nossa Casa, Santiago, RS
Ana Paula Souto Melo, Instistuto Raul Soares, FHEMIG
Carla Jorge Machado, Universidade Federal de Minas Gerais
Cassiane Echevenguá dos Santos Amaral, Casa Vida, Capão do Leão, RS
Celso Aparecido Fattori Júnior, Mental Medicina Especializada, Sorocaba, SP
Edgar Rodrigues, CAPS Assis, Assis, SP
Flávia Fernanda de Oliveira, Clínica São Bento Menni, Divinópolis, MG
Florence Hostalácio Freitas, CAPS Formiga, Formiga, MG
Francisca Gerlane Sarmento de Oliveira, Hosp. Col. Dr. João Machado, Natal, RN
Francisco de Assis Acúrcio, Faculdade de Farmácia, UFMG
Hanna Karine de Carvalho, CAPS Morada Nova, Morada Nova, CE
Helian Nunes de Oliveira, Instituto Raul Soares, FHEMIG
Heloísa Agnes Mendes Marra, Instituto Raul Soares, Belo Horizonte, MG
Jackson Mattos Medrado, Hospital Psiquiátrico de Maringá, Maringá, PR
Juliana Marcela Flausino, CAPS São José do Rio Pardo, S. J. do Rio Pardo, SP
Juliane Macedo Ney da Silva, CAPS Vidativa, Anápolis, GO
Kátia Galbinksy, CGSM/DAPE/SAS/MS
Kelly Cristian Ribeiro Graeff, CAPS Cantagalo, Cantagalo, RJ
Lorenza Nogueira Campos, Universidade Federal de Minas Gerais
Lucimar da Mota Alves, CAPS Paraíso, Paraíso,TO
Marcilene Cristina Fonseca, Hospital Galba Veloso, Belo Horizonte, MG
Maria Alice Saccani Scardoelli, SES/SP, Dept. Psiquiatria II, Franco da Rocha, SP
Maria Cristina Correa Lopes Hoffmann, CGSM/DAPE/SAS/MS
Maria das Graças Nunes Martins, Hosp. Psiquiátrico Eduardo Ribeiro, Manaus, AM
Maria Elizete Silva Penido, CAPS II José Foster Jr., Guarujá, SP
Maria Imaculada de Fátima Freitas, Universidade Federal de Minas Gerais
Maria Tereza Gomes da Silva, SPSES Hospital Clemente Ferreira, Lins, SP
Mariângela Cherchiglia, Universidade Federal de Minas Gerais
Mark Drew Crosland Guimarães, Universidade Federal de Minas Gerais
Murillo Mascarenhas Nascente, Clínica Isabela, Goiânia, GO
Renata Cristina de Souza Ramos, CAPS Renascer, Ribeirão das Neves, MG
Ricardo Andrade Carmo, Hospital Eduardo de Menezes, FHEMIG
Ronaldo Efigênio de Oliveira, CAPS Carmo, Carmo, RJ
Stanley Crosland Guimarães, CAPS Policlínica Dr. Hélio Sales, Montes Claros, MG
Suely Broxado de Oliveira, Instituto de Psiquiatria da UFRJ
Suely Maria Pinto Tozato, CAPS Francisco Morato, Francisco Morato, SP
Zelândia Marcheni Elizeche, Hosp. Psiquiátrico Vera Cruz, Sorocaba, SP