BACKGROUND: The needle exchange programme (NEP) started in Sweden in 1986 in Lund and shortly after in Malmo. The first NEP in Stockholm opened in spring 2013. The NEP is a service aimed at intravenous drug users (IDU) from 18 years old, with a goal of preventing the blood borne diseases, such as HIV, Hepatitis B (HBV), and Hepatitis C (HCV). With the on going HIV and Hepatitis epidemics, numerous countries around the world have adopted control strategies, such as the NEP to halt the spread of HIV, HBV, and HCV. The objective of this study was to examine if the needle exchange programme has decreased the incidence of HIV, HBV, and HCV in Sweden over a six-year period.  METHODS: Data for incidence and prevalence was extracted from the yearly reports of the Stockholm’s needle exchange programme from 2013 to 2018 and the yearly reports of the public health agency in Sweden from 2013 to 2018. The data was collected for Stockholm, and compared to Västra Götaland, and the whole of Sweden. RESULTS: The incidence of HIV was zero in 2013 and 2015 in the NEP. The incidence of HBV decreased to zero in 2013 in the NEP. There is an increased incidence of HCV in the NEP. CONCLUSION: The NEP has a protective effect through its combination of needle exchange, opiate substitute therapy, counselling, and vaccinations in reducing and stabilising incidences of the infections, in some instances to zero, as well as providing surveillance and treating infections.

L’infection par le virus de l’hépatite B (VHB) reste un problème de santé publique avec plus de 880 000 décès chaque année dans le monde. Au stade chronique de l’infection virale B, des complications peuvent survenir comme la fibrose, la cirrhose et le carcinome hépatocellulaire. L'implication du VHB, de ses protéines ou de sa variabilité génétique dans la fibrose hépatique reste à élucider. Toutefois, des méta-analyses semblent montrer un lien statistiquement significatif entre la présence de la double mutation A1762T/G1764A dans le promoteur basal du core (PBC) du VHB et la fibrose sévère. C’est pourquoi nous avons orienté nos travaux de recherche selon deux axes : l’implication des mutations du PBC et de la région précore (PC) dans la sévérité des lésions hépatiques ainsi que le rôle des protéines HBc et HBe du VHB dans l’induction de la fibrogénèse. Dans un premier temps, deux études cliniques ont permis de confirmer l’association significative du double mutant PBC avec la fibrose sévère indépendamment du génotype viral. Nous avons également démontré un effet antagoniste de la mutation G1899A située dans la région PC vis-à-vis du double mutant PBC dans la sévérité de la fibrose. La deuxième partie de nos travaux a consisté à développer une technique innovante de production de protéines en utilisant la transduction de la lignée HepaRG par des vecteurs lentiviraux contenant la séquence de la protéine GFP (green fluorescent protein). En parallèle, nous avons synthétisé des particules lentivirales contenant les séquences sauvages et mutées du PBC et de la région PC, avec pour objectif de produire les protéines HBc et HBe dans les HepaRG. / The hepatitis B virus (HBV) infection remains a significant public health problem with more than 880 000 deaths every year worldwide. At the stage of chronic HBV infection, complications can occur such as fibrosis, cirrhosis and hepatocellular carcinoma. The role of HBV, its protein and its genomic variability in fibrosis are still unclear. Meta-analysis seems to indicate a strong link between the double mutation A1762T/G1764A detection in the basal core promotor (BCP) of HBV and the development of fibrosis. In this context, our work aimed to explore: i. the implication of BCP or precore (PC) regions mutations on the severity of fibrosis, and ii. the role of HBc and HBe proteins in fibrosis induction. For the first approach, our studies confirmed the association between the presence of the BCP double mutation and severe fibrosis, independently of the viral genotype. We also showed that the G1899A mutation in the PC region presents an antagonist effect regarding the double BCP mutant for fibrosis severity. In the second part of our work, we developed an innovative technology to produce protein via the transduction of HepaRG cells using lentiviral technology with a plasmid vector containing GFP (greenfluorescent protein) sequence. We also obtained lentiviral particles containing the wild and mutated sequences for the BCP and PC regions, in order to produce HBc and HBeprotein in HepaRG cells and to explore of the pathogenic role of BCP and PC mutants.

Infecções pelos vírus da hepatite B (HBV) e vírus da hepatite C (HCV) na população prisional apresentam prevalências bastante elevadas, alcançando taxas, algumas vezes, de mais de 40%. Contribuem para isso diversos comportamentos de risco, adotados já antes do encarceramento ou desenvolvidos durante o período de reclusão. Entre eles, destacam-se o uso de drogas ilícitas intravenosas com compartilhamento de agulhas, tatuagens e atividade sexual desprotegida. Esta pesquisa objetivou estimar a prevalência dos marcadores do HBV e HCV com seus respectivos fatores de risco para estas exposições na população masculina carcerária da Penitenciária de Ribeirão Preto - SP, no período de maio a agosto de 2003. Do total de 1030 presidiários, foram sorteados 333 participantes por amostragem casual simples, os quais foram submetidos à aplicação de um questionário padronizado e tiveram coletada uma amostra de sangue. Para diagnóstico do HBV e HCV foi utilizado o ensaio imunoenzimático para detecção do HBsAG, anti-HBc total, anti-HBs e anti-HCV. A confirmação deste foi feita através de reação de polimerase em cadeia (HCV RNA). As prevalências encontradas para HBV e HCV nos presidiários foram de 19,5%% (IC 95% : 15,2 - 23,8) e 8,7% (IC 95% : 5,7 - 11,7), respectivamente . Todas as variáveis que apresentaram \"p\" abaixo de 0,25, através de análise univariada, foram submetidas a um modelo multivariado de regressão logística. Nesta análise, as variáveis que se mostraram preditoras de forma independente da infecção pelo HBV foram: idade acima de 30 anos e passado de droga injetável. Já para o HCV, as variáveis foram idade acima de 30 anos, história prévia de hepatite, tatuagem, passado de droga injetável e passado de compartilhamento de agulhas. / The hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in correctional settings have quite high prevalences, reaching rates of up to 40%. Several risk behaviors, adopted before or during the imprisonment, accounts for that. Among them, the use of intravenous illicit drugs, sharing of needles, tattoos and unprotect sexual activity are the most important. This survey aimed to estimate the prevalence of HBV and HCV serological marker and risk factors for these infections in men inmates at the Penitentiary of Ribeirão Preto, State of São Paulo, Brazil, between May and August 2003. Out of 1030 inmates, a simple random sample of 333 participants was chosen. The participants were interviewed in a standardized questionnaire and provided blood for serological tests. An enzyme-linked immunosorbent assay (ELISA) was used for diagnosis of HBV and HCV infection (HBsAg, anti-HBs, anti-HBc, anti-HCV). Polymerase chain reaction (HCV RNA) was used to confirm HCV infection. The overall prevalence for HBV and HCV markers in inmates was 19,5% (CI 95%: 15,2 - 23,8) and 8,7% (CI 95%: 5,7 - 11,7), respectively. The variables that displayed p<0,25, through univariate analysis, were assessed by a logistic regression multivariate model. At the level of 5%, HBV infection was associated with age > 30 years and previous injecting drug use. For HCV infection, age > 30 years, previous injecting drug use, previous sharing of needles, tattoos and previous hepatitis.

Introdução: No mundo especula-se que 15 a 20 milhões tenham infecção crônica pelo HDV. No Brasil, a área endêmica de hepatite Delta corresponde aos estados da Amazônia Ocidental, incluindo Rondônia. Hepatite Delta é a mais grave e com mais rápida evolução para cirrose dentre as hepatites virais. Poucos estudos avaliaram os aspectos epidemiológicos, clínicos e laboratoriais de uma coorte de pacientes em nosso país e no mundo. Objetivos: Em uma coorte de pacientes acompanhados em um serviço de referência: 1. Avaliar as características demográficas, epidemiológicas e clínicas; 2. Avaliar a frequência de doença hepática avançada; 3. Avaliar as características da população atendida com idade <=18 anos; 4. Avaliar a acurácia de escores não invasivos (razão AST/ALT, APRI e FIB-4) na determinação dos diferentes graus de fibrose. Métodos: Trata-se de um estudo transversal, descritivo, de uma coorte de pacientes retrospectivamente identificadas no ambulatório especializado em hepatites virais, pertencente ao Centro de Pesquisa em Medicina Tropical do Estado de Rondônia (CEPEM), situado na cidade de Porto Velho, com diagnóstico de infecção pelo HDV. Foram incluídos todos os pacientes com diagnóstico dessa infecção por sorologia (ELISA) ou por biologia molecular (HDV-RNA reagente), matriculados e atendidos neste serviço entre novembro de 1996 a março de 2015. Resultados: Dentre 4.101 pacientes diagnosticado com HBV, 224 (5,5%) apresentavam coinfecção com o HDV, e 205 foram incluídos nas análises. Dentre eles, 132 (64,4%) eram do sexo masculino, com idade média de 35,1 anos. O contato familiar foi o fator de exposição para infecção pelo VHB/VHD mais frequente. A determinação do genótipo do HDV foi obtida em 78 pacientes, destes 74 (94,9%) eram genótipo III e 4 (5,1%) genótipo I. Noventa e dois (44,9%) pacientes apresentavam evidência de doença hepática avançada. Dentre os pacientes incluídos 22 (10,7%) tinham idade <= 18 anos, sendo que 6 (27,3%) apresentavam sinais e sintomas de doença hepática avançada ou fulminante à primeira consulta. Métodos não invasivos foram calculados e comparados à biópsia hepática em 50 pacientes. A razão AST/ALT não teve valor significativo para avaliar fibrose em nenhum dos estágios. APRI e FIB-4 tiveram melhor desempenho para avaliar fibrose significativa (>=F2), com acurácia de 86 e 80, respectivamente. Conclusões: 1. O HDV representa importante agravo de saúde pública em Rondônia com frequência expressiva entre pessoas do sexo masculino e população indígena; 2. A presença da infecção pelo HDV esteve associada a expressivo número de complicações hepáticas e foi frequente causa de óbito na população analisada, particularmente entre adultos jovens; 3. Entre pacientes com idade <= 18 anos a hepatite delta esteve associada a significante morbidade e mortalidade e a falta de adesão dessa população pareceu contribuir para esse tipo de desfecho; 4. A utilização dos métodos não invasivos (APRI e FIB-4) foi capaz de identificar pacientes com fibrose significativa entre indivíduos infectados com HDV na Amazônia brasileira, podendo, apesar de todas as limitações destes métodos servir como alternativa para avaliação de fibrose hepática significativa, na ausência de outros métodos mais efetivos / Introduction: In the world, it is speculated that 15 to 20 million people have chronic HDV infection. In Brazil, the endemic area of hepatitis Delta corresponds to the states of the Western Amazon, including Rondônia. Hepatitis Delta is the most serious and most rapidly evolving cirrhosis among viral hepatitis. Few studies have evaluated the epidemiological, clinical, and laboratory aspects of a cohort of patients in our country and around the world. Objectives: In a cohort of patients followed at a referral service: 1. Evaluate demographic, epidemiological and clinical characteristics; 2. Assess the frequency of advanced liver disease; 3. Evaluate the characteristics of the population served with age <=18 years; 4. To evaluate the accuracy of non-invasive scores (AST/ALT ratio, APRI and FIB-4) in determining the different degrees of fibrosis. Methods: This is a cross-sectional, descriptive study of a cohort of patients retrospectively identified in the ambulatory specialized in viral hepatitis, belonging to the Research Center of Tropical Medicine of Rondônia State (CEPEM), located in the city of Porto Velho. All patients diagnosed with this serological method (ELISA) or molecular biology (HDV-RNA), enrolled in this service between November 1996 and March 2015, were included. Results: Out of 4,101 patients diagnosed with infection by HBV, 224 (5.5%) had coinfection with the hepatitis delta virus, and 205 were included in the analyzes. Among them, 132 (64.4%) were males, with a mean age at the time of enrollment of 35.1 years. Family contact was the most frequent exposure factor for HBV/HDV infection. It was identified seventy-eight patients (94.9%) of genotype III and four (5.1%) of genotype I. Ninety-two (44.9%) patients had evidence of advanced liver disease. Among the patients included, 22 (10.7%) were aged <= 18 years, and 6 (27.3%) had signs and symptoms of advanced or fulminant liver disease at the first visit. Noninvasive methods were calculated and compared to liver biopsy in 50 patients. The AST/ALT ratio had no significant value for evaluating fibrosis in any of the stages. APRI and FIB-4 had better performance to evaluate significant fibrosis (>=F2), with the accuracy of 86 and 80 respectively. Conclusions: 1. The hepatitis delta virus represents an important public health problem in the State of Rondônia, affecting both adults and children, with significant frequency among males and the indigenous population; 2. The presence of HDV infection was associated with a significant number of hepatic complications and was a frequent cause of death in the analyzed population, particularly among young adults; 3. Among patients aged <= 18 years, delta hepatitis was associated with significant morbidity and mortality and the lack of adherence of this population to follow-up seemed to contribute to this type of outcome; 4. The use of the non-invasive APRI and FIB-4 methods were able to identify patients with significant fibrosis among individuals infected with HDV in the Brazilian Amazon, although all limitations of these methods may serve as an alternative for the evaluation of significant hepatic fibrosis in the absence of other more effective methods

L'hépatite B chronique reste un problème majeur de santé publique. Sous traitement par analogues nucléos(t)idiques (NUCs), l'objectif thérapeutique ultime est la clairance de l'antigène (Ag) HBs. Nous avons étudié l'influence de la variabilité des protéines d'enveloppe, impliquées dans l'entrée cellulaire du virus et cibles de la réponse immune, sur la clairance de l'Ag HBs. Des patients traités par NUCs ayant obtenu une clairance de l'Ag HBs (resolvers) ont été appariés à des non-resolver. Deux mutations combinées sT125M/sP127T, caractéristiques des non-resolver, étaient associées à une baisse de l'antigénicité prédite. L'analyse par séquençage haut débit montrait une plus grande variabilité du gène S chez les non resolver. Des tests fonctionnels portant sur des particules virales mutées en sT125M et sP127T sont en cours. Ces données moléculaires sont en faveur de l'existence de "motifs" spécifiques dans le gène S associés à la persistance de l'Ag HBs sous traitement par NUCs / Hepatitis B virus (HBV)-related chronic infection remains difficult to eradicate. On treatment by nucleos(t)ide analogues (NUCs), HBs Antigen (Ag) clearance is the ultimate but difficult therapeutic goal. Our aim was to investigate how variability of HBV envelope protein, crucial in viral cellular entry and targeted by host immune response, could play a role in HBsAg clearance. HBV chronically infected patients, treated by NUCs with HBsAg clearance (resolver) were matched with patients without HBsAg clearance (non resolver). Combined mutations sT125M/sP127T, associated with HBsAg persistence, displayed a lower predicted antigenicity. Ultra Deep Sequencing of S gene showed a higher variability in non resolver. Functional assays on viral particles including sT125M and sP127T mutations versus reference particles are in progress. As a conclusion, molecular features observed in non NR argue in favor of a different pattern in HBV S characteristics according to variable NUCs efficiency

L’hépatite B chronique touche environ 257 millions de personnes dans le monde. La perte de l’antigène HBs (AgHBs), marqueur de guérison fonctionnelle, n’est que très rarement observée, même sous traitement antiviral (3-16 %). Les protéines d’enveloppe du virus de l’hépatite B (VHB), formant l’AgHBs, sont très variables et cruciales pour le pouvoir infectieux du virus de l’hépatite B (VHB) et la physiopathologie. Nous avons émis l’hypothèse que cette variabilité pourrait expliquer, au moins partiellement, l’évolution de l’infection par le VHB, évaluée par la clairance de l’AgHBs, chez des patients traités ou non par analogues nucléos(t)idiques anti-VHB. Chez 29 patients infectés par différents génotypes du VHB (A, C et D), présentant différents profils cliniques (infection aigüe ou chronique, co-infection VHB/VIH) et thérapeutiques, une très grande variabilité des protéines d’enveloppe du VHB a été mise en évidence. Chez ces patients, la persistance de l’AgHBs était corrélée avec la présence de mutations et délétions localisées dans des régions des protéines d’enveloppe virale jouant un rôle important dans la reconnaissance du virus par le système immunitaire. Ces résultats renforcent l’hypothèse que l’étude des protéines d’enveloppe du VHB pourrait mettre en évidence des signatures moléculaires influençant le fitness du VHB et par conséquent l’évolution clinique de la maladie liée à l’infection par le VHB / Chronic hepatitis B affects about 257 million people worldwide. The loss of HBS antigen (HBsAg), a marker of the functional cure, is very rarely observed, even on anti-HBV treatment (3-16%). The hepatitis B virus (HBV) envelope proteins (HBsAg) are highly variable and crucial for the viral infectivity and pathogeny. We hypothesized that the HBV variability in the envelope proteins could explain, at least partially, the evolution of HBV infection, evaluated by HBsAg clearance, in patients treated or not by anti-HBV nucleos(t)idic analogues. For 29 patients infected with different HBV genotypes (A, C and D), presenting different clinical profiles (acute or chronic infection, HBV/HIV co-infection) and therapies, a very high variability of HBV envelope proteins was observed. In these patients, the persistence of HBsAg was correlated with the presence of mutations and deletions located in areas that play a key role in the viral recognition by the immune system. These results reinforce the hypothesis that the study of HBV envelope proteins could highlight molecular signatures influencing HBV fitness which would subsequently modify the clinical evolution of HBV-related disease

Após anos de debates, o teste de detecção de ácidos nucleicos (NAT) para HIV e HCV na triagem de sangue foi implementado de forma obrigatória no Brasil em 2013, e HBV, em 2016. Um dos motivos citados sobre o atraso em sua implementação foi o custo elevado que seria adicionado à sorologia e, até o momento, uma ampla avaliação econômica em saúde (AES) a respeito de sua eficiência no país não está disponível. Diversos artigos já demonstraram que a razão incremental de custo-utilidade (ICUR) do NAT em relação à sorologia varia de 0,21 a 8,84 milhões de dólares americanos (US$) para cada QALY ganho. Esta grande variação dá-se, principalmente, por diferenças entre a idade média dos receptores de sangue (RS), incidência/prevalência dos vírus entre os doadores de sangue (DS), custo dos testes e tratamentos médicos, cobertura da vacina contra o HBV e sensibilidade do teste utilizado. Assim, faz-se necessária uma avaliação abrangente desta tecnologia e sua efetividade para o cenário brasileiro. Objetivos: Realizar uma revisão sistemática (RevS) de estudos econômicos completos sobre o uso do NAT para HIV, HCV e/ou HBV no mundo; realizar a AES sobre o NAT sob a perspectiva pública brasileira; caracterizar as doações de sangue em janela imunológica no país. Métodos: Metodologia Cochrane de RevS das bases de dados Medline, Embase, LILACS, CRD, BVS ECO, Google Scholar e IDEAS; questionário aplicado aos bancos de sangue e modelo econômico on-line da International Society of Blood Transfusion (ISBT) para cálculo da ICUR do \"NAT em mini-pool de seis amostras individuais\" (MP6) versus \"testes sorológicos\" (SR) no Brasil. Resultados: Quatorze estudos de dezesseis diferentes países foram avaliados. O NAT apresentou a maior relevância nos países de baixa renda, onde há as maiores prevalências e incidências virais, menores taxas de doadores de repetição (DR) e RS mais jovens. A maioria dos estudos concluiu que o NAT, independente do vírus analisado, não é custo-efetivo. As principais diferenças entre as características dos estudos foram relacionadas aos custos médicos e idade dos RS. O maior desvio dos padrões de uma RevS foram: não incluir o racional para definição dos desfechos e o modelo utilizado e não ter claro o conflito de interesse dos autores; para esta AES, o MP6 versus SR apresentou um ICUR de US$ 231.630,00/QALY, ou seja, 26,2 vezes o PIB per capita nacional) e um ICER de US$ 330.790,00/Ano de vida ganho (AVG). A análise de sensibilidade univariada do modelo demonstrou que somente a taxa de desconto, idade do RS, custo do NAT e epidemiologia dos vírus alteraram de forma significativa o ICUR obtido, variando desde US$ 76.957,00/QALY a US$ 933.311,00/QALY; a maioria dos casos de janela imunológica no Brasil são jovens, média de 29 anos, do sexo masculino, com pelo menos o ensino médio completo e mesmo com a obrigatoriedade do Anti-HBc no Brasil, o NAT-HBV é o que apresentou o maior rendimento. Conclusões: Os jovens, principalmente, ainda buscam os bancos de sangue como locais de testagem após comportamento de risco e é de extrema importância a revisão do custo real e completo do teste NAT no Brasil para ampla abordagem da tecnologia nacional incorporada e, se necessário, revisar a forma e modelo de reembolso da mesma e permitir a defesa do bem-estar da população e do bem público. / After years of discussion, nucleic acid (NAT) testing in the blood screening for HIV and HCV was implemented in Brazil in 2013 and HBV in 2016. One of the reasons cited for the delay in its implementation was the high cost that would be added to serology screening and a comprehensive economic assessment of its efficiency in the country is not yet available. Several articles have already shown that the incremental cost-utility ratio (ICUR) of NAT versus serology ranges from 0.21 to 8.84 million American dollars (US$) for each QALY gained. This large variation is mainly due to differences between the mean age of the blood recipient, viruses\' incidence / prevalence among donor population, cost of medical tests and treatments, HBV vaccine coverage, and sensitivity of the test used. Thus, a comprehensive evaluation of this technology and its effectiveness under the perspective of the Brazilian public health system (SUS) is needed. Objectives: Development of a systematic review (RevS) of complete economic studies about the use of NAT for HIV, HCV and / or HBV in the world. Conduct an economic evaluation of NAT under SUS perspective; characterize Brazilian blood donations in the serology \"window period\". Methods: Cochrane RevS Methodology of the Medline, Embase, LILACS, CRD, CRD ECO, Google Scholar and IDEAS databases; Questionnaire applied to blood banks and online economic model from the International Society of Blood Transfusion (ISBT) to calculate the ICUR for \"NAT in mini-pool of six individual samples\" (MP6) versus \"Serology Tests\" (SR) in Brazil. Results: Fourteen studies from sixteen different countries were assessed. NAT was most relevant in low-income countries, where there are the highest prevalences and viral incidences, lower rates of repeat donors and younger recipients of blood (RS). Most of the studies concluded that NAT, regardless of the virus evaluated, is not cost-effective. Differences in the characteristics of the studies were related to the costs and age of RS. The major deviations from RevS standards were: not including the rationale for selecting the outcomes and the model used and not being clear about the authors\' conflict of interest; MP6 vs SR showed an ICUR of US$ 231.630,00/QALY, 26,2 times Brazilian GND per capita) and an ICER of US$ 330.790,00/Life year gained (AVG). The univariate sensitivity analysis of the model demonstrated that only changes on discount rate, NAT cost, RS age and viruses\' epidemiology significantly altered the ICUR in a range between US$ 76.957,00/QALY and US$ 933.311,00/QALY; Most RS window period cases in Brazil are young, average of 29 years old, male, with at least high school education completed and even with the requirement of Anti-HBc in Brazil, NAT-HBV is the one that presented the highest yield. Conclusions: Young people, mainly, still seek blood banks as testing sites, especially after a risk behavior. It is extremely important to reveal the real and complete cost of the Brazilian NAT to fully evaluate its efficiency and, if needed, reassess its current reimbursement model, allowing the wellbeing defense of the population and public interest.

Introdução: A população confinada é um segmento exposto a certas situações que aumentam sua vulnerabilidade frente às doenças sexualmente transmissíveis. Infecções pelo HIV, hepatites B e C e sífilis encontram no sistema prisional um ambiente favorável às suas propagações. Estudos em população confinada são cercados de entraves tanto burocráticos como relacionados com a ética e segurança. Assim, assume grande importância um estudo - piloto para, entre outras coisas, identificar pontos prós e contras que possam surgir durante a execução do estudo principal. Objetivo: Desenvolver um estudo piloto para uma pesquisa sobre fatores de risco comportamentais referentes à contaminação pelas infecções pelo HIV, hepatites B e C e sífilis numa população carcerária. Métodos: Estudo epidemiológico transversal. Em julho de 2007, numa amostra de conveniência, 107 reeducandos foram estrevistados usando um questionário padrão e tecnica face-face. O estudo foi aprovado pelo Comitê de Ética em Pesquisa do HCFMUSP. Resultados: Foram realizadas todas as etapas planejadas, a saber: Reuniões na unidade: entre a direção e diversas equipes da unidade prisional; Convite aos participantes: contato com representantes dos reeducandos; Assinatura do TCLE: após formalização do convite à participação do estudo e Aplicação do questionário. Realizadas reuniões sistemáticas para ajuste do questionário. Feita a capacitação de entrevistadores. Elaborado um banco de dados no Microsoft Office para receber os dados por meio de dupla digitação. Foram entrevistados 16,5% da população da unidade. Apresentaram um perfil jovem com média de 31,1 anos de idade. O tempo médio de prisão foi de 18,7 meses. A idade média de início de uso de drogas legais foi de 14,7 e ilegais de 16,6 anos. Após o confinamento, houve redução no consumo de drogas e sem relatado de droga injetável no presídio. 55,1% realizaram tatuagem na prisão. 41,2% relataram ocorrência de DST na vida e 34,0% no ultimo mês, 2,5% referiram serem soropositivos para o HIV. 53,8% mantiveram o numero de relações sexuais após o confinamento e dos 28,6% que faziam uso sistemático de preservativos, 26,3% mantiveram esta freqüência no presídio. Envolvidos com agressões: 78,5% verbais e 65,1% físicas, sendo que 33,6% referiram ameaças de morte. Maconha, álcool e crack foram as drogas envolvidas nestas situações. Discussão: O estudo piloto possibilitou testar o instrumento de pesquisa, sua aplicabilidade e capacidade de identificar fatores de riscos para transmissão das infecções citadas, tanto fora quanto dentro do ambiente prisional. O treinamento dos entrevistadores favoreceu tanto a familiarização com o instrumento, quanto o contato adequado ético e seguro - com os reeducandos. A vivência com esta realidade contribuiu para mapear pontos vulneráveis do planejamento para a execução do estudo principal. Limites do estudo: As análises e a obtenção da sorologia não faziam parte do estudo piloto, postergadas para o estudo principal com amostra adequada. Questionários, quando utilizados como instrumento de coleta, podem apresentar problemas relacionados com as informações obtidas. Muitas delas podem não condizer com a realidade, tanto de forma proposital viés de informação quanto de forma não proposital viés de memória. / Introduction: Confined populations are exposed to circumstances that increase their vulnerability to sexually transmitted infections. HIV, hepatitis B and C, and syphilis, encounter at the prison system an environment favorable to their dissemination. Studies in confined populations are surrounded by bureaucratic, ethical and security barriers. Thus, a pilot study is of great importance -for identify obstacles and opportunities that may arise during the implementation of the main study. Objective: implementation of a pilot study on risk behaviors associated to the dissemination of HIV, hepatitis B and C, and syphilis in an incarcerated population. Methods: Cross Sectional study. In July of 2007, in a convenience sample, 107 prisoners were interviewed, face to face, using a standardized questioner. The study was approved by the Human Subject Committee of the Hospital das Clinicas of the School of Medicine from the University of Sao Paulo. Results: the research protocol was strict followed: institutional meetings of the direction and the different professional teams of the prison system; invitation to participants in close contact with prisoners representatives; signature of the consenting forms after the invitation and before the questionnaire was applied. Meetings were conducted to adjust the questionnaire. Interviewers were trained. A dataset using Microsoft Office was elaborated to allow insertion of the data collected. Subjects represented 16, 5% of the prison population. Participants were young, average of 31, 1 years of age. The length time in prison was 18, 7 months in average. The average of the initiation in the use of legal drugs was 14, 7 and illegal drugs 16, 6 years of age. After the arrestment there was a diminishment of the use of drugs, and no injection of drugs was reported. Tattoo inside of the prison was reported by 55, 1%. STI were reported by 41, 2% in life and by 34% in the last month, and 2, 5% reported to be HIV positive. 53, 8% maintained the same amount of sexual relation that they had outside of the prison. From the 28, 6% that regularly used condoms, 26, 3 regularly used inside of the prison too. Interviewed that were involved in aggression were 78, 5% verbal and 65, 1% physic, and 33, 6% refereed being threatened of dead. Marijuana, Alcohol and crack were the drugs involved in such circumstances. Discussion: The pilot study has tested the instrument of research, its applicability and ability to identify risk factors for transmission of the mentioned infections, both within or outside of the prison. The training of interviewers favored both the familiarity with the instrument, as the appropriate contact secure and ethical - with inmates. The experience with this reality has contributed to map vulnerabilities in the implementation of the main study. Limitations of the study: serology and analysis were not part of the pilot study, therefore postponed for the main study with adequate sample. Questionnaires may present problems with the information obtained. Many of the information may not match the reality; both, information or memory biases could be identified.

INTRODUÇÃO: A vacina contra o vírus da hepatite B é recomendada a todos os pacientes cirróticos, por outra etiologia, em lista de espera para transplante de fígado. Entretanto, a resposta vacinal descrita nesta população é inferior à da população de adultos imunocompetentes. Estratégias para aumentar sua imunogenicidade são discutidas na literatura, como a aplicação de doses dobradas, recomendada a populações de imunodeprimidos. Neste estudo, foi comparada a resposta à vacina contra o vírus da hepatite B de um esquema com doses simples a um com doses dobradas, e avaliada a influência de outros fatores associados à resposta vacinal no cirrótico em lista de espera para transplante de fígado. MÉTODO: Desenvolveu-se um estudo clínico, prospectivo, randomizado, entre outubro de 2006 e setembro de 2008. Adotando-se intervalo de confiança de 95% e poder de 80%, o cálculo da amostra resultou em 103 pacientes em cada grupo. Estimou-se uma perda de 10%, resultando em 113 pacientes a receber o esquema 0, 1, 2 e 6 meses com dose simples, e 113 a receber esquema semelhante com dose dobrada. As vacinas utilizadas foram Euvax e Butang. A imunogenicidade da vacina foi avaliada através da dosagem do anti-HBs após a terceira e a quarta dose da vacina. RESULTADO: Foram selecionados 738 pacientes inscritos em lista de espera para transplante de fígado, e incluídos 232. Na análise de resposta vacinal após a terceira dose, não houve diferença estatisticamente significativa entre os grupos que receberam dose simples ou dobrada (35,2% x 37,2%, p = 0,8). A soroconversão global após a quarta dose foi 66,9% (85/127). Também não houve diferença entre o grupo com dose simples e dobrada após a quarta dose (64,5% x 69,2%, p = 0,57), mas ao desenvolver a análise com ajuste para alguns fatores de confusão como idade, IMC, MELD e grupo sanguíneo, encontrou-se uma razão de probabilidade de soroconversão entre os pacientes que receberam a dose dobrada de 2,57 vezes a razão entre os pacientes que receberam a dose simples. Esta diferença foi estatisticamente significante, mas o intervalo de confiança incluiu 1 (OR=2,57, IC 95%=1 até 6,63, p=0,043). Fatores como idade, IMC e grupo sanguíneo O foram preditivos de resposta vacinal após a quarta dose da vacina. CONCLUSÃO: Não houve diferença na resposta vacinal entre dose simples e dobrada no cirrótico após esquema proposto. A má resposta após o esquema acelerado (0,1 e 2 meses) não contribui para que este esquema seja adotado na prática clínica. Provavelmente, o número de doses e o intervalo entre elas têm maior relevância, em relação a dose simples ou dobrada, como estratégia para aumentar a resposta vacinal. / BACKGROUND: Vaccine against hepatitis B is recommended for all cirrhotic patients, by another etiology, in waiting list for liver transplantation. However the vaccine response described in this population is lower than in immunocompetent adults. Strategies to increase its immunogenicity are discussed in the literature, as the application of double doses, usually recommended in immunocompromised populations. This study compared response to the vaccine against hepatitis B virus in a single dose regimen with a double dose regimen, and evaluated the influence of other features associated with vaccine response in cirrhotic on the waiting list for liver transplantation. METHOD: A prospective and randomized clinical trial was conducted between October 2006 and September 2008. Adopting confidence interval of 95% and a power of 80%, calculated sample comprised 103 patients in each group. Considering an estimated mortality of 10%, final calculated sample resulted in 113 patients to receive the scheme 0, 1, 2 and 6 months with a single dose, and 113 to receive a similar scheme with double doses. Vaccines used were Euvax and Butang. Vaccine immunogenicity was assessed measuring anti-HBs after the third and fourth dose of vaccine. RESULT: We selected 738 patients in waiting list for liver transplantation and included 232. There was no statistically significant difference between the groups that received single or double doses in the analysis of vaccine response after the third dose (35.2% vs. 37.2%, p = 0,8). Overall seroconversion after the fourth dose was 66.9% (85/127). There was no difference between the groups with double and single dose after the fourth dose (64.5% vs. 69.2%, p = 0,57), but analysis adjusted for some confounding factors such as age , BMI, MELD and blood group, found odds of seroconversion among patients who received double doses 2.57 times that of patients who received single doses. This difference was statistically significant, but confidence interval included 1 (OR = 2.57, 95% CI = 1 to 6.63, p = 0.043). Features as age, BMI and blood group were predictors of vaccine response after the fourth dose of vaccine. CONCLUSION: There was no difference in vaccine response between single and double doses in cirrhotic patients after the proposed scheme. The poor response after accelerated schedule (0.1 and 2 months) does not contribute to adopting this scheme in clinical practice. Number of doses and interval between them may be more important to vaccine response than single or double doses.

Introdução: Pacientes com infecção crônica pelo VHC e superinfecção pelo vírus da hepatite A (VHA) ou o vírus da hepatite B (VHB), têm maior morbi-mortalidade quando comparados com pacientes que apresentam infecção aguda somente pelo VHA ou VHB. A mortalidade associada à hepatite A aguda pode estar particularmente elevada em pacientes com pré-existência de hepatite crônica causada pelo VHC. Por esta razão, a imunização ativa com vacinas contra o VHA e o VHB vem a ser obrigatória nesta população, e consequentemente esta sorologia deve ser determinada. Objetivos: O objetivo deste trabalho foi avaliar a prevalência de marcadores sorológicos da hepatite A e hepatite B em 1.000 pacientes com infecção crônica pelo VHC atendidos no Ambulatório de Hepatites da Divisão de Gastroenterologia e Hepatologia Clínica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Resultados: O anti-VHA IgG foi positivo em 923 de 1000 pacientes (92,3%). Quando estratificados por idade, o anti-VHA IgG foi encontrado em 61% dos pacientes entre 20 e 29 anos, 70% entre 30 e 39 anos, 85% entre 40 e 49 anos, 94% entre 50 e 59 anos e 99% nos pacientes com mais de 60 anos . O anti-HBc total foi positivo em 244 pacientes (24%). Estratificados por idade, em 4,3% dos pacientes entre 20 e 29 anos, 17% entre 30e 39 anos, 21% entre 40 e 49 anos, 24% entre 50 e 59 anos, e 28% dos pacientes com mais de 60 anos. Dos 244 pacientes anti-HBc IgG positivos, 0,8% são HBsAg positivo, 8,5% anti-HBc IgG isolado e 16% anti-HBs positivo. Conclusões: A prevalência de anti-VHA IgG nod nossos pacientes com hepatite C crônica foi semelhante à da população geral no município de São Paulo. No entanto, o anti-HBc totaI foi maior em nossos pacientes, quando comparada historicamente à população geral dos países ocidentais, sugerindo fatores de risco semelhantes para as hepatites B e C, o que enfatiza a importância dos programas de imunização nesta população / Background and Aims: Patients with chronic HCV and superinfection by hepatitis A virus (HAV) or hepatitis B virus (HBV) have higher morbidity and mortality when compared with those without HCV. For this reason, HAV and HBV active immunization has become mandatory in this population and hence their serological markers must be determined. The aim of this study was to evaluate the prevalence of serological markers of HAV and HBV infection in patients with chronic HCV. Methods: 1.000 chronic HCV infected patients at the University of Sao Paulo School of Medicine outpatient Liver Clinic were evaluated for the prevalence of serological markers of HAV and HBV infection. Results: Anti-HAV IgG was positive in 923 of 1000 patients (92.3%). When stratified by age, the anti-HAV IgG was found in 61% of patients between 20-29 years, 70% between 30-39 years, 85% between 40-49 years, 94% between 50-59 years, and 99% over 60 years of age. Anti-HBc IgG was positive in 244 patients (24%). Stratified by age, anti-HBc IgG was found in 4.3% of patients between 20-29 years, 17% between 30-39 years, 21% between 40 -49 years, 24% between 50-59 years, and 28% of patients over 60 years of age. Of the 244 anti-HBc IgG positive patients, 0.8% were also HBsAg positive, 8.5% were anti-HBc IgG isolated and 16% were also anti-HBs positive. Conclusions: The prevalence of anti-HAV IgG was similar to the general population in the city of São Paulo. However, anti-HBc IgG was higher in our chronic HCV patients, when compared historically to the general population of western countries, suggesting similar risk factors for HBV and HCV acquisition, so emphasizing the importance of immunization programs in this population. Keywords: Hepatitis C, Chronic; Hepatitis C; Hepacivirus, Prevalence; Hepatitis A; Hepatitis B Título: Prevalência de Marcadores Sorológicos das Hepatites A e B em Pacientes com Hepatite C Crônica atendidos no Ambulatório de Hepatites do Serviço de Gastroenterologia Clínica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HCFMUSP Background and Aims: Patients with chronic HCV and superinfection by hepatitis A virus (HAV) or hepatitis B virus (HBV) have higher morbidity and mortality when compared with those without HCV. For this reason, HAV and HBV active immunization has become mandatory in this population and hence their serological markers must be determined. The aim of this study was to evaluate the prevalence of serological markers of HAV and HBV infection in patients with chronic HCV. Methods: 1.000 chronic HCV infected patients at the University of Sao Paulo School of Medicine outpatient Liver Clinic were evaluated for the prevalence of serological markers of HAV and HBV infection. Results: Anti-HAV IgG was positive in 923 of 1000 patients (92.3%). When stratified by age, the anti-HAV IgG was found in 61% of patients between 20-29 years, 70% between 30-39 years, 85% between 40-49 years, 94% between 50-59 years, and 99% over 60 years of age. Anti-HBc IgG was positive in 244 patients (24%). Stratified by age, anti-HBc IgG was found in 4.3% of patients between 20-29 years, 17% between 30-39 years, 21% between 40 -49 years, 24% between 50-59 years, and 28% of patients over 60 years of age. Of the 244 anti-HBc IgG positive patients, 0.8% were also HBsAg positive, 8.5% were anti-HBc IgG isolated and 16% were also anti-HBs positive. Conclusions: The prevalence of anti-HAV IgG was similar to the general population in the city of São Paulo. However, anti-HBc IgG was higher in our chronic HCV patients, when compared historically to the general population of western countries, suggesting similar risk factors for HBV and HCV acquisition, so emphasizing the importance of immunization programs in this population