ABSTRACT

Objective:

The aim of this study was to analyze the spatiotemporal evolution of the incidence rates of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) in the state of Paraná, Brazil.

Methods:

An ecological study with an analytical component of time series analysis was conducted in the state of Paraná from 2007 to 2022. The data source was the Notifiable Diseases Information System. To study the trend, the Prais–Winsten generalized linear regression model was used by decomposing the time series, and for spatial analysis, the Moran's index was applied.

Results:

The total sample consisted of 50,676 HIV/AIDS records. The incidence rate showed an increasing trend, with an average growth of 2.14% [95% confidence interval – 95%CI 1.16–3.13] per month. From 2007 to 2014 and from 2015 to 2022, the average number of cases in the state was 105.64 and 159.20 per 100,000 inhabitants, respectively, with significant variation among municipalities. Spatial clusters of high risk persisted in the metropolitan region, the capital, and coastal areas, and a new cluster was observed in the northern region of the state.

Conclusion:

The incidence rates of HIV/AIDS showed an upward trend over time. The number of cases varied considerably in some municipalities, especially in the coastal region. Spatial analysis revealed geospatial patterns of high risk in the main metropolitan areas of Paraná: Curitiba (including the coastal area), Londrina, and Maringá, which share characteristics such as a high degree of urbanization and ongoing economic development.

Keywords:
HIV; AIDS; Time series studies; Spatial analysis; Incidence

RESUMO

Objetivo:

Este estudo teve como objetivo analisar a evolução espaçotemporal das taxas de incidência do vírus da imunodeficiência humana (HIV) e da síndrome da imunodeficiência adquirida (AIDS) no estado do Paraná, Brasil.

Métodos:

Foi realizado um estudo ecológico com componente analítico de séries temporais e análise espacial no estado do Paraná, de 2007 a 2022. A fonte de dados foi o Sistema de Informação de Agravos de Notificação. Para estudar a tendência, foi utilizado o modelo de regressão linear generalizada de Prais-Winsten por meio da decomposição de séries temporais e, para a análise espacial, foi aplicado o Índice de Moran.

Resultados:

A amostra total foi composta de 50.676 registros de HIV/AIDS. A taxa de incidência apresentou tendência crescente, com crescimento médio de 2,14% (intervalo de confiança de 95% — IC95% 1,16–3,13) ao mês. Nos períodos de 2007 a 2014 e 2015 a 2022, a média de casos no estado foi de 105,64 e 159,20 a cada 100 mil habitantes, respectivamente, com importantes variações entre os municípios. Agrupamentos espaciais de alto risco permaneceram na região metropolitana à capital e litoral e um novo agrupamento foi observado à região norte do estado.

Conclusão:

As taxas de incidência do HIV/AIDS apresentaram tendência temporal crescente. O número de casos variou substancialmente em alguns municípios, principalmente naqueles localizados na região litorânea. A análise espacial revelou padrões geoespaciais de alto risco nas principais regiões metropolitanas do Paraná: Curitiba (abrange o litoral), Londrina e Maringá, as quais compartilham características como elevado grau de urbanização e constante desenvolvimento econômico.

Palavras-chave:
HIV; AIDS; Estudos de séries temporais; Análise espacial; Incidência

INTRODUCTION

In 2022, an estimated 39 million people worldwide were living with the human immunodeficiency virus (HIV), including 2.2 million in Latin America. Brazil accounted for nearly half (990,000) of the people living with HIV in the Latin American region and had the third highest incidence of HIV among adults in 2022 (0.39% per 1000 uninfected population), behind Chile and Uruguay¹1 AIDSinfo. Joint United Nations Programme on HIV/Aids [Internet]. Geneva: UNAIDS; 2023 [cited on Oct 16, 2023]. Available at: https://aidsinfo.unaids.org/
https://aidsinfo.unaids.org/... .

A study assessing the spatial distribution and temporal evolution of the epidemic in Brazil revealed a higher incidence of cases in the southern region over a 16-year period²2 Batista JFC, Oliveira MR, Pereira DLM, Matos MLS, Souza IT, Menezes MO. Spatial distribution and temporal trends of AIDS in Brazil and regions between 2005 and 2020. Rev Bras Epidemiol 2023; 26: e230002. https://doi.org/10.1590/1980-549720230002
https://doi.org/10.1590/1980-54972023000... . The state of Paraná, currently the most populous in the region³3 Instituto Paranaense de Desenvolvimento Econômico e Social. Censo 2022: Paraná ultrapassa o Rio Grande do Sul e se torna o mais populoso da região Sul [Internet]. Curitiba: IPARDES; 2023 [cited on Oct 16, 2023]. Available at: https://www.ipardes.pr.gov.br/Noticia/Censo-2022-Parana-ultrapassa-o-Rio-Grande-do-Sul-e-se-torna-o-mais-populoso-da-regiao-Sul
https://www.ipardes.pr.gov.br/Noticia/Ce... , accounted for 29% of HIV cases over a 15-year period, making it the second state with the highest number of cases in southern Brazil and the 22nd among the federal units⁴4 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Boletim Epidemiológico HIV/AIDS 2022 [Internet]. Brasília: Ministério da Saúde; 2022 [cited on Oct 16, 2023]. Available at: https://www.gov.br/aids/pt-br/central-de-conteudo/boletins-epidemiologicos/2022/hiv-aids/boletim_hiv_aids_-2022_internet_31-01-23.pdf/@@download/file
https://www.gov.br/aids/pt-br/central-de... .

Surveillance of HIV infection and the acquired immune deficiency syndrome (AIDS) is the responsibility of the Unified Health System (Sistema Único de Saúde-SUS), which focuses on three aspects: viral infection, progression to AIDS, and mortality. These data are provided by the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação-SINAN) and other information systems. Both HIV and AIDS were included in the national list of notifiable diseases, with AIDS being included since 1986 and HIV infection since 2014⁴4 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Boletim Epidemiológico HIV/AIDS 2022 [Internet]. Brasília: Ministério da Saúde; 2022 [cited on Oct 16, 2023]. Available at: https://www.gov.br/aids/pt-br/central-de-conteudo/boletins-epidemiologicos/2022/hiv-aids/boletim_hiv_aids_-2022_internet_31-01-23.pdf/@@download/file
https://www.gov.br/aids/pt-br/central-de... . This change was aimed at expanding the scope of diagnosis in order to improve prevention and control strategies⁵5 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Articulação Estratégica de Vigilância em Saúde. Guia de vigilância em saúde [Internet]. Brasília: Ministério da Saúde; 2022 [cited on Oct 16, 2023]. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/guia_vigilancia_saude_5ed_rev_atual.pdf
https://bvsms.saude.gov.br/bvs/publicaco... .

One of the main strategies for situational and epidemiological diagnosis in the context of HIV/AIDS relates to the use of spatial and temporal analysis tools, such as geoprocessing and time series, which contribute to the identification and understanding of disease transmission dynamics, providing evidence for prioritizing areas or zones for control and intervention activities⁶6 Alene KA, Viney K, Moore HC, Wagaw M, Clements ACA. Spatial patterns of tuberculosis and HIV co-infection in Ethiopia. PLoS One 2019; 14(12): e0226127. https://doi.org/10.1371/journal.pone.0226127
https://doi.org/10.1371/journal.pone.022... .

In a literature review conducted for this research, no studies were found that estimated the incidence of HIV/AIDS considering both spatial and temporal dimensions at the state level in Paraná. Therefore, this is the first study to analyze the disease in the country using these tools, contributing to the development of specific strategies and the creation and implementation of public policies aimed at addressing this health condition.

In this perspective, this study aimed to analyze the spatiotemporal evolution of the incidence rates of HIV and AIDS in the state of Paraná, Brazil, both in space and time, for the period from 2007 to 2022.

METHODS

A mixed ecological study of temporal and spatial analysis was conducted⁷7 Medronho RA, Bloch KV, Luiz RR, Werneck GL. Epidemiology. 2rd ed. São Paulo: Atheneu; 2009.. The state of Paraná is in the southern region of Brazil and comprises 399 municipalities, with an estimated population of 11,835,379 inhabitants in 2022⁸8 Instituto Brasileiro de Geografia e Estatística. Censo demográfico [Internet]. Rio de Janeiro: IBGE; 2022 [cited on Mar 10, 2023]. Available at: https://www.ibge.gov.br/estatisticas/sociais/populacao/22827-censo-demografico-2022.html?edicao=35938&t=resultados
https://www.ibge.gov.br/estatisticas/soc... ,⁹9 Instituto Paranaense de Desenvolvimento Econômico e Social. Anuário estatístico do estado do Paraná – 2021 [Internet]. Curitiba: IPARDES; 2021 [cited on Oct 15, 2023]. Available at: http://www.ipardes.gov.br/anuario_2021/index.html
http://www.ipardes.gov.br/anuario_2021/i... .

Regarding the Health Care Network (Rede de Atenção à Saúde [RAS] in Portuguese), it comprises 177 establishments dedicated to the care of people living with HIV/AIDS¹⁰10 Brasil. Ministério da Saúde. Departamento de HIV/Aids, Tuberculose, Hepatites Virais e Infecções Sexualmente Transmissíveis. Serviços de saúde – Paraná [Internet]. Brasília: Ministério da Saúde; 2022 [cited on Mar 10, 2023]. Available at: https://www.gov.br/aids/pt-br/acesso-a-informacao/servicos-de-saude/parana
https://www.gov.br/aids/pt-br/acesso-a-i... . This network is divided into four health macroregions, which, in turn, are decentralized into 22 health regions¹¹11 Paraná. Secretaria da Saúde. Regionais de saúde [Internet]. Curitiba: Secretaria da Saúde; 2023 [cited on Mar 10, 2023]. Available at: https://www.saude.pr.gov.br/Pagina/Regionais-de-Saude
https://www.saude.pr.gov.br/Pagina/Regio... .

Data from the Brazilian HIV/AIDS national database, reported in the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação-SINAN) from 2007 to 2022, was used. The State Department of Health (Secretaria de Estado da Saúde-SESA) provided the data after receiving authorization from the Research Ethics Committee in September 2023.

All cases of HIV and AIDS reported in SINAN for individuals aged 13 years or older, residing in municipalities within the state of Paraná during the study period, were included. The case definition was based on the internal field contained in SINAN: case definition criteria (HIV+, Rio/Caracas, and Centers for Disease Control and Prevention (CDC) adapted for AIDS cases). Laboratory evidence of HIV/AIDS infection in adults in Brazil is considered for those aged 13 years or older. Cases without a recorded municipality or not belonging to the state had the case definition criteria discarded, and duplicate records were excluded.

To eliminate duplicates, a method similar to that used by the Ministry of Health was employed¹²12 Paraná. Governo do Estado. Secretaria da Saúde. Boletim epidemiológico HIV/AIDS [Internet]. Curitiba: Secretaria do Estado da Saúde do Paraná; 2015 [cited on Oct 15, 2023]. Available at: https://www.saude.pr.gov.br/sites/default/arquivos_restritos/files/documento/2020-04/boletimhivaids2015_1.pdf
https://www.saude.pr.gov.br/sites/defaul... . Duplications were identified by comparing the following fields: patient name, mother's name, and date of birth. Subsequently, the date of diagnosis and notification were considered. Records with the earliest diagnosis date were retained, and in case of a tie, the first notification date was considered. For duplicate records resulting from a new notification due to a change in the case definition criteria, meaning they had been previously reported as HIV infection and were later reported as AIDS, the same duplication exclusion method was applied, considering only one notification based on the hierarchy of diagnosis and notification date. A flowchart depicting the population selection process leading to the sample was created (Figure 1).

A time series was constructed for analysis according to the month of diagnosis. Incidence rates were calculated, with the numerator being the total number of HIV/AIDS cases diagnosed per month in the population aged 13 years or older residing in Paraná and the denominator being the total population of Paraná aged 13 years or older, based on population estimates for each year available in the DATASUS database – ("Estudo de estimativas populacionais por município, sexo e idade 2000–2021),"¹³13 DATASUS. População residente [Internet]. Brasília: DATASUS; 2023 [cited on Mar 10, 2023]. Available at: https://datasus.saude.gov.br/populacao-residente
https://datasus.saude.gov.br/populacao-r... with multiplication by 100,000 inhabitants. It should be noted that the population estimate for the year 2021 is the most recent available based on age stratification.

For the temporal trend analysis, the Seasonal Decomposition of Time Series by LOESS (STL) method was applied¹⁴14 Cleveland RB, Cleveland WS, Terpenning I. STL: a seasonal-trend decomposition procedure based on Loess. J Off Stat 1990; 6(1): 3-73.. Assuming an additive decomposition, the incidence rate of HIV/AIDS in month t (Yt) is given by the following formula: Y_(t=) S_(t) + T_t + R_t, where S_(t) represents the seasonal component, T_t is the trend component, and R_t is the residual or noise component. The Rstudio 3.5.2 software was used to construct the series and trend analysis graphs.

Subsequently, the Prais–Winsten method was employed to numerically estimate the temporal trend¹⁵15 Prais SJ, Winsten CB. Trend estimators and serial correlation. Chicago: Cowles Commission Discussion Paper; 1954.. This method, based on linear regression, is given by the following formula: Yt = b0 + b1t + et, where b0 corresponds to a constant parameter, b1t corresponds to the slope of the line, and et is a random error. Through this linear regression, it is possible to estimate the value of the coefficient b1, applying a 95% confidence interval (CI) for this coefficient to calculate the monthly percentage change (MPC) and the 95% CI of the measure, as follows:¹⁶16 Antunes JLF, Cardoso MRA. Uso da análise de series temporais em estudos epidemiológicos. Epidemiol Serv Saúde 2015; 24(3): 565-76. https://doi.org/10.5123/S1679-49742015000300024
https://doi.org/10.5123/S1679-4974201500... MPC = [–1 + 10b1] * 100; 95% CI = [–1 + 10b1min.] * 100; [–1 + 10b1max.] * 100. When the rate is positive, the time series is considered increasing; when negative, it is decreasing; and when there is no significant difference between its value and zero¹⁶16 Antunes JLF, Cardoso MRA. Uso da análise de series temporais em estudos epidemiológicos. Epidemiol Serv Saúde 2015; 24(3): 565-76. https://doi.org/10.5123/S1679-49742015000300024
https://doi.org/10.5123/S1679-4974201500... , it is considered stationary. For this analysis, the Stata 12.0 software (StataCorp LP, College Station, United States) was used.

For spatial analysis, HIV/AIDS rates were calculated for two periods: from 2007 to 2014 and from 2015 to 2022. The incidence rate was calculated for each municipality in the state of Paraná, with the numerator being the total number of HIV/AIDS cases diagnosed in the municipality during the respective period in the population aged 13 years or older, and the denominator being the total population of the municipality aged 13 years or older, based on population estimates for 2014 (for the first period) and for 2021 (for the second period), with multiplication by 100,000 inhabitants¹³13 DATASUS. População residente [Internet]. Brasília: DATASUS; 2023 [cited on Mar 10, 2023]. Available at: https://datasus.saude.gov.br/populacao-residente
https://datasus.saude.gov.br/populacao-r... .

To determine the presence or absence of a spatial pattern, rates were subjected to Moran's index, identifying clusters of areas with similar risk for the occurrence of the condition. A neighborhood matrix was constructed based on the binary contiguity criterion in Queen's case model¹⁷17 Anselin L. Global spatial autocorrelation: visualizing spatial autocorrelation [Internet]. GeoDA; 2020 [cited on Mar 10, 2023]. Available at: http://geodacenter.github.io/workbook/5a_global_auto/lab5a.html#moran-scatter-plot
http://geodacenter.github.io/workbook/5a... . The Moran's index ranges from –1 to +1, with values close to zero indicating the absence of spatial correlation and positive values indicating positive spatial autocorrelation. The results underwent pseudo-significance tests, involving 999 permutations to verify p-values for p<0.001¹⁷17 Anselin L. Global spatial autocorrelation: visualizing spatial autocorrelation [Internet]. GeoDA; 2020 [cited on Mar 10, 2023]. Available at: http://geodacenter.github.io/workbook/5a_global_auto/lab5a.html#moran-scatter-plot
http://geodacenter.github.io/workbook/5a... .

The Moran's I mirroring diagram was used for result interpretation. The diagram compares the values of a normalized variable with the average of the same variable for neighboring municipalities, where Q1 refers to positive variable values and positive neighbor averages; Q2 refers to negative variable values and negative neighbor averages; Q3 refers to positive variable values and negative neighbor averages; and Q4 refers to negative variable values and positive neighbor averages. Moran's I corresponds to the linear regression coefficient¹⁸18 Brasil. Ministério da Saúde. Introdução à estatística espacial para a saúde pública. Brasília: Ministério da Saúde; 2007..

To spatialize clusters, we utilized the digital cartographic database of the Instituto Brasileiro de Geografia e Estatística (IBGE)¹⁹19 Instituto Brasileiro de Geografia e Estatística. Downloads [Internet]. Brasília: IBGE; 2023 [cited on Oct 16, 2023]. Available at: https://www.ibge.gov.br/geociencias/downloads-geociencias.html
https://www.ibge.gov.br/geociencias/down... . The maps of spatial clusters were generated by detecting regions with local spatial correlation (p<0.005), identified by BoxMap, with spatial statistical significance above 95%¹⁷17 Anselin L. Global spatial autocorrelation: visualizing spatial autocorrelation [Internet]. GeoDA; 2020 [cited on Mar 10, 2023]. Available at: http://geodacenter.github.io/workbook/5a_global_auto/lab5a.html#moran-scatter-plot
http://geodacenter.github.io/workbook/5a... . Critical areas were defined as those formed by municipalities falling into Q1 (high-high). For data processing and result mapping, the following software tools were used: GeoDa version 1.18.10 and QGIS version 3.16.7-Hannover.

The study was approved by the Ethics Committee of the State University of Londrina with Certificate of Ethical Consideration No. 00603718.6.0000.5231 and opinion No. 4.063.442 (June 2, 2020). Records were compiled securely, ensuring individual confidentiality and data security under the supervision of a single examiner.

RESULTS

The temporal trend of HIV/AIDS incidence rates is depicted in Figure 2. From 2007 to 2014, the trend exhibited an upward trajectory, followed by a decline and subsequent plateau in 2016, which persisted until 2019. Subsequently, the trend showed another decline between 2020 and 2021 and began to exhibit a rising pattern toward the end of the study period.

According to the results of the Prais–Winsten regression for the period from 2007 to 2022, the monthly time series of HIV/AIDS incidence demonstrated a growth trend (MPC=2.14; 95%CI 1.16–3.13), signifying an average monthly increase of 2.14% for the series.

Figure 3 presents the distribution and evolution of HIV/AIDS rates by municipalities in the state of Paraná, considering two analysis periods: 2007–2014 and 2015–2022.

For the first period (Figure 3a), the average number of cases was 105.64 per 100,000 inhabitants. It is noteworthy that 10% of municipalities in the state did not report any HIV/AIDS cases during this period. Higher rates were observed in municipalities in the state's Northern, Eastern, and Western regions, with concentrations of cases exceeding 400 per 100,000 inhabitants in the metropolitan region of Curitiba and the port city of Paranaguá. In terms of case quantity per 100,000 inhabitants, Paranaguá led the ranking during this period with 673.50 cases, followed by Pontal do Paraná with 556.45 cases, Matinhos with 531.91 cases, Guaratuba with 522.96 cases, and Pinhais with 487.12 cases.

For the second period (Figure 3b), the average number of cases registered was 159.20 per 100,000 inhabitants, with only 4% of municipalities reporting no cases. Paranaguá dropped to sixth place in the ranking, with 505.99 cases. The highest number of cases per 100,000 inhabitants was recorded in the municipalities of Guaratuba, with 654.56 cases, followed by Nova Fátima with 602.59 cases, Pinhais with 563.64 cases, Piraquara with 522.16 cases, and Curitiba with 518.26 cases.

It is noteworthy that, in both periods, the highest incidence rates are concentrated in municipalities in the metropolitan region of the capital and the coastal region, except for the second period, where Nova Fátima, located in the Northern Pioneer region of the state, stands out.

Regarding Moran's index, the results indicated the formation of significant clusters for both periods, with Moran's index values of 0.404 for the first period and 0.295 for the second period. Furthermore, the validation results (permutation test/z-value) suggest that the observed clusters are not random, indicating the presence of spatial autocorrelation with similar values among neighboring areas in terms of HIV/AIDS incidence rates, as shown in Table 1.

For the first period (Figure 4a), a significant cluster (high-high) is observed in the metropolitan region of the state, encompassing 22 municipalities, including the capital, Curitiba, coastal municipalities like Matinhos, Guaraqueçaba, and Guaratuba, and the port city of Paranaguá. In the second period (Figure 4b), the cluster observed in the metropolitan region remains, and a new significant cluster (high-high) is observed further in the Northern Central region of the state, including the municipalities of Maringá, Rolândia, Sarandi, Cambé, Ângulo, Astorga, Arapongas, Ibiporã, Iguaraçu, Marialva, and Mandaguaçu.

DISCUSSION

Throughout the 15-year analysis, a growing trend in HIV/AIDS incidence was observed in the state of Paraná. Higher incidence rates were concentrated in municipalities within the coastal and metropolitan regions of the capital. Subsequently, there was an increase in incidence rates in municipalities within the North Central and Western regions and bordering municipalities. Spatial clustering analysis identified significant clusters in the metropolitan region during the 1st and 2nd periods. Additionally, a new clustering was identified in the North Central region during the 2nd period, indicating the presence of geographical areas with a high concentration of HIV/AIDS incidence.

Although the temporal analysis revealed a monthly growth trend, signifying a consistent increase in incidence rates, fluctuations within the time series were identified among the years. These fluctuations can be attributed to changes and advancements in public policies and healthcare surveillance related to HIV/AIDS prevention, diagnosis, treatment, and monitoring²⁰20 UNAIDS. 40 anos da resposta à AIDS [Internet]. UNAIDS; 2022 [cited on Oct 15, 2023]. Available at: https://unaids.org.br/wp-content/uploads/2022/07/40-years-of-the-AIDS-response_en_traduzido.pdf
https://unaids.org.br/wp-content/uploads... .

A pivotal moment was the Ministry of Health's decision to expand HIV diagnosis access through rapid testing (RT), decentralizing to primary healthcare (PHC) in 2012²¹21 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria no 77, de 12 de janeiro de 2012. Dispõe sobre a realização de testes rápidos, na atenção básica, para a detecção de HIV e sífilis, assim como testes rápidos para outros agravos, no âmbito da atenção prénatal para gestantes e suas parcerias sexuais. Diário Oficial da União, de 12 de janeiro de 2012; Seção 1.. Following this decision, the temporal pattern shifted toward an upward trajectory, as evidenced by a significant increase of 132% in the distribution of RT in Paraná, rising from 315,375 in 2012 to 730,340 in 2015²²22 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Distribuição de testes rápidos de HIV, por Unidade da Federação. Brasil, 2011-2017 [Internet]. Brasília: Ministério da Saúde; 2018 [cited on Nov 16, 2023]. Available at: https://www.gov.br/aids/pt-br/central-de-conteudo/publicacoes/2018/2011-2017-distribuicao-de-testes-rapidos-para-hiv/@@download/file
https://www.gov.br/aids/pt-br/central-de... . A similar increasing trend in 2013 was reported in a study conducted in the state of Paraná, suggesting that decentralization impacted the epidemic among young men who have sex with men (MSM)²³23 Seabra IL, Pedroso AO, Rodrigues TB, Ferreira GRON, Ferreira ALS, Arcêncio RA, et al. Temporal trend and spatial analysis of the HIV epidemic in young men who have sex with men in the second largest Brazilian Amazonian province. BMC Infect Dis 2022; 22(1): 190. https://doi.org/10.1186/s12879-022-07177-w
https://doi.org/10.1186/s12879-022-07177... .

The implementation of mandatory HIV notification in 2014²⁴24 Brasil. Ministério da Saúde. Boletim epidemiológico especial – HIV/Aids 2021 [Internet]. Brasília: Ministério da Saúde; 2022 [cited on Apr 26, 2023]. Available at: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/boletins/epidemiologicos/especiais/2021/boletim-epidemiologico-especial-hiv-aids-2021.pdf/view
https://www.gov.br/saude/pt-br/centrais-... may have directly influenced the peak of indicators observed in the same year. Diagnoses made before the change in criteria also began to be reported, resulting in increased incidence rates and a more accurate and comprehensive representation of the true extent of the epidemic in the state.

The stationary pattern in the time series from 2016 to 2019 may reflect the Ministry of Health's ongoing efforts to achieve the targets proposed by the Joint United Nations Programme on HIV/AIDS (UNAIDS) by 2020 through the 90-90-90 strategy: 90% of all people living with HIV know their status; 90% of diagnosed individuals receive antiretroviral therapy (ART); and 90% of those receiving treatment have suppressed viral loads (VL). Currently, the 95-95-95 targets are projected for 2030²⁵25 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Relatório de monitoramento clínico do HIV 2022 [Internet]. Brasília: Ministério da Saúde; 2022 cited on Oct 15, 2023]. Available at: https://www.gov.br/aids/pt-br/central-de-conteudo/publicacoes/2022/relatorio-de-monitoramento-clinico-do-hiv-setembro-2022.pdf/@@download/file
https://www.gov.br/aids/pt-br/central-de... . These findings suggest a strengthening of the healthcare system at the regional level²⁶26 Organização Mundial da Saúde. Organização Pan-Americana da Saúde. Ministério da Saúde. Relatório técnico 2022: 112 Políticas públicas de controle das IST, do HIV/Aids, das Hepatites Virais, da Tuberculose, Micobacterioses não Tuberculosas, Micoses Sistêmicas (TB) e da Hanseníase fortalecidas de acordo com os princípios e diretrizes do SUS [Internet]. Brasília: OPAS, Ministério da Saúde; 2022 [cited on Oct 15, 2023]. Available at: https://www.paho.org/pt/documentos/termo-cooperacao-no-112-politicas-publicas-controle-das-ist-do-hivaids-das-hepatites
https://www.paho.org/pt/documentos/termo... .

This strengthening is reflected in a study conducted in Paraná, where 93.1% of those diagnosed were on ART, and 90.0% had a VL below 50 copies of viral RNA/ml of blood²⁷27 Dias FA, Höfelmann DA, Rattmann YD. Virologic success under antiretroviral therapy among people living with HIV/AIDS in the state of Paraná, Brazil. Einstein (Sao Paulo) 2021; 19: eAO5800. https://doi.org/10.31744/einstein_journal/2021AO5800
https://doi.org/10.31744/einstein_journa... . Furthermore, the benefits of these achievements can be seen through multicenter studies. When HIV VL is suppressed, the risk of transmission in unprotected sexual relations, whether among MSM couples or heterosexuals, is effectively zero²⁸28 Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, Lunzen JV, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA 2016; 316(2): 171-81. https://doi.org/10.1001/jama.2016.5148
https://doi.org/10.1001/jama.2016.5148... ,²⁹29 Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, Degen O, et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet 2019; 393(10189): 2428-38. https://doi.org/10.1016/s0140-6736(19)30418-0
https://doi.org/10.1016/s0140-6736(19)30... . This underscores the importance of treatment adherence and consistent viral suppression.

The time series experienced a sharp decline between 2020 and 2021. It is important to note that this decline may be related to underreporting cases due to the coronavirus disease 2019 (COVID-19) pandemic.

The COVID-19 pandemic significantly impacted HIV-related healthcare services in various regions of the world. In KwaZulu-Natal, South Africa, there was a 48% decrease in HIV testing after the first national lockdown³⁰30 Global AIDS Update 2021: confronting inequalities: lessons for pandeminc responses from 40 years of AIDS [Internet]. 2021 [cited on Oct 15, 2023]. Available at: https://www.unaids.org/sites/default/files/media_asset/2021-global-aids-update_en.pdf
https://www.unaids.org/sites/default/fil... . In the state of Paraná, reported cases to the Notifiable Diseases Information System (SINAN) decreased by 27% when comparing 2019 and 2020⁴4 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Boletim Epidemiológico HIV/AIDS 2022 [Internet]. Brasília: Ministério da Saúde; 2022 [cited on Oct 16, 2023]. Available at: https://www.gov.br/aids/pt-br/central-de-conteudo/boletins-epidemiologicos/2022/hiv-aids/boletim_hiv_aids_-2022_internet_31-01-23.pdf/@@download/file
https://www.gov.br/aids/pt-br/central-de... .

Lockdowns and other restrictive measures adopted to contain the spread of COVID-19 negatively impacted HIV/AIDS programs³⁰30 Global AIDS Update 2021: confronting inequalities: lessons for pandeminc responses from 40 years of AIDS [Internet]. 2021 [cited on Oct 15, 2023]. Available at: https://www.unaids.org/sites/default/files/media_asset/2021-global-aids-update_en.pdf
https://www.unaids.org/sites/default/fil... . Even during emergencies, it is crucial to maintain established plans to prevent setbacks in the progress made.

HIV/AIDS incidence maps in Paraná revealed that the epidemic was concentrated in the coastal and metropolitan regions, particularly in the metropolitan region of Curitiba, which houses 31.6% of the state's population and serves as a significant economic hub, attracting a workforce³¹31 Agência de Assuntos Metropolitanos do Paraná. Sobre a RM de Curitiba [Internet]. Curitiba: AMEP; 2023 [cited on Oct 15, 2023]. Available at: https://www.amep.pr.gov.br/Pagina/Sobre-RM-de-Curitiba#:~:text=A%20Regi%C3%A3o%20Metropolitana%20de%20Curitiba%20%2D%20RMC%2C%20%C3%A9%20a%20oitava%20regi%C3%A3o,extens%C3%A3o%2C%20com%2016.581%2C21km%C2%B2
https://www.amep.pr.gov.br/Pagina/Sobre-... . The high population density and extensive movement of people in the region contribute to the spread of infectious diseases.

This association is consistent with major urban centers, likely due to a higher transmission rate in densely populated areas, enabling the intensification of epidemic processes³²32 Rocha LEC, Thorson AE, Lambiotte R. The non-linear health consequences of living in larger cities. J Urban Health 2015; 92(5): 785-99. https://doi.org/10.1007/s11524-015-9976-x
https://doi.org/10.1007/s11524-015-9976-... . A study in Rio de Janeiro highlighted the association between urbanization and a high HIV incidence rate³³33 Alves ATJ, Nobre FF, Waller LA. Exploring spatial patterns in the associations between local AIDS incidence and socioeconomic and demographic variables in the state of Rio de Janeiro, Brazil. Spat Spatiotemporal Epidemiol 2016: 17: 85-93. https://doi.org/10.1016/j.sste.2016.04.008
https://doi.org/10.1016/j.sste.2016.04.0... . Geographical clustering is a common phenomenon in urban areas and has also been identified in other countries such as India and Ethiopia³⁴34 Krishnamoorthy Y, Majella MG, Rajaa S, Bharathi A, Saya GK. Spatial pattern and determinants of HIV infection among adults aged 15 to 54 years in India – Evidence from National Family Health Survey-4 (2015-16). Trop Med Int Health 2021; 26(5): 546-56. https://doi.org/10.1111/tmi.13551
https://doi.org/10.1111/tmi.13551... ,³⁵35 Gelibo T, Lulseged S, Eshetu F, Abdella S, Melaku Z, Ajiboye S, et al. Spatial distribution and determinants of HIV prevalence among adults in urban Ethiopia: Findings from the Ethiopia Population-based HIV Impact Assessment Survey (2017–2018). PLoS One 2022; 17(7): e0271221. https://doi.org/10.1371%2Fjournal.pone.0271221
https://doi.org/10.1371%2Fjournal.pone.0... .

In addition, larger cities often serve as primary healthcare providers for residents of smaller cities. In Paraná, they have a larger health infrastructure and serve as the headquarters of health regions (RS) such as Curitiba, Paranaguá, Londrina, Maringá, Cascavel, and Foz do Iguaçu¹¹11 Paraná. Secretaria da Saúde. Regionais de saúde [Internet]. Curitiba: Secretaria da Saúde; 2023 [cited on Mar 10, 2023]. Available at: https://www.saude.pr.gov.br/Pagina/Regionais-de-Saude
https://www.saude.pr.gov.br/Pagina/Regio... . A positive correlation between HIV/AIDS cases in cities serving as headquarters for macroregions was also found in a study by Mato Grosso do Sul³⁶36 Werle JE, Teston EF, Rossi RM, Marcon SS, Sá JS, Frota OP, et al. HIV/AIDS and the social determinants of health: a time series study. Rev Bras Enferm 2022; 75(4): e20210499. https://doi.org/10.1590/0034-7167-2021-0499
https://doi.org/10.1590/0034-7167-2021-0... .

Notably, the four municipalities with the highest incidence rates in the first period of analysis in Paraná were located in the coastal region. The presence of spatial autocorrelation in this region reinforces these findings, as significant clusters indicate that geographically close areas tend to have similar incidence patterns.

The economic, demographic, and social dynamics of the coastal region are influenced by the dynamism of the Port of Paranaguá, and other factors such as the location of the state's major roadways, high fluctuating population density, mobility, seasonal labor migration, and tourism are elements that can contribute to the propagation and maintenance of HIV³⁴34 Krishnamoorthy Y, Majella MG, Rajaa S, Bharathi A, Saya GK. Spatial pattern and determinants of HIV infection among adults aged 15 to 54 years in India – Evidence from National Family Health Survey-4 (2015-16). Trop Med Int Health 2021; 26(5): 546-56. https://doi.org/10.1111/tmi.13551
https://doi.org/10.1111/tmi.13551... ,³⁷37 Gelaw YA, Magalhães RJS, Assefa Y, Williams G. Spatial clustering and socio-demographic determinants of HIV infection in Ethiopia, 2015–2017. Int J Infect Dis 2019; 82: 33-9. https://doi.org/10.1016/j.ijid.2019.02.046
https://doi.org/10.1016/j.ijid.2019.02.0... . These characteristics, also recognized in border regions, represent critical points facilitating multiple casual partners, unprotected sexual relations, drug concentration, and sexual exploitation³⁸38 Davoglio RS, Gandin H, Mocellin LP. HIV/AIDS epidemic in a western border municipality of Rio Grande do Sul, Brazil: evolution, HIV cascade of care and lethality. Rev Bras Epidemiol 2021; 24(suppl 1): e210018. https://doi.org/10.1590/1980-549720210018.supl.1
https://doi.org/10.1590/1980-54972021001... . This implies implementing prevention strategies tailored to the local context, taking into account the population-specific characteristics within the context of combined HIV prevention³⁹39 Brasil. Ministério da Saúde. Prevenção combinada [Internet]. Brasília: Ministério da Saúde; 2023 [cited on Oct 15, 2023]. Available at: https://www.gov.br/aids/pt-br/assuntos/prevencao-combinada
https://www.gov.br/aids/pt-br/assuntos/p... .

The significant clusters in the North Central region in recent years, particularly around Maringá and its adjacent municipalities, as well as municipalities in the metropolitan region of Londrina, may be related to constant population growth, geoeconomic factors, strong education, healthcare, and transportation infrastructures, and migratory patterns⁴⁰40 Costa FR, Rocha MM. Nova dinâmica dos municípios do Paraná. Mercator (Fortaleza) 2014; 13(2): 91-104. https://doi.org/10.4215/RM2014.1302.0007
https://doi.org/10.4215/RM2014.1302.0007... .

Migration has played a significant role in population growth, especially in Maringá⁴¹41 Instituto Paranaense de Desenvolvimento Econômico e Social. Análise conjuntural [Internet]. Curitiba: IPARDES; 2023 [cited on Oct 15, 2023]. Available at: https://www.ipardes.pr.gov.br/sites/ipardes/arquivos_restritos/files/documento/2023-10/bol_jul_ago_2023.pdf
https://www.ipardes.pr.gov.br/sites/ipar... . The expansion of higher education institutions in the last decade, attracting prospective students and academics, has contributed to changes in urban and interurban space, generating employment and, consequently, socio-spatial impacts⁴²42 Mota AA. A cidade de Maringá e as instituições de ensino superior: novos erior: novos espaços de concentração e exclusão. Acta Sci Human Soc Sci 2006; 28(2): 249-55. https://doi.org/10.4025/actascihumansoc.v28i2.156
https://doi.org/10.4025/actascihumansoc.... .

Besides, it is known that migration and education are considered important social determinants in the HIV epidemic dynamics⁴³43 Dean HD, Fenton KA. Addressing social determinants of health in the prevention and control of HIV/AIDS, viral hepatitis, sexually transmitted infections, and tuberculosis. Public Health Rep 2010; 125(Suppl 4): 1-5. https://doi.org/10.1177/00333549101250S401
https://doi.org/10.1177/00333549101250S4... ,⁴⁴44 McGrath N, Eaton JW, Newell ML, Hosegood V. Migration, sexual behaviour, and HIV risk: a general population cohort in rural South Africa. Lancet HIV 2015; 2(6): e252-9. https://doi.org/10.1016/s2352-3018(15)00045-4
https://doi.org/10.1016/s2352-3018(15)00... . Changes in the social environment, increased mobility, and exposure to different social networks can lead to risky sexual behaviors such as multiple sexual partners or inconsistent condom use³⁷37 Gelaw YA, Magalhães RJS, Assefa Y, Williams G. Spatial clustering and socio-demographic determinants of HIV infection in Ethiopia, 2015–2017. Int J Infect Dis 2019; 82: 33-9. https://doi.org/10.1016/j.ijid.2019.02.046
https://doi.org/10.1016/j.ijid.2019.02.0... ,⁴⁴44 McGrath N, Eaton JW, Newell ML, Hosegood V. Migration, sexual behaviour, and HIV risk: a general population cohort in rural South Africa. Lancet HIV 2015; 2(6): e252-9. https://doi.org/10.1016/s2352-3018(15)00045-4
https://doi.org/10.1016/s2352-3018(15)00... . Despite good knowledge of prevention among the university population, risky behaviors continue, which are often associated with alcohol and drug use⁴⁵45 Silva LHF, Andrade SSC, Oliveira SHS, Matos SDO, Silva MLN, Diniz ERS. Risco à infecção pelo HIV/AIDS entre estudantes de ensino superior. Rev Enferm UFPE on line 2016; 10(5): 1781-8. https://doi.org/10.5205/1981-8963-v10i5a13557p1781-1788-2016
https://doi.org/10.5205/1981-8963-v10i5a... . In China, the proportion of cases among individuals with a university degree or higher has substantially increased, and the number of university students diagnosed with AIDS grows by 30–50% annually⁴⁶46 Qin Q, Guo W, Tang W, Mahapatra T, Wang L, Zhang N, et al. Spatial analysis of the human immunodeficiency virus epidemic among men who have sex with men in China, 2006-2015. Clin Infect Dis 2017; 64(7): 956-63. https://doi.org/10.1093/cid/cix031
https://doi.org/10.1093/cid/cix031... ,⁴⁷47 Wongkongdech R, Chanthamath S, Wongkongdech A. Knowledge, attitude and prevention behavior related to HIV/AIDS among students of a college in Lao-PDR: a cross-sectional study [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2022; 9(181): 1-14. https://doi.org/10.12688/f1000research.22306.1
https://doi.org/10.12688/f1000research.2... .

In our findings, spatial clusters with a high risk for HIV/AIDS were found in the municipalities of Curitiba and Maringá, with the highest human development index (HDI), higher levels of education among the population, and a lower proportion of individuals without income⁹9 Instituto Paranaense de Desenvolvimento Econômico e Social. Anuário estatístico do estado do Paraná – 2021 [Internet]. Curitiba: IPARDES; 2021 [cited on Oct 15, 2023]. Available at: http://www.ipardes.gov.br/anuario_2021/index.html
http://www.ipardes.gov.br/anuario_2021/i... . The positive relationship between the high risk of HIV/AIDS in areas with high economic activity, higher socioeconomic status, and better indicators measuring population living conditions was evident in other regions of Brazil and around the world³³33 Alves ATJ, Nobre FF, Waller LA. Exploring spatial patterns in the associations between local AIDS incidence and socioeconomic and demographic variables in the state of Rio de Janeiro, Brazil. Spat Spatiotemporal Epidemiol 2016: 17: 85-93. https://doi.org/10.1016/j.sste.2016.04.008
https://doi.org/10.1016/j.sste.2016.04.0... ,³⁶36 Werle JE, Teston EF, Rossi RM, Marcon SS, Sá JS, Frota OP, et al. HIV/AIDS and the social determinants of health: a time series study. Rev Bras Enferm 2022; 75(4): e20210499. https://doi.org/10.1590/0034-7167-2021-0499
https://doi.org/10.1590/0034-7167-2021-0... ,⁴⁸48 Rodrigues-Junior AL, Ruffino-Neto A, Castilho EA. Spatial distribution of the human development index, HIV infection and AIDS-Tuberculosis comorbidity: Brazil, 1982 – 2007. Rev Bras Epidemiol 2014; 17: 204-15. https://doi.org/10.1590/1809-4503201400060017
https://doi.org/10.1590/1809-45032014000...

49 Paiva SS, Pedrosa NL, Galvão MTG. Spatial analysis of AIDS and the social determinants of health. Rev Bras Epidemiol 2019; 22: e190032. https://doi.org/10.1590/1980-549720190032
https://doi.org/10.1590/1980-54972019003... -⁵⁰50 Bulstra CA, Hontelez JAC, Giardina F, Steen R, Nagelkerke NJD, Bärnighausen T, et al. Mapping and characterising areas with high levels of HIV transmission in sub-Saharan Africa: a geospatial analysis of national survey data. PLoS Med 2020; 17(3): e1003042. https://doi.org/10.1371/journal.pmed.1003042
https://doi.org/10.1371/journal.pmed.100... . Nevertheless, it is essential to consider the social context and living conditions in each geographical area, as different territories may be more affected by socioeconomic factors regarding the incidence of the disease²2 Batista JFC, Oliveira MR, Pereira DLM, Matos MLS, Souza IT, Menezes MO. Spatial distribution and temporal trends of AIDS in Brazil and regions between 2005 and 2020. Rev Bras Epidemiol 2023; 26: e230002. https://doi.org/10.1590/1980-549720230002
https://doi.org/10.1590/1980-54972023000... ,³³33 Alves ATJ, Nobre FF, Waller LA. Exploring spatial patterns in the associations between local AIDS incidence and socioeconomic and demographic variables in the state of Rio de Janeiro, Brazil. Spat Spatiotemporal Epidemiol 2016: 17: 85-93. https://doi.org/10.1016/j.sste.2016.04.008
https://doi.org/10.1016/j.sste.2016.04.0... ,³⁶36 Werle JE, Teston EF, Rossi RM, Marcon SS, Sá JS, Frota OP, et al. HIV/AIDS and the social determinants of health: a time series study. Rev Bras Enferm 2022; 75(4): e20210499. https://doi.org/10.1590/0034-7167-2021-0499
https://doi.org/10.1590/0034-7167-2021-0... .

The absence of reported HIV/AIDS cases in some cities, particularly smaller ones in rural areas, requires attention from municipal and state healthcare management. These areas are recognized as having a higher chance of underreporting⁵¹51 Santos ML, Coeli CM, Batista JAL, Braga MC, Albuquerque MFPM. Factors associated with underreporting of tuberculosis based on data from Sinan Aids and Sinan TB. Rev Bras Epidemiol 2018; 21: e180019. https://doi.org/10.1590/1980-549720180019
https://doi.org/10.1590/1980-54972018001... . Measures such as promoting rapid testing in primary care clinics, encouraging spontaneous visits, showing sensitivity to vulnerable populations, and establishing strong patient-provider relationships can contribute to changing this epidemiological landscape⁵²52 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde e Ambiente. Departamento de HIV/Aids, Tuberculose, Hepatitis Virais e Infecções Sexualmebte Transmissíveis. Manual do cuidado contínuo das pessoas vivendo com HIV/AIDS [Internet]. Brasília: Ministério da Saúde; 2023 [cited on Oct 15, 2023]. Available at: https://www.gov.br/aids/pt-br/central-de-conteudo/publicacoes/2023/manual-do-cuidado-continuo-das-pessoas-vivendo-com-hivaids-atual/@@download/file
https://www.gov.br/aids/pt-br/central-de... . These strategies should be prioritized not only in cities that have not reported cases but also in regions that have shown significant spatial clustering of low incidence (low-low) such as the extreme southwestern, southeastern, and northwestern regions.

Our analysis had a large sample and broad geographical coverage across Paraná. However, the study has some limitations. First, the study was conducted based on data available in SINAN, which may not reflect exact numbers due to potential underreporting and underdetection of cases. Second, incidence rates were calculated based on population estimates, which may not fully reflect the actual population size during the period.

It is hoped that the results of this study will contribute to improving healthcare actions in the state of Paraná across various contexts, providing insights for developing strategies to achieve better future outcomes in epidemiological indicators.

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