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© Guimarães MDC. Grand Rounds April 24, 2008. HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute.

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Presentation on theme: "© Guimarães MDC. Grand Rounds April 24, 2008. HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute."— Presentation transcript:

1 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute  BRIEF BACKGROUND  OVERVIEW OF PESSOAS PROJECT (Pesquisa em Soroprevalência de Aids na Saúde Mental) (AIDS Seroprevalence study in Mental Health)  DESCRIPTIVE  SEROPREVALENCE  ASSOCIATONS WITH UNSAFE SEXUAL / HIV INFECTION  VIOLENCE April 24, 2008 “HIV seroprevalence and risk behavior among psychiatric patients: A national health service study in Brazil" Mark D C Guimarães, MD, ScD Universidade Federal de Minas Gerais, Brasil HIV Center for Clinical and Behavioral Studies, Columbia University, NY, USA CAPES/Ministério da Educação, Brasil

2 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute  BRIEF BACKGROUND “HIV seroprevalence and risk behavior among psychiatric patients: A national health service study in Brazil"

3 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Sexually active 12 months 51%- 74% Sexually active 3 months 32%- 65% Anal sex 12 months 2%- 10% Anal sex ever 13%- 84% Inconsistent condom use 12 months 12%- 68% Inconsistent condom use 3 month 43%- 78% Two or more partners 12 months 7%- 69% Two or more partners 3 months 13%- 46% Sex with high risk partner 12 months 2%- 58% Exchange sex for money 12 months 2%- 48% Exchange sex for money 3 months 5%- 38% Drug or alcohol use during sex 5%- 45% Good level of HIV/AIDS knowledge 63%- 80% Selected behavior data among psychiatric patients worldwide Source: Campos et al, 2008 (in submission)

4 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Median =1.5%Median = 5% Source: Campos et al, 2008 (in submission)

5 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Median = 19% Median = 23% Source: Campos et al, 2008 (in submission)

6 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Median = 6%Median = 19% Source: Campos et al, 2008 (in submission)

7 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Median = 3% Source: Campos et al, 2008 (in submission)

8 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute PSYCHIATRIC HOSPITAL: SEVERE MENTAL ILLNESS COMMUNITY: PRIMARY HEALTH CARE CENTERS INTERMEDIATE CARE CAPS (Psycho-Social Care Centers) Multiprofessional Diverse therapeutic approaches OUTLINE OF PUBLIC MENTAL HEALTH CARE IN BRAZIL

9 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Type of care: Intensive25 days / month or 3 days / week Semi-intensive12 days / month or 2 days / week Non-intensive 3 days / month Outpatient only< 3 days / month Capacity of Care / month: I: 70 registered patients (daily activities) II: 120 registered patients (daily activities) III: 220 registered patients (24 hour activities) CAPS (Psycho-Social Care Centers): Adults (CAPS I, II, III) Alcohol and drug addiction centers (CAPS Ad) Children and Adolescents (CAPSi) OUTLINE OF PUBLIC MENTAL HEALTH CARE IN BRAZIL

10 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Source: Mental Health National Program, 2006

11 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute RATIONALE  Increased vulnerability and higher STI prevalence among mentally ill patients [ ? ? ? ]  Need to establish prevention and health care strategies for both, AIDS and Mental Health Programs  Absence of representative risk behavior or STI seroprevalence data

12 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute  OVERVIEW OF PESSOAS PROJECT “HIV seroprevalence and risk behavior among psychiatric patients: A national health service study in Brazil"

13 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute EXAMS PERFORMED DADA PROCESSED SEROLOGY RESULTS INTERVIEWS BLOOD COLLECTED PATIENTS INVITED CAPABLE CONSENTED RESEARCH GROUP Planning Conducting GOVERNMENT National AIDS and Mental Health Programs MENTAL HEALTH SERVICES REFERRED FOR CARE AND COUNSELING

14 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute PESSOAS PROJECT OBJECTIVES  To determine the prevalence of HIV, syphilis, and Hepatitis B and C among mentally ill patients in psychiatric hospitals and CAPS units in Brazil  To describe socio-demographic, behavioral, clinical aspects of the study population

15 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute DIMENSIONS INDIVIDUAL QUANTITATIVE REPRESENTATIVE ORGANIZATIONAL QUANTITATIVE REPRESENTATIVE INDIVIDUAL QUALlTATIVE SOCIAL AND ETHNOGRAPHIC REPRESENTATION

16 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric InstituteMETHODS  DESIGN: Cross-sectional national sample  POPULATION: Chronic mentally ill patients hospitalized in public hospitals or under care in CAPS units randomly selected Eligibility criteria: Adults (> 18 years old) Hospitalized for at least seven days (Inpatients) OR Under care in CAPS units [ Except CAPS Ad] Capable of answering the questionnaire Written consent to participate 3400 patients

17 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute PROCEDURES SEMI-STRUCTURED INTERVIEW Socio-demographics, STI perception and knowledge, behavior, risk and vulnerability profiles MEDICAL CHARTS Clinical data (Psychiatric & STI Dx and Treatment) SEROLOGY Hepatitis B Surface Antigen (HBsAg) (ELISA, BioMérieux®) Hepatitis B Total Antibody (Anti-HBc) (ELISA, BioMérieux®) Hepatitis C antibody (Anti-HCV) (ELISA, Adaltis®) HIV (Anti-HIV 1 e 2) (ELISA, Dade Bhering®) & WB (Genelabs Abbott®) Syphilis (VDRL, Wiener Lab®) & Hemaglutinin – HAI, BioMérieux®). HEALTH SERVICE EVALUATION Structural and process aspects: referral system, STI prevention programs, counseling, services offered QUALITATIVE INTERVIEW Ethnographic and social representation aspects Guimarães MDC et al, Reliability and validity of a questionnaire on vulnerability to sexually transmitted infections among adults with chronic mental illness - PESSOAS Project. Rev Bras. Psiquiat. 2008; 30(1):55-59.

18 Stage I Selection of Centers Hospitals 11 CAPS 15 Stage II Selection of patients Hospitals 1281 CAPS 2119 TWO STAGE PROBABILITY SAMPLE Proportional to: Type of service AIDS cases by Region

19 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric InstituteANALYSIS  DESCRIPTIVE  SEROPREVALENCE Corrected for clustering by Huber/White Sandwich (Rogers, 1993) Weighted by sample size relative to the total population  Associations with UNSAFE SEX: Sexually active past six months Not always using condoms in the past six months Multivariate logistic regression Odds Ratio with 95% confidence limits  Associations with PREVALENT HIV infection: Multivariate Poisson regression Prevalence ratio with 95% confidence Corrected for clustering by Huber/White Sandwich (Rogers, 1993) Weighted by sample size relative to the total population  Database: Paradox / Analysis: SAS, STATA

20 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute  DESCRIPTIVE

21 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute RECRUITMENT – PESSOAS PROJECT, 2007 RecruitedNot Capable492 (15%) Non participants 288 (10%) 3255(100%) Capable2763 (85%) 2238 (69%)2475 (76%)2300 (71%) Blood Sample Interviewed Interviewed + blood sample

22 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Insuficient psychiatric medication Insuficient clinical care medication Structured reference and counter-reference system Unsatisfactory reference system Unsatisfactory counter-reference system Any sexual education program STI prevention programs Condom distribution Acknowledged the existence of HIV positive patients Specific group therapy for HIV positive patients Selected health service characteristics (n=26), PROJETO PESSOAS % Melo APS, Acurcio FA, Cherchiglia ML, Veloso CCG, Guimarães MDC. Evaluation of mental health services: care and prevention of sexually transmitted diseases within PESSOAS(*) Project context. Rev Med Minas Gerais 2007; 17(1/2 Supl 4): S240-S248

23 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute DESCRIPTIVE RESULTS DESCRIPTIVE RESULTS (n=2475), PROJETO PESSOAS Sociodemographics(%) CAPS(64) Women (52) White or mulato (84) Singles/Separated(67) Age > 39 yeas old(56) Didn’t know how to read or write(18) Schooling < 4 years(34) Monthly family income (< US$ 150)(35) No health insurance(90) History of homelessness(18) Currently living in institutional setting(10)

24 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute RESULTADOS DESCRITIVOS RESULTADOS DESCRITIVOS (n=2475), PROJETO PESSOAS Clinical Characteristics (%) Previous hospitalizations (1+)(58) Psychiatric diagnoses (ICD-10): Schizophrenia(47)* Depression(13) Bipolar disorders ( 9)* Dementias( 7) Substance Use( 7) Anxiety( 4) (*)Severe mental illness(56) Non-psychiatric medical Dx (22) Self-reported medical co-morbidity(45) History of STD(24) History of HIV testing(27)

25 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute RESULTADOS DESCRITIVOS RESULTADOS DESCRITIVOS (n=2475), PROJETO PESSOAS Behavior characteristics (%) Alcohol use (ever)(64) Smoking (ever)(71) Illicit drug use(25) Injecting drug use ( 3) Sharing needles/serynges ( 3) Sexual activity ever(88) Sexual activity past six months(61) More than one partner (ever)(61) More than one partner (past six months)(16) Aways used condoms( 8) Always used condom past six months(17) Used condom last intercourse(26) Some self-perceived HIV risk(44) Low HIV knowledge(45)

26 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute

27  SEROPREVALENCES

28 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Guimarães et al, 2008; Szwarcwald et al., 2001; Szwarcwald C et al, 2005; Szwarcwald C et al, 2005; Dourado et al. 2007; Figueiró- Filho et al 2007; De Souza et al, 2004;

29 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Guimarães et al, 2008; Figueiró-Filho et al 2007; De Souza et al, 2004; Nascimento et al, 2008; Reiche et al, 2000

30 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Guimarães et al, 2008; Focaccia et al, 1998; Figueiró-Filho et al 2007; Nascimento et al, 2008; Reiche et al, 2000

31 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Guimarães et al, 2008; Focaccia et al, 1998; Nascimento et al, 2008

32 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Guimarães et al, 2008; Rodrigues et al, 2004; Szwarcwald C et al, 2005; Figueiró- Filho et al 2007; De Souza et al, 2004; Reiche et al, 2000

33 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Guimarães et al, 2008

34 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute  ASSOCIATIONS

35 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Characteristics Odds Ratio (95% CI) Univariate p-value Multivariate p-value Gender (female) Age (40 +) Marital status (married/in union) Read and Write (no) Schooling (< 5 years) Monthy family income (< US$150) History of homelessness 2.33 (1.75 – 3.09) 1.99 (1.50 – 2.64) 3.84 (2.79 – 5.29) 1.83 (1.15 – 2.91) 1.51 (1.14 – 2.00) 1.03 (0.76 – 1.39) 1.04 (0.72 – 1.49) < < < < SMI Diagnoses Depression Diagnosis History of STD Had never been HIV tested Low HIV/AIDS knowledge High HIV risk perception 0.78 (0.59 – 1.03) 1.76 (1.15 – 2.69) 1.15 (0.84 – 1.58) 1.44 (1.17 – 2.06) 1.50 (1.12 – 2.02) 0.96 (0.73 – 1.27) < Factors associated with unprotected sex(*), Projeto PESSOAS (*) NOT ALWAYS USING CONDOM IN ALL PRACTICES IN THE PAST SIX MONTHS (AMONS THOSE SEXUALLY ACTIVE) (*) 1230 / 1475 = 83%

36 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Characteristics Odds Ratio (95% CI) Univariate p-value Multivariate p-value Age first intercourse (< 18 years old) Partners’ refusal to use condoms Only one partner (lifetime) Only one partner (past six months) Sex under drugs Sex under alcohol Received money/drug for sex Oferered money/drug for sex 0.86 (0.64 – 1.14) 0.87 (0.65 – 1.17) 2.16 (1.44 – 3.24) 2.36 (1.76 – 3.18) 1.00 (0.64 – 1.57) 1.00 (0.74 – 1.35) 0.88 (0.62 – 1.27) 0.46 (0.34 – 0.64) < < Ever use of illlicit drug Ever injected drug Ever smoked Ever used alcohol 0.72 (0.54 – 0.97) 1.36 (0.61 – 3.04) 1.32 (0.98 – 1.78) 0.79 (0.58 – 1.08) History on incarceration History of verbal violence History of physical violence History of sexual violence 0.99 (0.73 – 1.36) 1.32 (0.98 – 1.77) 1.17 (0.89 – 1.55) 1.41 (0.98 – 2.02) Factors associated with unprotected sex(*), Projeto PESSOAS (*) NOT ALWAYS USING CONDOM IN ALL PRACTICES IN THE PAST SIX MONTHS

37 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute CharacteristicsPrevalence Ratio (95% CI) Univariate p-value Multivariate p-value Type of service (Hospital)3.74 (1.13 – 12.40) 0.031* Age (40+ years old)1.02 (0.56 – 1.87)0.938 Gender (women)1.55 (0.33 – 7.31)0.577 Schooling (< 5 years)0.46 (0.26 – 0.81) 0.008** Marital status (married/in union)0.18 (0.04 – 0.89)0.036*0.059* Monthy family income (< US$150)1.73 (0.58 – 5.15)0.323 History of homelessness 3.06 (1.20 – 7.81)0.019* SMI Diagnoses3.29 (0.65 – 16.67)0.150 Previous HIV testing (2.50 – 81.60)0.003**0.009** History of STD2.88 (0.50 – 16.55)0.236 High HIV risk perception2.57 (1.12 – 5.91)0.026* Low level of HIV knowledge0.64 (0.15 – 2.68)0.543 Factors associated with HIV, Projeto PESSOAS, 2006 Guimarães et al, 2008

38 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute CharacteristicsPrevalence Ratio (95% CI) Univariate p-value Multivariate p-value Age first sex (< 18 years old)7.63 (0.82 – 71.26) 0.075*0.098 Sex under drug influence3.52 (0.95 – 13.03)0.060 Sex under alcohol influence3.75 (0.96 – 14.58)0.057 Refusal of condom use by partner3.06 (1.26 – 7.43)0.014 Condom in last intercourse5.91 (1.19 – 29.26)0.029* Received money/drug for sex5.46 (2.48 – 12.05)< 0.01** Illicit drug use (any) 4.16 (1.56 – 11.08)0.004** Alcohol use (ever)4.25 (0.92 – 7.48)0.064 History of STD2.88 (0.50 – 16.55)0.236 Only one partner (lifetime)0.27 (0.05 – 1.29)0.270 Inconsistent condom use (ever)1.24 (0.42 – 3.65)0.699 Physical Violence 2.05 (0.40 – 10.45)0.387 Sexual Violence2.53 (0.86 – 7.48)0.092 Verbal Violence 5.72 (0.80 – 40.76)0.082 Factors associated with HIV, Projeto PESSOAS, 2006 Guimarães et al, 2008

39 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute  VIOLENCE

40 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute

41

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45  CONCLUSIONS

46 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute CONSIDERATIONS Exclusion of CAPs Ad Exclusion of pacients not capable of participating  sample of chronic mentally ill patients under care  may have underestimated seroprevalence and risk behaviors Sample representative of patients, mas not necessarily of services  Cluster effect potencially present Comparability should be with other representative data

47 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute CONCLUSIONS Higher IST seroprevalence, corrected for clustering, as compared to other representative populations in Brazil Extremely high rate of unprotected sex High proportion of violence, with important gender differences Younger women have higher HIV and syphilis prevalence Services are not prepared to deal with this reality

48 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute CONCLUSIONS Public policies are urgently needed:  Increase number of sites with any sexual education programs  Increase condom distribution  Increase availability of HIV testing  Improve reference and counter-reference systems  Training  Dissemination of results to society and community organizations Research agenda  Expand services evaluation, including CAPS Ad and primary care  Include non-capable patients  Subsample of CMI: investigate violence, stigma and human rights issues  Preparedness for dissemination and implementation agenda  PRISSMA-PESSOAS CONNECTION

49 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute GENERAL HOSPITALS: AIDS INTERMEDIATE CARE SAES (Specialized Care Centers) HIV/AIDS Dx ARV Treatment Monitoring (CD4 and VL) COMMUNITY: PRIMARY HEALTH CARE CENTERS OUTLINE OF AIDS CARE IN BRAZIL

50 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute Brazilian AIDS Program: CHALLENGES Non-adherence37% Drop-outs (pharmacy)30% Irregular pharmacy pick-ups58% Late ARV therapy start44-68% Unsafe sex among HIV+ men25-30% Low general HIV Testing Increasing HIV/AIDS prevalence among women Increasing HIV/AIDS prevalence among young MSM

51 Estudo de soroprevalência da infecção pelo HIV, Sífilis, Hepatite B e C em instituições públicas de atenção em saúde mental: Um estudo multicêntrico nacional Funding: PN DST/Aids, Ministério da Saúde, Brasil (ED 36688/2005-SA 964/2005 – 914BRA 1101 UNESCO / PN DST/ Aids) Área Técnica de Saúde Mental, Ministério da Saúde, Brasil Other supports: Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) Coordenação de Aperfeiçoamento de Pessoal de Ensino Superior (CAPES) Fundação de Amparo à Pesquisa de Minas Gerais (FAPEMIG) Institutional Support Universidade Federal de Minas Gerais Collaborators Prof. Mark Drew Crosland Guimarães, Faculdade de Medicina/UFMG Dra. Ana Paula Souto Melo, Faculdade de Medicina, UFMG Prof. Francisco de Assis Acúrcio, Faculdade de Farmácia, UFMG Dr. Helian Nunes de Oliveira, Faculdade de Medicina, UFMG Psicóloga Katia Galbinski Rodrigues, CGSM/DAPE/SAS/MS Dra. Lorenza Nogueira Campos, Faculdade de Medicina, UFMG Psicóloga Maria Cristina Hoffmann, CGSM/DAPE/SAS/MS Profa. Maria Imaculada de F. Freitas, Escola de Enfermagem, UFMG Profa. Mariângela Leal Cherchiglia, Faculdade de Medicina, UFMG Dr. Ricardo Andrade Carmo, CTR/SMS/BH Profa. Suely Broxado de Oliveira, Instituto de Psiquiatria da UFRJ Estagiários de iniciação científica

52 Ana Maria Amaral Ragazzi, CERSAM César Campos, Betim, MG Ana Maria Damian Souto, CAPS Nossa Casa, Santiago, RS 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 Hanna Karine de Carvalho, CAPS Morada Nova, Morada Nova, CE Heloísa Agnes Mendes Marra, Instituto Raul Soares, Belo Horizonte, MG Jackson Mattos Medrado, Hospital Psiquiátrico de Maringá, Maringá, PR Juliana Marcela Flausino, CAPS S. J. R. Pardo, S. J. do Rio Pardo, SP Juliane Macedo Ney da Silva, CAPS Vidativa, Anápolis, GO Kelly Cristian Ribeiro Graeff, CAPS Cantagalo, Cantagalo, RJ Lucimar da Mota Alves, CAPS Paraíso, Paraíso,TO Marcilene Cristina Fonseca, Hospital Galba Veloso, Belo Horizonte, MG Maria Alice Saccani Scardoelli, SES/SP, Dept. Psiq II, Franco da Rocha, SP Maria das Graças Nunes Martins, Hosp. Psiq. Eduardo Ribeiro, Manaus, AM Maria Elizete Silva Penido, CAPS II José Foster Jr., Guarujá, SP Maria Tereza Gomes da Silva, SPSES Hospital Clemente Ferreira, Lins, SP Murillo Mascarenhas Nascente, Clínica Isabela, Goiânia, GO Renata Cristina de Souza Ramos,NAP Renascer, Rib. Neves, MG Ronaldo Efigênio de Oliveira, CAPS Carmo, Carmo, RJ Stanley Crosland Guimarães, CAPS Dr. Hélio Sales, Montes Claros, MG Suely Maria Pinto Tozato, CAPS Franc Morato, Francisco Morato, SP Zelândia Marcheni Elizeche, Hosp. Psiquiátrico Vera Cruz, Sorocaba, SP SUPERVISORS

53 © Guimarães MDC. Grand Rounds April 24, HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute


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