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Metrics details. Our goal was to conduct a systematic review and meta-analysis of studies assessing HIV prevalence among MSM, FSW and DU, calculating a combined pooled prevalence and summarizing factors associated the pooled prevalence for each group. The studies targeting the three populations analyzed mostly young participants aged 30 years or less.

Among FSW, eight studies were selected 3, participantsconsistently identifying higher condom use with sexual clients than with occasional and stable partners. Ten studies targeting MSM were identified 6, participants. Unprotected anal intercourse was commonly reported on those studies, but with great variability according to the nature of the relationship - stable vs. Twenty nine studies targeting DU were identified 13, participants. Those vulnerable populations should be targeted by focused prevention strategies that provide accurate information, counseling and testing, as well as concrete means to foster behavior change e.

Programs that provide these services need to be implemented on public health services throughout the country, in order to decrease the vulnerability of those populations to HIV infection. Peer Review reports. According to the UNAIDS, "for every two people who start taking antiretroviral drugs, another five become newly infected.

Unless we take urgent steps to intensify HIV prevention we will fail to sustain the gains of the past few years, and universal access will simply be a noble aspiration. In a concentrated epidemic, HIV spre rapidly in one or more specific subpopulations, but its spread has been relatively modest in the general population.

In these contexts the networks of at-risk populations have a key role in the epidemic dynamics. The future course of the epidemic is determined by the nature and intensity of the interactions between subpopulations with high infection rates and the general population [ 3 — 5 ]. To reduce the likelihood that a low-level or concentrated epidemic may become a generalized epidemic, prevention programs should focus on potential epidemiological bridges, such as the sex partners of injecting drug users IDUfemale sex workers FSW or truck drivers [ 67 ].

Brazil was the first middle-income country to provide free and universal access to highly active antiretroviral therapy HAARTlaboratory monitoring and clinical care at no cost at the point of health care delivery to any eligible patient, since [ 1314 ]. Brazil has also implemented prevention initiatives targeting both the general population and different at-risk populations [ 18 ]. This information is vital to inform health planning, resources allocation and might also be an important tool for advocacy and the elaboration of future scenarios [ 1 ].

As only observational studies rather than clinical trials have been found, the MOOSE recommendations were used to conduct and report the findings from the meta-analysis, while the TREND checklist Version 1. The same strategy was used by our group in reviews [ 2425 ].

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Search strategies were developed using systematic automated and manual searches. Such databases were searched for the period extending from January to June ; except for AIDSLINE, which was searched from up towhen the inclusion of new citations was discontinued.

Citations that intersect all four domains were downloaded into the study database. To reduce publication bias and gaps in the automated search, we implemented four supplementary search strategies to identify additional studies.

Third, we contacted authors of selected papers to obtain additional data on upcoming publications. Finally, we reviewed the reference lists of all selected studies for additional citations. All studies identified through these procedures that met our eligible criteria were entered into the study database. For those factors multivariable analyses were carried out. Standard meta-analytic methods were employed [ 2627 ]. We chose a random-effects model for aggregating individual effect sizes because it provides a more conservative estimate than a fixed-effects model of variance.

This approach generates more accurate inferences due to the fact it recognizes the selected studies as a sample of all potential studies and incorporates between-study variability in the overall pooled estimation [ 2829 ]. HIV prevalence and the crude non-adjusted proportion of participants recorded as HIV-positive by each study were used to pool the overall proportion, using the DerSimonian-Laird random-effects method [ 3031 ].

The I 2 index was calculated as a measure of the overall variation in prevalence that was attributable to between-study heterogeneity [ 3233 ]. Higgins and Thompson [ 32 ] proposed a tentative classification of I 2 values with the purpose of helping to interpret its magnitude. According to a recent review [ 34 ], the I 2 index assesses not only heterogeneity in a meta-analysis but also the extent of that heterogeneity.

It is considered a more appropriate procedure than the Q test in assessing whether there is true heterogeneity among the studies in a meta-analysis [ 33 ]. According to standard meta-analysis guidelines, when observational studies are pooled, heterogeneity of populations e. Publication bias was examined through the use of a funnel plot [ 36 ], and funnel plot asymmetry was further tested by using Egger's method [ 37 ]. Sensitivity analyses were performed to assess whether there were potential heterogeneity sources and studies that may bias the analyses.

Studies potentially influencing heterogeneity were therefore removed from the analyses and compared. For studies addressing drug users we also conducted a mixed-effects meta-regression model to assess the underlying reasons for between-study heterogeneity.

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The small of eligible studies targeting FSW and MSM, and the absence of key information that could influence between studies heterogeneity precluded meta-regression analysis for those populations [ 38 ]. The following covariates were included in the meta-regression multivariable model: incarceration currently incarcerated vs.

NIDUregion where the study was conducted Brazilian southern region vs. According to Hacker et al.

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Recently, Bastos et al. Therefore, we dichotomized studies according to data collection period as well. Analyses were conducted using Stata version In the initial searches, studies were selected 45 peer-reviewed papers and 90 additional studies. Of these, there was perfect agreement between reviewers on the exclusion of 89 behavioral surveys without information on HIV seroprevalence. In a second screening, 21 studies conducted in other countries rather assessing Brazilian expatriates were excluded.

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Agreement between reviewers was also perfect on the second screening. A third screening excluded 13 studies, primarily because authors did not stratify according to the actual engagement of the interviewees in commercial sex. A final screening excluded four other reviews.

Agreement on the two final screenings was also perfect. We thus included eight eligible reports for full data extraction [ 41 — 48 ] Figure 1. Selected studies analyzed 3, FSW range: ; median: The largest study was conducted in 9 Brazilian cities and included 2, participants [ 47 ]. The majority of participants were young women aged 30 years or less. However, self-reported condom use across selected studies presented a great variability overall and for each specific study.

Variability was higher with sexual clients than with occasional and stable partners. According to the largest study conducted with FSW in Brazil, condom use was more than threefold greater when we compared sexual intercourse among sexual clients and stable partners: Only three studies conducted multivariable analyses, which precluded additional pooled analysis of factors putatively associated with the outcome HIV-prevalence.

According to Trevisol and Silva [ 45 ], covariates independently associated with HIV prevalence included: "having more than two sexual clients per day", "frequent use of inhalants" and "inconsistent condom use". Pires and Miranda [ 48 ] identified as key risk factors: "syphilis" and "injection drug use".

The Brazilian Ministry of Health study [ 47 ] identified "injection drug use" and "having an IDU partner" as covariates independently associated with the outcome, as well as syphilis and HCV infection. We kept the risk factors as described in the original paper, despite the fact that, for instance, HCV infection should be rather viewed as a biomarker of underlying risk behaviors e. After conducting a sensitivity analysis, we decided to present the combined HIV prevalence separately, with the inclusion or exclusion of one "outlier".

The identification of this study as an 'outlier' was not based on an a priori statistical criterion e. The "outlier" study, conducted by Benzaken and colleagues [ 46 ], was developed in a municipality with less thaninhabitants located in the Tropical rain forest, in the state of Amazon, and did not identify a single HIV-positive participant. This absence of HIV-positive participants is likely due to the study's sampling frame. Additional studies conducted with FSW from the same region identified a prevalence of 2. The combined HIV prevalence across all studies was 5.

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In the initial searches, studies were selected peer-reviewed papers and 53 additional studies. Of these, there was perfect agreement between reviewers on the exclusion of behavioral surveys which did not measure HIV seroprevalence. In a second screening, 4 studies conducted in other countries were excluded. A third screening excluded 21 studies, primarily because authors did not stratify according to homosexual practices.

A final screening excluded 11 reviews. We thus included ten studies for full data extraction [ 49 — 58 ] Figure 3.

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