title: Making the invisible, visible: a cross-sectional study of late presentation to HIV/AIDS services among men who have sex with men from a large urban center of Brazil.
abstract: BACKGROUND
  Late presentation to testing, treatment and continued care has detrimental impacts on the health of HIV-positive individuals as well as their sexual partners' health. Men who have sex with men (MSM) experience disproportionately high rates of HIV both globally and in Brazil. However, the factors that inhibit linkage to care among MSM remain unclear.
  
  
  METHODS
  We conducted a cross-sectional study of HIV-positive MSM (n = 740) enrolled in HIV/AIDS services in a large urban center of Brazil from August 2010 to June 2011. Descriptive, bivariate and multivariate statistics were conducted using STATA 12 to examine the relationship between a range of variables and late presentation, defined as having a first CD4 count <350 cells/mm3.
  
  
  RESULTS
  Within the sample, the prevalence of LP was 63.1%. Men who self-identified as heterosexual (AOR 1.54 and 95% CI 1.08 - 2.20) compared to men who self-identified as homosexual and bisexual were at increased odds of late presentation. Additionally, men age 30 and older (AOR 1.56, 95% CI 1.01 - 2.43) compared to individuals age 18-29 experienced increased odds of late presentation among MSM.
  
  
  CONCLUSIONS
  The prevalence of LP in this population was higher than noted in the global literature on LP among MSM. Heterosexual men and older age individuals experienced substantial barriers to HIV care. The stigma around same-sex behaviors and the current focus of HIV prevention and treatment campaigns on younger age individuals may limit patients' and providers' awareness of the risk for HIV and access to available services. In addition to addressing HIV-specific barriers to care, developing effective strategies to reduce late presentation in Brazil will require addressing social factors - such as stigma against diverse sexualities - to concretely identify and eliminate barriers to available services. Only in so doing can we make currently invisible people, visible.
authors.affiliation: Rand Corporation, 1776 Main Street, Santa Monica, CA 90407, USA. sarahm@rand.org.
authors.forename: Sarah
authors.initials: S
authors.lastname: MacCarthy
authors.forename: Sandra
authors.initials: S
authors.lastname: Brignol
authors.forename: Manasa
authors.initials: M
authors.lastname: Reddy
authors.forename: Amy
authors.initials: A
authors.lastname: Nunn
authors.forename: Ines
authors.initials: I
authors.lastname: Dourado
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000453:epidemiology*; D000293:Adolescent; D000328:Adult; D000367:Age Factors; D001727:Bisexuality / Q000706:statistics & numerical data*; D001938:Brazil; D018791:CD4 Lymphocyte Count; D003430:Cross-Sectional Studies; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D015658:HIV Infections / Q000453:epidemiology; D020010:Heterosexuality / Q000706:statistics & numerical data*; D018451:Homosexuality, Male / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D015995:Prevalence; D012307:Risk Factors; D012649:Self Concept; D012725:Sexual Behavior; D012747:Sexual Partners; D011795:Surveys and Questionnaires; D061665:Time-to-Treatment; D014505:Urban Population; D055815:Young Adult