Alexandre Grangeiro

Sustentabilidade da política de acesso a medicamentos anti-retrovirais no Brasil

OBJETIVO: Os gastos com a aquisicao de anti-retrovirais no Brasil tem suscitado debates sobre a sustentabilidade da politica de acesso universal a medicamentos para Aids, a despeito de seus evidentes beneficios. O objetivo do estudo foi analisar, no periodo de 1998 a 2005, a evolucao dos gastos do Ministerio da Saude do Brasil com a aquisicao de anti-retrovirais e seus determinantes, assim como a sustentabilidade desta politica a medio prazo (2006-2008). METODOS: O estudo da evolucao dos gastos com anti-retrovirais compreendeu a analise de seus precos, do dispendio ano a ano, do numero de pacientes que utilizam a medicacao, do gasto medio por paciente e das estrategias para a reducao de precos adotadas no periodo. No tocante a analise de sustentabilidade da politica de acesso a anti-retrovirais foram estimadas as despesas com a aquisicao de medicamentos no periodo de 2006 e 2008 e a participacao desses gastos no Produto Interno Bruto e nas despesas federais com saude. Os dados foram coletados do Ministerio da Saude, do Instituto Brasileiro de Geografia e Estatistica e do Ministerio do Planejamento. RESULTADOS: As despesas com anti-retrovirais aumentaram 66% em 2005, interrompendo a tendencia de reducao observada no periodo 2000-2004. Os principais fatores associados a esse aumento foram o enfraquecimento da industria nacional de genericos e os resultados insatisfatorios dos processos de negociacao com empresas farmaceuticas. CONCLUSOES: A politica de acesso universal no Brasil nao e sustentavel com as atuais taxas de crescimento do Produto Interno Bruto, sem que o Pais comprometa investimentos em outras areas.

Late Entry into HIV Care: Estimated Impact on AIDS Mortality Rates in Brazil, 2003–2006

Background Worldwide, a high proportion of HIV-infected individuals enter into HIV care late. Here, our objective was to estimate the impact that late entry into HIV care has had on AIDS mortality rates in Brazil. Methodology/Principal Findings We analyzed data from information systems regarding HIV-infected adults who sought treatment at public health care facilities in Brazil from 2003 to 2006. We initially estimated the prevalence of late entry into HIV care, as well as the probability of death in the first 12 months, the percentage of the risk of death attributable to late entry, and the number of avoidable deaths. We subsequently adjusted the annual AIDS mortality rate by excluding such deaths. Of the 115,369 patients evaluated, 50,358 (43.6%) had entered HIV care late, and 18,002 died in the first 12 months, representing a 16.5% probability of death in the first 12 months (95% CI: 16.3–16.7). By comparing patients who entered HIV care late with those who gained timely access, we found that the risk ratio for death was 49.5 (95% CI: 45.1–54.2). The percentage of the risk of death attributable to late entry was 95.5%, translating to 17,189 potentially avoidable deaths. Averting those deaths would have lowered the 2003–2006 AIDS mortality rate by 39.5%. Including asymptomatic patients with CD4+ T cell counts >200 and ≤350 cells/mm3 in the group who entered HIV care late increased this proportion by 1.8%. Conclusions/Significance In Brazil, antiretroviral drugs reduced AIDS mortality by 43%. Timely entry would reduce that rate by a similar proportion, as well as resulting in a 45.2% increase in the effectiveness of the program for HIV care. The World Health Organization recommendation that asymptomatic patients with CD4+ T cell counts ≤350 cells/mm3 be treated would not have a significant impact on this scenario.

Avaliação das estratégias de controle da tuberculose no Brasil

Although tuberculosis is one of the oldest known infectious diseases and has been treatable with drugs for more than half a century, it remains one of the most important health problems that need to be faced worldwide. Social inequalities, insuffi cient research aimed at developing new treatments and vaccines, human migratory fl ows, defi ciencies in health systems, high prevalence of multidrug-resistant tuberculosis cases and cases associated with HIV infection contribute towards this problem.

Resposta à aids no Brasil: contribuições dos movimentos sociais e da reforma sanitária

This paper briefly outlines how the political scenario and the mobilization of different actors have contributed to the construction of a public health policy in response to the AIDS epidemics in Brazil. Three factors are presented and discussed: the political context of the 1980s, characterized by redemocratization, growth of social movements, and consolidation of the Brazilian health care reform; the socio-cultural context of the 1970s and 1980s, characterized by achievement of individual freedom, which was key to the organization of the AIDS movement; and finally the actions carried out in the international scenario to support the sustainability of the Brazilian domestic policy and the reinforcement of a global response to face the epidemics in lower-middle income economies.

Prevalência e vulnerabilidade à infecção pelo HIV de moradores de rua em São Paulo, SP

OBJECTIVE To assess the prevalence and vulnerability of homeless people to HIV infection. METHODS Cross-sectional study conducted with a non-probabilistic sample of 1,405 homeless users of shelters in the city of São Paulo, southeastern Brazil, from 2006 to 2007. They were all tested for HIV and a structured questionnaire was applied. Their vulnerability to HIV was determined by the frequency of condom use: those who reported using condoms only occasionally or never were considered the most vulnerable. Multinomial and logistic regression models were used to estimate effect measures and 95% confidence intervals. RESULTS There was a predominance of males (85.6%), with a mean age of 40.9 years, 72.0% had complete elementary schooling, and 71.5% were non-white. Of all respondents, 15.7% reported being homosexual or bisexual and 62,0% reported having casual sex. The mean number of sexual partners in the last 12 months was 5.4. More than half (55.7%) of the respondents reported lifetime drug use, while 25.7% reported frequent use. Sexually-transmitted disease was reported by 39.6% of the homeless and 38.3% reported always using condoms. The prevalence of HIV infection was 4.9% (17.4% also tested positive for syphilis) and about half of the respondents (55.4%) had access to prevention programs. Higher HIV prevalence was associated with younger age (18-29 years, OR = 4.0 [95%CI 1.54;10.46]); past history of sexually-transmitted disease (OR = 3.3 [95%CI 1.87;5.73]); homosexual sex (OR = 3.0 [95%CI 1.28;6.92]); and syphilis (OR = 2.4 [95%CI 1.13;4.93]). Increased vulnerability to HIV infection was associated with being female; young; homosexual sex; having few partners or a steady partner; drug and alcohol use; not having access to prevention programs and social support. CONCLUSIONS The HIV epidemic has a major impact on homeless people reflecting a cycle of exclusion, social vulnerability, and limited access to prevention.OBJETIVO: Analisar a prevalencia e o perfil de vulnerabilidade ao HIV de moradores de rua. METODOS: Estudo transversal com amostra nao probabilistica de 1.405 moradores de rua usuarios de instituicoes de acolhimento de Sao Paulo, SP, de 2006 a 2007. Foi realizado teste anti-HIV e aplicado questionario estruturado. O perfil de vulnerabilidade foi analisado pela frequencia do uso do preservativo, considerando mais vulneraveis os que referiram o uso nunca ou as vezes. Foram utilizadas regressoes logistica e multinomial para estimar as medidas de efeito e intervalos de 95% de confianca. RESULTADOS: Houve predominância do sexo masculino (85,6%), media de 40,9 anos, ter cursado o ensino fundamental (72,0%) e cor nao branca (71,5%). A pratica homo/bissexual foi referida por 15,7% e a parceria ocasional por 62,0%. O numero medio de parcerias em um ano foi de 5,4 e mais da metade (55,7%) referiu uso de drogas na vida, dos quais 25,7% relataram uso frequente. No total, 39,6% mencionaram ter tido uma doenca sexualmente transmissivel e 38,3% relataram o uso do preservativo em todas as relacoes sexuais. A prevalencia do HIV foi de 4,9% (17,4% dos quais apresentaram tambem sorologia positiva para sifilis). Pouco mais da metade (55,4%) tinha acesso a acoes de prevencao. A maior prevalencia do HIV esteve associada a ser mais jovem (OR 18 a 29 anos = 4,0 [IC95% 1,54;10,46]), historia de doenca sexualmente transmissivel (OR = 3,3 [IC95% 1,87;5,73]); pratica homossexual (OR = 3,0 [IC95% 1,28;6,92]) e a presenca de sifilis (OR = 2,4 [IC95% 1,13;4,93]). O grupo de maior vulnerabilidade foi caracterizado por ser mulher, jovem, ter pratica homossexual, numero reduzido de parcerias, parceria fixa, uso de drogas e alcool e nao ter acesso a acoes de prevencao e apoio social. CONCLUSOES: O impacto da epidemia entre moradores de rua e elevado, refletindo um ciclo que conjuga exclusao, vulnerabilidade social e acesso limitado a prevencao.

The AIDS epidemic in Brazil and differences according to geographic region and health services supply

The aim of this study was to identify different profiles in the AIDS epidemic in Brazil by relating them to the health sectors organization, situations involving increased risk of infection, and the degree of implementation of the response by health services. The Brazilian municipalities (counties) were grouped according to the magnitude of the epidemic and its trends from 2002 and 2006, and were then studied using indicators obtained from secondary databases. Municipalities with large epidemics (39%) displayed more situations associated with risk of infection, and those with an upward trend in incidence (11.5%) showed a lower degree of response. Cities with large epidemics but with downward or stable trends had 68.6% of all the anonymous testing centers and 75.8% of the outpatient clinics, and performed 81.4% of all the HIV antibody tests in the health system. Preventive measures in schools and primary health services showed low coverage rates. Differences were observed between geographic regions. Inequalities in the degree of implementation of the response to HIV may contribute to different profiles in the epidemic around the country.

Late entry into HIV care: lessons from Brazil, 2003 to 2006

BackgroundTo ascertain the population rates and proportion of late entry into HIV care, as well as to determine whether such late entry correlates with individual and contextual factors.MethodsData for the 2003–2006 period in Brazil were obtained from public health records. A case of late entry into HIV care was defined as one in which HIV infection was diagnosed at death, one in which HIV infection was diagnosed after the condition of the patient had already been aggravated by AIDS-related diseases, or one in which the CD4+ T-cell count was ≤ 200 cells/mm3 at the time of diagnosis. We also considered extended and stricter sets of criteria (in which the final criterion was ≤ 350 cells/mm3 and ≤ 100 cells/mm3, respectively). The estimated risk ratio was used in assessing the effects of correlates, and the population rates (per 100,000 population) were calculated on an annual basis.ResultsRecords of 115,369 HIV-infected adults were retrieved, and 43.6% (50,358) met the standard criteria for late entry into care. Diagnosis at death accounted for 29% (14,457) of these cases. Late entry into HIV care (standard criterion) was associated with certain individual factors (sex, age, and transmission category) and contextual factors (region with less economic development/increasing incidence of AIDS, lower local HIV testing rate, and smaller municipal population). Use of the extended criteria increased the proportion of late entry by 34% but did not substantially alter the correlations analyzed. The overall population rate of late entry was 9.9/100,000 population, specific rates being highest for individuals in the 30–59 year age bracket, for men, and for individuals living in regions with greater economic development/higher HIV testing rates, collectively accounting for more than half of the cases observed.ConclusionsAlthough the high proportion of late entry might contribute to spreading the AIDS epidemic in less developed regions, most cases occurred in large cities, with broader availability of HIV testing, and in economically developed regions.

Voluntary counseling and testing (VCT) services and their contribution to access to HIV diagnosis in Brazil

The Voluntary Counseling and Testing (VCT) Network was implemented in Brazil in the 1980s to promote anonymous and confidential access to HIV diagnosis. As a function of the population and dimensions of the local epidemic, the study assessed the networks coverage, using data from a self-applied questionnaire and data from the Information Technology Department of the Unified National Health System (SUS), UNDP, and National STD/AIDS Program. The Student t test was used for comparison of means and the chi-square test for proportions. Brazil has 383 VCT centers, covering 48.9% of the population and 69.2% of the AIDS cases. The network has been implemented predominantly in regions where the epidemic shows a relevant presence, but 85.3% of the cities with high HIV incidence lack VCT centers; absence of VCT was associated with more limited health infrastructure and worse social indicators. A slowdown in expansion of the network was observed, with VCT Centers implemented on average 16 years after the first AIDS case in the given municipality. The number of HIV tests performed under the SUS is 2.3 times higher in cities with VCT centers. The networks scope is limited, thus minimizing the contribution by these services to the supply of HIV diagnosis in Brazil.

The HIV-Brazil Cohort Study: Design, Methods and Participant Characteristics

Background The HIV-Brazil Cohort Study was established to analyze the effectiveness of combination antiretroviral therapy (cART) and the impact of this treatment on morbidity, quality of life (QOL) and mortality. The study design, patients’ profiles and characteristics of cART initiation between 2003 and 2010 were described. Methodology/Principal Findings Since 2003, the HIV-Brazil Cohort has been following HIV-infected adults receiving cART at 26 public health care facilities, using routine clinical care data and self-reported QOL questionnaires. When not otherwise available, data are obtained from national information systems. The main outcomes of interest are diseases related or unrelated to HIV; suppression of viral replication; adverse events; virological, clinical and immunological failures; changes in the cART; and mortality. For the 5,061 patients who started cART between 2003 and 2010, the median follow-up time was 4.1 years (IQR 2.2–5.9 years) with an 83.4% retention rate. Patient profiles were characterized by a predominance of men (male/female ratio 1.7∶1), with a mean age of 36.9 years (SD 9.9 years); 55.2% had been infected with HIV via heterosexual contact. The majority of patients (53.4%) initiated cART with a CD4+ T-cell count ≤200 cells/mm3. The medications most often used in the various treatment regimens were efavirenz (59.7%) and lopinavir/ritonavir (18.2%). The proportion of individuals achieving viral suppression within the first 12 months of cART use was 77.4% (95% CI 76.1–78.6). Nearly half (45.4%) of the patients presented HIV-related clinical manifestations after starting cART, and the AIDS mortality rate was 13.9 per 1,000 person-years. Conclusions/Significance Results from cART use in the daily practice of health services remain relatively unknown in low- and middle-income countries, and studies with the characteristics of the HIV-Brazil Cohort contribute to minimizing these shortcomings, given its scope and patient profile, which is similar to that of the AIDS epidemic in the country.

UNGASS-HIV/AIDS: a review of the Brazilian response, 2001-2005

Recognizing the HIV/AIDS pandemic as an unprecedented worldwide emergency and one of the greatest challenges to life and the enjoyment of human rights the United nations called on member states to reflect on this matter. In June 2001 around 20 years after the first AIDS cases were recorded the United Nations General Assembly Special Session on HIV and AIDS (UNGASS HIV/AIDS) was held in New York. The Session culminated in the drafting of the Declaration of Commitment on HIV and AIDS: a document that reflected the consensus between 189 countries including Brazil and stated some essential principles for an effective response to the epidemic. The Declaration recognized that economic racial ethnic generational and gender inequalities among others were factors that boosted vulnerability and whether acting separately or in synergy favored HIV infection and the onset and evolution of AIDS. The Declaration of Commitment on HIV and AIDS has become transformed into a tool for reaffirming the urgency and necessity of promoting the solidarity that the epidemic demands. It aims towards better management of the actions and resources destined for controlling HIV and AIDS and towards social control over public HIV/AIDS policies. (excerpt)