Maria Ines Battistella Nemes

Challenges of treatment adherence by people living with HIV/AIDS in Brazil

OBJECTIVE To analyze the difficulties related to treatment adherence by patients living with HIV/AIDS in highly active antiretroviral therapy. METHODS Qualitative research based on 34 interviews with patients under treatment in several outpatient services in the state of São Paulo, in 1998-1999. The group was comprised of people from different socioeconomic levels, gender, length of treatment and varied adherence levels, according to healthcare staff perception. The interviews focused on the patients narrative about his/her disease. The content analysis classified the difficulties as follows: related to social factors and life styles, including the stigma; related to beliefs about the use of medication; and directly related to the use of medication. RESULTS All the interviewees reported having difficulties concerning the stigma of living with HIV/AIDS. The difficulties related to the use of medication were the most important among patients with the best adherence level. Patients with average adherence level presented all three types of difficulties. CONCLUSIONS Social and cultural factors are more difficult to be overcome in order to achieve treatment adherence than those related to taking medication, thus making the role played by the health sector important, supported by clear public social policies. These dimensions must be faced not only in the health sector, but also on social and political levels.

Desenvolvimento e validação de questionário multidimensional para medir não-adesão ao tratamento com medicamentos

O estudo objetivou desenvolver e validar instrumento capaz de medir nao-adesao ao tratamento com medicamentos em suas multiplas dimensoes. O Questionario de Adesao a Medicamentos com tres perguntas foi aplicado a 46 pessoas com hipertensao arterial em Blumenau, SC, 2006. Compararam-se as medidas de nao-adesao obtidas com outros quatro metodos: testes de Haynes, Morisky, contagem de comprimidos e desfecho clinico. As medidas de nao-adesao variaram de acordo com o metodo. A medida composta obtida a partir do questionario desenvolvido resultou em nao-adesao de 47,8% (IC 95%: 32,9;63,1), enquanto o padrao-ouro foi 69,6% (IC 95%: 54,3;82,3). As medidas de acuracia para detectar nao-adesao mostraram sensibilidade de 62,5% e especificidade de 85,7%, area sob a curva ROC de 74,1% e valor preditivo positivo de 90,9%. Os resultados sugerem bom desempenho do Questionario de Adesao a Medicamentos.The study aimed to develop and validate an instrument capable of measuring non-adherence to drug treatment in its multiple dimensions. The Questionário de Adesão a Medicamentos (Adherence to Medicines Questionnaire) with three questions was applied to 46 people with arterial hypertension in the city of Blumenau, Southern Brazil, in 2006. Non-adherence measures obtained were compared to four other methods (Haynes, Morisky, pill count and clinical outcome). Non-adherence measures varied according to the method. The combined Questionário de Adesão a Medicamentos non-adherence measure was 47.8% (95% CI: 32.9;63.1), whereas the gold standard was 69.6% (95% CI: 54.3;82.3). Accuracy measures to detect non-adherence showed a sensitivity of 62.5% and specificity of 85.7%, ROC curve area of 74.1%, and positive predictive value of 90.9%. Results suggest the Questionário de Adesão a Medicamentos has a good fit.

Avaliação da estrutura organizacional da assistência ambulatorial em HIV/Aids no Brasil

OBJETIVO: No contexto de acesso universal a terapia antiretroviral, os resultados do Programa de Aids dependem da qualidade do cuidado prestado. O objetivo do estudo foi avaliar a qualidade do cuidado dos servicos ambulatoriais que assistem pacientes de Aids. METODOS: Estudo realizado em sete Estados brasileiros, em 2001 e 2002. Foi avaliada a qualidade do atendimento a pacientes com Aids quanto a disponibilidade de recursos e a organizacao do trabalho de assistencia. Um questionario com 112 questoes estruturadas abordando esses aspectos, foi enviado a 336 servicos. RESULTADOS: A taxa de resposta foi de 95,8% (322). Os indicadores de disponibilidade de recursos mostram uma adequacao maior do que os indicadores de organizacao do trabalho. Nao faltam antiretrovirais em 95,5% dos servicos, os exames de CD4 e Carga Viral estao disponiveis em quantidade adequada em 59 e 41% dos servicos, respectivamente. Em 90,4% dos servicos ha pelo menos um profissional nao medico (psicologo, enfermeiro ou assistente social). Quanto a organizacao, 80% nao agendavam consulta medica com hora marcada; 40,4% agendavam mais que 10 consultas medicas por periodo; 17% nao possuiam gerentes exclusivos na assistencia e 68,6% nao realizavam reunioes sistematicas de trabalho com a equipe. CONCLUSOES: Os resultados apontam que alem de garantir a distribuicao mais homogenea de recursos, o programa precisa investir no treinamento e disseminacao do manejo do cuidado, conforme evidenciado nos resultados da organizacao de trabalho.

Fatores associados à não-adesão ao tratamento com anti-hipertensivos em pessoas atendidas em unidades de saúde da família

In order to estimate the prevalence of treatment non-adherence and associated factors among individuals with systemic arterial hypertension treated at family health care facilities, a cross-sectional study was performed with 595 patients. The dependent variable non-adherence was measured with a Medication Adherence Questionnaire (MAQ). A hierarchical logistic regression model was used to analyze socioeconomic, health care-related, personal, and treatment-related variables. Prevalence of non-adherence was 53%. Variables associated with non-adherence were: (1) socioeconomic--belonging to economic classes C, D, or E; work market participation in unskilled labor; (2) health care--out-of-pocket payment for medication; more than six months since last physician consultation; and (3) personal and treatment characteristics--previous interruption of treatment; being on treatment for less than three years; and presence of a common mental disorder. The study of determinants of non-adherence articulated in a hierarchical model suggests that social inequalities are either directly associated with non-adherence or mediated by personal and health services factors.

Brazilian Response to the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Epidemic among Injection Drug Users

The Brazilian response to the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic is being observed all over the world because of its success. Understanding the role of injection drug users (IDUs) in the epidemic and the political response thereto is a key factor in the control of the epidemic in Brazil. This paper summarizes some of the most important analyses of the Brazilian response to the HIV/AIDS epidemic among and from IDUs. Key elements of the response include the support of the Brazilian Universal Public Health System, the provision of universal access to highly active antiretroviral therapy, and the creation of harm reduction projects that are politically and financially supported by the federal government. The response among and from IDUs is a key element in overall control of the HIV/AIDS epidemic. The response to the epidemic among and from IDUs has been headed in the correct direction since its beginning and is now being intensively expanded.

Transformações da "aids aguda" para a "aids crônica": percepção corporal e intervenções cirúrgicas entre pessoas vivendo com HIV e aids

The Brazilian government has been providing free and universal access to the HAART therapy for people living with HIV and AIDS for ten years. Since then, many epidemiological characteristics have changed, and AIDS passed scientifically and medically to be classified as a chronic condition. This qualitative study aims to comprehend the challenges posed by self-perception of body changes experienced by people living with AIDS during recent years, as a result of prolonged use of antiretroviral medication.With this purpose, in 1999 and 2005, 32 semi-structured interviews with HIV positive individuals were held in the State of Sao Paulo to capture the challenges occurred during this period, in particular with regard to the lipodystrophy syndrome. The analysis of the data indicates that even with the availability and use of new technologies that allowed for AIDS to transform into a chronic, clinically treatable disease, there are still important aspects lived by patients that reedit fears and difficulties similar to those of the initial periods of the epidemic, among others appearance-impairing physical stigma.

Assessing patient adherence to chronic diseases treatment: differentiating between epidemiological and clinical approaches

This review discusses the concepts and methods for assessing patient adherence to treatment, as applied to both epidemiological and clinical approaches within real health care practices. For the epidemiological approach, the assessment must be as accurate as possible. Self-reported questionnaires are the most feasible option in most circumstances, but most demonstrate low sensitivity combined with high specificity. We suggest that self-reported outcomes, where feasible, can increase the sensitivity for non-adherence of these questionnaires. In the clinical approach an accurate distinction between adherents and non-adherents is less useful. For the health provider, it is more important to be aware of the particular situation that each patient is currently experiencing with his/her treatment. Self-reported questionnaires applied in clinical settings can help the health provider to form an objective opinion. In any event, the patient-provider dialogue is still the best approach to assess patient adherence as well as to deliver good care.

Avaliação da qualidade da atenção básica em 37 municípios do centro-oeste paulista: características da organização da assistência

No Estado de Sao Paulo, existe uma rede extensiva de servicos de Atencao Basica (AB) com perfil organizacional heterogeneo e pouco conhecido. Este estudo objetiva caracterizar a organizacao dos servicos de AB em 37 municipios do Centro-oeste paulista, como primeira etapa de um projeto de avaliacao da qualidade desses servicos. Trata-se de um estudo transversal conduzido mediante questionario estruturado, autorrespondido pelos gerentes e equipes locais, com questoes que abordam caracteristicas institucionais e de organizacao e gerencia do trabalho. Esses questionarios foram enviados para 131 UBS, distribuidas em 37 municipios. Obteve-se resposta de 113 unidades (87%) localizadas em 32 municipios (86,4%). Do total de unidades, 57 (50%) sao UBS tradicionais, 26 (22,8%), Unidades de Saude da Familia, e 31, (27,2%) organizadas segundo formas mistas. A maioria dos servicos (62%, 70/113) nao trabalha com area de abrangencia delimitada de modo planejado. Os servicos se polarizam entre aqueles que realizam entre 70 e 100% de consultas medicas agendadas (37,6%, 41/109), e aqueles que realizam entre 70 e 100% de nao agendadas (39,4%, 43/109). Nao possuem conselhos locais organizados 65 unidades (63,7%, 65/102). Os dados coletados permitem discutir as caracteristicas dos principais programas, procedimentos e acoes realizados pelos servicos. Os perfis organizacionais predominantes apontam a presenca de deficiencias de estrutura e processo em relacao as diretrizes do SUS. O desenvolvimento de instrumentos de autoavaliacao permite que as equipes se apropriem, de forma critica, de seu trabalho, e possam elaborar novos arranjos tecnologicos para melhoria da qualidade.

The variability and predictors of quality of AIDS care services in Brazil.

BackgroundSince establishing universal free access to antiretroviral therapy in 1996, the Brazilian Health System has increased the number of centers providing HIV/AIDS outpatient care from 33 to 540. There had been no formal monitoring of the quality of these services until a survey of 336 AIDS health centers across 7 Brazilian states was undertaken in 2002. Managers of the services were asked to assess their clinics according to parameters of service inputs and service delivery processes. This report analyzes the survey results and identifies predictors of the overall quality of service delivery.MethodsThe survey involved completion of a multiple-choice questionnaire comprising 107 parameters of service inputs and processes of delivering care, with responses assessed according to their likely impact on service quality using a 3-point scale. K-means clustering was used to group these services according to their scored responses. Logistic regression analysis was performed to identify predictors of high service quality.ResultsThe questionnaire was completed by 95.8% (322) of the managers of the sites surveyed. Most sites scored about 50% of the benchmark expectation. K-means clustering analysis identified four quality levels within which services could be grouped: 76 services (24%) were classed as level 1 (best), 53 (16%) as level 2 (medium), 113 (35%) as level 3 (poor), and 80 (25%) as level 4 (very poor). Parameters of service delivery processes were more important than those relating to service inputs for determining the quality classification. Predictors of quality services included larger care sites, specialization for HIV/AIDS, and location within large municipalities.ConclusionThe survey demonstrated highly variable levels of HIV/AIDS service quality across the sites. Many sites were found to have deficiencies in the processes of service delivery processes that could benefit from quality improvement initiatives. These findings could have implications for how HIV/AIDS services are planned in Brazil to achieve quality standards, such as for where service sites should be located, their size and staffing requirements. A set of service delivery indicators has been identified that could be used for routine monitoring of HIV/AIDS service delivery for HIV/AIDS in Brazil (and potentially in other similar settings).

Avaliação de serviços de assistência ambulatorial em aids, Brasil: estudo comparativo 2001/2007

OBJETIVO: Avaliar os servicos do Sistema Unico de Saude brasileiro de assistencia ambulatorial a adultos vivendo com aids em 2007 e comparar com a avaliacao de 2001. METODOS: Os 636 servicos cadastrados no Ministerio da Saude em 2007 foram convidados a responder a um questionario previamente validado (Questionario Qualiaids) com 107 questoes de multipla escolha sobre a organizacao da assistencia prestada. Analisaram-se as frequencias das respostas de 2007 comparando-as com as obtidas em 2001 na forma de variacao percentual (VP). RESULTADOS: Responderam o questionario 504 (79,2%) servicos. Cerca de 100,0% dos respondentes relataram ter pelo menos um medico, suprimento sem falhas de antirretrovirais e de exames CD4 e carga viral. Varios aspectos mostraram melhor desempenho em 2007 comparados a 2001: registro de numero de faltas a consulta medica (de 18,3 para 27,0%, VP: 47,5%), agendamento de consulta em menos de 15 dias no inicio da terapia antirretroviral (de 55,3 para 66,2%, VP: 19,7%) e participacao organizada do usuario (de 5,9 para 16,7%, VP: 183,1%). Houve manutencao de dificuldades: pequena variacao na disponibilidade de exames especializados em ate 15 dias, como endoscopia (31,9 para 34,5%, VP: 8,1%), e a piora de indicadores como tempo ideal de acesso a consultas especializadas (55,9 para 34,5% em cardiologia, VP negativa de 38,3%). O tempo medio despendido nas consultas medicas de seguimento manteve-se baixo: 15 minutos ou menos (52,5 para 49,5%, VP negativa de 5,8%). CONCLUSOES: A avaliacao de 2007 mostrou que os servicos contam com os recursos essenciais para a assistencia ambulatorial. Houve melhoras em muitos aspectos em relacao a 2001, mas persistem desafios. Pouco tempo dedicado a consulta medica pode estar vinculado ao numero insuficiente de medicos e/ou a baixa capacidade de escuta e dialogo. A acessibilidade prejudicada a consultas especializadas mostra a dificuldade das infraestruturas locais do Sistema Unico de Saude.OBJECTIVE To assess Brazilian Unified Health System outpatient services delivering care to adults living with AIDS in 2007 and to compare with the assessment conducted in 2001. METHODS The 636 health services registered in the Ministry of Health in 2007 were invited to respond to a previously validated questionnaire (Qualiaids Questionnaire) with 107 multiple-choice questions about the organization of care delivery. It analyzed the frequencies of responses to the 2007 questionnaire compared with those found in that of 2001 through percent variation (PV). RESULTS 504 (79.2%) of the services responded to the questionnaire. Almost 100.0% of the respondents reported having essential resources for outpatient care: having at least one doctor, sufficient supplies of antiretroviral drugs, CD4 and viral load tests. Many aspects displayed improvement in 2007 compared to 2001: registry of missed medical appointments (from 18.3 to 27.0%, PV: 47.5%), follow-up appointment within 15 days of starting antiretroviral treatment (from 55.3 to 66.2%, PV: 19.7%) and users organized participation (from 5.9 to 16.7%, PV: 183.1%). However, some difficulties remained: little change in the availability of specialized exams, such as endoscopy, within 15 days, (31.9 to 34.5%, PV: 8.1%) and decreases in indicators such as optimal time access to specialized appointments (55.9 to 34.5% in cardiology, negative PV: 38.3%). Mean time spent in follow-up medical appointments remained low: about 15 minutes (52.5 to 49.5%, negative PV: 5.8%). CONCLUSIONS The 2007 assessment revealed that services have essential resources for ambulatory assistance. There was some improvement in many aspects compared to 2001, although some challenges still remain. Little time dedicated to medical appointments may be linked to insufficient number of doctors and/or due to reduced capacity of listening and dialogue. Impaired access to specialized appointments reveals the difficulty local Brazilian Unified Health System facilities have regarding infrastructure.