Regina Melchior

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.

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.

Healthcare for adolescents: perceptions by physicians and nurses in family health teams

This descriptive qualitative study was conducted in basic healthcare units to analyze the perceptions of physicians and nurses from family health teams concerning healthcare for adolescents, using content analysis with an emphasis on thematic analysis. The discourse of these health professionals showed that care exists for adolescents in the family health service, but that: it is not systematized because of other priorities; adolescents fail to use the service; the health professionals feel unprepared to draw adolescents to the service and treat them; and in order to implement a healthcare program for adolescents in the family health strategy it would be necessary to reorganize the service to train the existing team members and hire other professionals. Thus, the interviewees value differentiated care for adolescents, and even while recognizing their limitations and reporting not having been trained, they conduct joint actions with other areas beyond health, demonstrating that they transcend the limits of the health service and seek new ways of treating adolescents holistically.

Condições de trabalho e riscos no trânsito urbano na ótica de trabalhadores motociclistas

Uma das profissoes que mais se expandem no Brasil e a dos motociclistas profissionais, o que pode aumentar os acidentes de trânsito envolvendo esta categoria. Este estudo tem como objetivo identificar e analisar qualitativamente a percepcao de motoboys acerca de aspectos relacionados ao seu trabalho, aos riscos no trânsito e a ocorrencia de acidentes. Os dados foram coletados por meio de grupo focal, realizado em fevereiro de 2005, com 11 motoboys atuantes em Londrina (PR). Este artigo focaliza os principais motivos que levaram os motoboys a insercao na profissao, suas condicoes de trabalho, os riscos a que estao expostos e seu envolvimento em acidentes de trânsito. Os principais motivos para a insercao na profissao foram o desemprego e a baixa escolaridade. A pressao exercida pelas empresas e clientes por entregas rapidas e fator determinante para a adocao de comportamento de risco no trânsito, tendo o ganho por produtividade menor peso na tomada de decisoes. Todos os participantes do estudo relataram envolvimento em acidentes de trânsito. Melhorar suas condicoes de trabalho e o grande desafio colocado no momento, tanto para os proprios motoboys, por meio da uniao da categoria e luta por seus direitos, como para a sociedade em geral, cabendo ao Estado fiscalizar as empresas que oferecem servicos de entrega e estabelecer normas que aumentem a seguranca desses motociclistas no desempenho do seu trabalho.

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.

Tendência da epidemia de casos de aids no Sul do Brasil no período de 1986 a 2008

OBJECTIVE To describe trends in the incidence of Aids cases according to age and gender from 1986 to 2008. METHODS Analyses of Aids trends according to age group and to gender was carried out Londrina, Southern Brazil. The timeframe was divided into two periods (1986-1995 and 1996-2008). Of the polynomial models, it was the first-degree polynomial model which best explained the Aids epidemic within the two periods. The incidence rate of Aids among men who have sex with other men (MSM), injecting drug users (IDU), heterosexual men and women was calculated. RESULTS During the first period, from 1986 to 1995, there was an increase in the incidence of Aids in almost all age groups and the epidemic spread across both sexes (p < 0.001), although this was more marked in men aged 14-39. The second period (1996-2008) did not show a positive or negative statistical increase, indicating that the epidemic had stabilized. A significant fall in the rate for the male 14 to 29 age group was found, with increases of 0.88 and 0.87 for the first and second period respectively. Cases in women aged 50 and over showed a marked increase (p = 0.019). The IDU and MSM groups predominated as the categories with the most exposure, with MSM taking over from IDU in the last three years of the study. From 2000 onwards, incidences in females aged 15 to 49 overtook that of heterosexual men. CONCLUSIONS The study showed a decrease in incidence in the younger age groups and stabilization in the other age groups. There is a need for different approaches in order to reach groups with several characteristics due to the increase in the proportion of women and MSM within the exposure categories.OBJETIVO: Descrever a tendencia dos casos de aids por sexo e faixa etaria de 1986 a 2008. METODOS: Foi analisada a tendencia da aids por faixa etaria e por sexo, em Londrina, PR, em dois periodos: 1986-1995 e 1996-2008. Dentre os modelos polinomiais, o de primeiro grau explicou melhor a tendencia da epidemia da aids nos dois periodos. Foram calculadas as taxas de incidencia para homens que fazem sexo com homens (HSH), usuarios de drogas injetaveis (UDI), homens heterossexuais e mulheres. RESULTADOS: No primeiro periodo, de 1986 a 1995, houve incremento das taxas de incidencia em quase todas as faixas etarias e crescimento da epidemia em ambos os sexos (p < 0,001), mais acentuado em homens de 14 a 39 anos. O segundo periodo (1996-2008) nao apresentou incremento estatistico positivo ou negativo, indicando estabilizacao da epidemia. Verificou-se que ocorreu queda significativa na faixa de 14 a 29 anos no sexo masculino, com incremento de 0,88 no primeiro periodo e 0,87 no segundo. Mulheres de 50 anos e mais apresentaram aumento significativo (p = 0,019). Os grupos UDI e HSH predominaram como categorias de exposicao e HSH ultrapassou UDI no ultimo trienio do estudo. A partir de 2000, a taxa de incidencia entre mulheres de 15 a 49 anos superou a de homens heterossexuais. CONCLUSOES: Houve queda nas taxas de incidencia nas faixas etarias mais jovens e estabilizacao nas demais idades. O aumento da proporcao de mulheres e do predominio de HSH entre as categorias de exposicao aponta para necessidade de estrategias diferenciadas para atingir grupos com caracteristicas diversas.

Assessment of outpatient services for AIDS patients, Brazil: comparative study 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.

Trends in the epidemic of Aids cases in Southern Brazil from 1986 to 2008

OBJECTIVE To describe trends in the incidence of Aids cases according to age and gender from 1986 to 2008. METHODS Analyses of Aids trends according to age group and to gender was carried out Londrina, Southern Brazil. The timeframe was divided into two periods (1986-1995 and 1996-2008). Of the polynomial models, it was the first-degree polynomial model which best explained the Aids epidemic within the two periods. The incidence rate of Aids among men who have sex with other men (MSM), injecting drug users (IDU), heterosexual men and women was calculated. RESULTS During the first period, from 1986 to 1995, there was an increase in the incidence of Aids in almost all age groups and the epidemic spread across both sexes (p < 0.001), although this was more marked in men aged 14-39. The second period (1996-2008) did not show a positive or negative statistical increase, indicating that the epidemic had stabilized. A significant fall in the rate for the male 14 to 29 age group was found, with increases of 0.88 and 0.87 for the first and second period respectively. Cases in women aged 50 and over showed a marked increase (p = 0.019). The IDU and MSM groups predominated as the categories with the most exposure, with MSM taking over from IDU in the last three years of the study. From 2000 onwards, incidences in females aged 15 to 49 overtook that of heterosexual men. CONCLUSIONS The study showed a decrease in incidence in the younger age groups and stabilization in the other age groups. There is a need for different approaches in order to reach groups with several characteristics due to the increase in the proportion of women and MSM within the exposure categories.OBJETIVO: Descrever a tendencia dos casos de aids por sexo e faixa etaria de 1986 a 2008. METODOS: Foi analisada a tendencia da aids por faixa etaria e por sexo, em Londrina, PR, em dois periodos: 1986-1995 e 1996-2008. Dentre os modelos polinomiais, o de primeiro grau explicou melhor a tendencia da epidemia da aids nos dois periodos. Foram calculadas as taxas de incidencia para homens que fazem sexo com homens (HSH), usuarios de drogas injetaveis (UDI), homens heterossexuais e mulheres. RESULTADOS: No primeiro periodo, de 1986 a 1995, houve incremento das taxas de incidencia em quase todas as faixas etarias e crescimento da epidemia em ambos os sexos (p < 0,001), mais acentuado em homens de 14 a 39 anos. O segundo periodo (1996-2008) nao apresentou incremento estatistico positivo ou negativo, indicando estabilizacao da epidemia. Verificou-se que ocorreu queda significativa na faixa de 14 a 29 anos no sexo masculino, com incremento de 0,88 no primeiro periodo e 0,87 no segundo. Mulheres de 50 anos e mais apresentaram aumento significativo (p = 0,019). Os grupos UDI e HSH predominaram como categorias de exposicao e HSH ultrapassou UDI no ultimo trienio do estudo. A partir de 2000, a taxa de incidencia entre mulheres de 15 a 49 anos superou a de homens heterossexuais. CONCLUSOES: Houve queda nas taxas de incidencia nas faixas etarias mais jovens e estabilizacao nas demais idades. O aumento da proporcao de mulheres e do predominio de HSH entre as categorias de exposicao aponta para necessidade de estrategias diferenciadas para atingir grupos com caracteristicas diversas.

A dimensão política na formação dos profissionais de saúde

Sao necessarios avancos na implementacao do SUS no Brasil. Os trabalhadores da saude sao agentes instituintes de mudanca nas praticas do mundo do trabalho. O presente artigo buscou compreender algumas possibilidades para contemplar a dimensao politica na formacao desses trabalhadores. O territorio de estudo foi um programa de residencia multiprofissional em saude no interior de Sao Paulo. Para a producao dos dados, alem de observacao, foram realizadas 14 entrevistas semiestruturadas com residentes, preceptores, tutores e com a coordenacao do programa. A analise foi dividida em potencias para a dimensao politica nas praticas pedagogicas e nas praticas de gestao da Residencia. Encontraram-se potencias nos espacos pedagogicos, de gestao e no mundo do cuidado. As tensoes dispararam um processo de autoanalise nos sujeitos envolvidos e propiciaram novos arranjos no processo formativo. Evidenciou-se que as residencias podem ser dispositivos para a formacao de trabalhadores da saude na defesa do SUS.