RESUMO
Brazil has recently integrated HIV Pre-exposure Prophylaxis (PrEP) into its public health system and offered to key populations such as transgender women (TGW). This study investigates factors associated with PrEP refusal among TGW living in one of the largest and poorest cities of Brazil. We recruited 127 TGW using Respondent Driven Sampling (RDS) in Salvador, Brazil. Latent class analysis (LCA) was used to define acceptability of PrEP. Two latent classes were identified: "high acceptability of PrEP" (91.3%) and "PrEP refusal" (8.7%). PrEP was less acceptable among white TGW and among those age 25 or older, with income above minimum wage (≥ US$252.87), and reporting unprotected receptive anal intercourse with (URAI) causal partners. The findings highlight how nuanced strategies that takes into consideration unique characteristics are needed to effectively address the acceptability of PrEP.
Assuntos
Fármacos Anti-HIV/administração & dosagem , Infecções por HIV/prevenção & controle , Homossexualidade Masculina/psicologia , Profilaxia Pré-Exposição , Pessoas Transgênero/psicologia , Recusa do Paciente ao Tratamento , Adulto , Brasil/epidemiologia , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Homossexualidade Masculina/estatística & dados numéricos , Humanos , Análise de Classes Latentes , Masculino , Pessoa de Meia-Idade , Parceiros Sexuais/psicologia , Pessoas Transgênero/estatística & dados numéricosRESUMO
Few studies evaluate knowledge and willingness to use pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in middle-income countries. Brazil added PrEP to public drug formularies in December 2017, but little is known about local knowledge and attitudes about PrEP among MSM outside metropolitan areas in Southern Brazil. The cross-sectional HIV Surveillance Survey Project in Brazil estimates HIV and STD prevalence among MSM in 12 state capitals. Among 32 participants at the Salvador, Bahia study site, we used qualitative interviews to assess knowledge, willingness, and barriers to PrEP use among MSM; few MSM had previous knowledge of PrEP and were willing to use PrEP. Clinical, behavioural, social, and structural factors influencing participants' knowledge and willingness to take PrEP included concerns about efficacy and side effects, access to culturally congruent services for MSM, and stigma. Some participants reported that learning about PrEP online positively influenced their willingness to use PrEP. Participants' opinions about PrEP's contribution to risk compensation varied. Interventions to provide culturally congruent care and destigmatise PrEP for MSM at high risk for HIV acquisition, particularly those conducted collaboratively with Brazil's civil society movement, may enhance the public health effort to expand access to PrEP in Brazil.
Assuntos
Infecções por HIV/prevenção & controle , Homossexualidade Masculina , Profilaxia Pré-Exposição , Sexo Seguro , Adulto , Brasil , Estudos Transversais , Cultura , Conhecimentos, Atitudes e Prática em Saúde , Inquéritos Epidemiológicos , Humanos , Entrevistas como Assunto , Masculino , Pesquisa QualitativaRESUMO
This is a cross-sectional study examining highly effective contraceptive (HEC) use among HIV-positive women in Salvador, Brazil. We used multivariate logistic regression to look for predictors of alternative contraceptive choices among women who discontinued HEC after HIV diagnosis. Of 914 participants surveyed, 38.5% of participants used HEC before but not after diagnosis. Of these, 65.9% used condoms alone; 19.3% used no protection; and 14.8% reported abstinence. Use of condoms alone was associated with a history of other sexually transmitted infections (AOR 2.18, 95% CI 1.09-4.66, p = 0.029). Abstinence was associated with recent diagnosis (AOR 8.48, 95% CI 2.20-32.64, p = 0.002). Using no method was associated with age below 25 (AOR 5.13, 95% CI 1.46-18.00, p = 0.011); income below minimum wage (AOR 2.54, 95% CI 1.31-4.92, p = 0.006); HIV-positive partner status (AOR 2.69, 95% CI 1.03-7.02, p = 0.043); and unknown partner status (AOR 2.90, 95% CI 1.04-8.05, p = 0.042). Improved contraceptive counseling is needed after HIV diagnosis. Continuation of HEC should be encouraged for women wishing to prevent pregnancy, and may increase contraceptive coverage among HIV-positive women.
Assuntos
Preservativos , Comportamento Contraceptivo/psicologia , Infecções por HIV/diagnóstico , Infecções por HIV/psicologia , Soropositividade para HIV/psicologia , Parceiros Sexuais , Adolescente , Adulto , Brasil , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Infecções Sexualmente Transmissíveis/epidemiologia , Infecções Sexualmente Transmissíveis/prevenção & controle , Inquéritos e Questionários , Adulto JovemRESUMO
INTRODUCTION: HIV continues to be a major health concern with approximately 2.1 million new infections occurring worldwide in 2015. In Central America, Guatemala had the highest incident number of HIV infections (3,700) in 2015. Antiretroviral pre-exposure prophylaxis (PrEP) was recently recommended by the World Health Organization (WHO) as an efficacious intervention to prevent HIV transmission. PrEP implementation efforts are underway in Guatemala and success will require providers that are knowledgeable and willing to prescribe PrEP. We sought to explore current PrEP awareness and prescribing attitudes among Guatemalan physicians in order to inform future PrEP implementation efforts. METHODS: We conducted a cross-sectional survey of adult internal medicine physicians at the main teaching hospital in Guatemala City in March 2015. The survey included demographics, medical specialty, years of HIV patient care, PrEP awareness, willingness to prescribe PrEP, previous experience with post-exposure prophylaxis, and concerns about PrEP. The primary outcome was willingness to prescribe PrEP, which was assessed using a 5-point Likert scale for different at-risk population scenarios. Univariate and multivariate logistic regression was performed to identify predictors for willingness to prescribe PrEP. RESULTS: Eighty-seven physicians completed the survey; 66% were male, 64% were internal medicine residency trainees, and 10% were infectious disease (ID) specialists. Sixty-nine percent of physicians were PrEP aware, of which 9% had previously prescribed PrEP. Most (87%) of respondents were willing to prescribe PrEP to men who have sex with men (MSM), sex workers, injection drug users, or HIV-uninfected persons having known HIV-positive sexual partners. Concerns regarding PrEP included development of resistance (92%), risk compensation (90%), and cost (64%). Univariate logistic regression showed that younger age, being a resident trainee, and being a non-ID specialist were significant predictors for willingness to prescribe PrEP. In multivariate logistic regression, being a non-ID specialist was a significant predictor. CONCLUSIONS: Guatemalan physicians at an urban public hospital were PrEP aware and willing to prescribe, but few have actually done so yet. Future education programs should address the concerns identified, including the low potential for the development of antiretroviral resistance. These findings can aid PrEP implementation efforts in Guatemala.
Assuntos
Atitude do Pessoal de Saúde , Infecções por HIV/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Padrões de Prática Médica/estatística & dados numéricos , Profilaxia Pré-Exposição/estatística & dados numéricos , Adulto , Fármacos Anti-HIV/uso terapêutico , Estudos Transversais , Feminino , Guatemala , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Médicos/psicologia , Inquéritos e QuestionáriosRESUMO
ABSTRACT Objective Early, continued engagement with the HIV treatment continuum can help achieve viral suppression, though few studies have explored how risk factors for delays differ across the continuum. The objective of this study was to identify predictors of delayed diagnosis, delayed linkage to care, and nonadherence to treatment in the city of Salvador, Bahia, Brazil. Methods Data were collected during 2010 in a cross-sectional study with a sample (n = 1 970) of HIV-infected individuals enrolled in care. Multiple logistic regression analyses identified sociodemographic variables, behaviors, and measures of health service quality that were associated with delayed diagnosis, delayed linkage to care, and treatment nonadherence. Results For delayed diagnosis, male gender (adjusted odds ratio (AOR), 3.02; 95% confidence interval (CI), 2.0–4.6); age 45 years and older (AOR, 1.67; 95% CI, 1.1–2.5); and provider-initiated testing (AOR, 3.00; 95% CI, 2.1–4.4) increased odds, while drug use (AOR, 0.29; 95% CI, 0.2–0.5) and receiving results in a private space (AOR, 0.37; 95% CI, 0.2–0.8) decreased odds. For delayed linkage to care, unemployment (AOR, 1.42; 95% CI, 1.07–1.9) and difficulty understanding or speaking with a health care worker (AOR, 1.61; 95% CI, 1.2–2.1) increased odds, while posttest counseling (AOR, 0.49; 95% CI, 0.3–0.7) decreased odds. For nonadherence, experiencing verbal or physical discrimination related to HIV (AOR, 1.94; 95% CI, 1.3–3.0) and feeling mistreated or not properly attended to at HIV care (AOR, 1.60; 95% CI, 1.0–2.5) increased odds, while posttest counseling (AOR, 0.34; 95% CI, 0.2–0.6) decreased odds. Conclusions More attention is needed on how policies, programs, and research can provide tailored support across the treatment continuum.
RESUMEN Objetivo La participación temprana y continua en el continuo de tratamiento de la infección por el VIH puede ayudar a lograr la supresión viral, aunque pocos estudios han explorado la manera en que los factores de riesgo debidos a los retrasos difieren a lo largo del proceso continuo. El objetivo de este estudio fue determinar los factores predictivos de un diagnóstico tardío, la demora en la vinculación con la atención y el incumplimiento del régimen terapéutico en la ciudad de Salvador de Bahía, en Brasil. Métodos Se recopilaron datos en un estudio transversal realizado durante el 2010, con una muestra (n = 1 970) de personas con la infección por el VIH que recibían atención. Por medio de múltiples análisis de regresión logística se determinaron variables sociodemográficas, comportamientos y mediciones de la calidad del servicio de salud que estaban asociadas a un diagnóstico tardío, así como a la demora en la vinculación con la atención y el incumplimiento del régimen terapéutico. Resultados Con relación a los diagnósticos tardíos, ser de sexo masculino (razón de posibilidades ajustada (AOR) 3,02; intervalo de confianza (IC) de 95%, 2,0-4,6), tener más de 45 años (AOR, 1,67; IC de 95%, 1,1-2,5) y que las pruebas hayan sido iniciadas por el proveedor (AOR, 3,00; IC de 95%, 2,1-4,4) aumentaron las probabilidades, mientras que el consumo de drogas (AOR, 0,29; IC de 95%, 0.2-0.5) y la recepción de los resultados en un espacio privado (AOR, 0,37; IC de 95%, 0,2-0,8) disminuyeron las probabilidades. Con respecto a la vinculación tardía a la atención, el desempleo (AOR, 1,42; IC de 95%, 1,07-1,9) y las dificultades para comprender al trabajador de salud o hablar con él (AOR, 1,61; IC de 95%, 1,2-2,1) aumentaron las probabilidades, mientras que la orientación posterior a las pruebas (AOR, 0,49; IC de 95%, 0,3-0,7) disminuyó las probabilidades. Con respecto al incumplimiento del régimen terapéutico, la discriminación verbal o física relacionada con la infección por el VIH (AOR, 1,94; IC de 95%, 1,3-3,0) y el sentirse maltratado o no atendido adecuadamente en los establecimientos de atención (AOR, 1,60; IC de 95%, 1,0-2,5) aumentaron las probabilidades, mientras que la orientación posterior a las pruebas (AOR, 0,34; IC de 95%, 0,2-0,6) disminuyó las probabilidades. Conclusiones Debe prestarse mayor atención a la forma en que las políticas, los programas y la investigación pueden prestar apoyo personalizado a lo largo del proceso continuo de tratamiento.
Assuntos
Infecções por HIV/tratamento farmacológico , Programas de Rastreamento , Estudos Transversais Seriados , Diagnóstico Tardio , BrasilRESUMO
Objective: Early, continued engagement with the HIV treatment continuum can help achieve viral suppression, though few studies have explored how risk factors for delays differ across the continuum. The objective of this study was to identify predictors of delayed diagnosis, delayed linkage to care, and nonadherence to treatment in the city of Salvador, Bahia, Brazil. Methods: Data were collected during 2010 in a cross-sectional study with a sample (n = 1 970) of HIV-infected individuals enrolled in care. Multiple logistic regression analyses identified sociodemographic variables, behaviors, and measures of health service quality that were associated with delayed diagnosis, delayed linkage to care, and treatment nonadherence. Results: For delayed diagnosis, male gender (adjusted odds ratio (AOR), 3.02; 95% confidence interval (CI), 2.0–4.6); age 45 years and older (AOR, 1.67; 95% CI, 1.1–2.5); and provider-initiated testing (AOR, 3.00; 95% CI, 2.1–4.4) increased odds, while drug use (AOR, 0.29; 95% CI, 0.2–0.5) and receiving results in a private space (AOR, 0.37; 95% CI, 0.2–0.8) decreased odds. For delayed linkage to care, unemployment (AOR, 1.42; 95% CI, 1.07–1.9) and difficulty understanding or speaking with a health care worker (AOR, 1.61; 95% CI, 1.2–2.1) increased odds, while posttest counseling (AOR, 0.49; 95% CI, 0.3–0.7) decreased odds. For nonadherence, experiencing verbal or physical discrimination related to HIV (AOR, 1.94; 95% CI, 1.3–3.0) and feeling mistreated or not properly attended to at HIV care (AOR, 1.60; 95% CI, 1.0–2.5) increased odds, while posttest counseling (AOR, 0.34; 95% CI, 0.2–0.6) decreased odds. Conclusions: More attention is needed on how policies, programs, and research can provide tailored support across the treatment continuum.
Objetivo: La participación temprana y continua en el continuo de tratamiento de la infección por el VIH puede ayudar a lograr la supresión viral, aunque pocos estudios han explorado la manera en que los factores de riesgo debidos a los retrasos difieren a lo largo del proceso continuo. El objetivo de este estudio fue determinar los factores predictivos de un diagnóstico tardío, la demora en la vinculación con la atención y el incumplimiento del régimen terapéutico en la ciudad de Salvador de Bahía, en Brasil. Métodos: Se recopilaron datos en un estudio transversal realizado durante el 2010, con una muestra (n = 1 970) de personas con la infección por el VIH que recibían atención. Por medio de múltiples análisis de regresión logística se determinaron variables sociodemográficas, comportamientos y mediciones de la calidad del servicio de salud que estaban asociadas a un diagnóstico tardío, así como a la demora en la vinculación con la atención y el incumplimiento del régimen terapéutico. Resultados: Con relación a los diagnósticos tardíos, ser de sexo masculino (razón de posibilidades ajustada (AOR) 3,02; intervalo de confianza (IC) de 95%, 2,0-4,6), tener más de 45 años (AOR, 1,67; IC de 95%, 1,1-2,5) y que las pruebas hayan sido iniciadas por el proveedor (AOR, 3,00; IC de 95%, 2,1-4,4) aumentaron las probabilidades, mientras que el consumo de drogas (AOR, 0,29; IC de 95%, 0.2-0.5) y la recepción de los resultados en un espacio privado (AOR, 0,37; IC de 95%, 0,2-0,8) disminuyeron las probabilidades. Con respecto a la vinculación tardía a la atención, el desempleo (AOR, 1,42; IC de 95%, 1,07-1,9) y las dificultades para comprender al trabajador de salud o hablar con él (AOR, 1,61; IC de 95%, 1,2-2,1) aumentaron las probabilidades, mientras que la orientación posterior a las pruebas (AOR, 0,49; IC de 95%, 0,3-0,7) disminuyó las probabilidades. Con respecto al incumplimiento del régimen terapéutico, la discriminación verbal o física relacionada con la infección por el VIH (AOR, 1,94; IC de 95%, 1,3-3,0) y el sentirse maltratado o no atendido adecuadamente en los establecimientos de atención (AOR, 1,60; IC de 95%, 1,0-2,5) aumentaron las probabilidades, mientras que la orientación posterior a las pruebas (AOR, 0,34; IC de 95%, 0,2-0,6) disminuyó las probabilidades. Conclusiones: Debe prestarse mayor atención a la forma en que las políticas, los programas y la investigación pueden prestar apoyo personalizado a lo largo del proceso continuo de tratamiento.
Assuntos
HIV , Síndrome da Imunodeficiência Adquirida , Síndrome da Imunodeficiência Adquirida , Diagnóstico , Cooperação do Paciente , HIV , Continuidade da Assistência ao Paciente , Diagnóstico , Cooperação do Paciente , BrasilRESUMO
Sampling strategies such as respondent-driven sampling (RDS) and time-location sampling (TLS) offer unique opportunities to access key populations such as men who have sex with men (MSM) and transgender women. Limited work has assessed implementation challenges of these methods. Overcoming implementation challenges can improve research quality and increase uptake of HIV services among key populations. Drawing from studies using RDS in Brazil and TLS in Peru, we summarize challenges encountered in the field and potential strategies to address them. In Brazil, study site selection, cash incentives, and seed selection challenged RDS implementation with MSM. In Peru, expansive geography, safety concerns, and time required for study participation complicated TLS implementation with MSM and transgender women. Formative research, meaningful participation of key populations across stages of research, and transparency in study design are needed to link HIV/AIDS research and practice. Addressing implementation challenges can close gaps in accessing services among those most burdened by the epidemic.
Assuntos
Síndrome da Imunodeficiência Adquirida , Coleta de Dados/métodos , Homossexualidade Masculina , Pessoas Transgênero , Adulto , Brasil , Estudos Transversais , Feminino , Humanos , Masculino , Peru , Estudos de AmostragemRESUMO
Abstract: Sampling strategies such as respondent-driven sampling (RDS) and time-location sampling (TLS) offer unique opportunities to access key populations such as men who have sex with men (MSM) and transgender women. Limited work has assessed implementation challenges of these methods. Overcoming implementation challenges can improve research quality and increase uptake of HIV services among key populations. Drawing from studies using RDS in Brazil and TLS in Peru, we summarize challenges encountered in the field and potential strategies to address them. In Brazil, study site selection, cash incentives, and seed selection challenged RDS implementation with MSM. In Peru, expansive geography, safety concerns, and time required for study participation complicated TLS implementation with MSM and transgender women. Formative research, meaningful participation of key populations across stages of research, and transparency in study design are needed to link HIV/AIDS research and practice. Addressing implementation challenges can close gaps in accessing services among those most burdened by the epidemic.
Resumo: Estratégias de amostragem como respondent-driven sampling (RDS) e time-location sampling (TLS) são importantes opções metodológicas para acessar populações chaves para a epidemia de HIV/AIDS como homens que fazem sexo com homens (HSH) e mulheres transexuais. Porém são poucos os estudos que avaliam desafios de implementação desses métodos. Objetivamos apresentar os principais desafios na implementação dos RDS no Brasil e TLS no Peru. No Brasil, o local da pesquisa, a seleção das sementes, e o tipo de ressarcimento foram desafios na implementação do RDS-HSH. E no Peru, as questões geográficas, preocupações com segurança, e o tempo necessário para participar no estudo complicaram o TLS com HSH e mulheres transexuais. Pesquisa formativa, participação das populações chaves em todas as fases da pesquisa, e transparência no desenvolvimento do estudo são necessários para utilização prática dos resultados. Melhorar a implementação dessas pesquisas pode contribuir para aumentar o acesso aos serviços de prevenção e controle do HIV/AIDS entre aqueles que mais precisam.
Resumen: Estrategias de muestra como respondent-driven sampling (RDS) y time-location sampling (TLS) son importantes opciones metodológicas para acceder a poblaciones claves para la epidemia de VIH/SIDA como los hombres que tienen sexo con hombres (HSH) y mujeres transexuales. No obstante, son pocos los estudios que evalúan los desafíos de implementación de esos métodos. Tenemos como objetivo presentar los principales desafíos en la implementación de los RDS en Brasil y TLS en Perú. En Brasil, el lugar de la investigación, la selección de las muestras, y el tipo de compensación fueron desafíos en la implementación del RDS-HSH. Y en Perú, las cuestiones geográficas, preocupaciones con la seguridad, y el tiempo necesario para participar en el estudio complicaron el TLS con HSH y mujeres transexuales. Se trata de una investigación formativa, con participación de las poblaciones claves en todas las fases de la investigación, y transparencia en el desarrollo del estudio, todo ello necesario para la utilización práctica de los resultados. Mejorar la implementación de esas investigaciones puede contribuir a aumentar el acceso a los servicios de prevención y control del VIH/SIDA entre aquellos que más lo necesitan.
Assuntos
Humanos , Masculino , Feminino , Adulto , Coleta de Dados/métodos , Síndrome da Imunodeficiência Adquirida , Homossexualidade Masculina , Pessoas Transgênero , Peru , Brasil , Estudos Transversais , Estudos de AmostragemRESUMO
OBJECTIVE: To analyze the factors associated with late presentation to HIV/AIDS services among heterosexual men. METHODS: Men infected by HIV who self-identified as heterosexual (n = 543) were included in the study. Descriptive, biivariate and logistic regression analyses were performed to evaluate the factors associated with late presentation (defined as individuals whose first CD4 count was <350 cells/mm3) in the study population. RESULTS: The prevalence of late presentation was 69.8%. The multivariate logistic analysis showed testing initiated by the provider (ORadjusted 3.75; 95%CI 2.45-5.63) increased the odds of late presentation. History of drug use (ORadjusted 0.59; 95%CI 0.38-0.91), history of having sexually transmitted infections (ORadjusted 0.64; 95%CI 0.42-0.97), and having less education (ORadjusted 0.63; 95%CI 0.41-0.97) were associated with a decreased odds of LP. CONCLUSIONS: Provider initiated testing was the only variable to increase the odds of late presentation. Since the patients in this sample all self-identified as heterosexual, it appears that providers are not requesting they be tested for HIV until the patients are already presenting symptoms of AIDS. The high prevalence of late presentation provides additional evidence to shift towards routine testing and linkage to care, rather than risk-based strategies that may not effectively or efficiently engage individuals infected with HIV.
Assuntos
Diagnóstico Tardio , Infecções por HIV/diagnóstico , Heterossexualidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Atitude Frente a Saúde , Brasil/epidemiologia , Contagem de Linfócito CD4 , Estudos Transversais , Progressão da Doença , Feminino , Infecções por HIV/epidemiologia , Acessibilidade aos Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Adulto JovemRESUMO
OBJECTIVE: Early, continued engagement with the HIV treatment continuum can help achieve viral suppression, though few studies have explored how risk factors for delays differ across the continuum. The objective of this study was to identify predictors of delayed diagnosis, delayed linkage to care, and nonadherence to treatment in the city of Salvador, Bahia, Brazil. METHODS: Data were collected during 2010 in a cross-sectional study with a sample (n = 1 970) of HIV-infected individuals enrolled in care. Multiple logistic regression analyses identified sociodemographic variables, behaviors, and measures of health service quality that were associated with delayed diagnosis, delayed linkage to care, and treatment nonadherence. RESULTS: For delayed diagnosis, male gender (adjusted odds ratio (AOR), 3.02; 95% confidence interval (CI), 2.0-4.6); age 45 years and older (AOR, 1.67; 95% CI, 1.1-2.5); and provider-initiated testing (AOR, 3.00; 95% CI, 2.1-4.4) increased odds, while drug use (AOR, 0.29; 95% CI, 0.2-0.5) and receiving results in a private space (AOR, 0.37; 95% CI, 0.2-0.8) decreased odds. For delayed linkage to care, unemployment (AOR, 1.42; 95% CI, 1.07-1.9) and difficulty understanding or speaking with a health care worker (AOR, 1.61; 95% CI, 1.2-2.1) increased odds, while posttest counseling (AOR, 0.49; 95% CI, 0.3-0.7) decreased odds. For nonadherence, experiencing verbal or physical discrimination related to HIV (AOR, 1.94; 95% CI, 1.3-3.0) and feeling mistreated or not properly attended to at HIV care (AOR, 1.60; 95% CI, 1.0-2.5) increased odds, while posttest counseling (AOR, 0.34; 95% CI, 0.2-0.6) decreased odds. CONCLUSIONS: More attention is needed on how policies, programs, and research can provide tailored support across the treatment continuum.
Assuntos
Diagnóstico Tardio , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Cooperação e Adesão ao Tratamento , Brasil , Cidades , Estudos Transversais , Feminino , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-IdadeRESUMO
Global and national HIV/AIDS policies utilize the care cascade to emphasize the importance of continued engagement in HIV services from diagnosis to viral suppression. Several studies have documented barriers that men experience in accessing services at specific stages of care, but few have analyzed how these barriers operate along the care cascade. Brazil offers a unique setting for analyzing barriers to HIV care because it is a middle-income country with a large HIV epidemic and free, universal access to HIV/AIDS services. Semi-structured interviews were conducted in 2011 with HIV-infected men (n = 25) receiving care at the only HIV/AIDS state reference center in Salvador, Brazil, the third largest city in the country. Interviews were transcribed and coded for analysis. Researchers identified barriers to services along the care cascade: health service-related obstacles (poor-quality care, lengthy wait times, and drug supply problems); psychosocial and emotional challenges (fear of disclosure and difficulty accepting HIV diagnosis); indirect costs (transportation and absenteeism at work or school); low perceived risk of HIV; and toxicity and complexity of antiretroviral drug (ARV) regimens. The stages of the care cascade interrupted by each barrier were also identified. Most barriers affected multiple, and often all, stages of care, while toxicity and complexity of ARV regimens was only present at a single care stage. Efforts to eliminate more prevalent barriers have the potential to improve care continuity at multiple stages. Going forward, assessing the relative impact of barriers along one's entire care trajectory can help tailor improvements in service provision, facilitate achievement of viral suppression, and improve access to life-saving testing, treatment, and care.
Assuntos
Continuidade da Assistência ao Paciente , Infecções por HIV/tratamento farmacológico , Acessibilidade aos Serviços de Saúde , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Preconceito , Qualidade da Assistência à Saúde , Adulto , Antirretrovirais/uso terapêutico , Brasil , Atenção à Saúde/normas , Revelação , Infecções por HIV/etnologia , Infecções por HIV/psicologia , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Relações Profissional-Paciente , Pesquisa Qualitativa , Apoio Social , População Urbana/estatística & dados numéricosRESUMO
ABSTRACT OBJECTIVE To analyze the factors associated with late presentation to HIV/AIDS services among heterosexual men. METHODS Men infected by HIV who self-identified as heterosexual (n = 543) were included in the study. Descriptive, biivariate and logistic regression analyses were performed to evaluate the factors associated with late presentation (defined as individuals whose first CD4 count was <350 cells/mm3) in the study population. RESULTS The prevalence of late presentation was 69.8%. The multivariate logistic analysis showed testing initiated by the provider (ORadjusted 3.75; 95%CI 2.45-5.63) increased the odds of late presentation. History of drug use (ORadjusted 0.59; 95%CI 0.38-0.91), history of having sexually transmitted infections (ORadjusted 0.64; 95%CI 0.42-0.97), and having less education (ORadjusted 0.63; 95%CI 0.41-0.97) were associated with a decreased odds of LP. CONCLUSIONS Provider initiated testing was the only variable to increase the odds of late presentation. Since the patients in this sample all self-identified as heterosexual, it appears that providers are not requesting they be tested for HIV until the patients are already presenting symptoms of AIDS. The high prevalence of late presentation provides additional evidence to shift towards routine testing and linkage to care, rather than risk-based strategies that may not effectively or efficiently engage individuals infected with HIV.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Adulto Jovem , Infecções por HIV/diagnóstico , Heterossexualidade , Diagnóstico Tardio , Brasil/epidemiologia , Atitude Frente a Saúde , Infecções por HIV/epidemiologia , Prevalência , Estudos Transversais , Fatores de Risco , Progressão da Doença , Contagem de Linfócito CD4 , Acessibilidade aos Serviços de Saúde , Pessoa de Meia-IdadeRESUMO
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.
Assuntos
Síndrome da Imunodeficiência Adquirida/epidemiologia , Bissexualidade/estatística & dados numéricos , Diagnóstico Tardio/estatística & dados numéricos , Heterossexualidade/estatística & dados numéricos , Homossexualidade Masculina/estatística & dados numéricos , Autoimagem , Adolescente , Adulto , Fatores Etários , Brasil , Contagem de Linfócito CD4 , Estudos Transversais , Infecções por HIV/epidemiologia , Humanos , Masculino , Análise Multivariada , Prevalência , Fatores de Risco , Comportamento Sexual , Parceiros Sexuais , Inquéritos e Questionários , Tempo para o Tratamento , População Urbana , Adulto JovemRESUMO
Exclusive and safe formula feeding can eliminate the risk of vertical HIV transmission due to breastfeeding. Therefore, many countries advise all HIV-positive women to avoid breastfeeding their infants. However, little research explores the experiences of women attempting to exclusively formula feed in countries with free and universal access to highly active antiretroviral therapy (HAART). This article examines the success of Brazil in supporting HIV-positive women as engage in exclusive formula feeding (EFF). We conducted in-depth interviews with 30 HIV-positive women receiving care at the primary facility for HIV/AIDS in Salvador, Brazil about their attitudes and practices related to EFF as well as challenges with adhering to EFF. All interviews were recorded, professionally transcribed and translated, and then analyzed. Our results showed that one woman reported both breastfeeding and formula feeding her infant; all others reported EFF. Postpartum counseling regarding the risk of HIV transmission through breastfeeding was the primary motivation for EFF. Challenges included difficulty reconciling their perceptions that breastfeeding is an important maternal responsibility, trouble accepting that breastfeeding can cause potential to harm their infants, confronting HIV-related stigma associated with EFF, and unexpected financial burdens due to EFF. We conclude that HIV-positive women adhered to national guidelines recommending EFF; this phenomenon has likely contributed to declining rates of vertical transmission in Brazil. Despite this success, many women experienced challenges with EFF. Greater support services may enhance Brazil's success in empowering HIV-positive women and eliminating vertical HIV transmission via breastfeeding.
Assuntos
Alimentação com Mamadeira/psicologia , Aleitamento Materno/psicologia , Infecções por HIV/transmissão , Transmissão Vertical de Doenças Infecciosas/prevenção & controle , Mães/psicologia , Adulto , Terapia Antirretroviral de Alta Atividade , Brasil , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/prevenção & controle , Humanos , Lactente , Fórmulas Infantis , Leite Humano/virologia , Educação de Pacientes como Assunto , Gravidez , Adulto JovemRESUMO
Brazil and South Africa were among the first countries profoundly impacted by the HIV/AIDS epidemic and had similar rates of HIV infection in the early 1990s. Today, Brazil has less than 1% adult HIV prevalence, implemented treatment and prevention programmes early in the epidemic, and now has exemplary HIV/AIDS programmes. South Africa, by contrast, has HIV prevalence of 18% and was, until recently, infamous for its delayed and inappropriate response to the HIV/AIDS epidemic. This article explores how differing relationships between AIDS movements and governments have impacted the evolving policy responses to the AIDS epidemic in both countries, including through AIDS programme finance, leadership and industrial policy related to production of generic medicines.
Assuntos
Infecções por HIV , Política de Saúde , Defesa do Paciente , Brasil/epidemiologia , Indústria Farmacêutica , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Infecções por HIV/epidemiologia , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Humanos , Liderança , Masculino , África do Sul/epidemiologiaRESUMO
Brazil has one of the developing world's largest, and arguably most successful, AIDS treatment programs. In this paper we review the treatment program, including controversial policies that Brazil has used to promote widespread local and global access to AIDS treatment. We also examine the lessons learned from this program and highlight the challenges Brazil faces, including the rising costs of AIDS treatment and changes in donors' funding priorities. Finally, we explore the relevance of Brazil's treatment program for other countries and its broad implications for global AIDS and health policy.
Assuntos
Síndrome da Imunodeficiência Adquirida/terapia , Acessibilidade aos Serviços de Saúde/normas , Síndrome da Imunodeficiência Adquirida/prevenção & controle , Antirretrovirais/economia , Antirretrovirais/provisão & distribuição , Antirretrovirais/uso terapêutico , Brasil , Custos de Medicamentos , Educação em Saúde , Política de Saúde , Acessibilidade aos Serviços de Saúde/economia , Humanos , Avaliação de Programas e Projetos de SaúdeRESUMO
BACKGROUND: Little is known about the long-term drug costs associated with treating AIDS in developing countries. Brazil's AIDS treatment program has been cited widely as the developing world's largest and most successful AIDS treatment program. The program guarantees free access to highly active antiretroviral therapy (HAART) for all people living with HIV/AIDS in need of treatment. Brazil produces non-patented generic antiretroviral drugs (ARVs), procures many patented ARVs with negotiated price reductions, and recently issued a compulsory license to import one patented ARV. In this study, we investigate the drivers of recent ARV cost trends in Brazil through analysis of drug-specific prices and expenditures between 2001 and 2005. METHODS AND FINDINGS: We compared Brazil's ARV prices to those in other low- and middle-income countries. We analyzed trends in drug expenditures for HAART in Brazil from 2001 to 2005 on the basis of cost data disaggregated by each ARV purchased by the Brazilian program. We decomposed the overall changes in expenditures to compare the relative impacts of changes in drug prices and drug purchase quantities. We also estimated the excess costs attributable to the difference between prices for generics in Brazil and the lowest global prices for these drugs. Finally, we estimated the savings attributable to Brazil's reduced prices for patented drugs. Negotiated drug prices in Brazil are lowest for patented ARVs for which generic competition is emerging. In recent years, the prices for efavirenz and lopinavir-ritonavir (lopinavir/r) have been lower in Brazil than in other middle-income countries. In contrast, the price of tenofovir is US$200 higher per patient per year than that reported in other middle-income countries. Despite precipitous price declines for four patented ARVs, total Brazilian drug expenditures doubled, to reach US$414 million in 2005. We find that the major driver of cost increases was increased purchase quantities of six specific drugs: patented lopinavir/r, efavirenz, tenofovir, atazanavir, enfuvirtide, and a locally produced generic, fixed-dose combination of zidovudine and lamivudine (AZT/3TC). Because prices declined for many of the patented drugs that constitute the largest share of drug costs, nearly the entire increase in overall drug expenditures between 2001 and 2005 is attributable to increases in drug quantities. Had all drug quantities been held constant from 2001 until 2005 (or for those drugs entering treatment guidelines after 2001, held constant between the year of introduction and 2005), total costs would have increased by only an estimated US$7 million. We estimate that in the absence of price declines for patented drugs, Brazil would have spent a cumulative total of US$2 billion on drugs for HAART between 2001 and 2005, implying a savings of US$1.2 billion from price declines. Finally, in comparing Brazilian prices for locally produced generic ARVs to the lowest international prices meeting global pharmaceutical quality standards, we find that current prices for Brazil's locally produced generics are generally much higher than corresponding global prices, and note that these prices have risen in Brazil while declining globally. We estimate the excess costs of Brazil's locally produced generics totaled US$110 million from 2001 to 2005. CONCLUSIONS: Despite Brazil's more costly generic ARVs, the net result of ARV price changes has been a cost savings of approximately US$1 billion since 2001. HAART costs have nevertheless risen steeply as Brazil has scaled up treatment. These trends may foreshadow future AIDS treatment cost trends in other developing countries as more people start treatment, AIDS patients live longer and move from first-line to second and third-line treatment, AIDS treatment becomes more complex, generic competition emerges, and newer patented drugs become available. The specific application of the Brazilian model to other countries will depend, however, on the strength of their health systems, intellectual property regulations, epidemiological profiles, AIDS treatment guidelines, and differing capacities to produce drugs locally.
Assuntos
Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Antirretrovirais/economia , Terapia Antirretroviral de Alta Atividade/economia , Custos de Medicamentos/tendências , Programas Nacionais de Saúde/economia , Brasil , Redução de Custos , Países em Desenvolvimento/economia , Medicamentos Genéricos/economia , Fundações/economia , Acessibilidade aos Serviços de Saúde , Humanos , InternacionalidadeRESUMO
Little is known about the long-term drug costs associated with treating AIDS in developing countries.Brazils AIDS treatment program has been cited widely as the developing worlds largest and mostsuccessful AIDS treatment program. The program guarantees free access to highly active antiretroviraltherapy (HAART) for all people living with HIV/AIDS in need of treatment. Brazil produces non-patentedgeneric antiretroviral drugs (ARVs), procures many patented ARVs with negotiated price reductions, andrecently issued a compulsory license to import one patented ARV. In this study, we investigate the driversof recent ARV cost trends in Brazil through analysis of drug-specific prices and expenditures between 2001and 2005.
Assuntos
Humanos , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Antirretrovirais/economia , Terapia Antirretroviral de Alta Atividade/economia , Custos de Medicamentos/tendências , Programas Nacionais de Saúde/economia , Brasil , Redução de Custos , Países em Desenvolvimento/economia , Medicamentos Genéricos/economia , Fundações/economia , Acessibilidade aos Serviços de Saúde , InternacionalidadeRESUMO
O artigo avalia como a descentralização dos recursos e ações do Programa Nacional de DST e AIDS influenciou as transferências de recursos para os programas de prevenção ao HIV/AIDS entre usuários de drogas injetáveis no Rio de Janeiro, Brasil (1999-2006). Foram avaliados os efeitos da política de descentralização sobre as transferências de recursos para os Programas de Redução de Danos (PRD) no Rio de Janeiro. A descentralização das transferências para os PRD no Rio de Janeiro se efetivou em 2006, com a virtual supressão do financiamento federal direto, obrigando estes programas a buscarem fontes alternativas de financiamento. Constata-se uma fragilidade dos PRD no Estado, agravada pela redução recente do volume de recursos. Dos 22 programas, existentes em 2002, o Estado passou a contar, em 2006, com apenas dois programas, financiados pelo Estado e por um município. A descontinuidade dessas ações pode vir a favorecer a reemergência da epidemia de AIDS nesta população, o que reclama um processo de descentralização mais gradual e melhor pactuado dessas iniciativas.
This paper assesses how decentralization of resources and initiatives by the Brazilian National SDT/AIDS Program has impacted the transfer of funds for programs to prevent HIV/AIDS among injecting drug users in Rio de Janeiro, Brazil (1999-2006). The effects of the decentralization policy on Rio de Janeiro's Syringe Exchange Programs (SEPs) are assessed in detail. Decentralization effectively took place in Rio de Janeiro in 2006, with the virtual elimination of any direct transfer from the Federal government. The elimination of direct transfers forced SEPs to seek alternative funding sources. The structure of local SEPs appears to be weak and has been further undermined by current funding constraints. Of 22 SEPs operating in 2002, only two are still operational in 2006, basically funded by the State Health Secretariat and one municipal government. The current discontinuity of SEP operations may favor the resurgence of AIDS in the IDU population. A more uniform, regulated decentralization process is thus needed.