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INTRODUCTION: Chronic hepatitis C (CHC) is considered an important public health challenge. Traditionally identified risk factors have undergone an epidemiological transition where other risk factors have become the main cause of new infections. OBJECTIVE: To describe risk factors associated to hepatitis C positivity through the evaluation of the epidemiological profile in hepatitis-C high-risk populations. METHODS: Cross-sectional study was conducted as part of an HCV screening program in Mexican population. All participants answered an HCV risk-factor questionnaire and took a rapid test (RT). All patients reactive to the test were subject to HCV PCR (polymerase chain reaction) confirmation. A logistic regression model was used to examine associations between HCV infection and risk factors. RESULTS: The study included 297 631 participants that completed a risk factor questionnaire and underwent an HCV rapid test (RT). In total, 12 840 (4.5%) were reactive to RT and 9257 (3.2% of participants) were confirmed as positives by PCR test. Of these, 72.9% had at least one risk factor and 10.8% were in prison. Most common risk factors were history of acupuncture/tattooing/piercing (21%), intravenous drug use (15%) and high-risk sexual practices (12%). Logistic regressions found that having at least one risk factor increased the probability of having an HCV-positive result by 20% (OR = 1.20, 95% CI: 1.15-1.26), compared to the population without risk factors. CONCLUSIONS: We identified 3.2% of HCV-viremic subjects, all associated with risk factors and older age. Screening and diagnosis of HCV in high-risk populations (including underserved populations) should be more efficient.
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Hepatite C , Abuso de Substâncias por Via Intravenosa , Humanos , Estudos Transversais , Hepatite C/diagnóstico , Hepatite C/epidemiologia , Hepatite C/tratamento farmacológico , Fatores de Risco , Hepacivirus , Abuso de Substâncias por Via Intravenosa/complicações , PrevalênciaRESUMO
INTRODUCTION: Paediatric HIV follow-up is challenging, and treatment indicators are markedly far from Joint United Nations Programme on HIV/AIDS (UNAIDS) goals. In this study, we describe the 2019 Brazilian HIV cascade according to age categories and sociodemographic variables and address temporal trends between 2009 and 2019. METHODS: We obtained data from the Brazilian Ministry of Health monitoring database. Cascade outcomes included retention in care, antiretroviral use, and viral suppression. We assessed the effect of age on timely initiation of antiretroviral treatment (ART; initiation with CD4+ T-cell count ≥350 cells/mm3 or a first ART dispensation ≤30 days after the first CD4+ T-cell measurement) and detectable HIV viral load (>50 copies/mL) in univariable and multivariable analysis adjusted for sex, race, and social vulnerability index (SVI). Temporal trends in timely ART initiation and viral suppression were evaluated graphically. RESULTS: Among 771 774 people living with HIV, those in the youngest age categories had poorer indicators in the care cascade. Those in younger age groups, those with higher SVI, and those declaring Black and native Brazilian race/ethnicity had higher odds of having detectable viral load and delayed ART initiation. Although children living with HIV tend to start ART with higher CD4+ T-cell counts, time-series analysis suggests that improvements in treatment indicators seen in the adult population are not observed in the paediatric population. CONCLUSION: Our results highlight the challenges faced by children and adolescents living with HIV in achieving UNAIDS goals. Lower access to ART among children is a central barrier to improved paediatric care.
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Síndrome da Imunodeficiência Adquirida , Fármacos Anti-HIV , Infecções por HIV , Adulto , Adolescente , Humanos , Criança , Infecções por HIV/epidemiologia , Brasil/epidemiologia , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Antirretrovirais/uso terapêutico , Contagem de Linfócito CD4 , Carga Viral , Continuidade da Assistência ao Paciente , Fármacos Anti-HIV/uso terapêuticoRESUMO
OBJECTIVE: To characterize losses from the pediatric tuberculosis (TB) infection care cascade to identify ways to improve TB infection care delivery. STUDY DESIGN: We conducted a retrospective cohort study of children (age <18 years) screened for TB within 2 Boston-area health systems between January 2017 and May 2019. Patients who received a tuberculin skin test (TST) and/or an interferon gamma release assay (IGRA) were included. RESULTS: We included 13â353 tests among 11â622 patients; 93.9% of the tests were completed. Of 199 patients with positive tests for whom TB infection evaluation was clinically appropriate, 59.3% completed treatment or were recommended to not start treatment. Age 12-17 years (vs < 5 years; aOR 1.59; 95% CI, 1.32-1.92), non-English/non-Spanish language preference (vs English; aOR, 1.34; 95% CI, 1.02-1.76), and receipt of an IGRA (vs TST, aOR, 30.82; 95% CI, 21.92-43.34) were associated with increased odds of testing completion. Odds of testing completion decreased as census tract social vulnerability index quartile increased (ie, social vulnerability worsened; most vulnerable quartile vs least vulnerable quartile, aOR, 0.77; 95% CI, 0.60-0.99). Odds of completing treatment after starting treatment were higher in females (vs males; aOR, 2.35; 95% CI, 1.14-4.85) and were lower in patients starting treatment in a primary care clinic (vs TB/infectious diseases clinic; aOR, 0.44; 95% CI, 0.27-0.71). CONCLUSIONS: Among children with a high proportion of negative TB infection tests, completion of testing was high, but completion of evaluation and treatment was moderate. Transitions toward IGRA testing will improve testing completion; interventions addressing social determinants of health are important to improve treatment completion.
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Tuberculose Latente , Tuberculose , Masculino , Criança , Feminino , Humanos , Adolescente , Boston , Estudos Retrospectivos , Tuberculose/diagnóstico , Tuberculose/epidemiologia , Tuberculose Latente/diagnóstico , Testes de Liberação de Interferon-gama , Teste TuberculínicoRESUMO
To achieve WHO's goal of eliminating hepatitis C virus (HCV), innovative strategies must be designed to diagnose and treat more patients. Therefore, we aimed to describe an implementation strategy to identify patients with HCV who were lost to follow-up (LTFU) and offer them re-linkage to HCV care. We conducted an implementation study utilizing a strategy to contact patients with HCV who were not under regular follow-up in 13 countries from Latin America. Patients with HCV were identified by the international classification of diseases (ICD-9/10) or equivalent. Medical records were then reviewed to confirm the diagnosis of chronic HCV infection defined by anti-HCV+ and detectable HCV-RNA. Identified patients who were not under follow-up by a liver specialist were contacted by telephone or email, and offered a medical reevaluation. A total of 10,364 patients were classified to have HCV. After reviewing their medical charts, 1349 (13%) had undetectable HCV-RNA or were wrongly coded. Overall, 9015 (86.9%) individuals were identified with chronic HCV infection. A total of 5096 (56.5%) patients were under routine HCV care and 3919 (43.5%) had been LTFU. We were able to contact 1617 (41.3%) of the 3919 patients who were LTFU at the primary medical institution, of which 427 (26.4%) were cured at a different institutions or were dead. Of the remaining patients, 906 (76.1%) were candidates for retrieval. In our cohort, about one out of four patients with chronic HCV who were LTFU were candidates to receive treatment. This strategy has the potential to be effective, accessible and significantly impacts on the HCV care cascade.
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Hepatite C Crônica , Hepatite C , Humanos , Hepatite C Crônica/diagnóstico , Hepatite C Crônica/tratamento farmacológico , Hepatite C Crônica/epidemiologia , América Latina/epidemiologia , Perda de Seguimento , Hepacivirus/genética , Organização Mundial da SaúdeRESUMO
UNAIDS' 90-90-90 goal for 2020 is for 90% of HIV-infected people to know their status, 90% of infected individuals to receive antiretroviral therapy (ART), and 90% of those on ART to achieve viral suppression. To achieve these ambitious goals, effective care delivery programs are needed. In this paper we present a case study showing how HIV care can be improved by viewing the patient care process as a production process and applying methods of process improvement analysis. We examine the continuum of HIV care at a hospital-based HIV clinic in Kingston, Jamaica. We perform qualitative analysis to identify key programmatic, personnel, and clinical areas for process improvement. We then perform quantitative analysis. We develop a stochastic model of the care process which we use to evaluate the effects of potential process improvements on the number of patients who receive ART and the number who achieve viral suppression. We also develop a model for optimal investment of a fixed budget among interventions aimed at improving the care cascade and we use the model to determine the optimal investment among three interventions that the clinic could invest in. By viewing the patient care process as a production process and applying qualitative and quantitative process improvement analysis, our case study illustrates how clinics can identify the best ways to maximize clinical outcomes. Our methods are generalizable to other HIV care clinics as well as to clinics that provide care for other chronic conditions (e.g., diabetes, hepatitis B, or opioid use disorder).
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BACKGROUND: Trend data on hypertension prevalence and attainment indicators at each step of the care cascade (awareness, treatment, control) are required in Chile. This study aims to quantify trends (2003-2017) in prevalence and in the proportion of individuals with hypertension attaining each step of the care cascade among adults aged 17 years or older, and to assess the impact of lowering the blood pressure (BP) thresholds used to define elevated BP on these indicators. METHODS: We used data from 2003, 2010, and 2017 Chilean national health surveys. Each year we assessed levels of (1) mean systolic (SBP) and diastolic (DBP) blood pressure, (2) hypertension prevalence (BP ≥ 140/90 mmHg or use of antihypertensive treatment), and (3) awareness, treatment, and control. Logistic regression on pooled data was used to assess trends in binary outcomes; linear regression was used to assess trends in continuous SBP and DBP. We compared levels of hypertension prevalence using two sources to ascertain antihypertensive treatment (self-reported versus medicine inventory). The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines were used to re-define hypertension using lower thresholds (BP ≥ 130/80 mmHg). RESULTS: Hypertension prevalence was 34.0, 32.0 and 30.8% in 2003, 2010 and 2017, respectively. Levels of treated- and controlled-hypertension were significantly higher in 2017 than in 2003 (65% versus 41% for treatment, P < 0.001; 34% versus 14% for control, P < 0.001), while levels of awareness were stable (66% versus 59%, P = 0.130). Awareness, treatment, and control levels were higher among females in 2003, 2010, and 2017 (P < 0.001). Mean SBP and DBP decreased over the 15-year period, except for SBP among females on treatment. Adopting the 2017 ACC/AHA guidelines would increase hypertension prevalence by 17 and 55% in absolute and relative terms, respectively. CONCLUSIONS: Chile has experienced a positive population-wide lowering in blood pressure distribution which may be explained partly by a significant rise in levels of treated- and controlled-hypertension since 2003. Lowering the thresholds used to define elevated BP would substantially increase the financial public health challenge of further improving attainment levels at each step of the care cascade. Innovative and collaborative strategies are needed to improve hypertension management, especially among males.
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Hipertensão , Adolescente , Adulto , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea , Chile/epidemiologia , Estudos Transversais , Feminino , Inquéritos Epidemiológicos , Humanos , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Masculino , Prevalência , Fatores de RiscoRESUMO
HISTÓRICO: A cascata de cuidado contínuo surgiu como uma estratégia para se transpor a infecção por HIV e se alcançar o objetivo final em cuidados, que seria a supressão viral. Este estudo tem como objetivo descrever a cascata de cuidado contínuo em indivíduos com HIV/AIDS em um Serviço Ambulatorial Especializado. METODOLOGIA: Esse é um estudo de coorte retrospectivo que analisou indivíduos adultos com diagnóstico confirmado de HIV/AIDS e que iniciaram seu acompanhamento no Núcleo de Atenção Médica Integrada (NAMI) da Universidade de Fortaleza (UNIFOR), cidade de Fortaleza, estado do Ceará, na região Nordeste do Brasil. Os dados que se seguem foram usados na pesquisa: carga viral CD4+/CD8+ e carga viral do HIV. Os participantes foram classificados em dois grupos: retidos no cuidado em saúde (grupo 1) e não retidos no cuidado em saúde (grupo 2), totalizando uma coorte de 511 participantes. RESULTADO: A análise univariada entre os grupos demonstrou que havia predominância significativa de pacientes homens com média de idade mais alta no grupo 1 (p = 0,01). Um histórico prévio de dependência química, e na primeira consulta, foi mais frequente no grupo 2 (p = 0,001 e p = 0,01 respectivamente). Os pacientes do grupo 1 tinham um histórico mais frequente de infecções sexualmente transmissíveis (IST) (p=0,002) e estavam mais imunossuprimidos quando do diagnóstico (p = 0,002). O uso de terapia antirretroviral (TARV) na primeira consulta foi mais significativo no grupo de pacientes retidos (p<0,001). CONCLUSÕES: Este estudo sugere a necessidade de aprimoramento da "cascata de cuidados" através de sua expansão, na medida em que considere riscos comportamentais dinâmicos, o que poderia transpor as barreiras sistêmicas de acesso aos serviços de saúde para as pessoas que vivem com HIV/AIDS.
ANTECEDENTES: La cascada constante de tratamiento/cuidados ha emergido como una estrategia a fin de dejar atrás la infección por VIH en busca de la meta última del tratamiento, que es la supresión viral. El estudio apunta a describir la cascada de cuidados en individuos con VIH/SIDA en un Servicio Ambulatorio Especializado. MÉTODOS: El diseño del estudio es un grupo retrospectivo de individuos adultos con diagnosis confirmada del VIH/SIDA, quienes iniciaron su seguimiento en el Centro de Cuidados Médicos Integrados (NAMI) de la Universidad de Fortaleza (UNIFOR), en la ciudad de Fortaleza, estado de Ceará, en el nordeste de Brasil. Las informaciones siguientes fueron utilizadas en la investigación: CD4+/CD8+ carga viral y carga viral del VIH/SIDA. Los individuos fueron clasificados en dos grupos: retenidos (grupo 1) y no retenidos (grupo 2), totalizando una muestra de 511 participantes. RESULTADOS: El análisis de variable única entre estos grupos demostró que había una predominancia significativa de pacientes masculinos con una edad promedio más elevada en el grupo 1 (p = 0.01). Un antecedente de adicción previa a narcóticos durante la primera consulta fue más frecuente en el segundo grupo (p = 0.001 y p = 0.01 respectivamente). Los pertenecientes al grupo 1, de manera más frecuente, tenían antecedentes de infecciones sexualmente transmitidas (IST) (p = 0.002) y estaban más inmunosuprimidos a la época del diagnóstico (p = 0.002). El uso de TARV (terapia antirretroviral) en la primera consulta fue también más significativo en el grupo de pacientes retenidos (p <0.001). CONCLUSIONES: El estudio sugiere la necesidad de mejorar la "cascada de tratamiento/cuidados" mediante su expansión, a fin de abordar los riesgos de conducta dinámica, lo cual puede transponer las barreras sistémicas de acceso a los servicios de salud para las personas que conviven con VIH/SIDA.
BACKGROUND: The continuous care cascade has emerged as a strategy to transpose HIV infection to attain the ultimate goal of care, which is viral suppression. The study aims to describe the care cascade in individuals with HIV / AIDS in a Specialized Ambulatory Service. METHODS: The study design is a retrospective cohort of adult individuals with a confirmed diagnosis of HIV/AIDS who initiated their follow-up at the Integrated Medical Care Center (NAMI) of Universidade de Fortaleza (UNIFOR), in the city of Fortaleza, state of Ceará, northeastern Brazil. The following data were used in the investigation: CD4+/CD8+ viral load and HIV viral load. The subjects were classified into two groups: retained (group 1) and non-retained (group 2), totaling a sample of 511 participants. RESULTS: The univariate analysis between these groups showed that there was a significant predominance of male patients with a higher mean age in group 1 (p = 0.01). A history of previous drug addiction and at the first consultation was more frequent in the second group (p = 0.001 and p = 0.01 respectively). Patients from group 1 more often had a history of sexually-transmitted infections (STIs) (p = 0.002) and were more immunosuppressed at the time of diagnosis (p = 0.002). The use of ART at the first consultation was also more significant in the group of retained patients (p <0.001). CONCLUSIONS: The study suggests a need to improve the "cascade of care" by expanding it to address dynamic behavioral risks, which can transpose the systemic barriers of access to health services for people living with HIV/AIDS.
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Humanos , Masculino , Feminino , Síndrome da Imunodeficiência Adquirida/diagnóstico , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , HIV , Terapia Antirretroviral de Alta Atividade , Assistência Ambulatorial , Resposta Viral Sustentada , Perfil de Saúde , Saúde Pública , Estudos Retrospectivos , Síndrome da Imunodeficiência Adquirida/transmissãoRESUMO
Emerging evidence suggests that HIV incidence rates in Brazil, particularly among men, may be rising. Here we use Brazil's integrated health systems data to develop a mathematical model, reproducing the complex surveillance systems and providing estimates of HIV incidence, number of people living with HIV (PLHIV), reporting rates and ART initiation rates. An age-structured deterministic model with a flexible spline was used to describe the natural history of HIV along with reporting and treatment rates. Individual-level surveillance data for 1,077,295 cases (HIV/AIDS diagnoses, ART dispensations, CD4 counts and HIV/AIDS-related deaths) were used to calibrate the model using Bayesian inference. The results showed a second wave of infections occurring after 2001 and 56,000 (95% Credible Interval 43,000-71,000) new infections in 2015, 37,000 (95% CrI 28,000-54,000) infections in men and 16,000 (95% CrI 10,000-23,000) in women. The estimated number of PLHIV by end-2015 was 838,000 (95% CrI 675,000-1,083,000), with 80% (95% CrI 62-98%) of those individuals reported to the Ministry of Health. Women were more likely to be diagnosed and reported than men; 86.8% of infected women had been reported compared with 75.7% of men. Likewise, ART initiation rates for women were higher than those for men. The second wave contradicts previous estimates of HIV incidence trends in Brazil and there were persistent differences in the rates of accessing care between men and women. Nevertheless, the Brazilian HIV program has achieved high rates of detection and treatment, making considerable progress over the past ten years.
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Infecções por HIV/epidemiologia , Adolescente , Adulto , Distribuição por Idade , Teorema de Bayes , Brasil/epidemiologia , Contagem de Linfócito CD4 , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
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.
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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
The Caribbean has the highest adult HIV prevalence in the world after sub-Saharan Africa (2011). One sub-population in the Dominican Republic is the migratory Batey community primarily comprised of Haitian immigrants with limited access to healthcare and HIV prevalence rates of between 3.0% and 9.0%, compared to 0.7% nationally. This retrospective cohort study describes the cumulative retention from diagnosis to virological suppression for newly-diagnosed HIV-infected adults presenting to the Clínica de Familia and its Batey programme in La Romana, during 2011. Of the patients diagnosed with HIV, 65% entered into care, 59% completed immunologic testing, 53% were eligible for antiretroviral therapy (ART) initiation, 36% initiated ART within three months of eligibility and 27% were retained in care. Seventeen per cent of those retained on ART with a 12-month viral load measure had undetectable viral load. Attrition primarily occurred before ART initiation. The Batey programme had a first step lost-to-follow-up of 88% compared to 20% at the clinic (p < 0.001). This retrospective study details the continuum of care and indicates where structural changes must occur to increase continuity between steps. The manuscript results are important to help implement programmes to enhance engagement and retention in HIV primary care.