Beyond access to medication: the role of SUS and the characteristics of HIV care in Brazil / Para além do acesso ao medicamento: papel do SUS e perfil da assistência em HIV no Brasil

ABSTRACT OBJECTIVE To estimate the public-private composition of HIV care in Brazil and the organizational profile of the extensive network of public healthcare facilities. METHODS Data from the Qualiaids-BR Cohort were used, which gathers data from national systems of clinical and laboratory information on people aged 15 years or older with the first dispensation of antiretroviral therapy between 2015-2018, and information from SUS healthcare facilities for clinical-laboratory follow-up of HIV, produced by the Qualiaids survey. The follow-up system was defined by the number of viral load tests requested by any SUS healthcare facility: follow-up in the private system - no record; follow-up at SUS - two or more records; undefined follow-up - one record. SUS healthcare facilities were characterized as outpatient clinics, primary care and prison system, according to the respondents' self-classification in the Qualiaids survey (72.9%); for non-respondents (27.1%) the classification was based on the terms present in the names of the healthcare facilities. RESULTS During the period, 238,599 people aged 15 years or older started antiretroviral therapy in Brazil, of which 69% were followed-up at SUS, 21.7% in the private system and 9.3% had an undefined system. Among those followed-up at SUS, 93.4% received care in outpatient clinics, 5% in primary care facilities and 1% in the prison system. CONCLUSION In Brazil, antiretroviral treatment is provided exclusively by SUS, which is also responsible for clinical and laboratory follow-up for most people in outpatient clinics. The study was only possible because SUS maintains records and public information about HIV care. There is no data available for the private system.

RESUMO OBJETIVO Estimar a composição público-privada da assistência em HIV no Brasil e o perfil organizacional da extensa rede de serviços públicos. MÉTODOS Foram utilizados dados da Coorte Qualiaids-BR, que reúne dados dos sistemas nacionais de informações clínicas e laboratoriais de pessoas com 15 anos ou mais com primeira dispensação de terapia antirretroviral, entre 2015-2018, e informações dos serviços do SUS de acompanhamento clínico-laboratorial do HIV, produzidas pelo inquérito Qualiaids. O sistema de acompanhamento foi definido pelo número de exames de carga viral solicitados por algum serviço do SUS: acompanhamento no sistema privado - nenhum registro; acompanhamento no SUS - dois ou mais registros; acompanhamento indefinido - um registro. Os serviços do SUS foram caracterizados como ambulatórios, atenção básica e sistema prisional, segundo autoclassificação dos respondentes ao inquérito Qualiaids (72,9%); para os não respondentes (27,1%) a classificação baseou-se nos termos presentes nos nomes dos serviços. RESULTADOS No período, 238.599 pessoas com 15 anos ou mais iniciaram a terapia antirretroviral no Brasil, das quais, 69% receberam acompanhamento no SUS, 21,7% no sistema privado e 9,3% tiveram o sistema indefinido. Entre os acompanhados no SUS, 93,4% foram atendidos em serviços do tipo ambulatório, 5% em serviços de atenção básica e 1% no sistema prisional. CONCLUSÃO No Brasil o tratamento antirretroviral é fornecido exclusivamente pelo SUS, que também é responsável pelo acompanhamento clínico-laboratorial da terapia da maior parte das pessoas em serviços ambulatoriais. O estudo só foi possível porque o SUS mantêm registros e informações públicas acerca do acompanhamento em HIV. Não há nenhum dado disponível para o sistema privado.

HTA and HIV: The Case of Dual NRTI Backbones in the Italian Setting.

The aim of this study is to analyze the potential advantages of emtricitabine/tenofovir alafenamide (FTC/TAF) introduction, creating evidence-based information to orient strategies to reduce costs, thus preserving effectiveness and appropriateness. An Health Technology Assessment (HTA) was implemented in the years 2017-2018 comparing the dual backbones available in the Italian market: FTC/TAF, FTC/TDF (tenofovir disoproxil fumarate/emtricitabine) and ABC/3TC (abacavir/lamivudine). From an efficacy point of view, FTC/TAF ensured a higher percentage of virologic control and a better safety impact than FTC/TDF (improving the renal and bone safety profile, as well as the lipid picture). From an economic point of view, the results revealed a 4% cost saving for the Italian National Healthcare Service NHS with FTC/TAF introduction compared with the baseline scenario. Qualitative perceptions' results showed that FTC/TAF would decrease the burden of adverse events management, increasing the accessibility of patients to healthcare providers (FTC/TAF: 0.95, FTC/TDF: 0.10, ABC/3TC: 0.28; p-value: 0.016) and social costs (FTC/TDF: -0.23, FTC/TAF: 1.04, ABC/3TC: 0.23; p-value < 0.001), improving patient quality of life (FTC/TDF: 0.31, FTC/TAF: 1.85, ABC/3TC: 0.38; p-value < 0.001). Healthcare services may consider the evidence provided by the present study as an opportunity to include HIV patients in a more adequate antiretroviral treatment arm, guaranteeing a personalized clinical pathway, thus becoming more efficient and effective over time.

COVID-19 pandemic and antiretrovirals (ARV) availability in Nigeria: recommendations to prevent shortages.

HIV/AIDS is an infectious disease that has claimed the lives of millions of people worldwide. Currently, there is no vaccine that has been developed in a bid to fight this deadly infection, however, antiretrovirals (ARVs), which are drugs used in the treatment of HIV infection are routinely prescribed to infected persons. They act via several mechanisms of action to reduce the severity of infection and rate of infectivity of the virus by decreasing the viral load while increasing CD4 counts. COVID-19 pandemic has resulted in unprecedented events affecting almost all areas of humans' life including availability of medicines and other consumables. This paper analyses the availability of ARVs during COVID-19 era and offered recommendations to be adopted in order to prevent shortages.

Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models.

BACKGROUND: The COVID-19 pandemic could lead to disruptions to provision of HIV services for people living with HIV and those at risk of acquiring HIV in sub-Saharan Africa, where UNAIDS estimated that more than two-thirds of the approximately 38 million people living with HIV resided in 2018. We aimed to predict the potential effects of such disruptions on HIV-related deaths and new infections in sub-Saharan Africa. METHODS: In this modelling study, we used five well described models of HIV epidemics (Goals, Optima HIV, HIV Synthesis, an Imperial College London model, and Epidemiological MODeling software [EMOD]) to estimate the effect of various potential disruptions to HIV prevention, testing, and treatment services on HIV-related deaths and new infections in sub-Saharan Africa lasting 6 months over 1 year from April 1, 2020. We considered scenarios in which disruptions affected 20%, 50%, and 100% of the population. FINDINGS: A 6-month interruption of supply of antiretroviral therapy (ART) drugs across 50% of the population of people living with HIV who are on treatment would be expected to lead to a 1·63 times (median across models; range 1·39-1·87) increase in HIV-related deaths over a 1-year period compared with no disruption. In sub-Saharan Africa, this increase amounts to a median excess of HIV deaths, across all model estimates, of 296 000 (range 229 023-420 000) if such a high level of disruption occurred. Interruption of ART would increase mother-to-child transmission of HIV by approximately 1·6 times. Although an interruption in the supply of ART drugs would have the largest impact of any potential disruptions, effects of poorer clinical care due to overstretched health facilities, interruptions of supply of other drugs such as co-trimoxazole, and suspension of HIV testing would all have a substantial effect on population-level mortality (up to a 1·06 times increase in HIV-related deaths over a 1-year period due to disruptions affecting 50% of the population compared with no disruption). Interruption to condom supplies and peer education would make populations more susceptible to increases in HIV incidence, although physical distancing measures could lead to reductions in risky sexual behaviour (up to 1·19 times increase in new HIV infections over a 1-year period if 50% of people are affected). INTERPRETATION: During the COVID-19 pandemic, the primary priority for governments, donors, suppliers, and communities should focus on maintaining uninterrupted supply of ART drugs for people with HIV to avoid additional HIV-related deaths. The provision of other HIV prevention measures is also important to prevent any increase in HIV incidence. FUNDING: Bill & Melinda Gates Foundation.

[Access to the management of HIV infected children: Overview of the healthcare supply in Cameroon in 2014]. / Accès à la prise en charge de l'infection VIH pédiatrique ­ État des lieux de l'offre des soins au Cameroun en 2014.

BACKGROUND: In Cameroon in 2012, the proportion (15%) of children eligible for antiretroviral treatment (ART) was one of the lowest among the 21 Global Fund priority countries. The objective of this study was to carry out a situational analysis of the existing care offer for pediatric HIV in Cameroon. METHODS: A descriptive cross-sectional study was conducted over a 4-month period (April to August 2014) in 12 healthcare facilities in 7 regions of Cameroon selected by systematic sampling. The data were collected in a self-administered questionnaire filled out by the caregiving and administrative personnel included in the study. RESULTS: All in all, 142 persons in charge of pediatric HIV treatment were included in the study, of whom 115 were working at the operational level: 59 (51.2%) health personnel, 44 (38.3%) community agents and 12 (10.4%) department heads; the other 27 exercised responsibilities at the regional (19) and the local (8) levels. An overwhelming majority of the caregivers involved in pediatric VIH treatment were nurses, a factor necessitating the delegation of medical tasks institutionalized in Cameroon. Few standardized nationwide documents take into account these treatment modalities. Inadequate dissemination of the documents at all levels of the healthcare pyramid may justify the non-compliance with the care protocols that has been observed in the training programs dedicated to the subject. CONCLUSION: The updating and large-scale dissemination of standardized nationwide documents taking into account the specificities of HIV-infected children are required to improve implementation at the operational level of the Cameroonian healthcare system of the existing guidelines for pediatric HIV treatment.

Policy- and county-level associations with HIV pre-exposure prophylaxis use, the United States, 2018.

PURPOSE: HIV pre-exposure prophylaxis (PrEP) is highly efficacious, and yet most individuals indicated for it are not currently using it. To provide guidance for health policymakers, researchers, and community advocates, we developed county-level PrEP use estimates and assessed locality and policy associations. METHODS: Using data from a national aggregator, we applied a validated crosswalk procedure to generate county-level estimates of PrEP users in 2018. A multilevel Poisson regression explored associations between PrEP use and (1) state policy variables of Medicaid expansion and state Drug Assistance Programs (PrEP-DAPs) and (2) county-level characteristics from the U.S. Census Bureau. Outcomes were PrEP per population (prevalence) and PrEP-to-need ratio (PnR), defined as the ratio of PrEP users per new HIV diagnosis. Higher levels of PrEP prevalence or PnR indicate more PrEP users relative to the total population or estimated need, respectively. RESULTS: Our 2018 county-level data set included a total of 188,546 PrEP users in the United States. Nationally, PrEP prevalence was 70.3/100,000 population and PnR was 4.9. In an adjusted model, counties with a 5% higher proportion of black residents had 5% lower PnR (rate ratio (RR): 0.95, 95% confidence interval (CI): 0.93, 0.96). Similarly, counties with higher concentration of residents uninsured or living in poverty had lower PnR. Relative to states without Medicaid expansion or PrEP-DAPs, states with only one of those programs had 25% higher PrEP prevalence (RR: 1.25, 95% CI: 1.09, 1.45), and states with both programs had 99% higher PrEP prevalence (RR: 1.99, 95% CI: 1.60, 2.48). There was a significant linear trend across the three policy groups, and similar findings for the relation between PnR and the policy groups. CONCLUSIONS: In a data set comprising approximately 80% of PrEP users in the United States, we found that Medicaid expansion and PrEP-DAPs were associated with higher PrEP use in states that adopted those policies, after controlling for potential confounders. Future research should identify which components of PrEP support programs have the most success and how to best promote PrEP among groups most impacted by the epidemic. States should support the admirable health decisions of their residents to get on PrEP by implementing policies that facilitate access.

Impact of the 12 January 2010 earthquake on HIV case reporting in Haiti.

OBJECTIVE: To evaluate the impact of the 12 January 2010 earthquake on HIV cases from Haiti's national HIV surveillance system and assess the characteristics of people living with HIV 1-year before and after the earthquake. DESIGN: An interrupted time-series design and cross-sectional analysis. METHODS: We used autoregressive integrated moving average structures to model abrupt changes to the monthly, incident HIV case counts from HIV care clinics as reported to the Haitian Active Longitudinal Tracking of HIV System (French acronym SALVH) by clinical networks (n = 3) and earthquake instrumental intensity zones (n = 4). Preearthquake and postearthquake differences in patient-level characteristics including clinical values were examined using the χ test, t tests, Wilcoxon rank-sum test. RESULTS: In the month immediately following the earthquake, all three clinical networks experienced statistically significant declines in cases reported: iSanté (-31.4%), Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (-29.9%) and Zamni Lasante (-32.2%). Zone 8 (the most severe) was the only area with a statistically significant decline (-45.5%). Of the three clinical networks, only iSanté returned to preearthquake reporting levels by the end of our study period. Patient-level characteristics did not change dramatically after the earthquake. CONCLUSION: Despite case reporting declines, especially in clinics near the earthquake epicenter, SALVH remained intact with less impact than expected. This national system is a critical component of Haiti's strategic health information system initiative and plays a central role to HIV monitoring and evaluation efforts.

The fight against COVID-19 in sub-Saharan Africa-a threat to the continuous management of HIV patients: application of the action areas of the Ottawa charter for health promotion.

The Novel Coronavirus (2019-nCoV) was detected in December 2019 in the Hubei Province of China. Also known as COVID-19, the outbreak was declared a pandemic by the World Health Organization (WHO) in March 2020. Sub-Saharan Africa (SSA), which is the region hardest hit by HIV, is also highly affected by COVID-19. The fight against COVID-19 in SSA might threaten the continuous management of persons living with HIV (PLHIV). This commentary uses the five action areas of the Ottawa charter for health promotion to address the issue. If the issues raised in this commentary are not addressed quickly by SSA governments, every single link of the supply chain in the HIV response will be disrupted. This disruption might result in more stock-outs, shortages and a lack of access to ART in the months ahead. The SSA governments must ensure that HIV treatment adherence is not compromised owing to a shift of focus to the fight against COVID-19. They should ensure that everyone on HIV treatment gets an adequate supply of antiretroviral therapy (ART).

Current experiences of accessing and using HIV pre-exposure prophylaxis (PrEP) in the United Kingdom: a cross-sectional online survey, May to July 2019.

The 2019 online pre-exposure prophylaxis (PrEP) user survey in the United Kingdom was conducted to assess HIV PrEP access, and user characteristics. One in five respondents continued experiencing difficulties accessing PrEP; users were almost exclusively gay or bisexual men at high risk of HIV. The majority obtained PrEP through health service clinics and rated PrEP positively. High STI rates were reported among users. Renal and sexual health checks are advised for those sourcing PrEP privately.