The complexity of TB/HIV coinfection: an analysis of the social and health services context in the state of São Paulo, Brazil.

INTRODUCTION: Brazil is in the 19th position of priority countries for the control of TB/HIV coinfection, so we aimed to analyze the social and health services contexts that are associated with TB/HIV coinfection in São Paulo state. METHODOLOGY: Ecological study conducted in 645 cities of the state. The study population consisted of 10,389 new cases of TB/HIV coinfection in state residents between 2010 and 2015. The variables and indicators used in the study were collected from secondary sources. To identify the factors associated with the occurrence of TB/HIV coinfection cases, generalized additive models for location, scale and shape were used. The best distribution model was defined from the lowest Akaike information criterion value. RESULTS: There was an association between the occurrence of coinfection and the diagnosis of TB after death and greater treatment default. There was also an association with greater coverage of nurses and Family Health Strategy, which comprises Primary Care settings focused on families. Regarding the social context, the Gini Coefficient of inequality was identified as a determinant of coinfection. CONCLUSIONS: The study presents the complexity of TB/HIV coinfection, proposing critical points in the health services and social context. Despite the high coverage of nurses and Family Health Strategy in some cities, this did not affect the reduction of the incidence of coinfection. These findings may be attributed to a fragmented care and focused on acute conditions. Furthermore, this model of care holds few prospects for care integration or prioritization of prevention and health promotion actions.

Social risk and its association with tuberculosis mortality in a context of high inequality in South Brazil: A geo-epidemiology analysis.

BACKGROUND: Tuberculosis (TB) is one of the top 10 causes of death worldwide; in 2016, over 95% of TB deaths occurred in low- and middle-income countries. Although the incidence and deaths from TB have decreased in Brazil in recent years, the disease has increased in the vulnerable population, whose diagnosis is more delayed and the chances for abandonment and deaths are significantly higher. This study aimed to identify high-risk areas for TB mortality and evidence their social determinants through a sensitive tailored social index, in a context of high inequality in South Brazil. METHODS: A multistep statistical methodology was developed, based on spatial clustering, categorical principal components analysis, and receiver operating characteristic curves (ROC). This study considered 138 spatial units in Curitiba, South Brazil. TB deaths (2008-2015) were obtained from the National Information Mortality System and social variables from the Brazilian Human Development Atlas (2013). RESULTS: There were 128 TB deaths recorded in the study: the mortality rate was 0.9/100,000 inhabitants, minimum-maximum: 0-25.51/100,000, with a mean (standard deviation) of 1.07 (2.71), and 78 space units had no deaths. One risk cluster of TB mortality was found in the south region (RR=2.64, p=0.01). Considering the social variables, several clusters were identified in the social risk indicator (SRI): income (899.82/1752.94; 0.024), GINI Index (0.41/0.45; 0.010), and overcrowding (25.07/15.39; 0.032). The SRI showed a high capacity to discriminate the TB mortality areas (area under ROC curve 0.865, 95% CI: 0.796-0.934). CONCLUSIONS: A powerful risk map (SRI) was developed, allowing tailored and personalised interventions. The south of Curitiba was identified as a high-risk area for TB mortality and the majority of social variables. This methodological approach can be generalised to other areas and/or other public health problems.