ABSTRACT
INTRODUCTION: Patient satisfaction with clinical services can have an effect on retention in HIV care and adherence to antiretroviral therapy. This study assessed patient satisfaction and its association with retention and viral suppression in Zambézia Province, Mozambique. METHODS: Monthly exit interviews with persons living with HIV were completed from August 2017-January 2019 in 20 health facilities; clinical data were extracted from medical records. Regression analyses assessed the effect of satisfaction scores on retention and viral suppression, adjusting for age, sex, education, civil status, time on treatment, and site. Satisfaction scores were correlated with time spent at health facilities using generalized linear regression models. RESULTS: Data from 4388 patients were analyzed. Overall median satisfaction score was 75% (IQR 53%-84%); median time spent at facilities (from arrival until completion of clinical services) was 2h54min (IQR 1h48min-4h). Overall satisfaction score was not associated with higher odds of retention or viral suppression, but association was seen between satisfaction regarding attention given to patient and respect and higher odds of viral suppression. Patient satisfaction was negatively associated with time spent in facility (Spearman's correlation -0.63). Increased time spent at facility (from 1 to 3 hours) was not associated with lower retention in care (OR 0.72 [95%CI:0.52-1.01] and 0.83 [95%CI: 0.63-1.09] at 6- and 12-months, respectively), nor with a lower odds of viral suppression (OR 0.96 [95%CI: 0.71-1.32]). CONCLUSIONS: Strategies to reduce patient wait times at the health facility warrant continued prioritization. Differentiated models of care have helped considerably, but novel approaches are still needed to further decongest crowded health facilities. In addition, a good client-provider communication and positive attitude can improve patient satisfaction with health services, with an overall improved retention.
Subject(s)
HIV Infections , Patient Satisfaction , Humans , Cross-Sectional Studies , Mozambique , Health Facilities , HIV Infections/drug therapyABSTRACT
Introduction: Mentor Mothers (MM) provide peer support to pregnant and postpartum women living with HIV (PPWH) and their infants with perinatal HIV exposure (IPE) throughout the cascade of prevention of vertical transmission (PVT) services. MM were implemented in Zambézia Province, Mozambique starting in August 2017. This evaluation aimed to determine the effect of MM on PVT outcomes. Methods: A retrospective interrupted time series analysis was done using routinely collected aggregate data from 85 public health facilities providing HIV services in nine districts of Zambézia. All PPWH (and their IPE) who initiated antiretroviral therapy (ART) from August 2016 through April 2019 were included. Outcomes included the proportion per month per district of: PPWH retained in care 12 months after ART initiation, PPWH with viral suppression and IPE with HIV DNA PCR test positivity by 9 months of age. The effect of MM on outcomes was assessed using logistic regression. Results: The odds of 12-month retention increased 1.5% per month in the pre-MM period, compared to a monthly increase of 7.6% with-MM (35-61% pre-MM, 56-72% with-MM; p < 0.001). The odds of being virally suppressed decreased by 0.9% per month in the pre-MM period, compared to a monthly increase of 3.9% with-MM (49-85% pre-MM, 59-80% with-MM; p < 0.001). The odds of DNA PCR positivity by 9 months of age decreased 8.9% per month in the pre-MM period, compared to a monthly decrease of 0.4% with-MM (0-14% pre-MM, 4-10% with-MM; p < 0.001). The odds of DNA PCR uptake (the proportion of IPE who received DNA PCR testing) by 9 months of age were significantly higher in the with-MM period compared to the pre-MM period (48-100% pre-MM, 87-100% with-MM; p < 0.001). Conclusions: MM services were associated with improved retention in PVT services and higher viral suppression rates among PPWH. While there was ongoing but diminishing improvement in DNA PCR positivity rates among IPE following MM implementation, this might be explained by increased uptake of HIV testing among high-risk IPE who were previously not getting tested. Additional efforts are needed to further optimize PVT outcomes, and MM should be one part of a comprehensive strategy to address this critical need.
Subject(s)
Humans , Female , Pregnancy , Child , HIV Infections/transmission , HIV Infections/epidemiology , Mozambique , Pregnancy Complications/drug therapy , Pregnancy Complications, Infectious/prevention & control , HIV Infections/drug therapy , Retrospective Studies , Infectious Disease Transmission, Vertical , Infectious Disease Transmission, Vertical/prevention & control , Interrupted Time Series AnalysisABSTRACT
Before the 2015 implementation of "Test and Start," the initiation of combination antiretroviral therapy (ART) was guided by specific CD4 cell count thresholds. As scale-up efforts progress, the prevalence of advanced HIV disease at ART initiation is expected to decline. We analyzed the temporal trends in the median CD4 cell counts among adults initiating ART and described factors associated with initiating ART with severe immunodeficiency in Zambézia Province, Mozambique. We included all HIV-positive, treatment-naive adults (age ≥ 15 years) who initiated ART at a Friends in Global Health (FGH)-supported health facility between September 2012 and September 2017. Quantile regression and multivariable logistic regression models were applied to ascertain the median change in CD4 cell count and odds of initiating ART with severe immunodeficiency, respectively. A total of 68,332 patients were included in the analyses. The median change in CD4 cell count under "Test and Start" was higher at +68 cells/mm3 (95% CI: 57.5-78.4) compared with older policies. Younger age and female sex (particularly those pregnant/lactating) were associated with higher median CD4 cell counts at ART initiation. Male sex, advanced age, WHO Stage 4 disease, and referrals to the health facility through inpatient provider-initiated testing and counseling (PITC) were associated with higher odds of initiating ART with severe immunodeficiency. Although there were reassuring trends in increasing median CD4 cell counts with ART initiation, ongoing efforts are needed that target universal HIV testing to ensure the early initiation of ART in men and older patients.
Subject(s)
Humans , Male , Female , Pregnancy , Adult , Young Adult , Rural Population , Antiretroviral Therapy, Highly Active , Immunologic Deficiency Syndromes/epidemiology , Anti-HIV Agents/therapeutic use , Drug Therapy, Combination , Health Policy , Mozambique/epidemiologyABSTRACT
Background: In resource-limited rural settings, scale-up of services to eliminate mother-to-child transmission of HIV has not been as effective as in better resourced urban settings. In sub-Saharan Africa, women often require male partner approval to access and remain engaged in HIV care. Our study will evaluate a promising male engagement intervention ("Homens para Saúde Mais" (HoPS+) [Men for Health Plus]) targeting the elimination of mother-to-child transmission in rural Mozambique. Design: We will use a cluster randomized clinical trial design to engage 24 health facilities (12 intervention and 12 standard of care), with 45 HIV-infected seroconcordant couples per clinic. The planned intervention will engage male partners to address social-structural and cultural factors influencing eMTCT based on new couple-centered integrated HIV services. Conclusions: The HoPS+ study will evaluate the effectiveness of engaging male partners in antenatal care to improve outcomes among HIV-infected pregnant women, their HIV-infected male partners, and their newborn children. Our objectives are to: (1) Implement and evaluate the impact of male-engaged, couple-centered services on partners' retention in care, adherence to antiretroviral therapy, early infant diagnosis uptake, and mother-to-child transmission throughout pregnancy and breastfeeding; (2) Investigate the impact of HoPS+ intervention on hypothesized mechanisms of change; and (3) Use validated simulation models to evaluate the cost-effectiveness of the HoPS+ intervention with the use of routine clinical data from our trial. We expect the intervention to lead to strategies that can improve outcomes related to partners' retention in care, uptake of services for HIV-exposed infants, and reduced MTCT.
Subject(s)
Humans , Male , Female , Pregnancy , Infant, Newborn , Adult , HIV Infections/diagnosis , HIV Infections/psychology , HIV Infections/therapy , Infectious Disease Transmission, Vertical/prevention & control , Rural Population , Breast Feeding/methods , Infant, Newborn , HIV Infections/transmission , Interpersonal Relations , Mozambique/epidemiologyABSTRACT
Background: In resource-limited rural settings, scale-up of services to eliminate mother-to-child transmission of HIV has not been as effective as in better resourced urban settings. In sub-Saharan Africa, women often require male partner approval to access and remain engaged in HIV care. Our study will evaluate a promising male engagement intervention ("Homens para Saúde Mais" (HoPS+) [Men for Health Plus]) targeting the elimination of mother-to-child transmission in rural Mozambique. Design: We will use a cluster randomized clinical trial design to engage 24 health facilities (12 intervention and 12 standard of care), with 45 HIV-infected seroconcordant couples per clinic. The planned intervention will engage male partners to address social-structural and cultural factors influencing eMTCT based on new couple-centered integrated HIV services. Conclusions: The HoPS+ study will evaluate the effectiveness of engaging male partners in antenatal care to improve outcomes among HIV-infected pregnant women, their HIV-infected male partners, and their newborn children. Our objectives are to: (1) Implement and evaluate the impact of male-engaged, couple-centered services on partners' retention in care, adherence to antiretroviral therapy, early infant diagnosis uptake, and mother-to-child transmission throughout pregnancy and breastfeeding; (2) Investigate the impact of HoPS+ intervention on hypothesized mechanisms of change; and (3) Use validated simulation models to evaluate the cost-effectiveness of the HoPS+ intervention with the use of routine clinical data from our trial. We expect the intervention to lead to strategies that can improve outcomes related to partners' retention in care, uptake of services for HIV-exposed infants, and reduced MTCT.
Subject(s)
Humans , Male , Female , Pregnancy , Infant, Newborn , Adult , HIV Infections , Public Health , Infectious Disease Transmission, Vertical , Rural Population , Breast Feeding , Interpersonal Relations , MozambiqueABSTRACT
Despite recent changes to expand the ART eligibility criteria in sub-Saharan Africa, many patients still initiate ART in the advanced stages of HIV infection, which contributes to increased early mortality rates, poor patient outcomes, and onward transmission. To evaluate individual and clinic-level factors associated with late ART initiation in Mozambique, we conducted a retrospective sex-specific analysis of data from 36,411 adult patients who started ART between January 2005 and June 2009 at 25 HIV clinics in Mozambique. Late ART initiation was defined as CD4 count<100 cells/µL or WHO stage IV. Mixed effects models were used to identify patient- and clinic-level factors associated with late ART initiation. The proportion of patients initiating ART late decreased from 46% to 37% during 20052007, but remained constant (between 3733%) from 20072009. Of those who initiated ART late (median CD4â=â57 cells/µL), 5% were known to have died and 54% were lost to clinic within 6 months of ART initiation (compared with 2% and 47% among other patients starting ART [median CD4â=â192 cells/µL]). In multivariate analysis, female sex and pregnancy at ART initiation (AORfemale_not_pregnant_vs._maleâ=â0.66, 95%CI [0.620.69]; AORpregnant_vs._non_pregnantâ=â0.60, 95%CI [0.490.73]), younger and older age (AOR1525_vs.2630â=â0.86, 95%CI [0.790.94], AOR>45_vs.2630â=â0.72, 95%CI [0.670.77]), entry into care via PMTCT (AORentry_through_PMTCT_vs.VCTâ=â0.42, 95%CI [0.350.50]), marital status (AORmarried/in union_vs.singleâ=â0.87, 95%CI [0.830.92]), education (AORsecondary_or_higher_vs.primaryâ=â0.87, 95%CI [0.830.93]) and year of ART initiation were associated with a lower likelihood of late ART initiation. Clinic-level factors independently associated with a lower likelihood of late ART initiation included CD4 machine on-site (AORCD4_machine_onsite_vs.offsiteâ=â0.83, 95%CI [0.740.94]) and presence of PMTCT services onsite (AORâ=â0.85, 95%CI [0.770.93]). The risk of starting ART late remained persistently high. Efforts are needed to ensure identification and enrollment of patients at earlier stages of HIV disease. Individual and clinic level factors identified may provide clues for upstream structural interventions.
Subject(s)
Humans , Female , Adolescent , Adult , Middle Aged , Patients , HIV Infections , Mortality , Treatment Outcome , Africa South of the Sahara , Infectious Disease Transmission, Vertical , Anti-Retroviral AgentsABSTRACT
Em julho de 1997, foi publicado relatório sob coordenaçäo da American Diabetes Association, contendo uma revisäo sobre definiçäo, classificaçäo e diagnóstico do diabetes melittus (DM). Os autores apresentam de forma sucinta as principais conclusöes publicadas por aquela entidade com o objetivo de divulgá-las na comunidade acadêmica, sobretudo junto aos näo endocrinologistas. No novo modelo, foi alterada a nomenclatura utilizada na descriçäo do DM e a tolerância à glicose diminuída deixou de ser classe específica de DM. Os valores da glicemia de jejum para diagnóstico de DM passaram a ser de 126mg/dl. Quando realizado o teste oral de tolerância à glicose (TOTG), säo valorizados apenas os níveis de glicemia 2 horas após a ingestäo de glicose, para diagnóstico de DM. A partir da discussäo pela comunidade médica podem surgir sugestöes e críticas a esses novos conceitos o quê, aliás, é sugerido também pela Organizaçäo Mundial de Saúde.
Subject(s)
Humans , Diabetes Mellitus , Blood Glucose , Diabetes MellitusABSTRACT
Este trabalho foi desenvolvido para estudar os fatores que influem no adoecimento dos contatos intradomiciliares de hanseníase. Foi estabelecida uma coorte de contatos intradomiciliares de hanseníase no setor de Hanseníase da Fiocruz, no Rio de Janeiro. Entre 1987 e 1991, em que foram acompanhados 670 contatos saudáveis, a taxa de incidência por pessoa-ano de follow-up foi de 0,01694. Porém, houve variação com o tempo de acompanhamento de cada indivíduo, sendo de 0,06385 ao final do primeiro ano, de 0,03299 ao final do segundo, 0,02370 ao final do terceiro, 0,018622 ao final do quarto e 0,01694 ao final do período. Foi especificado um modelo de regressão logística para os indivíduos acompanhados nos primeiros cinco anos, envolvendo 758 contatos, incluindo nessa situação os casos co-prevalentes. O risco de incidência de hanseníase está relacionado com a negatividade do teste de Mitsuda, com OR de 3,093 (IC95 percent = 1,735-5,514), com a vacinação pelo BCG, OR de 0,3802 (IC95 por cento = 0,2151-0,66719), e com a forma multibacilar do caso-índice, OR de 2,547 (IC95 por cento = 1,249-5,192). Os resultados indicam que a incidência da hanseníase em contatos está associada à forma multibacilar da doença e aos fatores imunes dos contatos
Subject(s)
Humans , Leprosy/epidemiology , Logistic Models , Residence Characteristics , Brazil/epidemiology , Cohort Studies , Follow-Up Studies , Incidence , Leprosy/classification , Leprosy/transmission , Multivariate Analysis , Risk Factors , Time FactorsABSTRACT
Este trabalho foi desenvolvido para estudar os fatores que influem no adoecimento dos contatos intradomiciliares de hanseniase. Foi estabelecida uma coorte de contatos intradomiciliares de hanseniase no Setor de Hanseniase da Fiocruz, no Rio de Janeiro. Entre 1987 e 1991, em que foram acompanhados 670 contatos saudaveis, a taxa de incidencia por pessoa-ano de follow-up foi de 0,01694. Porem, houve variacao com o tempo de acompanhamento de cada individuo, sendo de 0,06385 ao final do primeiro ano, de 0,03299 ao final do segundo, 0,02370 ao final do terceiro, 0,018622 ao final do quarto e 0,01694 ao final do periodo. Foi especificado um modelo de regressao logistica para os individuos acompanhados nos primeiros cinco anos, envolvendo 758 contatos
Subject(s)
Time Factors , Brazil , Incidence , Risk Factors , Cohort Studies , Follow-Up Studies , Multivariate Analysis , Residence Characteristics , Leprosy/classification , Leprosy/epidemiology , Leprosy/transmission , Logistic ModelsABSTRACT
Apresenta-se neste trabalho uma revisão referente ao Sistema Nacional de Vigilância Epidemiológica, principalmente, quanto ao processo de revisão e seleção de doenças de Notificação Compulsória. Foi elaborada uma proposta da Lista Brasileira de Doenças de Notificação Compulsória, fruto de um exercício de seleção baseado na avaliação de doenças com relação a 13 critérios e de debates com técnicos de áreas específicas do Ministério da Saúde, das Secretarias Estaduais/Municipais de Saúde, de instituições acadêmicas e da Organização Pan-Americana da Saúde. Várias recomendações são feitas, úteis para as três esferas do governo no processo de definição das doenças e agravos de notificação compulsória, levando-se em consideração o principal objetivo desse instrumento - fornecer informação de forma rápida e ágil, servir de base para a tomada de decisões e implementação de ações de controle e/ou prevenção
This paper reviews the National Epidemilogical Surveillance System, particularly the process of revision and selection of obligatory notifiable diseases. A proposal for a Brazilian List of Obligatory Notifiable Diseases was elaborated, resulting from a selection process based on the assessment of diseases against 13 criteria and on discussions with staff from specific areas of the Ministry of Health, The State and Municipal Health Secretaries and Pan-American Health Organization. The recommendations made are useful for the process of establishing the reportable diseases and conditions, taking into account the purpose of this tool to provide information in a quick and agile manner, and to serve as a basis for decision-making and for the implementation of control and/or prevention activities.
Subject(s)
Disease Notification/methods , Epidemiological Monitoring , Brazil , GovernmentABSTRACT
Estudo comparativo de evoluçäo clínica e baciloscópica de 140 casos de hanseníase classificados como multibacilares, divididos em dois grupos e submetidos a dois tratamentos com associaçäo de quimioterápicos com duraçäo fixa. Grupo I: 70 casos submetidos a Rifampicina (RFM) 600 mg e Dapsona (DDS) 100 mg diários auto administrados por 3 meses consecutivos seguidos de DDS - 100 mg diários auto administrados por 21 meses. Grupo II: RFM - 600 mg e Clofazimina (CFZ) 300 mg uma vêz ao mês, supervisionados, associados a DDS - 100 mg e CFZ 50 mg diários, auto administrados com duraçäofixa de 24 doses supervisionadas. Näo foram encontradas diferenças significativas (p > 0.05) na evoluçäo baciloscópica e neuromotora entre os grupos, na vigência dos tratamentos e no seguimento pós alta cura. Foi encontrada difrença estatística (p < 0.05) na ocorrência de manifestaçöes reacionais tendo o Grupo I apresentado maior número de casos com reaçäo durante o tratamento e pós alta. Esta diferença foi atribuida a presença da CFZ no esquema terapêutico do Grupo II. O follow-up total do grupo I foi de 2.110/pacientes ano com média de 50.32(mais ou menos) 19.62 meses sendo diagnosticado dois casos de recidiva. Em 1 dos casos procedeu-se a inoculaçäo da biópsia cutânea para inoculaçäo no coxim plantar do camundongo de acordo com Shepard para verificaçäo da viabilidade bacilar e rsistência a RFM e DDS. Os resultados demonstraram bacilos viáveis, susceptíveis as drogas testadas. Este resultado foi confirmado pela evoluçäo clínica e baciloscópica do caso após introduçäo no esquema poliquimioterápico preconizado pela OMS. Para o Grupo II, submetido ao esquema preconizado pela OMS e o atual em vigência em nosso país, o seguimento total foi de 1.897/pacientes ano, média 39.70 (mais ou menos) 19.47 meses näo tendo sido diagnosticada nenhuma recidiva
Subject(s)
Humans , Adult , Leprosy , Rifampin , Clofazimine , Dapsone , Drug Therapy, Combination , Leprosy/therapyABSTRACT
Relata oficina de trabalho orientada para a consecuçäo de três produtos básicos: normas técnicas, notificaçäo e investigaçäo de caso humano de Leishmaniose visceral e de caso de LTA
Subject(s)
Incidence , Leishmaniasis/epidemiology , Disease NotificationABSTRACT
O presente estudo se propôs a determinar o efeito protetor da vacinação intradérmica com BCG (bacilodeCalmette-Guérin) em contatos de pacientes de hanaseníase através do desenho de estudo caso-controle.Selecionou-se 65 casos e 904 controles, de zero a 29 anos de idade, provenientes de uma população base de contatos de pacientes de hanseníase residentes no Município e Área Metropolitando do Rio de Janeiro (área endêmica de hanseníase). De ambos os grupos obtiveram-se informações quanto a exposição ao BCG (presença ou ausência de cicatriz vacinal), idade, sexo, tipo de contato, parentesco e forma clínica,bacterioscopia, Mitsuda e grau de incapacidade. Realizou-se análise não pareada dos dados onde a presença de cicatriz de BCG mostrou-se negativamente associada com hanseníase indicando uma eficácia protetora de 59% (95% I.C. = 29% - 77%). A análise estratificada não revelou que as variáveis idade, sexo, tipo de contato, parentesco e forma clínica do caso primário introduziram confusão na avaliação da eficácia vacinal.Discute-se a adequação do desenho de estudo tipo caso-controle para a avaliação de eficácia vacinal em doença crônica, as implicações dos resultados e sua importância para a atividade de vigilância de contatos no Programa de Controle da Hanseníase.
Subject(s)
Humans , BCG Vaccine , LeprosyABSTRACT
Foram testados intradermicamente com PPD (RT23 e FAP 5U) 236 pacientes hansenianos (138 multibacilares e 98 paucibacilares) e 291 contatos sadios. Observa-se um percentual menores de reatores ao PPD em pacientes multibacilares (42%), quando comparados a paucibacilares (62,2%) e contatos sadios (63,2%). Entre os pacientes multibacilares, o índice bacteriológico (IB) mostrou ser fator de interferência na resposta ao PPD, sendo significativamente maior o percentual de respondedores em pacientes com IB negativo, quando comparados aos com IB igual ou acima de 3. Foi obervado um elevado índice de positividade à tuberculina em contatos sadios (61,0%) e pacientes paucibacilares (65,3%) com teste de Mitsuda positivo
Subject(s)
Leprosy , Mycobacterium leprae , Tuberculin TestABSTRACT
Foi determinado o grau de incapacidade em 189 pacientes hansenianos virgens de tratamento, sendo 39 Tuberculóides, 16 Indeterminados, 91 Dimorfos e 43 Virchowianos. Apenas 62 (32,8%) dos pacientes apresentavam grau 0, nos 127 (67,2%) restantes, os graus I, II e III determinados indicam a necessidade de educaçao sanitária e técnicas simples de fisioterapia, para evitar a instalaçao de sequelas irreversíveis