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Int J Drug Policy ; 74: 52-61, 2019 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-31525640


BACKGROUND: Colonization and colonial systems have led to the overrepresentation of Indigenous people impacted by substance use and HCV infection in Canada. It is critical to ensure Indigenous people's equitable access to new direct acting antiviral HCV treatments (DAAs). Identifying culturally-safe, healing-centered approaches that support the wellbeing of Indigenous people living with HCV is an essential step toward this goal. We listened to the stories and perspectives of HCV-affected Indigenous people and HCV treatment providers with the aim of providing pragmatic recommendations for decolonizing HCV care. METHODS: Forty-five semi-structured interviews were carried out with Indigenous participants affected by HCV from the Cedar Project (n = 20, British Columbia (BC)) and the Canadian Coinfection Cohort (n = 25, BC; Ontario (ON); Saskatchewan (SK)). In addition, 10 HCV treatment providers were interviewed (n = 4 BC, n = 4 ON, n = 2 SK). Interpretive description identified themes to inform clinical approaches and public health HCV care. Themes and related recommendations were validated by Indigenous health experts and Indigenous participants prior to coding and re-contextualization. RESULTS: Taken together, participants' stories and perceptions were interpreted to coalesce into three overarching and interdependent themes representing their recommendations. First: treatment providers must understand and accept colonization as a determinant of health and wellness among HCV-affected Indigenous people, including ongoing cycles of child apprehension and discrimination within the healthcare system. Second: consistently safe attitudes and actions create trust within HCV treatment provider-patient relationships and open opportunities for engagement into care. Third: treatment providers who identify, build, and strengthen circles of care will have greater success engaging HCV-affected Indigenous people who have used drugs into care. CONCLUSION: There are several pragmatic ways to integrate Truth and Reconciliation as well as Indigenous concepts of whole-person wellness into the HCV cascade of care. By doing so, HCV treatment providers have an opportunity to create greater equity and support long-term wellness of Indigenous patients.

Liver Int ; 39(10): 1818-1836, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31433902


Viral hepatitis is a leading cause of morbidity and mortality worldwide, but has long been neglected by national and international policymakers. Recent modelling studies suggest that investing in the global elimination of viral hepatitis is feasible and cost-effective. In 2016, all 194 member states of the World Health Organization endorsed the goal to eliminate viral hepatitis as a public health threat by 2030, but complex systemic and social realities hamper implementation efforts. This paper presents eight case studies from a diverse range of countries that have invested in responses to viral hepatitis and adopted innovative approaches to tackle their respective epidemics. Based on an investment framework developed to build a global investment case for the elimination of viral hepatitis by 2030, national activities and key enablers are highlighted that showcase the feasibility and impact of concerted hepatitis responses across a range of settings, with different levels of available resources and infrastructural development. These case studies demonstrate the utility of taking a multipronged, public health approach to: (a) evidence-gathering and planning; (b) implementation; and (c) integration of viral hepatitis services into the Agenda for Sustainable Development. They provide models for planning, investment and implementation strategies for other countries facing similar challenges and resource constraints.

Lancet Glob Health ; 7(9): e1148-e1149, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31353060
Lancet Glob Health ; 7(9): e1180-e1188, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31353061


BACKGROUND: The World Health Assembly calls for elimination of viral hepatitis as a public health threat by 2030 (ie, -90% incidence and -65% mortality). However, WHO's 2017 cost projections to achieve health-related Sustainable Development Goals did not include the resources needed for hepatitis testing and treatment. We aimed to estimate the incremental commodity cost of adding scaled up interventions for testing and treatment of hepatitis to WHO's investment scenarios. METHODS: We added modelled costs for implementing WHO recommended hepatitis testing and treatment to the 2017 WHO cost projections. We quantified additional requirements for diagnostic tests, medicines, health workers' time, and programme support across 67 low-income and middle-income countries, from 2016-30. A progress scenario scaled up interventions and a more ambitious scenario was modelled to reach elimination by 2030. We used 2018 best available prices of diagnostics and generic medicines. We estimated total costs and the additional investment needed over the projection of the 2016 baseline cost. FINDINGS: The 67 countries considered included 230 million people living with hepatitis B virus (HBV) and 52 million people living with hepatitis C virus (HCV; 90% and 73% of the world's total, respectively). Under the progress scenario, 3250 million people (2400 million for HBV and 850 million for HCV) would be tested and 58·2 million people (24·1 million for HBV and 34·1 million for HCV) would be treated (total additional cost US$ 27·1 billion). Under the ambitious scenario, 11 631 million people (5502 million for HBV and 6129 million for HCV) would be tested and 93·8 million people (32·2 million for HBV and 61·6 million for HCV) would be treated (total additional cost $58·7 billion), averting 4·5 million premature deaths and leading to a gain of 51·5 million healthy life-years by 2030. However, if affordable HCV medicines remained inaccessible in 13 countries where medicine patents are protected, the additional cost of the ambitious scenario would increase to $118 billion. Hepatitis elimination would account for a 1·5% increase to the WHO ambitious health-care strengthening scenario costs, avert an additional 4·6% premature deaths, and add an additional 9·6% healthy life-years from 2016-30. INTERPRETATION: Access to affordable medicines in all countries will be key to reach hepatitis elimination. This study suggests that elimination is feasible in the context of universal health coverage. It points to commodities as key determinants for the overall price tag and to options for cost reduction strategies. FUNDING: WHO, United States Centers for Disease Control and Prevention, Unitaid.

Washington, D.C.; OPS; 2019-05-17.
em Inglês, Espanhol | PAHO-IRIS | ID: phr-50993


En el presente documento se comunica el progreso logrado en la Región hacia la eliminación de la transmisión maternoinfantil del VIH y la sífilis entre los años 2010 y 2017. Se trata también del primer informe regional sobre la eliminación de la transmisión maternoinfantil y durante la primera infancia de la hepatitis B y la enfermedad de Chagas congénita. Los resultados principales son los siguientes: El acceso de las embarazadas a la atención prenatal y del parto es alto en la Región de las Américas. El tamizaje de la infección por el VIH y la sífilis en las embarazadas sigue siendo alto, pero se han logrado pocos avances para salvar las brechas; por otra parte, el tamizaje de la enfermedad de Chagas en las embarazadas es muy variable, dado que oscila entre 7% y 55% en los pocos países que presentan informes al respecto. El tratamiento de la infección por el VIH y la sífilis en las embarazadas seropositivas sigue en aumento. La vacunación contra la hepatitis B se ha estabilizado en 87% de los menores de 1 año que completan su tercera dosis, aunque continúa en aumento la adopción de políticas de administración de una dosis al nacer de la vacuna contra el virus de la hepatitis B a todos los recién nacidos. Durante mucho tiempo se ha observado una disminución continua de la transmisión maternoinfantil del VIH, pero comienza a estabilizarse. Los casos de sífilis congénita están en aumento. Se considera que la transmisión maternoinfantil causa más de 20% de los casos nuevos de enfermedad de Chagas.

This document reports the progress made in the Americas towards the EMTCT of HIV and syphilis between 2010 and 2017. It is the first Regional report regarding elimination of mother-to-child and early childhood transmission of hepatitis B and congenital Chagas disease. The main findings are as follows: Access to prenatal and delivery care for pregnant women is high in the Americas. Screening of pregnant women for HIV and syphilis remains high but little progress has been made in closing the gaps; meanwhile, screening of pregnant women for Chagas disease varies widely, ranging from 7% to 55% among the few reporting countries. HIV and syphilis treatment of seropositive pregnant women continues to increase. Vaccination for hepatitis B has stabilized at 87% of children under one year old who completed their third dose, and policies for universal timely hepatitis B vaccine birth dose are increasingly being adopted. MTCT of HIV experienced longstanding reductions but has begun to stabilize. Congenital syphilis cases are on the rise. Mother-to-child transmission is estimated to cause over 20% of new cases of Chagas disease.

Sífilis , Hepatite B , Doença de Chagas , HIV , Doenças Transmissíveis , Américas , Sífilis , HIV , Doenças Transmissíveis
Implement Sci ; 14(1): 26, 2019 03 12.
Artigo em Inglês | MEDLINE | ID: mdl-30866982


BACKGROUND: Researchers could benefit from methodological advancements to advance uptake of new treatments while also reducing healthcare disparities. A comprehensive determinants framework for healthcare disparity implementation challenges is essential to accurately understand an implementation problem and select implementation strategies. METHODS: We integrated and modified two conceptual frameworks-one from implementation science and one from healthcare disparities research to develop the Health Equity Implementation Framework. We applied the Health Equity Implementation Framework to a historical healthcare disparity challenge-hepatitis C virus (HCV) and its treatment among Black patients seeking care in the US Department of Veterans Affairs (VA). A specific implementation assessment at the patient level was needed to understand any barriers to increasing uptake of HCV treatment, independent of cost. We conducted a preliminary study to assess how feasible it was for researchers to use the Health Equity Implementation Framework. We applied the framework to design the qualitative interview guide and interpret results. Using quantitative data to screen potential participants, this preliminary study consisted of semi-structured interviews with a purposively selected sample of Black, rural-dwelling, older adult VA patients (N = 12), living with HCV, from VA medical clinics in the Southern part of the USA. RESULTS: The Health Equity Implementation Framework was feasible for implementation researchers. Barriers and facilitators were identified at all levels including the patient, provider (recipients), patient-provider interaction (clinical encounter), characteristics of treatment (innovation), and healthcare system (inner and outer context). Some barriers reflected general implementation issues (e.g., poor care coordination after testing positive for HCV). Other barriers were related to healthcare disparities and likely unique to racial minority patients (e.g., testimonials from Black peers about racial discrimination at VA). We identified several facilitators, including patient enthusiasm to obtain treatment because of its high cure rates, and VA clinics that offset HCV stigma by protecting patient confidentiality. CONCLUSION: The Health Equity Implementation Framework showcases one way to modify an implementation framework to better assess health equity determinants as well. Researchers may be able to optimize the scientific yield of research inquiries by identifying and addressing factors that promote or impede implementation of novel treatments in addition to eliminating healthcare disparities.

Equidade em Saúde , Disparidades em Assistência à Saúde , Hepatite C Crônica/tratamento farmacológico , Ciência da Implementação , Adulto , Afro-Americanos/etnologia , Idoso , Assistência à Saúde/organização & administração , Assistência à Saúde/normas , Difusão de Inovações , Estudos de Viabilidade , Hepatite C Crônica/etnologia , Humanos , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Saúde da População Rural , Estados Unidos , United States Department of Veterans Affairs
Washington, D.C.; OPS; 2019-01. (OPS/CDE/19-005).
em Espanhol | PAHO-IRIS | ID: phr-49783


Público destinatario y alcance de la herramienta. Esta herramienta para la implementación de la PrEP está constituida por módulos destinados a diversos interesados directos, cuyo propósito es apoyarlos en la consideración, planificación, introducción e implementación de la PrEP por vía oral. Estos módulos pueden usarse por separado o en combinación. Hay además un módulo dirigido a las personas interesadas en tomar la PrEP o que ya la están tomando. (Véase el resumen de los módulos, más adelante.) Esta herramienta es producto de la colaboración entre muchos expertos, organizaciones y redes comunitarias, implementadores, investigadores y asociados de todas las regiones. La información que se presenta está en consonancia con las directrices unificadas de la OMS del 2016 sobre el uso de los antirretrovirales en el tratamiento y la prevención de la infección por el VIH. Todos los módulos hacen referencia a la recomendación de la OMS del 2015 sobre la PrEP. No se formulan nuevas recomendaciones sobre la PrEP, sino que los módulos se centran en los enfoques propuestos para la implementación. Módulo para consejeros. Este módulo se dirige al personal en los entornos clínicos y de otro tipo que asesoran a los usuarios de la PrEP. Este módulo se dirige a los responsables de realizar las pruebas en los establecimientos que ofrecen la PrEP y laboratorios asociados. Brinda orientación sobre la elección de los servicios de pruebas pertinentes, incluido el tamizaje apropiado de las personas antes de comenzar la PrEP y el seguimiento mientras la reciben. Se aporta información sobre las pruebas de detección del VIH, la determinación de la creatinina, la detección de los virus de la hepatitis B y C, el embarazo y las infecciones de transmisión sexual.

HIV , Infecções por HIV , Serviços de Saúde Comunitária , Educação em Saúde
Artigo em Inglês | PAHO-IRIS | ID: phr-49727


[ABSTRACT]. Objective. To identify and summarize existing literature on the burden of HIV, sexually transmitted infections (STIs), and viral hepatitis (VH) in indigenous peoples and Afrodescendants in Latin America to provide a broad panorama of the quantitative data available and highlight problematic data gaps. Methods. Published and grey literature were systematically reviewed to identify documents published in English, Spanish, or Portuguese with data collected between January 2000 and April 2016 on HIV, STI, and VH disease burden among indigenous peoples and Afrodescendants in 17 Latin American countries. Results. Sixty-two documents from 12 countries were found. HIV prevalence was generally low (< 1%) but pockets of high prevalence (> 5%) were noted in some indigenous communities in Venezuela (Warao) (9.6%), Peru (Chayahuita) (7.5%), and Colombia (Wayuu females) (7.0%). High active syphilis prevalence (> 5%) was seen in some indigenous communities in Paraguay (11.6% and 9.7%) and Peru (Chayahuita) (6.3%). High endemicity (> 8%) of hepatitis B was found in some indigenous peoples in Mexico (Huichol) (9.4%) and Venezuela (Yanomami: 14.3%; Japreira: 29.5%) and among Afro-descendant quilombola populations in Brazil (Frechal: 12.5%; Furnas do Dionísio: 8.4% in 2008, 9.2% in 2003). Conclusions. The gaps in existing data on the burden of HIV, STIs, and VH in indigenous peoples and Afro-descendants in Latin America highlight the need to 1) improve national surveillance, by systematically collecting and analyzing ethnicity variables, and implementing integrated biobehavioral studies using robust methodologies and culturally sensitive strategies; 2) develop a region-wide response policy that considers the needs of indigenous peoples and Afro-descendants; and 3) implement an intercultural approach to health and service delivery to eliminate health access barriers and improve health outcomes for these populations.

[RESUMEN]. Objetivo. Identificar y resumir la bibliografía existente sobre la carga de la infección por el VIH, las infecciones de transmisión sexual (ITS) y las hepatitis virales en las poblaciones indígenas y afrodescendientes en América Latina para proporcionar un panorama amplio de los datos cuantitativos disponibles y poner de relieve las brechas problemáticas que pudiera haber en los datos. Métodos. Se hizo un examen sistemático de la bibliografía publicada y la bibliografía gris para encontrar documentos publicados en inglés, español o portugués con datos recogidos entre enero del 2000 y abril del 2016 sobre la carga de la infección por el VIH, las ITS y las hepatitis virales en las poblaciones indígenas y afrodescendientes en 17 países latinoamericanos. Resultados. Se encontraron 62 documentos de 12 países. La prevalencia de la infección por el VIH fue generalmente baja (< 1%), pero se observaron focos de prevalencia alta (> 5%) en algunas comunidades indígenas en Venezuela (Warao) (9,6%), Perú (Chayahuita) (7,5%) y Colombia (las mujeres Wayuus) (7,0%). Se observó prevalencia alta de sífilis activa (> 5%) en algunas comunidades indígenas en Paraguay (11,6% y 9,7%) y Perú (Chayahuita) (6,3%). Se encontró endemicidad alta (> 8%) de la hepatitis B en algunos pueblos indígenas en México (Huichol) (9,4%) y Venezuela (Yanomami: 14,3%; Japreira: 29,5%) y en las poblaciones quilombola de afrodescendientes en Brasil (Frechal: 12,5%; Furnas do Dionísio: 8,4% en el 2008, 9,2% en el 2003). Conclusiones. Las brechas en los datos existentes sobre la carga de la infección por el VIH, las ITS y las hepatitis virales en las poblaciones indígenas y afrodescendientes en América Latina destacan la necesidad de: 1) mejorar la vigilancia nacional mediante la recolección y el análisis sistemáticos de las variables de etnicidad y la ejecución de estudios bioconductuales integrados que utilicen metodologías sólidas y estrategias sensibles a diferencias entre las culturas; 2) elaborar una política de respuesta de alcance regional que considere las necesidades de las poblaciones indígenas y de afrodescendientes; y 3) aplicar un enfoque intercultural de la salud y de la prestación de servicios conexos para eliminar las barreras de acceso a la salud y mejorar los resultados en materia de salud para estas poblaciones.

[RESUMO]. Objetivo. Identificar e sintetizar a literatura existente sobre a carga de HIV, infecções sexualmente transmissíveis (IST) e hepatite viral nos povos indígenas e afrodescendentes da América Latina para traçar um amplo panorama dos dados quantitativos disponíveis e destacar as lacunas problemáticas nos dados. Métodos. Foi realizada uma revisão sistemática da literatura publicada e da literatura cinzenta para identificar documentos publicados em inglês, espanhol ou português com dados coletados entre janeiro de 2000 e abril de 2016 sobre a carga de HIV, IST e hepatite viral nos povos indígenas e afrodescendentes em 17 países latino-americanos. Resultados. Sessenta e dois documentos de 12 países foram encontrados. A prevalência de HIV observada foi em geral baixa (<1%), com focos de alta prevalência (>5%) observados em comunidades indígenas da Venezuela (warao) (9,6%), Peru (chayahuita) (7,5%) e Colômbia (mulheres wayúu) (7,0%). Foi verificada uma alta prevalência de sífilis ativa (> 5%) em comunidades indígenas no Paraguai (11,6% e 9,7%) e Peru (chayahuita) (6,3%). A alta endemicidade (>8%) de hepatite B foi observada em povos indígenas no México (huichol) (9,4%) e Venezuela (ianomâmi 14,3%; japrería 29,5%) e em comunidades negras quilombolas no Brasil (Frechal 12,5%; Furnas do Dionísio 8,4% em 2008 e 9,2% em 2003). Conclusões. As lacunas nos dados existentes sobre a carga de HIV, IST e hepatite viral nos povos indígenas e afrodescendentes na América Latina destacam a necessidade de: melhorar a vigilância nacional com coleta sistemática e análise de variáveis de etnicidade e realizar estudos integrados de análise biocomportamental com o uso de metodologias robustas e estratégias sensíveis à diversidade cultural; desenvolver uma política de resposta regional que considere as necessidades dos povos indígenas e afrodescendentes; e implementar um enfoque intercultural à saúde e prestação de serviços para derrubar as barreiras de acesso à saúde e melhorar os resultados de saúde nestas populações.

HIV , Doenças Sexualmente Transmissíveis , Sífilis , Hepatite Viral Humana , Saúde de Populações Indígenas , América Latina , HIV , Doenças Sexualmente Transmissíveis , Sífilis , Hepatite Viral Humana , Saúde de Populações Indígenas , América Latina , Doenças Sexualmente Transmissíveis , Hepatite Viral Humana , Saúde de Populações Indígenas
Immunological basis for immunization series;module 18
Monografia em Inglês | WHO IRIS | ID: who-326501