Adherence to antiretroviral therapy and viral suppression: Analysis of three periods between 2011 and 2017 at an HIV-AIDS center, Brazil.

The increased effectiveness of antiretroviral therapy (ART) in the last 30 years is a scientific landmark, and viral suppression is directly associated with treatment adherence. The aim of this study was to compare the results of ART adherence and viral load suppression with the evolution of the protocols and other associated factors, in people living with HIV. A panel analysis of three descriptive longitudinal studies investigating ART adherence and viral load suppression was conducted in people with HIV treated at a drug dispensing unit in the Federal District. The studies were carried out during periods of 2011, 2013, and 2017, coinciding with the three different recommended treatment schemes for the country. Adherence was assessed using drug dispensing records. Viral load data were obtained from the Ministry of Health's Laboratory Examination Information System. Analysis of the data of 522 individuals in the three periods showed sociodemographic differences such as a decline in the percentage of women (from 33% in period 1 to 4% in period 3) and an increase in the percentage of young people. ART adherence was higher in period 2 (tenofovir/lamivudine/efavirenz scheme). Viral load suppression was greater in period 3 (tenofovir/lamivudine/dolutegravir scheme). The relative detectable viral load risk was nearly two-fold higher (RR 1.83) in people living with HIV with less than 80% adherence when compared to those above 80%. With respect to the different schemes recommended in Brazil during the periods studied, ART containing dolutegravir was the most effective in achieving viral load suppression. By contrast, there was better ART adherence in the daily combined fixed dose consisting of tenofovir/lamivudine/efavirenz in tablet form. Adherence to ART above 80% seemed to be enough to promote an effective treatment in therapeutic schemes including efavirenz or dolutegravir.

[Rocky Mountain spotted fever in Brazil]. / A febre maculosa no Brasil.

Although the number of confirmed cases of spotted fever has been declining in Brazil since 2005, the mortality rate (20% to 30%) is still high in comparison to other countries. This high mortality rate is closely related to the difficulty in making the diagnosis and starting the correct treatment. Only two groups of antibiotics have proven clinical effectiveness against spotted fever: chloramphenicol and tetracyclines. Until recently, the use of tetracyclines was restricted to adults because of the associated bone and tooth changes in children. Recently, however, the American Academy of Pediatrics and various researchers have recommended the use of doxycycline in children. In more severe cases, chloramphenicol injections are often preferred in Brazil because of the lack of experience with injectable tetracycline. Since early diagnosis and the adequate drug treatment are key to a good prognosis, health care professionals must be better prepared to recognize and treat spotted fever.

Feasibility of De-Escalation Implementation for Positive Blood Cultures in Patients With Sepsis: A Prospective Cohort Study.

Purpose: The aim of the present study was to determine whether de-escalation guided by blood cultures for patients with a diagnosis of sepsis, severe sepsis or septic shock reduces mortality, and antimicrobial drug resistance (ADR). Methods: A prospective, single-center, cohort study was conducted with adults admitted to the ICU with a diagnosis of sepsis, severe sepsis, or septic shock at a public hospital in Sorocaba, State of São Paulo, Brazil, from January 2013 to December 2013. We excluded patients who had negative blood cultures. Patients who had replaced the initial empirical broad-spectrum antibiotic therapy (EAT) by the antibiotic therapy guided by blood cultures were compared with those who continued receiving EAT. The outcome included mortality and antimicrobial drug resistance. We used the Cox regression (proportional hazards regression) and the Poisson regression to analyze the association between antibiotic therapy guided by blood cultures (ATGBC) and outcomes. The statistical adjustment in all models included the following variables: sex, age, APACHE II (Acute Physiology And Chronic Health Evaluation II) score and SOFA (Sequential Organ Failure Assessment) score. Results: Among the 686 patients who were admitted to the intensive care unit, 91 were included in this study. The mean age of the patients was 52.7 years (standard deviation = 18.5 years) and 70.3% were male. EAT was replaced by ATGBC in 33 patients (36.3%) while 58 patients (63.7%) continued receiving EAT. Overall hospital mortality decreased from 56.9% in patients who received EAT to 48.5% in patients who received ATGBC [Hazard ratio- HR 0.44 (95% CI 0.24-0.82), p = 0.009]. There was no association between ATGBC and ADR [HR 0.90 (95% CI 0.78 - 1.03) p = 0.15]. Conclusions: Although the early and appropriate empirical EAT is undoubtedly an important factor prognostic, ATGBC can reduce the mortality in these patients.

The Use of Assessment of Chronic Illness Care Technology to Evaluate the Institutional Capacity for HIV/AIDS Management.

The effectiveness of antiretroviral therapy has rendered HIV infection a manageable chronic condition. Currently, the health systems face the challenge of adopting organizational healthcare models capable of ensuring the delivery of comprehensive care. The Chronic Care Model has been reported for its effectiveness, particularly in terms of delivery system design. In this study, the Assessment of Chronic Illness Care (ACIC) questionnaire, a soft technology widely used for other chronic conditions, was employed on a teaching hospital to evaluate healthcare provided to people living with HIV/AIDS. The ACIC technology is a self-explanatory instrument which diagnoses, among the six components of the Chronic Care Model Framework, areas for quality improvements, indicating at the same time, intervention strategies and achievements. These components are healthcare network organization, delivery system design, self-management support, decision support, clinical information systems, and community. From May to October 2014, the tool was applied to the multidisciplinary teamwork at the points of care identified, as well as to the hospital management board. Respondents broadly rated care as basic. A pronounced contrast was observed from evaluation by management board and health professional staff in some components like organization of healthcare and clinical information system. The self-management support and delivery system design were the components best evaluated by the multidisciplinary team. Combined with the array of services offered, the entry points available at the hospital can ensure healthcare comprehensiveness. However, some gaps were detected, precluding the delivery of an effective care. The ACIC was considered an adequate technology to provide knowledge of the gaps, to promote productive discussions and reflections within teams and to indicate actions to achieve improvements on healthcare for people living with HIV/AIDS.

Evaluation of Pharmaceutical Services in Public Hospital Pharmacies of Federal District - Brazil.

OBJECTIVE: To evaluate pharmaceutical services in public hospital pharmacies of  the Federal District Health Department - Brazil (Secretaria de Saúde do Distrito  Federal, SES-DF). METHOD: A cross-sectional evaluative study involving the 15 public hospitals under the SES-DF management. Hospitals were characterized and classified into four hierarchical strata. The pharmaceutical services related  to programming (quantity of medication to order), acquisition, storage,  distribution, management, selection, information, pharmacotechnical  component, pharmacotherapy follow-up, teaching and research were evaluated  using validated indicators. Next, algorithms were applied and the approximation percentages of service compliance were calculated, then  correlated to variables that could influence their results through linear regression analysis. RESULTS: Only four hospital pharmacies presented good compliance with the  evaluated services, three of them belonging to less complex hospitals. Only the  storage and management services presented good performance. The variables  that most influenced the performance of the services were managerial aspects  related to pharmacists and non pharmacists' workload per bed, the existence of  a program for human resources qualification, planning goals and targets and a  manual of norms and procedures, as well as professional qualification and  adequacy of the area in which the services were performed (p < 0.01). CONCLUSIONS: The evaluated hospital pharmacies had average performance for  services compared to the ideal and better performance in logistics activities.  Pharmaceutical services require constant evaluation for rational interventions  that increase the proportion of executed health care activities and local  management capacity to make such actions more effective, efficient, qualified  and safe in the context of the SES-DF hospital network.

Objetivo: Evaluar los servicios farmacéuticos en farmacias públicas de hospitales del Departamento de Salud del Distrito Federal ­ Brasil (Secretaria de Saúde do Distrito Federal, SES-DF).Método: Estudio transversal evaluativo de los 15 hospitales públicos bajo  gestión de la SES-DF. Los hospitales fueron caracterizados y se clasificaron en  cuatro estratos jerárquicos. Los servicios de programación, adquisición, almacenamiento, distribución, gestión, selección, información, farmacotécnica, seguimiento farmacoterapéutico, enseñanza y  investigación fueron evaluados utilizando indicadores validados. Se aplicaron  algoritmos y se calcularon los porcentajes de aproximación del cumplimiento del  servicio, que se correlacionaron con variables que podrían influir en los  resultados a través de la regresión lineal.Resultados: Solo cuatro farmacias hospitalarias presentaron un buen cumplimiento de los servicios evaluados; tres pertenecientes a hospitales menos complejos. Solo el almacenamiento y la gestión presentaron  un buen desempeño. Las variables que más influyeron en el desempeño de los  servicios fueron la carga de trabajo de farmacéuticos y no farmacéuticos por  cama; la existencia de un programa de cualificación de recursos humanos,  objetivos y metas; el manual de normas y procedimientos, y la cualificación  profesional y la adecuación del área de ejecución de los servicios (p < 0,01).Conclusiones: Las farmacias hospitalarias evaluadas presentaron un cumplimiento medio de los servicios en comparación con el ideal y el mejor desempeño de las actividades logísticas. Los servicios farmacéuticos requieren una evaluación constante con vistas a intervenciones  racionales que amplíen la ejecución de las actividades asistenciales y la  capacidad de gestión local con el objetivo de hacer tales acciones más efectivas, eficientes, cualificadas y seguras.

Access to medicines for diabetes treatment in Brazil: evaluation of "health has no price" program.

BACKGROUND: In 2011, private pharmacies associated to the Brazilian Ministry of Health provided patients with two types of insulin (regular human insulin and isophane insulin or NPH) and three oral antidiabetic medications (5 mg glibenclamide and 500 and 850 mg metformin) free of charge. The aim was to evaluate the impact of the "Health Has No Price" Program [Saúde Não Tem Preço (SNTP)] for access to diabetes treatment medicines in Brazil. METHODS: This longitudinal and observational study is based on the number of units of oral hypoglycemic agents, insulin and insulin analogues supplied in 55,000 private pharmacies from February 1, 2010 to January 31, 2012. The number of tablets (oral hypoglycemic agents) and international units (insulins and insulin analogues) supplied in the first 12 months of the SNTP Program were compared with the number of tablets and international units supplied in the 12 months prior to its implementation. RESULTS: The insulins in the SNTP program had the highest percentage change in the number of international units supplied; regular human insulin increased by 97.8 % and isophane insulin (NPH) by 78.0 %. Among the oral hypoglycemic agents, 5 mg glibenclamide increased by 65.9 %, and 500 and 850 mg metformin increased by 46.8 and 39.9 %, respectively, in the number of tablets dispensed in the first year of the SNTP Program. Among the hypoglycemic agents not available in SNTP, 4 mg glimepiride had the highest percentage increase in units supplied (19.2 %) in the same period. Among the insulin analogues, which were not available in the SNTP Program, insulin glulisine showed the greatest increase in units dispensed (34.2 %). CONCLUSIONS: The SNTP Program contributed to increased access to medicines for the treatment of diabetes in Brazil.