Desenvolvimento tecnológico e extensão inovadora em atenção básica e educação em saúde coletiva Saúde em Redes. 2017; 3 (1):40-49 40 ARTIGO ORIGINAL

Resumo O objetivo foi compreender como desigualdades e violações de direitos humanos se articulam em trajetórias de vulnerabilidade à internação por tuberculose. Foram realizadas entrevistas com pessoas internadas para tratamento da tuberculose em um hospital localizado em Porto Alegre, região sul do Brasil, no ano de 2014. Coinfecção tuberculose-HIV/aids, uso nocivo de drogas (especialmente o crack) e estar em situação de rua foram os acontecimentos mais expressivos nas trajetórias estudadas. A análise, orientada pelo quadro da vulnerabilidade e dos direitos humanos, e pelo construcionismo social como uma de suas bases teóricas, fez emergir a reflexão sobre marcadores sociais da diferença - gênero, raça, classe social e estigma relacionado à aids e ao uso de drogas - e suas intersecções na constituição das situações associadas ao adoecimento. A expressividade desses marcadores e seus efeitos na produção de desigualdades, discriminação, exploração e opressão permitiu desvelar o cenário sociocultural em que as trajetórias de internação por tuberculose são construídas. Esse conhecimento pode contribuir com a resposta que a tuberculose demanda, especialmente, ao reconhecer que as propostas em saúde precisam buscar mitigar vulnerabilidades sem negligenciar o enfrentamento às desigualdades sociais e à proteção aos direitos humanos.

In locations with a high rate of tuberculosis (TB) and HIV infection, there are a number of strategies to prevent negative outcomes such as opportunistic infections, hospitalizations and death, and this article investigates risk factors for the occurrence of hospitalization and death in cases of TB/HIV co-infection in the south of Brazil. The data are taken from a population-based retrospective cohort study on cases of TB/HIV co-infection from 2009 to 2013 in Porto Alegre, Brazil. Sociodemographic, epidemiological and clinical variables were analyzed. Relative risk (RR) estimates for hospitalization and death were determined by regression models. There were 2,419 co-infection cases, of which 1,527 (63.1%) corresponded to hospitalizations, and 662 (27.4%) to death. The occurrence of hospitalization was associated with ≤ 7 years of schooling (RR = 3.47, 95%CI: 1.97–6.29), 8–11 years of schooling (RR = 2.56, 95%CI: 1.44–4.69), place of origin—district health authorities Northwest/Humaitá/Navegantes/Ilhas (RR = 2.01, 95%CI: 1.44–2.82), type of entry into the surveillance system as in cases of reentry after withdrawal (RR = 1,35, 95%CI: 1.07–1.70), closure in surveillance as in withdrawal of treatment (RR = 1.47, 95%CI: 1.18–1.83) and multidrug-resistant tuberculosis (RR = 3.94, 95%CI: 1.97–8.81). The occurrence of death was associated with age (RR = 1.07, 95%CI: 1,01–1,14), ≤ 7 years of schooling (RR = 3.94, 95%CI: 2.26–7.09), 8–11 years of schooling (RR = 2.84, 95%CI: 1.61–5.16), place of origin—district health authorities Baltazar (RR = 2.05, 95%CI: 1.48–2.86), type of entry in the surveillance system as cases of re-entry after withdrawal (RR = 1.53, 95%CI: 1.22–1.91), relapse (RR = 1.33, 95%CI: 1.03–1.73). The occurrence of hospitalizations and deaths is high among co-infected patients. Our estimation approach is important in order to identify, from the surveillance data, the risk factors for hospitalization and death in co-infected patients, so that they may receive more attention from the Brazilian national healthcare system.

Objective: to describe the experience of applying of The Silences Framework to underpin health research investigating Tuberculosis/ HIV/AIDS coinfection.Method: the Silences Framework originally developed following a study exploring the decisions and silences surrounding black Caribbean men living in England, discussing the themes 'sexual health' and 'ethnicity'. Following this study, a conceptual theory for research on sensitive issues and health care of marginalized populations was developed called 'Screaming Silences', which forms the foundation of The Silences Framework. 'Screaming Silences' define research areas and experiences that are poorly studied, little understood or silenced.Results: the Silences Framework supports researchers in revealing "silences" in the subjects they study -as such, results may reflect how beliefs, values, and experiences of some groups influence their health. This framework provides the application of four complementary stages: working the silences, hearing silences, voicing silences and working with the silences. The analysis occurs cyclically and can be repeated as long as the silences inherent in a study are not revealed. Conclusion: this article presentsThe Silences Framework and the application of the notion of "sounds of silence", mapping an antiessentialist theoretical framework for its use in sensitive research in health and nursing areas, being a reference for other researchers in studies involving marginalized populations. DESCRIPTORS:Inequalities in health. Methods. Nursing. Coinfection. Research. Tuberculosis. Acquired immunodeficiency syndrome. THE SILENCES FRAMEWORK: METODOLOGIA PARA PESQUISAS DE TEMAS SENSÍVEIS E PERSPECTIVAS MARGINALIZADAS NA SAÚDE RESUMOObjetivo: descrever a utilização da metodologia The Silences Framework em uma pesquisa na área da saúde, envolvendo a temática da coinfecção tuberculose/HIV/aids.Método: a metodologia foi originalmente utilizada para estudar decisões e silêncios de homens negros do Caribe que viviam na Inglaterra, problematizando-se os temas 'saúde sexual' e 'etnicidade' e resultando em uma teoria para a pesquisa de questões sensíveis e de cuidados de saúde de populações marginalizadas. The Silences Framework define áreas de pesquisa e experiências que são pouco estudadas, compreendidas ou silenciadas.Resultados: os "silêncios" podem refletir aspectos não compartilhados sobre como crenças, valores e experiências de alguns grupos influenciam sua saúde. Esse referencial prevê a aplicação de quatro estágios complementares: trabalhando os silêncios, ouvindo os silêncios, dando voz aos silêncios e trabalhando com os silêncios. A análise ocorre de modo cíclico e pode ser repetida enquanto os silêncios não forem desvelados.Conclusão: este artigo apresenta a noção de "sons do silêncio", mapeando um quadro teórico antiessencialista para sua utilização em pesquisas sensíveis na area da saúde e da enfermagem, podendo ser referência para outros investigadores em estudos envolvendo populações marginalizadas. DESCRITORES: THE SILENCES...

Objective: To describe and compare the epidemiological profile of cases of tuberculosis and HIV coinfection of the District Administration Health Units of Porto Alegre, Brazil, from 2009 to 2013. Method: Retrospective cohort with data from national health information systems. Sociodemographic, clinical and follow-up variables were investigated through association tests. Results: 2,419 cases of tuberculosis and HIV coinfection were reported, with a mean age of 38 ± 9.91 years, predominantly white and with up to 7 years of study. The comparison between the District Administration Health Units was significant in terms of race/color (p<0.001), gender (p<0.001), schooling (p<0.004), age (p<0.003), place of origin (p<0.001), (p<0.001), alcoholism (p<0.001), indication and performance of Directly Observed Therapy (p<0.001), closure (p<0.001). Conclusion: Socioeconomic and treatment variables influence the occurrence of coinfection in different areas of Porto Alegre, reinforcing that the sum of different factors explains the indicators of the disease.

BackgroundTB/HIV coinfection is a serious public health issue in Brazil, and patients with coinfection have difficulty adhering to treatments. Directly observed treatment (DOT) has been recommended by the World Health Organization, considering the vulnerability of those affected. The purpose is to investigate the occurrence of DOT and associated factors compared to conventional treatment in Porto Alegre, Brazil.MethodsA retrospective cohort study was carried out with all patients with coinfection from 2009 to 2013 in the city of Porto Alegre, Brazil, the state capital with the highest rate of coinfection in Brazil. The data came from national health information systems. The dependent variable was the performance of DOT. Bivariate and multivariable models were used to determine factors associated with DOT. The percentage of cure and death was verified in a period of two years, comparing patients who received and did not receive DOT.Results2,400 cases of coinfection were reported, with 1,574 males and 826 females and a mean age of 38 years ± 9.91 years. The occurrence of DOT was 16.9%. In the multivariable analysis, factors independently associated to DOT were the year (with greater chances of being received in 2012 and 2013), place of origin, non-white race (OR = 1.29, 95% CI = 1.08–1.54), cases of relapse (OR = 1.33; 95% CI = 1.03–1.73), readmission after abandonment (OR = 1.48, 95% CI = 1.20–1.83), transfer (OR = 2.04; 95% CI = 1.40–2.98), acid-fast bacilli (AFB) test with positive result in first sample (OR = 1.73, 95% CI = 1.24–2.42), alcohol abuse (OR = 1.39; 95% CI = 1.16–1.67), and mental disorders (OR = 1.83; 95% CI = 1.38–2.44.) Of the 532 cases of death, occurring in two years, 10.2% were in patients who underwent DOT and 89.8% in patients who did not undergo DOT (p<0.001). O percentual de óbitos em pessoas que receberam DOT foi de 13% e o percentual de óbitos para pessoas que receberam tratamento convencional foi de 24%.ConclusionsThere was an increase in the percentage of DOT over the years in the scenario studied, and the predictors for DOT were related to social vulnerability. In relation to death within two years, a lower proportion was found in patients who underwent DOT, suggesting a protective effect of the strategy.

Background Tuberculosis is a curable disease, which remains the leading cause of death among infectious diseases worldwide, and it is the leading cause of death in people living with HIV. The purpose is to examine survival and predictors of death in Tuberculosis/HIV coinfection cases from 2009 to 2013. Methods We estimated the survival of 2,417 TB/HIV coinfection cases in Porto Alegre, from diagnosis up to 85 months of follow-up. We estimated hazard ratios and survival curves. Results The adjusted risk ratio (aRR) for death, by age, hospitalization, and Directly Observed Treatment was 4.58 for new cases (95% CI: 1.14–18.4), 4.51 for recurrence (95% CI: 1.11–18.4) and 4.53 for return after abandonment (95% CI: 1.12–18.4). The average survival time was 72.56 ± 1.57 months for those who underwent Directly Observed Treatment and 62.61 ± 0.77 for those who did not. Conclusions Case classification, age, and hospitalization are predictors of death. The occurrence of Directly Observed Treatment was a protective factor that increased the probability of survival. Policies aimed at reducing the mortality of patients with TB/HIV coinfection are needed.

136Objetivo: comparar a atenção à saúde dos usuários com hipertensão arterial sistêmica ofertada no Rio Grande do Sul com aquela ofertada nas demais unidades federativas do país. Método: Trata-se de um estudo epidemiológico, observacional e analítico, de cunho ecológico, com dados oriundos do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB), ano 2012. A amostra nacional foi composta por 65.391 usuários, dos quais 36,5% possuía hipertensão arterial sistêmica. Comparações foram realizadas quanto à atenção a saúde dos 23.797 hipertensos residentes no Rio Grande do Sul (RS) e nas demais UFs. Resultados: A prevalência de HAS no RS foi de 35,9% (n = 1.156). Observou-se diferença estatística entre RS e demais UFs quanto à ocorrência de consulta nos últimos 6 meses (p<0,001), realização de exames (p<0,001), agendamento de consulta (p<0,001), e local de retirada de medicamentos (p<0,001). Conclusões: Apesar do RS ser apontado como uma das UFs com maior prevalência de HAS, as comparações apontam melhores resultados nas demais UFs quanto à atenção a saúde do hipertenso na atenção básica. Os resultados permitem discutir melhorias de acesso e qualidade da atenção básica. Sugere-se que o PMAQ-AB inclua questões relativas à adesão ao tratamento e questões sobre o tratamento não medicamentoso para a avaliação da qualidade da atenção à saúde do hipertenso. Palavras-chave:Hipertensão; Promoção da Saúde; Atenção Primária à Saúde; Saúde Pública. Abstract:Objective: To compare the health care provided for users who suffer from systemic arterial hypertension in Rio Grande do Sul and other states of Brazil. Method: This is an epidemiological, observational and analytic ecological study with data from the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB) -2012. The sample consisted of 65,391 users, 36.5% of whom suffered from systemic arterial hypertension (SAH) and answered questions regarding health care for hypertensive patients in primary care facilities. The service provided in Rio Grande do Sul was compared to that of other states. Results: The prevalence of SAH in the national sample was 36.5% (n = 23,797),