Objective
The TB/HIV in Rio (THRio) study was launched in September 2005 to assess the impact of integrated tuberculosis (TB) and HIV treatment strategies in 29 HIV clinics in Rio de Janeiro, Brazil.
Design
THRio is a cluster-randomized trial (CRT) to determine whether routine screening for and treatment of latent TB in HIV clinic patients with access to antiretroviral therapy will reduce TB incidence at the clinic level. THRio is part of the Consortium to Respond Effectively to AIDS/TB Epidemic that is implementing research studies to assess the impact of bold, new public health paradigms for controlling the AIDS/TB epidemic.
Methods
Twenty-nine public primary HIV clinics were randomly assigned a date to begin implementing TB screening procedures and provision of isoniazid preventive therapy (IPT) for TB/HIV coinfected patients. Final analysis of the CRT is expected in 2011.
Results
Starting at date of tuberculin skin test (TST)/IPT implementation at each clinic through August 2010, 1670 HIV-infected patients initiated IPT, of which 215 are still receiving treatment. Of the remaining 1455 patients, 1230 (85%) completed therapy and only 20 (1.2%) patients initiating IPT reported adverse reactions leading to discontinuation of therapy. IPT completion was higher among HIV-infected patients receiving HAART (87%) than those not yet receiving HAART (79%, P < 0.01). Times to TST and IPT have markedly decreased postintervention, but remain considerably long. The richness of the THRio database has resulted in several analyses of this expansive cohort of HIV-infected patients that are reviewed here.
Conclusions
The national implementation of TST and IPT for HIV-positive patients in Brazil has been invigorated partly due to THRio’s baseline results. Expanded use of IPT in HIV patients in Rio de Janeiro is achievable with high adherence and low adverse events, although this effort requires a package of activities including training, advocacy and reorganization of services.
A partir da construção da base de dados das Campanhas para a Eliminação da Sífilis Congênita, realizadas no Município do Rio de Janeiro em 1999 e 2000, estabeleceu-se a confiabilidade dos dados informados ao Sistema Nacional de Agravos de Notificação (SINAN). Procedeu-se também a um estudo da qualidade do preenchimento das variáveis, que são as informações solicitadas para a notificação do caso. O percentual de concordância simples para a variável número de consultas de pré-natal foi de 91% e 92,1% e para a variável sífilis na gravidez foi de 62,7% e 76,3%, para os anos de 1999 e 2000, respectivamente. A concordância para as variáveis idade da mãe, data do tratamento e tipo de tratamento foi estabelecida pelo coeficiente kappa. A variável idade apresentou excelente concordância. Contudo, as outras duas resultaram em baixa concordância para os dois anos estudados. Em relação à qualidade, variáveis importantes como realização do primeiro VDRL, do segundo VDRL e a idade gestacional no tratamento, apresentaram percentuais de caselas vazias/ignoradas superiores a 20%. O estudo da confiabilidade entre a base primária das campanhas e o SINAN-SC corrobora a necessidade de desenvolver estratégias para aprimorar a qualidade do último nos vários níveis dos sistemas de saúde. A mudança da definição de caso de sífilis congênita, realizada em 2004, e a introdução do Curso Básico de Vigilância Epidemiológica para sífilis na gestação e sífilis congênita devem contribuir para o aprimoramento do sistema.
SUMMARY
We measured quality of life (QOL) among individuals receiving treatment for human immunodeficiency virus (HIV; n = 45), active tuberculosis (TB; n = 44) and both TB and HIV (n = 9) in Rio de Janeiro, Brazil. Active treated TB was associated with lower physical health (absolute decrease of 0.95 standard deviation in summary score), but not mental health, among people being treated for HIV. Visual analogue scale scores were similar across all three populations, and corresponded closely to standard disability weights used in the literature. Among patients receiving treatment, those with HIV, active TB and both conditions together appear to have similar QOL.
Physicians are substantially more compliant with HIV monitoring and PCP prophylaxis than with TB prophylaxis guidelines. Efforts to improve TB control in HIV patients are badly needed.
OBJETIVOS: avaliar as campanhas de eliminação da sífilis congênita(SC), realizadas no município do Rio de Janeiro em 1999 e 2000, buscando identificar os acertos e falhas ocorridas durante e após a intervenção proposta. MÉTODOS: foi utilizado o modelo teórico-lógico como base para a avaliação de efetividade. RESULTADOS: após a montagem de um modelo lógico das campanhas, foram introduzidas pontuações onde foi possível obtê-las, e uma coluna final mostrando se a avaliação pôde ser realizada. Duas questões se destacaram nessa avaliação: a qualidade da assistência prestada pela rede municipal de saúde na atenção pré-natal e à saúde da criança exposta à transmissão vertical da sífilis, e a questão da vigilância epidemiológica da SC. CONCLUSÕES: o modelo pode contribuir para a construção de uma cultura de avaliação das secretarias, mostrando que somente quando os serviços de saúde adquirem a prática de olhar por dentro de seus programas é que podem tirar proveito de intervenções realizadas, dando o melhor uso possível para os recursos que dispõem para a saúde da população. No caso específico da sífilis, dar visibilidade para o agravo e reorganizar os serviços de assistência, de vigilância e de apoio diagnóstico são aspectos fundamentais, de baixo custo e com impacto positivo no desfecho perinatal.
Background: Tuberculosis is the most common opportunistic infection among HIV-infected patients in Brazil. Brazil's national policy for HIV care recommends screening for latent tuberculosis (TB) and implementing isoniazid preventive therapy (IPT). Objectives: We compared physician adherence to TB screening and other prevention and care policies among HIV primary care clinics in Rio de Janeiro City. Methods: Data on performance of CD4 counts, viral load testing, tuberculin skin testing (TST) and IPT were abstracted from patient charts at 29 HIV clinics in Rio de Janeiro as part of the TB/HIV in Rio (THRio) study. Data on use of pneumocystis jiroveci pneumonia (PCP) prophylaxis were also abstracted from a convenience sample of 150 patient charts at 10 HIV clinics. Comparisons were made between rates of adherence to TB guidelines and other HIV care guidelines. Results: Among the subset of 150 patients with confirmed HIV infection in 2003, 96% had at least one reported CD4 counts result; 93% had at least one viral load result reported; and, PCP prophylaxis was prescribed for 97% of patients with CD4 counts < 200 cells/mm 3 or when clinically indicated. In contrast, 67 patients (45%) had a TST performed (all eligible); and only 11% (17) of eligible patients started IPT. Among 12,027 THRio cohort participants between 2003 and 2005, the mean number of CD4 counts and viral load counts was 2.5 and 1.9, respectively, per patient per year. In contrast, 49% of 8,703 eligible patients in THRio had a TST ever performed and only 53% of eligible patients started IPT. Conclusion: Physicians are substantially more compliant with HIV monitoring and PCP prophylaxis than with TB prophylaxis guidelines. Efforts to improve TB control in HIV patients are badly needed.
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