The Effect of Complete Integration of HIV and TB Services on Time to Initiation of Antiretroviral Therapy: A Before-After Study.

Studies have shown that early ART initiation in TB/HIV co-infected patients lowers mortality. One way to implement earlier ART commencement could be through integration of TB and HIV services, a more efficient model of care than separate, vertical programs. We present a model of full TB/HIV integration and estimate its effect on time to initiation of ART

Turismo e ?reas naturais protegidas: possibilidades incipientes da migra??o por amenidades em tempos de p?s-COVID 19

Territ?rios com ?reas naturais protegidas ganham visibilidade, seja para serem consumidas pelo turista; seja para serem adotadas como lugares de empreendedorismo de pequena a grande escala, e a expans?o do turismo em ?reas naturais configura-se como poss?vel legado p?s-COVID-19. Neste sentido, o crescimento da procura por atividades relacionadas ao turismo em ?reas naturais protegidas pode desencadear uma s?rie de fatores que alteram drasticamente o cotidiano das pessoas dentre as quais a especula??o imobili?ria que, atraindo poss?veis investidores que queiram ou fixar segunda moradia nesses locais ou investirem em neg?cios que deem retornos lucrativos, acabam procurando por im?veis nas proximidades dessas localidades. Assim, compreende-se como uma conjectura fact?vel que o processo de migra??o por amenidades possa se tornar uma tend?ncia p?s-COVID-19, principalmente no entorno de unidades de conserva??o de prote??o integral, como as localizadas pr?ximas ? cidade de Diamantina. A pesquisa realizou a an?lise de referencial te?rico que trata do contexto das transforma??es que as migra??es por amenidades podem gerar no entorno de unidades de conserva??o de prote??o integral, considerando o desenvolvimento do turismo na regi?o de Diamantina, em Minas Gerais. Foi realizado um levantamento documental considerando os planos de manejo do Parque Nacional Sempre-Vivas; e dos Parques Estaduais: Biribiri, Pico do Itamb?, Rio Preto, e Serra do Intendente. Esta pesquisa se classifica quanto aos crit?rios de finalidade como pesquisa aplicada, e pode ser classificada de natureza qualitativa. Quanto aos seus objetivos, compreende-se que se trata de uma pesquisa prioritariamente explorat?ria, que adotou como procedimentos metodol?gicos: a) pesquisa bibliogr?fica; b) pesquisa documental; e c) estudo de caso. Para tanto, foram aplicados, diante da anu?ncia do CEP/UFVJM, um formul?rio on-line com os gestores de tais ?reas protegidas, que se consolidaram como dados para subsidiar a an?lise territorial de cada AP quanto aos processos de ocupa??o em seu entorno, ainda que as mesmas tenham sido contextualizadas sob perspectiva macro. Obteve-se como resultados uma fundamenta??o te?rica consistente, que contextualiza tem?ticas relevantes como: patrimonializa??o da natureza; turismo em ?reas protegidas; ciclo de vida do produto tur?stico/destino tur?stico; turismo de segunda resid?ncia; tipos de migra??o e migra??o por amenidades; e os objetivos de desenvolvimento sustent?vel (ODS). A contextualiza??o das ?reas protegidas evidenciou informa??es referentes as especificidades das mesmas, com especial interesse acerca das localidades que est?o no entorno destes territ?rios, considerando as informa??es dispon?veis em seus respectivos planos de manejo. O formul?rio proposto aos gestores procurou sanar informa??es a respeito de v?rios fatores que interferem e modificam as localidades do entorno dos cinco parques analisados. As respostas obtidas trazem, de modo geral, informa??es a respeito de como se ocorre o turismo e sua poss?vel influencia e, ou presen?a no uso e ocupa??o do solo, assim como parcelamentos irregulares. Os dados obtidos. a partir da aplica??o do formul?rio on-line, com 38 quest?es abertas, foi dividido em cinco dimens?es, a saber: ambiental; social; cultural; econ?mica; territorial e pol?tico-institucional. As respostas obtidas foram contextualizadas aos aspectos econ?micos, sociais, ambientais, culturais e pol?ticos, al?m de problemas acarretados devido a atividade tur?stica mal planejada e desorganizada nos territ?rios do entorno destes parques, considerando refer?ncias te?ricas diversas. Para tanto, foram pautadas publica??es cient?ficas das ?reas protegidas relacionadas a tem?tica, assim como demais documentos t?cnicos dispon?veis que tratam da situa??o de ocupa??o territorial no entorno destes territ?rios protegidos. E tais conte?dos versam, diretamente, com a possibilidade de desenvolvimento da migra??o por amenidades nestas localidades que, considerando as hip?teses iniciais, poderiam ser melhor corroboradas caso houvesse a oportunidade de realiza??o de trabalho de campo, prejudicado pela pandemia e falta de recursos para a pesquisa, que vem sofrendo um desmonte sem precedentes. Ainda assim, como considera??es finais se reconhece que, ainda que os resultados da pesquisa sejam incipientes, fica evidente o qu?o a mesma ? contempor?nea por associar a ?rea de conhecimento do turismo em ?reas naturais protegidas ? pandemia do COVID-19, se mostrando uma quest?o importante de ser debatida diante das tend?ncias do conceito de ?viajar? ter que se reinventar, assim como o pr?prio conceito de ?turista?.Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior (Capes

Clinical mentorship of nurse initiated antiretroviral therapy in Khayelitsha, South Africa: a quality of care assessment.

To combat the AIDS epidemic and increase HIV treatment access, the South African government implemented a nurse-based, doctor-supported model of care that decentralizes administration of antiretroviral treatment (ART) for HIV positive patients through nurse initiated and managed ART. Médecins Sans Frontières (MSF) implemented a mentorship programme to ensure successful task-shifting, subsequently assessing the quality of clinical care provided by nurses

Barriers to Initiation of Antiretrovirals during Antituberculosis Therapy in Africa

In the developing world, the principal cause of death among HIV-infected patients is tuberculosis (TB). The initiation of antiretroviral therapy (ART) during TB therapy significantly improves survival, however it is not known which barriers prevent eligible TB patients from initiating life-saving ART.Setting. A South African township clinic with integrated tuberculosis and HIV services. Design. Logistic regression analyses of a prospective cohort of HIV-1 infected adults (≥18 years) who commenced TB therapy, were eligible for ART, and were followed for 6 months.Of 100 HIV-1 infected adults eligible for ART during TB therapy, 90 TB patients presented to an ART clinic for assessment, 66 TB patients initiated ART, and 15 TB patients died. 34% of eligible TB patients (95%CI: 25-43%) did not initiate ART. Male gender and younger age (<36 years) were associated with failure to initiate ART (adjusted odds ratios of 3.7 [95%CI: 1.25-10.95] and 3.3 [95%CI: 1.12-9.69], respectively). Death during TB therapy was associated with a CD4+ count <100 cells/µL.In a clinic with integrated services for tuberculosis and HIV, one-third of eligible TB patients--particularly young men--did not initiate ART. Strategies are needed to promote ART initiation during TB therapy, especially among young men

Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa

Background: Lengthy antiretroviral treatment (ART) preparation contributes to high losses to care between communicating ART eligibility and initiating ART. To address this shortfall, Médecins Sans Frontières implemented a revised approach to ART initiation counselling preparation (integrated for TB co-infected patients), shifting the emphasis from pre-initiation sessions to addressing common barriers to adherence and strengthening post-initiation support in a primary healthcare facility in Khayelitsha, South Africa. Methods: An observational cohort study was conducted using routinely collected data for all ART-eligible patients attending their first counselling session between 23 July 2012 and 30 April 2013 to assess losses to care prior to and post ART initiation. Viral load completion and suppression rates of those retained on ART were also calculated. Results: Overall, 449 patients enrolled in the study, of whom 3.6% did not return to the facility to initiate ART. Of those who were initiated, 96.7% were retained at their first ART refill visit and 85.9% were retained 6 months post ART initiation. Of those retained, 80.2% had a viral load taken within 6 months of initiating ART, with 95.4% achieving viral load suppression. Conclusions: Adapting counselling to enable rapid ART initiation is feasible and has the potential to reduce losses to care prior to ART initiation without increasing short-term losses thereafter or compromising patient adherence

Patient experiences following acute HIV infection diagnosis and counseling in South Africa

Individuals in the acute stage of HIV infection (AHI) have an elevated potential to transmit HIV and play a critical role in the growth of the epidemic. Routine identification and counseling of individuals during AHI could decrease transmission behavior during this key period. However, diagnosis of AHI may present challenges distinct from those experienced through diagnosis of established HIV infection. A study was conducted in a public youth clinic outside of Cape Town, South Africa, to identify and counsel individuals with acute stage HIV infection. In-depth interviews were conducted with patients following diagnosis. After counseling, patients were accepting of the testing regimen used to diagnose AHI. They used the knowledge of having been recently infected to identify the source of their infection, but did not retain or place importance on information regarding the increased ability to transmit HIV during the acute stage. Future interventions directed at the reduction of HIV transmission following diagnosis with AHI will need to find ways of making this information more salient, possibly through more culturally meaningful educational approaches

Loss from treatment for drug resistant tuberculosis: risk factors and patient outcomes in a community-based program in Khayelitsha, South Africa

BACKGROUND: A community based drug resistant tuberculosis (DR-TB) program has been incrementally implemented in Khayelitsha, a high HIV and TB burden community in South Africa. We investigated loss from treatment (LFT), and post treatment outcomes of DR-TB patients in this setting. METHODOLOGY: LFT, defined as interruption of treatment for ≥2 consecutive months was assessed among patients initiating DR-TB treatment for the first time between January 2009 and July 2011. Patients were traced through routine data sources to identify those who subsequently restarted treatment and those who died. Additional information on patient status and survival after LTF was obtained from community DR-TB counselors and from the national death registry. Post treatment outcomes were observed until July 2013. RESULTS: Among 452 patients initiating treatment for the first time within the given period, 30% (136) were LFT, with 67% retention at 18 months. Treatment was restarted in 27 (20%) patients, with additional resistance recorded in 2/25 (8%), excluding two with presumed DR-TB. Overall, 34 (25%) patients died, including 11 who restarted treatment. Males and those in the age category 15-25 years had a greater hazard of LFT; HR 1.93 (95% CI 1.35-2.75), and 2.43 (95% CI 1.52-3.88) respectively. Older age (>35 years) was associated with a greater hazard of death; HR 3.74 (1.13- 12.37) post treatment. Overall two-year survival was 62%. It was lower (45%) in older patients, and was 92% among those who received >12 months treatment. CONCLUSION: LFT was high, occurred throughout the treatment period and was particularly high among males and those aged 15-25 years. Overall long term survival was poor. High rates of LFT should however not preclude scale up of community based care given its impact in increasing access to treatment. Further research is needed to support retention of DR-TB patients on treatment, even within community based treatment programs

La peregrinación de las gestantes en lo municipio del rio de janeiro: perfil de obitos y nacimiento

This ecological study presented analyze of the birth pathways in the Rio de Janeiro City and identification of the relationship between the health services offer and pregnant flow between their households and the maternity. It was used the data available in the Mortality Information System (MIS) and Live Birth Information System (LBIS) in 2004. The TabWin program processed the data and drew the maps. The LBIS processed 99,042 declarations of live birth and MIS processed 1,318 declarations of deaths in less than one year old in the Rio Janeiro City. The conclusion was that the possibility of intervention in the infantile and maternal mortality profile has happened at the health services, and the access to the quality assistance has fundamental hole in the mortality determination. The existence of access inequalities to the services must be investigated.Tratase de un estudio ecológico que tiene como objetivo analizar las trayectorias de los nacimientos en lo Municipio del Rio de Janeiro y identificar la relación entre oferta de servicios de la salud y del flujo de gestantes entre el lugar de la residencia y la maternidad. Fueron utilizados los datos de los Sistemas de la Información sobre Mortalidad (SIM) y Nacidos Vivos (SINASC) de 2004. El proceso y el mapeamento de los datos fueron hechos a través del programa TabWin. El SINASC procesó 99.042 declaraciones de nacidos vivos y el SIM procesó 1.318 declaraciones de óbitos en menores de un año en lo Municipio del Rio de Janeiro. Concluyese que la posibilidad de intervención en el perfil de la mortalidad infantil y materna dislocase cada vez más para la esfera de los servicios de la salud, y el acceso a la asistencia de calidad tiene papel fundamental en la determinación de la mortalidad, débese, investigar la existencia de desigualdades en el acceso a tales servicios.Trata-se de um estudo ecológico. Objetivou-se analisar as trajetórias dos nascimentos no município do Rio de Janeiro e identificar a relação entre oferta de serviços de saúde e fluxo de gestantes entre local de residência e a maternidade. Foram utilizados dados dos Sistemas de Informação sobre Mortalidade (SIM) e Nascidos Vivos (SINASC) de 2004. O processamento e mapeamento dos dados foram feitos através do programa TabWin. O SINASC processou 99.042 declarações de nascidos vivos e o SIM processou 1.318 declarações de óbitos em menores de um ano no Município do Rio de Janeiro. Concluiu-se que a possibilidade de intervenção no perfil da mortalidade infantil e materna desloca-se cada vez mais para a esfera dos serviços de saúde, e o acesso à assistência de qualidade tem papel fundamental na determinação da mortalidade. Deve-se investigar a existência de desigualdades no acesso a tais serviços

Childbirth care in a Rio de Janeiro coastal lowlands hospital: challenges for respectful birth / Assistência ao parto em um hospital da baixada litorânea do Rio de Janeiro: desafios para um parto respeitoso

Objetivo: Analisar a assistência ao parto das mulheres assistidas em um hospital público da baixada litorânea do Rio de Janeiro. Métodos: Trata-se de um estudo descritivo, de natureza quantitativa, de delineamento transversal, que utilizou a técnica documental retrospectiva. Os dados da pesquisa são relativos aos partos que ocorrem na instituição durante o período de janeiro a junho de 2015. Resultados: Dos 796 partos, 352 (44,22%) ocorreram por via vaginal e 444 (55,77%) por via abdominal. Constatou-se que as primíparas e as mulheres com mais de 35 anos foram submetidas com maior frequência a cesárea. Das 352 parturientes que tiveram parto vaginal, 164 (46,59%) tiveram a episiotomia realizada. Conclusão: A instituição apresenta alto índice de partos cirúrgicos e realização de intervenções obstétricas, tais como a episiotomia, sendo realizada de forma rotineira e sem indicação adequada. A assistência encontra-se desumanizada e em desacordo com as atuais recomendações e evidências cientificas. Descritores: Parto, Episiotomia, Saúde da Mulher