Ocorrência de doenças oportunísticas e utilização de serviços emindivíduos vivendo com o HIV/AIDS: 1986-2002

Abstract

The natural evolution of HIV infection is a progressive depletion of TCD4 lymphocytes, along with other immune alterations, which leads to the Acquired Immune Deficiency Syndrome (AIDS). In AIDS natural history, opportunistic diseases are described, and the co-infection HIV and Mycobacterium tuberculosis is a potential risk for the individuals morbid -mortality. In Brazil, since 1996, a new chapter in the history of HIV/AIDS epidemics was written. That was possible because of the implementation of public policies aiming the structuring of healthservices and the universal access by the patients to high efficiency anti -retroviral therapies (HAART). The multicenter study Avaliação dos Custos e Impacto da Terapia Anti-retroviral no Brasil (ACITARVB) (Assessment of Costs and Impact of Anti-retroviral Therapy in Brazil) was designed to evaluate the use of services by patients living with HIV/AIDS and related factors. This thesis presents results of part of that study which refers to the consultation of medical registers of patients assisted in reference centers that offer such treatment, from January 1986 to June 2002, with design of non-concurrent cohort. The constitution of the random sample is proportional to the incidence of AIDS cases informed to PN DST/AIDS in five Brazilian cities (Belo Horizonte, Recife, Rio de Janeiro, Itajaí and São Paulo), and is stratified according to availability of anti-retroviral treatments in Brazil: 1986- 1990 TARV unavailable; 1991 -1995 beginning of TARV use and 1996-2002 implementation of HAART and policies to universal access to health services. In the data collection an instrument was used which contained information that indicates the use of services, clinic-lab conditions, occurrence and prophylaxis for opportunistic diseases. The qui-square test and Mann-Whitney U distributions were used to compare the proportions. In the first study,morbidity related to TB was assessed by means of: a) bearing or not TB and b) episodes of TB/period free from any opportunistic disease. Bi/multivariate logistic analyses and Poisson models were carried out. The occurrence of TB was associated to the absence of ARV prescription and prophylaxis for any opportunistic disease, in males, injecting drug users (IDU), who entered in the service between 1991 and 1995; the next segment is the 1986 to 1990 period, those who had other opportunistic diseases. Recurrence of TB is related to being woman, non IDU, with low counts of CD4 and other opportunistic diseases. The divergence, as to the exposition, between occurrence and recurrence, suggests distinct profiles for the manifestation or possibility of a continuation of life. Another finding was the smaller risk of disease by TB during the 1996-2002 period, which concurs with public policies towards the implementation of universal access to HAART and improvements in the provision andsupervision of TB treatment. In the second paper the indicators of service use were used to compare IDU and non IDU. Indicators of service use such as medical consultations, CD4 viral load countings were analyzed both graphically and by the logistic model to check calendar effects, exposition source and gender. The main findings were: UDI entered in the service mainly between 1991 and 1995; had smaller use of propaedeutic and therapeutic services, weather in the first consultation or in all consultations, and took longer to get medical attention. The access to health services lesser than the necessary or the delay greater than isrecommended can contribute to conditions of more serious diseases in the segment of individuals living with HIV/AIDS. Taking into consideration the co-relations among HIV/AIDS, tuberculosis and use of drugs which were demonstrated, it is recommended the institution of specialized services which meet in a whole such conditions and also the designof prospective studies to understand the possible relations between the use of health services, IV/AIDS, drug use and morbidity associated to HIV in the HAART age.