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HIV services are at risk from fragmentation, report warns

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2001 (Published 25 April 2017) Cite this as: BMJ 2017;357:j2001

Coordination of HIV services in primary care: moving away from fragmentation

Brazil is currently moving in the opposite direction from that described by Gulland et al. (1). As a participant in the Fast-Track Project (2) – which aims to increase the number of people living with HIV in antiretroviral treatment, reduce new cases, and reduce mortality, as recommended by the World Health Organization (WHO) – Brazil is implementing measures to enable management of HIV positive patients in primary care.
Since the inception of the current public unified health care system (SUS) in Brazil, primary care has been in a constant process of reorganization (3). Perhaps because of that, HIV care has historically been provided at the secondary or tertiary care levels. This started to change in 2013 (4), when the Ministry of Health established the legal basis for HIV care in the primary setting. This move is of vital importance to our country, and can contribute to both the solidification of primary care and the improvement of patient follow-up – especially considering that institutions do not share an integrated electronic medical record system. Nevertheless, planning of this strategy was insufficient and led to a situation in which unprepared professionals with no HIV experience were asked to handle complex cases.
In order to overcome this problem, our primary care health center – Santa Cecília, affiliated with the Federal University of Rio Grande do Sul (UFRGS) in Porto Alegre, Brazil – created a multidisciplinary space specifically for the care and follow-up of HIV patients. Thus, specialized care is being provided within the primary care setting, with support from nurses, pharmacists, dieticians, and social workers, in addition to a physician specializing in infectious medicine who is available to clarify doubts. Finally, a UFRGS-based telehealth program (TelessaudeRS-UFRGS) (5) provides a toll-free hotline through which primary care professionals can ask questions in real-time. Rapid tests (6) are used for diagnosis, decreasing wait times, and a group of professionals are self-training by routinely reviewing the literature and holding discussion sessions. It should be noted that the incidence of HIV/Aids is high in Porto Alegre: 71.7/100 thousand population in 2015, which corresponds to twice the rate for the state of Rio Grande do Sul (34.7) and more than three times the national incidence (19.1) (7).

Our HIV program was started 2 months ago and, to date, 11 patients (8 males) have been evaluated, with a mean age of 37.2 years. Of these, 5 patients were diagnosed in 2017, and the remaining patients had a diagnosis time between 2 and 30 years. It should be noted that 10 out of 28 patients scheduled so far (including the 11 completed evaluations) did not show up. This high no-show rate (35%) is a sign of the need for active surveillance in the unit, and reflects the numerous barriers we still have to overcome to provide adequate care for this specific population.
We plan to expand our service to include active surveillance, since our region covers a catchment area of approximately 40 thousand, of which about 20% rely on private health insurance. Our planning also includes a focused search for the elderly, who account for about 39.4% of all consultations at our facility in the past 5 years. As national and global estimates show, there is an increase in the number of diagnoses and in HIV mortality in people over 60 years of age.
Finally, we have just started pre-exposure prophylaxis for high-risk patients . We hope that by doing this, and by adopting the strategies that placed HIV care in the UK among the best in the world, we will enhance person-centered care and maintain the movement away from the fragmentation of care.

References
1. Gulland A. HIV services at risk from fragmentation, report warns. BMJ 2017;357:j2001 doi: 10.1136/bmj.j2001.
2. UNAIDS. Get on the Fast-Track. 2016;1-4. http://www.unaids.org/sites/default/files/media_asset/Get-on-the-Fast-Tr...
3. Campos. CEA. A organização dos serviços de Atenção Primária à Saúde no Brasil. Rev Bras Med Fam e Com. 2006;3(6):131–47.
4. Brazil. Portaria Conjunta No. 1. January 2013. 2013;53(9):1689–99. http://www.aids.gov.br/sites/default/files/anexos/legislacao/2013/52759/...
5. Harzheim E, Gonçalves MR, Umpierre RN, et al. Telehealth in Rio Grande do Sul, Brazil: bridging the gaps. Telemed J E Health. 2016;22(11):938-44.
6. Brazil. Portaria No. 29. December 2013. 2013;2–3. http://www.aids.gov.br/sites/default/files/anexos/legislacao/2014/56078/...
7. Prefeitura de Porto Alegre. Público pode fazer exames gratuitos de HIV no Largo Glênio Peres. June 2017. http://www2.portoalegre.rs.gov.br/sms/default.php?p_noticia=999190672&PU...

Competing interests: No competing interests

18 June 2017
Juliana Nunes Pfeil
Family Physician
Kizzy Ludnila Corezola, Cynthia Goulart Molina-Bastos, Patricia Sampaio Chueiri, Marcelo Rodrigues Gonçalves
TelessaudeRS-UFRGS
Rua Mostardeiro, 366
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