Revista de saude publica最新文献

Objective: To identify the factors associated with HIV self-testing (HIVST) uptake among adolescent men who have sex with men (AMSM) and adolescent transgender women (ATGW) before and during the COVID-19 pandemic.

Methods: A cross-sectional HIVST uptake study was conducted among AMSM and ATGW. Peer educators and health professionals began providing HIVST in February 2019. The outcome was the HIVST uptake before and during the COVID-19 pandemic. The association between each predictor and outcome in each period was analyzed using simple and multiple logistic regressions, estimating odds ratios, and their respective 95% confidence intervals.

Results: The uptake was 229/510 (44.9%) and 382/1,075 (35.5%) before and during the pandemic. During the pre-pandemic period, HIVST uptake was higher in participants who reported receptive anal sex. During the pandemic, uptake was lower in participants with a steady sexual partner and higher in those with frequent oral sex with a steady partner in the previous three months. Before and during the pandemic, HIVST uptake was lower in ATGW and higher in those aged 18-19 years and in participants who lived alone.

Conclusions: Uptake decreased during the pandemic. Sexual behavioral factors associated with HIVST uptake changed during the COVID-19 pandemic, showing the fluid dynamics of sexuality in AMSM and ATGW during this period. HIV programs can optimize the implementation of HIVST among adolescents and young people by incorporating effective and differentiated service delivery models to increase HIV testing uptake and to reach undiagnosed individuals effectively.

Objective: To evaluate whether adolescents from sexual minorities who initiated pre-exposure prophylaxis (PrEP) in community-based organizations (COs) are more socially and HIV-vulnerable compared with their counterparts from a conventional health service. In addition, to evaluate whether these adolescents had more timely access to prophylaxis.

Methods: A PrEP demonstration study was conducted in the city of São Paulo in two COs, located in the center (CO-center) and the outskirts (CO-outskirts), and a conventional HIV testing service (CTA-center). Between 2020 and 2022, cisgender male adolescents who have sex with men (aMSM), transgender and gender diverse adolescents (aTTrans) aged 15 to 19 years, HIV-negative, with higher-risk practices for HIV were eligible for PrEP. Indicators of timely access and vulnerabilities of adolescents initiating PrEP in COs were analyzed using CTA-center as a reference and multinomial logistic regression.

Results: 608 adolescents initiated PrEP in COs and CTA-center. Adolescents from COs were associated with a shorter time to PrEP initiation (1-7 days; CO-outskirts: ORa = 2.91; 95%CI 1.22-6.92; CO-center: ORa = 1.91; 95%CI 1.10-3.31); and a lower housing Human Development Index (HDI) (CO-center: ORa = 0.97; 95%CI 0.94-1.00; CO-outskirts: ORa = 0.82; 95%CI 0.78-0.86). In CO-outskirts, there was an increased chance of adolescents being younger (ORa = 3.06; 95%CI 1.63-5.75) and living closer to the service (ORa = 0.82; 95%CI 0.78-0.86, mean 7.8 km). While adolescents from the CO-center were associated with greater prior knowledge of PrEP (ORa = 2.01; 95%CI 1.10-3.91) and high-risk perception (ORa = 2.02; 95%CI 1.18-3.44), adolescents from the COs were not associated with higher-risk sexual practices and situations of vulnerability to HIV.

Conclusion: The provision of PrEP in the COs facilitated access for vulnerable adolescents and may contribute to reducing inequities.

Objective: To analyze the impact of intersecting systems of oppression on the continuum of PrEP care among adolescent gays, bisexuals, and other men who have sex with men (aGBMSM), and to examine how health professionals (HP) identify and address these challenges to provide sexual health care and HIV prevention.

Methods: This qualitative exploratory study was part of a cohort research project involving aGBMSM, travesties, and transgender women (aTrTW) using PrEP. Data analyzed consisted of 16 interviews with aGBMSM and eight with health professionals (HPs) in São Paulo study site. The methodological and theoretical framework for the interactive categorization of thematic analysis was based on an intersectional approach.

Results: The knowledge of aGBMSM about PrEP was influenced by the adverse effects of systems of oppression, particularly among Black adolescents, who acquired knowledge in a less technical manner compared to White adolescents. Most professionals recognized oppression and its impact on the PrEP care continuum (PrEPCC), especially noting the presence of racism. However, few articulated how different social markers compound barriers to the success of the PrEPCC.

Conclusion: Social oppression affects the success of the PrEP care continuum (PrEPCC) in multiple ways. Health professionals (HPs) play a crucial role in mitigating and not perpetuating these negative experiences within health services, as well as in PrEP access, use, and adherence.

Objective: To understand the perceptions and experiences of transsexual and travesti women and non-binary or gender-fluid people (TGWT+) in health services where they took pre-exposure prophylaxis (PrEP) in the periods before and during the pandemic, focusing on the resignification in the relationship with services and the continuity of HIV prevention via PrEP.

Methods: Qualitative research and analysis of empirical material generated in the context of broader studies were conducted. A total of 45 semi-structured interviews were conducted with TGWT+ PrEP users in the city of São Paulo and analyzed using iterative thematic content analysis.

Results: The TGWT+ interviewees gave new meanings to their struggles, daily lives and ways of caring for their health and played a central role within them. With its particularities, the COVID-19 pandemic became one more event among all the others that TGWT+ face daily. Alongside the COVID-19 pandemic, the TGWT+ were faced with the HIV epidemic, but with the possibility of prevention via PrEP.

Conclusion: Based on a situated and conscious perspective, more explicit in the context of the health crisis, the TGWT+ intertwined conscious actions and care practices in dialog with health services. Further research on these groups from a spatiotemporal dynamic situated in specific contexts of meaning production would make it possible to advance prevention and care strategies, especially in times of health crisis.

Objective: This study aims to analyze the knowledge about the HIV event-driven pre-exposure prophylaxis (event-driven PrEP) scheme and the perception of its potential use among young men who have sex with men (MSM), travestis, and transgender women (TrTW) who were followed up in the cohort.

Methods: This qualitative study included 50 interviews with participants from the municipalities of Salvador and São Paulo, aged 15 to 19 years, who made daily use of PrEP or other preventive methods. They were addressed by different demand creation strategies. The in-depth interviews covered topics such as sexual practices, event-driven PrEP knowledge, acceptability, and motivations for its use. A two-stage thematic analysis was carried out on Nvivo, version 12.

Results: Most participants were unaware of event-driven PrEP, and many questioned its effectiveness and safety when receiving information about it. However, on learning about the program, many young people saw advantages, such as not having to take daily medication and the possibility of using it only at times of greater risk. Participants also found barriers to using event-driven PrEP, such as the unpredictability of sexual relations and the difficulty in administering dosages in this modality.

Conclusion: Limited knowledge and experiences with daily oral PrEP influenced interest in event-driven PrEP, which highlights the need for information strategies that enable young MSM and TrTW to read about event-driven PrEP. Young people valued the autonomy and management of preventive methods provides by this new modality, which is more in line with the dynamics of their sexual lives, but they face challenges in managing event-driven PrEP.

Objective: To confirm the diagram of the program's impact pathways and Estratégia Amamenta e Alimenta Brasil (EAAB - Brazilian Breastfeeding and Complementary Feeding Strategy) core functions, and to determine indicators for evaluating EAAB.

Methods: This is a qualitative study within the field of implementation research. Data collection included two focus groups with EAAB implementers, document analysis, and literature review. The analysis included a review of the participants' suggestions and two stages of reviewing the diagram and the names of the impact pathways and core functions. Questions for evaluating the EAAB were then constructed based on the confirmed diagram. The indicators of the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance) were adapted to the EAAB context. The evaluation questions were revised according to the RE-AIM domains and, finally, indicators were determined for each evaluation question.

Results: This study advanced the analysis of EAAB implementation, defining 22 indicators for its monitoring and evaluation. Most of the indicators are already used in implementation, however, the analysis with the RE-AIM framework allowed the indicators to be updated to be more specific, measurable, and relevant to the desired objectives.

Conclusion: The results of the study support the pragmatic application of RE-AIM evaluation in health programs and encourage the planning of evaluation indicators for other child health and development programs in primary care.

Objective: To analyze the impact of the fiscal austerity policy (PAF) on health spending in Brazilian municipalities, considering population size and source of funds.

Methods: The interrupted time series method was used to analyze the effect of the PAF on total expenditure, resources transferred by the Federal Government, and own/state per capita resources allocated to health in the municipalities. The time series analyzed covered the period from 2010 to 2019, every six months. The first semester of 2015 was adopted as the start date of the intervention. The municipalities were grouped into small (up to 100,000 inhabitants), medium (101,000 to 400,000 inhabitants), and large (over 400,000 inhabitants). The data was obtained from the Sistema de Informações sobre Orçamentos Públicos em Saúde (Information System on Public Health Budget).

Results: The results for the national average of municipalities show that the PAF had a negative impact on the level of total expenditure and own/state resources allocated to health in the first half of 2015, without causing statically significant changes in the trends of any of the indicators analyzed in the period after 2015. Small municipalities saw a drop in total expenditure, while large municipalities saw a drop in own/state resources, and medium-sized municipalities saw a drop in both variables. There was no statistically significant drop in the volume of funds transferred by the Federal Government in the immediate aftermath of the implementation of the PAF in any of the municipal groups analyzed. In the medium-term, the PAF only had a negative impact on the large municipalities, which saw significant reductions in the trends of own/state resources and those transferred by the Union for health.

Conclusion: In general, the impact of the PAF on health financing in municipalities was immediate and based on the decrease in own/state resources allocated to health. In large municipalities, however, the impact lasted from 2015 to 2019, mainly affecting health expenditure from federal funds.

Objective: To develop and validate a predictive model utilizing machine-learning techniques for estimating the length of hospital stay among patients who underwent coronary artery bypass grafting.

Methods: Three machine learning models (random forest, extreme gradient boosting and neural networks) and three traditional regression models (Poisson regression, linear regression, negative binomial regression) were trained in a dataset of 9,584 patients who underwent coronary artery bypass grafting between January 2017 and December 2021. The data were collected from hospital discharges from 133 centers in Brazil. Algorithms were ranked by calculating the root mean squared logarithmic error (RMSLE). The top performing algorithm was validated in a never-before-seen database of 2,627 patients. We also developed a model with the top ten variables to improve usability.

Results: The random forest technique produced the model with the lowest error. The RMLSE was 0.412 (95%CI 0.405-0.419) on the training dataset and 0.454 (95%CI 0.441-0.468) on the validation dataset. Non-elective surgery, admission to a public hospital, heart failure, and age had the greatest impact on length of hospital stay.

Conclusions: The predictive model can be used to generate length of hospital stay indices that could be used as markers of efficiency and identify patients with the potential for prolonged hospitalization, helping the institution in managing beds, scheduling surgeries, and allocating resources.