MANAGEMENT IN THE CARE OF PEOPLE LIVING WITH HIV IN PRIMARY HEALTH CARE

GESTIÓN EN LA ATENCIÓN A PERSONAS CON VIH EN LA ATENCIÓN PRIMARIA DE LA SALUD

ABSTRACT

Objective

to understand the best management practices in the health care provided to people living with HIV in Primary Health Care services from Florianópolis, Santa Catarina.

Method

a qualitative research study anchored in the Constructivist Grounded Theory. The study participants were nurses and managers involved with management practices in the care provided to people living with HIV in the municipality. The data were collected between July and September 2020 from intensive interviews with 12 nurses in four Basic Health Units and with five managers of the Municipal Health Department, Florianópolis, Santa Catarina, Brazil, totaling 17 participants. Data collection and analysis took place concomitantly, following the initial and focused coding phases.

Results

this resulted in the phenomenon entitled “Unveiling the best management practices in the care provided to people living with HIV related to decentralized, shared and evidence-based care”, supported by three categories that point to decentralization of the clinical management of the HIV infection to Primary Health Care in Florianópolis, to instrumentalization and training of professionals to manage the infection through the use of scientific evidence, and to the care practices developed in the face of the COVID-19 pandemic.

Conclusion

decentralization of care for people living with HIV to Primary Health Care was presented as the foundation of the best practices, supported by teamwork and evidence-based clinical management.

DESCRIPTORS
HIV; Evidence-based clinical practice; Clinical management; Primary health care; Acquired immunodeficiency syndrome

RESUMEN

Objetivo

comprender las mejores prácticas de gestión de la atención médica provista a personas que viven con VIH en los servicios de Atención Primaria de la Salud de Florianópolis, Santa Catarina.

Método

investigación cualitativa, basada en la Teoría Fundamentada en los Datos constructivista. Los participantes del estudio fueron enfermeros y gerentes con participación en las prácticas de gestión de la atención provista a personas que viven con VIH en el municipio. Los datos se recolectaron entre julio y septiembre de 2020 a partir de entrevistas intensivas con 12 enfermeros en cuatro Unidades Básicas de Salud y con cinco gerentes de la Secretaría Municipal de Salud de Florianópolis, Santa Catarina, Brasil, totalizando 17 participantes. La recolección y el análisis de los datos tuvieron lugar simultáneamente, para luego desarrollar las fases de codificación inicial y focalizada.

Resultados

se arribó al fenómeno llamado “Revelando las mejores prácticas de gestión de la atención provista a personas que viven con VIH relacionadas con la asistencia descentralizada, compartida y basada en evidencias”, sustentado por tres categorías que apuntan a la descentralización del manejo clínico de la infección por VIH al ámbito de la Atención Primaria de la Salud en Florianópolis, a la instrumentalización y capacitación de los profesionales para el manejo de la infección aplicando evidencias científicas, y a las prácticas de atención desarrolladas frente a la pandemia de COVID-19.

Conclusión

la descentralización de la atención provista a personas que viven con VIH al ámbito de la Atención Primaria de la Salud se presentó como la base de las mejores prácticas, sustentadas en el trabajo en equipo y el manejo clínico basado en evidencias.

DESCRIPTORES
VIH; Práctica clínica basada en evidencias; Gestión clínica; Atención primaria de la salud; Síndrome de inmunodeficiencia adquirida

RESUMO

Objetivo

compreender as melhores práticas de gestão no cuidado à saúde das pessoas que vivem com HIV em serviços de Atenção Primária à Saúde em Florianópolis, Santa Catarina.

Método

pesquisa qualitativa, ancorada na teoria fundamentada nos dados construtivista. Os participantes do estudo foram enfermeiros e gestores envolvidos com as práticas de gestão no cuidado às pessoas que vivem com HIV no município. Os dados foram coletados entre julho e setembro de 2020, a partir de entrevistas intensivas com 12 enfermeiros, em quatro Unidades Básicas de Saúde e cinco gestores da Secretaria Municipal de Saúde, de Florianópolis, Santa Catarina, Brasil, totalizando 17 participantes. A coleta e análise dos dados ocorreram de forma concomitante, seguindo as fases de codificação inicial e focalizada.

Resultados

chegou-se ao fenômeno intitulado “Desvelando as melhores práticas de gestão no cuidado às pessoas que vivem com HIV relacionadas com o cuidado descentralizado, compartilhado e baseado em evidências,” sustentado por três categorias que apontam para a descentralização do manejo clínico da infecção por HIV para a Atenção Primária à Saúde em Florianópolis, a instrumentalização e treinamento dos profissionais para o manejo da infecção mediante o uso de evidências científicas e as práticas de cuidado desenvolvidas frente à pandemia de Covid-19.

Conclusão

a descentralização do cuidado às pessoas que vivem com HIV para a Atenção Primária à Saúde foi apresentada como alicerce das melhores práticas, amparadas no trabalho em equipe e manejo clínico baseado em evidências.

DESCRITORES
HIV; Prática clínica baseada em evidências; Gerenciamento clínico; Atenção primária à saúde; Síndrome de imunodeficiência adquirida

INTRODUCTION

Throughout the HIV epidemic in Brazil, the Unified Health System (Sistema Único de Saúde, SUS) always sought to incorporate new coping proposals. These measures include modernization of the antiretroviral therapy (ART), simplification of the treatment, less drug toxicity and interaction, combined prevention measures, provision of condoms, immediate ART initiation for all people living with HIV and prescription of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), in addition to the proposed model of shared care between the Primary Health Care (PHC) service and the Specialized Care Service (SCS) 1^-3.

From January 2007 to June 2021, 381,793 HIV cases were reported in Brazil and, of these, 36,218 (9.5%) occurred in the South region of the country, which ranks third with the highest number of diagnoses in the period. The state of Santa Catarina notified 17,479 HIV cases and was one of the Federation units with a higher rate of HIV detection in pregnant women than the national one, with 5.5 cases/1,000 live births, as well as it stood out for the 47.6% reduction in the mortality coefficient due to AIDS between 2010 and 2020. Florianópolis, capital city of the state, presented an AIDS detection rate of 34.2 cases/1,000,000 inhabitants in 2020, emerging as the fourth Brazilian capital city with the highest detection rate4^,5.

The scenario in the capital of Santa Catarina represents the commitment made by the Florianópolis Municipal Health Department (Secretaria Municipal de Saúde, SMS) to reach the 95-95-95 goal of the Joint United Nations Programme on HIV/AIDS (UNAIDS), which aims at informing and knowing the HIV status of 95% of the population living with HIV; linking 95% of the diagnosed individuals to uninterrupted antiretroviral treatment, and achieving viral suppression in 95% of all people undergoing ART6.

To achieve these goals, it is indispensable to expand access to HIV diagnosis, early treatment and clinical follow-up by decentralizing care for people living with HIV to the PHC services. The change from a care model centered on specialties to shared care in PHC is promising when considering the leading role of PHC in comprehensive and longitudinal care of the population, contributing benefits in the use of financial resources, expanded access, increased resoluteness and qualification of care for people living with HIV7. However, there are some difficulties associated with decentralization of HIV management to PHC, among which are scarcity of human resources, professional turnover, resistance to change and concern about work overload, perception of technical inability for decentralized clinical management, and other challenges of the everyday PHC practice8^,9.

In this path, health management stands out as an essential process to define strategies and solutions for coping with these challenges. Management practices in the care of people living with HIV can be understood as "better" based on their results, whether through the evaluation of strategies, tools, health services, health programs, interventions, and actions that sought to improve a specific health condition, as well as prevention and care directed at people living with HIV10.

As the decentralization guidelines are recent, there is a need to conduct studies analyzing the care provided to people living with HIV in PHC services, in order to identify best management practices in the care developed in places where decentralization has already been instituted, such as Florianópolis. According to the World Health Organization definitions, best practices are considered to be methodologies that, through experience and research, are reliable in achieving the best health results and can be adapted to other realities11.

It is in this setting that the following study guiding question was selected: what meanings do health professionals attribute to the best management practices in the care provided to people living with HIV? Thus, the objective of this study is to understand the best management practices in the health care provided to people living with HIV in Primary Health Care services from Florianópolis, Santa Catarina.

METHOD

This is an exploratory research study of a qualitative nature, anchored in the methodological framework of the Grounded Theory (GT), which consists of an inductive-deductive method where theory building requires interaction between researchers and participants, producing an interpretive picture of reality12. The current study followed the guidelines set forth by the GT Constructivist strand.

The study settings were four Basic Health Units, one from each health district in the municipality of Florianópolis. These loci were defined by the Municipal Health Department (Secretaria Municipal de Saúde, SMS). The selection criteria used by them were not shared with the researchers. At a second moment, the specialized care, clinical management, care integration, and epidemiological surveillance SMS sectors also comprised the research.

The initial sample group consisted of twelve nurses who worked in PHC and met the criteria of working as assistant nurses or coordinators or being Nursing Residency students in the previously defined Basic Health Units, as well as having at least six months of experience in relation to the data collection date. The theoretical sampling group was comprised by 5 managers, who met the criteria of having been in management positions at the SMS of Florianópolis/SC for more than six months in relation to the data collection date. For both sampling groups, the exclusion criterion considered corresponded to the professionals who were distanced from work during the data collection period, regardless of the reason.

Data collection took place from July to September 2020 through intensive interviews, which were conducted in a non-face-to-face format due to the COVID-19 pandemic and were carried out by means of video calls using the Google Meet^® digital communication tool. Interviews allow the researchers to explore a given subject matter, idea, feeling and experience, in order to develop the discussion on the phenomenon with the interviewee12.

The participants were invited to comprise the research via email or telephone contacts. The interviews were previously scheduled and carried out at the research participants' preferred location, some of them at the workplace or at the end of the working day, when the participants were already home. The free and informed consent form was sent virtually for the participants' signature in the Google Forms^® format, with one copy kept on file in the researcher's custody.

In the initial sampling group, the intensive interviews had the following triggering question: Talk to me about the best care practices targeted at people living with HIV. The interview script also addressed aspects related to the participants' sociodemographic characteristics. From the analysis of these interviews, the hypothesis emerged that the best management practices for people living with HIV were related to the decentralization of the clinical management, backed up by scientific evidence protocols and guides. In this setting, the need was identified to create a theoretical sampling group, consisting of managers from Florianópolis SMS, seeking to understand how the care practices in PHC are conditioned to the municipal management definitions. The objective of the interviews with this group was to explore aspects related to the elaboration and implementation of clinical management protocols targeted at HIV, by means of the following question: Talk to me about the use of protocols and clinical management guides for best care practices targeted at people living with HIV.

Data saturation was reached at the end of the interviews with the second theoretical sampling group, comprised by five managers, with well-developed categories and subcategories and the absence of new elements, rendering it unnecessary to search for new information to support the phenomenon found. There were refusals to participate: four from nurses working in PHC and one from an SMS manager. Thus, the study totaled 17 participants.

Both versions of the interview script were validated in the research group of the graduate Nursing course at Universidade Federal de Santa Catarina (UFSC) to which the researchers belonged and tested with the interviewees (nurse 01 and manager 01), requiring no changes/adjustments. The test interviews did comprise the dataset that was analyzed. Data collection was conducted by a researcher, a graduate in Nursing who, at the data collection moment, was attending a master's degree program in Nursing, and had undergone training in the areas of health management and nursing, care of people living with HIV, and use of the Grounded Theory methodology. These training sessions took place during participation in the research group and joint guidance meetings with the researcher in charge, an expert in the area.

The interviews lasted a mean of 29 minutes, with a maximum of 01h:02min:34s and a minimum of 15:56 minutes. Only the researcher and the study participant were present during the interviews. Subsequently, the interviews were transcribed to a Word® file and sent for validation by the participants. The representative diagram of the phenomenon was also forwarded for validation, which, according to the participants' evaluation, contemplated the meanings attributed to their experiences. After validation, the interviews were organized for analysis in the NVivo 10® software.

Data analysis followed two coding phases, namely: initial and focused. The first phase was initial coding, in which the incidents were coded to understand the information from the meanings and experiences of the participants, constituting the first dimensions of the analyzed experience. In the second phase, focused coding took place, in which the most expressive codes were grouped to assemble abstract categories to synthesize a given data fragment.12 Memos and diagrams were elaborated, consisting of textual and graphic records developed to help analytical data development.

This study met the ethical principles for research studies with human beings and was approved by the UFSC Research Ethics Committee. In order to ensure the participants' anonymity, the statements will be presented and identified by means of codes, which represent the sample group (G1 and G2), followed by the number of the interview (N01, N02 for nurses; and M01, M02 for managers).

RESULTS

Among all 12 participants from the initial sampling group, two (16.6%) were male and 10 were female (83.3%). The mean age of the group was 37.1 years old. Regarding the participants' schooling level, two (16.6%) were MSc and 10 (83.3%) were specialists. The mean time of performance was three years, with eight (66.6%) working as clinical nurses, two (16.6%) as coordinating nurses, and two (16.6%) as resident nurses.

Among the five participants from the theoretical sampling group, two (40%) were male and three were female (60%). The mean age of the group was 41.4 years old. Regarding the participants' schooling level, two (40%) had attended MSc and PhD courses, respectively. All (100%) were graduates in Medicine and had some specialization. The mean time of performance was three years, with two (40%) holing managerial positions, one (20%) a coordination position, one (20%) a technical position, and one (20%) working as department head.

The findings of this study point to three categories that, interrelated, support the phenomenon entitled “Unveiling the best management practices in the care provided to people living with HIV related to decentralized, shared, and evidence-based care.” According to the participants' statements, the best management practice in the care provided to people living with HIV can be understood in three pillars: 1) decentralization of care to PHC, which resulted in changes in structuring of the services and organization of care for people living with HIV; 2) care based on scientific evidence, which can be considered the foundation of the phenomenon of best management practices in the care of people living with HIV, as it instrumentalizes and prepares PHC professionals for the clinical management of HIV infection, and 3) development of best management practices in the care of people living with HIV in the face of the COVID-19 pandemic, which, although not part of the initial objective of the study, gained analytical relevance during data collection and analysis, therefore representing the efforts and adjustments developed in the study setting.

From the analysis undertaken, it is possible to conceptualize decentralization as a triggering initiative and a necessary condition for the change in the care model to take effect. The instrumentalization of the professionals to provide evidence-based care represents the status quo of care for people living with HIV in the city of Florianópolis, while care shared among the team can be considered a product of this process. The details of the categories and subcategories representing the phenomenon under study are presented in the Chart 1.

Chart 1-
Phenomenon, categories, and subcategories of the study. Florianópolis, SC, Brasil, 2022.

Unveiling the best management practices in the care provided to people living with HIV related to decentralized, shared, and evidence-based care
Categories	Subcategories
1. Decentralizing the shared care provided to people living with HIV to Primary Health Care	1. Assuming responsibility for the care provided
	2. Involving the multidisciplinary team in the care provided
	3. Creating a bond, reducing stigmas and preconceptions
	4. Expanding access to health services
	5. Coordinating access to health services
2. Instrumentalizing the professionals for evidence-based clinical management	6. Grounding the care practices on protocols and scientific evidence guides
	7. Simplifying the HIV infection therapeutic scheme
	8. Caring for people who live with HIV with confidence and security
	9. Training physicians and nurses for HIV clinical management
3. Developing best care practices for people living with HIV in the face of the COVID-19 pandemic	10. Prioritizing the care of people who live with HIV
	11. Easing access and flexibilizing routines in the health service
	12. Seeking an intersectoral care network to maintain care
	13. Sharing the care provided to people living with HIV among the health team members

Decentralizing the shared care provided to people living with HIV to Primary Health Care

The findings of this study indicate decentralization of care to PHC as an advancement for the clinical management of people living with HIV. The benefits from this process are unveiled in different ways, such as shared care among the team members, increased access and bonding, and reduction of stigmas and prejudices related to the disease. A feeling of accountability towards the comprehensive care provided to this population group in PHC emerged in the participants.

[…] today, as a Family Health nurse, it's super important for me to know that the care of the person with HIV is my responsibility, it's not up to infecto(logy) [...], it's mine and the family doctor's. I believe it's something that makes a difference in our practice. From the moment I understand that it’s my responsibility, my look at that, my focus, the focus of the care I provide, will change (G1N04). […] so, as I’m here, I assist them, not specifically to the HIV issue, because I end up attending to the person as a whole (G1N07).

Involvement of the multidisciplinary team in the care of people living with HIV can also be understood as an advance, as the participants assert that they share responsibilities and duties in the care provided.

[…] shared care in a team is what best works for a problem that is so complex (G2M01). […] we divide the tasks of active search, of monitoring these patients, and use the space of our team meetings, which are weekly, to discuss the more complex cases, which are more difficult, and need to expand the search and support in this network, be it family, with other professionals [from the team] or professionals from the Family Health Support Center (G1N04).

The participants also pointed to Increased bonding between the users and the health care team and a decrease in stigmas and prejudices related to living with HIV.

[…] the bond that the Family Health team has with these people is what guarantees these good practices and [...] when you ask me about good practices [...] we don't have anything very revolutionary, but something that we have very firmly established, even in our team, is the issue of facilitated access (G1N04). […] I've always been in favor of decentralization, I believe that it reduces the stigma, it reduces the preconception, it grants access [...] (G1N03).

Expanding access to health services also stood out as a product of care decentralization to PHC. In this logic, it was possible to identify some strategies already implemented in the study setting.

[…] we have several ways to access the unit today, we have email, WhatsApp, telephone, home visits […] Then we use all these mechanisms to be able to ease access for the user to the maximum possible (G1N08).

Likewise, the participants evidenced the PHC role as a coordinator of the care provided to people living with HIV in the access to other points of the Health Care Network.

[…] [The team] manages to maintain care coordination because the patients are under their responsibility. Even if you need some matrix support to solve doubts or refer this patient to other specialties, you still keep this patient under your care (G2M04). […] when he [the patient] was in infectology, even though there was also a link with the infectologist, the patient got lost in the other network issues that end up being ordered by primary care (G2M05).

Instrumentalizing the professionals for evidence-based clinical management

Clinical management by professional physicians and nurses in PHC from Florianópolis is guided by scientific evidence. The Practical Approach to Care Kit (PACK) stood out among the sources used, which systematizes the clinical guidelines for the care provided in cases of HIV infection.

[…] I believe that the best practices are those based on the best scientific evidence (G1N10). […] it’s [the PACK] an easy-to-use guideline, a whole evidence-based structure, locally adapted and with a training strategy (G2M03). […] sometimes the patient arrives complaining, [...] women, for example, “I’m taking this cocktail, can I take this contraceptive?”. I go search in the PACK, and there I find this answer. It’s well-structured, well organized (G1N02).

Some strategic routines were identified for early HIV diagnosis, such as requesting the serology test for the patients at risk of HIV infection.

[…] I talk a lot about this with the residents: “it's to ask for the serology of everyone”, “you can forget to request any other exam, but serology is obvious for everyone”. If we don't do serology, we’re going to stop making diagnoses and will leave these people with HIV without knowing what they have (G1N04).

It was also evidenced that the use of the PACK has contributed to the systematization and simplification of the clinical follow-up and treatment of HIV infection, which can now be carried out in a protocol by the multidisciplinary team.

[…] now we have protocol-based HIV treatment in Primary Care. I’ll tell you that there’s little to think about in terms of what to do and what not to do. When it gets complicated [...] we’ll discuss the case with infecto. But the majority, the great percentage of people, fits into those very precise criteria [...] that they’ll take a specific medication, that they’ll have the same periodicity of tests [...]. Then, I usually tell the patients that it’s easier to treat HIV than diabetes today (G1N04).

[…] I think that a best practice is through good, proper, standardized clinical management in the health network, […] which’we're trying to do through training, through the PACK. Clinical management also eases this a lot because you have quick access to specialists from the network (G1N07).

Thus, it can be understood that using instruments based on scientific evidence has contributed to the Nursing profession’ls' feeling of confidence and safety in managing HIV infection.

[…] the PACK helps a lot and confers some dynamism to management, some very good dynamism […] because you just go in there and do everything.’It's all evidence-based. So it gives you confidence in management (G1N01).

The PACK was also highlighted as the main continuing education instrument for medical and nursing professionals in managing the main complications monitored in PHC.

[…] so, in some situations, clinical cases, were given, and we would discuss according to the PACK the management that was given to that situation of the patient, that clinical case of the day, right? (G1N01).

Developing best care practices for people living with HIV in the face of the COVID-19 pandemic

The adaptations implemented by the health services for maintaining follow-up care for people living with HIV during the COVID-19 pandemic were highlighted in the participants’ statements.

[…] as we have quite a lot [of patients], we need this control of who’s my focus, and who’s my priority. […] HIV patients meet the criteria for continued care, even during the pandemic (G1N04).

[...] the HIV tests are considered a priority, and then they’re still performed (G1N07).

Now in the pandemic, everything is out of the ordinary, but we have priorities such as prenatal care, childcare, tuberculosis, people with HIV/AIDS, […] also come into this follow-up and monitoring, where periodic tests are done, active search [...] (G1N09).

The need to restructure the services to meet the new demand for respiratory symptoms and to maintain the care provided to people with chronic conditions who were already being monitored by the health team led to proposals to ease access and render previous routines more flexible, with emphasis on the incorporation of new communication technologies.

[...] we have a totally organized work process for people to come the least possible to the unit. The main gateway is WhatsApp, we evaluate the situation. So, we have, for example, refills of prescriptions that are all done by Teleconsultation […], the vaccines are scheduled via WhatsApp [...], dental care is evaluated by the dentist, [...] the medications, the person brings the prescription, the community agent receives this prescription, separates the medication and delivers it to that person (G1N03). […] people contact us and fill in a form [Google Forms] telling us their complaints, for example: "refill of an ART prescription", [...] it'll be prioritized before other people (G1M12).

The existence of an intersectoral network of care for people living with HIV was also evidenced, which supported ART distribution during the COVID-19 pandemic, in partnership with Non-Governmental Organizations (NGOs).

[…] I took three leaders from Non-Governmental Organizations that I trusted and I had a meeting with them, and I said: “Guys, you'll have to help us get the names [of the patients] and we'll help with [ART] distribution”. So, this partnership with the NGOs is working out great! I have to check the updated data, but we've certainly exceeded the 500 people that we have offered ART delivery (G2M01).

[…] sometimes, the NGOs also identify people who abandon the treatment, […] sometimes the person has moved, returned here,’t's frequent [...], and these people seek GAPA [AIDS Prevention Support Group] to resume treatment, seek guidance [...], sometimes they don't know how the city's health system works [...], and GAPA ends up putting the patient back in the line of care (G2M02).

Teamwork also proved to be relevant given the adaptations that were necessary during the COVID-19 pandemic.

[…] what I told you at the beginning, about easy access [...] we have a team prepared for this (G1N04). […] we can evaluate with the team some other situations that we consider a risk (G1N03).

DISCUSSION

The line of care for people living with HIV in the municipality of Florianópolis is structured according to the decentralization guidelines for PHC services, which acts as the preferential gateway and care organizer. The municipality has been gradually instituting this change of model since 20151. The benefits of decentralization were evidenced in the statements of nurses and managers, who portrayed advances in expanding access to health services, accountability for the territory, bonding, professional training to offer evidence-based care, strengthening and coordinating the Health Care Network, and reducing stigmas and prejudices. The scientific literature complements these findings by pointing to the contributions of decentralization to treatment adherence, retention in care, and expansion of early diagnosis2^,8^,13^,14.

Despite the advances, it is noticed that follow-up and assistance for people living with HIV are still incipient in PHC. The literature points to other experiences related to HIV care decentralization, which focus on the nurses' role in prevention and diagnosis activities, with rapid tests and counseling9^,15. If compared to the results of this study, such findings point to a reduction in nurses' clinical role in HIV management in other settings in Brazil. In these locations, tensions related to communication of the HIV diagnosis were identified, as well as to nurses' work overload and limitation of the training sessions' theme (focused on rapid tests), access barriers to other network services, and fear of exposing the patient's health condition among unit professionals and other users9^,15.

Thus, it is understood that the process of decentralizing management of the HIV infection to PHC requires prudence and attention to some ethical challenges, related to the work performed by the teams in the territory; as well as to technical challenges, regarding instrumentalization for clinical management and professional training; PHC organizational challenges, with the flexibility to adapt its modus operandi to the users' needs and expectations; external organizational challenges, with structuring of the support and interaction mechanisms between PHC and specialized care professionals; and political challenges, for conducting the agenda and dialogue between different actors7.

Florianópolis has instituted Teleconsulting and a matrix support of infectious disease professionals to foster discussion of clinical cases and construction of the Singular Therapeutic Project (STP) by multidisciplinary teams. This entire process occurred through technical-pedagogical and institutional and specialized support13^,16. For this purpose, rapid response communication channels were established, such as email to discuss cases and WhatsApp groups to discuss general issues related to HIV clinical management. Clinical protocols for referral to specialized care, access flows, and different care management tools, such as health surveillance spreadsheets, have also been established.

With the advances in ART and the consequent improvement in the quality of life of people living with HIV, infection by the virus is now considered a chronic health condition. Given the above, it is understood that PHC coordination and shared care in a team are the strategies that work best for such a complex disease. As broad as the practice of family and community doctors may be, the centrality and primacy of their work make one reflect on the consequent limitations of the care provided to people living with HIV in PHC in terms of integrality, as it is understood that team care tends to expand the analysis and resolution capabilities for problems, demands and health needs of the population15.

The Florianópolis Adult PACK has gained prominence as a guide to support clinical decision-making and a guiding tool for the work process of physicians and nurses in PHC. It is structured in a flowchart format and presents an HIV care guidance chapter, initially addressing the conduction of new case diagnosis, routine care, review of routine test results, counseling, treatment, and re-evaluation. It also has a special page with guidelines for ART initiation17. Thus, the PACK is perceived as an innovative technology for HIV management decentralization and advanced practices in PHC, as it has enabled an expansion of physicians’ and nurses' clinical performance.

The large number of respiratory symptoms imposed adjustments to the routines of the health services, which had to suppress monitoring of other demands of public health importance to the detriment of actions to face the COVID-19 pandemic18^,19. In the study setting, prioritization of the follow-up of people living with HIV was evidenced, which was a determining factor in reducing the effects of the COVID-19 pandemic, which exerts impacts on the health of chronically-ill patients and those with multimorbidities.

With the social isolation imposed by the COVID-19 pandemic, it was necessary to invest in technological solutions to conduct non-face-to-face clinical follow-up of patients20. Among the initiatives instituted in Florianópolis, the creation of a clinical decision support guide related to the new coronavirus is highlighted21, as well as the flexibility of routines and access means to the health service, with emphasis on the use of digital technologies. Telehealth was highlighted as a potential intervention to increase access to care for people living with HIV22.

In addition, the partnership between municipal management and non-governmental organizations for ART distribution during the pandemic stood out, in order to guarantee treatment continuity at a time when public services were prioritizing face-to-face care for COVID-19-related demands. Social and family support networks are significant factors associated with adherence to ART and self-care for people living with HIV23^,24.

The limitations of this research are related to the analysis of the phenomenon from the point of view of PHC nurses and managers, for understanding the importance of investigating the perception of other PHC professionals involved in the decentralization process, as well as of people living with HIV. It also presents limitations related to virtual data collection, which did not allow physical closeness to the professionals in their daily work, which may have interfered with the analysis and understanding of the study phenomenon.

Disseminating knowledge about the best practices instituted in the Florianópolis PHC services can subsidize the development of similar initiatives in other contexts, providing changes in the work process and contributing to expanding access and improving the care provided to people living with HIV in PHC. In addition, the results of this study may help consolidate scientific knowledge about care practices and clinical management of HIV infection in PHC, based on a shared perspective between physicians and nurses, which is still underdeveloped in Brazil and needs further studies.

CONCLUSION

The best management practices in the care provided to people living with HIV in the city of Florianópolis are related to the institution of decentralized care to the PHC services, with positive repercussions in the expansion of access, bonding, the definition of flows and protocols, professional accountability for the territory, and reduction of stigmas and prejudices.

Decentralization triggered a process of training and instrumentalization of PHC professionals for evidence-based clinical management, which is materialized in the joint work between PHC physicians and nurses, with the matrix support specialists. In this setting, the PACK gained prominence as a guiding instrument for clinical decision-making.

The strategies and adjustments instituted due to the COVID-19 pandemic sought to ensure access to ART and follow-up maintenance for people who were already linked to the health teams. Therefore, it is worth emphasizing institutional support and organization of the HIV care line in the study setting.

Analyzing these initiatives is fundamental for the representation of the efforts and visualization of the good results that the municipality of Florianópolis has been building in the decentralized care provided to people living with HIV.

ACKNOWLEDGMENT

We wish to thank the health professionals from Primary Health Care and from the Florianópolis Municipal Health Department who contributed to conducting this research.

REFERENCES

• 1. Carvalho VKA, Godoi DF, Perini FB, Vidor AC, Baron G. Shared care for people living with HIV/AIDS in primary care: results of decentralization in Florianopolis. Rev Bras Med Fam Comunidade [Internet]. 2020 [cited 2022 Mar 15];15(42):2066. Available from: https://doi.org/10.5712/rbmfc15(42)2066
  » https://doi.org/10.5712/rbmfc15(42)2066
• 2. Zambenedetti G, Silva RA. Decentralization of health care to HIV-AIDS for primary care: tensions and potentialities. Physis [Internet]. 2016 [cited 2022 Mar 15];26(03):785-806. Available from: https://doi.org/10.1590/S0103-73312016000300005
  » https://doi.org/10.1590/S0103-73312016000300005
• 3. Rodrigues Filho FJ, Pereira MC. O perfil das tecnologias em saúde incorporadas no SUS de 2012 a 2019: quem são os principais demandantes? Saúde Debate [Internet]. 2021 [cited 2022 Jan 13];45(130):707-19. Available from: https://doi.org/10.1590/0103-1104202113011
  » https://doi.org/10.1590/0103-1104202113011
• 4. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Infecções Sexualmente Transmissíveis, do HIV/Aids e das Hepatites Virais. Boletim Epidemiológico HIV/Aids [Internet]. Brasília, DF(BR): Ministério da Saúde; 2021 [cited 2022 Jan 12]. Available from: https://www.aids.gov.br/pt-br/pub/2021/boletim-epidemiologico-hivaids-2021
  » https://www.aids.gov.br/pt-br/pub/2021/boletim-epidemiologico-hivaids-2021
• 5. Diretoria de Vigilância Epidemiológica. Boletim Epidemiológico HIV/AIDS [Internet]. Florianópolis, SC(BR): DIVE; 2018 [cited 2020 Oct 10]. Available from: http://www.dive.sc.gov.br/barrigaverde/pdf/Aids_2020.pdf
  » http://www.dive.sc.gov.br/barrigaverde/pdf/Aids_2020.pdf
• 6. Duncombe C, Ravishankar S, Zuniga JM. Fast-track cities: striving to end urban HIV epidemics by 2030. Curr Opin HIV AIDS [Internet]. 2019 [cited 2022 Jan 13];14(6):503-8. Available from: https://doi.org/10.1097/COH.0000000000000583
  » https://doi.org/10.1097/COH.0000000000000583
• 7. Melo EA, Maksud I, Agostini R. Cuidado, HIV/Aids e atenção primária no Brasil: desafio para a atenção no Sistema Único de Saúde? Rev Panam Salud Publica [Internet]. 2018 [cited 2022 Jan 13];42:e151. Available from: https://doi.org/10.26633/RPSP.2018.151
  » https://doi.org/10.26633/RPSP.2018.151
• 8. Colaço AD, Meirelles BHS, Heidemann IT, Villarinho MV. Care for the person who lives with hiv/aids in primary health care. Texto Contexto Enferm [Internet]. 2019 [cited 2022 Jan 13];28:e20170339. Available from: https://doi.org/10.1590/1980-265x-tce-2017-0339
  » https://doi.org/10.1590/1980-265x-tce-2017-0339
• 9. Lima MCL, Pinho CM, Dourado CARO, Silva MASD, Andrade MS. Diagnostic aspects and in-service training in the decentralization of care to people living with HIV. Rev Esc Enferm USP [Internet]. 2021 [cited 2022 Jan 13];55:e20210065. Available from: https://doi.org/10.1590/1980-220X-REEUSP-2021-0065
  » https://doi.org/10.1590/1980-220X-REEUSP-2021-0065
• 10. Celuppi IC, Metelski FK, Suplici SER, Costa VT, Meirelles BHS. Best management practices in HIV care: scoping review. Saúde Debate [Internet]. 2022 [cited 2022 Jun 13];46(133):571-84. Available from: https://doi.org/10.1590/0103-1104202213322
  » https://doi.org/10.1590/0103-1104202213322
• 11. Organização Mundial da Saúde (OMS). Guia para a documentação e partilha das “Melhores Práticas” em Programas de Saúde. Ruanda, (RW): Escritório Regional Africano Brazzaville/OMS; 2008.
• 12. Charmaz K. A construção da teoria fundamentada: guia prático para análise qualitativa. Porto Alegre, RS(BR): Bookman Editora; 2009. 272 p.
• 13. Coelho B, Meirelles BHS. Care sharing for people with HIV/AIDS: a look targeted at young adults. Rev Bras Enferm [Internet]. 2019 [cited 2022 Jun 13];72(5):1341-8. Available from: https://doi.org/10.1590/0034-7167-2018-0248
  » https://doi.org/10.1590/0034-7167-2018-0248
• 14. Rossi ADM, Albanese SPR, Vogler IH, Pieri FM, Lentine EC, Birolim MM, et al. HIV care continuum from diagnosis in a counseling and testing center. Rev Bras Enferm [Internet]. 2020 [cited 2022 Jan 13];73(6):e20190680. Available from: https://doi.org/10.1590/0034-7167-2019-0680
  » https://doi.org/10.1590/0034-7167-2019-0680
• 15. Melo EA, Agostini R, Damião JJ, Filgueiras SL, Maksud I. Care for persons living with HIV in primary health care: reconfigurations of the healthcare network? Cad Saúde Pública [Internet]. 2021 [cited 2022 Jun 13];37(12):e00344120. Available from: https://doi.org/10.1590/0102-311X00344120
  » https://doi.org/10.1590/0102-311X00344120
• 16. Vidor AC, Lancini AB, Fernandes CM, Mettrau ER, Atherino IZ, Pereira J. HIV/AIDS em Florianópolis-Cascata 90/90/90 [Internet]. Florianópolis, SC(BR): Boletim Epidemiológico; 2017 [cited 2020 Nov 15]. 12 p. Available from: http://www.pmf.sc.gov.br/arquivos/arquivos/pdf/18_01_2018_18.02.33.c4958c10c46ea33ed4e33d1514aea7f2.pdf
  » http://www.pmf.sc.gov.br/arquivos/arquivos/pdf/18_01_2018_18.02.33.c4958c10c46ea33ed4e33d1514aea7f2.pdf
• 17. Prefeitura de Florianópolis Saúde. Pack Brasil Adulto: Versão Florianópolis. Kit de Cuidados em Atenção Primária. Ferramenta de manejo clínico em Atenção Primária à Saúde [Internet]. Florianópolis, SC(BR): PACK; 2020 [cited 2020 Nov 14]. 137 p. Available from: https://knowledgetranslation.co.za/download/15025/
  » https://knowledgetranslation.co.za/download/15025/
• 18. Shiau S, Krause KD, Valera P, Swaminathan S, Halkitis PN. The burden of COVID-19 in people living with HIV: a syndemic perspective. AIDS Behav [Internet]. 2020 [cited 2022 Jan 13];24(8):2244-9. Available from: https://doi.org/10.1007/s10461-020-02871-9
  » https://doi.org/10.1007/s10461-020-02871-9
• 19. Barbera LK, Kamis KF, Rowan SE, Davis AJ, Shehata S, Carlson JJ, et al. HIV and COVID-19: review of clinical course and outcomes. HIV Res Clin Pract [Internet]. 2021 [cited 2022 Oct 31];22(4):102-18. Available from: https://doi.org/10.1080/25787489.2021.1975608
  » https://doi.org/10.1080/25787489.2021.1975608
• 20. Celuppi IC, Lima GD, Rossi E, Wazlawick RS, Dalmarco EM. An analysis of the development of digital health technologies to fight COVID-19 in Brazil and the world. Cad Saúde Pública [Internet]. 2021 [cited 2022 Jan 13];37(3):e00243220. Available from: https://doi.org/10.1590/0102-311X00243220
  » https://doi.org/10.1590/0102-311X00243220
• 21. Pack Covid-19. Covid-19: Guia para profissionais de Atenção Primária [Internet]. Florianópolis, SC(BR): Pack; 2020 [cited 2020 Nov 14]. 40 p. Available from: https://knowledgetranslation.co.za/download/9225/
  » https://knowledgetranslation.co.za/download/9225/
• 22. Lesko CR, Bengtson AM. HIV and COVID-19: intersecting epidemics with many unknowns. Am J Epidemiol [Internet]. 2021 [cited 2022 Oct 31];190(1):10-6. Available from: https://doi.org/10.1093/aje/kwaa158
  » https://doi.org/10.1093/aje/kwaa158
• 23. Carvalho PP, Barroso SM, Coelho HC, Penaforte FRO. Factors associated with antiretroviral therapy adherence in adults: an integrative review of literature. Cien Saúde Colet [Internet]. 2019 [cited 2022 Jan 13];24(7):2543-55. Available from: https://doi.org/10.1590/1413-81232018247.22312017
  » https://doi.org/10.1590/1413-81232018247.22312017
• 24. Cajado LCS, Monteiro S. Social movement of women with HIV/AIDS: an experience between posithive citizen from Rio de Janeiro, Brazil. Cien Saúde Colet [Internet]. 2018 [cited 2022 Jan 13];23(10):3223-32. Available from: https://doi.org/10.1590/1413-812320182310.13992018
  » https://doi.org/10.1590/1413-812320182310.13992018

NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the dissertation - Best management practices in the care provided to people living with HIV in a capital city from southern Brazil, presented to the Graduate Program in Nursing of Universidade Federal de Santa Catarina, in 2021.

• FUNDING INFORMATION

  National Council for Scientific and Technological Development (CNPq) - Funding Code 134112/2019-9. Academic Excellence Program (PROEX) belonging to Coordenação de Aperfeiçoamento de Pessoalde Nível Superior (CAPES) - Funding code 001.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research of the Universidade Federal de Santa Catarina, opinion N^o. 4,063,338/2020, Certificate of Presentation for Ethical Appreciation 29148020.0.0000.0121.

Edited by

EDITORS

Associated Editors: Laura Cavalcanti de Farias Brehmer, Ana Izabel Jatobá de Souza. Editor-in-chief: Elisiane Lorenzini.

Publication Dates

• Publication in this collection
  06 Jan 2023
• Date of issue
  2022

History

• Received
  29 June 2022
• Accepted
  08 Nov 2022