Evaluation of implementation of the protocol for managing tuberculosis / HIV coinfection in specialized care services in the state of Ceará , Brazil *

Tuberculosis (TB) is related to poor living conditions and is an aggravating factor for people with human immunodeficiency virus (HIV) infection––one that has repercussions on mortality from AIDS in Brazil (1) and is a reality throughout Latin America (2). People with this coinfection are up to 34 times more prone to developing tuberculosis than the general population and HIV infection is often diagnosed as tuberculosis develops (3). The public network for TB treatment in Brazil was structured and decentralized in the 1990s with TB control policies based on primary health care. The care network for AIDS is relatively recent, however, and control efforts concentrate on the secondary and tertiary levels of care (4). In the state of Ceará, poverty and low levels of schooling also contribute to an increased relevance of TB/HIV coinfection, increased reactivation of latent infections, and problems with adherence to treatment. The cure rate dropped from 73.2% in 2004 to 59.2% in ABSTRACT Objectives. Identify barriers and strategies for implementation of the protocol for managing tuberculosis/human immunodeficiency virus (TB/HIV) coinfection in specialized care services in Ceará state, through implementation research. Methods. The study followed the iPIER methodology, a new initiative to help improve the implementation of health programs through the use of research that is conducted as a part of the implementation process. Data were collected on the structure and processes of 22 services, and barriers were explored in four focus groups with 28 participants, from the standpoint of the health team, administrators, and users. The discussions were transcribed and interpreted with regard to the objectives of the study. Results. The information on structure and process revealed that six services manage TB/HIV coinfection and 16 do not. The barriers were: team members were unaware of the protocol; lack of clinical practice guidelines in the services; specialized care services working at all three levels of the health system; inadequate spaces for treatment of airborne diseases; and lack of communication with primary health care sectors for patient transfers. The results were discussed with teams and administrators in seminars held in the services and with program managers for sexually transmitted infections, human immunodeficiency virus, AIDS, hepatitis, and tuberculosis. Conclusions. Direct dialogue between administrators, implementers, users, and researchers generated knowledge about the services and led to joint preparation of modifications in workflow aimed at acceptance and use of the protocol; however, users continue to resist adherence to treatment.