ABSTRACT

OBJECTIVE

To understand management practices in the care of people living with the human immunodeficiency virus (HIV) in primary health care in a Brazilian capital, in times of the new coronavirus (covid-19) pandemic.

METHOD

Qualitative research, anchored in the methodological-analytical framework of the grounded theory, constructivist aspect. Data were collected by using intensive online interviews with nurses from health centers and managers of the municipal health department. Data collection and analysis occurred concomitantly in two phases of analysis: initial and focused coding.

RESULTS

They point to the development of best care practices, with emphasis on initiatives for coordination of care, decentralization of clinical management for primary health care services, establishment of protocols and flows, agreement of intersectoral partnerships, use of groups and social networks, use of tools such as teleconsultation and health surveillance spreadsheet and formation of support networks.

CONCLUSION

The Brazilian capital restructured its network of health services with the implementation of clinical and management protocols, seeking to maintain care for people living with HIV. We highlighted the incorporation of non-face-to-face care technologies and the facilitation of routines, as strategies for expanding access.

HIV; HIV Long-Term Survivors; Continuity of Patient Care; COVID-19; Qualitative Research

INTRODUCTION

The pandemic of the new coronavirus disease (covid-19), caused by the SARS-CoV-2 virus, has caused significant morbidity and mortality worldwide¹1. Governo Federal do Brasil. Painel coronavírus. Brasília, DF; 2021 [cited 2020 Apr 13]. Available from: https://covid.saude.gov.br/
https://covid.saude.gov.br/... ,²2. World Health Organization. Coronavirus (COVID-19). Geneva (CH): WHO; 2021 [cited 2020 Apr 13]. Available from: https://covid19.who.int/
https://covid19.who.int/... . This scenario has fostered discussions about the forms of organization and adaptation of health services in the face of new demands that emerged with the pandemic, seeking to develop tools and strategies to comply with the guidelines and principles of the Brazilian Unified Health System (SUS). Primary health care (PHC) is the priority gateway into the SUS, to order and coordinate the health care network and, therefore, plays a fundamental role in coping with the covid-19 pandemic³3. Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Cienc Saude Coletiva. 2020;25(4):1475-82. https://doi.org/10.1590/1413-81232020254.01842020
https://doi.org/10.1590/1413-81232020254... .

Some axes of PHC action in this context stand out, such as health surveillance in the territories, care for users with suspected or confirmed cases of covid-19 without severity, social support to vulnerable groups and continuity of care directed to priority groups for this level of health care. Thus, the Brazilian model centered on the family health strategy with a territorial focus already has positive impacts on the health of the population and becomes promising as a strategy for community approach, necessary to cope with any pandemic⁴4. Medina MG, Giovanella L, Bousquat A, Mendonça MH, Aquino R. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica. 2020;36(8):e00149720. https://doi.org/10.1590/0102-311X00149720
https://doi.org/10.1590/0102-311X0014972... .

The covid-19 pandemic and the actions taken in response to it are expected to have far-reaching consequences in other diseases⁵5. Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. Qual o papel da Atenção Primária à Saúde diante da pandemia provocada pela COVID-19? Epidemiol Serv Saude. 2020;29(2):e2020166. https://doi.org/10.5123/S1679-49742020000200024
https://doi.org/10.5123/S1679-4974202000... . The impacts on the care of other ailments are directly related to interruptions in the usual activities and services to meet the demand for covid-19⁶6. Silva-Sobrinho RA, Zilly A, Silva RMM, Arcoverde MAM, Deschutter EJ, Palha PF, et al. Coping with COVID-19 in an international border region: health and economy. Rev Lat Am Enfermagem. 2021;29:e3398. https://doi.org/10.1590/1518-8345.4659.3398
https://doi.org/10.1590/1518-8345.4659.3... ,⁷7. Hogan AB, Jewell BL, Sherrard-Smith E, Vesga JF, Watson OJ, Whittaker C, et al. Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study. Lancet Glob Health. 2020;8(9):e1132-41. https://doi.org/10.1016/S2214-109X(20)30288-6
https://doi.org/10.1016/S2214-109X(20)30... .

Studies show that comorbidities associated with chronic conditions are determining factors for covid-19 mortality, which warns about the need for greater care and caution regarding people living with HIV (PLHIV)⁸8. Wang B, Li R, Lu Z, Huang Y. Does comorbidity increase the risk of patients with COVID-19: evidence from meta-analysis. Aging (Albany NY). 2020;15;12(7):6049-57. https://doi.org/10.18632/aging.103000
https://doi.org/10.18632/aging.103000... ,⁹9. Mirzaei H, McFarland W, Karamouzian M, Sharifi H. COVID-19 among people living with HIV: a systematic review. AIDS Behav. 2020;25:85-92. https://doi.org/10.1007/s10461-020-02983-2
https://doi.org/10.1007/s10461-020-02983... , who, have a greater need for social distancing due to their immunodeficiency status. In places with high HIV loads, care interruptions during the covid-19 pandemic are estimated to cause an increase in HIV deaths of up to 10%⁷7. Hogan AB, Jewell BL, Sherrard-Smith E, Vesga JF, Watson OJ, Whittaker C, et al. Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study. Lancet Glob Health. 2020;8(9):e1132-41. https://doi.org/10.1016/S2214-109X(20)30288-6
https://doi.org/10.1016/S2214-109X(20)30... .

This scenario emphasizes the importance of attention to the multimorbidity of PLHIV and ensuring the provision of antiretroviral treatment (ART), without detriment to compliance and to clinical follow-up⁹9. Mirzaei H, McFarland W, Karamouzian M, Sharifi H. COVID-19 among people living with HIV: a systematic review. AIDS Behav. 2020;25:85-92. https://doi.org/10.1007/s10461-020-02983-2
https://doi.org/10.1007/s10461-020-02983... . However, although international institutions and government agencies have already expressed concern about the HIV epidemic over the years, the covid-19 pandemic presents numerous barriers and challenges to the continuity of care¹⁰10. Jiang H, Zhou Y, Tang W. Maintaining HIV care during the COVID-19 pandemic. Lancet HIV. 2020;7(5):e308-9. https://doi.org/10.1016/S2352-3018(20)30105-3
https://doi.org/10.1016/S2352-3018(20)30... .

Considering that, we elected the following question as the guide of the study: How are management practices carried out in the care of PLHIV in times of covid-19 pandemic? This study proposes to understand the covid-19 pandemic, an emerging and impactful phenomenon in world public health, focusing on the best practices of health care of PLHIV, a population considered a priority by health policies. Best practices are those presenting the best results, being useful tools for the dissemination of innovations in care¹¹11. Higa DH, Crepaz N, Mullins MM; The Prevention Research Synthesis Project. Identifying best practices for increasing linkage to, retention, and re-engagement in HIV Medical Care: findings from a systematic review, 1996-2014. AIDS Behav. 2016;20(5):951-66. https://doi.org/10.1007/s10461-015-1204-x
https://doi.org/10.1007/s10461-015-1204-... .

Thus, the study aimed to understand the management practices in the care of PLHIV in PHC in a Brazilian capital in times of covid-19 pandemic.

METHODS

This is exploratory research of qualitative nature, anchored in the methodological-analytical framework of the grounded theory, in the constructivist aspect, idealized by Kathy Charmaz¹²12. Charmaz K. A construção da teoria fundamentada: guia prático para análise qualitativa. Porto Alegre, RS: Artmed; 2009..

The study was conducted in the municipality of Florianópolis, considered the capital with the highest performance in the national program to improve access and quality of primary care, higher percentage of family health strategy coverage and shared and decentralized care offer in PHC to PVHIV, a national reference in the management and provision of PHC services¹³13. Carvalho VKA, Godoi DF, Perini FB, Vidor AC. Cuidado compartilhado de pessoas vivendo com HIV/AIDS na Atenção Primária: resultados da descentralização em Florianópolis. Rev Bras Med Fam Comun. 2020;30;15(42):2066-. https://doi.org/10.5712/rbmfc15(42)2066
https://doi.org/10.5712/rbmfc15(42)2066... .

Data collection occurred from July to September 2020, initially interviewing nursing professionals from four PHC centers and subsequently managers in the sectors of specialized care, clinic management, care integration, and epidemiological surveillance of the municipal health department. As recommended by the grounded theory, we opted for the initial selection of nurses due to the different competencies assumed by these professionals in health care, considered a leadership for the management of the work of the multidisciplinary team.

The participants who composed the initial sampling were intentionally selected, considering the inclusion criteria of being a care nurse, coordinator, or resident in PHC and having experience in the management of PLHIV care for at least six months at the date of data collection.

The invitation to join the study was made via e-mail and/or by telephone. The informed consent form was sent virtually to the participants and authorized by using Google Forms^Ⓡ , a copy was filed with the researcher.

The intensive interviews took place in non-face-to-face format due to the covid-19 pandemic, by video call using the Google Meet communication system^Ⓡ . The first sample group had as its initial question: Tell me about care practices directed at PLHIV in times of covid-19 pandemic. This group consisted of 12 nurses.

From the analysis of the interviews of the first sample group, we hypothesized that the practices of care for PLHIV during the covid-19 pandemic were related to the decentralization of clinical management to PHC, the restructuring of services, and the establishment of protocols and scientific evidence guides.

Therefore, the need to constitute the second sample group with managers of the municipal health department from Florianópolis was identified. The interviews aimed to explore aspects of the establishment of clinical management protocols directed at HIV, and mechanisms for the adequacy of health services for the covid-19 pandemic scenario based on the question: Tell me about managing care for people living with HIV/SIDA in times of pandemic. Thus, the inclusion criterion for this second group was working in management positions in the Florianópolis municipal health department for more than six months at the date of data collection.

Professionals who were away from work during the data collection period, regardless of the reason were excluded from both sample groups. At the end of the interviews of the second sample group, data saturation was achieved with five managers and information to support the investigated phenomenon, totaling 17 participants.

The data were collected by the researchers by interviews recorded in audio, which were transcribed into Word^Ⓡ and organized for analysis in the NVIVO10^Ⓡ software. The average duration of each interview was 29 minutes. To ensure the anonymity of the participants, the speeches were identified by codes. To obtain the data to ensure the quality and reliability of the study, the principles of the consolidated criteria for reporting qualitative research were followed.

The concomitant analysis of the data, according to the guidelines of the constructivist grounded theory, was performed in two phases. In the first, the initial codification was performed, in which the incidents were coded to understand the information from the participants’ meanings and experiences, constituting the first dimensions of the analyzed experience. In the second phase, focused coding occurred, in which the codes of greater expressiveness were grouped, to form abstract categories to synthesize a given data fragment¹²12. Charmaz K. A construção da teoria fundamentada: guia prático para análise qualitativa. Porto Alegre, RS: Artmed; 2009.. Memorandums and diagrams were elaborated to assist the analytical development of the data, leading to the understanding of the phenomenon.

This study respected the ethical precepts of research with human beings, according to Resolution No. 466/2012 and its complementary, including the new procedures for conducting research in a virtual environment, according to Circular Office No. 02/2021.

RESULTS

The Box shows the categories and subcategories that emerged during the analysis process and that, interrelated, support the phenomenon of study.

The prioritization and concern with the provision of care and monitoring of PLHIV stood out.

The services also adopted the practice of sending requests for exams and prescriptions via mobile, which facilitates access and continuity of care in a scenario of social distancing.

With the decentralization of care to PLHIV for PHC, care was consequently shared among the health team, with division of responsibilities and attributions, including in times of pandemic.

The professionals also emphasized the importance of social distancing for immunosuppressed patients, such as PLHIV.

Initiatives related to the expansion of access and the creation of bonds with PLHIV also stood out. The participants point out the different approaches to communication, among which are the groups and social networks.

Thinking about the continuity of care and treatment of PLHIV, a support network was established with non-governmental organizations (NGOs) so that people who could not retrieve the ART at the distribution center could receive them at home or at the nearest health center. The telephone number of four centers for testing and rapid response was disclosed so that users could communicate their difficulties regarding treatment and request help from this support network.

We made a lot of divulgation through the local health council, community leaders, residents’ association. (G1E04)

The use of management tools, such as surveillance spreadsheets, facilitated the monitoring of PLHIV. This instrument stood out by enabling the visualization of all PLHIV in the territory, and their situation of treatment, medication, examinations, consultations, among others.

The professionals identified that prioritizing face-to-face care for the management of respiratory symptoms led to a decrease in the screening of new HIV cases, which results from the decrease in routine consultations for the population without ailments, which were disregarded due to the scarce human resources.

Furthermore, new ways of accessing the population were incorporated, such as receiving of demands via WhatsApp^Ⓡ, email, telephone, and video call. Thus, the professionals had to grasp the use and functionality of these technologies and adapt to the new model of care imposed by the pandemic.

Thus, teleconsultation was instituted for routine care without severity and that did not require an initial physical examination. In situations that required face-to-face follow-up, users were instructed to attend the health center for scheduled care.

The various technologies incorporated in the health work process improved contact with PLHIV to expand their access to services, which previously occurred in the face-to-face modality. The use of digital means for teleconsultation is a promising tool for health services.

A protocol was elaborated authorizing and regulating teleconsultation to collaborate in the care of users during the covid-19 pandemic.

We can understand that PHC services were reconfigured in the face of the pandemic scenario, to transform the workflow, clinical, and managerial practices and incorporate new technologies in the care process, ensuring continuity of care to priority populations for the PHC. The decentralization of care added to the greater autonomy of professionals, represent a potential for the development of better health practices.

The Figure shows the meanings attributed to the best management practices in the care of PLHIV, illustrating the initiatives instituted in the study scenario.

DISCUSSION

We understand that the best practices of care for PLHIV identified in this study constitute “innovations in care” and are associated with strategies and tools instituted in PHC in the municipality of Florianópolis, with emphasis on establishing mechanisms of communication and access to services and protocols and guidelines for clinical management, forming intersectoral partnerships, and monitoring and managing remote care. These initiatives promote the coordination of care to PLHIV and reinforce important discussions about the attributes of PHC as the guide of health policy in Brazil.

Reorganizing of PHC services in times of covid-19 pandemic, seeking to simultaneously meet the demand of respiratory symptomatic patients and of regular actions that were already monitored at this level of health care, is imperative to the sustainability of the SUS care model¹⁴14. Daumas RP, Silva GA, Tasca R, Leite IC, Brasil P, Greco DB, et al. The role of primary care in the Brazilian healthcare system: limits and possibilities for fighting COVID-19. Cad Saude Publica. 2020;36(6):e00104120. https://doi.org/10.1590/0102-311X00104120
https://doi.org/10.1590/0102-311X0010412... ,¹⁵15. Aquino EML, Silveira IH, Pescarini JM, Aquino R, Souza-Filho JA. Social distancing measures to control the COVID-19 pandemic: potential impacts and challenges in Brazil. Cienc Saude Coletiva. 2020;25 Suppl 1:2423-46. https://doi.org/10.1590/1413-81232020256.1.10502020
https://doi.org/10.1590/1413-81232020256... . Thus, care flows have been implemented for the management of these different audiences, with a distinction between mild, severe, and non-symptomatic respiratory conditions⁴4. Medina MG, Giovanella L, Bousquat A, Mendonça MH, Aquino R. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica. 2020;36(8):e00149720. https://doi.org/10.1590/0102-311X00149720
https://doi.org/10.1590/0102-311X0014972... ,⁵5. Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. Qual o papel da Atenção Primária à Saúde diante da pandemia provocada pela COVID-19? Epidemiol Serv Saude. 2020;29(2):e2020166. https://doi.org/10.5123/S1679-49742020000200024
https://doi.org/10.5123/S1679-4974202000... .

All team professionals, especially community health agents, who have a greater approach to the community, should encourage social distancing mobilizing local leaders for the wide dissemination of information and taking measures necessary to the context⁴4. Medina MG, Giovanella L, Bousquat A, Mendonça MH, Aquino R. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica. 2020;36(8):e00149720. https://doi.org/10.1590/0102-311X00149720
https://doi.org/10.1590/0102-311X0014972... . Therefore, the vital role of community and intersectoral work in the logistical and operational support of care to PLHIV in times of pandemic is evidenced.

In the scenario of our study, the community and NGO partnerships, such as GAPA, aimed at the transport and distribution of ART, which resulted in access to treatment for countless people who found themselves unable to retrieve it themselves. Studies indicate positive results of the work developed by non-governmental organizations aimed at the prevention, treatment, and monitoring of PLHIV, highlighting improvements in harm reduction, access to condoms and ART, linkage to care and access to health services¹⁶16. Trickey A, Stone J, Semchuk N, Saliuk T, Sazonova Y, Varetska O, et al. Is contact between men who have sex with men and non‐governmental organizations providing harm reduction associated with improved HIV outcomes? HIV Med. 2020;22(4):262-72. https://doi.org/10.1111/hiv.13010
https://doi.org/10.1111/hiv.13010... ,¹⁷17. Shamu S, Slabbert J, Guloba G, Blom D, Khupakonke S, Masihleho N, et al. Linkage to care of HIV positive clients in a community based HIV counselling and testing programme: a success story of non-governmental organisations in a South African district. PloS One. 2019;14(1):e0210826. https://doi.org/10.1371/journal.pone.0210826
https://doi.org/10.1371/journal.pone.021... . Articulating solutions in the face of adverse scenarios requires coordinated action in the territory with local leaders, equipment, and institutions, highlighting community engagement and intersectoral actions as important strategies to cope with the covid-19 syndemic¹⁸18. Geremia DS, Vendruscolo C, Celuppi IC, Adamy EK, Toso BRGO, Souza JB. 200 Years of Florence and the challenges of nursing practices management in the COVID-19 pandemic. Rev Lat Am Enfermagem. 2020;28:e3358. https://doi.org/10.1590/1518-8345.4576.3358
https://doi.org/10.1590/1518-8345.4576.3... .

The concept of syndemic consists of the interaction between two or more epidemics, which produce an increase in the burden of diseases of the population¹⁹19. 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. 2020;24(8):2244-9. https://doi.org/10.1007/s10461-020-02871-9
https://doi.org/10.1007/s10461-020-02871... . In other words, the covid-19 pandemic joins the HIV epidemic and creates another health problem for PLHIV, such as decreased access to health services. In this case, with encouraged social distancing and decreased flow of people in health services, the strategy is the management of non-face-to-face care, which can be done with spreadsheets containing clinical data and shared among the health team, and the use of digital communication tools.

The use of management instruments is opportune for maintaining adherence to treatment, identifying gaps and monitoring viral load, CD4, and CD8 tests. However, we highlight some difficulties faced for non-face-to-face clinical monitoring of PLHIV, such as the out-of-date of information, lack of human and material resources, little communication among team professionals, divergent opinions regarding the importance of clinical follow-up, and resistance to changes in work processes²⁰20. Loch AP, Caraciolo JMM, Rocha SQ, Fonsi M, Souza RD, Gianna MC, et al. An intervention for the implementation of clinical monitoring in specialized care services to people living with HIV/AIDS. Cad Saude Publica. 2020;36(5):e00136219. https://doi.org/10.1590/0102-311X00136219
https://doi.org/10.1590/0102-311X0013621... .

The covid-19 pandemic has led to the emergence of non-face-to-face health care technologies, such as teleconsultation, which enables the provision of care by using information and communication technologies in the health area²¹21. 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 Saude Publica. 2021;37(3):e00243220. https://doi.org/10.1590/0102-311X00243220
https://doi.org/10.1590/0102-311X0024322... . Implementing the teleconsultation in PHC in Florianópolis allowed ensuring access to users who needed health services. Thus, it can be considered a crucial tool of care organization for coping with the pandemic.

We emphasize that teleconsultation should be established in PHC based on protocols that regulate the workflow and establish guidelines²³23. Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ. 2020;368:m1182. https://doi.org/10.1136/bmj.m1182
https://doi.org/10.1136/bmj.m1182... , which requires telephony and internet resources, and qualification of professionals and users to take advantage of this new possibility of care²²22. Catapan SD, Calvo MC. Teleconsultation: an integrative review of the doctor-patient interaction mediated by technology. Rev Bras Educ Med. 2020;44(1):e002. https://doi.org/10.1590/1981-5271v44.1-20190224.ing
https://doi.org/10.1590/1981-5271v44.1-2... .

The use of applications such as WhatsApp^Ⓡ and phone calls ensure the offer of actions in a safe way⁴4. Medina MG, Giovanella L, Bousquat A, Mendonça MH, Aquino R. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica. 2020;36(8):e00149720. https://doi.org/10.1590/0102-311X00149720
https://doi.org/10.1590/0102-311X0014972... favoring the continuity of care. The PHC services under study applied these technologies in different situations of PLHIV care, such as to respond to ART related demands, request for routine tests, and receive clinical complaints.

Based on the results of our study, we observe that care management and clinical management, made possible by flows, protocols, and integrated health policy, are fundamental for developing better practices. The restructuring of the health care network and the autonomy, competence and skills of professionals and managers in this scenario of action can effectively intervene in factors that determine the management of health conditions in times of covid-19.

The need for efforts and initiatives to build a strong, vigilant, capillarized PHC, adapted to the pandemic context and faithful to its principles is evidenced. The emerging health crisis with the covid-19 pandemic is sanitary, political, economic, and social, and requires the transformation of the ways of doing health⁴4. Medina MG, Giovanella L, Bousquat A, Mendonça MH, Aquino R. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica. 2020;36(8):e00149720. https://doi.org/10.1590/0102-311X00149720
https://doi.org/10.1590/0102-311X0014972... , without forgetting the continuity of the monitoring of priority groups.

Our study analyzed the meanings of the best management practices in care attributed by nurses of health centers and municipal managers, thus presenting limitations regarding the lack of exploration of the perspective of PLHIV on the same phenomenon. Another limitation pertains to the online interviews since we believe that face-to-face interviews could result in greater interaction between interviewer and participant, favoring the deepening of the phenomenon.

Our study contributes to scientific knowledge about the management of care in coping with the covid-19 pandemic and maintenance of PLHIV care, especially regarding the tools, strategies, and technologies used to disseminate the initiatives implemented in the health network studied, which have the potential for replication in other scenarios in which primary health care practices occur.

CONCLUSION

This study comprised the management practices in the care of PLHIV in the face of the covid-19 pandemic in the PHC in a Brazilian capital, which restructured its network of health services and implemented changes in clinical and management practices to meet the new demands resulting from the covid-19 pandemic and, at the same time, maintain care to PLHIV with quality and effectiveness. The incorporation of technologies and tools for the management of non-face-to-face care as a strategy to expand access and the guarantee of equity and integrality to the care of users in a scenario in which social distancing is reinforced stood out as the best practices.

We highlight the implementation of protocols and flows to guide access to health services to systematize new ways of providing care in times of pandemic, with tools of a digital and technological nature. In this regard, WhatsApp^Ⓡ has gained prominence as a tool for receiving demands, doing teleconsultations, requesting exams, renewing recipes, and scheduling of face-to-face activities when necessary.

To that we add the importance of facilitating the routines of performing follow-up exams and retrieving ART. However, the access restrictions resulting from the covid-19 pandemic for routine follow-up of users without aggravated or priority conditions also evidently culminated in the decrease in screening of new HIV cases and control of other chronic conditions.

REFERENCES

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