ABSTRACT

This study aimed to investigate, from the perspective of People Living with HIV/Aids (PLWHA), the use of and satisfaction with public oral health services within the Unified Health System (SUS) in Fortaleza (Northeastern Brazil). Structured questionnaires on socioeconomic profile and public oral health service use and satisfaction were administered to 241 PLWHA attending eight Specialized Healthcare Services (SAE) in HIV/Aids. The mean age was 37.8 ± 9.6 years, 161 (68.3%) were male, 79 (32.8%) had completed high school, and 59 (24.5%) reported earning ≤1 minimum wage (USD 225). Only 155 (64.3%) had been to the dentist in the preceding 2 years. Of these, 68 (28.2%) attended public services, but nearly half (45.6%) did not complete treatment due to lack of supplies, malfunctioning equipment or ongoing repair of facilities. On average, the service was graded 7.6 ± 2.5, and 50 PLWHA (73.6%) reported being satisfied/very satisfied. As for humanized care, 86.7% were satisfied/very satisfied. Patients referred by SAE or residing near the facility were significantly more likely to use public services. Despite the limited use of public oral health services, mainly due to insufficient access and ineffective appointment scheduling and referral procedures, the services were mostly graded as satisfactory.

KEYWORDS:
Oral health; Access to health services; HIV

Introduction

With the introduction of antiretroviral therapy for Acquired Immunodeficiency Syndrome (Aids) in the late 1990s, the life expectancy and quality of life of People Living with HIV/Aids (PLWHA) improved considerably. In addition, the number of new Human Immunodeficiency Virus (HIV) infections worldwide has decreased by 19% in the last decade¹1. World Health Organization. Global health sector strategy on HIV/AIDS 2011-2015. Geneva: World Health Organization; 2011.. Despite these advances, HIV/Aids remains a serious public health problem, mainly due to its high prevalence and high morbidity and mortality rates²2. Buchala CM, Cavalheiro TR. A classificação internacional de funcionalidade, incapacidade e saúde e a aids: uma proposta de core set. Acta Fisiatrica. 2008; 15(1):42-8.,³3. Brasil. Ministério da Saúde. Boletim epidemiológico HIV/AIDS. Brasília, DF: Ministério da Saúde; 2019 [acesso em 2020 jan 10]. Disponível em: http://www.aids.gov.br/pt-br/pub/2019/boletim-epidemiologico-de-hivaids-2019.
http://www.aids.gov.br/pt-br/pub/2019/bo... .

Worldwide, there were 37.9 million PLWHA in 2018⁴4. Report on the global AIDS epidemic. Relatório Informativo. Geneva: UNAIDS 2019. [acesso em 2019 dez 6]. Disponível em: https://unaids.org.br/wp-content/uploads/2019/11/2019_UNAIDS_WAD2019_FactSheet.pdf.
https://unaids.org.br/wp-content/uploads... . In Brazil, from 1980 to 2019, 966,058 cases of Aids were identified; and 338,905 people died with HIV/Aids as the underlying cause between 1980 and 2018³3. Brasil. Ministério da Saúde. Boletim epidemiológico HIV/AIDS. Brasília, DF: Ministério da Saúde; 2019 [acesso em 2020 jan 10]. Disponível em: http://www.aids.gov.br/pt-br/pub/2019/boletim-epidemiologico-de-hivaids-2019.
http://www.aids.gov.br/pt-br/pub/2019/bo... . However, integrated care for PLWHA – from health promotion measures and disease prevention to recovery and multidisciplinary monitoring – is still a challenge in the care setting. to public health⁵5. Naidoo P. Barriers to HIV Care and Treatment by Doctors: A review of the literature. S Afr fam pract. 2006; 48(2):55-16e., despite the strong legislation supporting this population⁶6. Brasil. Lei nº 9.133, de 13 de novembro de 1996. Dispõe sobre a distribuição gratuita de medicamentos aos portadores do HIV e doentes de AIDS. Diário Oficial da União. 14 Nov 1996. [acesso em 2019 set 16]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/l9313.htm.
http://www.planalto.gov.br/ccivil_03/lei... .

It is important to emphasize that health promotion is conceptualized as a determinant and conditioner of health because it is concerned with the population’s way of life, with its economic, environmental, ecological, and cultural factors; incorporating targeted policy initiatives⁷7. Silva KL, Sena RR, Grillo MJC, et al. Formação do enfermeiro: desafios para a promoção da saúde. Esc Anna Nery Rev Enferm. 2010 [acesso em 2012 set 12]; 14(2):368-376. Disponível em: http://www.scielo.br/pdf/ean/v14n2/21.pdf.
http://www.scielo.br/pdf/ean/v14n2/21.pd... ,⁸8. Mooneya B, Timminsb F, Byrneb G, et al. Nursing students’ attitudes to health promotion to: Implications for teaching practice. Nurse educ. today. 2011 [acesso em 2013 ago 15]; 31(8):841-848. Disponível em: http://www-sciencedirect-com.ez18.periodicos.capes.gov.br/science/article/pii/S026069171000256X#bb0255.
http://www-sciencedirect-com.ez18.period... . The prevention of diseases, in turn, seeks the absence of disease, with a focus on epidemiological knowledge, aiming to control transmission and reduce the risk of health problems⁹9. Czeresnia D. O Conceito de Saúde e a diferença entre Prevenção e Promoção. In: Czeresnia D, Freitas CMF, organizadores. Promoção da Saúde, conceitos, reflexões, tendências. Rio de Janeiro: Fiocruz; 2003..

The increasing survival of PLWHA implies a growing demand for oral health care. The training and willingness of dentists to treat PLWHA is essential for integrated care, mainly because of the early onset of Aids-related injuries in the oral cavity. Such lesions are seen in up to 80% of patients with this syndrome, being an important marker of immunosuppression¹⁰10. Coogan MM, Greenspan J, Challacombe SJ. Oral lesions in infection with human immunodeficiency virus. Bull World Health Organ. 2005; 83(9):700-706..

Created in 1988, anchored on the principles of universality, equity, and integrated care, the Unified Health System (SUS) offers primary, secondary, and tertiary care to all people¹¹11. Barros AJD, Santos IS, Bertold ID. Can mothers rely on the Brazilian health system for their deliveries? An assessment of the use of public system and out of- pocket expenditure in 2004 Pelotas Birth Cohort Study, Brazil. BMC Health e Serv Res. 2008; (8):57-63.. The SUS is the first health system in a developing country to provide free and universal access to the treatment of PLWHA, including the systematic free distribution of antiretroviral drugs⁶6. Brasil. Lei nº 9.133, de 13 de novembro de 1996. Dispõe sobre a distribuição gratuita de medicamentos aos portadores do HIV e doentes de AIDS. Diário Oficial da União. 14 Nov 1996. [acesso em 2019 set 16]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/l9313.htm.
http://www.planalto.gov.br/ccivil_03/lei... .

In the 1990s, the Ministry of Health of Brazil encouraged state and municipal governments to implement the Specialized Healthcare Services in HIV/Aids (SAE), which is responsible for monitoring patients, including referrals of HIV-positive patients for dental care in primary care and dispensing of antiretroviral medication¹²12. Borges MJL. Integralidade da atenção à saúde das pessoas vivendo com HIV/Aids: uma avaliação de serviços de assistência. [dissertação]. Recife: Fundação Oswaldo Cruz; 2010. 137 p..

The SUS provides a wide range of Primary Health Care (PHC) services under the aegis of the Family Health Strategy (ESF). Access to PHC services is provided by Family Health Teams (EqSF), which include doctors, nurses, nursing assistants and community health agents. Since the year 2000, the ESF has also been assisted by Oral Health Teams (ESB)¹³13. Giovanella L. Atenção Primária à Saúde: seletiva ou coordenadora dos cuidados? Rio de Janeiro: Cebes; 2008.. Each ESF/ESB, installed in the Family Health Centers (CSF), covers a specific geographic area¹⁴14. Brasil. Ministério da Saúde. Diretrizes da política nacional de saúde bucal [internet]. Brasília, DF: Ministério da Saúde; 2004. [acesso em 2019 dez 6]. Disponível em: http://dab.saude.gov.br/portaldab/biblioteca.php?conteudo=publicacoes/pnsb.
http://dab.saude.gov.br/portaldab/biblio... and, if necessary, forwards patients to Dental Specialty Centers (CEO). In 2019, the ESF covered 96% of Brazilian municipalities, corresponding to 64.2% of the population. Likewise, in the same year, 28,79⁷7. Silva KL, Sena RR, Grillo MJC, et al. Formação do enfermeiro: desafios para a promoção da saúde. Esc Anna Nery Rev Enferm. 2010 [acesso em 2012 set 12]; 14(2):368-376. Disponível em: http://www.scielo.br/pdf/ean/v14n2/21.pdf.
http://www.scielo.br/pdf/ean/v14n2/21.pd... ESB were implemented throughout the country, corresponding to a coverage of 42.8% of the population¹⁵15. Brasil. Ministério da Saúde. Portal Brasil. Informação e Gestão da Atenção Básica. Histórico de Cobertura. 2019. [acesso em 2019 dez 5]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaConsolidado.xhtml.
https://egestorab.saude.gov.br/paginas/a... . In the municipality of Fortaleza, Ceará (CE), in addition to the 8 SAE, the Care Network, in 2019, was composed of 109 CSF, 10 municipal public hospitals (secondary and tertiary care), 9 Emergency Care Units (UPA); 11 Psychosocial Care Centers (Caps), 4 CEO, and 4 Polyclinics. Information from the National Register of Health Establishments (CNES) reveals a coverage of the ESF in the city of 56% (379 EqSF) and 33% of Oral Health (260 ESB)¹⁵15. Brasil. Ministério da Saúde. Portal Brasil. Informação e Gestão da Atenção Básica. Histórico de Cobertura. 2019. [acesso em 2019 dez 5]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaConsolidado.xhtml.
https://egestorab.saude.gov.br/paginas/a... .

Studies have shown low average levels of education and income among PLWHA¹⁶16. Araújo DB. Condições de saúde bucal e utilização de serviços odontológicos por pessoas que vivem com HIV/AIDS no município de Fortaleza-Ceará. [dissertação]. Fortaleza: Universidade Federal do Ceará; 2010. 110 p. [acesso em 2019 set 7]. Disponível em: http://www.repositorio.ufc.br/bitstream/riufc/1011/1/2010_dis_dbaraujo.pdf.
http://www.repositorio.ufc.br/bitstream/... ,¹⁷17. Pires MBO, Martelli Júnior H, Melo Filho MR, et al. Dificuldades percebidas por pacientes vivendo com HIV/AIDS em obter tratamento odontológico. Arq Odontol. 2008; 44(3):25-31., indicating that an important part of this population depends on public services for their health needs. However, little is known about access, use of services, and satisfaction with public oral health services in countries with free universal health systems such as Brazil. Thus, the aim of this study was to evaluate, from the perspective of PLWHA, the use and satisfaction of public oral health services in a large Brazilian city.

Material and methods

Quantitative, descriptive, and analytical study carried out in all SAEs in Fortaleza (CE). Located in the Northeast region, it is the fifth largest capital in Brazil (2.5 million inhabitants). In this poor region, the Aids detection rate is above the national average in 2018 (Fortaleza and Brazil, detection rates 26.4 and 17.8 per 100,000 inhabitants, respectively)³3. Brasil. Ministério da Saúde. Boletim epidemiológico HIV/AIDS. Brasília, DF: Ministério da Saúde; 2019 [acesso em 2020 jan 10]. Disponível em: http://www.aids.gov.br/pt-br/pub/2019/boletim-epidemiologico-de-hivaids-2019.
http://www.aids.gov.br/pt-br/pub/2019/bo... ,¹⁸18. Ceará. Secretaria de Saúde do Estado. Boletim Epidemiológico HIV/Aids. Fortaleza; 2019. [acesso em 2020 jan 12]. Disponível em: http://www.saude.ce.gov.br/wp-content/uploads/sites/9/2018/06/BOLETIM_-AIDS_-2019_29_11_2019.pdf.
http://www.saude.ce.gov.br/wp-content/up... .

The study population consisted of 2,153 PLWHA residing in Fortaleza (CE) and registered in all eight municipal SAEs, according to secondary data obtained from the Epidemiological Surveillance Service of the municipality and the Coordination of Sexually Transmitted Diseases/Aids/Viral Hepatitis. With the level of statistical significance set at 90% and the sampling error at 5%, a sample size of 241 individuals was calculated.

To be included as a participant in the study, it was necessary to be PLWHA, user of one of the SAEs in Fortaleza (CE). PLWHA were proportionally recruited in all eight SAEs. After a routine consultation with infectologists, the patient was asked if he could participate in the research by the physician. These professionals were previously contacted by the researcher, being sensitized to support the research. All infectologists agreed to participate in the recruitment of patients for the present study. Patients were referred to the researcher after being accepted to participate in the research. Patients were excluded from the sample if: i) they lived outside Fortaleza (CE); ii) were under 18 years of age; iii) were on their first appointment; and iv) had been diagnosed with HIV for less than two years. The information was collected through a structured questionnaire, applied in person in 2013 by a single researcher in a private room, including questions about the socioeconomic level, use and satisfaction of the public oral health service, humanized care and health care processes, as defined by Donabedian¹⁹19. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988; 260(12):1743-1748..

In the statistical software Epidata 3.1., the database was built, being processed and analyzed in the Statistical Package for Social Science (SPSS) 19.0 for Windows (SPSS Inc, Chicago, IL, USA). Descriptive results were processed using simple frequencies and percentages. In addition, the analysis of associations between categorical variables was performed by cross-referencing, calculating Pearson’s chi-square test (x²). The p value was considered significant when less than or equal to 0.05.

All participants were informed of the objectives and methodology of the study and signed the Informed Consent Form. The research complied with all ethical precepts of Resolution No 466/2012, having been approved by the Research Ethics Committee of the State University of Ceará under number 357.459.

Results

A total of 241 PLWHA, proportionally distributed among the 8 SAEs in Fortaleza (CE), were included in the survey. Seven subjects refused to participate. Mean age was 37.8 ± 9.6 years (range: 18-65). Most were male (n=161; 68.3%), brown (n=183; 75.9%), single (n=152; 63.1%), with high school education (n=79; 32.8%), without children (n=126; 52.3%). Regarding economic conditions, 49 (20.3%) have no income, 59 (24.5%) earn up to one minimum wage and 83 (34.4%) earn between one and two minimum wages – at the time of writing this article, the official minimum wage was equivalent to R$ 998.00 (US$ 255) per month.

Regarding the use of the public oral health service, 122 (50.6%) reported receiving dental treatment in private clinics, 78 (32.4%) had health insurance, 68 (28.2%) attended public services (CSF/CEO), 44 (18.3%) used services provided by unions, 16 (6.6%) were attended at the Faculty of Dentistry, and 5 (2.0%) had funeral insurance with dental coverage. Only 155 (64.3%) of respondents had been to the dentist in the last 2 years, 83 (34.4%) had been to the dentist for more than 2 years and 3 (1.2%) had never received oral health care. In the first subset, 120 (77.4%) were routine appointments; 19 (12.6%), emergencies; and 16 (10.3%) were specialized care.

Respondents reported attending public services such as CSF (n=61; 25.3%) and CEO (n=7; 2.9%) or other services (n=173; 71.8%). Half (n=34; 50%) of the PLWHA who use public services (CSF/CEO) did so by spontaneous demand, while 19 (27.9%) were referred by the SAE. Almost two-thirds (64.7%; n=44) of patients using the public health system reported that their oral health problem had been resolved. Table 1 shows the evaluation of respondents who used the public health system in relation to ease of access, problem solving, and treatment completion (n=68).

Table 2 shows the results of the assessment of patients in a sub-sample of 39 people who received oral health care in public (CSF/CEO) and private clinics. Two of them (5.2%) considered CSF/CEO better or much better than private clinics, 19 (48.7%) rated CSF/CEO worse or much worse, while 18 (46.1%) deemed the two options to be similar. Many users of public health services reported having omitted their HIV-positive status during dental appointments (n=16; 23.5%). Fourteen (87.6%) did so for fear of discrimination or denial of the appointment.

Table 3 shows the respondents’ responses regarding location, physical structure and availability of supplies in public health units (CSF/CEO). Only 68 (28.2%) attended public services, 31 (45.6%) did not complete treatment for various reasons, including lack of materials/supplies, defective equipment or infrastructure reforms at the health facility. Almost half (n=32; 47.1%) considered the physical structure adequate, while 28 (41.2%) confirmed the availability of the necessary supplies to treat their condition.

When CSF/CEO users were asked to rate the care received (0-10), the mean score was 7.6 ± 2.5. Three quarters (n=50; 73.6%) were satisfied/very satisfied with the service, while one quarter (n=18; 26.5%) were not very satisfied/dissatisfied. Table 4 shows the responses of users of the CSF/CEO in relation to humanized care practices observed during the consultation.

To verify the association between the use of the public oral health care service and the variables in tables 1 to 4, the findings were submitted to cross tabulation and the chi-square test. The results indicate that patients referred by the SAE and patients living close to health facilities were significantly more likely to use public services (p≤0.001 and p≤0.01 respectively).

Discussion

Due to its amplitude, this study allowed a better understanding of the use and satisfaction regarding the public oral health service among PLWHA and some of the aspects that can moderate its use from the perspective of these people. Furthermore, the level of satisfaction of PLWHA with the quality, access, and resoluteness of services enables an understanding of the challenges faced by free universal systems that encompass oral health care, serving as a basis for the formulation of public policies in the field.

The sample of this investigation is considered representative of the general population of PLWHA living in Fortaleza (CE), as they were interviewed where antiretroviral drugs are dispensed. Due to the high cost of antiretroviral drugs and their free distribution through the SUS, it is unlikely that a significant proportion of PLWHA would not use the public health system to purchase their drugs.

Integrated care by multidisciplinary teams is necessary to minimize the risk of avoidable health²2. Buchala CM, Cavalheiro TR. A classificação internacional de funcionalidade, incapacidade e saúde e a aids: uma proposta de core set. Acta Fisiatrica. 2008; 15(1):42-8.. However, the limited access of PLWHA to oral health care is a serious problem, considering that they have a greater need for this care than the general population²⁰20. Jones J, Mofidi M, Bednarsh H, et al. Increasing access to oral health care for people living with HIV/AIDS in rural Oregon. Public Health Rep. 2012; 127(supl2):65-72.,²¹21. Fox JE, Tobias CR, Bachman SS, et al. Increasing access to oral health care for people living with HIV/AIDS in the U.S.: baseline evaluation results of the Innovations in Oral Health Care Initiative. Public Health Rep. 2012; 127(supl2):5-16.. Unmet oral health care needs are common among PLWHA, and barriers to care seem to be associated with race and socioeconomic status²²22. Jeanty Y, Cardenas G, Fox JE, et al. Correlates of unmet dental care need among HIV-positive people since being diagnosed with HIV. Public Health Rep. 2012; 127(supl2):17-24.. In fact, as demonstrated by the socioeconomic indicators surveyed, the needs for oral health care are substantial in these patients. Only a third of those interviewed had completed high school, a quarter had no income, and the majority earned less than two minimum wages. These findings are corroborated by other studies that indicate low levels of education and income among PLWHA¹⁶16. Araújo DB. Condições de saúde bucal e utilização de serviços odontológicos por pessoas que vivem com HIV/AIDS no município de Fortaleza-Ceará. [dissertação]. Fortaleza: Universidade Federal do Ceará; 2010. 110 p. [acesso em 2019 set 7]. Disponível em: http://www.repositorio.ufc.br/bitstream/riufc/1011/1/2010_dis_dbaraujo.pdf.
http://www.repositorio.ufc.br/bitstream/... ,¹⁷17. Pires MBO, Martelli Júnior H, Melo Filho MR, et al. Dificuldades percebidas por pacientes vivendo com HIV/AIDS em obter tratamento odontológico. Arq Odontol. 2008; 44(3):25-31.. Due to unfavorable socioeconomic and educational conditions, a significant proportion of PLWHA depend exclusively on the SUS and are in urgent need of access to public services.

In a study based on a population sample from the United States of America (USA), almost half of the participants reported having unmet oral health needs after being diagnosed with HIV²²22. Jeanty Y, Cardenas G, Fox JE, et al. Correlates of unmet dental care need among HIV-positive people since being diagnosed with HIV. Public Health Rep. 2012; 127(supl2):17-24.. In Mississippi, oral health care and oral examination were the most frequently unmet needs among PLWHA²³23. Krause DD, May WL, Butler Jr KR. Determining unmet, adequately met, and overly met needs for health care and services for persons living with HIV/AIDS in Mississippi. AIDS Care. 2012; 25(8):973-979.. However, it is necessary to understand that the comparison between Brazil and the USA cannot be direct, given the discrepancy between the health care models used in the two countries. While Brazil has a public, universal and free system, which encompasses oral health, the USA has a private system, accessed by the majority of the population via health insurance, which does not always include oral health in the list of available procedures²⁴24. Noronha JC, Ugá MAD. O sistema de saúde dos Estados Unidos. In: Buss PM, Labra ME, organizadores. Sistemas de saúde: continuidades e mudanças. Rio de Janeiro: Editora Fiocruz; 1995. 265 p. [acesso em 2019 set 30]. Disponível em: http://books.scielo.org.
http://books.scielo.org... . Thus, the low access of PLWHA patients among North Americans is understandable, which would not be so predictable in the Brazilian system.

In a sample of Nigerian patients, unmet needs were reported by 79.4%²⁵25. Adedigba MA, Ogunbodede E, Jeboda SO, et al. Self-perceived and unmet general health need among PLWHA in Nigeria. East Afr J Public Health. 2008; 5(3):199-204.. A Brazilian study demonstrated a high demand for oral health care services in PLWHA¹⁶16. Araújo DB. Condições de saúde bucal e utilização de serviços odontológicos por pessoas que vivem com HIV/AIDS no município de Fortaleza-Ceará. [dissertação]. Fortaleza: Universidade Federal do Ceará; 2010. 110 p. [acesso em 2019 set 7]. Disponível em: http://www.repositorio.ufc.br/bitstream/riufc/1011/1/2010_dis_dbaraujo.pdf.
http://www.repositorio.ufc.br/bitstream/... . On the other hand, participation in government programs aimed at improving access to oral health care was associated with general well-being in low-income PLWHA²⁶26. Bachman SS, Walter AW, Umez-Eronini A. Access to oral health care and self-reported health status among low-income adults living with HIV/AIDS. Public Health Rep. 2012; 127(supl2):55-64., which should encourage these patients to seek oral health care. However, in this study, the use of free public health services was limited, as only a quarter of the sample reported that they got care at the CSF/CEO.

Understanding the importance of oral health care in the quality of life of PLWHA, we sought to understand how it is being performed in the researched group. The results revealed that more than a third of the interviewees had not seen a dentist in the last two years, and that, of those who were seen, more than half had dental treatment using private services. In this context, it is important to mention that the findings by Cavalcante et al.²⁷27. Cavalcante CAT, Gonçalves DHA, Maia DKA, et al. A atenção em saúde bucal para DST/HIV/AIDS na rede municipal de Belo Horizonte: diagnóstico loco-regional. Belo Horizonte: Secretaria Municipal de Saúde; 2006. [acesso em 2015 ago 18]. Disponível em: http://www.pbh.gov.br/smsa/biblioteca/saudebucal/atencaoemsaudebucalparadsthivaids.pdf.
http://www.pbh.gov.br/smsa/biblioteca/sa... and Araújo¹⁶16. Araújo DB. Condições de saúde bucal e utilização de serviços odontológicos por pessoas que vivem com HIV/AIDS no município de Fortaleza-Ceará. [dissertação]. Fortaleza: Universidade Federal do Ceará; 2010. 110 p. [acesso em 2019 set 7]. Disponível em: http://www.repositorio.ufc.br/bitstream/riufc/1011/1/2010_dis_dbaraujo.pdf.
http://www.repositorio.ufc.br/bitstream/... highlight that 21.0% and 45.1% of users, respectively, claimed to have consulted a dentist for less than a year; while in a study in the USA, most patients (52.4%) had not consulted a dentist for more than two years, 48.2% reported one or more oral needs not met after HIV diagnosis, and 63.2% classified the health of their teeth and gums as ‘fair’ or ‘poor’²⁷27. Cavalcante CAT, Gonçalves DHA, Maia DKA, et al. A atenção em saúde bucal para DST/HIV/AIDS na rede municipal de Belo Horizonte: diagnóstico loco-regional. Belo Horizonte: Secretaria Municipal de Saúde; 2006. [acesso em 2015 ago 18]. Disponível em: http://www.pbh.gov.br/smsa/biblioteca/saudebucal/atencaoemsaudebucalparadsthivaids.pdf.
http://www.pbh.gov.br/smsa/biblioteca/sa... . Considering that the costs of private dental services are high and that the population studied, for the most part, is of low socioeconomic status, the interest of PLWHA in dental consultation and a low accessibility of public dental services to this population. This highlights the importance of developing strategies to reduce costs, increase use and reduce personal barriers to oral health care, especially considering the impact of poor oral health among this population²²22. Jeanty Y, Cardenas G, Fox JE, et al. Correlates of unmet dental care need among HIV-positive people since being diagnosed with HIV. Public Health Rep. 2012; 127(supl2):17-24..

In addition, there is the concern about the difficulty of access to health services by this population, the low level of health education activities developed by the ESB to PLWHA. More than two thirds of SUS users who were assisted in the CSF/CEO did not participate in this educational activity, results in agreement with other studies¹⁶16. Araújo DB. Condições de saúde bucal e utilização de serviços odontológicos por pessoas que vivem com HIV/AIDS no município de Fortaleza-Ceará. [dissertação]. Fortaleza: Universidade Federal do Ceará; 2010. 110 p. [acesso em 2019 set 7]. Disponível em: http://www.repositorio.ufc.br/bitstream/riufc/1011/1/2010_dis_dbaraujo.pdf.
http://www.repositorio.ufc.br/bitstream/... ,²⁷27. Cavalcante CAT, Gonçalves DHA, Maia DKA, et al. A atenção em saúde bucal para DST/HIV/AIDS na rede municipal de Belo Horizonte: diagnóstico loco-regional. Belo Horizonte: Secretaria Municipal de Saúde; 2006. [acesso em 2015 ago 18]. Disponível em: http://www.pbh.gov.br/smsa/biblioteca/saudebucal/atencaoemsaudebucalparadsthivaids.pdf.
http://www.pbh.gov.br/smsa/biblioteca/sa... . This finding is worrisome, given that oral health care impacts the quality of life of PLWHA²⁸28. Brown JB, Rosenstein D, Mullooly J, et al. Impact of intensified dental care on outcomes in human immunodeficiency virus infection. AIDS Patient Care STDS. 2002; 16(10):479-86., especially when supported by health education for the prevention of periodontal diseases, as well as opportunistic oral infections²2. Buchala CM, Cavalheiro TR. A classificação internacional de funcionalidade, incapacidade e saúde e a aids: uma proposta de core set. Acta Fisiatrica. 2008; 15(1):42-8..

However, having access to the public oral health care service does not mean resoluteness/completion of treatment. Almost half of users reported not having completed their dental treatment. Lack of materials, equipment problems, or renovations to the CSF were the reasons most cited by PLWHA who did not complete dental treatment. These difficulties, along with the overcrowding and lack of vacancies in the CSF, were described by almost all users who tried but were unable to be assisted in municipal services. These findings indicate a serious problem of access and problem-solving in the care of PLWHA seeking public oral health care in Fortaleza (CE). Araújo¹⁶16. Araújo DB. Condições de saúde bucal e utilização de serviços odontológicos por pessoas que vivem com HIV/AIDS no município de Fortaleza-Ceará. [dissertação]. Fortaleza: Universidade Federal do Ceará; 2010. 110 p. [acesso em 2019 set 7]. Disponível em: http://www.repositorio.ufc.br/bitstream/riufc/1011/1/2010_dis_dbaraujo.pdf.
http://www.repositorio.ufc.br/bitstream/... highlights the lack of vacancies in public services as the main problem for PLWHA to get access to dental appointments, pointed out by 46.2% of users. In addition, the author highlights the professionals’ refusal of care as a relevant inconvenience. This may explain the high percentage of patients who omit their HIV-positive status to dental professionals²³23. Krause DD, May WL, Butler Jr KR. Determining unmet, adequately met, and overly met needs for health care and services for persons living with HIV/AIDS in Mississippi. AIDS Care. 2012; 25(8):973-979..

Discrimination, or the fear of it, can induce PLWHA to self-discriminate in their search for dental care, causing them to hide their seropositivity and/or seek treatment far from their home, where, theoretically, they are less known, and, consequently, they end up having less connection with the service and greater access difficulties. Corroborating the results of the literature¹⁶16. Araújo DB. Condições de saúde bucal e utilização de serviços odontológicos por pessoas que vivem com HIV/AIDS no município de Fortaleza-Ceará. [dissertação]. Fortaleza: Universidade Federal do Ceará; 2010. 110 p. [acesso em 2019 set 7]. Disponível em: http://www.repositorio.ufc.br/bitstream/riufc/1011/1/2010_dis_dbaraujo.pdf.
http://www.repositorio.ufc.br/bitstream/... ,¹⁷17. Pires MBO, Martelli Júnior H, Melo Filho MR, et al. Dificuldades percebidas por pacientes vivendo com HIV/AIDS em obter tratamento odontológico. Arq Odontol. 2008; 44(3):25-31.,²³23. Krause DD, May WL, Butler Jr KR. Determining unmet, adequately met, and overly met needs for health care and services for persons living with HIV/AIDS in Mississippi. AIDS Care. 2012; 25(8):973-979.,²⁵25. Adedigba MA, Ogunbodede E, Jeboda SO, et al. Self-perceived and unmet general health need among PLWHA in Nigeria. East Afr J Public Health. 2008; 5(3):199-204.,²⁶26. Bachman SS, Walter AW, Umez-Eronini A. Access to oral health care and self-reported health status among low-income adults living with HIV/AIDS. Public Health Rep. 2012; 127(supl2):55-64.,²⁷27. Cavalcante CAT, Gonçalves DHA, Maia DKA, et al. A atenção em saúde bucal para DST/HIV/AIDS na rede municipal de Belo Horizonte: diagnóstico loco-regional. Belo Horizonte: Secretaria Municipal de Saúde; 2006. [acesso em 2015 ago 18]. Disponível em: http://www.pbh.gov.br/smsa/biblioteca/saudebucal/atencaoemsaudebucalparadsthivaids.pdf.
http://www.pbh.gov.br/smsa/biblioteca/sa... , the present investigation showed that more than a third of the users who had access to the CSF/CEO were assisted far from the neighborhood in which they live; and, of these, when referred by the SAE to the dentist, almost half requested care far from their home.

Researches showed that more than half of PLWHA did not reveal their serological status to the dental surgeon before dental treatment. The main justifications of these people for omitting their HIV-positive status are the fear of refusal of care and the fear of being discriminated against or treated with prejudice¹⁶16. Araújo DB. Condições de saúde bucal e utilização de serviços odontológicos por pessoas que vivem com HIV/AIDS no município de Fortaleza-Ceará. [dissertação]. Fortaleza: Universidade Federal do Ceará; 2010. 110 p. [acesso em 2019 set 7]. Disponível em: http://www.repositorio.ufc.br/bitstream/riufc/1011/1/2010_dis_dbaraujo.pdf.
http://www.repositorio.ufc.br/bitstream/... ,¹⁷17. Pires MBO, Martelli Júnior H, Melo Filho MR, et al. Dificuldades percebidas por pacientes vivendo com HIV/AIDS em obter tratamento odontológico. Arq Odontol. 2008; 44(3):25-31.. Likewise, in the present investigation, almost a quarter of the users seen stated that they had already omitted the HIV-positive status during dental care. Almost 90% mentioned fear of being refused in their care or being discriminated against as reasons.

Difficulties in accessing the service can be a consequence of the vulnerability and prejudice that this group suffers. They may also be related to the precarious humanistic and technical training of health professionals; with the way of the work process of the EqSFs, which do not favor the creation of a bond with the user and the living territory; with the non-prioritization of vulnerable groups, which may allow discrimination (explicit or implicit) to be installed in the CSF; with the social, cultural, economic and political structure of society. These issues can be considered as structural violence against PLWHA, which is expressed in unequal opportunities, discrimination and injustice, such as, for example, access to education and health services. Johan Galtung²⁹29. Galtung J. Violence, Peace, and Peace Research. J Peace Res. 1969; 6(3):167-191. defines it as violence that is not practiced by a concrete agent with the objective of inflicting suffering, but is generated by the social structure itself. Structural violence is not necessarily an active and deliberate process, it can be revealed by the absence of protection and guarantee of rights and needs. It is closely linked to social injustice, as it affects people in different ways within different social structures³⁰30. Farmer PE, Nizeye B, Stulac S, et al. Structural Violence and Clinical Medicine. PLOS Med. 2006; 3(10):1686-1691.. These aspects lead, then, to the reflect upon the importance of applying the principles of ethics and bioethics in the care of PLWHA, since discriminatory and prejudiced environments, which generate invasion of privacy, make it difficult to assist this group of users³¹31. Carneiro HG. Ética e Bioética no atendimento aos pacientes portadores de HIV/aids no Sistema Único de Saúde. Cad IberAmer Direito Sanit. 2013; 2(2):839-849., and can compromise their access and adherence to treatment, affecting their health.

Considering all these issues under discussion, it was also evidenced that, in order to carry out a resolute and continuous oral health care, it is essential to guarantee the user’s adherence to the treatment, in addition to wide access and good quality of service. Therefore, the practice of humanized care for PLWHA, by the ESB, can significantly contribute, supporting these users in the continuity of treatment. The humanization of care must be carried out in the daily service, establishing a good professional-patient relationship and seeking to improve the quality of life of users³²32. Campos GWS. Humanização na saúde: um projeto em defesa da vida? Interface (Botucatu). 2005 [acesso em 2019 ago 27]; 9(17):398-403. Disponível em: http://www.scielo.br/pdf/icse/v9n17/v9n17a16.pdf.
http://www.scielo.br/pdf/icse/v9n17/v9n1... . Technically, humanization means quality care, associated with the recognition of patients’ subjectivity, rights and cultural references³³33. Deslandes SF. Análise do discurso oficial sobre a humanização da Assistência hospitalar. Ciênc. Saúde Colet. 2004; 9(1):7-14.. In this sense, the humanization of care seeks to change the relationships between workers and users and among workers, establishing a bond/responsibility of teams with users. Autonomy must be respected, considering its uniqueness, and, when it comes to care for PLWHA, its vulnerability, taking into account the subjectivity of the disease³²32. Campos GWS. Humanização na saúde: um projeto em defesa da vida? Interface (Botucatu). 2005 [acesso em 2019 ago 27]; 9(17):398-403. Disponível em: http://www.scielo.br/pdf/icse/v9n17/v9n17a16.pdf.
http://www.scielo.br/pdf/icse/v9n17/v9n1... ,³³33. Deslandes SF. Análise do discurso oficial sobre a humanização da Assistência hospitalar. Ciênc. Saúde Colet. 2004; 9(1):7-14..

Regarding the humanized care practices observed during the consultation of PLWHA, it was found, in this present study, a score of 7.6 (±2.5) attributed by patients to the care provided by the dentist. Most users interviewed believe that the professionals who saw them were prepared to solve their oral health problems, declaring themselves very satisfied or satisfied in relation to the level of general satisfaction with the service. More than 70% of the PLWHA seen at the CSF/CEO marked very satisfied or satisfied, considering the respect, attention, and clear transfer of information during the service.

In contrast to a previous study³⁴34. Andrade JT, Holanda VMS, Gondim APS. Em busca do humano: avaliação do Humaniza SUS em ações municipais de saúde em Fortaleza. Relatório Final. Observatório de Recursos Humanos em Saúde – CETREDE /UFC; Fortaleza: Núcleo de Pesquisa em Educação e Saúde Coletiva – UECE; 2007. [acesso em 2015 set 30]. Disponível em: http://www.observarh.org.br/observarh/repertorio/Repertorio_ObservaRH/CETREDE/Busca_humano.pdf.
http://www.observarh.org.br/observarh/re... , in the present investigation, when the PLWHA seen at the CSF/CEO were asked if they had already experienced any form of discrimination and/or prejudice during dental care, or if they had observed any type of resistance on the part of the professionals in assisting them, only a very low percentage answered yes. This finding is relevant, as it proves that, at least from the perspective of the PLWHA attended, the ESB has been able to offer humanized care, considering the results discussed. In other words, the professionals who are willing to assist PLWHA do it in a way that is humanized and free from prejudice.

It is interesting to emphasize, as discussed above, that greater user adherence to treatment involves several issues, ranging from accessibility (for example, distance of the health unit from their residence, availability of appointments), to presence of dental material in the necessary quantity and quality, professionals who are qualified for the service and able to welcome and solve the patient’s demands, to more subjective issues, such as humanization of care and creation of a patient-professional bond. Thus, it is necessary that public policies aimed at the care of those patients understand and work on these aspects, focusing on professional training, the organization of the care network, the qualification of the referral and counter-referral process, the structuring of oral health services, among others aspects.

Final considerations

We can conclude that humanized dental care for PLWHA in the CSF/CEO of Fortaleza (CE) may be a fundamental tool in the process of user adherence to treatment, as well as its importance in the evaluation of these services. Thus, the methodology used in this study allowed a description of the reality, with most users declaring themselves satisfied with the quality of the dental service provided by the ESB, although complaints were observed regarding the interruption of treatment caused by the lack of physical resources and materials. It is evident, therefore, that oral health care for PLWHA in Fortaleza (CE) is difficult to access and has obstacles in the scheduling and referral procedures of patients. Professionals willing to treat PLWHA were perceived as offering a satisfactory level of care, although significant advances in access to antiretroviral drugs and the establishment of reference centers for PLWHA, integrated public health services – including oral health care – are still at an early stage.

This study highlighted the importance of integrated care for PLWHA, requiring the distribution of antiretroviral drugs, which proves to be insufficient to fully support the quality of life of these patients. Furthermore, this research may contribute to a relevant discussion about these issues while taken into account by systems that intend to face the challenge of caring for PLWHA.

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