THE EPI DEMI OLOGI CAL DI MENSI ON OF TB/ HI V CO-I NFECTI ON
Mar ia de Lour des Sper li Ger aldes Sant os1 Mar ia Am élia Zanon Ponce2 Silv ia Helena Figueir edo Vendr am ini3 Ter eza Cr ist ina Scat ena Villa4 Nat ália Sper li Ger aldes Mar in dos Sant os5 An n eliese Dom in gu es Wy sock i6 Fát im a Gr isi Kuy um ij ian7 Cláudia Eli Gazet t a8
Sant os MLSG, Ponce MAZ, Vendram ini SHF, Villa TCS, Sant os NSGM, Wy sock i AD, Kuy um ij ian FG, Gazet t a CE. Th e epidem iological dim en sion of TB/ HI V co- in f ect ion . Rev Lat in o- am En f er m agem 2 0 0 9 set em br o- ou t u br o; 1 7 ( 5 ) : 6 8 3 - 8 .
This st udy aim ed t o analyze t he epidem iological indicat ors of TB/ HI V co- infect ion in São José do Rio Pret o, São Paulo, Br azil fr om 1 9 9 8 t o 2 0 0 6 . Dat a of new TB cases t hat init iat ed t r eat m ent bet w een Januar y 1 9 9 8 and Decem ber 2 0 0 6 w er e obt ained fr om t he TB Not ificat ion Sy st em ( EPI - TB) and 3 0 6 cases w er e r epor t ed. The incidence rat e was 5.1/ 100,000 inhabit ant s in 2006. Most cases were m en ( 72.5% ) wit h ages ranging bet ween 20 and 59 years ( 96.4 % ) . The m aj orit y ( 51% ) had incom plet e prim ary educat ion. Pulm onary TB was t he m ost com m on t y pe ( 52.9% ) and 46.1% of t he pat ient s r eceiv ed super v ised t r eat m ent . I n 2006, t he cur e r at e w as 33.3% , 14.3% deat h rat e and no pat ient abandoned t he t reat m ent . Diagnosis occurred at t he hospit al in 60% of t he cases. Result s show t he need of im proved coordinat ion bet w een t he cit y’s Tuberculosis Cont rol Program and t he Sex ually Tr ansm it t ed Diseases and HI V Pr ogr am .
DESCRI PTORS: t u ber cu losis; epidem iology ; HI V; com or bit y
LA DI MENSI ÓN EPI DEMI OLÓGI CA DE LA COI NFECCI ÓN TB/ VI H
El obj et ivo fue analizar los indicadores epidem iológicos de la coinfección t uberculosis y virus de la inm unodeficiencia hum ana ( TB/ VI H) en el m unicipio de Sao José del Rio Pret o, Sao Paulo, Brasil, en el período de 1.998 a 2.006. Los dat os de los casos nuevos de TB, que iniciaron el t rat am ient o ent re enero de 1.998 y diciem bre de 2.006, fueron r ecolect ados del Sist em a de Not ificación de la TB ( EPI - TB) . Fu er on n ot ificados 3 0 6 casos. El coeficien t e de incidencia fue de 5,1/ 100.000 hab, en 2006. Hubo predom inio de personas del sexo m asculino ( 72,5% ) , en el int ervalo de edad de 20 a 59 años ( 96,4% ) . La m ayoría ( 51% ) no poseía la enseñanza fundam ent al com plet a. La form a clínica pulm onar fue relevant e ( 52,9% ) y recibieron t rat am ient o supervisado 46,1% enferm os. En 2.006, la t asa de cura fue de 33,3% , de m uert es 14,3% , y no hubo ningún caso de abandono. Ent re los casos, 60% fuer on diagnost icados en el hospit al. Los dat os r eflej an la necesidad de t ener una m ay or ar t iculación ent r e el Program a Municipal de Cont rol de la Tuberculosis y el Program a Municipal de DST/ SI DA.
DESCRI PTORES: t u ber cu losis; epidem iología; VI H; co- m or bilidad
A DI MENSÃO EPI DEMI OLÓGI CA DA COI NFECÇÃO TB/ HI V
O obj et iv o foi analisar os indicador es epidem iológicos da coinfecção t uber culose e o v ír us da im unodeficiência hum ana ( TB/ HI V) no m unicípio de São José do Rio Pr et o, São Paulo, Br asil, no per íodo de 1998 a 2006. Os dados dos casos novos de TB, que iniciar am o t r at am ent o ent r e j aneir o de 1998 a dezem br o de 2006, for am colet ados do Sist em a de Not ificação da TB ( EPI - TB) . For am not ificados 306 casos. O coeficient e de incidência foi de 5,1/ 100 000 hab, em 2006. Houve predom ínio de pessoas do sexo m asculino ( 72,5% ) , na faixa et ária de 20 a 59 anos ( 96,4% ) . A m aioria ( 51% ) não possuía o ensino fundam ent al com plet o. A form a clínica pulm onar era relevant e ( 52,9% ) e receberam t rat am ent o supervisionado 46,1% doent es. Em 2006, a t axa de cura foi de 33,3% , óbit os, 14,3% , e não houve nenhum caso de abandono. Dent re os casos, 60% foram diagnost icados no h ospit al. Os dados r eflet em a n ecessidade de m aior ar t icu lação en t r e o Pr ogr am a Mu n icipal de Con t r ole da Tuber culose e o Pr ogr am a Municipal de DST/ AI DS.
DESCRI TORES: t u ber cu lose; epidem iologia; HI V; com or bidade
1Doct oral St udent , Escola de Enferm agem de Ribeirão Pret o, Universidade de São Paulo, WHO Collaborat ing Cent re for Nursing Research Developm ent , Brazil,
Facult y, Faculdade de Medicina de São José do Rio Pret o, Brazil, e- m ail: m lsperli@gm ail.com ; 2Mast er’s St udent , Escola de Enferm agem de Ribeirão Pret o,
Universidade de São Paulo, WHO Collaborat ing Cent re for Nursing Research Developm ent , Brazil, e- m ail: am [email protected]; 3Ph.D. in Nursing, Facult y,
Faculdade de Medicina de São José do Rio Pret o, Brazil, e- m ail: silviahve@gm ail.com ; 4RN, Ph.D. in Nursing, Full Professor, Escola de Enferm agem de
Ribeirão Pret o, Universidade de São Paulo, WHO Collaborat ing Cent re for Nursing Research Developm ent , Brazil, e- m ail: t it [email protected]; 5Mast er’s St udent ,
Faculdade de Medicina de São José do Rio Pr et o, Br azil, e- m ail: nsper li@gm ail. com ; 6Mast er ’s St udent , Escola de Enfer m agem de Ribeir ão Pr et o,
Universidade de São Paulo, WHO Collaborat ing Cent re for Nursing Research Developm ent , Brazil, e- m ail: lilisew @yahoo.com .br; 7Dent ist , Technician,
Vigilância Epidem iológica da DRS XV de São José do Rio Pret o, Brazil; 8Ph.D. in Nursing, Facult y, Faculdade de Medicina de São José do Rio Pret o, Brazil,
e-m ail: claudiagazet t [email protected] .br.
I NTRODUCTI ON
H
I V infect ion is one of t he m ost im por t ant r isk f act or s f or acqu ir in g t u ber cu losis ( TB) an d on e disease leads t o t h e dev elopm en t of t h e ot h er w it hconsequent epidem iological t r ansfor m at ions in bot h. The risk of an individual wit hout HI V t o develop TB can
vary from 5 t o 15% over life, whereas for t hose infect ed by HI V an d co- in f ect ed by M. t u ber cu losis, t h is r isk varies from 5 t o 15% in a year or 50% over life( 1).
Accor din g t o t h e Wor ld Healt h Or gan izat ion
( WHO) t here were 1.4 m illion new cases of t uberculosis
worldwide am ong t hose infect ed by HI V, which led t o t he deat hs of 456,000 people( 1).
S i n c e 2 0 0 4 , n e w s t r a t e g i e s h a v e b e e n developed w it h a view t o include TB/ HI V co- infect ion
i n p o l i c i e s a i m e d t o c o n t r o l TB t h r o u g h s o c i a l m obilizat ion so as t o obt ain t he sam e successful result s
achieved in t he AI DS cont rol program . However, such goals r epr esent a gr eat challenge for t he cont r ol of
co - i n f e ct i o n , co n si d e r i n g t h e l a ck o f i n t e r a ct i o n bet w een t h e Nat ion al Tu ber cu losis Con t r ol Pr ogram
( N TCP) a n d t h e N a t i o n a l S e x u a l l y Tr a n s m i t t e d
Diseases ( STD) and AI DS Pr ogr am ( NP- STD/ AI DS)( 2). D esp i t e ef f o r t s, t h er e a r e st i l l d i f f i cu l t i es
h in d er in g t h e ach iev em en t of g oals t o con t r ol TB, especially due t o t he high r at es of m or t alit y am ong
HI V pat ient s under TB t reat m ent . The m aj or difficult y is relat ed t o t he fact t hat t he TB cont rol policy is linked
t o t h e b a si c h e a l t h ca r e l e v e l a n d t o AI D S ca r e deliv er y at t he secondar y and t er t iar y lev els( 3).
Du e t o t h e dim en sion of com or bidit ies an d
t he im pact of TB and HI V t oget her on public healt h, f u r t h e r r e se a r ch a d d r e ssi n g t h e e p i d e m i o l o g i ca l
p r o f i l e o f c o - i n f e c t e d p a t i e n t s i s n e e d e d . Th e dev elopm en t of scien t if ic st u dies t h at ev iden ce t h e
sociodem ogr aph ic an d epidem iological con t ex t s t h at affect t he disease’s behav ior and pat ient s’ t r eat m ent
can cont ribut e t o t he planning of act ions and st rat egies focused on public policies t o cont r ol co- infect ion.
These issues drive t his st udy, which analyzes t he epidem iological indicat or s of TB/ HI V co- infect ion
in Sao José d o Rio Pr et o, SP, Brazil b et w een 1 9 9 8
and 2006.
METHOD
Th i s i s an ep i d em i ol og i cal an d d escr i p t i v e
st udy based on t he TB Not ificat ion Sy st em ( EPI -TB)
of t he Municipal Secr et ar y of Healt h and Hy giene of
Sã o Jo sé d o Ri o Pr e t o , w h i ch u p d a t e s TB ca se s
regist ered in t he cit y’s disease cont rol program which
has been ex t ant since 1998.
A c c o r d i n g t o t h e B r a z i l i a n I n s t i t u t e o f
Geogr aph y an d St at ist ics ( I BGE) , in 2 0 0 6 São José
do Rio Pret o, Nort h of São Paulo, Brazil had 402,770
inhabit ant s. The cit y is ranked 5t h in not ified cases of AI DS in t he Sao Paulo st at e and present s a high rat e
of TB/ HI V co- in fect ion t h at r an ged fr om 3 5 - 5 1 % of
t he t ot al cases of TB( 4) bet ween 1998 and 2005, which l ed i t t o b e co n si d er ed a p r i o r i t y b y t h e Nat i o n al
Program of Tuberculosis Cont rol and t o receive support
f r o m t h e St a t e a n d Fe d e r a l Go v e r n m e n t s f o r i t s
pat ient s’ t r eat m ent( 4- 5).
I t has had a TB Cont rol Program ( TBCP) since
t h e 1 9 9 0 s. Up t o 2 0 0 7 , TB co n t r o l a ct i o n s w e r e
cent ralized in t he TBCP and were prim arily perform ed
in t he Out pat ient Managem ent Cent er – 60 ( OMC- 60)
which is considered a reference for t his kind of service) .
This st udy’s populat ion included new TB cases
co- infect ed by HI V, resident s in São José do Rio Pret o,
SP, Brazil, w ho began t reat m ent bet w een January 1st and Decem ber 31st 2006. Duplicat ed cases, pat ient s wit h negat ive or inconclusive HI V exam s or HI V exam s
n ot per f or m ed w er e ex clu ded as w ell as t h ose t h at
en d ed u p b ein g t r an sf er r ed or h ad t h eir d iag n oses
changed. Pat ient s fr om t he pr ison sy st em w er e also
ex clu d ed .
The following variables were used in t his st udy:
in ciden ce of TB/ HI V w it h dist r ibu t ion by age r an ge
and y ear obt ained t hr ough dir ect st andar dizat ion of
dat a ( epidem iological in dicat or ) , gen der, age ran ge
a n d e d u c a t i o n ( s o c i o d e m o g r a p h i c v a r i a b l e s ) ,
classificat ion of disease ( pulm onar y, ex t rapulm onar y
a n d p u l m o n a r y + e x t r a p u l m o n a r y ) , t r e a t m e n t
out com e ( cur e, abandonm ent and deat h) , opt ion for
supervised t reat m ent and t he service t hat discovered
t h e case ( clin ic- epidem iological v ar iables) .
Dat a were analyzed t hrough Epi I nfo Windows
and t he per cent age of all v ar iables w as com put ed.
Th e st u d y w as ap p r o v ed b y t h e Resear ch
Et hics Com m it t ee at t he São José do Rio Pret o Medical
Sch ool ( FAMERP) , SP, Brazil an d au t h or ized b y t h e
cit y ’s Secr et ar y of Healt h and Hy giene.
RESULTS
A t ot al of 1,457 new TB cases were report ed
which 306 were pat ient s co- infect ed by t he HI V virus.
According t o t he st udy’s exclusion crit eria, t he rat e of
co- infect ion w as 21% in t he per iod.
Th e st an dar dized in ciden t coef f icien t of
co-in fect ion co-in t h e cit y w as 9 . 9 / 1 0 0 , 0 0 0 co-in h abit an t s co-in
1 9 9 8 , w hich incr eased t o 1 2 . 6 in 2 0 0 0 , r eceding in
t h e f o l l o w i n g y e a r s u n t i l i t r e a ch e d 5 . 1 / 1 0 0 , 0 0 0
inhabit ant s in 2006 as showed in Figure 1.
Fi g u r e 1 – S t a n d a r d i z e d TB / H I V c o e f f i c i e n t o f
incidence, dist ribut ed by year in São José do Rio Pret o,
SP, Brazil, 1998 t o 2006
I n t h e w h o l e p e r i o d , t h e d i se a se m a i n l y
affect ed co- infect ed m en ( Table 1) ; t he rat io of m en
t o w om en w as 2.6: 1.
Table 1 – Dist ribut ion of new TB cases in HI V- posit ive
pat ient s, according t o gender, in São José do Rio Pret o,
SP, Brazil, 1998 t o 2006
r a e Y
e l a
M Female Total
s e s a c º
n % nºcases % nºcases
8 9 9
1 23 67.6 11 32.3 34
9 9 9
1 40 74.1 14 25.9 54
0 0 0
2 29 64.4 16 35.6 45
1 0 0
2 26 76.5 8 23.5 34
2 0 0
2 22 78.6 6 21.4 28
3 0 0
2 24 68.6 11 31.4 35
4 0 0
2 25 83.3 5 16.7 30
5 0 0
2 18 72 7 28 25
6 0 0
2 15 71.4 6 28.6 21
l a t o
T 222 72.5 84 27.5 306
Ages from 20 t o 59 years old st and out wit h
295 ( 96.4% ) of t he t ot al of cases. The average age in
all y ear s w as 36.3 y ear s old.
I n t erm s of educat ion, 51% of t he cases had
not com plet ed pr im ar y sch ool, 4 . 9 % h ad bachelor ’s
degr ee an d 4 . 6 % w er e illit er at e. I t is im por t an t t o
highlight t hat 29.6% ( 60) of t he t ot al of cases did not
provide t heir level of educat ion, which shows t hat not
all dat a were filled out in t he dat abase.
Th e m o st f r e q u e n t cl i n i c f o r m o f TB w a s
pulm onar y ( 52.9% ) follow ed by ex t r apulm onar y w it h
3 6 . 6 % an d 1 0 . 4 % of cases p r esen t ed b ot h f or m s
( pu lm on ar y + ex t r apu lm on ar y ) .
Only 4 6 . 1 % of pat ient s r eceiv ed super v ised
t r eat m ent ( ST) w hile m any died at t he beginning of
t reat m ent . Figure 2 present s t he t reat m ent out com es:
abandonm ent , deat h and cur e.
The r at e of abandonm ent am ong co- infect ed
pat ient s varied considerably: 26.5% in 1998 receding
t o 0 % in 2 0 0 2 an d 2 0 0 3 , w h ich w as m ain t ain ed in
2 0 0 6 .
Th e p e r ce n t a g e o f d e a t h a m o n g t h e co
-infect ed w as sim ilar, except in 2001 and 2002, w hen
t h er e w as a sig n if ican t d eclin e. I t is im p or t an t t o
h igh ligh t t h at t h e com or bididit y did n ot n ecessar ily
det er m ine such deat hs.
The rat e of cure of 41.2% st art ed t o im prove
fr om 1998 on and r eached 82.1% in 2002, r eceding
t o 6 0 % in 2 0 0 5 . Th e low r at e of cu r e of 3 3 . 3 % in
2006 can be explained by t he fact t hat dat a collect ion
ce a se d b e f o r e m a n y p a t i e n t s h a d f i n i sh e d t h e i r
t r eat m en t s.
Figur e 2 – TB t r eat m ent out com e in r elat ion t o t he
per cen t age of cu r e, t r eat m en t def au lt an d deat h in
t h e t ot al of TB/ HI V co- in f ect ed in São José d o Rio
Pr et o, SP, Brazil bet w een 1998 and 2006
Th e d i a g n o se s o f 1 5 6 ca se s ( 6 0 % ) w e r e
est ablished in t he hospit al and 86 cases ( 28. 2% ) in
pu blic, pr iv at e an d t each in g ou t pat ien t clin ics. I t is
wort h m ent ioning t hat t he facilit y where diagnosis was
DI SCUSSI ON
A t ot al of 12% of t he not ified TB cases in Brazil
in 2006 were associat ed wit h HI V infect ion( 6). I n 2007, t his rat e increased t o 14% in t he count ry( 1); it was 13% in t he st at e of São Paulo in 2005( 5). This st udy’s result s r ev eal t hat São José do Rio Pr et o has pr esent ed
co-infect ion rat es sim ilar t o t he st at e of São Paulo, which
is higher t han t he count ry’s. The populat ion’s current
behavior concerning TB is som ewhat unusual because
i n a h i st o r i ca l ser i es o f 2 4 y ea r s t h e ci t y a l w a y s
p r e se n t e d a l o w e r r i sk o f a cq u i r i n g t h e d i se a se
com pared t o nat ional and st at e levels( 4,7).
Co - i n f ect i o n m ai n l y af f ect s p o o r co u n t r i es
w h er e HI V is f eed in g t h e TB ep id em ic d u e t o t h e
populat ion’s low lev el of educat ion, lack of access t o
f r ee h ealt h ser v ices an d con dom s. Th is sit u at ion is
not com par able w it h São José do Rio Pr et o’s cont ext
since despit e t he fact t hat it is ranked one of t he cit ies
wit h t he best qualit y of life in t he st at e of Sao Paulo( 8), i t al so p r esen t s h i g h AI DS co ef f i ci en t , w h i ch al so
r eflect s TB co- infect ion.
Becau se t h e cit y h as an im por t an t r ail an d
road j unct ion, which is considered an im port ant rout e
o f d r u g t r a f f i c k i n g , a n e f f i c i e n t e p i d e m i o l o g i c a l
su r v eillan ce t o con t r ol AI DS, a h ealt h sy st em t h at
includes t he act iv e sear ch of cases of t he disease in
t h e pr im ar y h ealt h car e w it h a cou n selin g pr ogr am
im p lem en t ed in all Healt h Basic Un it s an d also an
out pat ient s clinic and a r efer ence Specialized Cent er
of Treat m ent , São José do Rio Pret o becam e a cent er
for t he diagnosis and t reat m ent of t he disease, which
are fact ors t hat can cont ribut e t o t he increased rat es
of co- infect ion( 4,7).
Th e p r e d o m i n a n c e o f c o - i n f e c t e d m e n
confir m s t he r esult s of st udies car r ied out in Br azil( 9-11)
. The reason m en are predom inant ly get t ing infect ed
is not very clear but it m ight be relat ed t o biological
fact ors, life st yle, self- care( 7) and also t o t he fact t hat m en sear ch for healt h ser v ices lat er t han w om en( 12). The high r at e of TB/ HI V co- infect ion in m en
is in accordance wit h dat a relat ed t o infect ion only by
HI V or TB, however, t he co- infect ion relat ion bet ween
m e n a n d w o m e n m a y b e a l t e r i n g d u e t o t h e
t ransform at ion of t he AI DS epidem ic in recent years,
w hich has t ended t o affect m or e w om en. Dat a fr om
São José do Rio Pret o are in accordance wit h nat ional
dat a from 2006 and show t hat t he num ber of wom en
in f ect ed b y HI V h as in cr eased in a r at io of 1 . 7 7 : 1
cases bet w een m en and w om en and has a t endency
t o becom e m or e hom ogeneous( 13).
Th e p r ed om in an ce of co- in f ect ed p eop le in
t h e econ om ically act iv e age r an ge ( 1 9 t o 6 5 y ear s
old) is also in agr eem ent w it h st udies car r ied out in
several Brazilian cit ies( 9- 12), and m ight also be relat ed t o t he lifest y le of y oung adult s w ho pr esent r eck less
behavior as t hough t hey were invulnerable: a lack of
condom s and a lack of appr opr iat e guidance, w hich
l e a d t o g r e a t e r e x p o s u r e t o H I V a n d t o t h e
Mycobact erium t uberculosis( 13), and as a consequence, gen er at in g con sider able econ om ic an d social losses
sin ce pat ien t s ar e affect ed in t h e pr odu ct iv e st ages
of t heir lives( 10).
The fact t hat few individuals younger t han 15
years of age – t he childhood period – w ere found t o
be infect ed in t his st udy is explained by t w o fact ors:
t h e ef f i ci en cy o f t h e ci t y ’s STD / AI D S su r v ei l l an ce
pr ogr am on t he v er t ical t r ansm ission of HI V and t he
h ig h cov er ag e an d ef f icacy of t h e BCG v accin e. A
t ot al of 1 7 4 pr egn an t w om en in fect ed by HI V w er e
r epor t ed bet w een 2 0 0 0 an d 2 0 0 6 an d of t h ese, six
childr en w er e infect ed ( dat a not show n)*. Accor ding t o D ATA S U S ( d a t a b a s e f r o m t h e S i n g l e H e a l t h
Sy st em ) , t he r at e of BCG cov er age w as 143.32% in
2006 and t he Cit y’s Mult i- Annual Plan has det erm ined
t hat all hospit als in t he cit y ( public and privat e) apply
t he vaccine t o all newborns up t o 2009.
The large num ber of pat ient s wit h a low level
of educat ion accords wit h t he lit erat ure( 9,11), evidencing t he close r elat ion of com or bidit y w it h fact or s r elat ed
t o social ( level of educat ion) and collect ive condit ions
( social depr iv at ion and m ar ginalit y ) , w hich point s t o
TB and AI DS as diseases of a m agnit ude t hat exceeds
biological barriers and which const it ut es a severe social
p r ob lem( 8 ). Th e v u ln er abilit y of t h ese in div idu als is based on t he fact t hey do not ack now ledge t he r isk
t hey are exposed t o, which in t urn leads t o dim inished
self- car e in addit ion t o a gr eat er difficult y accessing
healt h ser v ices( 11).
Addit ionally, t he predom inance of co- infect ion
in in div idu als w it h a low lev el of edu cat ion r ef lect s
t h e c o u n t r y ’ s e d u c a t i o n a l c o n t e x t , w h i c h i s
ch a r a ct e r i ze d b y f u n ct i o n a l i l l i t e r a cy ( l i t e r a cy i s
c o n s i d e r e d t o b e a c h i e v e d o n l y b y p e o p l e w h o
com plet e t h e 4t h gr ade of elem en t ar y sch ool) . On ly 27.8% of 15 year- olds or older individuals are in t his
sit uat ion, a consequence of school dr opout obser v ed
in t he educat ional syst em( 14).
The high r at es of pulm onar y TB follow ed by
ex t r apulm onar y TB r einfor ce t hat , despit e pulm onar y
TB bein g t h e m ost com m on f or m of t h e disease in
im m unosuppr essed indiv iduals, as is t he case of
co-i n f e ct e d p a t co-i e n t s, t h e r e co-i s a l a r m co-i n g l y sco-i g n co-i f co-i ca n t
i m m u n o d e f i c i e n c y, w h i c h c o u l d b e a v o i d e d i n a
t reat m ent appropriat e for HI V w it h t he est ablishm ent
of an ear ly d iag n osis of TB( 9 ). Sim ilar r esu lt s w er e found in ot her st udies( 10- 12).
I t w as possible t o obser v e t h at despit e t h e
increased rat es of cure bet ween 1998 and 2005, cure
r at es ar e st ill t oo low . I n 2 0 0 6 , t h e r at es of cu r e,
abandonm ent and deat h will probably be different from
t hose report ed because t here were pat ient s who were
st ill u n der t r eat m en t du r in g dat a collect ion . Th e TB
ep id em iolog ical d ev elop m en t in im m u n osu p p r essed
p e o p l e i s d i f f e r e n t f r o m t h a t o b s e r v e d i n
im m unocom pet ent because t her e is a higher chance
i n t h e f i r s t g r o u p t o d e v e l o p r e s i s t a n c e t o
an t it u ber cu losis dr u gs. I n addit ion , in f ect ion by t h e
M.t uberculosis speeds up t he HI V replicat ion process, w h i c h c a n h i n d e r c u r i n g a n d l e a d t o i n c r e a s e d
m or t alit y am ong co- infect ed pat ient s( 9).
I t is im port ant t o highlight t hat for HI V early
diagnosis and t reat m ent cont ribut e t o t he cure of
co-infect ion. The cit y’s STD/ AI DS program has im proved
a c c e s s t o t e s t i n g a n d c o u n s e l i n g t h r o u g h t h e
i m p l em en t at i o n o f f ast t est i n g at t h e Test i n g an d
Cou n selin g Cen t er sin ce Decem ber 2 0 0 6 , t h e ar eas
cov er ed by t he m obile healt h unit hav e ex panded t o
include dist ant neighbor hoods ( ir r egular set t lem ent s
a n d o t h e r s) a n d a r e a s o f p r e v e n t i o n d i r e ct e d t o
specific populat ions in addit ion t o fir m s and schools.
The Pr ogram “Fique Sabendo” [ Let Me Tell You] w as also enlar ged and all basic healt h unit s ar e cur r ent ly
t r a i n e d a n d p e r f o r m t e s t i n g a n d c o u n s e l i n g .
Consequent ly, co- infect ion cases ar e being diagnosed
and t r eat ed ear lier.
Dim inished incidence of TB has been observed
in count r ies w her e ant ir et r ov ir al t her apy is av ailable.
Brazil is virt ually t he only count ry wit h a large num ber
of co- infect ed individuals t hat has a policy t o provide
u n i v e r s a l a c c e s s t o H I V t h e r a p y a n d t h u s w i t h
c o n d i t i o n s t o e s t a b l i s h s t r a t e g i e s t o d i m i n i s h
m or bim or t alit y of TB associat ed w it h HI V. The m ain
m e a s u r e u s e d t o c o n t r o l t h e e p i d e m i c i s e a r l y
d i a g n o si s a n d a p p r o p r i a t e t r ea t m en t f o r b a ci l l a r y
indiv iduals and sear ch for cont act s( 11).
TB a n d H I V a r e d i s e a s e s h i s t o r i c a l l y
st igm at ized and t he negat iv e im pact one causes on
t he ot her can have severe consequences such as t he
abandonm ent of t reat m ent and high rat es of m ort alit y.
Th e d i f f i c u l t i e s f a c e d b y a c o - i n f e c t e d
in div idu al adh er in g t o t h e t r eat m en t ar e r elat ed t o
m ed icat ion sid e ef f ect s an d t o t h e ch oice of a TB
m edicat ion t hat can be com bined w it h ant ir et r ov ir al
an d n ot dim in ish it s effect iv en ess, alcoh olism , dr u g
addict ion, t he pat ient ’s own beliefs, lack of bonds wit h
h ealt h p r of ession als an d n o accep t an ce of t h e ST
because t hey oft en t im es hide t he disease.
ST i s a st r a t eg y, w h i ch i n a d d i t i o n t o i t s
t herapeut ic focus, also allows welcom ing, bonding and
r esponsibilit y. I t im pr ov es t he abilit y of pr ofessionals
and pat ient s t o int eract w it h a view t o ensure bet t er
qualit y of care delivery and adherence by pat ient s t o
t he t r eat m ent( 15).
DOTS w as im plem en t ed in São José do Rio
Pr et o in 1 9 9 8 . ST w as in it ially p er f or m ed at h om e
b y a n em p l o y ee h i r ed b y t h e AI D S p r o g r a m a n d
o n l y i n co - i n f e ct e d p a t i e n t s. Th e ST co v e r a g e i n
2 0 0 1 a n d 2 0 0 2 w a s 6 5 % a m o n g c o - i n f e c t e d
p at ien t s an d low er t h an 2 0 % am on g n on - in f ect ed .
Th o se w h o w er e at a h i g h er r i sk t o ab an d o n t h e
t r eat m en t su ch as ad d i ct s, al co h o l i cs, w an d er er s,
t h o se ex cl u d ed f r o m t h e co m m u n i t y a n d t h e co
-i n f ect ed h a d p r -i o r -i t y -i n ca r e d el -i v er y. Af t er m o r e
p er so n n el w as h i r ed , ST w as o f f er ed t o al l t h o se
w h o b e g a n t r e a t m e n t a n d co v e r a g e t o t h e n o n
-i n f e ct e d r e a ch e d 5 9 % -i n 2 0 0 2 , a l m o st t h e sa m e
cov er ag e p r ov i d ed t o t h e co- i n f ect ed( 4 ).
Th e d i a g n o si s o f co - i n f e ct i o n w a s m a i n l y
est ablished at t he secondar y and t er t iar y lev els. An
epidem iological st u dy of r epor t ed cases in a sch ool
hospit al in São José do Rio Pret o revealed a failure in
t h e o r g a n i z a t i o n o f t h e Pr i m a r y H e a l t h Ca r e :
in ef f ect iv en ess in t h e discov er y of TB cases at t h is
l e v e l o f c a r e b e c a u s e i t d e p e n d e d o n p a t i e n t s ’
spont aneous sear ch for car e at t he hospit al( 16).
FI NAL CONSI DERATI ONS
Alt hough t he cit y’s qualit y of life is considered
one of t he best in t he st at e of São Paulo and present s
an efficient epidem iological sur v eillance in t he AI DS
cont rol, t he TB epidem iological behavior in individuals
co- infect ed wit h HI V is worrying and reflect s t he need
f or im pr ov ed coor din at ion an d cooper at ion bet w een
t h e ci t y ’ s TB co n t r o l p r o g r a m a n d t h e STD / AI D S
Due t o t he im pact of t he superposit ion of t he
t w o d iseases, st r at eg ies an d p r og r am m at ic act ion s
are needed t hat focus on t he TS as one of t he m ain
st rat egies t o obt ain a TB cure and on im proved qualit y
of diagnosis at t he secondary and t ert iary levels, since
t h e Pr im ar y Healt h Car e h as n ot ef f ect iv ely play ed
it s r ole as t h e m ain en t r an ce of pat ien t s t o t h e TB
con t r ol ser v ices.
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