Response to HIV/AIDS in Brazil, public health system strengthening and programmatic integration

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1 Response to HIV/AIDS in Brazil, public health system strengthening and programmatic integration Fábio Mesquita Director STI, Aids and Viral Hepatitis Department Secretariat for Health Surveillance Ministry of Health - Brazil

2 Background Population: 190 million Federative democratic republic 27 States; 5,561 Municipalities

3 Unified Health System - SUS

4 Brazilian Health System Before Public health restricted to population campaigns, such as vaccination; 1923 Public health services provided just for a few professional categories; 1930 Public health services provided for many different professionals categories - unemployed people with no access to public health services.

5 Brazilian Health System 1988 New Federal Constitution Health as a right to all Health as a duty of the State Unified Health System - SUS

6 Unified Health System - SUS Before SUS - Health assistance based on hospitals high costs, low access, low quality; - Treatment was the focus; - Main responsible for planning and implementing health strategies federal level. SUS - Health assistance based on primary care; - Public Health approach: focus on prevention and promotion; - Main responsible for planning and implementing health strategies: municipalities.

7 Unified Health System - SUS Main Principles Universality Equity Community participation Integrality Decentralization

8 Unified Health System - SUS Social Control Health Conferences health planning, great discussions about the needs of Brazilian population in terms of health, in a multidisciplinary approach. Health Councils in city, state and national levels. Formulation of the Health Plans. 33% - population representatives, 33% Health Providers, 33% Governments

9 Response to HIV/AIDS in Brazil

10 Response to HIV/AIDS in Brazil 1980 first AIDS case in Brazil (registered in 1982) First AIDS programs structured: in the State of São Paulo National AIDS Program

11 Principles of the Unified Health System aplied to HIV/AIDS response

12 Equity To fit the needs of each person

13 Equity 12% 10% General Population 0,4% 10.5% 8% 6% 5.9% 5.0% 4.9% 4% 2% 0% PUD, 18+ (2011) PU crack, 18+ (2013) Gays e outros HSH, 18+ (2010) TS, 18+ (2009)

14 HIV and AIDS among young Equity people Young people: years old new AIDS cases Detection rate: 12,7 per 100,000 individuals new AIDS cases Detection rate: 9,6 per 100,000 individuals

15 Hotspots Equity AIDS Detection rates (2013) AIDS Mortality rates (2013)

16 Universality No one left behind

17 Access Universality to ART Number of PLWHA on ART. Brazil,

18 New targets, new approaches, new Universality strategies HIV treatment HIV Treatment Guidelines Test and Treat; Definition of first and second line regimens; Treatment optimization: Preferred regimen in fixed dose combination the same regimen for adults, pregnant women and TB co-infected patients;

19 New targets, new approaches, new Universality strategies Median pre-treatment CD4 count and proportional distribution of PLWHA who initiated ART, stratified by pre-treatment CD4 result. Brazil,

20 New targets, new approaches, new Universality strategies Distribution of PLWHA in treatment according to the value of viral load six months after starting ART. Brazil, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 75% 76% 77% 80% 78% 78% 5% 6% 4% 6% 4% 7% 4% 5% 6% 6% 6% 4% 4% 4% 6% 5% 5% 5% 8% 8% 7% 6% 8% 7% <=50

21 New targets, new approaches, new Universality strategies HIV treatment Information system in service level to trigger health actions: list of patients who are not on treatment (GAP); list of patients on ART with detectable viral load.

22 Lauching on July 28, 2015 (next Tuesday) new Hepatites C Guidelines, treating ALL co-infections with Hep C, regardless level of fibrosis

23 Community participation A differential in Brazilian response

24 Community participation - PLWHA representatives in all advisory boards and working groups of the Department of STD, AIDS and Viral Hepatitis; - Specific committee for articulation with civil society; - Projects with civil society organizations; - Posithive Fund; - Live Better Knowing (Viva Melhor Sabendo) - The Time is Now (A Hora é Agora)

25 Community participation NGO s testing Key Populations 50 NGOs Proporção de testes positivos para HIV tests (oral fluid) in 2014 Travesties Trasgender MSM Sex workers male Drug Users Trasgender MSM Sex workers male Drug Users Sex workers female Other populations

26 New targets, new approaches, Community new participation strategies Targeting Youth Young people s workshop 2014 Mass media New leaders workshop 2015

27 Integrality Sinergy to achieve efficiency

28 New targets, new approaches, new Integrality strategies classic prevention testing ARV prophylaxis PEP, PreP STI treatment HIV treatment

29 Integrality 2009 National Program for Hepatitis Control is integrated to the Department of STI and AIDS, in Ministry of Health. Response to viral hepatitis more effective

30 Integrality Tuberculosis primary care services BUT Coinfection TB-HIV Treatment for TB AND HIV in the same service HIV/AIDS traditionally on specialized services

31 Decentralization Local needs, local responses

32 Decentralization HIV care and treatment in primary care services - Primary care services and specialized services involved in care and treatment of PLWHA; - Treatment in primary care services: PLWHA on first line therapy, stable, with undetectable VL; - Support from specialized services; - Health promotion activities in primary care even patients who are being followed in specialized services nutrition, adherence, physical exercises, etc.

33 Decentralization HIV testing in primary care services : implementation of HIV rapid tests on primary care services initially targeting pregnant women; - Simplification of training on the execution of rapid tests on line platforms; - Simplification of pre and post test counselling focus on orientations for positives; - 4 million rapid tests performed in primary care services half of all HIV testing in 2014 perspective of continuous increase.

34 Public Health System Virtuous Cycle HIV Response

35 Thank you!

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