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Introdução: O cotrimoxazol e a isoniazida, fornecidos como tratamento preventivo (TPC, TPI),
demonstraram ser intervenções eficazes para a prevenção de algumas infeções oportunistas incluindo
tuberculose (TB) em pessoas infetadas com o vírus da imunodeficiência humana (VIH). A eficácia
destes medicamentos traduz-se em reduções significativas da mortalidade e morbilidade. Embora os
governos dos países com elevada carga de TB/VIH tenham feito esforços para implementar as
recomendações de terapêuticas preventivas em políticas, continua a ser um desafio nestes países.
Moçambique está entre os 30 países com uma elevada carga de TB/VIH, segundo a Organização Mundial
de Saúde (OMS). Contudo, Moçambique relata ter sucesso na implementação da TPC, assim requerendo
melhor compreensão para que esta boa prática possa ser partilhada.
Objetivos: O objetivo dos estudos desenvolvidos neste doutoramento é explorar as barreiras ao TPC e
TPI em países com elevada carga de TB/VIH, e identificar estratégias que possam melhorar a sua
implementação. Os objetivos específicos são: (1) explorar os obstáculos às terapias preventivas
identificadas nestes países e gerar um conhecimento explicativo das razões das dificuldades na sua
implementação; (2) comparar o TPC e o TPI nas semelhanças e diferenças nas barreiras de
implementação; e (3) identificar facilitadores para a implementação de ambos os tratamentos.
Considerando a experiência positiva de Moçambique, outro objetivo foi (4) explorar possíveis
factores responsáveis pelo sucesso da implementação do TPC em Moçambique.
Métodos: Para atingir estes objetivos foram desenvolvidos dois estudos. Foi realizada uma revisão
sistemática da literatura com métodos mistos, complementada por uma metassíntese, com o objetivo de
incluir evidência publicada com revisão por pares proveniente de países com elevada carga de
TB/VIH; Foi também realizado um estudo qualitativo, com entrevistas gravadas em áudio a
intervenientes governamentais, para obter a perspetiva de Moçambique.
Resultados: No primeiro estudo, foram identificados 482 artigos, dos quais 40 foram incluídos para
a revisão. A maioria dos temas relacionados com barreiras foi idêntica para ambas as terapias. As
"barreiras relacionadas com a prestação de serviços" e as "barreiras relacionadas com o paciente e
com a comunidade" foram as mais identificadas para ambas as terapias. As "barreiras relacionadas
com os prestadores de cuidados de saúde" foram também importantes na implementação do IPT. A
maioria dos facilitadores identificados referem-se a atividades de fortalecimento do sistema de
saúde. No segundo estudo, cinco temas emergiram como fundamentais para a implementação da TPC na
Província de Maputo: (a) O papel da governação e liderança, (b) Estratégias de gestão farmacêutica,
(c) Modificações na prestação de serviços, (d) Factores relacionados com os prestadores
de saúde e (e) Percepções dos pacientes.
Conclusão:
Esta Tese fornece informações sobre as barreiras que podem surgir a diferentes níveis do sistema de
saúde, críticas para a investigação em países com elevada carga de TB/VIH. Esta revisão propõe
ainda aos decisores políticos estratégias para melhorar a implementação de tratamentos preventivos
nestes países. Na Província de Maputo, a melhoria das estratégias de implementação (disponibilidade
de medicamentos e viabilidade da prestação de serviços baseados em unidades de saúde) foi crucial
para o progresso da implementação do TPC.
Background: Cotrimoxazole and Isoniazid provided as preventive therapy (CPT, IPT) have been shown to be highly efficacious interventions for the prevention of opportunistic infections and Tuberculosis (TB) among people living with the human immunodeficiency virus (HIV). Their benefits include significant reductions in deaths and morbidity which have been demonstrated under ‘ideal world’ study conditions. Although efforts have been made by governments of countries with a high burden of TB and HIV to translate preventive therapy recommendations into policy and practice, implementation remains challenging under ‘real world’ conditions. Mozambique is one of thirty countries with a high burden of TB and HIV, as per World Health Organization (WHO), reporting remarkable success with implementing CPT, suggesting there may be evidence-based best practices to be shared. Aims: This PhD project’s aim is to explore barriers to CPT and IPT in countries with a high burden of TB and HIV and to identify strategies with the potential to improve their implementation. Specific objectives are (1) to explore barriers to both preventive therapies reported across high TB/HIV burden countries (as per WHO) and to generate explanatory knowledge of why their implementation has been so challenging, (2) to compare CPT and IPT with respect to similarities and differences of barriers, and (3) to identify facilitators for the implementation of both preventive therapies. Considering the positive experience of Mozambique, another objective was (4) to explore possible factors responsible for the successful implementation of CPT in Maputo Province. Methods: To achieve these objectives, two studies were developed. A mixed-methods systematic review of the literature & metasummary were carried out to include the peerreviewed evidence from countries with a high burden of TB and HIV (as per WHO). A qualitative study including audio-recorded interviews with governmental stakeholders was conducted to gain insights from Mozambique. Results: We identified four hundred and eighty-two papers, of which we included forty for review. Most barrier themes were identical for both preventive therapies. Barriers identified were most frequently classified as ‘service delivery-related barriers’ and ‘patient & community-related barriers’. ‘Health provider-related barriers’ played an additional important role for implementing IPT. Most facilitators identified referred to health system strengthening activities. Five themes iteratively emerged as aspects that interviewees believed to be key for the implementation of CPT in the Province of Maputo, Mozambique: (a) Role of governance & leadership, (b) Pharmaceutical strategies, (c) Service delivery modifications, (d) Health care provider factors, and (e) Patients' perspectives. Conclusion: These Thesis findings can provide valuable insights about barriers that may arise at different levels of the health system, critical for research in countries with a high burden of TB and HIV. For policymakers in high TB/HIV burden countries, this review offers strategies for improving the preventive therapy implementation strategy. In Maputo Province, enhancing the implementation outcomes – drug availability and feasibility of the health facility based service delivery – seemed crucial for the implementation progress reported for CPT.
Background: Cotrimoxazole and Isoniazid provided as preventive therapy (CPT, IPT) have been shown to be highly efficacious interventions for the prevention of opportunistic infections and Tuberculosis (TB) among people living with the human immunodeficiency virus (HIV). Their benefits include significant reductions in deaths and morbidity which have been demonstrated under ‘ideal world’ study conditions. Although efforts have been made by governments of countries with a high burden of TB and HIV to translate preventive therapy recommendations into policy and practice, implementation remains challenging under ‘real world’ conditions. Mozambique is one of thirty countries with a high burden of TB and HIV, as per World Health Organization (WHO), reporting remarkable success with implementing CPT, suggesting there may be evidence-based best practices to be shared. Aims: This PhD project’s aim is to explore barriers to CPT and IPT in countries with a high burden of TB and HIV and to identify strategies with the potential to improve their implementation. Specific objectives are (1) to explore barriers to both preventive therapies reported across high TB/HIV burden countries (as per WHO) and to generate explanatory knowledge of why their implementation has been so challenging, (2) to compare CPT and IPT with respect to similarities and differences of barriers, and (3) to identify facilitators for the implementation of both preventive therapies. Considering the positive experience of Mozambique, another objective was (4) to explore possible factors responsible for the successful implementation of CPT in Maputo Province. Methods: To achieve these objectives, two studies were developed. A mixed-methods systematic review of the literature & metasummary were carried out to include the peerreviewed evidence from countries with a high burden of TB and HIV (as per WHO). A qualitative study including audio-recorded interviews with governmental stakeholders was conducted to gain insights from Mozambique. Results: We identified four hundred and eighty-two papers, of which we included forty for review. Most barrier themes were identical for both preventive therapies. Barriers identified were most frequently classified as ‘service delivery-related barriers’ and ‘patient & community-related barriers’. ‘Health provider-related barriers’ played an additional important role for implementing IPT. Most facilitators identified referred to health system strengthening activities. Five themes iteratively emerged as aspects that interviewees believed to be key for the implementation of CPT in the Province of Maputo, Mozambique: (a) Role of governance & leadership, (b) Pharmaceutical strategies, (c) Service delivery modifications, (d) Health care provider factors, and (e) Patients' perspectives. Conclusion: These Thesis findings can provide valuable insights about barriers that may arise at different levels of the health system, critical for research in countries with a high burden of TB and HIV. For policymakers in high TB/HIV burden countries, this review offers strategies for improving the preventive therapy implementation strategy. In Maputo Province, enhancing the implementation outcomes – drug availability and feasibility of the health facility based service delivery – seemed crucial for the implementation progress reported for CPT.
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Saúde pública SIDA Tuberculose Países de baixa renda Moçambique