Evaluation of the health attention to pregnant women with HIV : comparison between primary and specialized service

The public network for health care of pregnant women with HIV, in Santa Maria, Rio Grande do Sul/Brazil, includes primary and specialized care services. Objective: Evaluating whether the type of service interferes in the quality score of the health care in the experience of the pregnant women with HIV. Methods: Cross-sectional study, with data collection from April-November/2014, with 78 participants. The Primary Care Assessment Tool-Brazil instrument was applied and the Pearson's Chi-square test and Fisher's exact test were used. Results: The quality of care received was evaluated as unsatisfactory both in primary care (6.50) and in specialized care (6.35). Conclusion: The type of service interferes with the quality of care, which can affect women's choice of service. It is necessary to improve the quality of both types of services and to search for the management of shared care to attend both the usual care of gestation and the specificity of infection.


INTRODUCTION
The quality of attention for the health of pregnant women living with the Human Immunodeficiency Virus (HIV) has repercussions both in maternal and neonatal health, especially regarding to the success of the vertical transmission (VT) prophylaxis.The prophylaxis actions and maternal and child chronic condition management were listed as one of the priorities for the Single Health System (SUS) in Brazil, faced with the fact that the goal of eradicating the VT had not been complied with.Therefore, the performance of HIV diagnosis tests in the pre-natal follow--up should be available, and the provision of the anti-retroviral therapy for women and children exposed to the infection and the maintainance of the clinical follow-up during pregnancy should be implemented. 1n face of the double vulnerability marked by the gestational period and by the serological condition, it is necessary that the services of different technological densities which compose the Health Care Network (HCN) remain integrated to meet these pregnant women's specific demands 2 .These services vary from less technological level (PHC), intermediate density (secondary attention), to greater technological density (tertiary attention to health). 3 The PHC, with strategic character in the structuring of interventions, should promote the contact with individuals, family and community and coordinate the transfer flows among the points of the HCN.The specialized services consist of secondary and tertiary points of attention. 4his integration indicates the shared management of care for people living with the HIV, in order to strengthen the access to the diagnosis, to start treatment at the appropriate time and to keep the follow-up. 5This points out the need for the specialized services' professionals to share the clinical management knowledge with PHC network professionals.Also, professionals who work in the PHC need to inform the professionals from the specialized service about the prevention and promotion actions developed in this forum, so it can strengthen the care and give continuity to the creation and execution of protocols and health public policies.
However, predominantly, the actions of attention to the pregnant women with this condition are maintained by the specialized services and seem to address their needs, independent of the complexity of the health condition.This fact meets the proposal to establish a HCN. 6The implication is that the identification of the health service which pregnant women living with HIV use as reference for continuity of care is achieved by means of an affiliation to a specialized service.And, when the services offer a curative assistance, instead of a preventive and of health promotion one, they compromise, thos, the quality of the assistance provided, in addition to the affiliation, the link, the integration of the care and the longitudinality. 7herefore, the quality of the attention to health during the gestational period can be evaluated in the services in order to identify how much the users' needs are being met. 8,9Moreover, it is safeguarded to understand that the evaluation constitutes one of the mechanisms indicated to address the needs of planning and decision-making in the health field.
In the face of this proposal, from the emphasis on the PHC and the reality of the attention to these pregnant women (centralized in the specialized service), validated instruments are needed to assess the performance of services in different levels of attention, aiming at qualifying them.What indicated the purpose of this study: to evaluate if the type of service interferes in the health attention quality score, according to the PCATool--Brazil, in the experience of the pregnant women living with HIV.

METHOD
Cross-sectional study developed in the public health network for attention to pregnant women living with HIV, in Santa Maria, central region of the State of Rio Grande do Sul, Brazil.City with approximately 300,000 inhabitants, 31 PHC services, of which 18 are traditional Basic Health Units (BHU) with population coverage of 21%, 13 are Family Health Strategy (FHS) with coverage of 19%.According to national data on the epidemic, Santa Maria occupied, in 2014, year of this research's data collection, the 10 th position in the national ranking of 100 cities with more than 100, 000 inhabitants, according to composite index.At present, Santa Maria occupies the 94 th position.Among the first 20 ranked, ten belong to the South region, six of which in Rio Grande do Sul (RS), which reaffirms the need for assessment of the quality of the services that assist this population.Santa Maria counts on two HIV specialized services, one municipal and other the latter being a teaching hospital, and a reference for 32 cities of the state, members of the 4 th Healthcare Regional Coordinator.The study's population consisted of women living with HIV (n = 109).The inclusion criteria were: those who used the PHC public services during the gestational period (2012 to 2014).Abortions and stillbirths were excluded.The access to the woman occurred in the PHC services and in the specialized services.It is emphasized that in the federal service the search occurred in the sectors: adult and pediatric outpatients for infectious diseases, maternity and high risk prenatal outpatient.The choice of these services is justified by the organization of the same, which regular agenda of attendance provided access to the study population.The total population was 78 participants.There were two refusals and 29 losses, due to absenteeism in the consultations.
This number of participants is justified considering the fact that it is a vulnerable population either by the HIV infection, or the gestational period.Stigmatized, the women living with HIV are reluctant to participate in the researches, also for protection of the diagnosis secrecy, shared in a restrict support network.The telephone contact information in the notification forms and/ or medical records do not keep up to date.The women change PHC services and access the specialized services outside the city of residence, sometimes, for the birth also.Either in the geographical sense, or in the psychosocial sense, it is confirmed as a population of difficult access, which reiterates the relevance of researches with women living with HIV, more specifically regarding the gestational period.
The data collection occurred during the period from April to November 2014.A research instrument composed of the characterization of the socio-demographic and clinical profile was used; as well as the Primary Care Assessment Tool-Brazil (PCATool) reduced Adult version, which was applied in a presence way and the access to women was through the health service.The PCATool aims to assess how much the health services are oriented to the defining attributes of the PHC: access, coordination, integrality and longitudinality.An instrument developed by Barbara Starfield and applied in a national and international way. 10,11During the two decades after its creation in the United States of America (USA), this instrument was adapted for the health systems in Spain 12 , South Korea 13 China 14 , New Zealand 15 , Brazil 8 , Argentina 16 and Uruguay 17 .][14][15][16][17] The PCATool reduced Adult version is composed of a Likert type scale and the possible answers for each item of the instrument are: "yes, certainly" (value = four), "probably yes" (value = three), "probably not" (value = two), "certainly not" (value = one) and "I don't know/ I don't remember" (value = nine). 9he preferred type of service for the attention to the pregnant women's health was defined from three initial questions of the PCATool that establish the Degree of Affiliation regarding the service or professional that looks for, faced with a need, the one who knows well enough the pregnant woman and who is more responsible (involved) for her care. 9The other items were answered considering this affiliation.For analysis of the data, the answers were dichotomized as: PHC service and specialized service.
The socio-demographic variables were composed of: age, skin color (self-reported), housing city, marital status, instruction, occupation and clinical variables of the pregnancy: year of notification of the pregnancy in the Information of Diseases Notification System (SINAN), use of antiretroviral before and after pregnancy, route of infection, time of diagnosis and the carrying out of prenatal care.
For the quantitative variables (age and instruction), the median was employed as cutoff point due to the asymmetrical distribution of the data.The data were typed in the Epi Info version 7.0, using independent double entry, with check for errors and inconsistences, in order to guarantee accuracy of data.
The analysis of data was realized in the Predictive Analytics Software (PASW) version 18.0 for Windows.The internal consistency of the components of the PCATool was evaluated by means of the Cronbach's Alpha (α=0.893).The attributes were analyzed by means of the calculation of the overall score 9 , since the reduced version does not allow the assessment per attribute.The scores' values were transformed into a continuous scale ranging from zero to 10, in which the score ≥ 6.6 was considered satisfactory.This value equates, in a scale ranging from one to four, to the score three ("probably yes") that corresponds to the adequate extension of the attribute. 9e Pearson Chi-square test or the Fisher's exact test were employed both for the analysis of association of variables to the service that regularly assisted the pregnant women (socio--demographic and clinical of the pregnancy), and to analyze the proportions and to identify which of these variables could be associated to the quality of attention of the service referred to as regular source of attention to health.For this purpose, it was dichotomized, regarding the score attributed, in high or satisfactory (≥ 6.6) and low (< 6.6) score.The significance level assumed in the tests was 5%.
The ethical aspects contained in the Resolution CNS 466/12 were met.The Informed Consent Form (ICF) and the Confidentiality Term were offered.This research was approved by the Research Ethics Committee of the Federal University of Santa Maria, under protocol 773.483.

RESULTS
Among total participants (n = 78), the majority (74.4%) referred to the PHC services as the regular source of attention to health during the gestational period for the occurrence of health problems or in the search for the professionals' orientations.The PHC was indicated as the service that best knew them (58.9%) and as the service with greater responsibility for their health during pregnancy (39.7%).These questions defined the degree of affiliation to the PHC service.
Among the socio-demographic variables, the housing city (p = 0.035) was significantly associated with the affiliation of the user to the PHC for attention to pregnancy, in HBU or FHS.Among the clinical variables, the use of antiretroviral before the pregnancy (p = 0.038) was significant to the user's affiliation to the specialized service; and use of antiretroviral during pregnancy (p = 0.031) was significant both for affiliation to the PHC and for specialized (Table 1).
The participants considered the quality of the attention received low, even next to a satisfactory score (≥ 6.6), both in the primary attention (6.50) and in the specialized (6.35).(Table 2).
The analysis of association between the characteristics (sociodemographic and clinical) and the best assessment of the attention (high overall score) and lowest assessment of the attention (low overall score), was conducted in accordance with the type of service, established by the degree of affiliation (Table 3).
By evaluating the population characteristics associated with the PHC overall score, it did not show a significant difference that would be associated with low/high score, indicating that the population characteristics may not have interfered in the evaluation of the attention of both services.

DISCUSSION
The PHC services, as regular source of attention to health during the gestational period, prevailed among the evaluation in the participants' experience.The regular source recommends the users' affiliation for a service or professional and reinforces the importance of its role in receiving, advising the women in the Health attention to pregnant women with HIV Kleinubing RE, Eslava DG, Padoin SMM, Paula CC infection management, monitoring in the pregnancy and puerperal cycle, mainly, with regard to social and family cohabitation, healthcare routine and, even, reproductive planning.Similar result was found in studies conducted on the remaining communities of Brazilian Quilombos, in which the PHC was referred to maternal and child healthcare as entrance door for the most of users.The results indicated the reasons for affiliation to the service, the proximity of housing and the quality of attention, in spite of the difficulty of access to the services . 11eing the PHC the regular source of attention, it is necessary to minimize the barriers of the care's first contact and continuity. 18n this way, the coordination of health attention to people living with HIV, under the incentive of the current national policy of the PHC, signals the care's decentralization process, historically constructed in the specialized services for the access, in the services of FHS and HBU, to the consultations, vaccination and medicines or preservatives withdrawal, as well as gynecological and clinical follow-up. 5he analysis of the socio-demographic characteristics of the pregnant women living with HIV indicated that the housing city was significantly associated with the user's affiliation to the PHC.One may infer that using the PHC as regular source of attention can be related to the HBU and FHS localization.The affiliation to the PHC comes from actions such as the respect for people, confidentiality and the communication with the professionals, which tends to facilitate the access and the link both with the service and with the health team's professionals. 19This demonstrates that the Brazilian public sector has been investing in the PHC through better indicators of attention coverage during the gestational period, including in the solicitation of anti-HIV testing. 20he clinical characteristics show that most pregnant women who used antiretroviral previously to pregnancy indicated the specialized service as affiliation.In the users' experience, the positive evaluation of these services is related to the confidence, knowledge and commitment of the professionals, as well as agility for problem resolution. 21In the evaluation of the services, it can be pointed out the importance of the permanent investment in actions of promotion and monitoring of the treatment, that offer support to meet the needs of each and everyone. 22he multidisciplinary, integral and multidimensional approach that involves the treatment 23 reinforces the need for decentralization of the attention to people living with HIV.This movement from a model centralized in the specialized service to a matrix model has favorable factors such as the perspective  Health attention to pregnant women with HIV Kleinubing RE, Eslava DG, Padoin SMM, Paula CC of work in the PHC, according to the SUS principles and of the family health, training and matrix support.However, there are challenges such as incomplete teams, professionals' turnover, work overload, counselling and communication of the diagnosis. 24In addition, there is lack of communication among the points that compose the HCN, which can entail negatively the continuity of the attention. 6t was also identified that most participants, regardless of the service used as regular source of attention, used antiretroviral drugs during pregnancy.Which may indicate that, independent of the previous use of antiretroviral drugs, during this period, the women living with HIV adhere to vertical transmission prophylaxis in the service of affiliation.
Regarding the evaluation of the quality in the experience of the pregnant women living with HIV, both services presented unsatisfactory general values, being the PHC closer to the value Health attention to pregnant women with HIV Kleinubing RE, Eslava DG, Padoin SMM, Paula CC adopted as ideal.The low score evaluated by the participants in this research was convergent with general score also unsatisfactory 6,25 in the users' experience of FHS of a city in the interior of other Brazilian state; 26 as well as with the results of an evaluation study of health services, according to of resources (physical, human and material) and prenatal care process, developed in the BHU and FHS, which indicated deficient performance in both models, altough a little better in the FHS. 27This may indicate that the unsatisfactory evaluation is not exclusive of the serological condition, or of the type of service in which they are assisted, according to the results of other studies in the Brazilian context, the problem is in the attention to the woman, especially in the pregnancy-puerperal period. 28,29 national historical analysis of the quality of prenatal care identified good coverage, however, with high rates of inadequacies of the attention. 30It should be considered that the evaluation of the attention to people living with HIV recommends the adhesion to be a priority, in addition to counselling and testing, vertical transmission prevention, availability of human resources, equipment and of physical infrastructure. 31n relation to the association of high/low score with the sociodemographic and clinical characteristics, no variable was significantly associated, demonstrating that these characteristics did not interfere in the evaluation of these services, which suggests that the quality evaluation score, either of affiliation of the women to the PHV service, or to the specialized service, does not depend on their age, skin color, housing, marital status, instruction or occupation.The absence of significant association indicates, still, that the year of pregnancy, the moment of HIV diagnosis, the route of infection, the use of antiretroviral drugs before the pregnancy, the use of vertical transmission prophylaxis and the carrying out of the prenatal care did not interfere in the score either.Thus, it can be inferred that the score is not associated with the woman's characteristics, the pregnancy condition or the infection, but with the characteristics of the service itself, either from infrastructure resources or from actions.
One reiterates the importance of the active participation and the articulation between the PHC services and the specialized, in order that one can overcome the fragmentation of the actions of attention to health 32 , including reproductive and of management of infection, envisioning the woman who experiences these conditions, in search of the integrality of the care. 33One emphasizes the services integration for attention to the people living with HIV 34 , in which in the specificity of the women population must be since the attention to the sexual and reproductive health 35 , anti-HIV testing 36,37 and continuity of attention in the puerperal period. 38These integrated actions among the services should compose the care lines to the women.
Therefore, in order to achieve the quality desired in the evaluation of the attention to health of women living with HIV, it is recommended to invest in the access of pregnant women to the points of the PHC, under the coordination of the PHC, with negotiation of attributions of each service, according to its technological density, in addition to the communication between them and qualification of professionals.Such investment may positively affect both the vertical transmission rates and the integrality in the attention to health and in the continuity of the pregnancy care, puerperium and childcare.

CONCLUSION
Despite the study's participants making use of the PHC as regular source of attention to health during the gestational period, the evaluation showed that both the PHC and the specialized service had unsatisfactory score.However, the PHC score approached the value considered ideal.This may have reflected on their choice as regular source of attention.Thus, it stands out the importance of its role in the coordination, monitoring and promotion of the attached population, including by sharing some actions to meet demands related to the HIV infection with the specialized service.
As to the limitations, the non-attendance of some participants to health services during the data collection period might have culminated in the loss of users who possibly search for the PHC services, influencing statistically the chance of the association for the comparison between the services.It should be noted that the instrument used is not specific to people living with HIV and the uniqueness of this instrument application to this population points to the need for the investment in researches that propose the construction and validation of specific instruments.

FINIANCIAL SUPPORT
This work was carried out with support from the Brazilian Federal Agency for Support and Evaluation of Graduate Education -Brazil (CAPES) -Financing Code 001.Master´s degree fellowship awarded to Raquel Einloft Kleinubing.

Table 2 .
Comparison among the means of overall score among the types of services referred to as regular source of attention.Santa Maria, 2014.(N=78) ** Mann-Whitney Test

Table 3 .
Sociodemographic and clinical characteristics of pregnant women living with the HIV with the high /low score, regarding the type of service referred to as regular source of attention.Santa Maria, 2014.(N=78)