Tuberculosis control in people living with HIV/AIDS

ABSTRACT Objective: to analyze the offering of health actions and services for the control of tuberculosis for people living with HIV/AIDS being followed up in the Specialized Care Services for HIV/AIDS in Ribeirão Preto, SP, Brazil. Method: quantitative, exploratory survey study. Participated 253 people living with HIV/AIDS followed up by this service, considering as inclusion criteria: individuals older than 18 years living in the city and not inmates. Data collection was conducted from January 2012 to May 2013 through interviews with the support of a specific instrument. Data were analyzed using indicators and a composite index. Results: the offering of services for the control of tuberculosis in people living with HIV/AIDS by municipal services was considered as intermediate, reinforcing the need for better planning for comprehensive assistance, coordination of professionals in teams and among the services network, in addition to professional training and continuing education. Conclusion: it is necessary to implement strategies that promote shared actions between TB and HIV / AIDS programs and between different services in order to strengthen the local care network, aimed at producing an individualized care, comprehensive and responsive.


Introduction
Although Tuberculosis (TB) is a disease whose cure has been possible for decades now, it is still recognized as a current and persistent public health problem.
Linked to poverty, poor income distribution and poor quality of living conditions of the population (1)(2)(3) , TB leads to the death of about six thousand people a year in Brazil, and is aggravated by the increased numbers of cases of Acquired immunodeficiency Syndrome (AIDS) (4) . It is considered that the HIV infection is one of the most important known risk factors for tuberculosis (5)(6) , so that people living with HIV/AIDS (PLWH) are 21 to 34 times more likely to develop active TB as compared to the general population (7) .
In Brazil, the active TB in PLWH is the condition of greater impact on mortality from AIDS and TB. In 2011, among the cases of TB reported in the SINAN (71,000), about 10% had TB / HIV, and 6% of the mortality rate was related to the overlap of both infections (8) .
In this sense, both diseases are major challenges (9) for health services and government agencies (10)(11) . It is recognized the need for effective integration of the actions that are offered both within the service itself, by the teams of TB control programs (TCP) and by the ones of HIV / AIDS, and among the different health care points for creating an effective network of coherent services, with appropriate assistance to TB / HIV coinfection.
In this way, to think in the care services for PLWH with a focus on TB control, implies the establishment of a plan of care that is proactive, integrated and continuous (12) . It is understood that the assistance dynamics both for care to PLWH as well as for TB, must transcend the mere apprehension of epidemiological rates, assuming interdisciplinary practices that take into account the relationships and living conditions as they exist in a given territory in social vulnerability, enabling better planning and reorganization of health technologies (11.13) .
It is noteworthy that the studies analyzed in a survey of the literature on the subject in the last five years, pointed to the existence of gaps in the production of scientific knowledge in relation to the incorporation of aspects of the context of the subjects and the imbrication of this context with the care process. In this regard, it is remarked the importance of the development of this operational study, which allowed the identification of actions and health services taking into account the complexity of the management of these disorders.
Understanding that TB is a leading cause of death among PLWH, it should be imperative a greater commitment to prevention and diagnosis of this population, articulation and coordination between professionals, actions and health services. In this sense, the study aimed to analyze the supply of health actions and services for the control of TB in PLWH in Ribeirão Preto-SP.

Method
Descriptive, exploratory survey study using a quantitative approach, performed in Ribeirão Preto.
Ribeirao Preto's estimated population in 2011 was 614,759 inhabitants (14) . That same year, the public health care in the municipality was organized in five health districts, with five emergency units, 76 primary For data collection, interviews were carried out using a structured questionnaire developed from guidelines and protocols that address the organizational assessment of health care services for the care of HIV/AIDS (7)(8) . This instrument was perfected using procedures related to content analysis, semantic analysis and pilot testing for readjustment and verification of its

Results
The actions and services for the control of TB in PLWH showed an average of 3.1 (SD = 1.87), and for that, the research participants classified them as intermediate.     It is noteworthy that the regular use of antiretroviral therapy becomes an important protective factor against the development of TB in this population (18) .
Furthermore, studies show that the use of antiretroviral therapy can prevent deaths among co-infected TB / HIV (19)(20)(21) , therefore, its use should be implemented as soon as possible in individuals diagnosed with HIV (7) . However, the isolated use of therapy does not guarantee the effective prevention of TB / HIV co-infection. It is also needed to think in a comprehensive way, considering the lifestyle, socioeconomic and cultural conditions as factors of vulnerability to contagion.
In this way, attention to PLWH should cover educational activities regarding prevention, mode of transmission, signs and symptoms and the importance of early diagnosis of TB, as well as teamwork strategies to seek suspect cases and early detection of TB cases in these subjects (8) . Guidelines on diseases based on individual approaches constitute important elements for education and empowerment of the person to be able to perceive signs and symptoms of the disease, in the same way than to improve treatment adherence and strengthen the link between the professional and the individual (3,22,26) . Thus, to promote health education proposals able to educate the PLWH about the high likelihood of a TB infection, requires to extrapolate technical issues and, recurring to subjectivity and knowledge of them, sensitizing them with regard to transmission, care prevention, recognition of signs and symptoms and how to seek health services (24,(27)(28) .
Coupled with the social question, the supply of