Questionnaire for assessment of HIV/AIDS control actions in the primary care

Abstract

Objective

To validate the content of a questionnaire to assess the care provided by healthcare professionals to control the HIV/AIDS epidemic in primary care.

Methods

A methodological study was conducted, based on the development of a questionnaire using an integrative review, and subsequent validation by experts, using a two-round Delphi technique. Data were analyzed by considering the level of consensus responses, associated with the Kappa index. The criteria for retaining the questions were: ≤ 75% agreement, and Kappa ≤ 0.41.

Results

The first round eliminated 16 questions, five questions were revised according to vocabulary changes requested by experts, and criteria for topic coverage and clarity. In the second round, 31 questions were considered appropriate.

Conclusion

This questionnaire, unpublished nationally or internationally, achieved acceptable content validity after a careful review of its questions.

Acquired immunodeficiency syndrome; HIV; Primary health care; Validation studies

Resumo

Objetivo

Validar o conteúdo de um questionário para a avaliação da atenção ofertada pelos profissionais de saúde para o controle da epidemia do HIV/Aids na atenção básica.

Métodos

Estudo metodológico realizado a partir da construção de questionário por meio de uma revisão integrativa, com posterior validação por juízes, utilizando-se a técnica Delphi em duas rodadas. Os dados foram analisados tomando o nível de consenso das respostas, associado ao índice Kappa. Os critérios para a permanência das questões foram: porcentagem de concordância ≤ 75% e Kappa ≤ 0,41.

Resultados

Na primeira rodada, 16 questões foram eliminadas, 05 questões sofreram mudanças para atender à solicitação dos especialistas quanto aos critérios de vocabulário, abrangência ao tema e clareza e Na segunda rodada, as 31 questões foram consideradas adequadas.

Conclusão

O questionário, inédito tanto no âmbito nacional quanto no internacional, encontra-se validado em relação ao seu conteúdo, após cuidadosa revisão de suas questões.

Síndrome da imunodeficiência adquirida; HIV; Atenção primária à saúde; Estudos de validação

Introduction

Acquired Immune Deficiency Syndrome (AIDS) corresponds to the most advanced stage of the human immunodeficiency virus (HIV) infection.¹ A global challenge presented with its discovery, related to epidemiological, socio-cultural, economic and clinical aspects, characterizing the need to implement policies to address social and structural barriers to diagnosis and care, as well as discrimination and stigma associated with HIV.²

Around 1.6 million people live with HIV in Latin America, and data accumulated from 2007 to 2016, demonstrate 136,946 cases of infection in Brazil.³,⁴ The AIDS epidemic showed increased bias in the number of cases in the poorest population strata, and a general reduction in the male/female ratio in the Brazilian population. Given such a context, combating HIV/AIDS requires commitment and effort on the part of the entire society, as it involves not only behavioral aspects, but issues that contribute to increased vulnerability.⁵

Public policies have been implemented to fight and control HIV/AIDS that culminated in health care focused on: improving the quality of life of people living with HIV,¹ highlighting the availability of antiretroviral treatment in the Unified Health System (UHS-SUS) network, the creation of a Specialized Assistance Service (SAS) for people with HIV/AIDS, biosecurity actions of health workers in order to minimize the risk of HIV infection due to occupational accidents, as well as expanding the availability of diagnostic tests and prevention.⁶

In view of this epidemic, the 90-90-90 targets were established, which refer to: 90% of people living with HIV/AIDS (HIV-positive people) must be diagnosed, 90% of HIV-positive people should be receiving treatment with antiretroviral therapy, and 90% of HIV-positive people should be receiving viral suppression treatment.⁷ In order to meet these goals, it is necessary to rethink the construction and operationalization of responses in the health care network, with emphasis on primary care, which presents itself as a privileged locus of control to act in the fight against HIV/AIDS, because is one of the main gateways to the system’s health care network, as well as being committed to allocating actions for HIV/AIDS control, such as: health education, HIV prevention, early diagnosis, and access to appropriate treatment.⁸

The relevance of the study is related to the need to measure the attention offered to the control of HIV/AIDS by health professionals in primary care, in order to develop a situational diagnosis that supports the development of knowledge and practices aimed at prevention and management of the disease.

In this sense, a validated questionnaire will promote the development of theoretical and operational knowledge aimed at understanding and evaluating the performance of HIV/AIDS prevention and control actions, in the context of primary health care, especially in view of the different organizational models adopted in Brazil. In harmony with the diversity of the local and regional contexts, configuring pluralistic care (within traditional Basic Health Units, Community Health Agent Program, and the Family Health Strategy). Thus, the availability of tools allowing evaluation of the performance of these services is fundamental for qualification of health practices, especially in the control of HIV/AIDS. In addition, it is possible to collaborate on public policies at this level of health care, helping to plan interventions aimed at the 90-90-90 targets of the Brazilian Ministry of Health.

The objective was to complete the content validation of a questionnaire to evaluate HIV/AIDS control in the primary health care network, based on the care provided by health professionals.

Methods

This was methodological research with a quantitative approach, for face and sampling validation of questionnaire content,⁹,¹⁰ performed by a group of experts using the Delphi technique.¹¹ The study was developed in two sequential phases. In the first, an integrative review was completed to construct the instrument; in the second, the content validation was completed.

Development of the instrument

The questionnaire was developed after an integrative review of the literature was completed on HIV/AIDS control in periodicals that were: published in the last ten years, available in the Virtual Health Library (VHL- BVS), Latin American and Caribbean Literature (LILACS), International Literature in Health and Biomedical Sciences (MEDLINE), SCOPUS, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The following Health Sciences Descriptors (HSD-DeCS) were used: primary health care; acquired immunodeficiency syndrome and HIV. In a complementary way, materials available from the Ministry of Health that were associated with the researchers’ experiences were used.

The questionnaire was composed of two sections: socio-demographic and economic characteristics of the participants (containing seven questions regarding: sex, age, family income, religion, marital status, profession and time working in the primary health network); characteristics of the care provided (containing 47 questions related to the assessment of HIV/AIDS control, based on the following pillars: knowledge of professionals about control of the epidemic at the primary health care level, health education, diagnosis, continuity of care, availability of material resources and physical space in the health unit, and access to healthcare services and supplies for prevention of HIV infection).

Content validation of the instrument

Preceding the content validation, a peer review was developed with a committee of experts, selected by convenience, composed of three academic professors with experience in public policies to cope with HIV/AIDS, who performed an evaluation on the conceptual and semantic equivalence of the questionnaire.

In order to verify the content validity, the questionnaire was submitted to expert evaluation by professionals considered qualified to assess clarity, content, disposition and comprehension of a questionnaire,¹² to analyze the representativeness of the questions, and to constitute a representative sample of what it is proposed to measure.¹³

Because no consensus was found in the literature to define the number of subjects that should participate in content validation, the establishment of the sample was at the criterion and accessibility of the researcher. However, in order to minimize bias, the delimitation of the inclusion criteria of the participants must be in consonance with the object of the study.¹⁴

The specialists were selected through the review of their curriculum vitaes, based on the following inclusion criteria: undergraduate professors and/or healthcare professionals working in primary care; graduation lato sensu or stricto sensu in the area of public health, community health, health sciences and/or health management, research related to HIV/AIDS control in the last five years; professional experience equal to or greater than two years; the exclusion criterion was the return of incomplete instruments by a primary health care professional or professor.

The sample consisted of 20 participants: ten health professionals and ten undergraduate professors that met the criteria for inclusion. The study was conducted by electronic mail in the period from February of 2014 to April of 2014. The initial contact was made by means of an invitation letter, specifying the assessment criteria and the request for consideration and, after acceptance, the instrument and the Terms of Free and Informed Consent (TFIC), was sent to the participants.

The data collected from the specialists in the sample validation were obtained by means of a two-point scale for individual evaluation of the questions, regarding agreement (A) and disagreement (D) with the retention of the question in the questionnaire. In the face validation, the experts provided their judgments, which were captured in spaces destined for comments/suggestions.

The methodological process occurred in two rounds because the first, conducted with 20 participants, did not reach the consensus level adopted for this research. Data collection proceeded with eight experts, because the others did not present suggestions or comments in the first round.¹⁴

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 20.0. The data analysis for content validity was performed using the level of consensus of the answers,¹⁴ associated with the Kappa index to measure the level of agreement and consistency of the experts, regarding whether or not the questions should be retained in the instrument. These values ranged from +1 to -1; values between 0.41 and 0.60 were classified as moderate, 0.61 to 0.80 as substantial, and 0.81 to 1.0 as excellent.¹⁴

The Kappa coefficient value was considered as a criterion for retaining the questions, ranging between moderate, substantial and excellent, associated with an agreement of ≥75%. Questions with a Kappa coefficient and/or percentages of agreement less than the referred values were automatically excluded from the questionnaire, and the other questions were revised, using the suggestions and comments presented during the face validation, and submitted to a re-evaluation.¹⁵

The development of the study met standards of ethics in research involving human subjects (Certificado de Apresentação para Apreciação Ética - CAAE: 23067613.0.0000.5537).

Results

In the first round, experts agreed 100% on the socio-demographic and economic characteristics sections, obtaining Kappa values of +1. Of the 47 questions that comprised the questionnaire in the initial version, 13 obtained 100% concordance level and Kappa +1; any suggestion for revision was presented, as demonstrated in table 1.

Table 1
Expert judgment on issues

Questions		Appropriate	Appropriate with changes	Inappropriate	K**
		n(%)*	n(%)*	n(%)*
1	Do you have access to Ministry of Health handbooks regarding the management of STIs (sexually transmitted infections)?	19(95)	0(0)	1(5)	0.459
2	Is an active search conducted to identify the groups most vulnerable to HIV/AIDS infection?	17(85)	0(0)	3(15)	0.34
3	Have you participated in training/qualification on issues related to HIV/AIDS control in the last five years?	19(95)	0(0)	1(5)	0.943
4	Is the availability of time per week for Pap smears sufficient to meet the demand?	13(65)	0(0)	7(35)	0.501
5	Is an information and awareness campaign about risk behaviors for HIV infection conducted in the coverage area of the healthcare unit?	19(95)	0(0)	1(5)	0.459
6	Is the rapid or serological test offered to every person with symptoms suggestive of HIV/AIDS?	16(80)	0(0)	4(20)	0.138
7	Is the prenatal visit performed as soon as possible, after confirmation of pregnancy, in women who have sought health services?	16(80)	1(5)	3(15)	0.852
8	Does the unit have adequate physical space for educational activities?	15(75)	2(10)	3(15)	0.608
9	Is the rapid test offered to partners of people diagnosed with HIV/AIDS?	18(90)	1(5)	1(5)	0.459
10	Is welcoming accomplished along with an initial evaluation of people diagnosed with HIV, in the area covered by the health unit?	18(90)	0(0)	2(10)	0.318
11	Do injecting drug users have access to new/sterile syringes provided by the health unit?	14(70)	0(0)	6(30)	0.306
12	Does the delivery of condoms occur outside the physical space of the health unit?	16(80)	0(0)	4(20)	0.483
13	Are people who are diagnosed with HIV/AIDS monitored by the health unit?	18(90)	0(0)	2(10)	0.773
14	In the initial assessment, are HIV users that can be followed at the unit identified, along with those who should be referred for follow-up in the Specialized Care Services?	17(85)	0(0)	3(15)	0.216
15	Is the management of HIV infection conducted in this unit?	18(90)	0(0)	2(10)	0.318
16	Are you aware of the contents of the manuals provided by the Ministry of Health regarding the measures used to control HIV/AIDS in primary care?	19(95)	0(0)	1(5)	0.459
17	Are information and awareness campaigns conducted for HIV/AIDS prevention in social facilities in the area covered by the health unit?	18(90)	1(5)	1(5)	1
18	Are the laboratory tests recommended by the Ministry of Health requested at the first visit, when a pregnancy result is positive?	20(100)	0(0)	0(0)	1
19	Does the health unit provide educative materials for educational actions?	19(95)	0(0)	1(5)	0.459
20	Is early detection for failure of antiretroviral therapy, and referral to the specialized service performed?	18(90)	0(0)	2(10)	0.318
21	Is the health unit supplied with medications for treatment of STIs (sexually transmitted infections)?	18(90)	0(0)	2(10)	0.318
22	Is the HIV serological test required for all pregnant women?	18(90)	0(0)	2(10)	0.318
23	Are people diagnosed with HIV/AIDS referred by the unit?	20(100)	0(0)	0(0)	1
24	Is an active search conducted for partners when the HIV/AIDS diagnosis is positive?	20(100)	0(0)	0(0)	1
25	Are pregnant women identified with HIV/AIDS referred for medium and high complexity services monitored by the health unit?	19(95)	0(0)	1(5)	1
26	Are condoms not only provided at specific times?	18(90)	0(0)	2(10)	0.139
27	Is HIV serological testing requested for women with complaints suggestive of gynecological infection?	19(95)	1(5)	1(5)	1
28	In the first contact with people suspected of HIV/AIDS has the diagnostic opportunity?	19(95)	1(5)	1(5)	1
29	Does the health facility provide material for rapid HIV/AIDS testing?	20(100)	0(0)	0(0)	1
30	Did you receive training to perform rapid HIV/AIDS testing?	20(100)	0(0)	0(0)	1
31	Is health education on healthy living habits conducted in social facilities in the area covered by the unit?	19(95)	0(0)	1(5)	0.459
32	With the distribution of condoms, is guidance provided on male use?	20(100)	0(0)	0(0)	1
33	Are the results of the 1st and 2nd HIV serology tests requested during prenatal care given to pregnant women during their pregnancy?	17(85)	0(0)	3(15)	0.608
34	Are collective educational actions addressed to the population, related to the prevention of STI (sexually transmitted infections)/AIDS, conducted?	20(100)	0(0)	0(0)	1
35	Is the HIV rapid test provided to all users of the health care facility?	18(90)	0(0)	2(10)	0.318
36	Are educational actions for information and prevention of STIs (sexually transmitted infections) offered in the health unit?	20(100)	0(0)	0(0)	1
37	Are health facility patients educated for healthy sexual habits?	18(90)	0(0)	2(10)	0.31
38	Is notification made within the SINAN (Notifiable Diseases Information System) of STIs (sexually transmitted infection) and injuries?	19(95)	0(0)	1(5)	0.459
39	Is adequate space available for the pharmacy service?	14(70)	0(0)	6(30)	0.306
40	Is an active search performed for pregnant women who began prenatal care, but did not follow through with care?	18(90)	0(0)	2(10)	0.318
41	Is the amount of condoms the unit receives per month enough to meet the demand?	20(100)	0(0)	0(0)	1
42	Is an active search conducted for people whose HIV diagnosis was positive but who did not return to receive the result?	20(100)	0(0)	0(0)	1
43	Are sex workers, homosexuals and drug users identified as vulnerable to HIV/AIDS?	13(65)	0(0)	7(35)	0.136
44	Is HIV/AIDS testing requested at the first prenatal visit?	20(100)	0(0)	0(0)	1
45	Are educational actions about HIV/AIDS provided without difficulties?	20(100)	0(0)	0(0)	1
46	Is the HIV serological test offered to patients of this unit?	19(90)	1(5)	0(0)	1
47	Do you conduct rapid HIV/AIDS pre-test and post-test counseling?	20(100)	0(0)	0(0)	1

• * Number of respondents / percentage of agreement; ** Kappa test

Sixteen questions were automatically eliminated because they did not have the index of agreement established in the survey: K≥0.41 and/or level of agreement ≥75%. The other questions were evaluated with Kappa values, varying between substantial, moderate and excellent, with 75% to 100% approval regarding retaining questions in the questionnaire; however after analysis, modifications in the face validation were necessary (Chart 1).

Chart 1
Suggestions from experts on issues considered appropriate with changes needed

Question	Issues evaluated	Suggestions/ Expert comments (n*)	Acceptance	Reformulated question
Is the prenatal visit performed as soon as possible, after confirmation of pregnancy, in women who have sought health services?	Scope	Focus not only on the prenatal visit, but also on screening for STIs in pregnant women, such as anti-HIV, VDRL, Hepatitis B and Hepatitis C. (1)	No	-
Does the unit have available physical space for educational activities	Vocabulary	Replace available physical space with adequate physical space. (2)	Yes	Does the unit have adequate physical space for educational activities?
Is the rapid test offered to partners of people diagnosed with HIV/AIDS?	Scope	Add to the question: is the serological test also offered? (1)	Yes	Is the rapid test or serological test offered to partners of people diagnosed with HIV/AIDS?
Are information and awareness campaigns conducted for HIV/AIDS prevention in social facilities in the area covered by the health unit?	Vocabulary	Change the term social facilities to one that facilitates understanding, for example, social spaces. (1)	No	-
Is HIV serological testing requested for women with complaints suggestive of gynecological infection?	Scope	Add to the question: if the rapid HIV test is also requested in women who have complaints suggestive of gynecological infection? (1)	Yes	Is the rapid test or HIV serological testing requested for women with complaints suggestive of gynecological infection?
In the first contact with people suspected of HIV/AIDS has the diagnostic opportunity?	Clarity	Rephrase the question in a manner that facilitates understanding. (1)	Yes	Do people suspected of HIV infection seeking the health basic unit have the opportunity to perform the diagnostic test in the health care network
Is the HIV serological test offered to patients of this unit?	Scope	Add the question: is the rapid test also offered? (1)	Yes	Is the rapid test and HIV serological test offered to patients of this unit

• *Number of experts who commented on the question

Following the revision of the questions, as described in chart 1, and exclusion of questions that presented poor Kappa values, the questionnaire was submitted to a second round of review. Thirty-one questions composed the questionnaire in the second version and, among them, 15 presented an excellent level of agreement in the initial version and, subsequently, continued to show this result. A total of five questions were revised to meet the suggestions of the experts. Eleven questions of the instrument obtained Kappa values varying between moderate, substantial and excellent, and a consensus level of 75% to 100% in the sample validation, without suggestions/comments by the experts.

All issues analyzed in the second round were approved in relation to the criteria of relevance, clarity, objectivity, accuracy, vocabulary and comprehensiveness. The questionnaire, in its final version (Chart 2), is composed of two sections, containing seven questions aimed at the sociodemographic and economic characteristics of health professionals, and thirty-one questions to evaluate the control of HIV/AIDS in primary care.

Chart 2
Final version of the questionnaire for assessment of HIV/AIDS control in basic care, from the perspective of health professionals

SOCIODEMOGRAPHIC AND ECONOMIC CHARACTERISTICS
Sex: ( ) Male ( ) Female
Age: _________
Family income: ( ) One minimal wage ( ) Two minimal wage ( ) Three or more
Religion: __________________________________;
Marital status: ( ) Single ( ) Married ( ) Other
Occupation:____________________________________________________;
Time working in the primary health network: ______________________;
SPECIFIC QUESTIONS
1	Do you have access to Ministry of Health handbooks regarding the management of STIs (sexually transmitted infections)?
2	Have you participated in training/qualification on issues related to HIV/AIDS control in the last five years?
3	Are information and awareness campaign about risk behavior for HIV infection conducted in the coverage area of the healthcare unit?
4	Is the prenatal visit performed as soon as possible, after confirmation of pregnancy by women who have sought the health services
5	Does the unit have adequate physical space for educational activities?
6	Is the rapid test or serological test offered to partners of people diagnosed with HIV/AIDS?
7	Does the delivery of condoms occur outside the physical space of the health unit?
8	Are people who are diagnosed with HIV/AIDS monitored by the health unit?
9	Are you aware of the contents of the manuals provided by the Ministry of Health regarding the measures used to control HIV/AIDS in primary care?
10	Are information and awareness campaigns conducted for HIV/AIDS prevention in social facilities in the area covered by the health unit?
11	Are the laboratory tests recommended by the Ministry of Health requested at the first visit, when the pregnancy result is positive?
12	Does the health unit provide educative materials for educational actions?
13	Are people diagnosed with HIV/AIDS referred by the unit?
14	Is an active search conducted for partners when the HIV/AIDS diagnosis is positive?
15	Are pregnant women identified with HIV/AIDS referred for medium and high complexity services monitored by the health unit?
16	Is the rapid test or HIV serological testing requested for women with complaints suggestive of gynecological infection?
17	Do people suspected of HIV infection at the primary health unit have an opportunity to perform the diagnostic test in the health care network?
18	Does the health facility provide material for rapid HIV/AIDS testing?
19	Did you receive training to perform rapid HIV/AIDS tests?
20	Is health education on healthy living habits conducted in social facilities in the area covered by the unit?
21	With the distribution of condoms, is guidance provided on male use?
22	Are the results of the 1st and 2nd HIV serology tests requested during prenatal care given to pregnant women during their pregnancy?
23	Are collective educational actions addressed to the population, related to the prevention of STI(sexually transmitted infections)/AIDS conducted?
24	Are educational actions for information and prevention of STIs (sexually transmitted infections) offered in the health unit?
25	Is notification made within the SINAN (Notifiable Diseases Information System) of STI (sexually transmitted infection) and injuries?
26	Is the amount of condoms the unit receives per month enough to meet the demand?
27	Is an active search conducted for people whose HIV diagnosis was positive but did not return to receive the result?
28	Is HIV/AIDS testing requested at the first prenatal visit?
29	Are educational actions about HIV/AIDS provided without difficulties?
30	Is the rapid test and HIV serological test offered to patients of this unit?
31	Do you conduct HIV/AIDS pre-test and post-test counseling?

Discussion

The introduction of Highly Active Antiretroviral Therapy (HAART), in 1996, resulted in a significant reduction in the incidence of AIDS, due to the reduction in the viral load of HIV-positive patients, contributing to a decrease in transmission of the virus.¹⁶ Despite the relative control, some challenges to coping with HIV/AIDS persist, and among these is the expansion of prevention and early diagnosis actions within the healthcare services.¹⁷

At the national level, preventive actions that were restricted to referral services have been decentralized, and are present in primary care, which has developed actions directed at coping with HIV/AIDS at different degrees of complexity and quality. Despite the advances, there are major challenges for improvement.¹⁷

Because of the responsibility of the primary network to control HIV/AIDS, it becomes relevant to investigate diagnoses that have been made operational in this service. However, as seen in the lack of observed questionnaires proposed for this purpose, the importance of a questionnaire and its evaluation by means of a committee of experts is emphasized, since organized collective judgment is more productive than that of an individual or a group devoid of specific knowledge.¹⁶

A validated questionnaire can lead to a more precise diagnosis development, as it supports decision-making, insofar as it systematically allows collection of data, which are translated into pertinent information about a certain reality, seeking an identification of the needs within each context.¹³ The data presented in this study reaffirm the importance of the operationalization of rigorous methodological techniques, and responsibility for the data collected for the development of a validated questionnaire.¹²

The opinion of the experts allowed the development of a more precise questionnaire.¹⁸ After the first round, a significant portion of the suggestions concerning requirements related to vocabulary, clarity, and comprehensiveness were adopted. Of the seven questions considered appropriate, but with needed revision, five were modified for relevance and correspondence with the literature.

Three of the above five questions related to the HIV test were modified according to expert recommendation: “Is the rapid test or HIV serological testing requested for women with complaints suggestive of gynecological infection?” and “Is the rapid test and HIV serological test offered to patients of this unit”. These modifications allowed the inclusion of the rapid test along with the serological test, allowing the investigation of how the health team operationalizes the actions for the diagnosis of HIV in a broader way, thus supporting achievement of the target of 90% of people diagnosed with HIV. Brazil has until 2020 to reach the 90-90-90 target established by the country within the United Nations Organization, which was also assumed by the BRICS bloc (comprising Brazil, Russia, India, China and South Africa). The global target foresees a limitation of new infections to 500,000 a year, and zero discrimination.⁷

The expansion of diagnostic testing centers and the inclusion of the rapid tests in the primary health network, in addition to enabling early diagnosis, provide opportunities for individualized interventions across a large number of people.¹⁹,²⁰ Although there is increased testing in the country, the absence of counseling is a concerning reality that remains, without attention to the autonomous decision-making of the individual, and with inequalities inherent in the individual’s level of education, region and race.²¹,²²

For proper implementation of the rapid HIV test, four dimensions need to be developed: team awareness and dissemination of rapid testing procedures for target audiences; adequate physical space and equipment; availability of inputs and material and organizational workflow, with a definition of the roles. Based on this, the question, “Does the unit have adequate physical space for educational activities?”, the experts have suggested changes in terms of vocabulary and clarity, because the retention of terms or expressions which are difficult to understand can lead to uncertainty, and elicit responses that do not fit the reality.

The suggestion presented for the question: “In the first contact with people suspected of HIV/AIDS has the diagnostic opportunity?” regarding the aspects of vocabulary and clarity was accepted by facilitating the understanding of the question, and giving objectivity and clarity for the content of the questionnaire.¹²

In the question: Is the prenatal visit performed as soon as possible, after confirmation of pregnancy, in women who have sought health services?” the suggestion was pertinent, understanding that early detection of STIs and reduction of vertical HIV transmission can be achieved if these diseases are prevented and/or diagnosed during prenatal care. Thus, the sooner there is adherence to quality prenatal care, the more effective it may be in reducing transmission, according to the National STD/AIDS policy emphasizing the strategies of the Stork Network, which has primary health care as one of the pillars.¹⁹ However, revision was not performed, because another question in the questionnaire already encompassed this proposal: “Is HIV/AIDS testing requested at the first prenatal visit? “

As recommended by the Ministry of Health, prenatal care should begin in the first trimester and should include the complementary tests, such as the rapid screening test for syphilis and/or VDRL/RPR, rapid HIV test; IgM and IgG toxoplasmosis, and hepatitis B (HbsAg) testing. Thus, the suggestion to not focus solely on the prenatal visit was not accepted.¹⁸

The limitations of this study are related to the absence of some issues in the validated version, associated to the management of HIV infection in primary care. The first instrument included questions that contained this aspect, such as: welcoming and initial evaluation of people diagnosed with HIV, management of HIV infections, identification of users who could be treated at the unit and those who should be referred to a specialized service, and the early detection of antiretroviral therapy failure. The experts justified the removal of these issues based on the lack of permanent education of health professionals to act in the face of this new demand, inadequate physical structure of the units, and the lack of an integrated and articulated network of support in the case of therapeutic failures in primary health care.

However, given the change in the management of HIV infection in Brazil, in which the management of stable patients using simplified treatment regimens is identified, which is similar to the care of patients with chronic diseases, a new model of care has been established in Brazilian municipalities. This model presents an evolution of the models focused on specialized and dynamic services, in which different units of primary health care participate in the provision of care for those with HIV/AIDS, composing an integrated and articulated network.²³

In this new model, the design of the care network recognizes primary health care as the entrance into and coordinator of care. Strategies such as the support of specialized services for primary care, and the shared care between these services, guarantee greater access for the users into the health system. The decision to implement this new model is local, and one of the fundamental points is that health professionals are integrated into the processes of continuous education, thus guaranteeing adequate qualification for these new demands.²³

Conclusion

The content validation by expert evaluation proved useful for development and improvement, resulting in the provision of a valid questionnaire, composed of 31 questions focused on evaluating actions for the control of HIV/AIDS in primary health care. The lack of national or international published questionnaires presents this as a possible instrument to be considered by managers and health professionals, to develop a situational diagnosis of the possibilities and fragilities of primary care in the face of HIV/AIDS control, and may support them in defining a strategic plan. This may therefore contribute to changes in the epidemiological framework, resulting in benefits for the family, community and users of the primary health network.

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Publication Dates

• Publication in this collection
  May-Jun 2017

History

• Received
  9 Mar 2017
• Accepted
  29 May 2017