Perception of nurses about the decentralization process of HIV/Aids care: rapid test

Abstract

Objective

to describe the nurses' perception of the decentralization process of HIV/Aids care focused on rapid testing.

Method

this is a descriptive study with a qualitative approach, in which 32 primary care nurses participated. The data were obtained through interviews using a semi-structured script, which were processed by the software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ) with the word cloud analysis technique.

Results

the words “health unit” and “rapid test” stand out in the speeches. Among the obstacles to the implementation of decentralization, the expanded supply and access to early diagnosis are worth mentioning.

Conclusion and implications for the practice

the study reinforces the importance of nurses as active subjects in the care of people living with HIV and in the execution of individual and collective actions to strengthen the decentralization process among the levels of health care.

Keywords:
HIV; Primary Health Care; Healthcare Models; Nurse; Diagnosis

Resumo

Objetivo

descrever a percepção do enfermeiro acerca do processo de descentralização do atendimento ao HIV/Aids voltado à realização da testagem rápida.

Método

trata-se de um estudo descritivo com abordagem qualitativa, no qual participaram 32 enfermeiros da atenção básica. Os dados foram obtidos por meio de entrevista, utilizou-se roteiro semiestruturado, os quais foram processados pelo software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ) com a técnica de análise da nuvem de palavras.

Resultados

destaca-se nas falas maior frequência das palavras “unidade de saúde” e “teste rápido”. Dentre os obstáculos na concretização da descentralização, merecem realce a oferta ampliada e o acesso ao diagnóstico precoce.

Conclusão e implicações para a prática

o estudo reforça a importância da atuação do enfermeiro como sujeito ativo no cuidado às pessoas vivendo com HIV e na execução de ações individuais e coletivas para fortalecer o processo de descentralização entre os níveis de atenção à saúde.

Palavras-chave:
HIV; Atenção Primária à Saúde; Modelos de Assistência à Saúde; Enfermeiro; Diagnóstico

Resumen

Objetivo

describir la percepción del enfermero sobre el proceso de descentralización de la atención al VIH / SIDA orientado a la realización de pruebas rápidas.

Método

se trata de un estudio descriptivo con abordaje cualitativo, en el que participaron 32 enfermeros de atención básica. Los datos se obtuvieron a través de entrevista, se utilizó un guión semiestructurado, los cuales fueron procesados por el software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ) utilizando la técnica de análisis de la nube de palabras.

Resultados

en los enunciados destacan las palabras “unidad de salud” y “prueba rápida”. Entre los obstáculos para lograr la descentralización, cabe mencionar la ampliación de la oferta y el acceso al diagnóstico precoz.

Conclusión e implicaciones para la práctica

el estudio refuerza la importancia del rol del enfermero como sujeto activo en el cuidado de las personas que viven con el VIH y en la realización de acciones individuales y colectivas para fortalecer el proceso de descentralización entre los niveles de atención en salud.

Palabras clave:
VIH; Atención Primaria de Salud; Modelos de Atención de Salud; Enfermeros; Diagnóstico

INTRODUCTION

Infection by the Human Immunodeficiency Virus (HIV) is still a relevant global public health problem, as it causes the Acquired Immune Deficiency Syndrome (AIDS). The infection corresponds to a complex biological situation, in which there is a deterioration of the immune functions and a weakening of the individual's defense system, making him vulnerable and susceptible to opportunistic infections.^1,2

In recent years, with the advance of Antiretroviral Therapy (ART), the disease has assumed a chronic condition and resulted in a change in the profile of people living with HIV and a better quality of life.^3,4 Thus, in 2014, the Ministry of Health (MH) proposed a reorganization in the health care model with the decentralization of care from Specialized Care Services (SCS) to Primary Health Care (PHC).⁵

In this line, the MH publishes a series of reports on experiences of decentralization of care and monitoring of people living with HIV in four Brazilian cities, Curitiba, Porto Alegre, Rio de Janeiro and Fortaleza, through the Good Practices in HIV/Aids in Primary Care. The objective of the publication was to show how the experiences in the reorganization of care happen in practice in PHC and to demonstrate singular and diverse designs in the territory.⁶

In this perspective, to operationalize the assistance between the levels of complexity, it is recommended the risk stratification of individuals diagnosed with HIV in symptomatic and asymptomatic cases. Thus, the SCS is responsible for attending the most complex cases, namely: symptomatic, pregnant women, children, and co-infected individuals. In PHC, it is recommended the comprehensive care of asymptomatic patients, with initiation of ART, routine tests, including TCD4 lymphocyte count and viral load (VL).⁵

The diagnosis and follow-up of people living with HIV are a challenge for the reorganization of the Health Care Network (HCN), especially with regard to the routine of PHC professionals, who in the midst of the model transition face daily difficult situations, from the execution of the test to the disclosure of the positive result, such as deficit of material inputs, stigma and prejudice suffered by users and gaps in the training offered to professionals.^7-9

Among the actions carried out in the process of decentralization of care in the PHC units, the implementation of the Rapid Test (RT) for HIV is pointed out as a diagnostic technology that provides the patient with knowledge of the serology at an opportune moment.^6,7Thus, it is essential to adopt innovative approaches to care associated with testing, for example, in the combined prevention strategy of combining different prevention actions (biomedical, behavioral and structural), we have the Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP) as examples of prevention measures aimed at reducing the risk of exposure to HIV.¹⁰

Given the above and taking into account the awareness of the theme, this study aims to describe the perception of nurses about the decentralization process of HIV/Aids care focused on rapid testing.

METHODOLOGY

This is a descriptive field study with a qualitative approach, developed in 27 Family Health Units (FHUs), from the 131 FHUs that make up the PHC in the city of Recife, Pernambuco, Brazil. Thus, we randomly selected the FHUs distributed among the eight Health Districts (HD).

Thirty-two nurses who integrate the Family Health Strategy (FHS) and met the following inclusion criteria participated in the study: a) nurses of both genders; b) nurses in care positions in the studied FHUs; c) experience of at least one year in the FHS. The following were excluded from the sample: a) nurses on medical leave, pregnancy leave, or leave for other reasons, with a return time ≥ 90 days; b) nurses who performed only management or coordination positions in the studied units; c) nurses who had at least one year of experience in the FHU.

The choice of the number of participants in the sample considered 20 to 30 interviews. This quantity is suggested in the existence of speeches that produce longer texts, in homogeneous groups.¹¹ From these numbers, we used the data saturation criterion.¹²

Data collection took place from December 2019 to March 2020, using two instruments: a questionnaire of sociodemographic and professional characterization containing the variables age, gender, years of education, years of work in PHC, other employment ties and complementary education; and a semi-structured interview script, with questions related to the decentralization process of HIV/Aids care, which addressed access, diagnosis, structure, training, prevention activities and health education.

The interviews were previously scheduled with the professional and held in a private room on the premises of the healthcare facility to ensure privacy and minimize interference, with an average duration of 40 minutes. They were recorded with the participant's permission and the aid of a voice recorder, to ensure the authenticity of the statements.

It is noteworthy that, before the beginning of the collection, the individuals who agreed to take part in the research signed the Free and Informed Consent Term (FICT). Subsequently, the speeches from the recordings were transcribed in full, making up the text corpus of this study.

For data analysis, we used the software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ).¹³ Among the various analytical scenarios offered by the program, we decided to use the word cloud analysis technique. Thus, the words were grouped and organized graphically according to their frequency.¹³ From the most frequent words provided in the text segments, the lexical analysis was performed and their distribution into thematic categories. The participants' speeches are identified by the letter “E” (from the word interview), followed by the order of the interview (Example: E1, E2, E3...).

This study has preliminary results of a dissertation on the decentralization of HIV care, presenting data from one class of research. The ethical precepts of Resolution No. 466/2012 of the National Health Council of the Ministry of Health on studies with human beings were respected, and this research was approved by the Research Ethics Committee of the Oswaldo Cruz University Hospital/Cardiac Emergency of Pernambuco (REC HUOC/PROCAPE), under Certificate of Submission for Ethical Appreciation (CAAE) number 66779417.5.0000.5192 and Opinion number 2.224.605.

RESULTS

Of the 32 nurses participating in the study, most were female (96.9%), aged 40 to 50 years (46.9%), with time of training from 16 to 25 years (46.9%), 10 to 20 years working in PHC (59.4%) and with another employment relationship (68.8%). As for the complementary training of professionals, most of them did postgraduate studies in family health (34.4%).

Regarding the text corpus, the word cloud method grouped the words and organized them graphically according to their frequency, highlighting “health unit” (223), “rapid test” (213) and “professional” (128). In addition, the words “nurse” (77), “year” (75), and “training” (66) are noteworthy for the proximity of frequency, as shown in Figure 1.

Figure 1
Cloud of words about primary care nurses' perception of the decentralization process of care for people living with HIV among the levels of health care. Recife, PE, Brazil, 2020. Notes: [rapid test / health unit / training / professional / nurse / perform / year / doctor / day / dentist / training / month / past / primary care / relationship / now / pregnant / now / last / Syphilis / spontaneous demand / schedule alternative / sexual infection / offering / recently / prenatal / not / routine / agenda / population / priority / hepatitis / resistance / action / wanting / starting / participating / shift / meeting / frequent / abortion].

From the textual analysis through the cloud of words, two thematic categories were identified: “Decentralization of the HIV care process among the levels of health care” and “Primary health care nurses' performance with emphasis on RT for HIV”.

Decentralization of the HIV care process among the levels of health care

The first category presents the process of decentralization of care for people living with HIV from the SCS to PHC, as well as reflecting the challenges inherent in the transition of the health care model, and identifying in the speeches of the participants that the RT is a gateway to the health system. In this category, the words “health unit” and “rapid test” stand out.

I consider the rapid test as a gateway [...] (E14).

[...]many people come to the health unit and don't imagine that they will test positive for HIV and, many times, only find out when they come for a rapid test [...](E04)

It is perceived that the care for people living with HIV is still linked to specialized services and that PHC is limited to the execution of the RT, as can be observed in the following text segments of the participants' speeches:

[...]If the result of the rapid test is positive, the second test is done in the health unit itself just to have the confirmation, after that we refer the patient to the specialist who is in the SCS, from then on it is the specialized service that takes care and primary care is monitoring to not leave him (or her) without follow-up (E04).

Here in our health unit we do the rapid test indeed! After the test, if the result is positive, we refer the patient to a specialized service, after which the patient starts treatment at the SCS, we don't have antiretroviral drugs available at the health unit (E03).

[...] in the positive case, I receive the patient and send him/her to the reference hospital (E10).

Primary health care nurses' performance with emphasis on RT for HIV

The second category complements the previous category, since, in the context of decentralization of HIV care in PHC, the role of nurses as FHS professionals is of paramount importance for the implementation of the reorganization of the health care model, however, there are obstacles, especially in relation to the implementation of the RT, accountability for care and training of the multiprofessional team. The words “rapid test,” “professionals,” “nurse,” “year,” and “training” stand out, as evidenced in the following statements:

In the health unit only the nurse was trained to perform the rapid test, the doctors were not trained and do not perform the rapid test (E10).

Months ago, we received the materials for rapid HIV testing and had the training, but the first problem is that not all professionals want to do the rapid test (E03).

The nurses said they would not perform the rapid tests alone, we are always open to any training, to any change in attitude of the other professionals, because it is one thing if you say you are going to take on everything by yourself (E20).

“[...]I think it has been more than a year since the last training” (E23).

“The training of the rapid test, I think it's been about two years since we had it[...]”(E07).

“The unit has already received training for rapid testing, it has been about a year, all professionals have been trained”(E06).

DISCUSSION

The data from this study allowed us to identify the reorganization of the health care model regarding the care for people living with HIV from the perspective of nurses working in PHC. It was verified that the decentralization process is relatively recent and, in the PHC context, it is still very much linked to the performance of the RT, as well as the nurse's accountability in the process and deficient commitment of the other categories that make up the team, limiting the work process. It was observed, at the same time, in the participants' speech, as another aspect that weakens the care the absence or limitation of training of professionals in the management of the disease.

PHC must be considered as a potential space to improve accessibility, especially through early diagnosis by means of RT for HIV detection. Therefore, it is necessary to expand innovative strategies for the qualification of care for people living with HIV.³ The strategy of combined prevention is visualized as a set of preventive interventions with intersectoral reach focused on individuals, their social groups and the collective.¹⁰

Meanwhile, it is important to highlight in the biomedical intervention of combined prevention the strategies of PrEP and PEP as actions that help both for the prevention and containment of HIV. PrEP consists in the use of antiretroviral drugs (ARVs) by individuals not infected with HIV in order to reduce exposure to the virus. PEP, on the other hand, consists in the use of ARVs as a prophylaxis measure indicated in situations of risk, such as sexual violence, unprotected sexual intercourse, and occupational accidents.^10,14

The importance of performing the RT for the early diagnosis of HIV is highlighted, in that the loss of opportunity in the actions and activities of health promotion and prevention in the PHC, through the implementation of testing, can have as a consequence the late diagnosis that causes negative impacts on the timely detection of HIV and other Sexually Transmitted Infections (STI). In addition, due to the thematic limitation of training, there is a weakness of the teams in pre-test and post-test counseling, thus reducing the testing process for the execution of the RT.^3,9

A study developed in South Africa verifies advances in strategic community interventions with an approach to HIV testing, which results in benefits to individuals who receive timely care, thus optimizing the results. However, efforts are still needed to promote integrality at the systems level; the complete context of the lives of people living with HIV must be considered in order to develop a unique therapeutic plan. Given these findings, we can point to the RT as one of the advances in the deconstruction of the centralization of care for people living with HIV, thus assuming an important role in this process of decentralization of care.¹⁵

Referring health users between levels of complexity is a natural conduct in the process of comprehensive care, but it is observed that in the transition of the HIV care model, the referral of individuals is still linked to the non-belonging and responsibility of this population to the PHC team. From this perspective, when identifying people living with HIV, professionals refer users to specialized services for therapeutic management and treatment.

PHC nurses play key roles in HIV treatment adherence and support for the person living with HIV, especially in the long-term therapeutic relationship, beginning with the initial diagnosis, and remain interconnected throughout the course of infection through care, home visits, and health promotion activities.^16-18

On the other hand, despite the relevant role of nurses in the decentralization process, the research participants emphasize that the conduct of the performance of the RT within the scope of the PC in most health units is linked only to nurses as a professional category. However, it is known that the performance of the RT can be performed by other trained members of the FHS.^9,19,20 Given the above scenario, nurses are overloaded in the performance of this fundamental activity for changing the current model for people living with HIV.

In this sense, stress related to nursing work affects predominantly nurses, with significant repercussions in the care provided to patients, besides persisting in daily life due to the responses to people and to the work environment of these professionals. These triggers can be activated when there is a conflict of demands and if not solved they can become distressing.^21,22

This tendency has been verified in the execution of the RT by the PHC nurses in this study. Given the above, the non-execution of the RT by all the professionals that make up the team in the decentralization process ends up making the nurse, as a team member, responsible for the success of the change of model, which leads to physical and mental overload of these professionals.

In relation to the trainings offered with the HIV theme, it can be noticed that there are gaps regarding the depth inherent to the whole process of changing the profile of HIV in Brazil and the activities and actions performed among the levels of care.

In this aspect, currently, the conduction of training for PHC professionals focuses on HIV diagnosis. Despite the intrinsic context of the disease, the centrality in the diagnostic detection is linked to the biomedical health model, in which prevention and health promotion, essential in the activities and actions developed in PHC, end up weakening in this space preventive strategy and individual, family and collective promotions, in addition to the exchange of experience and in-depth approach to the subject.²³

A study conducted with 160 PHC nurses in the city of Recife showed that 52.8% of the sample had not received any training on HIV/Aids and/or STIs in the last year. Of the nurses who were trained, 33.7% said that the training was about RT.²⁴

Among the advances, we can identify the offer of RT to pregnant women; at the same time, the study points out the delimitation of the testing to this public,¹⁹ what can be seen as a weakness in limiting or directing the diagnostic access, hindering the opportunity for early diagnosis and its unfolding in the assistance to the general population that is enrolled in the FHU.

Corroborating the findings of the study, the limited number of tests is pointed out as a factor that hinders the non-attendance of spontaneous demand and the prioritization of pregnant women. It is emphasized that the diagnosis in the reduction of vertical transmission is essential for timely interventions and reduction of complications, but expanding access to the general population triggers a cascade of benefits in the implementation of the care process between levels of care.^25,26

CONCLUSION AND IMPLICATIONS FOR PRACTICE

When considering that the care for people living with HIV is contextualized in a transition movement of the health care model, PHC becomes a challenging space and a link in the expansion of access and integrality among the levels of care in the health network.

In this study, the perception of the FHS nurse as a professional active in the reorganization of the care provided still verifies gaps for the realization of the process. Among the weaknesses, there is a greater emphasis on the RT, which limits the strategic actions and activities that can be performed in the PHC, especially regarding the promotion and prevention of individual, family, and collective health.

Still, it is observed among the limitations the deficit in the engagement of all team members in the accountability of care to people living with HIV, which can result in negative repercussions, for example, in early diagnosis and treatment, resulting in late diagnosis and not timely initiation of ART. In addition to the reinforcement of management planning regarding the training and sensitization of professionals in conducting care and comprehensive approach to HIV.

REFERÊNCIAS

• ¹
  Ferreira DP, Souza FA, Motta MCS. Prevalência da Coinfecção HIV/TB em pacientes de um hospital de referência na cidade do Rio de Janeiro. Rev Pesqui Cuid Fundam. 2019;11(2): 358-362. https://doi.org/10.9789/2175-531.2019.v11i2.358-362.
  » https://doi.org/10.9789/2175-531.2019.v11i2.358-362
• ²
  Carvalho RC, Hamer ER. Perfil de alterações no hemograma de pacientes HIV. RBAC. 2017;49(1):57-64. http://dx.doi.org/10.21877/2448-3877.201600464.
  » https://doi.org/10.21877/2448-3877.201600464
• ³
  Colaço, A.D et al. O cuidado à pessoa que vive com HIV/AIDS na atenção primária à saúde. Texto Contexto - Enferm. 2019; 28: e20170339. https://doi.org/10.1590/1980-265x-tce-2017-0339.
  » https://doi.org/10.1590/1980-265x-tce-2017-0339
• ⁴
  World Health Organization. HIV programme: achieving our goals: operational plan 2014-2015 [Internet]. Genebra, Suíça: WHO; 2014 [citado 2020 out 24]. Available from: https://apps.who.int/iris/bitstream/handle/10665/112666/9789241507110_eng.pdf
  » https://apps.who.int/iris/bitstream/handle/10665/112666/9789241507110_eng.pdf
• ⁵
  Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Infecções Sexualmente Transmissíveis, do HIV/Aids e das Hepatites Virais. Cinco passos para a prevenção combinada ao HIV na Atenção Básica [Internet]. Brasília; 2017. [citado 2020 out 24]. Availablefrom: http://www.aids.gov.br/pt-br/pub/2014/5-passos-para-implementacao-do-manejo-da-infeccao-pelo-hiv-na-atencao-basica
  » http://www.aids.gov.br/pt-br/pub/2014/5-passos-para-implementacao-do-manejo-da-infeccao-pelo-hiv-na-atencao-basica
• ⁶
  Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, Aids e Hepatites Virais. Caderno de Boas Práticas em HIV/AIDS na Atenção Básica [Internet]. Brasília; 2014. [citado 2020 out 24]. Available from: http://www.aids.gov.br/pt-br/pub/2014/caderno-de-boas-praticas-em-hivaids-na-atencao-basica
  » http://www.aids.gov.br/pt-br/pub/2014/caderno-de-boas-praticas-em-hivaids-na-atencao-basica
• ⁷
  Almeida Jr JA, Moraes AADS, Barreto MASA, Santos FDS, Suto CSS, De Paiva LBF. Teste rápido para HIV: representações sociais de profissionais da atenção básica. Rev Baiana Enferm. 2018;32:e25885. http://dx.doi.org/10.18471/rbe.v32.25885
  » http://dx.doi.org/10.18471/rbe.v32.25885
• ⁸
  White BL, Walsh J, Rayasam S, Pathman DE, Adimora AA, Golin CE. What makes me screen for HIV? Perceived barriers and facilitators to conducting routine HIV testing among primary care physicians in the Southeastern United States. J Int Assoc Provid AIDS Care. 2015;14(2):127-35. http://dx.doi.org/10.1177/2325957414524025 PMid:24643412.
  » http://dx.doi.org/10.1177/2325957414524025
• ⁹
  Araújo WJ, Quirino EMB, Pinho CM, Andrade MS. Percepção de enfermeiros executores de teste rápido em Unidades Básicas de Saúde. Rev Bras Enferm. 2018;71(Suppl. 1):631-6. http://dx.doi.org/10.1590/0034-7167-2017-0298. PMid:29562021.
  » https://doi.org/10.1590/0034-7167-2017-0298
• ¹⁰
  Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Infecções Sexualmente Transmissíveis, do HIV/Aids e das Hepatites Virais. Prevenção Combinada do HIV/Bases conceituais para profissionais, trabalhadores(as) e gestores(as) de saúde/Ministério da Saúde [Internet]. Brasília; 2017. [citado 2020 out 24]. Available from: http://www.aids.gov.br/pt-br/pub/2017/prevencao-combinada-do-hiv-bases-conceituais-para-profissionais-trabalhadoresas-e-gestores
  » http://www.aids.gov.br/pt-br/pub/2017/prevencao-combinada-do-hiv-bases-conceituais-para-profissionais-trabalhadoresas-e-gestores
• ¹¹
  Ghiglione R, Matalon B. (1993). O inquérito: teoria e prática. Oeiras: Celta. 1993.
• ¹²
  Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011. 279p.
• ¹³
  Camargo BV, Justo AM. Tutorial para uso do software IRAMUTEQ. Porto Alegre: UFSC; 2018. [citado 2020 out 24]. Disponível em: http://iramuteq.org/documentation/fichiers/tutoriel-portugais-22-11-2018
  » http://iramuteq.org/documentation/fichiers/tutoriel-portugais-22-11-2018
• ¹⁴
  Gomes ESS, Galindo WCM. Equipes de saúde da família frente à testagem e ao aconselhamento das IST, HIV-AIDS. Rev Baiana Saúde Pública. 2018;41(3):628-49. http://dx.doi.org/10.22278/2318-2660.2017.v41.n3.a2376
  » http://dx.doi.org/10.22278/2318-2660.2017.v41.n3.a2376
• ¹⁵
  Naik R, Zembe W, Adigun F, Jackson E, Tabana H, Jackson D et al. What influences linkage to care after home-based hiv counseling and testing? AIDS Behav. 2018;22(3):722-32. http://dx.doi.org/10.1007/s10461-017-1830-6 PMid:28643242.
  » http://dx.doi.org/10.1007/s10461-017-1830-6
• ¹⁶
  Ngunyulu RN, Peu MD, Mulaudzi FM, Mataboge MLS, Phiri SS. Collaborative HIV care in primary health care: nurses’ views. Int Nurs Rev. 2017;64(4):561-7. http://dx.doi.org/10.1111/inr.12359 PMid:28181218.
  » http://dx.doi.org/10.1111/inr.12359
• ¹⁷
  Dumitru G, Irwin K, Tailor A. Updated federal recommendations for HIV prevention with adults and adolescents with HIV in the United States: The pivotal role of nurses. J Assoc Nurses AIDS Care. 2017;28(1):8-18. http://dx.doi.org/10.1016/j.jana.2016.09.011 PMid:27839911.
  » http://dx.doi.org/10.1016/j.jana.2016.09.011
• ¹⁸
  Dawson-Rose C, Cuca YP, Webel AR, Solís Báez SS, Holzemer WL, Rivero-Méndez M et al. Building trust and relationships between patients and providers: An essential complement to health literacy in HIV Care. J Assoc Nurses AIDS Care. 2016;27(5):574-84. http://dx.doi.org/10.1016/j.jana.2016.03.001 PMid:27080926.
  » http://dx.doi.org/10.1016/j.jana.2016.03.001
• ¹⁹
  Zambenedetti G, Silva RAN. Descentralização da atenção em HIV-Aids para a atenção básica: tensões e potencialidades. Physis. 2016;26(03):785-806. http://dx.doi.org/10.1590/s0103-73312016000300005
  » http://dx.doi.org/10.1590/s0103-73312016000300005
• ²⁰
  Rocha GSA, Andrade MS, Silva DMRD, Terra MG, Medeiros SEG, Aquino JM. Sentimentos de prazer no trabalho das enfermeiras na atenção básica. Rev Bras Enferm. 2019;72(4):1036-43. http://dx.doi.org/10.1590/0034-7167-2018-0518 PMid:31432963.
  » http://dx.doi.org/10.1590/0034-7167-2018-0518
• ²¹
  Alenezi AM, Aboshaiqah A, Baker O. Work-related stress among nursing staff working in government hospitals and primary health care centres. Int J Nurs Pract. 2018;24(5):e12676. http://dx.doi.org/10.1111/ijn.12676 PMid:30003631.
  » http://dx.doi.org/10.1111/ijn.12676
• ²²
  Al-Makhaita HM, Sabra AA, Hafez AS. Predictors of work-related stress among nurses working in primary and secondary health care levels in Dammam, Eastern Saudi Arabia. J Family Community Med. 2014;21(2):79-84. http://dx.doi.org/10.4103/2230-8229.134762 PMid:24987275.
  » http://dx.doi.org/10.4103/2230-8229.134762
• ²³
  Rocha KB, Santos RRG, Conz J, Silveira ACT. Transversalizando a rede: o matriciamento na descentralização do aconselhamento e teste rápido para HIV, sífilis e hepatites. Saúde Debate. 2016;40(109):22-33. http://dx.doi.org/10.1590/0103-1104201610902
  » http://dx.doi.org/10.1590/0103-1104201610902
• ²⁴
  Pinho CM, Dourado CARO, Lima MCL, Maia TS, Silva JFAS, Silva EL et al. Avaliação das medidas de controle do HIV na atenção básica. Revista Eletrônica Acervo Saúde. 2020;12(8):e3462. http://dx.doi.org/10.25248/reas.e3462.2020
  » http://dx.doi.org/10.25248/reas.e3462.2020
• ²⁵
  Silva ITS, Valenca CN, Silva RAR. Mapping the implementation of the rapid HIV test in the Family Health Strategy: the nurses’ perspective. Esc Anna Nery Rev Enferm. 2017;21(4):e20170019. http://dx.doi.org/10.1590/2177-9465-ean-2017-0019
  » http://dx.doi.org/10.1590/2177-9465-ean-2017-0019
• ²⁶
  Domingues RM, Szwarcwald CL, Souza Jr PR, Leal MC. Prenatal testing and prevalence of HIV infection during pregnancy: data from the “Birth in Brazil” study, a national hospital-based study. BMC Infect Dis. 2015;15(1):100. http://dx.doi.org/10.1186/s12879-015-0837-8 PMid:25880460.
  » http://dx.doi.org/10.1186/s12879-015-0837-8

Edited by

ASSOCIATE EDITOR

Maria Catarina Salvador da Motta

Publication Dates

• Publication in this collection
  17 May 2021
• Date of issue
  2021

History

• Received
  24 Oct 2020
• Accepted
  19 Mar 2021