Avaliação de serviços de assistência ambulatorial em aids , Brasil : estudo comparativo 2001 / 2007 Assessment of outpatient services for AIDS patients , Brazil : comparative study 2001 / 2007

RESULTADOS: Responderam o questionário 504 (79,2%) serviços. Cerca de 100,0% dos respondentes relataram ter pelo menos um médico, suprimento sem falhas de antirretrovirais e de exames CD4 e carga viral. Vários aspectos mostraram melhor desempenho em 2007 comparados a 2001: registro de número de faltas à consulta médica (de 18,3 para 27,0%, VP: 47,5%), agendamento de consulta em menos de 15 dias no início da terapia antirretroviral (de 55,3 para 66,2%, VP: 19,7%) e participação organizada do usuário (de 5,9 para 16,7%, VP: 183,1%). Houve manutenção de difi culdades: pequena variação na disponibilidade de exames especializados em até 15 dias, como endoscopia (31,9 para 34,5%, VP: 8,1%), e a piora de indicadores como tempo ideal de acesso a consultas especializadas (55,9 para 34,5% em cardiologia, VP negativa de 38,3%). O tempo médio despendido nas consultas médicas de seguimento manteve-se baixo: 15 minutos ou menos (52,5 para 49,5%, VP negativa de 5,8%).

Outpatient care for those living with HIV in Brazil takes place in different health care sites of the SUS (Brazilian Unifi ed Health System): primary care units, specialized outpatient clinics, hospital outpatient services and sites dedicated to sexually transmitted diseases (STD) and AIDS.The Ministry of Health, through the Department of STD/AIDS and Viral Hepatitis produces general guidelines for the services and is responsible for providing antiretroviral drugs and specifi c laboratory tests (viral load, CD4, genotyping).Apart from these resources, the implementation and organization of services depends on regional and local characteristics of the SUS.Local-regional distribution and organizational characteristics are diverse, although all are subject to the same set of general directives.Between 1996, when universal access to highly active antiretroviral therapy (HAART) was established, and 2007, the number of sites delivering special care to HIV patients increased from 33 to 636, according to outpatient sites registered by the Ministry of Health's Department of STD/AIDS and Viral Hepatitis.
Between 2001 and 2002, sites in seven Brazilian states were evaluated, based on evaluative research that developed and validated the Qualiaids Questionnaire.The instrument was completed by local managers.Questions included availability of resources, organization of the care process and management. 7e purpose of the questionnaire in supporting local management and defi ning policies encouraging quality, along with its potential as an instrument for monitoring and evaluating services, motivated the interest of the Ministry of Health in using it with all the sites in the country.The original questionnaire was adapted to be used electronically in 2005, accompanied by an online good practice recommendations guide referring to the dimensions of care assessed in the questionnaire.a From 2007, the Qualiaids Questionnaire was adopted as the offi cial quality evaluation instrument of SUS outpatient HIV services.The Ministry of Health conducted the evaluation requesting all sites in the country to answer the questionnaire.The survey report and database, developed in partnership with the Ministry of Health, were forwarded to the state level managers of the STD/AIDS program and disseminated in workshops conducted by national level managers.b This article aimed to assess outpatient care services for adults living with HIV in 2007 and compare it with the 2001 results.

METHODS
The Qualiaids Questionnaire was validated in 27 sites with different care organizational characteristics and the results of its fi rst application in 2001 were analyzed and disseminated among site managers, decision makers and specialized publications in the fi eld. 7,9,10For the 2007 evaluation, the electronic questionnaire was made available to the sites.
The universe of sites which participated in the 2007 evaluation was defi ned by a list of 636 outpatient care services provided by the 27 Brazilian federal STD/AIDS coordinators.The sites were invited to complete the questionnaire online, consisting of 107 multiple choice questions: nine questions concerning institutional characteristics, location and site size; 24 on availability of resources; 42 on organization of care and 32 on local care management.
Descriptive analysis was carried out for 464 sites evaluated in 2007 and comparative analysis was carried out for 204 of these sites which had also been assessed in 2001.Percentages of sites were calculated according to their responses regarding three evaluative dimensions: Resources, Care and Management.Sites missing out ten or more questions were excluded from the analysis.Geographical location and site size were not considered in this analysis.No statistical estimates were included in the comparison of percentages obtained in 2001 and in 2007 as they referred to all respondents sites.Percentage variation between the two applications was calculated (P2007 (% 2007)-P2001 (% 2001)/ P2001 *100).
Being able to schedule tests and appointments with specialists in under 15 days was deemed "promptness" This article used administrative data from the database produced by the application of Qualiaids carried out by the Ministry of Health Department of STD/AIDS and Viral Hepatitis, given to the authors of this article as part of a technical cooperation agreement.The health care sites' managers voluntarily agreed to participate.

RESULTS
Of the 636 sites existent in 2007, 504 (79.2%) answered the questionnaire, of which 464 (73.0%) answered at least 97 of the 107 questions in the instrument and constituted the universe analyzed (Table 1).
c Instituto Brasileiro de Geografi a e Estatística.Censos demográfi cos.Rio de Janeiro; [cited 2011 Oct 6].Available from: http://www.ibge.gov.br/home/estatistica/populacao/default_censo_2000.shtmOf the 464 sites analyzed, 67.2% were located in municipalities with fewer than 400,000 inhabitants.c Of the sites, 26.7% treated more than 500 patients on antiretroviral therapy (HAART); 36.0% between 101 and 500, 11.6% between 51 and 100 and 24.1% with up to 50 patients.It was in the south and southeast regions where 80.2% of the sites were located, of which 68.6% units were non-exclusive to STD and AIDS care.(Table 1).There were 91.4% of sites easily accessible by public transport; 82.8% were open to the public fi ve days or more per week, and 78.1% were open eight hours a day or more.
All sites reported the presence of at least one infectious diseases specialist or general physician responsible for HIV/AIDS care; 44.2% had one physician; 46.1% reported that the doctor(s) had fi ve or more years' experience treating HIV/AIDS.
There was at least one infectious diseases specialist in 68.5% sites and the availability of other professionals in the health care team was high, with the exception of dentists (Table 2).
Promptness in scheduling appointments was high for gynecologists (75.0%).Waiting time for other specialist appointments, taking > 45 days or unavailability, was 24.5% for cardiology and 31.9% for psychiatry.
Approximately 75.7% of sites provided, on average, three or more CD4 count tests per patient/year and 71.8% Viral Load.The promptness of the test results was lower: 28.5% and 19.2% respectively.
In 47.2% of the sites the results of HIV diagnosis using Anti-HIV (Elisa) were available promptly, and this was the case in 20.3% care units for the Western-Blot test.
Laboratory tests used to monitor the toxicity of the medications requiring more promptness (blood count, blood urea nitrogen, transaminases) were available in 74.8% of the sites.Simple imaging tests, such as x-ray (chest, sinuses, abdomen), had high availability (76.7%), while the more complex ones (such as endoscopy and CT) were less available.
There was high availability for all of the antiretroviral drugs.There were one week gaps in supply for 6.9% of care units for zidovudine+lamivudine, and 0.9% for amprenavir.Trimethoprim-sulfamethoxazole, the most widely used drug for prophylaxis and treating opportunistic infections, was reported unavailable in 3.2% of the sites; 7.5% reported gaps in supply of more than 15 days.First time patients were seen by a university-level professional on the same day in 72.0% of the sites.
Appointments were scheduled at the beginning of the period for all patients in 45.7%; 14.7% of the sites reported booking appointments in groups of patients and 27.4% made appointments for a specifi c time for each patient.Up to ten patients were scheduled for four hours/doctor in 65.7% of the sites; 14.4% scheduled 16 or more appointments per doctor for a 4 hours period.The average time for a follow-up consultation was 15 minutes in 49.4% of the sites.
In the event of patients without appointments, 59.3% of the sites would see the patient on the same day (regardless of whether there was space in the diary); 35.1% of the care units kept "free appointments" for this kind of eventuality.
Clinical complications are the main reason behind demand for unscheduled appointments in 77.8% of sites, followed by requests for testimonials for the purposes of claiming social benefi ts (43.1%).PV between 38% and 40% for psychiatry, neurology, cardiology and general surgery (Table 3).
Indicators of care organization showed an increase in the number of sites which booked appointments setting specifi c time (PV of 29.2%); in the percentage of sites which reported conducting adherence groups (PV 65.7%) and in the percentage of those which scheduled appointments within 15 days of starting antiretroviral therapy (PV of 59.0%).Routine gynecology appointments (regardless of complaints) remained practically unchanged, with a percentage of 37.3% in 2001 and 36.3% in 2007 (Table 4).
Clinical complications, the need to apply for social benefi ts, running out of medication and missing the previous appointment were the main reasons patients sought unscheduled appointments in 2001.In 2007, all of these percentages were lower, with negative PV between 19.5% and 33.0%.Clinical complications and applying for social benefi ts remained the fi rst and second most common reasons, respectively (Table 4).
The referral fl ow remained centralized around the doctors.There was a 15.7% variation in the number of sites whose professionals carried out the referrals for the entire team (Table 4).
The proportion of meetings to discuss cases remained low, with a small, positive variation.Regular staff meetings maintained similar proportions between 2001 and 2007 (Table 5).
A marked increase in patient participation was observed in 110 sites in 2007, especially through using a management council or similar (PV of 183.1%).
There was a signifi cant decrease in the proportion of sites that reported challenges in accessing viral load and CD4 count tests (negative PV of 80.4%).Diffi culties in hospital referrals and with supplies of opportunistic infections medication have also decreased.
Referral to specialists and hiring higher level staff remained the most commonly reported diffi culties, with little variation between the two assessments.

DISCUSSION
The 2007 evaluation demonstrated that the care unit network had the resources essential to outpatient care: doctors, antiretroviral drugs supplies, availability of the most important tests for monitoring cases.The majority also reported having a multidisciplinary teams and access to simple imaging tests.
There are, however, signifi cant shortcomings, such as the low availability of dentists, present in just over half the sites.
Viral load and CD4 tests are widely available and provided by the Federal Government, in contrast to other kinds of tests, which depend on the local public health network (state or municipality responsibilities).
Access to specialists also depends on regional and local networks, and is diffi cult or non-existent in many sites.
Although the majority of sites are open all day long, functional access is undermined in those units that schedule all patients (or group of patients) at the beginning of the shift.This frequently means long waiting times, typically associated with lower levels of patient satisfaction.
It is also worrying that follow-up appointments are expected to take less than 15 minutes in many sites.A similar study carried out with 21 American sites showed an average appointment time of 20 minutes, varying between 15 and 40, for this type of appointment. 16 is probable that, for some sites, the main problem is a lack of doctors, given the shortages and poor distribution of this professional, especially in public health services.Moreover, "squeezing in" patients who do not have appointments may contribute to doctors being over worked: 35.1% of sites reported having some kind of system (such as keeping slots free), although 59.3% stated that all patients without an appointment were seen.
Even with an appropriate number of hours/doctor, some sites may have professionals who work fewer hours than those offi cially contracted.This is a problem frequently experienced by health care managers, although no empirical studies on this topic exist.It is possible that, faced with the impossibility of changing this situation, some managers reach an informal agreement with doctors on the maximum number of hours within their actual time spent at the site.Thus, they guarantee to meet care demands, although the length of appointments are reduced and may compromise the quality of care.Doctors with shorter shifts may be the reason for scheduling all patients or group of patients at the beginning of the shift.
There is no available evidence to support guidelines for length of consultation on HIV/AIDS.In general clinical practice, the time varies between countries and site types.It is, however, considered at least a proxy measure of quality.Even seen as a proxy indicator of quality, studies emphasize the importance of the professionals' experience and specialization in obtaining good clinical outcomes, 4,5,13 something which has been highlighted since the beginning of the epidemic. 3Our study observed that almost half of the doctors has fi ve or more years' experience, which could be considered as adequate experience of dealing with HIV patients.On the other hand, around a third of sites did not have an infectious disease specialist, whose original training in HIV/AIDS is more specialized.
Qualifi ed and fl exible support systems (mentoring) contribute to the improvement of the quality of medical care in de-centralized systems. 6However, establishing such systems appropriately is not observed in most outpatient units of the SUS.In this study, the majority of HIV/AIDS sites reported that they had no systematic way of supervising or supporting professionals.
The opportunity to exchange opinions and discuss cases in day-to-day professional interaction, a traditional way of learning, is not viable in almost 40% of sites, in which there was one doctor responsible for monitoring HIV patients.Sites with only one doctor are associated with lower quality of care. 11 important as the qualifi cation of the professionals who care for the patients, effective technical -and not just bureaucratic -management enhances the effectiveness of health care: establishing and monitoring care routines, assessing and monitoring work, integrating the team and enhancing communication with patients and third parties. 12 is the responsibility of management to ensure minimum structures of care for all patients and, simultaneously, for those who are more vulnerable to falling ill.Among those are the groups most at risk of non-adherence to treatment.It is positive that most of the sites routinely schedule appointments at shorter intervals at the beginning or HAART, a period crucial to adherence.Comparison of the 204 sites, which completed both evaluations, showed improvements but also signifi cant persistent defi ciencies.
The improvement in the availability of resources under federal management stands out among the characteristics evaluated: there was a signifi cant improvement in the availability of CD4 count and viral load tests.Antiretroviral supply became more timely: running out of medication is no longer a factor for patients seeking unscheduled appointments.
The comparison showed some negative characteristics that persisted in managing health care, at a local level.Routine referral to a gynecologist is still not adequate, in spite of the importance of the women's health issue in the program guidelines.f Multi-professional team integration is fl awed, indicated by the large proportions of doctor-centered referrals and the lack of regular staff meetings.Moreover, there are few sites which seek to improve accessibility by scheduling appointments at a specifi c time.
The consolidation of broader access to essential resources, such as new medication and tests, reiterates the Brazilian AIDS program's justifi ed reputation for good performance, compared to other middle income countries at that time. 15V patient care in Brazil brought up ethical commitments and technological propositions that serve as examples to the Brazilian Health System.It is, however, in health care professionals' and local managers' day-to-day work that these proposals are realized.
Standardizing, encouraging and monitoring the quality of this work is the challenge faced by these surveyed sites, and the health care system as a whole.
This study has some limitations: it does not include indicators of results and is based on local managers' responses.The sample was determined by voluntary participation and 27% of the sites did not answer the questionnaire or did not fulfi ll all of the requisites, and could not be included in the analysis.The only known characteristics of the non-respondents were the states and municipalities in which they were located.These aspects are not suffi cient to understand possible differences in relation to the universe of the study, given the heterogeneity of sites within the same geographical area.On the other hand, the sites analyzed include the diversity of locations and types of delivery of care to HIV patients in Brazil.
As it examines process indicators, this assessment values the necessary conditions for the long-term care of a chronic condition, such as AIDS currently is.Assessing and monitoring essential characteristics of structure and process is the fi rst step in a broader initiative to improve health care quality.The possibility, albeit limited, of assessing the evolution of these characteristics over a six-year-period is unprecedented in SUS outpatient care.
The monitoring and evaluation initiative led by the Ministry of Health Department of STD/AIDS and Viral Hepatitis involved the participation of states and municipalities (capitals and larger cities) AIDS program coordinators in two rounds of analysis.This process was repeated in some states and municipalities with local health teams.The analysis resulting from this evaluation promoted conditions for changes in the management and organization process, thus completing the "assessment cycle".

Table 1 .
Outpatient care sites for adults living with HIV/AIDS according to geographical location and number of questions answered.Brazil, 2007.Except the states of Rio de Janeiro and São PauloThe use of some kind of care guideline form or appointment protocol was reported by 51.5% of the sites for first appointments and 56.3% for tuberculosis/HIV co-infection, pregnant women or occupational accidents.
aThe responses of the 204 sites which completed the Qualiaids Questionnaire in 2001 and 2007 were compared.Three or more viral load tests per patient/year were more widely available, with a percentage variation (PV) of 90.5%.On the other hand, promptness of referrals to all of the specialists investigated worsened, with

Table 2 .
Outpatient care sites for adults living with HIV/AIDS according to indicators of availability of resources, care organization and technical management.Brazil, 2007.

Table 3 .
Outpatient care sites for adults living with HIV/AIDS according to indicators of resource availability.Brazil, 2001 and 2007.(n = 204)

Table 4 .
Outpatient care sites for adults living with HIV/AIDS according to organization of care indicators.

Table 5 .
Outpatient care sites for adults living with HIV/AIDS according to indicators of management.Brazil, 2001 and 2007.
1,14Short consultations suggest insuffi cient technical quality and little capacity for listening and dialogue.This is a similar profi le to what Campos describes as "debased practice",1and typically observed in unscheduled appointments.