Evaluation of the Care of Women Living with HIV/AIDS in São Paulo, Brazil

Transcription

1 AIDS PATIENT CARE and STDs Volume 17, Number 2, 2003 Mary Ann Liebert, Inc. Evaluation of the Care of Women Living with HIV/AIDS in São Paulo, Brazil ALUISIO COTRIM SEGURADO, M.D., Ph.D., 1 SHIRLEI DUARTE MIRANDA, M.D., Ph.D., 2 MARIA-DO-ROSÁRIO DIAS OLIVEIRA LATORRE, Ph.D., 3 and THE BRAZILIAN ENHANCING CARE INITIATIVE TEAM ABSTRACT To evaluate care provided to women living with HIV in São Paulo, Brazil, based on their own experiences, patients from HIV/AIDS reference clinics answered a questionnaire on circumstances of HIV testing, health personnel s attitudes at diagnosis, adherence to follow-up, services provided by care centers and access to laboratory monitoring. From September 1999 to February 2000, 1,068 women were interviewed. Most had over 8 years of education and reported having regular sexual partners, being mothers and family caregivers. They were diagnosed as HIV-infected for years. The majority had been referred to testing without counseling. Post-test counseling was provided depending on the testing center. Neither pre-test nor post-test counseling were associated to time since diagnosis. Some patients reported having felt indifference, discrimination or criticism at diagnosis, depending on where testing occurred. Compliance to medical follow-up was associated to adherence to antiretrovirals and to shorter time since diagnosis, but not with having a primary caregiver or with commuting time to the care center. Psychological support, nutrition care and oral health were women s less addressed needs. Access to gynecological care was associated with counseling on mother-to-child transmission and on safe sex. Access to CD4 1 cell counts and HIV viral loads was concordant with guidelines, but the understanding of their meaning was incomplete. We conclude that women living with HIV/AIDS in São Paulo, Brazil have limited HIV risk perception and unmet care needs. Better training of professionals in charge of diagnosis and integrating women s health and family-planning actions to AIDS programs may enhance care. TO INTRODUCTION DATE, more than 40 million people worldwide are recognized as living with HIV/AIDS, 1 and their long-term prognosis is known to be highly dependent on effective access to quality clinical care that provides not only early diagnosis, potent antiretroviral drugs and prophylactic treatments for AIDS-defining illnesses, but also effective counseling on prevention of viral reexposure. 2,3 It is critical therefore to determine the most effective means of treating people living with HIV and to identify particular issues that might be amenable to enhancing care initiatives. 1 AIDS Clinic, Department of Infectious Diseases, School of Medicine, University of São Paulo, São Paulo, Brazil. 2 AIDS Reference and Training Center, São Paulo State Health Secretariat, São Paulo, Brazil. 3 Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, Brazil. 85

2 Recent data from the Brazilian AIDS epidemic show significant changes in its epidemiological profile. 4,5 Women are the fastest growing HIV-infected population group in the country. In the last 10 years, the number of reported AIDS cases has increased 24.3-fold in women as compared to 9.5-fold in men and heterosexual transmission has accounted for 56.6% of cases in women since the start of the epidemic. The majority of AIDS cases comes from the Southeast, and São Paulo State alone accounts for 46.8% of overall reports and for 45.8% of cases among women. AIDS is now one of the leading causes of death for Brazilian women from 25 to 49 years old and the first in São Paulo State. Moreover most women living with HIV/AIDS are at childbearing age, raising the concern of mother-to-child transmission and the need for specific prophylactic interventions. On the other hand, even though routine implementation of government-supported highly active antiretroviral therapy (HAART) has become available in São Paulo, Brazil since 1996, the decline in AIDS mortality has impacted women less dramatically than men (38% in women, as compared to 52% in men from 1995 to 1998). 6,6a Similar trends in AIDS incidence and mortality among women have also been reported in developed countries. 7 9 In accordance with earlier trends of the Brazilian HIV epidemic, health care settings in charge of providing HIV/AIDS care have been designed to respond to the needs of a predominantly male population. Particular demands of women living with HIV/AIDS had to be addressed subsequently and may not have reached the desired standards. It seems therefore important to evaluate to what extent these women are presently receiving quality care and what particular needs of this group are yet to be met. The present article describes experiences and impressions of women living with HIV/AIDS from three cities in São Paulo State in regard to their care. Special emphasis was given to clinical care issues, such as circumstances of HIV testing, access to health care and follow up, involvement of different health care professionals in care, as well as patients understanding and use of tests for monitoring HIV disease 86 SEGURADO ET AL. progression and their adherence to treatment. Of particular interest were their immediate reactions to disclosure of HIV diagnosis, the coping skills they used after learning of their infection and their ability to reach and use the established health care system and social networks involved in support. Our results point out that women living with HIV/AIDS have special care needs in multiple areas that include gynecological assistance, reproductive rights and psychosocial support. A more comprehensive approach to their health care needs must take into account the different stressors related to their dual roles as patients and family caregivers. MATERIALS AND METHODS Participants were enrolled from three HIV/AIDS outpatient clinics, affiliated to the University of São Paulo or to the HIV/AIDS State Program (both located in São Paulo) or to Santos STD/AIDS City Program. To be eligible for inclusion in the present study women had to have tested positive for HIV antibodies, be over 18 years old and be registered as an outpatient at any of the study centers. In the sampling approach, the first two women to come to the outpatient clinic for a medical visit with the infectious diseases physician at three different periods (8 12 a.m., 12 a.m. to 4 p.m., and 4 8 p.m.) were invited for the study. Women learned of the study by face-to-face contact with the reception staff in the waiting room. Those willing to participate were then asked to sign an informed consent form. Confidentiality was ensured since no names were recorded on the questionnaires and all interviews were performed in private rooms. The study protocol was reviewed and approved by the Institutional Ethics Committees of the participating centers. The data collection instrument consisted of a semistructured questionnaire that asked participant women to express their experiences concerning different time points in their lives, since they were diagnosed as HIV-infected. Some open-ended questions were included to obtain personal narratives. Different key themes were searched for during interviews,

3 WOMEN AND HIV/AIDS CARE, BRAZIL 87 including: reason for HIV testing, place of and health personnel s attitudes at time of disclosure of HIV diagnosis, women s adherence to clinical follow-up and to prescribed treatments, ability of health care professionals to make themselves understood by patients and to clarify their doubts, range of services provided by care centers, role of gynecologists in care and counseling and, finally, access to and actual understanding of the meaning of laboratory tests used for monitoring HIV disease progression (CD4 1 cell counts and viral load assessments). All interviews were carried out by collegelevel female trained personnel that included psychologists, social workers and health educators. The investigators were careful to make sure that no interviewer had ever been a caregiver to the patients she interviewed. A typical interview required about one hour. Women who alleged impossibility of being interviewed on the enrollment date for any reason, were given the chance of returning on a more convenient occasion. Data collection on the field lasted from September 1999 to February Throughout this period interviewers came together for a weekly meeting with members of the investigators team, when not only doubts on the research procedures were clarified, but the possibility was raised for them to express anxieties, share experiences and discuss ways of acting supportively. Statistical analysis was carried out using Pearson s chi-square test for proportions when comparing qualitative variables. One-way ANOVA was used to compare means (time since HIV diagnosis, length of follow-up at the participating center and commuting time to the HIV/AIDS care center). Levene s test was used to test for constancy of error variance and Kolmogorov-Smirnov s test to check whether a variable was normally distributed. Odds ratios and their corresponding 95% confidence intervals were calculated, using the exact maximum likelihood estimates. Throughout the analysis, a level of significance of 0.05 was used. RESULTS From 1,130 women invited for the present study, 1,068 (94.5%) were interviewed. Refusals for participation were more frequently due to patients personal problems or unwillingness to talk about their personal lives (21/62) or to lack of available time for being interviewed (22/62). Women who refused participating in the study did not differ from studied subjects in regard to their age, education, income, time since HIV diagnosis, or length of follow-up in HIV/AIDS care centers. The final sample corresponds to about 30.0% of the total number of women registered at the three participating centers. The mean age of 1,068 interviewed women, was 36.2 years (range, years old). Only 2.5% of the participants were illiterate, whereas about 55.0% had completed 8 years of education. Even though 42.0% of our sample consisted of women who informed to be employed at the time of interview, only 30% documented having a regular job. In regard to their families, 55.0% of studied women had a regular sexual partner and 82.0% had children, either her own or her partner s. Of particular relevance is the fact that 8% admitted having HIV-infected children and 84% to be family caregivers. Patients informed having been recognized as HIV-infected for years (mean 6 standard deviation), ranging from those recently diagnosed to patients living with HIV/AIDS for 15 years. The decision of whether to be tested for HIV requires not only self-perception of risk, but also recognition of the actual meaning and potential consequences of a seropositive result. In women from our study, HIV testing was performed in different environments, as described in Table 1. TABLE 1. SETTING WHERE HIV TESTING TOOK PLACE, ACCORDING TO 1,068 WOMEN LIVING WITH HIV/AIDS, SÃO PAULO STATE, BRAZIL, Health care setting n % General hospital Private service Primary care center HIV/AIDS care center Anonymous testing-counseling center Other Blood bank or milk bank Maternity Not informed Total 1,

4 The reported reason for HIV testing was quite variable: 25.8% were asked to be tested by a health professional because they were ill, 18.8% because their partner was ill or diagnosed as HIV-infected and 1.4% because one of their children was diagnosed as HIV-infected. In addition 9.4% were diagnosed during antenatal care routine screening, 4.1% at blood donation, 0.8% at delivery and 1.2% following a partner s advice. A more active reason was reported by 5.4% of women who decided themselves to be tested for precaution, by 2.8% tested after having discovered a partner was HIV-infected or by 14.6% who suspected they could be infected. Asked whether HIV testing had been preceded by counseling, only 42.1% gave affirmative answers. Statistical significant association was found between having received pretest counseling and the type of health care setting where HIV testing took place (chi-square , p, 0.001). For instance, 91.3% and 76.5% of studied women received pretest counseling when tested at anonymous testing-counseling or HIV/AIDS care centers, respectively, as compared to the minority (less than 45%) of women tested elsewhere. Pretest counseling was also associated to the reason for HIV testing (chi-square , p, 0.001), having occurred more frequently among women who had been tested after their partners or children were recognized as HIV-infected. Comparing access to pretest counseling among women tested for HIV in different time periods, we noticed that counseled women had been diagnosed at a mean of 4.30 years, as compared to 4.38 years among those who were not counseled (ANOVA, p ). Post-test counseling was reported as having occurred in 62.5% of women. Having received post-test counseling was significantly associated with the type of health care setting where HIV testing took place (chi-square , p, 0.001), in that it occurred with 64.3%, 72.0%, and 84.3% of women tested at maternities, anonymous testing-counseling centers, and HIV/AIDS care centers, respectively, as compared to 34.3% of those tested in private services and blood or milk banks. Comparing access to post-test counseling among women tested for HIV in different time 88 SEGURADO ET AL. periods, no difference in mean time since HIV diagnosis was found between women who received counseling and those who did not (4.33 years versus 4.38 years, ANOVA, p ). At the time of disclosure of HIV infection, 64.3% of our women felt supported, whereas 21.6% reported negative attitudes from the health care professional in charge of this task, such as indifference (14.4%), discrimination (5.1%), or even criticism (2.0%). The professional s attitude was strongly associated with the type of health care setting where HIV testing was carried out (chi-square , p, 0.001): 89.1% and 89.4% of women tested at an HIV/AIDS care center or an anonymous testing-counseling center, respectively, felt supported on that occasion. Nevertheless 9.3% of women tested at private services and 11.1% of those tested at maternities admitted having been discriminated or felt criticism. A statistically significant difference in mean time since HIV diagnosis was found between women who reported different professional s attitudes at the time of disclosure. Patients more recently diagnosed were more frequently treated supportively (ANOVA, p ). In this study, 56.4% of patients informed never and 33.8% seldom having missed a medical appointment with the assisting infectious diseases physician. Patients who referred never having missed appointments were more frequently those with better adherence to antiretroviral therapy (chi-square , p, 0.001) and those diagnosed as HIV-infected for less time (ANOVA, p ). In contrast patients under longer follow-up at the participating centers were more likely to miss their medical appointments (ANOVA, p ). Having a primary care giver (chi-square , p ) and the length of time spent in commuting to the HIV/AIDS center were not associated to better adherence to medical follow-up (ANOVA, p ). The range of services provided to women at the HIV/AIDS care center was investigated in accordance to access to different health professionals, as depicted in Table 2. The least addressed demands of women living with HIV/AIDS included psychological support, nutrition care, and oral health. Since 62.7% of interviewed women reported

5 WOMEN AND HIV/AIDS CARE, BRAZIL 89 TABLE 2. PARTICIPATION OF DIFFERENT HEALTH PROFES- SIONALS IN CARE PROVIDED TO 1,068 WOMEN LIVING WITH HIV/AIDS, SÃO PAULO STATE, BRAZIL, Women assisted Health professional n % Infectious disease physician 1, Gynecologist Nurse Social worker Psychologist Dentist Other physicians Dietician Other professionals having been seen by a gynecologist at the HIV/AIDS care center, we investigated the role of this professional in patient s counseling, with particular emphasis on means of preventing HIV transmission, as illustrated in TABLE 3. Table 3. Our results show that access to gynecological care at participating centers is statistically significantly associated with proper counseling on mother-to-child transmission (MCT) during pregnancy or breast feeding, on the need for safe sex practices with an HIV-infected partner, on no need to abstain from sex, and on the existence of contraceptive measures suitable for women living with HIV/AIDS, but not on MCT at delivery, the availability of antiretroviral chemotherapy to prevent MCT or the need for providing antiretroviral chemotherapy to the newborn in order to prevent MCT. Questioned about their doctor-patient relationship, most women in this cohort informed they understood clearly what the infectious disease physicians told them (most often 87.7% and sometimes 10.9%) and reported easiness in having their doubts clarified by and anxieties COUNSELING ON MEANS OF HIV TRANSMISSION AND PREVENTION AND GYNECOLOGICAL CARE TO 1,068 WOMEN LIVING WITH HIV/AIDS, SÃO PAULO STATE, BRAZIL, Women seen by a gynecologist Women who received counseling Total no. no % Odds ratio (OR) 95%CI (OR) Mother-to-child transmission (MCT) during pregnancy Yes [1.00; 1.82] No MCT at delivery Yes [0.95; 1.71] No MCT by breast feeding Yes [1.00; 1.84] No Antiretroviral chemotherapy to prevent MCT Yes [0.96; 1.70] No Need for antiretroviral chemotherapy to the newborn to prevent MCT Yes [0.93; 1.59] No Need for safe sex practices with HIV positive partner Yes [1.21; 2.57] No No need to avoid sex Yes [1.13; 2.56] No Contraceptive measures suitable for women living with HIV/AIDS Yes [1.03; 1.75] No

6 expressed to their attending physician (most often 85.1% and sometimes 9.9%). However, only 49.9% properly understood the meaning of CD4 1 cell counts, 35.4% reported they did not know what this test was meant for at all, and 12.5% misunderstood its meaning. As for viral load assessment, 59.5% understood its meaning properly, 30.0% reported they did not know what the test was meant for and 6.6% misunderstood its meaning. Proper understanding of the purpose of carrying out these monitoring laboratory tests was statistically significantly associated to the ability women had of understanding what the infectious disease physician told them (chi-square , p, 0.001, and chi-square , p, 0.001, for CD4 1 cell counts and viral load, respectively) and to their ability to have their doubts clarified by this professional (chi-square , p, 0.001, and chi-square , p, 0.001, for CD4 1 cell counts and viral load, respectively). Finally, women from our cohort informed having had their last viral load assessment performed in the previous months (mean 6 standard deviation) and their last CD4 1 cell count in the previous months. Only 5.5% and 2.8% reported never having been submitted to a viral load assessment or a CD4 1 cell count, respectively. 90 DISCUSSION SEGURADO ET AL. The ultimate goal of medical care is certainly to increase the quantity and quality of patients lives. 10 In order to accomplish these objectives at best, medical interventions whether aiming at health promotion and disease prophylaxis or at the therapy of or rehabilitation from disease, should focus on specific demands of the target population they are designed for. In this context, one should acknowledge that women living with HIV/AIDS have specific needs for care that must be addressed by policies, programs and practices. These are frequently multiple and complex, since these women are often faced with socioeconomic stressors that may have negative impact in physical and mental well-being. A comprehensive approach to care is therefore necessary, one that is able not only to deal with the clinical aspects of the disease, but also to provide opportunities for psychosocial assistance. 7,8,11 In recent years, remarkable advances in the development of highly effective antiretroviral drugs and prophylactic regimens for opportunistic infections have brought about the perspective of living many years with the disease. 12,13 Nevertheless the correct timing for being started on HIV/AIDS medical care basically depends on the ability of the health care system to provide an early diagnosis of infection. 7,14 This does not seem to happen with women in our cohort. Limited HIV risk perception may delay testing and access to care, as pointed out in previous studies among Brazilian women living with HIV/AIDS. 15 Attention should be drawn to the fact that few women from our cohort have an active attitude towards HIV testing. Most seem to have been driven to testing following recommendations of health care providers or sexual partners, in the absence of adequate pretest counseling. The disclosure of HIV diagnosis is certainly a profoundly distressing moment that may impact a woman s life forever and therefore deserves special attention. Even though the majority of women in our cohort informed having received post-test counseling, this procedure is associated to the health care setting where testing took place. Women diagnosed at blood banks, milk banks, and private services were less often properly counseled. It is also disappointing to find out that counseling is not being incorporated in routine practices over time, as needed. This points out for the urgent need to carry out better training of health professionals in charge of handing out test results at these particular sites, in order to improve their counseling skills. Moreover patients tested at maternities or private services were more likely to have felt discriminated, criticized or been treated with indifference. This supports the idea that health care personnel at these settings should undergo special training incorporating human rights issues into the framework of HIV/AIDS care. 16,17 After diagnosis is established, care becomes focused on therapeutic and prophylactic interventions. At this point, the successful management of women living with HIV/AIDS de-

7 WOMEN AND HIV/AIDS CARE, BRAZIL 91 pends on patient s adherence to medical follow-up and treatments. The fact that women under longer follow-up at the health center are more likely to miss medical appointments, reinforces the importance for physicians to establish and maintain close and long-lasting relationships with patients. In such a favorable environment, behavioral changes and, particularly, better adherence to antiretroviral chemotherapy are more likely to occur. 7,18 This seems much more critical than patients time or economic restraints, or even commuting distance to health care settings. We were able to identify particular demands of women from our cohort that must be addressed more efficiently, such as psychological support. Women living with HIV/AIDS face many challenges having to cope with a lifethreatening disease. Not only having to confront their own care needs, these women usually have to deal with their role as caregivers for their sick partners and children. 7 Psychosocial assistance and support for raising their children must be thus regarded as fundamental aspects of provided care. Nutritional care and oral health issues should not be underrated either in a comprehensive HIV/AIDS care approach They may aid promoting health and improving immune status, as well as may represent significant ancillary measures in raising women s self-esteem. The role of the gynecologist in the context of HIV/AIDS care is certainly crucial. This is the first physician a woman usually seeks when in need. Therefore if properly trained to deal with HIV infection, he may be responsible for an ear- lier diagnosis, better counseling and a mean of providing effective support to reproductive health issues, including prevention of HIV sexual and mother-to-child transmission. 9 Evidence from this study shows that women seen by a gynecologist at the participating centers were indeed more frequently counseled on important issues related to their reproductive health. Therefore the involvement of these health professionals in care and counseling of women living with HIV/AIDS should be reinforced. Integrating women s health programs and family-planning actions to STD/HIV prevention and care may be an attainable solution to be sought after. 9,18,23 Periodic evaluation of women living with HIV/AIDS should include careful monitoring for evidence of disease progression, based on clinical manifestations and laboratory assessments of the degree of immune deficiency and viral replication. 10 This is best accomplished by means of determining CD4 1 cell counts and quantitative plasma viral loads and is considered essential for deciding whether to start patients on antiviral and prophylactic therapy or to change antiretrovirals in case of insufficient response. Access to such tests in the present cohort is concordant to national and international HIV/AIDS guidelines. 18,24 However better understanding of the meaning and purpose of these tests by women living with HIV/AIDS is required if better adherence to therapy is desired. 25 Certain limitations may be pointed in the present investigation. It was based on women s own perception of provided care and sometimes required information on events that might have occurred a long time before. This is enough for recall bias to have occurred. Moreover self-selection might have also been an important confounder. Patients who have refused to be interviewed could include those with more difficulties in coping with the disease or even those who have suffered discrimination, fear or frustrating experiences with health care providers, so as not to be willing to recall those distressful moments. In case these biases occurred, we may have underestimated the frequency of unpleasant feelings experienced by women living with HIV/AIDS. The fact that only reference HIV/AIDS health care settings in São Paulo and Santos were included in the investigation must be taken into account. One can assume that patients assisted at these services are likely to have received better care, when compared to women living with HIV/AIDS and assisted elsewhere or even to those who are presently not being cared for at all or who remain unidentified as HIV-infected. CONCLUSION The present study was able to identify particular demands of women living with HIV/AIDS in São Paulo State, Brazil that are

8 92 amenable to intervention aiming at enhancing care. A comprehensive approach to care for these women must include medical treatment, emotional and social support, as well as incorporate a proper understanding about gender issues and human rights. APPENDIX Brazilian enhancing care initiative team José Ricardo M. Ayres, M.D., Ph.D., 1 Heloisa S. Marques, M.D., Ph.D., 2 Cássia Buchalla, M.D., Ph.D., 3 Ivan França Jr., M.D., Ph.D., 4 Vera Paiva, Ph.D., 5 Ana A. Pluciennik, M.D., 6 Neide Gravato-Silva, Social Worker; 7 Regina Lacerda, Psychologist; 7 Maria Lucia Salomão, M.D., 8 Marinella della Negra, M.D., Ph.D. 9 Participating institutions Departments of 1 Preventive Medicine and 2 Pediatrics, School of Medicine, University of São Paulo; Departments of 3 Epidemiology and 4 Mother and Child s Health, School of Public Health, University of São Paulo; 5 Department of Social Psychology, Psychology Institute, University of São Paulo; 6 AIDS Reference and Training Center, São Paulo State Health Secretariat; 7 Santos STD/AIDS City Program, 8 Department of Epidemiology and Public Health, São José do Rio Preto School of Medicine; 9 Emilio Ribas Institute for Infectious Diseases, São Paulo, Brazil. ACKNOWLEDGMENTS The present study was carried out as part of the Enhancing Care Initiative, a multinational program coordinated by the Harvard AIDS Institute (Dr. Richard Marlink) in partnership with the François-Xavier Bagnoud Center for Health and Human Rights (Dr. Sofia Gruskin) and was made possible by a grant from The Merck Company Foundation. REFERENCES 1. UNAIDS. Report on the global HIV/AIDS epidemic, December Available: SEGURADO ET AL. 2. Sepkowitz KA. Effect of prophylaxis on the clinical manifestations of AIDS-related opportunistic infections. Clin Infect Dis 1998;26: UK NGO AIDS Consortium Working Group on Access to Treatment for HIV in Developing Countries. Access to treatment for HIV in developing countries: statement from international seminar on access to treatment for HIV in developing countries, London, June 5 and 6, Lancet 1998;352: Ministério da Saúde do Brasil; Aids: Boletim Epidemiológico. Ano XIV, no. 02, abril a junho de Brasília: Ministério da Saúde, Available: 5. Giffin K, Lowdes CM. Gender, sexuality and the prevention of sexually transmissible diseases: a Brazilian study of clinical practice. Soc Sci Med 1999;48: Chequer P, Sudo E, Vitória MAA, et al. Impacto da terapêutica anti-retroviral. Available: assistencia/impacto_revisoes1.htm. 6a. Sowell RL, Moneyham L, Aranda-Naranjo B. The care of women with AIDS. Special needs and considerations. Nursing Clin North Am 1999;34: Hackl KL, Somlai AM, Kelly JA, et al. Women living with HIV/AIDS: the dual challenge of being a patient and caregiver. Health Soc Work 1997;22: MacDonald SR, Skor A, Socol ML, et al. Human immunodeficiency virus infection and women: a survey of missed opportunities for testing and diagnosis. Am J Obstet Gynecol 1998;178: Bozette AS, Asch S. Developing quality review criteria from standards of care for HIV disease: a framework. J Acquir Immune Defic Syndr Hum Retrov 1995;8:S45 S Duggan J, Walerius H, Purohit A, et al. Reproductive issues in HIV-seropositive women: a survey regarding counseling, contraception, safer sex and pregnancy choices. J Assoc Nurses AIDS care 1999;5: Wong T, Chiasson MA, Reggy A, et al. Antiretroviral therapy and declining AIDS mortality in New York City. J Urban Health 2000;77: The CASCADE Collaboration. Survival after introduction of HAART in people with known duration of HIV-1 infection. The CASCADE Collaboration: Concerted Action on SeroConversion to AIDS and Death in Europe. Lancet 2000;355: Siegel K, Raveis VH, Gorey E. Barriers and pathways to testing among HIV-infected women. AIDS Educ Prevent 1998;10: Vermelho LL, Barbosa RHS, Nogueira SA. Mulheres com Aids: desvendando histórias de risco (Women with AIDS: disclosing risk stories). Cad Saúde Pública Rio de Janeiro 1999;15: Gollub EL. Human rights is a U.S. problem, too: the case of women and HIV. Am J Public Health 1999; 89: Mann J. Human rights and AIDS: the future of the pandemic. In: Health and human rights: a reader. Mann J, Gruskin S, Grodin MA, et al., eds. New York: Routledge, 1999; Kirton CA, Ferri RS, Eleftherakis V. Primary care and

9 WOMEN AND HIV/AIDS CARE, BRAZIL 93 case management of persons with HIV/AIDS. Nurs Clin North Am 1999;34: Young JS. HIV and medical nutrition therapy. J Am Diet Assoc 1997;10:S161 S American Dietetic Association. Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection. J Am Diet Assoc 2000;100: Greene VA, Chu SY, Diaz T, et al. Oral health problems and use of dental services among HIV-infected adults. J Am Dent Assoc 1997;128: Shiboski CH, Palacio H, Neuhaus JM, et al. Dental care access and use among HIV-infected women. Am J Public Health 1999;89: MacNeil JM, Anderson S. Beyond the dichotomy: linking HIV prevention with care. AIDS 1998;12: S19 S Brasil. Ministério da Saúde: Componentes do Programa: principais ações e produtos Laboratório. In: AIDS no Brasil: um esforço conjunto governo-sociedade. Brasília: Ministério da Saúde, 1998: Jordan MS, Lopes JF, Okazaki E, et al. Aderência ao tratamento anti-retroviral em AIDS: revisão da literatura médica. In: Tá difícil de engolir. Experiências de adesão ao tratamento anti-retroviral em São Paulo. Teixeira PR, Paiva V, Shimma E, eds. São Paulo, SP: Nepaids, 2000:5 25. Address reprint requests to: Aluisio C. Segurado, M.D., Ph.D. Av. Dr. Eneas de Carvalho Aguiar São Paulo SP, Brazil segurado@usp.br