O HIV e a sífilis no Sistema Prisional Feminino do estado de São Paulo / HIV and syphilis in the Female Prison System in the state of São Paulo

O Centro de Referência e Treinamento em Doenças Sexualmente Transmissíveis e Aids da Secretaria de Estado da Saúde de São Paulo realizou ampla atividade de testagem para HIV e sífilis no sistema prisional feminino, entre 2012 e 2013, em parceria com a Secretaria da Administração Penitenciária – SAP. Ao todo, 8.914 mulheres aceitaram realizar o teste. Destas, 2.947 encontram-se em presídios da capital e 5.967 do interior. Observou-se que 2,8% delas apresentaram resultado reagente para HIV e 7% para testagem rápida de triagem para sífilis. A taxa de prevalência de HIV na população geral é de 0,4% e de sífilis 1,6%. A média de idade da população testada foi de 34,3 anos. As mulheres privadas de liberdade que participaram deste levantamento receberam informações pré e pós-teste para sífilis e HIV. Os profissionais dos serviços envolvidos foram capacitados para esta orientação. No caso de positividade para o HIV e ou sífilis, garantiram-se os procedimentos de acompanhamento e tratamento estabelecidos pelo SUS. O projeto teve por objetivo conhecer a soroprevalência do HIV e da sífilis nesta população, traçar o perfil das mulheres privadas de liberdade em relação a informações sobre sífilis e HIV, dar orientação de qualidade sobre o assunto para as presas e oferecer maior assistência em saúde para DST/ HIV/Aids mediante o estabelecimento, de maneira sustentável, de sistema de referência e contrarreferência. Até 2015, pretende-se elaborar e implementar, de forma escalonada e regionalizada, o projeto de DST/Aids da Proposta Integrada de Atenção à Saúde da População Privada de Liberdade, em parceria com a SAP. É a primeira ação deste porte no estado de São Paulo. Trata-se de uma iniciativa que poderá contribuir para a melhoria da qualidade de vida das mulheres, com repercussão no controle da transmissão vertical do HIV e sífilis...

Seroprevalence of Toxoplasma gondii IgG antibody in HIV/AIDS-infected individuals in Maputo, Mozambique / Seroprevalencia de IgG anti- Toxoplasma gondii en personas infectadas por el VIH/SIDA Maputo, Mozambique / Soroprevalência de IgG anti- Toxoplasma gondii em pessoas infectadas pelo HIV/Aids em Maputo, Moçambique

OBJECTIVE To analyze the prevalence of IgG antibodies to Toxoplasma gondii in patients infected with HIV/AIDS and the association of demographic and social variables. METHODS Descriptive cross-sectional study that included the analysis of sociodemographic data and laboratory findings of 200 patients infected with HIV/AIDS treated in a laboratory unit in Maputo, Mozambique, in 2010. Individual data for all participants were collected with a self-administered questionnaire. Plasma samples were tested for IgG testing of anti- T. gondii using hemagglutination for the analysis of antibodies. RESULTS The seroprevalence of IgG anti- T. gondii was 46.0% (95%CI 39.2;52.9), 39.3% (95%CI 29.5;50.0) in men and 50.9% (95%CI 41.9;59.8) in women, with no difference between sex (OR 1.30; 95%CI 0.95;1.77; p = 0.12). Ages ranged from 10 to 60 years, with a higher prevalence of infection in older age groups, but with no significant difference between them. Regularly consuming cattle meat (OR 1.74; 95%CI 1.04;2.89, p = 0.05), breeding cats/dogs (OR 6.18; 95%CI 3.60;10.62, p < 0.000) and having regular contact with soil (OR 3.38; 95%CI 2.19;5.21; p < 0.000) were significantly associated with risk of latent infection. CONCLUSIONS Toxoplasmosis is an infection with high prevalence in Mozambique. Cultural and behavioral aspects increase the risk. Toxoplasmosis can be responsible in our environment by the great burden of morbidity and mortality associated with meningoencephalic injuries in patients with HIV/AIDS. .

OBJETIVO Evaluar la prevalencia de anticuerpos IgG anti- Toxoplasma gondii en personas infectadas por VIH/SIDA y la asociación de variables demográficas y sociales. MÉTODOS Estudio transversal que incluyó el análisis de datos sociodemográficos y de laboratorio de 200 personas infectadas por VIH/SIDA, atendidas en unidad de laboratorio en 2010 en la Provincia de Maputo, Mozambique. Los datos fueron colectados por medio de cuestionario auto llenado por todos los participantes. Para el análisis de anticuerpos, las muestras de plasma colectadas fueron confirmadas para evaluación anti- T. gondii por hemaglutinación. RESULTADOS La seroprevalencia de IgG anti- T. gondii fue de 46% (IC95% 39,2;52,9), 39,3% (IC95% 29,5;50,0) en hombres y de 50,9% (41,9-59,8%) en mujeres, sin diferencia entre sexo (OR 1.30; IC95% 0.95;1.77; p = 0.12). La edad varió de 10 a 60 años, con mayor prevalencia de infección en grupos etarios más ancianos, pero sin haber diferencia significativa entre ellos. Consumir carne de ganado bovino regularmente (OR 1,74; IC95% 1,04;2,89, p = 0,05), poseer cria de gatos/perros (OR 6,18; IC95% 3,60;10,62, p < 0,000) y tener contacto regular con la tierra (OR 3,38; IC95% 2,19;5,21, p < 0,000) estuvieron significativamente asociados al riesgo de infección latente. CONCLUSIONES La infección por toxoplasmosis presenta alta prevalencia en la población de Mozambique, cuyo riesgo se amplía por los aspectos culturales y de comportamiento. La toxoplasmosis puede ser responsable por la gran carga de morbi-mortalidad asociada a lesiones meningoencefálicas en personas con VIH/SIDA en el país. .

OBJETIVO Avaliar a prevalência de anticorpos IgG anti- Toxoplasma gondii em pessoas infectadas pelo HIV/Aids e a associação de variáveis demográficas e sociais. MÉTODOS Estudo transversal que incluiu a análise de dados sociodemográficos e laboratoriais de 200 pessoas infectadas por HIV/Aids, atendidas em unidade laboratorial em 2010 na Província de Maputo, Moçambique. Os dados foram coletados por meio de questionário autopreenchido por todos os participantes. Para a análise de anticorpos, amostras de plasma coletadas foram confirmadas para testagem de IgG anti- T. gondii por hemaglutinação. RESULTADOS A soroprevalência de IgG anti- T. gondii foi de 46,0% (IC95% 39,2;52,9), 39,3% (IC95% 29,5;50,0) em homens e de 50,9% (IC95% 41,9;59,8) em mulheres, sem diferença entre sexo (OR 1.30; IC95% 0.95;1.77; p = 0.12). A idade variou de 10 a 60 anos, com maior prevalência de infecção em grupos etários mais idosos, mas sem haver diferença significativa entre eles. Ter consumo regular de carne de gado bovino (OR 1,74; IC95% 1,04;2,89, p = 0,05), possuir criação de gatos/cães (OR 6,18; IC95% 3,60;10,62, p < 0,000) e ter contato regular com a terra (OR 3,38; IC95% 2,19;5,21, p < 0,000) estiveram significativamente associados ao risco de infecção latente. CONCLUSÕES A infecção por toxoplasmose apresenta alta prevalência na população de Moçambique, cujo risco amplia-se pelos aspectos culturais e comportamentais. A toxoplasmose pode ser responsável pela grande carga de morbimortalidade associada a lesões meningoencefálicas em pessoas com HIV/Aids no país. .

Late-stage diagnosis of HIV infection in Brazilian children: evidence from two national cohort studies.

This study analyzed data from two consecutive retrospective cohort samples (1983 to 1998 and 1999 to 2002) of Brazilian children with AIDS (N = 1,758) through mother-to-child-transmission. Late-stage diagnosis (CDC category C) was investigated in relation to the following variables: year of birth, year of HIV diagnosis, and time periods related to changes in government treatment guidelines. Late-stage diagnosis occurred in 731 (41.6%) of cases and was more prevalent in infants under 12 months of age. The rate of late-stage diagnosis decreased from 48% to 36% between the two periods studied. We also observed a reduction in the proportion of late-stage diagnoses and the time lapse between HIV diagnosis and ART initiation. A significant association was found between timely diagnosis and having been born in recent years (OR = 0.62; p = 0.009) and year of HIV diagnosis (OR = 0.72; p = 0.002/OR = 0.62; p < 0.001). Infants under the age of 12 months were more likely to be diagnosed at a late stage than older children (OR = 1.70; p = 0.004). Despite advances, there is a need to improve the effectiveness of policies and programs focused on improving early diagnosis and management of HIV/AIDS.

Late-stage diagnosis of HIV infection in Brazilian children: evidence from two national cohort studies / Diagnóstico tardio da infecção por HIV em crianças brasileiras: evidências baseadas em dois estudos nacionais de coorte / Diagnóstico tardío de la infección por VIH en niños brasileños: evidencias basadas en dos estudios nacionales de cohorte

This study analyzed data from two consecutive retrospective cohort samples (1983 to 1998 and 1999 to 2002) of Brazilian children with AIDS (N = 1,758) through mother-to-child-transmission. Late-stage diagnosis (CDC category C) was investigated in relation to the following variables: year of birth, year of HIV diagnosis, and time periods related to changes in government treatment guidelines. Late-stage diagnosis occurred in 731 (41.6%) of cases and was more prevalent in infants under 12 months of age. The rate of late-stage diagnosis decreased from 48% to 36% between the two periods studied. We also observed a reduction in the proportion of late-stage diagnoses and the time lapse between HIV diagnosis and ART initiation. A significant association was found between timely diagnosis and having been born in recent years (OR = 0.62; p = 0.009) and year of HIV diagnosis (OR = 0.72; p = 0.002/OR = 0.62; p < 0.001). Infants under the age of 12 months were more likely to be diagnosed at a late stage than older children (OR = 1.70; p = 0.004). Despite advances, there is a need to improve the effectiveness of policies and programs focused on improving early diagnosis and management of HIV/AIDS.

Analisaram-se dados de duas coortes retrospectivas consecutivas (1983-1998, 1999-2002) de crianças brasileiras com AIDS (n = 1.758), expostas ao HIV por transmissão vertical. Ocorrência de diagnóstico tardio (categoria C-CDC) foi verificada para: ano de nascimento, ano de diagnóstico da infecção e períodos relacionados a mudanças das diretrizes terapêuticas governamentais. Encontramos 731 (41,6%) crianças com diagnóstico em estágio tardio, especialmente com < 1 ano de idade. No segundo período o desempenho do diagnóstico melhorou (36 vs. 48% de atraso diagnóstico no primeiro período). Verificou-se melhoria da proporção de crianças com diagnóstico tardio e do tempo entre o diagnóstico da infecção e a introdução da terapia antirretroviral. Ano de nascimento (OR = 0,62; p = 0,009) e ano de diagnóstico da infecção (OR = 0,72; p = 0,002/OR = 0,62; p < 0,001) mais recentes estiveram significativamente associados a diagnóstico oportuno. Crianças com idade < 1 ano tiveram maior risco para diagnóstico tardio do que as mais velhas (OR = 1,70; p = 0,004). Apesar dos avanços, há necessidade de potencializar diagnóstico e manejo oportunos.

Se analizaron datos de dos cohortes retrospectivas consecutivas (1983-1998, 1999-2002) de niños brasileños con SIDA (N = 1.758), expuestos al VIH por transmisión vertical. La ocurrencia de diagnóstico tardío (categoría C-CDC) fue verificada para: año de nacimiento, año de diagnóstico de la infección y períodos relacionados con cambios de las directrices terapéuticas gubernamentales. Hubo 731 (41,6%) niños con diagnóstico en estadio tardío, especialmente con < 1 año de edad. En el segundo período el desempeño del diagnóstico mejoró (36 versus 48% de atraso diagnóstico). Se verificó una mejoría de la proporción de niños con diagnóstico tardío y del tiempo entre diagnóstico de la infección e introducción de la terapia antirretroviral. Los años de nacimiento (OR = 0,62; p = 0,009) y años de diagnóstico de la infección (OR = 0,72; p = 0,002/OR = 0,62; p < 0,001) más recientes estuvieron significativamente asociados a un diagnóstico oportuno. Los niños con edad < 1 año tuvieron mayor riesgo para un diagnóstico tardío que los más viejos (OR = 1,70; p = 0,004). A pesar de los avances, existe una necesidad de potenciar el diagnóstico y tratamientos oportunos.

Seroprevalence of Toxoplasma gondii IgG antibody in HIV/AIDS-infected individuals in Maputo, Mozambique.

OBJECTIVE: To analyze the prevalence of IgG antibodies to Toxoplasma gondii in patients infected with HIV/AIDS and the association of demographic and social variables. METHODS: Descriptive cross-sectional study that included the analysis of sociodemographic data and laboratory findings of 200 patients infected with HIV/AIDS treated in a laboratory unit in Maputo, Mozambique, in 2010. Individual data for all participants were collected with a self-administered questionnaire. Plasma samples were tested for IgG testing of anti- T. gondii using hemagglutination for the analysis of antibodies. RESULTS: The seroprevalence of IgG anti- T. gondii was 46.0% (95%CI 39.2;52.9), 39.3% (95%CI 29.5;50.0) in men and 50.9% (95%CI 41.9;59.8) in women, with no difference between sex (OR 1.30; 95%CI 0.95;1.77; p = 0.12). Ages ranged from 10 to 60 years, with a higher prevalence of infection in older age groups, but with no significant difference between them. Regularly consuming cattle meat (OR 1.74; 95%CI 1.04;2.89, p = 0.05), breeding cats/dogs (OR 6.18; 95%CI 3.60;10.62, p < 0.000) and having regular contact with soil (OR 3.38; 95%CI 2.19;5.21; p < 0.000) were significantly associated with risk of latent infection. CONCLUSIONS: Toxoplasmosis is an infection with high prevalence in Mozambique. Cultural and behavioral aspects increase the risk. Toxoplasmosis can be responsible in our environment by the great burden of morbidity and mortality associated with meningoencephalic injuries in patients with HIV/AIDS.

Eliminating vertical transmission of HIV in São Paulo, Brazil: progress and challenges.

BACKGROUND: HIV infection in children is an important public health problem in the world, mainly in poorer countries. If all recommendations are followed, the elimination of HIV vertical transmission is a concrete possibility. This study aims to estimate vertical transmission rates of HIV in São Paulo State, Brazil, based on pregnant women diagnosed and reported in 2006, identifying potentially associated factors. METHODS: This study involves a retrospective cross-sectional analysis of information systems and records of infected pregnant women and children exposed to HIV. The rate of vertical transmission was estimated and variables associated with the antenatal, delivery, and postnatal periods were analyzed by the chi-square test, and Fisher exact test was used for variables with an expected frequency <5. The relative risks were calculated with 95% confidence intervals. RESULTS: The rate of vertical transmission in São Paulo state was 2.7% (95% confidence interval: 1.86 to 3.94) in 2006, decreasing 83.1% in comparison with 1988-1993. The main associated variables were lack of prenatal visits or <6 visits, no antiretroviral prophylaxis during labor or neonatal use for <6 weeks, and maternal breastfeeding. CONCLUSIONS: There is a decreasing trend of HIV vertical transmission in São Paulo with levels approaching elimination, which seems to be associated with antiretroviral policy and interruption of breastfeeding. Although there are serious operational issues, conditions exist to respond effectively. São Paulo state demonstrates that it is possible to achieve advanced levels of control for this mode of HIV transmission.

Mortality in Brazilian children with HIV/AIDS: the role of non-AIDS-related conditions after highly active antiretroviral therapy introduction.

AIDS-related mortality has been significantly reduced in areas that systematically adopted highly active antiretroviral therapy (HAART). In Brazil, despite advances in control policy, there is still a lack of evidence about trends in children on causes of death related or not related to HIV/AIDS. We evaluate temporal trends in mortality due to non-HIV-related causes of death in relation to HIV/AIDS-related conditions among children with and without HIV infection. This nationwide study included all deaths in children reported from 1999 to 2007. Mortality odds ratios (MOR) and rates were calculated to assess time trends of death in children with or without HIV/AIDS. These data were analyzed by calendar year, as obtained from official national database. A total of 680,763 deaths occurred in Brazilian children under 13 years of age; of these, 2191 (0.32%) had causes related to HIV/AIDS listed on the death certificate. The mortality rate from HIV/AIDS-related causes in Brazilian children ranged from 0.72 per 100,000 children in 1999 to 0.40 per 100,000 children in 2007, while for selected nonrelated causes the rate of death among HIV-infected children was stable at 0.08 per 100,000 Brazilian children. In children with HIV/AIDS, the MOR of having selected conditions unrelated to HIV/AIDS as a cause of death in 2007 (compared to 1999) was 1.85 (95% confidence interval [CI] = 1.11-3.08, p = 0.02), but without a significant temporal trend (p = 0.413) through the analyzed period. In Brazil, deaths related to HIV/AIDS mortality in children significantly decreased, while the unrelated causes in HIV-infected children maintained a stable trend. These data reinforce the success of national public health policies and the need to offer comprehensive care to children with HIV/AIDS.

AIDS morbidity and mortality in Brazilian children before and after highly active antiretroviral treatment implementation: an assessment of regional trends.

BACKGROUND: The objective of this study was to analyze regional trends over time of acquired immunodeficiency syndrome (AIDS) cases and deaths in Brazilian children, before and after implementation of free access to highly active antiretroviral treatment (HAART). METHODS: We performed a nation-wide study with an ecologic design and a time-series analysis of AIDS incidence and mortality rates in children (0-12 years of age), using polynomial regression models. Data were obtained from official national databases on age group, residence region, and year of AIDS diagnosis and death (1984-2008). RESULTS: Between 1984 and 2008, 14,314 (2.7%) AIDS cases and 5041 deaths (2.3% of all AIDS-related deaths) were reported in Brazilian children. Incidence after 1996 was reduced by 23%, as compared with the pre-HAART era. The mortality rate observed in the HAART era was reduced by 63.6%. There was a significant reduction in the incidence in the Southeast and Central-West regions (P < 0.001), but the less industrialized North region showed an increase in the pre-HAART era (P < 0.001), and the Northeast region showed a stabilization trend (P < 0.001). In the South region, the incidence of AIDS increased in the 0 to 4 years subgroup. A reduction of AIDS mortality in the Southeast (P < 0.001), South, and Central-West regions (P < 0.001) was seen, but the Northeast and North regions maintained an increasing mortality trend (P < 0.001). CONCLUSIONS: Despite the overall reduction in AIDS-related cases and deaths among children in Brazil since HAART, marked regional differences continue to exist. These reflect structural factors, different transmission dynamics, and operational issues. There is a need for improving the health service network with special emphasis on the less developed regions.

Improving survival in children with AIDS in Brazil: results of the second national study, 1999-2002.

The objective of this study is to characterize survival in children with AIDS diagnosed in Brazil between 1999-2002, compared with the first national study (1983-1998). This national retrospective cohort study examined a representative sample of Brazilian children exposed to HIV from mother-to-child transmission and followed through 2007. The survival probability after 60 months was analyzed by sex, year of birth and death, clinical classification, use of antiretroviral therapy (ART) and prophylaxis for opportunistic diseases. 920 children were included. The survival probability increased: comparing cases diagnosed before 1988 with those diagnosed from 2001-2002 it increased by 3.5-fold (from 25% to 86.3%). Use of ART, initial clinical classification, and final classification were significant (p < 0.001) predictors of survival. Issues regarding quality of records and care were identified. The results point to the success of the Brazilian policy of providing ART. The improvement of clinical status contributes to quality of life, while indicating challenges, particularly practices to improve long-term care.

AIDS in Brazilian children: history, surveillance, antiretroviral therapy, and epidemiologic transition, 1984-2008.

We present a systematic review of historical, political, and epidemiologic aspects of AIDS in Brazilian children. Over 25 years, Brazil has developed different strategies to control AIDS in children. Three revisions of criteria for defining AIDS cases in children and nine national guidelines on antiretroviral therapy administration for management of HIV infection were published. These guidelines represent important progress, including aspects of HIV/AIDS surveillance, antiretroviral treatment, opportunistic conditions, prophylaxis, and laboratory testing. Brazil has significantly expanded access to free therapy with different classes of antiretroviral drugs. Initially focusing on treatment for HIV and opportunistic conditions, the scope of treatment guidelines gradually expanded to comprehensive health care for children and adolescents. From 1996 to 2008, the number of AIDS cases and deaths in children has been reduced by 67% and 65%, respectively, as a result of different strategies to prevent mother-to-child transmission of HIV and highly active antiretroviral therapy administration to infected children. Improved morbidity, mortality, and survival of Brazilian children with AIDS demonstrate clear benefits of adopting a policy of free and universal access to antiretroviral drugs associated with comprehensive care. However, important issues remain to be resolved, mainly concerning social, operational, and regional inequalities in coverage and quality of care, and epidemiological surveillance in different regions of the country. This broad review shows that the overall situation of pediatric AIDS in Brazil represents an incomplete process of epidemiologic and demographic transition, with the coexistence of old and new clinical and epidemiologic challenges.

Improving survival in children with AIDS in Brazil: results of the second national study, 1999-2002 / Ampliação da sobrevida em crianças com AIDS no Brasil: resultados do segundo estudo nacional de 1999 a 2002

The objective of this study is to characterize survival in children with AIDS diagnosed in Brazil between 1999-2002, compared with the first national study (1983-1998). This national retrospective cohort study examined a representative sample of Brazilian children exposed to HIV from mother-to-child transmission and followed through 2007. The survival probability after 60 months was analyzed by sex, year of birth and death, clinical classification, use of antiretroviral therapy (ART) and prophylaxis for opportunistic diseases. 920 children were included. The survival probability increased: comparing cases diagnosed before 1988 with those diagnosed from 2001-2002 it increased by 3.5-fold (from 25 percent to 86.3 percent). Use of ART, initial clinical classification, and final classification were significant (p < 0.001) predictors of survival. Issues regarding quality of records and care were identified. The results point to the success of the Brazilian policy of providing ART. The improvement of clinical status contributes to quality of life, while indicating challenges, particularly practices to improve long-term care.

Este estudo caracteriza a sobrevida em crianças com AIDS no Brasil entre 1999-2002, contextualizando com o primeiro estudo nacional (1983-1998). Trata-se de coorte histórica, com crianças expostas ao HIV por transmissão vertical e acompanhadas até 2007. A probabilidade de sobrevivência em 60 meses foi analisada segundo sexo, ano de nascimento e de óbito, classificação clínica, uso de terapia antirretroviral (TARV) e de profilaxia para doenças oportunistas. No total, 920 crianças foram incluídas. A probabilidade de sobrevivência foi ampliada 3,5 vezes nos dois períodos avaliados, passando de 25 por cento antes de 1988 para 86,3 por cento no período de 2001-2002. Uso de TARV, classificação clínica inicial e atual/final foram preditores que influíram significativamente (p < 0,001) para a ampliação da sobrevida. Os resultados deste estudo indicam o sucesso da política brasileira para a abordagem das crianças infectadas com HIV. A melhora do estado clínico contribuiu para melhora da qualidade de vida, mas sinaliza-se para a necessidade de incorporação de práticas pautadas na integralidade do cuidado.

Atenção à gestante e à puérpera no SUS - SP: manual técnico do pré-natal e e puérperio / Pregnant woman attention at SUS-SP: prenatal care and postpartum period technical manual

Embora, nas últimas décadas, a cobertura de atenção ao pré-natal tenha aumentado, garantir sua qualidade permanece como o maior desafio. Essa melhoria da qualidade, no patamar em que estamos, refere-se a uma mudança sensível na atitude dos profissionais de saúde e na eficiência e presteza dos serviços. É preciso potencializar os recursos humanos e materiais existentes no Estado de São Paulo para o progressivo enfrentamento da morbimortalidade materna e perinatal. É verdade, também, que resultados nesse campo dependem de outros fatores, relativos ao desenvolvimento econômico, social e humano de cada região, que terminam por conferir maior ou menor suporte ás mulheres no momento da reprodução. A qualificação permanente da atenção ao pré-natal, ao parto e ao puerpério deve sempre ser perseguida na perspectiva de garantir uma boa condição de saúde tanto para a mulher quanto para o recém-nascido, bem como de possibilitar à mulher uma experiência de vida gratificante nesse período. Para isso, é necessário que os profissionais envolvidos em qualquer instância do processo assistencial estejam conscientes da importância de sua atuação e da necessidade de aliarem o conhecimento técnico específico ao compromisso com um resultado satisfatório da atenção, levando em consideração o significado desse resultado para cada mulher. A consulta pré-natal, para muitas mulheres, constitui-se na única oportunidde que possuem para verificar seu estado de saúde; assim, deve-se considerá-la também como uma chance para que o sistema possa atuar integralmente na promoção e, eventualmente, na recuperação de sua saúde. Feitas essas considerações, e respeitando-se as orientações constantes no Pacto pela Vida e as decisões emandad do Plano Estadual de Saúde de São Paulo, definem-se as seguintes diretrizes para nortear a atenção ao pré-natal e ao puerpério...