Evaluation of implementation of the protocol for managing tuberculosis/HIV coinfection in specialized care services in the state of Ceara, Brazil/Evaluacion de la implementacion del protocolo de imanejo de coinfeccion de tuberculosis y VIH en los servicios de asistencia especializada del estado de Ceara, Brasil

Objectives. Identify barriers and strategies for implementation of the protocol for managing tuberculosis/human immunodeficiency virus (TB/HIV) coinfection in specialized care services in Ceara state, through implementation research. Methods. The study followed the iPIER methodology, a new initiative to help improve the implementation of health programs through the use of research that is conducted as a part of the implementation process. Data were collected on the structure and processes of 22 services, and barriers were explored in four focus groups with 28 participants, from the standpoint of the health team, administrators, and users. The discussions were transcribed and interpreted with regard to the objectives of the study. Results. The information on structure and process revealed that six services manage TB/HIV coinfection and 16 do not. The barriers were: team members were unaware of the protocol; lack of clinical practice guidelines in the services; specialized care services working at all three levels of the health system; inadequate spaces for treatment of airborne diseases; and lack of communication with primary health care sectors for patient transfers. The results were discussed with teams and administrators in seminars held in the services and with program managers for sexually transmitted infections, human immunodeficiency virus, AIDS, hepatitis, and tuberculosis. Conclusions. Direct dialogue between administrators, implementers, users, and researchers generated knowledge about the services and led to joint preparation of modifications in workflow aimed at acceptance and use of the protocol; however, users continue to resist adherence to treatment. Keywords Tuberculosis; HIV; protocols; health services; Brazil. Objetivos. Identificar barreras y estrategias para la implementacion del protocolo "Manejo de coinfeccion por tuberculosis y virus de inmunodeficiencia humana (TBC/ VIH)" en los servicios de asistencia especializada (SAE) de Ceara, mediante investigacion evaluativa. Metodos. Estudio desarrollado siguiendo la metodologia iPIER, una nueva inicia tiva con el proposito de apoyar mejoras en la ejecucion de programas de salud a traves de investigaciones integradas en ellos acerca de su ejecucion. Se recogieron datos de estructura y procesos de 22 servicios y se exploraron las barreras mediante cuatro grupos focales, con 28 participantes, desde el punto de vista del equipo de salud, los administradores y los usuarios. Las discusiones fuero