RESUMO
BACKGROUND: In 1996, Brazil became the first developing country to provide free, universal access to HAART, laboratory monitoring, and clinical care to any eligible patient. As of June 2014, approximately 400,000 patients were under treatment, making it the most comprehensive HIV treatment initiative implemented thus far in a middle-income country, worldwide. The Brazilian epidemic is highly concentrated among men who have sex with men (MSM). METHODS: Four national information systems were combined and Cox regression was used to conduct retrospective cohort analysis of HAART availability/access on all-cause mortality among MSM diagnosed with AIDS reported to the information systems between 1998-2008, adjusting for demographic, clinical, and behavioral factors and controlling for spatially-correlated survival data by including a frailty effect. Multiple imputation by chained equations was used to handle missing data. RESULTS: Among 50,683 patients, 10,326 died during the 10 year of period. All-cause mortality rates declined following introduction of HAART, and were higher among non-white patients and those starting HAART with higher viral load and lower CD4 counts. In multivariable analysis adjusted for race, age at AIDS diagnosis, and baseline CD4 cell count, MSM diagnosed in latter periods had almost a 50% reduction in the risk of death, compared to those diagnosed between 1998-2001 (2002-2005 adjHR: 0.54, 95% CI:0.51-0.57; 2006-2008 adjHR: 0.51, 95% CI:0.48-0.55). After controlling for spatially correlated survival data, mortality remained higher among those diagnosed in the earliest diagnostic cohort and lower among non-white patients and those starting HAART with higher viral load and lower CD4 lymphocyte counts. CONCLUSIONS: Universal and free access to HAART has helped achieve impressive declines in AIDS mortality in Brazil. However, after a 10-years follow-up, differential AIDS-related mortality continue to exist. Efforts are needed to identify and eliminate these health disparities, therefore improving the Brazilian response towards HIV/AIDS epidemic.
Assuntos
Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Síndrome da Imunodeficiência Adquirida/mortalidade , Terapia Antirretroviral de Alta Atividade/estatística & dados numéricos , Programas Governamentais/organização & administração , Homossexualidade Masculina , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil/epidemiologia , Contagem de Linfócito CD4 , Países em Desenvolvimento , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Socioeconômicos , Carga Viral , Adulto JovemRESUMO
OBJECTIVE: Brazil accounts for approximately 70% of injection drug users (IDUs) receiving highly active antiretroviral therapy (HAART) in low-income/middle-income countries. We evaluated the impact of HAART availability/access on AIDS-related mortality among IDUs versus men who have sex with men (MSM). DESIGN: Nation-wide analysis on Brazilian IDU and MSM diagnosed with AIDS in 2000-2006. METHODS: Four national information systems were linked, and Cox regression was used to assess impact of HAART availability/access on differential AIDS-related mortality. RESULTS: Among 28,426 patients, 6777 died during 87,792 person-years of follow-up. Compared with MSM, IDU were significantly less likely to be receiving HAART, to have ever had determinations for CD4 or viral load. After controlling for confounders, IDU had a significantly higher risk of death (adjusted hazard ratio: 1.94; 95% confidence interval: 1.84 to 2.05). Among the subset that had at least 1 CD4 and viral load determination, higher risk of death among IDU persisted (hazard ratio: 1.82; 95% confidence interval: 1.58 to 2.11). Nonwhite ethnicity significantly increased this risk, whereas prompt HAART uptake after AIDS diagnosis reduced the risk of death. After controlling for spatially correlated survival data, AIDS-related mortality remained higher in IDU than in MSM. CONCLUSIONS: Despite free/universal HAART access, differential AIDS-related mortality exists in Brazil. Efforts are needed to identify and eliminate these health disparities.