AIDS mortality disparities in the era following Brazil´s
declaration of ART as a universal right
M.A.S.M. Veras1, W. McFarland2, F.I. Bastos3, K.B. Ribeiro1, M.C.A.S. Ribeiro1, L.F. Jamal4, R.B. Barata1, J.C. Moraes1, A. Reingold5, Grupo de Trabalho AMA-BRASIL
1Faculdade de Ciências Médicas da Santa Casa de São Paulo, Medicina Social, São Paulo, Brazil, 2University of California, San Francisco (USA), San Francisco, United States, 3Fundação Oswaldo Cruz, ICICT, Rio de Janeiro, Brazil, 4Centro de Referência em DST/AIDS de São Paulo, São Paulo, Brazil, 5School of Public Health University of California Berkeley, Epidemiology, Berkeley, United States
Background: Brazil was the first
developing nation to declare universal access to antiretroviral therapy (ART) a
human right and accomplished an early and successful comprehensive scale
up; however, AIDS remains a major cause of mortality in Brazil. We therefore
conducted a national study of AIDS cases to assess care
disparities and reasons for death in the post-ART scale up period in Brazil.
Methods: A case-control study was
conducted including a nationally representative sample of AIDS deaths and
living controls. Data were abstracted from medical records and merged with
information from nation-wide databases of AIDS case reporting, mortality statistics,
ART care, and laboratory testing.
Results: Late diagnosis (AOR 4.60,
95% CI 3.53-5.99) and interrupted (AOR 4.40,95% CI 3.18-6.11) or no use of ART
(AOR 2.40, 95% CI 1.52-3.67) were the strongest predictors of death. Persons
diagnosed by a criterion other than CD4 < 350 also had higher risk of death
(AOR 1.84, 95% CI 1.33-2.56), as did those not receiving any of the recommended vaccines
(AOR, 2.12, 95%CI 1.47-3.06). Presenting with diseases associated with AIDS
(AOR 1.96, 95% CI 1.06-3.63), and co-infection with tuberculosis also confered a higher risk of death (AOR 1.57, 95% CI
1.25-1.98) . IDU exposure category had a borderline association with a higher
odds of death (AOR 1,35, 95% CI 0,97-1,87).
Conclusions: Despite early and
remarkable success, Brazilians continue to die of AIDS in the post-ART scale up
period. Many factors contributing to continued mortality are preventable by
earlier diagnosis through increased HIV testing, wider and earlier use of ART,
and improved quality of care. The methods presented here provide a low-cost
means to efficiently track the impact of the response to the HIV epidemic using
definitive, hard end points such as death.
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