Survival benefit of universal HAART access in Brazil: a ten-years nation-wide comparison
Presented by Monica Malta (Brazil).
M. Malta1, C.M. Furtado Passos da Silva2, G.F. Mendes Pereira3, A.I. Alves de Sousa3, F.I. Bastos4, S.A. Strathdee5
1Oswaldo Cruz Foundation - FIOCRUZ, Social Science Department, Sergio Arouca School of Public Health (DCS/ENSP), Rio de Janeiro, Brazil, 2Oswaldo Cruz Foundation - FIOCRUZ, Department of Epidemiology and Quantitative Methods, Rio de Janeiro, Brazil, 3Brazilian National STD/AIDS and Viral Hepatitis Program, Surveillance Unit, Brasilia, Brazil, 4Oswaldo Cruz Foundation - FIOCRUZ, Health Information Department, Rio de Janeiro, Brazil, 5University of California San Diego, Division of International Health and Cross Cultural Medicine, San Diego, United States
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 Dec 2009, approximately 200,000 patients were under treatment, making it the most comprehensive HIV treatment initiative implemented thus far in a middle-income country, worldwide. However, no nation-wide evaluation has been conducted using longitudinal information of all people living with AIDS receiving treatment in Brazil.
Methods: Four national information systems were linked, and Cox regression was used to assess impact of HAART availability/access on AIDS-related mortality among injection drug users (IDU), men who have sex with men (MSM) and heterosexuals diagnosed with AIDS from 1998-2008, adjusting for demographic, clinical, and behavioral factors and controlling for spatially-correlated survival data by including a frailty effect.
Results: Among 382,012 patients (55.2% women), 121,346 died during 10 years of follow-up. AIDS mortality rates for both men and women and for all exposure categories declined following introduction of HAART. Heterosexual/female patients were diagnosed earlier and presented the lowest case-fatality rate, followed by MSM, heterosexual male, and injecting drug users. In multivariable analysis adjusted for sex, ethnicity, age at AIDS diagnosis, and baseline CD4 cell count, IDU had had significant increased risk of death after 10 years of follow-up, followed by heterosexual male, MSM and heterosexual female (p< 0.001). After controlling for spatially correlated survival data, AIDS-related mortality remained higher among IDU.
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 between male/female, and, most importantly, across major exposure categories - where IDU seem to benefit less from HAART access, having higher mortality. Efforts are needed to identify and eliminate these health disparities, therefore improving the Brazilian response towards HIV/AIDS epidemic.
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