Abstract
BackgroundBrazil was the first middle-income country to provide free and universal access to AIDS treatment. Understanding the impact of this policy is key to promote ongoing improvement of current intervention strategies. The aim of this study was to compare mortality rates and survival in a cohort of AIDS patients before and after the introduction of antiretrovirals (ARV) and to investigate predictors of survival.MethodsA retrospective cohort study of AIDS patients aged 13 years or more living in the city of Sao Paulo was conducted. All patients were recruited from an STD/HIV outpatient clinic between 1988 and 2003 and followed up until 2005. We estimated AIDS mortality rates in person-years (py) and carried out a survival analysis using the Kaplan-Meier method. The Cox proportional hazards model was used to assess predictors of survival in AIDS patients.ResultsThe study cohort comprised 6,594 patients. The yearly mean mortality rates were 17.6, 23.2, and 7.8 per 1,000 py for the study periods 1988-1993, 1994-1996, and 1997-2003, respectively. Median survival time was 13.4 and 22.3 months for patients entering the study in the first and second study periods and survival time was 108 months or more in 72% of those entering the study during 1997-2003. Factors independently associated with shorter survival included: AIDS diagnosis during the 1994-1996 (HR 2.0) and 1988-1993 (HR 3.2) periods; 50 years of age or more (HR 2.0); exposure category of injection drug users (IDU) (HR 1.5); 8 years of schooling or less (HR 1.4); no schooling (HR 2.1); and CD4+ counts between 350 and 500 cells/mm3 (HR 1.2) and less than 350 cells/mm3 at AIDS diagnosis (HR 1.3).ConclusionsThe study showed a strong impact following the introduction of HAART in 1996 with decreased AIDS mortality, increased survival rates, and benefits with early introduction of HAART. However, some groups of patients were less likely to benefit from the new drug regimens. Public policies promoting health equity create an enabling environment helping AIDS control programs in developing countries to achieve their goals as effectively as in developed countries.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-014-0599-8) contains supplementary material, which is available to authorized users.
Highlights
Brazil was the first middle-income country to provide free and universal access to Sexually transmitted diseases (STD)/STD/AIDS Referral and Training Center (AIDS) Referral and Training Center (AIDS) treatment
It shows their distribution according to exposure to different drug regimens and whether or not they died from AIDS-related causes
Compared with pre-highly active antiretroviral therapy (HAART), there was in the postHAART period a lower proportion of injecting drug users (IDU) (13% vs. 28%; p < 0.001) and a greater proportion of heterosexuals (45% vs. 28%, p < 0.001), which can be explained by an increase in the number of nonIDU women infected, and patients with more than eight years of schooling (61% vs. 46%, p < 0.001)
Summary
Brazil was the first middle-income country to provide free and universal access to AIDS treatment. The introduction of highly active antiretroviral therapy (HAART) has dramatically changed the course of the HIV/AIDS epidemic It has decreased AIDS mortality rates and both increased survival and improved quality of life of people living with HIV/AIDS [1]. Understanding the impact of HAART on the survival of AIDS patients and its predictors is key to promote ongoing improvement of current intervention strategies [2]. Brazil was the first middle-income country to provide in 1996 free and universal access to HAART for AIDS treatment [3] This policy resulted in increased survival of people living with AIDS, from an estimated five months during the period 1982–1989 [4] to 58 months among new cases diagnosed in 1996 [5]. A recent study of new cases diagnosed in South and Southeast Brazil during the period 1998–1999 showed a survival time of at least 108 months in 50% of patients after diagnosis [6]
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