Inequalities in HAART uptake and differential survival according to exposure category in Rio de Janeiro, Brazil

Abstract

Despite substantial improvement in prognosis and quality of life among people living with HIV/AIDS (PLWHA) in Brazil, inequalities in access to treatment remain. We assessed the impact of these inequalities on survival in Rio de Janeiro over a 12-year period (2000/11). Data were merged from four databases that comprise the national AIDS monitoring system: SINAN-AIDS (Brazilian Information System for Notificable Diseases; AIDS cases), SISCEL (laboratory tests), SICLOM (electronic dispensing system), and SIM (Brazilian Mortality Information System), using probabilistic linkage. Cox regressions were fitted to assess the impact of HAART (highly active antiretroviral therapy) on AIDS-related mortality among men who have sex with men (MSM), people who inject drugs (PWID), and heterosexuals diagnosed with AIDS, between 2000 and 2011, in the city of Rio de Janeiro, RJ, Brazil. Among 15,420 cases, 60.7% were heterosexuals, 36.1% MSM and 3.2% PWID. There were 2,807 (18.2%) deaths and the median survival time was 6.29. HAART and CD4+ > 200 at baseline were associated with important protective effects. Non-whites had a 33% higher risk of dying in consequence of AIDS than whites. PWID had a 56% higher risk and MSM a 11% lower risk of dying of AIDS than heterosexuals. Non-white individuals, those with less than eight years of formal education, and PWID, were more likely to die of AIDS and less likely to receive HAART. Important inequalities persist in access to treatment, resulting in disparate impacts on mortality among exposure categories. Despite these persistent disparities, mortality decreased significantly during the period for all categories under analysis, and the overall positive impact of HAART on survival has been dramatic.

HIV-1 Molecular Epidemiology, Transmission Clusters and Transmitted Drug Resistance Mutations in Central Brazil

“…Insufficient data to evaluate the time of HIV-1 infection and conventional sequencing usage may have caused an underestimation of TDRM prevalence (Palmer et al, 2005; Jain et al, 2011; Mohamed et al, 2014). Besides, it has been reported that significant inequalities in access to treatment persists in Brazil, resulting in different impacts on mortality in some groups, such as non-white individuals, or those with poor formal education (Lima et al, 2018).…”

Assessing antiretroviral therapy success in HIV/AIDS morbidity and mortality trends in Brazil, 1990–2017: an interrupted time series study

“…Free and universal access to ART in Brazil has also provided a significant increase in the quality of life and survival of PLHIV. 13 , 14 Equally important, there was a minimization of economic losses, due to the reduction of morbidity and mortality associated with AIDS, with a consequent decrease in public spending on hospitalizations, high cost and high complexity laboratory and clinical procedures. 14 After all, despite the persistence of inequalities in access to ART in the country, mortality decreased significantly, and the expanded access to ART had a dramatic impact on survival time.…”

“…14 After all, despite the persistence of inequalities in access to ART in the country, mortality decreased significantly, and the expanded access to ART had a dramatic impact on survival time. 13…”

“…It is particularly essential evidence for the Brazilian context that, despite a substantial improvement in the prognosis and quality of life of PLHIV, the inequality in access to treatment remains. 13 Due to this inequality, the immediate initiation of ART in asymptomatic adults with CD4 counts greater than 500 cells per μl as recommended may not always be possible in places with limited resources. 31 Thus, changes in protocols over time have been sensitive to these regional differences, and that is why we consider it appropriate to mention the most recent advances in Brazilian guidelines.…”

Measuring the uptake of continuous care among people living with HIV receiving antiretroviral therapy and social determinants of the uptake of continuous care in the southwest of China: a cross-sectional study

“…People living with HIV from a disadvantaged social class are more likely to have a delayed diagnosis, worse access to healthcare, and even worse treatment outcome, which are related to factors such as unemployment, low education, and poor living conditions [ 29 ]. People who inject drugs and other socially disadvantaged and marginalized populations generally suffer late diagnosis and initiate ART in the late stages of infection [ 30 ], compared to MSM who usually initiate ART earlier and are more likely to access HIV-related care, have higher adherence to ART, and experience better treatment outcomes [ 31 ]. Since HIV-acquisition risk has been demonstrated as a primary behavioral factor associated with HIV diagnosis and treatment, the effect of HIV-acquisition risk on uptake of continuous care among people living with HIV receiving ART should be carefully elucidated.…”