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JAIDS Journal of Acquired Immune Deficiency Syndromes:
doi: 10.1097/QAI.0b013e3181b31b8a
Epidemiology and Social Science

Differential Survival Benefit of Universal HAART Access in Brazil: A Nation-Wide Comparison of Injecting Drug Users Versus Men Who Have Sex With Men

Malta, Monica PhD*; Bastos, Francisco I PhD†; da Silva, Cosme M F P PhD‡; Pereira, Gerson Fernando Mendes MD§; Lucena, Francisca F A BS§; Fonseca, Maria G P PhD‖; Strathdee, Steffanie A PhD¶

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Objective: Brazil accounts for ∼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.

© 2009 Lippincott Williams & Wilkins, Inc.


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