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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

JAIDS Journal of Acquired Immune Deficiency Syndromes: December 2009 - Volume 52 - Issue 5 - p 629-635
doi: 10.1097/QAI.0b013e3181b31b8a
Epidemiology and Social Science

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.

From the *Social Science Department, Sergio Arouca School of Public Health (DCS/ENSP), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil; †Health Information Department, Center for Scientific and Technological Information (DIS/CICT), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil; ‡Department of Epidemiology and Quantitative Methods, Sergio Arouca School of Public Health (DEMQS/ENSP), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil; §Surveillance Unit, Brazilian National STD/AIDS Program, Brasilia, Brazil; ∥Evandro Chagas Clinical Research Institute (IPEC), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil; and ¶Division of International Health and Cross Cultural Medicine, Department of Family and Preventive Medicine at University of California, San Diego (UCSD) School of Medicine, San Diego, CA.

Received for publication December 16, 2008; accepted June 8, 2009.

Dr. Strathdee acknowledges support from the Fogarty International Center, grant R25-TW007500. Dr. Malta acknowledges support from the CICAD/NIDA Competitive Research Award Fund and the University of California Center for AIDS Research (NIAID 5 P30 AI 036214).

Part of this data were presented at the XVII International AIDS Conference, August 3-8, 2008, Mexico City, Mexico.

Correspondence to: Monica Malta, PhD, Oswaldo Cruz Foundation, Rua Leopoldo Bulhoes, 1480-room 905, Manguinhos, Rio de Janeiro, RJ 21041-210, Brazil (e-mail:

© 2009 Lippincott Williams & Wilkins, Inc.