Differential survival benefit of universal HAART access in Brazil: a nation-wide comparison of injecting drug users versus men who have sex with men.
OBJECTIVE
Brazil accounts for approximately 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).


METHODS
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.
Malta
Monica
M
Social Science Department, Sergio Arouca School of Public Health (DCS/ENSP), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil. momalta@cict.fiocruz.br
Bastos
Francisco I
FI
da Silva
Cosme M F P
CM
Pereira
Gerson Fernando Mendes
GF
Lucena
Francisca F A
FF
Fonseca
Maria G P
MG
Strathdee
Steffanie A
SA
D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy / Q000401:mortality*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D023241:Antiretroviral Therapy, Highly Active; D001938:Brazil / Q000453:epidemiology; D016208:Databases, Factual; D003906:Developing Countries; D015497:HIV-1; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D018451:Homosexuality, Male; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D015819:Substance Abuse, Intravenous
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