title: Effectiveness of first-line antiretroviral therapy in the IPEC cohort, Rio de Janeiro, Brazil.
abstract: BACKGROUND
  While Brazil has had a long-standing policy of free access to antiretroviral therapy (ART) for all in need, the epidemiological impact of ART on human immunodeficiency virus (HIV) RNA suppression in this middle-income country has not been well evaluated. We estimate first-line ART effectiveness in a large Brazilian cohort and examine the socio-demographic, behavioral, clinical and structural factors associated with virologic suppression.
  
  
  METHODS
  Virologic suppression on first-line ART at 6, 12, and 24 months from start of ART was defined as having a viral load measurement ≤400 copies/mL without drug class modification and/or discontinuation. Drug class modification and/or discontinuation were defined based on the class of a particular drug. Quasi-Poisson regression was used to quantify the association of factors with virologic suppression.
  
  
  RESULTS
  From January 2000 through June 2010, 1311 patients started first-line ART; 987 (75%) patients used NNRTI-based regimens. Virologic suppression was achieved by 77%, 76% and 68% of patients at 6, 12 and 24 months, respectively. Factors associated with virologic suppression at 12 months were: >8 years of formal education (compared to <4 years, risk ratio (RR) 1.13, 95% confidence interval (95% CI) 1.03-1.24), starting ART in 2005-2010 (compared to 2000-2004, RR 1.25 95% CI 1.15-1.35), and clinical trial participation (compared to no participation, RR 1.08 95% CI 1.01-1.16). Also at 12 months, women showed less virologic suppression compared to heterosexual men (RR 0.90 95% CI 0.82-0.99). For the 24-month endpoint, in addition to higher education, starting ART in the later period, and clinical trial participation, older age and an NNRTI-based regimen were also independently associated with virologic suppression.
  
  
  CONCLUSIONS
  Our results show that in Brazil, a middle-income country with free access to treatment, over three-quarters of patients receiving routine care reached virologic suppression on first-line ART by the end of the first year. Higher education, more recent ART initiation and clinical trial participation were associated with improved outcomes both for the 12-month and the 24-month endpoints, suggesting that further studies are needed to understand what aspects relating to these factors lead to higher virologic suppression.
authors.affiliation: Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Sandra W
authors.initials: SW
authors.lastname: Cardoso
authors.affiliation: Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Paula M
authors.initials: PM
authors.lastname: Luz
authors.affiliation: Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil ; Departamento de Matemática e Estatística, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brasil.
authors.forename: Luciane
authors.initials: L
authors.lastname: Velasque
authors.affiliation: Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Thiago
authors.initials: T
authors.lastname: Torres
authors.affiliation: Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Lara
authors.initials: L
authors.lastname: Coelho
authors.affiliation: The Divisions of Infectious Disease and General Medicine, and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital and the Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, U.S.A.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.affiliation: Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Valdilea G
authors.initials: VG
authors.lastname: Veloso
authors.affiliation: The Divisions of Infectious Disease and General Medicine, and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital and the Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, U.S.A.
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.affiliation: Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Grinsztejn
keywords: Antiretroviral treatment; Cohort study; Effectiveness; HIV/AIDS; Rio de Janeiro, Brazil