title: Implementation and Operational Research: Effect of Universal Access to Antiretroviral Therapy on HIV/AIDS Mortality in Mexico 1990-2011.
abstract: BACKGROUND
  Universal coverage of highly active antiretroviral therapy (HAART) for HIV/AIDS in Mexico was achieved in a staggered fashion. First, HAART was made available in 1997 for employees in the formal sector and subsequently, in 2003, for informal sector workers and the unemployed population. We evaluated the impact of this free universal HAART program on HIV/AIDS mortality in the Mexican population aged 15 years or older.
  
  
  METHODS
  Time-series cross-sectional data analysis of standardized HIV/AIDS mortality rates (1990-2011) using marginal linear models with inflection points at 1994, 1997, and 2003.
  
  
  RESULTS
  Men employed in the formal sector experienced the greatest effect of access to HAART, with a 32% reduction in mortality from 1997 to 2011 (P < 0.01). For men in this sector, mortality increased from 1990 to 2003, then stabilizing at 7 deaths per 100,000. For women in the informal sector, mortality increased from 1990 to 2011. We found large between-state variability: mortality decreased by 59% in Mexico City while it increased by 245% in Tabasco during the study period. Six of 32 states achieved statistically significant reductions in mortality while 5 states continued to experience increasing mortality rates despite universal HAART.
  
  
  CONCLUSIONS
  Access to universal HAART has had relative success in Mexico. The heterogeneity of HIV/AIDS mortality by employment status, gender, and state of residence highlight urgent needs to improve health equity with pro-poor and gender-responsive programs and a call for country-specific operational research in HIV/AIDS prevention and treatment. Our results may apply to other countries seeking to implement universal access to antiretroviral therapy.
authors.affiliation: *Centro de Información para Decisiones en Salud Pública, Instituto Nacional de Salud Pública, Cuernavaca, México; †Department of Epidemiology, Emory University, Atlanta, GA; ‡Global Health Sciences, University of California (UC) San Francisco, San Francisco, CA, USA and Emeritus Professor of Public Health, National Institute of Public Health, Mexico; **Centro de Investigación en Sistemas de Salud. Instituto Nacional de Salud Pública México; and ††Dirección General. Instituto Nacional de Salud Pública.
authors.forename: Juan E
authors.initials: JE
authors.lastname: Hernández-Ávila
authors.forename: Lina S
authors.initials: LS
authors.lastname: Palacio-Mejía
authors.forename: Alfonso
authors.initials: A
authors.lastname: Hernández-Romieu
authors.forename: Sergio
authors.initials: S
authors.lastname: Bautista-Arredondo
authors.forename: Jaime
authors.initials: J
authors.lastname: Sepúlveda Amor
authors.forename: Mauricio
authors.initials: M
authors.lastname: Hernández-Ávila
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy* / Q000453:epidemiology / Q000401:mortality*; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D003430:Cross-Sectional Studies; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D016014:Linear Models; D008297:Male; D008800:Mexico / Q000453:epidemiology; D009313:National Health Programs; D012959:Socioeconomic Factors
chemical_list: D019380:Anti-HIV Agents