title: Improvement of HAART in Brazil, 1998-2008: a nationwide assessment of survival times after AIDS diagnosis among men who have sex with men.
abstract: BACKGROUND
  In 1996, Brazil became the first developing country to provide free, universal access to HAART, laboratory monitoring, and clinical care to any eligible patient. As of June 2014, approximately 400,000 patients were under treatment, making it the most comprehensive HIV treatment initiative implemented thus far in a middle-income country, worldwide. The Brazilian epidemic is highly concentrated among men who have sex with men (MSM).
  
  
  METHODS
  Four national information systems were combined and Cox regression was used to conduct retrospective cohort analysis of HAART availability/access on all-cause mortality among MSM diagnosed with AIDS reported to the information systems between 1998-2008, adjusting for demographic, clinical, and behavioral factors and controlling for spatially-correlated survival data by including a frailty effect. Multiple imputation by chained equations was used to handle missing data.
  
  
  RESULTS
  Among 50,683 patients, 10,326 died during the 10 year of period. All-cause mortality rates declined following introduction of HAART, and were higher among non-white patients and those starting HAART with higher viral load and lower CD4 counts. In multivariable analysis adjusted for race, age at AIDS diagnosis, and baseline CD4 cell count, MSM diagnosed in latter periods had almost a 50% reduction in the risk of death, compared to those diagnosed between 1998-2001 (2002-2005 adjHR: 0.54, 95% CI:0.51-0.57; 2006-2008 adjHR: 0.51, 95% CI:0.48-0.55). After controlling for spatially correlated survival data, mortality remained higher among those diagnosed in the earliest diagnostic cohort and lower among non-white patients and those starting HAART with higher viral load and lower CD4 lymphocyte counts.
  
  
  CONCLUSIONS
  Universal and free access to HAART has helped achieve impressive declines in AIDS mortality in Brazil. However, after a 10-years follow-up, differential AIDS-related mortality continue to exist. Efforts are needed to identify and eliminate these health disparities, therefore improving the Brazilian response towards HIV/AIDS epidemic.
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street E7152, Baltimore, MD, 21205, USA. mmalta2@jhsu.edu.|Oswaldo Cruz Foundation - FIOCRUZ, Sergio Arouca National School of Public Health, Department of Social Sciences, Rua Leopoldo Bulhoes, 1480 suite 905 Manguinhos, Rio de Janeiro, RJ, 21041-210, Brazil. mmalta2@jhsu.edu.
authors.forename: Monica
authors.initials: M
authors.lastname: Malta
authors.affiliation: Department of Epidemiology and Quantitative Methods in Health, Oswaldo Cruz Foundation - FIOCRUZ, Sergio Arouca National School of Public Health, Rua Leopoldo Bulhoes, 1480- suite 802 Manguinhos, Rio de Janeiro, 21041-210, Brazil. cfpassos@ensp.fiocruz.br.
authors.forename: Cosme M F P
authors.initials: CM
authors.lastname: da Silva
authors.affiliation: Federal University of Rio de Janeiro, Institute of Public Health Studies, Praça da Prefeitura Universitária Cidade Universitária, Rio de Janeiro, 21941-598, Brazil. monica@iesc.ufrj.br.
authors.forename: Monica Mf
authors.initials: MM
authors.lastname: Magnanini
authors.affiliation: Department of Emergency Medicine, Johns Hopkins Bloomberg School of Public Health Department of Epidemiology, Johns Hopkins Medical Institute, 615 N. Wolfe St, E 7143, Baltimore, MD, 21205, USA. awirtz1@jhu.edu.
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Wirtz
authors.affiliation: Department of Biological Sciences, Rua Leopoldo Bulhoes, Oswaldo Cruz Foundation- FIOCRUZ, National School of Public Health, 1480, suite 21 Manguinhos, Rio de Janeiro, RJ 21041-210, Brazil. aperisse@ensp.fiocruz.br.
authors.forename: André R S
authors.initials: AR
authors.lastname: Perissé
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street E7152, Baltimore, MD, 21205, USA. cbeyrer@jhsph.edu.
authors.forename: Chris
authors.initials: C
authors.lastname: Beyrer
authors.affiliation: School of Medicine, University of California, UCSD 9500 Gilman Drive La Jolla, San Diego, CA, 92093-0507, USA. sstrathdee@ucsd.edu.
authors.forename: Steffanie A
authors.initials: SA
authors.lastname: Strathdee
authors.affiliation: Oswaldo Cruz Foundation - FIOCRUZ, Biblioteca de Manguinhos suite 229 Av. Brasil 4365, Rio de Janeiro, 21045-900, Brazil. francisco.inacio.bastos@hotmail.com.
authors.forename: Francisco I
authors.initials: FI
authors.lastname: Bastos
mesh_terms: 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 / Q000706:statistics & numerical data*; D001938:Brazil / Q000453:epidemiology; D018791:CD4 Lymphocyte Count; D003906:Developing Countries; D006078:Government Programs / Q000458:organization & administration*; D018451:Homosexuality, Male; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D019562:Viral Load; D055815:Young Adult