title: Health outcomes among HIV-positive Latinos initiating antiretroviral therapy in North America versus Central and South America.
abstract: BACKGROUND
  Latinos living with HIV in the Americas share a common ethnic and cultural heritage. In North America, Latinos have a relatively high rate of new HIV infections but lower rates of engagement at all stages of the care continuum, whereas in Latin America antiretroviral therapy (ART) services continue to expand to meet treatment needs. In this analysis, we compare HIV treatment outcomes between Latinos receiving ART in North America versus Latin America.
  
  
  METHODS
  HIV-positive adults initiating ART at Caribbean, Central and South America Network for HIV (CCASAnet) sites were compared to Latino patients (based on country of origin or ethnic identity) starting treatment at North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) sites in the United States and Canada between 2000 and 2011. Cox proportional hazards models compared mortality, treatment interruption, antiretroviral regimen change, virologic failure and loss to follow-up between cohorts.
  
  
  RESULTS
  The study included 8400 CCASAnet and 2786 NA-ACCORD patients initiating ART. CCASAnet patients were younger (median 35 vs. 37 years), more likely to be female (27% vs. 20%) and had lower nadir CD4 count (median 148 vs. 195 cells/µL, p<0.001 for all). In multivariable analyses, CCASAnet patients had a higher risk of mortality after ART initiation (adjusted hazard ratio (AHR) 1.61; 95% confidence interval (CI): 1.32 to 1.96), particularly during the first year, but a lower hazard of treatment interruption (AHR: 0.46; 95% CI: 0.42 to 0.50), change to second-line ART (AHR: 0.56; 95% CI: 0.51 to 0.62) and virologic failure (AHR: 0.52; 95% CI: 0.48 to 0.57).
  
  
  CONCLUSIONS
  HIV-positive Latinos initiating ART in Latin America have greater continuity of treatment but are at higher risk of death than Latinos in North America. Factors underlying these differences, such as HIV testing, linkage and access to care, warrant further investigation.
authors.affiliation: Investigaciones Clínicas, Fundación Huésped, Buenos Aires, Argentina; carina.cesar@huesped.org.ar.
authors.forename: Carina
authors.initials: C
authors.lastname: Cesar
authors.affiliation: Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: John R
authors.initials: JR
authors.lastname: Koethe
authors.affiliation: Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Giganti
authors.affiliation: Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Rebeiro
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Keri N
authors.initials: KN
authors.lastname: Althoff
authors.affiliation: Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
authors.forename: Sonia
authors.initials: S
authors.lastname: Napravnik
authors.affiliation: Department of Internal Medicine, Universidad Central del Caribe, Bayamón, Puerto Rico.
authors.forename: Angel
authors.initials: A
authors.lastname: Mayor
authors.affiliation: Instituto de Pesquisa Clinica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Grinsztejn
authors.affiliation: Fundación Arriarán and Facultad de Medicina, Universidad de Chile, Santiago, Chile.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Wolff
authors.affiliation: Instituto Hondureño de Seguridad Social and Hospital Escuela Universitario, Tegucigalpa, Honduras.
authors.forename: Denis
authors.initials: D
authors.lastname: Padgett
authors.affiliation: Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, Mexico.
authors.forename: Juan
authors.initials: J
authors.lastname: Sierra-Madero
authors.affiliation: Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Gotuzzo
authors.affiliation: Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Sterling
authors.affiliation: Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.
authors.forename: James
authors.initials: J
authors.lastname: Willig
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA.
authors.forename: Julie
authors.initials: J
authors.lastname: Levison
authors.affiliation: Division of Infectious Diseases, University of Washington, Seattle, WA, USA.
authors.forename: Mari
authors.initials: M
authors.lastname: Kitahata
authors.affiliation: Infectious Diseases Section, Michael E. De Bakey VAMC, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Maria C
authors.initials: MC
authors.lastname: Rodriguez-Barradas
authors.affiliation: Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
authors.forename: Richard D
authors.initials: RD
authors.lastname: Moore
authors.affiliation: Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: Catherine
authors.initials: C
authors.lastname: McGowan
authors.affiliation: Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: Bryan E
authors.initials: BE
authors.lastname: Shepherd
authors.affiliation: Investigaciones Clínicas, Fundación Huésped, Buenos Aires, Argentina.
authors.forename: Pedro
authors.initials: P
authors.lastname: Cahn
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D002170:Canada; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006630:Hispanic or Latino; D006801:Humans; D008297:Male; D009656:North America; D016016:Proportional Hazards Models; D013020:South America; D016896:Treatment Outcome; D014481:United States
chemical_list: D019380:Anti-HIV Agents
keywords: HIV; Latin America; North America; antiretroviral therapy; cohort studies; highly active; mortality