title: Survival benefits of antiretroviral therapy in Brazil: a model-based analysis.
abstract: OBJECTIVE
  In Brazil, universal provision of antiretroviral therapy (ART) has been guaranteed free of charge to eligible HIV-positive patients since December 1996. We sought to quantify the survival benefits of ART attributable to this programme.
  
  
  METHODS
  We used a previously published microsimulation model of HIV disease and treatment (CEPAC-International) and data from Brazil to estimate life expectancy increase for HIV-positive patients initiating ART in Brazil. We divided the period of 1997 to 2014 into six eras reflecting increased drug regimen efficacy, regimen availability and era-specific mean CD4 count at ART initiation. Patients were simulated first without ART and then with ART. The 2014-censored and lifetime survival benefits attributable to ART in each era were calculated as the product of the number of patients initiating ART in a given era and the increase in life expectancy attributable to ART in that era.
  
  
  RESULTS
  In total, we estimated that 598,741 individuals initiated ART. Projected life expectancy increased from 2.7, 3.3, 4.1, 4.9, 5.5 and 7.1 years without ART to 11.0, 17.5, 20.7, 23.0, 25.3, and 27.0 years with ART in Eras 1 through 6, respectively. Of the total projected lifetime survival benefit of 9.3 million life-years, 16% (or 1.5 million life-years) has been realized as of December 2014.
  
  
  CONCLUSIONS
  Provision of ART through a national programme has led to dramatic survival benefits in Brazil, the majority of which are still to be realized. Improvements in initial and subsequent ART regimens and higher CD4 counts at ART initiation have contributed to these increasing benefits.
authors.affiliation: The Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil; paula.luz@ipec.fiocruz.br.
authors.forename: Paula M
authors.initials: PM
authors.lastname: Luz
authors.affiliation: Medical Practice Evaluation Center, Massachusetts General Hospital Boston, MA, USA.|Division of General Internal Medicine, Massachusetts General Hospital Boston, MA, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Girouard
authors.affiliation: The Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Grinsztejn
authors.affiliation: Medical Practice Evaluation Center, Massachusetts General Hospital Boston, MA, USA.|Division of General Internal Medicine, Massachusetts General Hospital Boston, MA, USA.|Division of Infectious Disease, Massachusetts General Hospital Boston, MA, USA.|Harvard University Center for AIDS Research, Harvard Medical School Boston, MA, USA.|Department of Epidemiology, Boston University School of Public Health Boston, MA, USA.|Department of Health Policy and Management, Harvard School of Public Health Boston, MA, USA.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.affiliation: The Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Valdilea G
authors.initials: VG
authors.lastname: Veloso
authors.affiliation: Medical Practice Evaluation Center, Massachusetts General Hospital Boston, MA, USA.|Harvard University Center for AIDS Research, Harvard Medical School Boston, MA, USA.|Department of Orthopedic Surgery, Brigham and Women's Hospital Boston, MA, USA.|Department of Biostatistics, Boston University School of Public Health Boston, MA, USA.
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.affiliation: The Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Claudio J
authors.initials: CJ
authors.lastname: Struchiner
authors.affiliation: Medical Practice Evaluation Center, Massachusetts General Hospital Boston, MA, USA.|Division of General Internal Medicine, Massachusetts General Hospital Boston, MA, USA.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: MacLean
authors.affiliation: Medical Practice Evaluation Center, Massachusetts General Hospital Boston, MA, USA.|Harvard University Center for AIDS Research, Harvard Medical School Boston, MA, USA.|Biostatistics Center, Massachusetts General Hospital Boston, MA, USA.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Parker
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.
authors.forename: A David
authors.initials: AD
authors.lastname: Paltiel
authors.affiliation: Medical Practice Evaluation Center, Massachusetts General Hospital Boston, MA, USA.|Division of General Internal Medicine, Massachusetts General Hospital Boston, MA, USA.|Division of Infectious Disease, Massachusetts General Hospital Boston, MA, USA.|Harvard University Center for AIDS Research, Harvard Medical School Boston, MA, USA.|Division of Infectious Disease, Brigham and Women's Hospital Boston, MA, USA.
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001938:Brazil; D018791:CD4 Lymphocyte Count; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000401:mortality; D006801:Humans; D008017:Life Expectancy; D008962:Models, Theoretical
chemical_list: D019380:Anti-HIV Agents
keywords: Brazil; HIV; Latin America; highly active antiretroviral therapy; modelling; survival