Malta Monica, da Silva Cosme M F P, Magnanini Monica Mf, Wirtz Andrea L, Perissé André R S, Beyrer Chris, Strathdee Steffanie A, Bastos Francisco I
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street E7152, Baltimore, MD, 21205, USA.
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.
BMC Public Health. 2015 Mar 7;15:226. doi: 10.1186/s12889-015-1530-y.
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.
背景：1996年，巴西成为首个为所有符合条件的患者提供免费、普及性高效抗逆转录病毒治疗（HAART）、实验室监测及临床护理的发展中国家。截至2014年6月，约40万名患者正在接受治疗，这使其成为全球中等收入国家迄今实施的最全面的艾滋病毒治疗计划。巴西的艾滋病疫情高度集中在男男性行为者（MSM）中。 方法：整合四个国家信息系统，并采用Cox回归对1998年至2008年期间向信息系统报告的被诊断为艾滋病的男男性行为者中HAART的可及性/获取情况对全因死亡率进行回顾性队列分析，对人口统计学、临床和行为因素进行调整，并通过纳入脆弱效应来控制空间相关的生存数据。采用链式方程多重填补法处理缺失数据。 结果：在50683名患者中，10326人在10年期间死亡。引入HAART后全因死亡率下降，非白人患者以及开始接受HAART时病毒载量较高且CD4细胞计数较低的患者死亡率更高。在对种族、艾滋病诊断时的年龄和基线CD4细胞计数进行调整的多变量分析中，与1998年至2001年期间被诊断的男男性行为者相比，后期被诊断的男男性行为者死亡风险降低了近50%（2002年至2005年调整后风险比：0.54，95%置信区间：0.51 - 0.57；2006年至2008年调整后风险比：0.51，95%置信区间：0.48 - 0.55）。在控制了空间相关的生存数据后，最早诊断队列中被诊断的患者死亡率仍然较高，而非白人患者以及开始接受HAART时病毒载量较高且CD4淋巴细胞计数较低的患者死亡率较低。 结论：免费普及HAART有助于巴西在艾滋病死亡率方面取得显著下降。然而，经过10年随访，与艾滋病相关的死亡率差异仍然存在。需要努力识别并消除这些健康差距，从而改善巴西应对艾滋病毒/艾滋病疫情的状况。
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