Faculty of Health Sciences, Postgraduate Program in Public Health, University of Brasilia, Brasilia, Brazil.
Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France.
AIDS. 2020 Oct 1;34(12):1843-1854. doi: 10.1097/QAD.0000000000002621.
Despite free access to antiretroviral therapy (ART) from 1996 onward, and treatment for all people living with HIV (PLWHIV) from 2013, mortality in Brazil has not homogeneously decreased. We investigated to what extent delayed ART, hepatitis coinfections and sociodemographic factors predict all-cause mortality in Brazilian PLWHIV.
We included PLWHIV at least 18 years, with complete CD4 cell count data, followed up between 2007 and 2015 in Brazil.
After multiple imputation, an extended Cox model helped estimate the effects of fixed and time-varying covariates on mortality.
The study population (n = 411 028) were mainly male (61%), white (55%), 40 years or less (61%), heterosexually HIV infected (71%), living in the Southeast region (48%) and had basic education (79%). Hepatitis C virus and hepatitis B virus coinfection prevalences were 2.5 and 1.4%, respectively. During a 4-year median follow-up, 61 630 deaths occurred and the mortality rate was 3.45 (95% confidence interval: 3.42-3.47) per 100 person-years. Older age, male sex, non-white ethnicity, illiteracy/basic education and living outside the Southeast and Central-West regions were independently associated with increased mortality. The main modifiable predictors of mortality were delayed ART (i.e. CD4 cell count <200 cells/μl at ART initiation) (adjusted population attributable fraction: 14.20% [95% confidence interval: 13.81-14.59]), being ART-untreated (14.06% [13.54-14.59]) and ART-treated with unrecorded CD4 at ART initiation (5.74% [5.26-6.21]). Hepatitis C virus and hepatitis B virus coinfections accounted for 2.44 [2.26-2.62] and 0.42% [0.31-0.53] of mortality, respectively.
The current study demonstrates that besides early ART and coinfection control, actions targeting males, non-whites and illiterate people and those with basic education are important to reduce avoidable deaths among Brazilian PLWHIV.
尽管自 1996 年以来艾滋病毒感染者可免费获得抗逆转录病毒治疗（ART），且自 2013 年以来所有艾滋病毒感染者（PLWHIV）都可获得治疗，但巴西的死亡率并未均匀下降。我们研究了延迟接受 ART、肝炎合并感染和社会人口因素对巴西 PLWHIV 全因死亡率的影响程度。
我们纳入了至少 18 岁、CD4 细胞计数完整数据、2007 年至 2015 年期间在巴西接受随访的 PLWHIV。
采用多次插补后，扩展的 Cox 模型有助于评估固定和时变协变量对死亡率的影响。
研究人群（n=411028）主要为男性（61%）、白人（55%）、40 岁或以下（61%）、异性恋 HIV 感染者（71%）、居住在东南部（48%）和具有基本教育程度（79%）。丙型肝炎病毒和乙型肝炎病毒合并感染率分别为 2.5%和 1.4%。在中位随访 4 年期间，有 61630 人死亡，死亡率为 3.45（95%置信区间：3.42-3.47）/100 人年。年龄较大、男性、非白种人、文盲/基本教育程度以及居住在东南部和中-西部地区以外，与死亡率增加相关。死亡率的主要可改变预测因素是延迟接受 ART（即 ART 起始时 CD4 细胞计数<200 个/μl）（调整人群归因分数：14.20%[95%置信区间：13.81-14.59%]）、未接受 ART 治疗（14.06%[13.54-14.59%]）和 ART 起始时 CD4 未记录但接受 ART 治疗（5.74%[5.26-6.21%]）。丙型肝炎病毒和乙型肝炎病毒合并感染分别占死亡率的 2.44%[2.26-2.62%]和 0.42%[0.31-0.53%]。
本研究表明，除了早期接受 ART 和控制合并感染外，针对男性、非白种人、文盲和具有基本教育程度的人群以及针对东北部和中西部地区以外人群的行动，对于降低巴西 PLWHIV 的可避免死亡率至关重要。
