Objective-Brazil accounts for ∼70% of injection drug users (IDU) receiving HAART in low/ middle income countries. We evaluated the impact of HAART availability/access on AIDS-related mortality among IDU versus men who have sex with men (MSM). Design-Nationwide analysis on Brazilian IDU and MSM diagnosed with AIDS in 2000-2006.Methods-Four national information systems were linked and Cox regression was used to assess impact of HAART availability/access on differential AIDS-related mortality.Results-Among 28,426 patients, 6,777 died during 87,792 person-years of follow-up. Compared to MSM, IDU were significantly less likely to be receiving HAART, to have ever had determinations for CD4 or viral load. After controlling for confounders, IDU had a significantly higher risk of death (AHR: 1.94; 95% CI: 1.84-2.05). Among the subset that had at least one CD4 and viral load determination, higher risk of death among IDU persisted (HR: 1.82; 95% CI: 1.58-2.11). Non-white ethnicity significantly increased this risk, while prompt HAART uptake after AIDS diagnosis reduced the risk of death. After controlling for spatially-correlated survival data, AIDS-related mortality remained higher in IDU than in MSM.

This article presents the results of an evaluation of Orientation and Se rological Su pp o rt Ce n t e r s , or Anonymous HIV Testing Ce n t e r s , in the No rtheast of Bra z i l . Methodological triangulation was used to evaluate these health pro g rams and serv i c e s , including qualitative and q u a n t i t a t i ve methodology and pointing to the insufficiency of single-discipline reasoning to encompass phenomena in social organizations. The article also shows results from this triangulation ex p e r i e n c e , seeking to combine Social Sciences and Ep i d e m i o l o gy. It describes the structure and dynamics of these serv i c e s , a n a l y zes the re l a t i o n s h i p s , p e rc e p t i o n s , and re p resentations of the actors, p resents a self-evaluation by the pro f e s s i o n a l s , expounds on some quantitative res u l t s , and discusses some limits and pro b l e m s , as well as proposals to ove rcome them. Key words Pro g ram Eva l u a t i o n ; Health Se rvices Re s e a rc h ; Re s e a rch on Health Pe r s o n n e l ; C o mmunity Health Se rv i c e s ; Ac q u i red Immunodeficiency Sy n d ro m e Resumo Este artigo apresenta os resultados da avaliação dos Ce n t ros de Orientação e Apoio Soro l ó g i c o / C TA/Coas do No rdeste do Pa í s . Pa ra avaliar esses pro g ra m a s / s e rviços de saúde, u t i l i zo use a triangulação de métodos, que consiste na articulação das abordagens quantitativa e qualit a t i va ,m o s t rando a insuficiência da razão unidisciplinar para abranger os fenômenos contidos numa organização social. São também apresentados os resultados dessa experiência de triangul a ç ã o, que busca integrar a epidemiologia e as ciências sociais. Mo s t ra a estrutura formal e dinâ-mica dos serviços inve s t i g a d o s , analisa as re l a ç õ e s , p e rcepções e re p resentações do conjunto de a t o re s , efetua uma auto-avaliação dos pro f i s s i o n a i s , d e m o n s t ra alguns resultados quantitativo s de sua atuação e apresenta os principais limites, p roblemas e propostas de supera ç ã o.

BackgroundIn 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).MethodsFour 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.ResultsAmong 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.ConclusionsUniversal 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.