Effectiveness of first-line antiretroviral therapy in the IPEC cohort, Rio de Janeiro, Brazil

Abstract

BackgroundWhile Brazil has had a long-standing policy of free access to antiretroviral therapy (ART) for all in need, the epidemiological impact of ART on human immunodeficiency virus (HIV) RNA suppression in this middle-income country has not been well evaluated. We estimate first-line ART effectiveness in a large Brazilian cohort and examine the socio-demographic, behavioral, clinical and structural factors associated with virologic suppression.MethodsVirologic suppression on first-line ART at 6, 12, and 24 months from start of ART was defined as having a viral load measurement ≤400 copies/mL without drug class modification and/or discontinuation. Drug class modification and/or discontinuation were defined based on the class of a particular drug. Quasi-Poisson regression was used to quantify the association of factors with virologic suppression.ResultsFrom January 2000 through June 2010, 1311 patients started first-line ART; 987 (75%) patients used NNRTI-based regimens. Virologic suppression was achieved by 77%, 76% and 68% of patients at 6, 12 and 24 months, respectively. Factors associated with virologic suppression at 12 months were: >8 years of formal education (compared to <4 years, risk ratio (RR) 1.13, 95% confidence interval (95% CI) 1.03-1.24), starting ART in 2005-2010 (compared to 2000-2004, RR 1.25 95% CI 1.15-1.35), and clinical trial participation (compared to no participation, RR 1.08 95% CI 1.01-1.16). Also at 12 months, women showed less virologic suppression compared to heterosexual men (RR 0.90 95% CI 0.82-0.99). For the 24-month endpoint, in addition to higher education, starting ART in the later period, and clinical trial participation, older age and an NNRTI-based regimen were also independently associated with virologic suppression.ConclusionsOur results show that in Brazil, a middle-income country with free access to treatment, over three-quarters of patients receiving routine care reached virologic suppression on first-line ART by the end of the first year. Higher education, more recent ART initiation and clinical trial participation were associated with improved outcomes both for the 12-month and the 24-month endpoints, suggesting that further studies are needed to understand what aspects relating to these factors lead to higher virologic suppression.

Poor retention in early care increases risk of mortality in a Brazilian HIV-infected clinical cohort

“…In the present analysis, lower education was associated with increased mortality risk. Importantly, lower education has also been associated with virologic failure in this cohort (Cardoso et al, 2014), which likely contributes to our findings. Lower education may be an indicator of lower socio-economic status (Szwarcwald, Souza-Junior, & Damacena, 2010), which has also been associated with increased mortality risk (Burkey et al, 2014).…”

Expanding access to high-cost medicines through the E2 access program in Thailand: effects on utilisation, health outcomes and cost using an interrupted time-series analysis

“…Programmes implemented for increasing access to high-cost medicines are mostly found in developed countries such as Canada, 25–27 Australia, 28 29 England 30 and France, 25 but few studies have evaluated such policies. 28 29 In low and middle income countries, 31 32 policies aim to expand access to oncology medicines or medicines treating global health problems (HIV, malaria and tuberculosis) 31 32 and their evaluations usually focus on the number of patients treated and clinical benefits. 33–35 Our study covers those outcomes and assessed the policy impact on costs for the health system.…”

Retention in Early Care at an HIV Outpatient Clinic in Rio de Janeiro, Brazil, 2000–2013

“…In Brazil, behavioral and social factors associated with lower education level include lower socio-economic status (35), poorer health literacy (36), less healthcare utilization (35), alcohol dependence (37) and STD risk behaviors (38,39). Lower education level has also been associated with poor HIV-related outcomes, such as virologic failure and poor ART adherence (40–42). Thus, in Brazil, education is an indicator of social and behavioral determinants of health, which likely contribute to disparities in HIV related outcomes and retention in early care.…”

“…Consistent with retention studies in high-income settings (8–10), older individuals were more likely to achieve good retention in early care. Young adults are more likely to have poor adherence to ART (40,42,48) and suffer poor HIV-related outcomes, such as virologic failure and virologic rebound (49). However, compared to older age groups, young adults are more likely to experience viral suppression associated with improved retention in HIV care (7).…”