Gender and survival after AIDS in Rio de Janeiro, Brazil

Are there differences in disease progression and mortality among male and female HIV patients on antiretroviral therapy? A meta-analysis of observational cohorts

Studies examining the sex differences in morbidity and mortality among HIV/AIDS patients have yielded inconsistent results. We conducted a meta-analysis of sex differences in disease progression and mortality among HIV/AIDS patients. Medical literature databases from inception to August 2014 were searched for published observational studies assessing sex differences in immunologic and virologic response, disease progression and mortality among HIV-infected patients. Random effects meta-analyses of 115 eligible studies were conducted to obtain pooled estimates of outcomes and heterogeneity was explored in sub-group analyses. Pooled estimates showed an increased risk of progression to AIDS (relative risk [RR]=1.11,95% CI=1.02-1.21) and all-cause mortality (RR=1.23, 95% CI=1.17-1.29) among males compared to females. All-cause mortality differed by sex only in low and middle income countries. The risk of AIDS-related mortality (RR=1.03, 95% CI=0.82-1.30), immunologic failure (RR=1.19,95% CI: 0.97-1.47), virologic suppression (RR=0.98, 95% CI=0.84-1.14), virologic failure (RR=1.26, 95% CI=0.99-1.61) and the change in CD4 cell count (Weighted mean difference [WMD] = -5.15, 95% CI= -13.57 to 3.28) did not differ by sex. These findings were modified by disease severity, adherence and use of highly active antiretroviral therapy. We conclude that HIV-related disease progression and survival outcomes are poorer in males.

Survival benefits of antiretroviral therapy in Brazil: a model-based analysis

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.

Demographic determinants of survival of people living with HIV attending an outpatient reference unit in the city of Três Lagoas, state of Mato Grosso do Sul, Brazil, in the period 1984-2009

INTRODUCTION

While the incidence of HIV infection and AIDS is increasing in small Brazilian cities, epidemiological studies are often conducted in large urban centers.

METHODS

Our group conducted a retrospective analysis of survival determinants among 358 patients who attended a reference unit in a small city.

RESULTS

Death risk was lower among men that had sex with men, patients with an HIV-seropositive partner, and those admitted after highly active antiretroviral therapy (HAART) was available.

CONCLUSIONS

The study documents the striking beneficial effect of HAART. The finding of other groups with improved survival may aid in the development of programmatic strategies.

Gender-related mortality for HIV-infected patients on highly active antiretroviral therapy (HAART) in rural Uganda

The purpose of this study was to examine gender differences in mortality for human immunodeficiency virus (HIV) patients in rural Western Uganda after six months of highly active antiretroviral therapy (HAART). Three hundred eighty five patients were followed up for six months after initiating HAART. Statistical analysis included descriptive, univariate and multivariate methods, using Kaplan-Meier estimates of survival distribution and Cox proportional hazards regression. Mortality in female patients (9.0%) was lower than mortality in males (13.5%), with the difference being almost statistically significant (adjusted hazard ratio for females 0.55; 95% confidence interval [CI]: 0.28-1.07; P = 0.08). At baseline, female patients had a significantly higher CD4+ cell count than male patients (median 147 cells/μL vs 120 cells/μL; P < 0.01). A higher CD4+ cell count and primary level education were strongly associated with better survival. The higher CD4+ cell count in females may indicate that they accessed HAART services at an earlier stage of their disease progression than males. A borderline statistically significant lower mortality rate in females shows that females fare better on treatment in this context than males. The association between lower mortality and higher CD4+ levels suggest that males are not accessing treatment early enough and that more concerted efforts need to be made by HAART programs to reach male HIV patients.

The first ten years: achievements and challenges of the Brazilian program of universal access to HIV/AIDS comprehensive management and care, 1996-2006

A review was carried out of papers published between 1996 and 2006, documenting the introduction of highly active anti-retroviral therapy (HAART) in Brazil. Papers indexed in the MEDLINE and SciELO databases were retrieved using different combinations of keywords related to the management and care of AIDS in the post-HAART era: opportunistic diseases and co-infections, adherence to therapy, survival in the pre- and post-HAART eras, adverse events and side-effects, emergence and possible transmission of resistant viral strains, metabolic and cardiovascular disorders, and issues related to access to care and equity. The review documents the dramatic changes in HIV/AIDS disease progression in the post-HAART era, including an increase in survival and quality of life and a pronounced decrease in the episodes of opportunistic diseases. Notwithstanding such major achievements, new challenges have emerged, including slow evolving co-infections (such as hepatitis C, metabolic and cardiovascular disorders), the emergence of viral resistance, with consequences at the individual level (virological failure) and the community level (primary/secondary resistance at the population level), and impacts on the cost of new therapeutic regimens.

AIDS mortality, "race or color", and social inequality in a context of universal access to highly active antiretroviral therapy (HAART) in Brazil, 1999-2004

Highly active antiretroviral therapy (HAART) has led to a substantial increase in the survival of people living with AIDS, despite heterogeneities among individuals from different socioeconomic strata. The present paper analyzes AIDS deaths in Brazil during a period in which HAART became a key treatment regimen, exploring the hypothesis that "race or color" defines one dimension of socioeconomic inequality in Brazil. AIDS mortality, stratified by gender and "race or color", was calculated using data from the National Mortality System. The rates were highest among individuals classified as "black" and lower among those classified as "mixed-race", with a continuous increase among the later from 1999 to 2004 for men and women. Among individuals classified as "white", mortality rates remained stable among men, but not women. Median age at death among "mixed-race" individuals was lower for both men and women. Differential trends according to gender and "race or color" were highlighted by the present study, indicating the pressing need to further explore the underlying factors that might explain different mortality rates in a context of universal access.

Diferenças de gênero ao acolhimento de pessoas vivendo com HIV em serviço universitário de referência de São Paulo, Brasil

O número de mulheres brasileiras vivendo com HIV aumentou, exigindo dos serviços especializados atenção às demandas femininas. Neste estudo avaliaram-se diferenças de gênero ao acolhimento em serviço de referência no cuidado a pessoas vivendo com HIV em São Paulo, com revisão de 1.072 prontuários de pacientes atendidos entre 1998 e 2002. As mulheres eram mais jovens, mais freqüentemente casadas e heterossexuais e apresentavam menor escolaridade do que os homens à admissão. Enquanto 36% das mulheres realizaram teste anti-HIV por possuírem parceiro soropositivo, 43% dos homens o fizeram por apresentarem sintomas. Ao acolhimento, 55% dos homens e 38% das mulheres tinham AIDS. As mulheres apresentaram contagem de linfócitos CD4+ mais elevada e, mais freqüentemente, carga viral indetectável. Não houve diferença entre os sexos no acesso ao tratamento anti-retroviral após estratificação por estádio clínico. Embora as diferenças sócio-demográficas observadas à admissão apontem para a vulnerabilidade social das mulheres, estas buscaram cuidado especializado em estágios clínicos menos avançados. O conhecimento de características distintivas entre homens e mulheres ao acolhimento pode contribuir para estruturar serviços, aprimorar a assistência e otimizar os benefícios do cuidado.

Treatment at scale in Brazil: a physician's perspective

In 1996, Brazil became the first developing country to provide universal access to antiretroviral therapy (ART), based on a strategy that utilizes an individualized approach to treatment and an open formulary. At the time, the number of patients in need of treatment was less than 15% of what it is today, there were six approved drugs for the treatment of HIV infection (compared with 25 today), and the life expectancy of patients was measured in months and years, not in decades. In recent years, preventable and treatable conditions such as cardiovascular diseases increased significantly faster as causes of death among HIV-infected individuals than in the general population. In the near future there will be a substantial increase in the number of patients in need of therapy and in the number of patients using more complex regimens who also have co-morbidities that impact prognosis. Brazil will thus need to expand its network of treatment facilities, increase its capacity to manage more complex clinical conditions, and decide on the proper balance of sophistication that will be required. As the Brazilian scientific output is not commensurate with its successes in the treatment and prevention of HIV infection, there is little empirical basis to inform decisions on how best to allocate finite resources. The Brazilian response to the HIV/AIDS epidemic, universal access to ART in particular, is an example to other developing countries. The Brazilian experience also shows that operational research should be an integral part of programmes of access to treatment, if their long-term sustainability is to be ensured.

Gender differences in survival in an HIV/AIDS cohort from São Paulo, Brazil

Highly active antiretroviral therapy accounted for significant improvement in AIDS prognosis. However, in areas where access to antiretrovirals is universal, the impact of treatment might have been less remarkable among women. To compare survival between men and women living with HIV, we studied a retrospective cohort of 1072 patients who attended a Brazilian reference center. Time to AIDS-related death was the dependent variable. Medical charts were reviewed to obtain sociodemographic data, clinical, and laboratory outcomes. Cumulative survival probability was estimated by the Kaplan-Meier method and hazard ratios by Cox proportional hazards model. At admission, 55% of men and 38% of women had AIDS. Ninety-one AIDS-related deaths occurred in 6004 person-years of follow-up (PYFU). After adjustment for antiretroviral therapy, predictors of death included: female gender (p = 0.02), age at HIV diagnosis (p = 0.005), lowest CD4 count less than 200 cells/mm(3) (p < 0.001) and highest viral load greater than 100,000 copies per milliliter during follow-up (p = 0.007), having an AIDS-defining illness before admission or during follow-up (p < 0.001). We provide evidence that women have benefited less from care, though admitted to the clinic at earlier stages of HIV disease and offered standardised therapeutic interventions. However, the reasons for such gender differences in survival still remain unclear. Further studies are thus warranted to help recognize factors associated to a higher vulnerability in care among women, what may help establish strategies to enhance care for all people living with HIV and for women, in particular.

Gender differences in lymphocyte populations, plasma HIV RNA levels, and disease progression in a cohort of children born to women infected with HIV

OBJECTIVE

We sought to document gender differences in lymphocyte subsets and plasma RNA levels in a pediatric cohort with presumed minimal hormonal differences (on the basis of age).

METHODS

Blood samples from antiretroviral therapy-treated, HIV-infected children (n = 158) and HIV-uninfected children (n = 1801) who were enrolled in the Women and Infants Transmission Study were analyzed at specified study intervals with consensus protocols, and various parameters were compared.

RESULTS

Antiretroviral therapy-treated, HIV-infected female children had, on average, 0.38 log10 copies per mL lower plasma RNA levels than did their male counterparts, but lymphocyte differences were not noted in this cohort. Despite their higher plasma RNA level, a greater proportion of male children survived through 8 years of age. There were no gender differences with respect to the age of diagnosis of HIV, time to antiretroviral therapy after diagnosis of HIV, or type of antiretroviral therapy. Lymphocyte differences were noted for uninfected children.

CONCLUSIONS

Plasma RNA levels differed among antiretroviral therapy-treated, HIV-infected children according to gender, in a manner similar to that noted in previous pediatric and adult studies. Lymphocyte subsets varied according to gender in a cohort of HIV-exposed but uninfected children. Most importantly, overall mortality rates for this cohort differed according to gender.

Survival of AIDS patients using two case definitions, Rio de Janeiro, Brazil, 1986-2003

BACKGROUND

Recent studies have shown substantial increases in the survival of AIDS patients in developed countries and in Brazil as a result of antiretroviral therapy (ART) and prophylaxis for opportunistic infections. This study compares survival rates using the Brazilian Ministry of Health 2004 and Centers for Disease Control and Prevention (CDC) 1993 case definitions in a large HIV/AIDS referral centre in Rio de Janeiro.

METHODS

Survival after AIDS diagnosis was assessed in a clinic-based cohort of 1415 individuals using the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

There were 393 (88%) deaths from AIDS-related causes and 52 (12%) from unrelated or unknown causes. A total of 205 patients (14%) were lost to follow-up and 765 patients (55%) remained alive until the end of the study. Three-quarters of patients (75%) were still alive 22 months [95% confidence interval (CI) 19-26] after the AIDS diagnosis according to the CDC case definition and 31 months (95% CI 26-36) according to the Ministry of Health case definition. Independent predictors of survival included AIDS defined by CD4 cell count and any use of highly active antiretroviral therapy, with either case definition, and initial stage of the case, with the Ministry of Health case definition.

CONCLUSION

Survival observed in this reference centre is comparable or longer than other international studies, although the choice of case definition criterion influenced findings. Adoption of the Ministry of Health case definition may enhance the ability to track the use of and outcomes from ART among AIDS patients.

[Trends in AIDS incidence and mortality in Brazil, 1985 to 1998]

INTRODUCTION

AIDS mortality is decreasing in Brazil, especially after the introduction of anti-retroviral therapy. A study was conducted to evaluate AIDS incidence and mortality in a certain area of Brazil.

METHODS

The number of AIDS deaths according to sex in the study period, obtained from registry sources, were used as the numerator of mortality rates. From 1985 to 1995, deaths with underlying cause classified as code 279/1 in the 9th International Classification of Diseases (ICD) and, from 1996 onwards, B20 to B24 codes in the 10th Review were considered AIDS cases. SINAN/MS disease compulsory notification data were used as the numerator of incidence rates. Percentage of variation of the incidence and mortality rates were calculated using a Poisson regression model.

RESULTS

In the study period, there were 1,211 AIDS cases and 501 deaths. AIDS incidence increased 21.6% during this period (p<0.05) in both sexes, though higher among women. The mortality rates increased exponentially (122.5%) from 1985 to 1991. From 1991 to 1998, mortality remained steady among men but continued to rise among women.

CONCLUSIONS

Stabilization of AIDS mortality in men may be a reflection of large utilization of anti-retroviral therapy. Increasing mortality rate among women could be due to different epidemic dynamics according to sex. This trend is different from the observed in the rest of Brazil, where there has been a fall in AIDS mortality for both sexes since 1991.

Pneumocystis carinii pneumonia in patients in the developing world who have acquired immunodeficiency syndrome

We review Pneumocystis carinii pneumonia (PCP) in patients in the developing world (i.e., Africa, Asia, the Philippines, and Central and South America) who have acquired immunodeficiency disease (AIDS). During the first decade of the AIDS pandemic, PCP rarely occurred in African adults. More recent reports have noted that PCP comprises a significantly greater percentage of cases of pneumonia than it did in the past. This trend dramatically contrasts with that observed in industrialized nations, where a reduction in the number of cases of PCP has occurred as a result of the widespread use of primary P. carinii prophylaxis and highly active antiretroviral therapy. Throughout the developing world, the rate of coinfection with Mycobacterium tuberculosis and PCP is high, ranging from 25% to 80%. Initiation of treatment when PCP is in an advanced stage may account for the high mortality rates (20%-80%) associated with pediatric PCP in the developing world.

[Aids as underlying and associated causes of death, State of S. Paulo, Brazil, 1998]

OBJECTIVES

To describe the Aids mortality according to its underlying and associated causes of death in the State of S. Paulo in 1998.

METHODS

Mortality and population data for 1998 were obtained from the State Data Analysis System Department (Fundação Sistema Estadual de Análise de Dados - Seade). Causes of death were coded according to the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems.

RESULTS

Aids was the underlying cause in 4,619 deaths, corresponding to the 10th leading cause of death (2.0%) and a mortality rate of 13.1/100,000 population. Male/female death ratio and rate ratios were respectively 2.4 and 2.5. Aids was the second leading cause of death among men aged 20--34 and women aged 25--34 years. Median age at death for women (34.1+/-12.2 years old) was lower than men (36.4+/-10.7 years old) - p<0,001. The main associated causes of Aids deaths were respiratory insufficiency (36.1%), pneumonia (27.0%), tuberculosis (19.6%), septicemia (18.6%), toxoplasmosis (12.2%), P. carinii pneumonia (8.3%) and cachexia (7.9%). Aids was an associated cause of death in additional 84 cases. The main underlying causes of these deaths were malignant neoplasms (28/84), conditions secondary to alcohol abuse (23/84) and diabetes mellitus (7/84). The median age at death due to Aids as an underlying cause (35.7+/-11.2 years old) was lower than the age at death with Aids as an associated cause (39.9+/-11.8 years old - p<0.001).

CONCLUSIONS

Multiple causes of death allow to track part of the Aids natural history and provide additional data to develop adequate and specific preventive actions.

Cellular restoration in HIV infected persons treated with abacavir and a protease inhibitor: age inversely predicts naive CD4 cell count increase

OBJECTIVE

To characterize early and later indices of cellular restoration among HIV-1 infected persons treated with abacavir and one protease inhibitor and to identify predictors of CD4 cell increases.

METHODS

Flow-cytometric analyses of lymphocyte phenotypes among 71 antiretroviral treatment naive adults in a 48 week treatment trial.

RESULTS

During the first 4 weeks of therapy, increases in naive and memory CD4 cells and in B cells were seen; naive CD8 cells increased while CD8 cells remained stable as memory CD8 cells decreased. During the second phase total CD4 and naive CD4 and CD8 cells increased while total CD8 and memory CD8 cells decreased. The numbers of CD4 cells that expressed CD28 increased from a median of 308 x 10(6)/l at baseline to 477 x 10(6)/l at week 48. Higher baseline plasma HIV-1 RNA levels predicted the magnitude of early CD4 (r = 0.35; P = 0.01), memory CD4 (r = 0.38; P = 0.001) and CD28 CD4 cell (r = 0.29; P = 0.01) restoration but was not related to second phase changes. Younger age predicted a greater second phase (but not first phase) increase in naive CD4 cells (r = -0.31; P = 0.03).

CONCLUSIONS

Higher baseline levels of HIV-1 replication determine the magnitude of first phase CD4 cell increases after suppression of HIV-1 replication. Second phase (primarily naive) CD4 cell increases are not related to HIV-1 replication but are inversely relate to age suggesting that thymic potential is a major determinant of long term cellular restoration in HIV-1 infected persons receiving antiretroviral therapy.

HIV disease progression and V3 serotypes in Brazil: is B different from B-Br?

HIV-1 serotype B-Br (GWGR) is rare in the United States but predominates in Brazil. Differences in prognosis for patients infected with serotype B-Br or serotype B (GPGR) have not been addressed previously. In this prospective cohort study, we compared the rate of disease progression between patients infected with the HIV-1 V3 serotype B or B-Br in Brazil. Progression to AIDS or death was studied by the Kaplan-Meier and Cox proportional hazard methods. Among 445 HIV-infected patients who were tested with a specific enzyme immune assay, 204 (46%) had serotype B-Br infection and 127 (28%) had serotype B infection. Both groups were similar with regard to baseline CD4+ cell count, serum HIV RNA viral load, initial clinical stage, and the proportions who were treated with antiretroviral drugs. Patients with serotype B infection were significantly younger (p = 0.005) and tended to report homosexual behavior more frequently (p = 0.08). Mean follow-up was 30 +/- 13.5 months. During the study period, 41 (32%) patients infected with serotype B and 44 (22%) infected with serotype B-Br developed AIDS (p = 0.03). In a regression model adjusted for age and risk factor for HIV infection, progression to AIDS was faster in patients infected with serotype B (hazard ratio [HR] 1.59; 95% CI, 1.03-2.43; p = 0.03). A similar trend was observed in a model that considered AIDS or death as the outcome (HR, 1.43; 95% CI, 0.95-2.0; p = 0.09). These results suggest that patients infected with closely related HIV-1 serotypes may differ in the rate of progression to AIDS and indicate that serotype should be taken into account in HIV vaccine studies in Brazil.

Differential trends in mortality from AIDS in men and women in Brazil (1984-1995)

OBJECTIVE

To analyse trends in AIDS mortality in men and women in Brazil, for the period 1984-1995.

DESIGN AND METHODS

National statistics on yearly numbers of reported deaths by cause, in conjunction with census population counts and inter-censory estimates, were used to calculate age- and sex-specific AIDS mortality rates for Brazil as a whole and for São Paulo and Rio de Janeiro, the two largest cities in Brazil, and those most affected by the AIDS epidemic to date.

RESULTS

Numbers of reported deaths from AIDS have increased yearly in Brazil since 1984, to approximately 15,000 in 1995. The data suggest that after a very dramatic rise in mortality rates, the epidemic may have started to slow even before the introduction of freely available highly-active anti-retroviral therapy, although unequally in terms of both geographical and sex distributions. Women also tended to die at relatively younger ages than men in all areas studied, and by 1995 the impact of AIDS on overall mortality was practically the same for men and women aged 25-34 years (21% in São Paulo).

CONCLUSIONS

Trends in mortality from AIDS in Brazil reflect both the geographical expansion of the epidemic outwards from its original epicentres, and the fact that women are becoming increasingly affected by the AIDS epidemic.