CHANGES IN CAUSES OF DEATH IN HIV/AIDS PATIENTS IN BRAZIL IN THE HAART ERA

The introduction and widespread use of highly active antiretroviral therapy (HAART) in the past decade has changed the profile of HIV/AIDS epidemic. Marked decreases in mortality and morbidity have been reported in low- and high-income settings. Recently, significant relative increases in non-AIDS-associated conditions in HIV-infected individuals have been reported in developed countries.In Brazil, where access to HAART has been universal for all eligible patients since 1996, a steep decrease in mortality among HIV/AIDS patients has also been documented, but the rates have been stable since 1999. So far, no data have been available about the pattern of non-HIV-related mortality in these patients. In these studies, we assessed temporal changes in causes of death among HIV-infected patients in Brazil.In the first paper using Brazilian national mortality data, we demonstrate that, between 1999 and 2004, the odds of having conditions not usually considered to be related to HIV-infection among individuals who had HIV/AIDS listed on their death certificate significantly increased over time. Specific diseases that increased were cardiovascular diseases and diabetes mellitus.In the second paper, we studied temporal trends in cause of death in a cohort of HIV-infected patients in Rio de Janeiro. Results showed an increase of non-AIDS causes of death and a decrease of AIDS causes of death in HIV-infected patients, which appeared to be driven by an aging of the population.This cohort study was facilitated by a linkage algorithm that was developed to recover vital status from patients lost to follow-up. In a third paper that validated the algorithm, sensitivity and specificity were found to be 95% and 100%, respectively. In addition, the use of the algorithm led to a 50% increase in the observed mortality rate.These findings have major public health and programmatic implications for developing countries that are scaling-up access to antiretroviral therapy. In the HAART era, HIV infection has become a manageable disease and is now associated with an increase in chronic illness. Public health measures that are not normally targeted to this population need to be included in their regular care, such as smoking cessation, lipid-lowering drugs, and hypertension control