Desigualdades no acesso à HAART e diferenças de sobrevida de acordo com a categoria de exposição ao HIV no Rio de Janeiro, Brasil

Lima, Tatiana de Araujo; Beyrer, Chris; Golub, Jonathan E.; Mota, Jurema Corrêa da; Malta, Monica Siqueira; Silva, Cosme Marcelo Furtado Passos da; Bastos, Francisco I.

Acessibilidade / Reportar erro

Brasil

Cadernos de Saúde Pública

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

ARTICLE • Cad. Saúde Pública 34 (8) • 2018 • https://doi.org/10.1590/0102-311X00009617 copiar

Desigualdades no acesso à HAART e diferenças de sobrevida de acordo com a categoria de exposição ao HIV no Rio de Janeiro, Brasil

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo:

Apesar de uma melhora substancial no prognóstico e na qualidade de vida de pessoas vivendo com HIV/aids (PVHA) no Brasil, permanecem desigualdades no acesso ao tratamento. Avaliamos o impacto dessas desigualdades na sobrevida na cidade do Rio de Janeiro ao longo de 12 anos (2000/11). Os dados foram consolidados a partir de quatro bases que constituem o sistema nacional de monitoramento da aids: SINAN-aids (Sistema de Informação de Agravos de Notificação; casos de aids), SISCEL (exames laboratoriais), SICLOM (controle logístico de medicamentos) e SIM (Sistema de Informações sobre Mortalidade), usando relacionamento probabilístico. As regressões de Cox foram ajustadas para avaliar o impacto da HAART (terapia antirretroviral altivamente ativa) na mortalidade relacionada à aids entre homens que fazem sexo com homens (HSH), usuários de drogas injetáveis (UDI) e heterossexuais diagnosticados com aids entre 2000 e 2011 na cidade do Rio de Janeiro. Dos 15.420 casos, 60,7% eram heterossexuais, 36,1% HSH e 3,2% UDI. Houve 2.807 óbitos (18,2%) e a sobrevida mediana foi 6,29 anos. Houve associação significativa entre HAART e contagem de CD4+ > 200 na linha de base e importantes efeitos protetores. Comparados aos brancos, os não-brancos tiveram um risco 33% maior de morrer de aids. Os UDI tiveram um risco 56% maior, enquanto HSH tiveram um risco 11% menor de morrer de aids, comparados aos heterossexuais. Os indivíduos não-brancos, aqueles com menos de oito anos de escolaridade e UDI mostraram probabilidade mais alta de não receber HAART e de morrer de aids. No Rio de Janeiro, persistem desigualdades importantes no acesso ao tratamento, que resultam em impactos diferenciados na mortalidade de acordo com as categorias de exposição. Apesar da persistência dessas disparidades, a mortalidade diminuiu significativamente ao longo do período em todas as categorias analisadas, e o acesso à HAART teve impacto dramático no tempo de sobrevida.

Palavras-chave:
Síndrome de Imunideficiência Adquirida; Análisis de Sobrevida; Mortalidade Diferencial; Iniquidade Social; Terapia Antirretoviral de Alta Atividade

Population characteristics	Outcomes n [% of outcome in each category (95%CI)]
Population characteristics	Proportion of people dying of AIDS	Proportion of who ever received HAART	Proportion of people with CD4 exam at baseline
Ethnicity	p < 0.001	p < 0.001	p < 0.001
White	3,741 [23.1 (22.5-23.7)]	10,195 [63.0 (62.5-63.5)]	7,675 [47.5 (47.0-47.9)]
Non-white	5,058 [30.2 (29.8-30.6)]	9,598 [57.3 (56.8-57.8)]	9,024 [53.9 (53.4-54.4)]
Unspecified	156 [1.5 (1.4-1.6)]	5,360 [52.3 (51.8-52.8)]	5,923 [57.8 (57.3-58.3)]
Level of education (years)	p < 0.001	p < 0.001	p < 0.001
Primary (0-7)	3,413 [22.5 (22.1-22.9)]	8,823 [58.2 (57.7-58.7)]	7,304, 48.2 (47.7-48.7)
Secondary (8-11)	1,068 [14.0 (13.7-14.3)]	5,654 [74.3 (73.9-74.7)]	4,136, 54.3 (53.8-54.8)
Superior/over (12 or more)	163 [3.7 (3.5-3.9)]	4,004 [91.0 (90.7-91.3)]	1,954, 44.4 (43.9-44.9)
Unspecified	4,311 [26.9 (26.5-27.3)]	6,672 [41.6 (41.1-42.1)]	9,228, 57.6 (57.1-58.1)
Exposure category	p < 0.001	p < 0.001	p < 0.001
Heterosexual	1,435 [15.3 (15.0-15.6)]	5,760 [61.6 (61.1-62.1)]	5,096 [54.5 (54.0-55.0)]
MSM	609 [10.9 (10.6-11.2)]	3,588 [64.5 (64.0-65.0)]	2,509 [45.1 (44.6-45.6)]
PWID	123 [24.7 (24.3-25.1)]	219 [44.0 (43.5-44.5)]	201 [40.4 (39.9-40.9)]
Others	32 [13.2 (12.9-13.5)]	153 [63.0 (62.5-63.5)]	135 [55.6 (55.1-56.1)]
Unspecified	6,756 [24.5 (24.1-24.9)]	15,433 [56.0 (55.5-56.5)]	14,681 [53.3 (52.8-53.8)]
Sex	p < 0.01	p = 0.8	p < 0.001
Women	3,074 [19.9 (19.5-20.3)]	9,001 [58.3 (57.8-58.8)]	8,813 [57.1 (56.6-57.6)]
Men	5881, 21.2 (20.8-21.6)	16,152 [58.2 (57.7-58.7)]	13,809 [49.7 (49.2-50.2)]
HIV-1 RNA exam at baseline	p < 0.001	p < 0.001	p < 0.001
No	7,739 [33.5 (33.1-33.9)]	9,372 [40.5 (40.0-41.0)]	3,341 [14.4 (14.1-14.7)]
Yes	1,216, 6.1 (5.9-6.3)	1,5781 [78.6 (78.2-79.0)]	19,281 [96.1 (95.9-96.3)]
CD4+ exam at baseline	p < 0.001	p < 0.001	-
No	7,547 [36.7 (36.2-37.2)]	7,635 [37.1 (36.6-37.6)]	-
Yes	1,408 [6.2 (6.0-6.4)]	17,518 [77.4 (77.0-77.8)]	-
HAART uptake after diagnosis	p < 0.001	-	p < 0.001
Never received HAART	7,564 [41.9 (41.4-42.4)]	-	5,104 [28.3 (27.9-28.7)]
Ever received (or still under) HAART	1,391 [5.6 (5.4-5.8)]	-	17,518 [69.6 (69.2-70.0)]

Characteristics	Exposure category n (% among those with known category)
Characteristics	MSM	PWID	Heterosexual
Subjects	5,564 (36.1)	498 (3.2)	9,358 (60.7)
Sex
Male	5,564 (100.0)	364 (73.1)	3,795 (40.6)
Female	-	134 (26.9)	5,561 (59.4)
Ethnicity
White	2,792 (50.2)	171 (34.3)	3,367 (36.0)
Non-white	1,902 (34.2)	213 (42.8)	4,514 (48.2)
Unspecified	870 (15.6)	114 (22.9)	1,477 (15.8)
Level of education (years)
Primary (0-7)	2,299 (41.3)	295 (59.2)	5,649 (60.4)
Secondary (8-11)	1,615 (29.0)	86 (17.3)	1,960 (20.9)
Superior/over (12 or more)	1,121 (20.2)	26 (5.2)	719 (7.7)
Unspecified	529 (9.5)	91 (18.3)	1,030 (11.0)
HAART uptake after diagnosis
Never received HAART	1,976 (35.5)	279 (56.1)	3,598 (38.4)
Ever received (or still under) HAART	3,588 (64.5)	219 (44.0)	5,760 (61.6)
CD4+ exam at baseline
No	3,055 (54.9)	297 (59.6)	4,262 (45.5)
Yes	2,509 (45.1)	201 (40.4)	5,096 (54.5)
CD4+ lymphocytes (cells/mm³) *
Mean (± SD)	331.0 (±242.59)	298.94 (±217.22)	306.79 (±236.64)
Range	1-2,221	1-984	1-2,867
Median (interquartile range)	292 (319)	258 (300)	269 (298.75)
HIV-1 RNA Viral Load exam at baseline
No	3,286 (59.1)	326 (65.5)	4,846 (51.8)
Yes	2,278 (40.9)	172 (34.5)	4,512 (48.2)
HIV-1 RNA in plasma, log₁₀ copies/mL (first exam available)
Mean (± SD)	3.60 (±1.43)	3.67 (±1.48)	3.60 (±1.40)
Range	1.70-6,82	1.70-6.04	1.70-6.76
Median (interquartile range)	3.95 (3.14)	4.11 (3.31)	3.87 (3.05)
Deaths for every causes
No	4,762 (85.6)	338 (67.9)	7,513 (80.3)
Yes	802 (14.4)	160 (32.1)	1,845 (19.7)
AIDS-related deaths **
No	193 (24.0)	37 (23.1)	410 (22.2)
Yes	609 (76.0)	123 (76.9)	1,435 (77.8)
New AIDS cases through periods
2000-2003	2,055 (32.9)	234 (3.7)	3,958 (63.4)
2004-2007	1,745 (33.3)	164 (3.1)	3,340 (63.6)
2008-2011	1,764 (45.0)	100 (2.5)	2,060 (52.5)

Predictor	Unadjusted HR (95%CI)	Adjusted - Cox model HR (95%CI)	Adjusted - frailty model HR (95%CI)
Exposure category
Heterosexual	1.00	1.00	1.00
MSM	0.77 (0.70-0.85) *	0.85 (0.77-0.93) *	0.89 (0.81-0.98) **
PWID	1.56 (1.30-1.88) *	1.54 (1.28-1.85) *	1.56 (1.30-1.88) *
Age (per year of increase)	1.01 (1.00-1.01) *	1.00 (1.00-1.00)	1.00 (1.00-1.01)
Ethnicity
White	1.00	1.00	1.00
Non-white	1.45 (1.33-1.58) *	1.41 (1.29-1.54) *	1.33 (1.21-1.45) *
Unspecified	0.04 (0.03-0.06) *	0.02 (0.01-0.03) *	0.02 (0.01-0.03) *
HAART uptake after diagnosis
Never received HAART	1.00	1.00	1.00
Ever received (or still under) HAART	0.20 (0.18-0.22) *	0.19 (0.17-0.21) *	0.19 (0.17-0.21) *
CD4+ cells count (cells/mm³) [first exam available]
< 200	1.00	1.00	1.00
200-349	0.49 (0.40-0.60) *	0.51 (0.42-0.63) *	0.51 (0.42-0.63) *
350-499	0.38 (0.29-0.48) *	0.36 (0.29-0.47) *	0.37 (0.29-0.47) *
> 500	0.23 (0.17-0.31) *	0.23 (0.17-0.31) *	0.23 (0.17-0.32) *
Unspecified	1.83 (1.62-2.07) *	1.16 (1.01-1.32) ***	1.24(1.09-1.43) ***
HIV-1 RNA (log₁₀ copies/mL) [first exam]
< 4.00	1.00	Not included in the model	Not included in the model
4.00-4.99	1.86 (1.52-2.27) *
> 5.00	2.20 (1.77-2.73) *
Unspecified	4.05 (3.51-4.67) *
Education (years)
Primary (0-7)	1.00	Not included in the model	Not included in the model
Secondary (8-11)	0.59 (0.52-0.66) *
Superior/over (12 or more)	0.23 (0.17-0.30) *
Unspecified	1.77 (1.57-1.99) *
Estimated frailty variance	-	-	0.11 *

Predictor	Exposure category and model
	MSM		PWID		Heterosexual
	Cox model HR (95%CI)	Frailty model HR (95%CI)	Cox model HR (95%CI)	Frailty model HR (95%CI)	Cox model HR (95%CI)	Frailty model HR (95%CI)
Age (per year of increase)	0.99 (0.98-1.00)	1.00 (0.99-1.00)	0.99 (0.97-1.01)	0.99 (0.97-1.01)	1.00 (0.99-1.01)	1.00 (0.99-1.01)
Ethnicity
White	1.00	1.00	1.00	1.00	1.00	1.00
Non-white	1.54 (1.31-1.81) *	1.42 (1.20-1.67) *	1.84 (1.26-2.69) **	1.97(1.33-2.93) *	1.31 (1.18-1.47) *	1.27 (1.13-1.42) *
Unspecified	0.02 (0.01-0.03) *	0.02 (0.01-0.04) *	***	***	0.02 (0.01-0.03) *	0.02 (0.01-0.03) *
HAART uptake after diagnosis
Never received	1.00	1.00	1.00	1.00	1.00	1.00
Ever received (or still under)	0.17 (0.14-0.20) *	0.17 (0.14-0.21) *	0.29 (0.17-0.49) *	0.30(0.17-0.50) *	0.20 (0.17-0.23) *	0.20 (0.17-0.22) *
CD4+ cells count (cells/mm³)
< 200	1.00	1.00	1.00	1.00	1.00	1.00
200-349	0.47 (0.31-0.71) **	0.46 (0.31-0.70) **	0.68 (0.31-1.50)	0.66 (0.30-1.46)	0.52 (0.41-0.66) *	0.52 (0.41-0.66) *
350-499	0.46 (0.30-0.71) *	0.46 (0.30-0.72) *	0.83 (0.34-2.02)	0.71 (0.27-1.85)	0.31 (0.22-0.42) *	0.31 (0.23-0.43) *
> 500	0.18 (0.10-0.34) **	0.19 (0.10-0.35) *	0.12 (0.02-0.90) ^#	0.13 (0.02-0.98) ^#	0.26 (0.18-0.36) *	0.26 (0.18-0.36) *
Unspecified	1.08 (0.83-1.40)	1.17 (0.89-1.52)	1.26 (0.68-2.33)	1.42 (0.75-2.68)	1.22 (1.03-1.43) ^#	1.28 (1.08-1.50) **
Estimated frailty variance	-	0.12 *	-	0.12	-	0.05 *

Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz Rua Leopoldo Bulhões, 1480 , 21041-210 Rio de Janeiro RJ Brazil, Tel.:+55 21 2598-2511, Fax: +55 21 2598-2737 / +55 21 2598-2514 - Rio de Janeiro - RJ - Brazil
E-mail: cadernos@ensp.fiocruz.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Correspondence
T. A. Lima Departamento de Enfermagem em Saúde Pública, Faculdade de Enfermagem, Universidade do Estado do Rio de Janeiro. Boulevard 28 de Setembro 157, Rio de Janeiro, RJ 20551-030, Brasil. tatirodriguesaraujo@yahoo.com.br