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J Acquir Immune Defic Syndr. 2009 Dec;52(5):629-35. doi: 10.1097/QAI.0b013e3181b31b8a.

Differential survival benefit of universal HAART access in Brazil: a nation-wide comparison of injecting drug users versus men who have sex with men.

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Social Science Department, Sergio Arouca School of Public Health (DCS/ENSP), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.



Brazil accounts for approximately 70% of injection drug users (IDUs) receiving highly active antiretroviral therapy (HAART) in low-income/middle-income countries. We evaluated the impact of HAART availability/access on AIDS-related mortality among IDUs versus men who have sex with men (MSM).


Nation-wide analysis on Brazilian IDU and MSM diagnosed with AIDS in 2000-2006.


Four national information systems were linked, and Cox regression was used to assess impact of HAART availability/access on differential AIDS-related mortality.


Among 28,426 patients, 6777 died during 87,792 person-years of follow-up. Compared with 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 (adjusted hazard ratio: 1.94; 95% confidence interval: 1.84 to 2.05). Among the subset that had at least 1 CD4 and viral load determination, higher risk of death among IDU persisted (hazard ratio: 1.82; 95% confidence interval: 1.58 to 2.11). Nonwhite ethnicity significantly increased this risk, whereas 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.


Despite free/universal HAART access, differential AIDS-related mortality exists in Brazil. Efforts are needed to identify and eliminate these health disparities.

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