Increase in non-AIDS related conditions as causes of death among HIV-infected individuals in the HAART era in Brazil

Abstract

Background: In 1996, Brazil became the first developing country to provide free and universal access to HAART. Although a decrease in overall mortality has been documented, there are no published data on the impact of HAART on causes of death among HIV-infected individuals in Brazil. We assessed temporal trends of mortality due to cardiovascular diseases (CVD), diabetes mellitus (DM) and other conditions generally not associated with HIV-infection among persons with and without HIV infection in Brazil between 1999 and 2004.

Methodology/principal findings: Odds ratios were used to compare causes of death in individuals who had HIV/AIDS listed on any field of the death certificate with those who did not. Logistic regression models were fitted with generalized estimating equations to account for spatial correlation; co-variables were added to the models to control for potential confounding. Of 5,856,056 deaths reported in Brazil between 1999 and 2004 67,249 (1.15%) had HIV/AIDS listed on the death certificate and non-HIV-related conditions were listed on 16.3% in 1999, increasing to 24.1% by 2004 (p<0.001). The adjusted average yearly increases were 8% and 0.8% for CVD (p<0.001), and 12% and 2.8% for DM (p<0.001), for those who had and did not have HIV/AIDS listed on the death certificate, respectively. Similar results were found for these conditions as underlying causes of death.

Conclusions/significance: In Brazil between 1999 and 2004 conditions usually considered not to be related to HIV-infection appeared to become more likely causes of death over time than reported causes of death among individuals who had HIV/AIDS listed on the death certificate than in those who did not. This observation has important programmatic implications for developing countries that are scaling-up access to antiretroviral therapy.

Figure 1. Death Rates and non-HIV-related causes of death.

A–Death rates per 100 000 inhabitants of individuals that had HIV/AIDS listed on the death certificate, 1999–2004 (p-value for trend = 0.67, solid circles) and AIDS mortality as an underlying disease from 1996 to 2004 (open circles). B–Odds ratios and 95% confidence intervals of non-HIV-related causes of death listed on the death certificate in individuals who had and who did not have HIV listed on the death certificate. Slopes of trends are significantly different between the two groups (p-value<0.001)

Figure 2. CVD and DM in HIV-infected/AIDS patients.

Odds ratios and 95% confidence intervals comparing the chance of having the disease listed on the death certificate over time, compared with 1999. A–CVD; B–DM. Slopes for trends are significantly different between groups for CVD (p-value<0.001) and DM (p-value<0.001).