Impact of ART on HIV disease under the “Universal antiretroviral treatment program for uninsured population†in Mexico: analysis of an open cohort, 2004-2011 Público

Abstract

In Mexico, universal health care coverage began in 2003 with the legislation of the "Seguro Popular" (SPS) law. Through SPS all outpatient care and antiretroviral therapy (ART) for the treatment of the Human Immunodeficiency Virus (HIV) is provided. However, the scale-up of ART has not been homogeneous throughout the country. Using a monitoring system designed for the surveillance of the distribution of ART at a national level, we studied the cascade of HIV care and the demographic and geographic inequalities linked to HIV care for patients enrolled in care under SPS from 2004 to 2011. The objectives of the study where to describe the immune status of patients at first presentation to care, to assess the quality of care by estimating the time between treatment initiation and achieving a suppressed viral load and to quantify loss to follow-up. Between 2004 and 2011, 63,403 patients entered care under SPS. The male to female ration significantly increased from 3:1 in 2004 to 4:1 in 2011 (p<0.01). The median CD4+ T-lymphocyte (CD4+) count at presentation to care increased from 154 copies/µl in 2004 to 227 copies/µl in 2011. Important differences were observed between states; Mexico City had a median CD4+ count of 289 copies/µl in 2011, while other high prevalence states such as Veracruz and Chiapas had a median CD4+ of less than 200 copies/µl. Time from initiation of treatment to achieving a suppressed HIV-1 RNA viral load significantly decreased from a mean of 10 months in 2004 to 4 months in 2011 (p<0.01). In total, 25% of the cohort was lost to follow-up from 2004 to 2011, and ranged from >30% in some states to 15% in others. There has been an important increase in ART coverage in Mexico through the government funded SPS. However, many challenges remain, including late presentation to care and retention in care. This suggests that programs to improve early diagnosis, linkage to and retention in care need to be implemented in order to achieve better outcomes of ART in Mexico.

Table of Contents

Table of Contents

Introduction ................................................................................................................................... 1

Problem Statement................................................................................................................... 4

Purpose Statement.................................................................................................................... 6

Significance Statement.............................................................................................................. 9

Definition of Terms................................................................................................................ 10

Literature Review ........................................................................................................................ 12

Research....................................................................................................................................... 22

Methods.................................................................................................................................. 22

Results.................................................................................................................................... 25

Discussion.................................................................................................................................... 30

Conclusions and Recommendations......................................................................................... 34

References.................................................................................................................................... 37

Tables and Figures...................................................................................................................... 41

Figure 1. The Spectrum of Engagement in Care.................................................................... 41

Figure 2. The Cascade of HIV Care....................................................................................... 41

Table 1. Characteristics of HIV-infected patients enrolled in SPS by year............................. 42

Figure 3. Median CD4+ and Interquartile Range at first entry into care and proportion of patients entering care with a CD4+ count >350 cells/µl.......................................................................................... 43

Table 2. Data on CD4+ T-Lymphocyte (CD4+) count at first presentation to care.............. 44

Table 3. Predictors of Late Presentation (CD4+ <200 cells/ µl............................................ 45

Figure 4. Kaplan Meier survival estimates from initiation of ART to achieving a serum HIV-1 RNA <50 copies/µl by year of treatment................................................................................................ 46

Figure 5. Time (months) from initiation of ART to achieving a serum HIV- 1RNA <50 copies/µl by CD4+ at entry into care......................................................................................................................... 47

Figure 6. Mean time (months) from initiation of ART to achieving a serum HIV-1 RNA <200 copies/µl by year of treatment............................................................................................................................ 48

Figure 7. CD4+ and HIV-1 RNA test results per year excluding new patients...................... 49

Figure 8. Time from entry into care to death.......................................................................... 50

Figure 9. Time from entry into care to death by CD4+level at entry into care....................... 51

Table 4. Immunologic and Virologic characteristics of deceased patients at last visit........... 52

Table 5. Data on CD4+ T-Lymphocyte (CD4+) count stratified by follow-up status........... 53

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Palavra-chave	cascade of care HIV ART
Committee Chair / Thesis Advisor	Del Rio, Carlos, Emory University
Partnering Agencies	Non-US governmental agency (e.g., Minister of Health in Haiti) University, college or educational institution (other than Emory)

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