HIV and Hepatitis infection among End Stage Renal Disease Patients in Brazil Open Access

Pereira de Almeida, Isabel (2014)

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Background: This study aims to examine the survival differences of HIV, HCV, and HBV-positive positive patients among the ESRD population in Brazil. This study will compare survival amongst groups of mono-infected people in the population as well as the survival associated with patients who seroconverted to become co- or multiply-infected with a second infection of HIV, HCV, or HBV during renal replacement therapy.

Methods: The dataset used in this study is part of a larger database of all ESRD patients in hemodialysis treatment through SUS in Brazil. The inclusion criteria for the final dataset include having one of the following infections: HIV, HCV, or HBV at the initiation of ESRD treatment or start of study period (January 2000-December 2012). The covariates are age, sex, race, region of residence, and year of entry into study. The outcome variable of interest is death, and the time-dependent covariate is seroconversion with another infection. The time-dependent covariate defines the two study groups being compared; mono-infected and multiply-infected. Statistical analyses used in this study include univariate and multivariate analysis, Kaplan-Meier curves, and an extended Cox model to calculate hazard ratios and determine if there is any significant difference in survival time between the two groups of interest.

Results: Multiple-infection (HR 1.68, 95% CI (1.36, 2.08)) is significantly associated with increased risk of mortality when compared to mono-infected patients in ESRD treatment in SUS in Brazil. Male sex (OR 1.43, 95% CI (1.19, 1.71)) and residence in the South region (OR 1.38, 95% CI (1.13, 1.67)) are associated with increased odds of seroconversion in this population.

Discussion: There is a significant risk of mortality in multiply-infected patients in ESRD treatment in Brazil when compared to mono-infected patients. Although there were several limitations to this study, like grouping of similar yet different diseases into the same category, the strengths include having a large sample size, long study period and comparable demographic distributions matched to other studies in similar populations. The results of this study are important and relevant to the treatment of ESRD patients in Brazil, especially for the continued study of multiply-infected individuals.

Table of Contents

Abbreviations i
Chapter 1: Introduction 1
Study Aims 1
Background 2
Purpose Statement 4
Research Questions 4
Significance Statement 5
Chapter 2: Literature Review 6
HIV in Brazil 6
HIV Population shift 8
Hepatitis 9
Hepatitis B Virus 9
Hepatitis C Virus 10
Co-infection 10
HIV/HCV co-infection globally 10
HIV/HCV co-infection in Brazil 11
HIV/HBV co-infection in Brazil 13
End Stage Renal Disease 13
ESRD in Brazil 13
ESRD and Hepatitis in Brazil 15
ESRD and HIV 16
ESRD, HIV and Hepatitis 17
Conclusion 18
Chapter 3: Methods 20
Study Population 21
Inclusion criteria 21
Covariates 22
Survival Time 23
Statistical Analysis 23
Conclusion 24
Chapter 4: Results 25
Demographics 25
Demographics at baseline 25
Demographics of exposure groups 27
Survival Analysis 29
Overall survival 29
Survival time 29
Kaplan-Meier curves 30
Extended Cox Model with time-dependent covariate 30
Conclusion 31
Chapter 5: Discussion 32

Summary of Findings 32
Public Health implications 34
Limitations 34
Strengths 35
Future studies 36
Conclusion 36
Tables and Figures 38
References 46

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