Lack of Prior Antiretroviral Therapy is Associated with Increased Mortality Among Hospitalized Patients with AIDS in São Paulo, Brazil

Brazil has the highest incidence of AIDS cases in Latin America. More than 170,000 cases have been reported in the last 20 years, 25 percent of these from the city of São Paulo. HIV/AIDS is the second cause of death of 24- to 40-year-old males in São Paulo. A major decrease in morbidity and mortality has been reported in developed countries after the use of combined antiretroviral therapy (ART). Even though HIV/AIDS is becoming a controllable disease, it is has been suspected that HIV drug resistance may lead to more treatment, hospitalization and disease progression. The authors in this study attempted to identify risk factors for AIDS death among patients who were hospitalized in November 1998 in a clinical setting where ART is widely available.

Clinical charts were reviewed from patients with HIV/AIDS who were hospitalized during November 1998 at the Institute of Infectious Diseases Emilio Ribas (IIER) teaching hospital in São Paulo. Gender, risk factors for HIV transmission, time of hospitalization, estimated time for diagnosis of HIV/AIDS, and the use of ART information were collected.

The mortality rate in adults with AIDS decreased significantly from 29 percent in 1995 to 19.8 percent in 1999. Also, the average hospitalization time decreased by 4 days from 20 days in 1998 to 16 days in 1999. The authors noted that the number of deaths per 1,000 patients per year has also been decreasing over time, from 21 in 1995 to 10 in 1999.

In 1998, 1,455 adult AIDS patients were hospitalized at IIER. The clinical charts of the 111 AIDS patients hospitalized in November were reviewed. Eighty-six of them were released (mean age 35) and 25 died (mean age 37) during that period. Sixty-four males (79 percent, mean age 35) were survivors and 17 (21 percent, mean age 37) were nonsurvivors. Twenty-two women (73 percent, mean age 36) survived and 8 (27 percent, mean age 35) died.

The distribution of risk was as follows: 25 men who had sex with men (MSM) (23 percent); 22 intravenous drug users (IDU) (20 percent); 36 with heterosexual contacts (32 percent); 25 others or unknown risk (23 percent). There was no statistical difference between survivors and nonsurvivors regarding gender, age, risk factors, number of previous hospitalizations before outcome or type/number of previous opportunistic infections. The authors observed an increased risk for death among the patients with AIDS who had never had antiretroviral therapy.

The authors were able to determine the length of treatment in only 72 patients. In this subgroup, 9 of 56 (12 percent) survivors and 10 of 16 (69 percent) nonsurvivors had not been on ART for 10 weeks prior to admission. Overall, the mean time for ART was 63 and 44 weeks for the survivors and nonsurvivors, respectively. Survivors used similar time of therapy (two or three drugs), whereas patients who died used ART less than 13 weeks for 2 drugs and 10 weeks for 3 drugs. In contrast, survival was associated with previous use of three or more antiretroviral drugs when compared to naive for ART patients.

The authors recommended an aggressive campaign for HIV antibody screening among the at-risk populations in Brazil to ensure that ART is provided before moderate or severe immune suppression is established and the risk of appearance of opportunistic infections is higher, thus improving the recovery rate and avoiding the risk of death.

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