Causes of Death among People Living with AIDS in the Pre- and Post-HAART Eras in the City of S(a)over-tildeo Paulo, Brazil

Objective: We examine the trend in causes of death among people living with AIDS in the city of S (a) over tildeo Paulo, Brazil, in the periods before and after the introduction of highly active antiretroviral therapy (HAART), and we investigate potential disparities across districts of residence. Methods: Descriptive study of three periods: pre-HAART (1991-1996); early post-HAART (1997-1999); and late post-HAART (2000-2006). The data source was the S (a) over tildeo Paulo State STD/AIDS Program and S (a) over tildeo Paulo State Data Analysis Foundation. Causes of death were classified by the ICD-9 (1991-1995) and ICD-10 (1996-2006). We estimated age-adjusted mortality rates for leading underlying causes of death and described underlying and associated causes of death according to sociodemographic characteristics and area of residence. We used Pearson's chi-square test or Fisher's exact test to compare categorical variables. Areas of residence were categorized using a socioeconomic index. To analyze trends we apply generalized linear model with Poisson regression. Results: We evaluated 32,808 AIDS-related deaths. Between the pre- and late post-HAART periods, the proportion of deaths whose underlying causes were non-AIDS-related diseases increased from 0.2% to 9.6% (p < 0.001): from 0.01% to 1.67% (p < 0.001) for cardiovascular diseases; 0.01% to 1.62% (p < 0.001) for bacterial/unspecified pneumonia; and 0.03% to 1.46% (p < 0.001) for non-AIDS-defining cancers. In the late post-HAART period, the most common associated causes of death were bacterial/unspecified pneumonia (35.94%), septicemia (33.46%), cardiovascular diseases (10.11%) and liver diseases (8.0%); and common underlying causes, besides AIDS disease, included non-AIDS-defining cancers in high-income areas, cardiovascular diseases in middle-income areas and assault in low-income areas. Conclusions: The introduction of HAART has shifted the mortality profile away from AIDS-related conditions, suggesting changes in the pattern of morbidity, but heterogeneously according to area of residence. There is a need for public policies aimed at adapting health care services to address the new scenario.