Predictors of progression to AIDS after HIV infection diagnosis in the pre- and post-HAARTeras in a Brazilian AIDS-free cohort Mariza Vono Tancredi a and Eliseu Alves Waldman b, * a STD/AIDS Referral and Training Center, Department of Health, Sa ˜o Paulo, Brazil; b Department of Epidemiology, School of Public Health, University of Sa ˜o Paulo, Avenida Doutor Arnaldo 715, Cerqueira Ce ´sar, Sa ˜o Paulo SP, CEP 01246-904, Brazil *Corresponding author: Tel: +55 11 3061-7109; E-mail: eawaldma@usp.br Received 7 October 2013; revised 13 March 2014; accepted 17 March 2014 Background: The impact of HAART (highly active antiretroviral therapy) on the time for progression from HIVdiag- nosis to AIDS (TPHA) has been little studied in middle-income countries. This study aimed to analyze the TPHA in the pre- and post-HAART eras and to investigate its predictors. Method: We carried out a retrospective cohort study, including 1879 AIDS-free HIV-infected individuals diag- nosed between 1988 and 2003 and followed up until 2005. The incidences of AIDS were estimated in person- years. The Kaplan–Meier method was applied to estimate TPHA and the Cox proportional hazard model used to assess predictors of TPHA. Results: AIDS incidence decreased from 12.8 to 5.0 per 1000 person-years over the period 1992 to 2003. TPHA (cumulative probability of AIDS-free time) for the maximum follow-up of 9 years was 21.9% among untreated individuals and 76.8% among those on HAART. Predictors of shorter TPHA included non-HAARTART treatment; no treatment; age ≥50 years; black/brown skin color; injection drug use; no schooling; and baseline CD4 lower than 500 cells/mm 3 . Conclusion: HAART has decreased AIDS incidence, prolonged life and increased the number of people living with HIV/AIDS. The post-HAART era presents new challenges to healthcare services in middle-income countries, the main requirements being enhanced strategies focused on early diagnosis, more resource allocation and devel- oping approaches for healthcare systems to manage AIDS as a chronic disease. Keywords: AIDS, AIDS-free time, HAART, HIV Introduction The introduction of highly active antiretroviral therapy (HAART) has dramatically changed the course of the HIV/AIDS epidemic. It has increased survival and improved quality of life for people liv- ing with HIV/AIDS and reduced viral loads, thus potentially redu- cing HIV transmission. 1 It has also increased time for progression from HIV infection to AIDS. 2 The best time to start HAART has not yet been well established, but studies have suggested more lasting benefits when therapy is started with baseline CD4+ counts above 200 cells/mm 3 , i.e., before an individual’s immune function is significantly impaired. 3–5 Patients with lower CD4+ counts receiving antiretro- viral therapy (ART) may have persistent immune dysfunction des- pite increased CD4+ counts, which contrasts with more favorable outcomes evidenced when therapy is initiated earlier. 6–8 Since 2008, the Brazilian Ministry of Health has recommended the introduction of ART in asymptomatic HIV-infected individuals with CD4+ counts of 200–350 cells/mm 3 . 9 Few studies of AIDS-free HIV-infected individuals in Brazil have investigated the potential impact of early initiation of ART on the time for progres- sion from HIV to AIDS (TPHA) and incidence rates of AIDS. 10,11 This study aimed to estimate incidence rates of AIDS and TPHA in the pre- and post-HAART periods, and to assess factors asso- ciated with TPHA in a cohort of AIDS-free HIV-infected individuals living in the city of Sa ˜o Paulo, Brazil. Methods Study design, population and setting We conducted a retrospective cohort study of AIDS-free HIV-infected outpatients in a sexually transmitted diseases (STD)/HIV outpatient clinic in the city of Sa ˜o Paulo, southeastern Brazil. Sa ˜o Paulo is the largest city in Brazil, with a population of about 11 million. It has been hard hit by the HIV/AIDS epidemic, # The Author 2014. Published by Oxford University Press on behalf of Royal Societyof Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. ORIGINAL ARTICLE Trans R Soc Trop Med Hyg 2014; 108: 408–414 doi:10.1093/trstmh/tru078 Advance Access publication 16 May 2014 408 at Universidade de São Paulo on June 29, 2014 http://trstmh.oxfordjournals.org/ Downloaded from