Study indicates changes in the profile of AIDS in São Paulo

Free universal access to diagnosis and treatment has resulted in falling death rates and increased prevalence within the state in recent years, says study.

By Elton Alisson

Agência FAPESP – The availability of free universal access to the diagnosis and treatment of AIDS in São Paulo beginning in 1996 has resulted in an average 30% drop in the death rate and a 50% increase in prevalence (the number of people living with the disease) in the state over recent years.

The drastic fall in mortality and the increased lifespans of AIDS patients are changing the profile of the disease and bringing about changes in patient care strategies in São Paulo. This new profile is becoming something very different from the profile that the health system is familiar and accustomed to dealing with.

This change in the disease profile has been substantiated by a project carried out by researchers at four institutions in São Paulo State: the Schools of Medicine and Public Health (FSP) at the Universidade de São Paulo (USP), the Health Institute and the State STD/Aids Program, the São Paulo State Health Secretariat and the State Data Analysis System Foundation (SEADE).

Financed by FAPESP through its Public Policy Research Program, the study aimed to create a classification system to determine the vulnerability to AIDS in São Paulo. This was done through the selection of social, individual and programmatic indicators that will identify communities and segments of the population in geographical areas of the state that are in need of specific public policy and intervention.
 
To identify these populations, researchers evaluated the impact of the introduction of highly potent antiretroviral drugs in 1996 in the state, analyzing three epidemiologic indicators: mortality rate, prevalence and incidence (number of new cases).

Some of the primary findings of the study were that the introduction of the program resulted in a fall in the mortality rate due to AIDS throughout the state of São Paulo and that the incidence of new cases also began to fall in 1998.

“From 1998 to 2005 (the last year that we analyzed), we found an average 30% drop-off in mortality, and because treatment does not cure the disease, prevalence increased by 50%. The quality of patients’ lives also improved,” said Eliseu Alves Waldman, a researcher at the USP School of Public Health and project coordinator, to Agência FAPESP.

Waldman stated that the state STD/AIDS prevention and control program has had a 93% success rate in the municipalities of São Paulo state with AIDS cases. However, the success of the program is not equivalent in small, medium and large urban areas.

The program has been more successful in medium and large urban centers that have better basic health services and more specialized services and where the population’s educational level is higher, which increases the probability of early diagnosis and treatment.

In smaller municipalities (approximately 5% of the regions analyzed in the study), the results call for specific intervention strategies. “They are such small towns that they often don’t have their own specialized health services, and cases end up being diagnosed and treated very late,” explained Waldman. “Because of this, there have been some attempts to work in consortiums where a traveling, specialized health unit would offer services to a number of small towns.”

In the São Paulo Metropolitan Region, one of the most homogenous areas studied, the mortality rate and incidence fell by 60% in recent years, and there was a greater increase in prevalence.
“These results are equivalent to the STD/AIDS prevention and control programs developed in North American and European urban centers,” Waldman noted.

Changing profiles

Waldman says that among the most successful results of the program in the state are the notable drop-off in vertical transmission (from mothers to their children) in São Paulo State and the longer lifespans of individuals born with the disease.

In all regions within the state, including small towns, and with greater frequency, large cities, the researchers found that due to longer lifespans, there were higher numbers of adolescents and young adults living with AIDS. This patient profile is different from the profile that health services are familiar with.

Waldman says this implies the need for public policy that promotes the development of new technology and the creation of services that are appropriate for this type of patient in the São Paulo State public health system.

“It will be necessary not only to accompany the collateral effects of the antiretroviral drugs in these patients, but we will also need, as there are more people being treated over longer periods of time, to have laboratories to accompany, for example, developed resistance to drugs—something that has to be monitored because it oftentimes implies changes in therapeutic systems,” he said.

Another of the study’s findings was that the mortality rate did not fall as much in people over 50 years of age as it did among young people. This smaller decrease indicates that this group needs special professional care and clinical services, requiring specific strategies in the state AIDS control and prevention program, as have already been implemented in other countries.
 
“The weaker response to antiretroviral drugs presented by this age group calls for more study. In part, it can be attributed to the natural reduction of the immune response among older people, and also to the greater prevalence of concomitant but unrelated pathological disease processes oftentimes treated with medicines that repress the immune system,” Waldman noted.

According to Waldman, these changes in the AIDS profile within São Paulo State signal the need for technological R&D resources to develop new treatment and accompaniment strategies for patients with chronic progression of the disease and who are vulnerable, for example, to the collateral effects of the prolonged use of treatment drugs.

One result of the project was a set of social, demographic and programmatic indicators for monitoring the AIDS epidemic in the state of São Paulo. These indicators can be accessed via an application on the CRT DST/AIDS web site for municipal directors, who are responsible for running the program within the state.