School of Public Health - Epidemiology
Brazil - Evaluate new treatment recommendations for universal antiretroviral therapy for people living with HIV in Brazil
Early initiation of ART is highly efficacious for improving outcomes among persons living with HIV (PLHIV) and reducing HIV transmission, and is endorsed by the World Health Organization (WHO). However, while the benefits of early ART are well established in controlled settings, the public health impact of universal HIV treatment guidelines has not been quantified in many settings. The Brazilian government released guidelines recommending universal ART for all PLHIV, regardless of CD4 count, in December 2013. Multiple citywide databases allow for comprehensive monitoring of HIV-infected patients, including surveillance databases with individual information on HIV/AIDS, mortality, and other reportable infections such as tuberculosis and hepatitis; laboratory and pharmaceutical databases with information on viral load, CD4 counts, and antiretroviral use; and a local poverty reduction program database with information on cash payments to people living in extreme poverty. Through this project, these databases will be linked to enable epidemiologic investigation of the local HIV epidemic.
Global Health PI/Mentor: Jonathan Golub
Brazil has been a global leader in the fight against HIV since the early days of the epidemic. However, despite having a strong health care system and national commitment to HIV control, Brazil continues to struggle with high rates of new infections; in 2015, there were estimated to be over 820,000 people living with HIV throughout the country. Rio de Janeiro is at the heart of the Brazilian epidemic, with more than 60,000 people—over 1% of the city’s population—infected with the virus.
My field placement project was to help develop a study to evaluate the impact of a novel strategy for HIV control: universal antiretroviral therapy (ART). First endorsed by the World Health Organization in 2015, universal ART—treatment for all people diagnosed with HIV, regardless of CD4 count—both prevents transmission of the virus and improves clinical outcomes for people living with HIV. In keeping with its reputation of being on the cutting edge of HIV care and control, Brazil has recommended universal ART since late 2013, and our collaborators hope to assess the policy’s long-term public health effects.
Left: Entrance to a public primary care clinic, Rio de Janeiro. Right: Health statistics board in a primary care clinic, Rio de Janeiro
The majority of my time in Rio was spent working with our team at the Health Department on study design and logistics. In this way, I learned about Rio’s health care system from an operational standpoint. The scope of the city’s HIV program is remarkable, with the government providing a multitude of HIV-related services free of charge, including HIV testing, antiretrovirals, and testing and treatment for HIV-related comorbidities, such as tuberculosis and viral hepatitis. With over 50,000 people engaged in care and over 30,000 receiving ART, overseeing Rio’s HIV care and control efforts is a major undertaking. I learned in detail about the Health Department’s large surveillance databases, which contain records for all patients diagnosed with HIV and include information on disease history, presence of comorbidities, and longitudinal HIV clinical markers and prescription information. These rich data sources provide us with a unique opportunity to evaluate the impact of universal ART, and planning our study in this context was exciting for me as an epidemiologist.
In addition to learning about Rio’s health care network from the view of public health officials, I had the opportunity to see the system in action during a trip to a clinic in Rocinha, the largest favela in Rio. Originally built in the 1990s to provide tuberculosis care, Rocinha’s clinics have since expanded as part of a citywide universal health program to include comprehensive primary care services, including infectious disease screening, diagnosis, and treatment; maternal and child care; and even dental care. Visiting the clinic provided me with insight into how HIV care is administered in one of the poorest neighborhoods in the city and further emphasized the strength of Rio’s health care system.
I left Rio with a thorough understanding of the public health care system and the challenges the city faces in achieving HIV control. Our proposal is currently undergoing ethics review, and we hope to obtain approval and begin data analyses in the coming months. Brazil continues to make great strides in reducing the burden of HIV, and I am excited to continue researching the impact of universal ART in this setting.
Left: Rio de Janeiro Health Department. Right: Rocinha favela, Rio de Janeiro