Background: While Brazil has had a long-standing policy of free access to antiretroviral therapy (ART) for all in need,\nthe epidemiological impact of ART on human immunodeficiency virus (HIV) RNA suppression in this middle-income\ncountry has not been well evaluated. We estimate first-line ART effectiveness in a large Brazilian cohort and examine\nthe socio-demographic, behavioral, clinical and structural factors associated with virologic suppression.\nMethods: Virologic suppression on first-line ART at 6, 12, and 24 months from start of ART was defined as having a\nviral load measurement ?400 copies/mL without drug class modification and/or discontinuation. Drug class modification\nand/or discontinuation were defined based on the class of a particular drug. Quasi-Poisson regression was used\nto quantify the association of factors with virologic suppression.\nResults: From January 2000 through June 2010, 1311 patients started first-line ART; 987 (75%) patients used\nNNRTI-based regimens. Virologic suppression was achieved by 77%, 76% and 68% of patients at 6, 12 and\n24 months, respectively. Factors associated with virologic suppression at 12 months were: >8 years of formal\neducation (compared to <4 years, risk ratio (RR) 1.13, 95% confidence interval (95% CI) 1.03-1.24), starting ART\nin 2005-2010 (compared to 2000-2004, RR 1.25 95% CI 1.15-1.35), and clinical trial participation (compared to\nno participation, RR 1.08 95% CI 1.01-1.16). Also at 12 months, women showed less virologic suppression\ncompared to heterosexual men (RR 0.90 95% CI 0.82-0.99). For the 24-month endpoint, in addition to higher\neducation, starting ART in the later period, and clinical trial participation, older age and an NNRTI-based\nregimen were also independently associated with virologic suppression.\nConclusions: Our results show that in Brazil, a middle-income country with free access to treatment, over\nthree-quarters of patients receiving routine care reached virologic suppression on first-line ART by the end of\nthe first year. Higher education, more recent ART initiation and clinical trial participation were associated with\nimproved outcomes both for the 12-month and the 24-month endpoints, suggesting that further studies are\nneeded to understand what aspects relating to these factors lead to higher virologic suppression.
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