By: Dr. Carlos Magis-Rodríguez, Professor at the Faculty of Medicine, UNAM.

MSP Enrique Bravo-García, Doctorate of the National Institute of Public Health

For the first time since the introduction of antiretroviral treatment, mortality from HIV / AIDS in people with social security increased 22.2% during the period from 2017 to 2019.

Background

On 1997, AIDS patients who had social security in Mexico began to receive High Activity Antiretroviral Treatment (HAART), which meant avoid evolution towards near certain death. Nevertheless, HIV patients without social security were referred for management to second and third level hospitals of the Ministry of Health, CONASIDA Care Centers, private doctors or medical care units created by non-governmental organizations; but they did not receive antiretroviral drugs, except those that were within a research protocol. Therefore, in case of requiring treatment, they had to pay for it out of pocket. This profound inequality generated a great mobilization of people without social security to demand that the government access the TARAA, whose main barrier was its high cost. (1)

In 2001, CENSIDA prepared the Action program: HIV / AIDS and sexually transmitted infections (STIs) 2001-2006. In its fourth component, called “Comprehensive care for people with HIV / AIDS and STIs”, it established as one of its four goals “Expand the coverage of antiretroviral treatment to the entire population that requires it”(2) Since 2003, the Ministry of Health consolidated the public policy of universal and free access to antiretroviral drugs by guaranteeing the provision of HAART to all people with HIV without social security (3).

Mortality from HIV / AIDS in Mexico

From 1990 to 2019, 129,615 people died of HIV / AIDS in Mexico (83% men, 27% women), of which 52,502 (40.6%) occurred in people with social security and 77,113 (59.5%) in people without social security (Seguro Popular and federal and state health services, since INSABI started operating in 2020).

The highest mortality rate was recorded in 2008. From that year until 2015, mortality from HIV / AIDS decreased by more than 20%. (4) Two years later, a new estimate for the period 2008-2017 showed that mortality continued to decrease significantly, both in men (-17.7%) and women (-22.6%). However, the downward trend in mortality from HIV / AIDS stopped in 2017, so that between 2017 to 2019, mortality increased more than 10% in just two years, both in men and women. (5) This increase meant a return to the HIV / AIDS mortality rate registered in 2013, that is, a six-year setback (Figure 1).

Figure 1. Mortality from HIV / AIDS according to year of registration and sex. Mexico, 1990-2019.

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Source: Own elaboration based on reference (6).

Mortality from HIV / AIDS in people with and without social security in Mexico

The trend in mortality from HIV / AIDS, in people with and social security, can be divided into four periods:

  • From 1990 to 1996, Mortality grew exponentially, both at the national level (163.7%) and in people with social security (179.0%) and without social security (149.7%).
  • From 1997 to 2008, and as a result of the provision of HAART, mortality decreased 29.7% in people with social security. However, the gradual provision of HAART in people without security – and the gradual creation of the national network of medical units for medical care for people without social security – has not yet managed to reverse the upward trend in mortality (increase of 35.5 %).
  • From 2008 to 2017, it was possible to reverse the upward trend of mortality in people without social security, achieving a decrease of 14.2%. Mortality in people with social security continued to decrease (21.0%); and the national reduction stood at 18.7%.
  • From 2017 to 2019, the national mortality increased 10.2%. However, the most remarkable thing is that mortality in people with social security increased 22.2%, while, in people without social security, it only increased 3.7%. For the first time since the introduction of antiretroviral treatment, mortality from HIV / AIDS in people with social security increased.

Figure 2. Mortality from HIV / AIDS in people with and without social security. Mexico, 1990-2019.

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Source: Own elaboration based on reference (6).

However, the most worrying thing is the differentiated increase in mortality: while in people with social security the increase was 22.2%, in people without social security, mortality from HIV / AIDS only increased 3.7%. This constitutes a new phenomenon in the history of the Mexican epidemic since, Starting in 1996, mortality from HIV / AIDS in people with social security decreased continuously, but in the last three years it increased significantly.

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Although it would be premature to say that this is a trend that will continue in the following years, there are two factors related to this increase: the decrease in the timely detection of HIV in key populations; and a growing shortage of antiretroviral drugs, especially in the IMSS and ISSSTE.

Mortality in Mexico during 2020 and the paradox of deaths from HIV / AIDS

The COVID-19 pandemic had a huge impact on mortality in Mexico during 2020. According to the definitive figures published by INEGI, with a total of 200,256 deaths, Covid-19 was the second cause of death in Mexico in 2020, although it was ranked as the first cause of death in men and the third in women. In addition, its impact on mortality can also be observed in the increase in deaths from other causes. For example, the number of deaths from heart disease -the leading cause of mortality in Mexico- increased 40% between 2019 and 2020; Deaths from Diabetes, the second cause of mortality in recent years, grew 40% (7).

Due to the impact that the pandemic has had on people with HIV, by limiting their access to detection and timely medical care, the provision of medicines and laboratory tests to monitor their viral load, the most likely scenario was that HIV / AIDS mortality would increase in 2020.

The INEGI official figures attribute only 4,573 deaths to HIV / AIDS during 2020, which means, when compared with the 5,253 deaths from this cause in 2019, a decrease of 12.9% from one year to another. (8) If so, we would be returning to the pre-2017 HIV / AIDS mortality rate, which would be excellent news. Nevertheless, there are many questions: What can be attributed to such a sudden reduction in mortality in one year? Is it a real reduction in HIV mortality, in the context of a pandemic that severely limited detection and care services for people with HIV? Did a significant number of people with HIV die from Covid-19 and not from HIV? Is it a new trend or a phenomenon caused by the Covid-19 pandemic? Once the 2020 mortality databases are available, a detailed analysis of the situation can be carried out and some of these questions answered.

For now, the only way to prevent mortality from HIV / AIDS from increasing in the coming years is to expand the coverage of the timely detection of people with HIV; link HIV people to antiretroviral treatment as quickly as possible and achieve sustained viral suppression. Our country needs to resume the policies on HIV prevention and care that had proven effective in previous years.

This, and other interesting articles, accompanied by reports; interviews and special collaborations with the most renowned national and international specialists; you can find them in our next Multimedia Special Edition of the LaSalud.mx Magazine: “Selected Topics HIV / AIDS 2021”, International Edition with Ibero-Latin American presence.

References

1. Uribe Zúñiga P, Magis Rodríguez C, Egremy Mendívil G, Arellano Delgado LM, Hernández Tepichín G. Institutional response to HIV / AIDS. In: Alarcón Segovia D, Ponce de León Rosales S, editors. AIDS in Mexico: twenty years of the epidemic. Mexico: The National College; 2003. p. 203-68.

2. National Center for the Prevention and Control of HIV / AIDS. Action program: HIV / AIDS and sexually transmitted infections (STIs), 2001-2006. Mexico: Ministry of Health. Undersecretary of Prevention and Health Protection. National Center for the Prevention and Control of HIV / AIDS 2002. Available at: https://buff.ly/3FCDIwE.

3. National Center for the Prevention and Control of HIV / AIDS. Specific Action Program – Response to HIV, AIDS and STIs 2013-2018. Mexico: CENSIDA; 2014. Available at: https://buff.ly/3oQA4Ze.

4. Bravo-García E, Magis-Rodríguez C, Palacios-Martínez M, Guarneros-Soto N, Uribe-Zúñiga P. HIV mortality in the Health Jurisdictions of Mexico from 1990 to 2015. Salud Publica Mex. 2019; 61 (5): 563-71. Available in: https://buff.ly/3cBnPda.

5. Magis-Rodríguez C, Bravo-García E. Mortality from HIV / AIDS in Mexico from 1990 to 2019: Advances and Setbacks. MundoDeHoycom. 2021 July 17. Available in: https://buff.ly/30Irjb9.

6. National Institute of Statistics and Geography. Mortality – INEGI Mexico: INEGI; 2021.Available at: https://buff.ly/3Fsi5jp.

7. Bravo-García E. Mortality in Mexico: definitive figures for 2020. Bulletin on COVID-19: public health and epidemiology. 2021; 2 (23): 1. Available in: https://buff.ly/3t3IYUx.

8. National Institute of Statistics and Geography. Characteristics of the deaths registered in Mexico during 2020. Mexico: INEGI; 2021 [comunicado de prensa núm 592/21, 28 de octubre] Available in: https://buff.ly/3wdocnv.