The effects of social determinants of health on acquired immune deficiency syndrome in a low-income population of Brazil: a retrospective cohort study of 28.3 million individuals

Summary

Background

Social determinants of health (SDH) include factors such as income, education, and race, that could significantly affect the human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS). Studies on the effects of SDH on HIV/AIDS are limited, and do not yet provide a systematic understanding of how the various SDH act on important indicators of HIV/AIDS progression. We aimed to evaluate the effects of SDH on AIDS morbidity and mortality.

Methods

A retrospective cohort of 28.3 million individuals was evaluated over a 9-year period (from 2007 to 2015). Multivariable Poisson regression, with a hierarchical approach, was used to estimate the effects of SDH—at the individual and familial level—on AIDS incidence, mortality, and case-fatality rates.

Findings

A total of 28,318,532 individuals, representing the low-income Brazilian population, were assessed, who had a mean age of 36.18 (SD: 16.96) years, 52.69% (14,920,049) were female, 57.52% (15,360,569) were pardos, 34.13% (9,113,222) were white/Asian, 7.77% (2,075,977) were black, and 0.58% (154,146) were indigenous. Specific socioeconomic, household, and geographic factors were significantly associated with AIDS-related outcomes. Less wealth was strongly associated with a higher AIDS incidence (rate ratios—RR: 1.55; 95% confidence interval—CI: 1.43–1.68) and mortality (RR: 1.99; 95% CI: 1.70–2.34). Lower educational attainment was also greatly associated with higher AIDS incidence (RR: 1.46; 95% CI: 1.26–1.68), mortality (RR: 2.76; 95% CI: 1.99–3.82) and case-fatality rates (RR: 2.30; 95% CI: 1.31–4.01). Being black was associated with a higher AIDS incidence (RR: 1.53; 95% CI: 1.45–1.61), mortality (RR: 1.69; 95% CI: 1.57–1.83) and case-fatality rates (RR: 1.16; 95% CI: 1.03–1.32). Overall, also considering the other SDH, individuals experiencing greater levels of socioeconomic deprivation were, by far, more likely to acquire AIDS, and to die from it.

Interpretation

In the population studied, SDH related to poverty and social vulnerability are strongly associated with a higher burden of HIV/AIDS, most notably less wealth, illiteracy, and being black. In the absence of relevant social protection policies, the current worldwide increase in poverty and inequalities—due to the consequences of the COVID-19 pandemic, and the effects of war in the Ukraine—could reverse progress made in the fight against HIV/AIDS in low- and middle-income countries (LMIC).

Funding

doi 10.13039/100000060, National Institute of Allergy and Infectious Diseases; (NAIDS), doi 10.13039/100000002, National Institutes of Health; (NIH), US Grant Number: 1R01AI152938.