A retrospective study of 28.3 million people evaluated the effects of social determinants of health on HIV/AIDS incidence and mortality in Brazil.
Social determinants of health—the social conditions in which people grow up, live, and work—can influence the risk of contracting AIDS and the mortality associated with the disease. This is the main conclusion of a new study carried out by the Barcelona Institute for Global Health (ISGlobal), a center promoted by Obra Social "la Caixa", and published in The Lancet Regional Health .
The research team evaluated a cohort of 28.3 million people, representative of the low-income Brazilian population, based on data collected between 2007 and 2015. This is the largest evaluation of the social determinants of health and AIDS in Brazil to date. The researchers concluded that social determinants related to poverty and social vulnerability are strongly associated with a higher burden of AIDS. Specifically, Black, economically disadvantaged, and uneducated people are disproportionately affected by the burden of the disease.
"The results of the study show that social determinants of health play an important role in the burden of HIV/AIDS in a highly unequal country like Brazil. The entire chain of events related to the disease, whether the risk of becoming infected, developing an advanced disease or dying from it is influenced by these factors," says Davide Rasella, ISGlobal researcher and lead author of the study.
Despite Brazil’s pioneering response to the HIV/AIDS epidemic, being the first middle-income country to offer free antiretroviral treatment to all people living with the disease and widespread free HIV testing, the mortality rate for the disease in Brazil in 2020 was 6 per 100,000 inhabitants. Of the new infections registered in Latin America in 2020, almost half (48%) were registered in Brazil.
The lower the wealth, the higher the incidence and mortality of AIDS
According to the study results, lower wealth was strongly associated with higher AIDS incidence and mortality. Specifically, people with less wealth were 55% more likely to be infected and 99% more likely to die. "Lower wealth may be closely related to social exclusion and food insecurity, which are potential barriers to early diagnosis and starting or adhering to HIV/AIDS treatment," says Rasella.
Lower levels of education were also associated with higher AIDS incidence and mortality. Illiterate people were 46% more likely to get sick and 176% more likely to die than people with higher education. This may be explained by factors such as lack of access to health information, risky sexual behavior, and difficulty accessing medical care. Previous studies have shown that people with lower levels of education are more likely to engage in risky sexual behavior, be diagnosed late with HIV/AIDS, and have poorer access to and adherence to treatment.
Additionally, black people had a 53% higher risk of AIDS and a 69% higher risk of death than people who identified as white or Asian. This increased risk could be a consequence of structural racism, including racial health disparities in access to and quality of health services. "Structural racism in Brazil, as in many other parts of the world, also manifests itself in poorer living conditions, which expose people to worse HIV/AIDS outcomes," Rasella notes.
The effects of cash transfer programs
Of the total participants in the evaluated cohort, 64.75% were beneficiaries of the Bolsa Família monetary transfer program . People who received the Bolsa Família cash transfer for less than two years were at higher risk of developing HIV/AIDS than those who did not meet the eligibility criteria for the program. A protective effect was also observed for long-term perception, with those who received the benefit between 5 and 10 years or for more than 10 years having a lower risk of becoming ill and dying from the disease.
“This may be due to the poverty-reducing effect of the program’s subsidies and the requirements to receive these benefits, such as visits to health services and school attendance for children and adolescents. This brings families closer to diagnostic services and health education, Rasella argues.
Implications for prevention programs
The results of the study highlight the need to invest in public health policies to expand access and guarantee equity in health care, prioritizing people with the greatest social vulnerability. "Our study has important implications for HIV/AIDS prevention and control programs in other low- and middle-income countries. The results provide further evidence of the need to reduce social inequalities by focusing on key determinants of health that affect the HIV/AIDS," says the ISGlobal researcher.
"Without the implementation of significant interventions to reduce inequalities, there is a risk that the current increase in poverty and social vulnerability rates will reverse the progress made in the fight against HIV/AIDS in recent decades and make it difficult to achieve the Goals. of Sustainable Development related to this disease,” concludes Rasella.
Interpretation In the study population, social determinants of health (SDH) related to poverty and social vulnerability are strongly associated with a higher burden of HIV/AIDS, especially less wealth, illiteracy, and being black. In the absence of relevant social protection policies, the current global rise in poverty and inequalities, due to the consequences of the COVID-19 pandemic and the effects of the war in Ukraine, could reverse the progress made in the fight against HIV/AIDS in low and middle income countries (LMIC). Implications of all available evidence Our findings show that the most economically disadvantaged population groups (the poor, the black, the illiterate and those with inadequate housing) are at greater risk of becoming ill and dying from AIDS. Understanding the influence of social determinants of health on the health/disease process of AIDS is urgent to confront the disease, especially in countries characterized by large economic and health disparities, such as Brazil. Strategies aimed at health education, prevention of infection, timely diagnosis, early initiation of antiretroviral therapy (ART) and adherence to treatment are crucial to confront the disease and are already applied around the world. However, direct investments in the health sector must be accompanied by those to improve social inequalities, focusing on socioeconomic determinants. |
