Bolsa Família beneficiaries are 41% less likely to develop AIDS

Living on an extremely low income is a risk factor for a variety of health conditions, such as tuberculosis, malaria and AIDS. Previous studies have shown that public policies such as conditional cash transfer programs are among the most effective interventions for improving the well-being of individuals and families in low- and middle-income countries living in situations of vulnerability. A study published in the scientific journal Nature Communications assessed the impact of a Brazilian conditional cash transfer program, the Bolsa Família Program (PBF), on AIDS outcomes, specifically incidence, mortality and lethality rates, and on HIV infection notifications.

Led by the Institute of Collective Health (ISC) of the Federal University of Bahia (UFBA) and the Center for Data and Knowledge Integration for Health (Cidacs/Fiocruz Bahia), in partnership with the University of California, Los Angeles (UCLA), the research presents as its main piece of evidence that the PBF can significantly reduce illness and mortality by AIDS in countries with extremely vulnerable populations.

Worldwide, according to statistics from the Joint United Nations Programme on HIV/AIDS (UNAIDS), more than 40.4 million people have died from AIDS-related illnesses since the epidemic began in the first half of the 1980s. Moreover, more than 39 million people were living with HIV across the globe in 2022. Notwithstanding these data, addressing this infection requires going beyond the stigmas of this health condition, which has emerged and been established under many prejudices.

According to Andréa Silva, researcher associated with ISC/UFBA and Cidacs/Fiocruz Bahia and one of the authors of the study, the difference between this research and previous studies "lies in its scope and the size of the sample used, providing a broader and more robust view of the effects of a conditional cash transfer program". This research analyzed data from a 9-year period (2007 – 2015) from almost 23 million Brazilians aged 13 and over.

Evidence

By tracking the data of 22,788,998 million Brazilians in a cohort with information from Unified Registry (Cadastro Único) linked to two sets of health data, the Notifiable Diseases Information System (Sinan) and the Mortality Information System (SIM), 22.212 AIDS cases were found, of which 9,201 occurred among PBF beneficiaries and 13,011 among non-beneficiaries. Among these figures, there were 7,650 AIDS-related deaths. Of these figures, 42.2% occurred among PBF beneficiaries and 57.8% among non-beneficiaries.

During the period of analysis in the cohort, it was observed that more people who did not receive the Bolsa Família benefit developed AIDS than those who did. The incidence was around 30 cases per 100,000 people among non-beneficiaries, compared to around 25 cases per 100,000 people among beneficiaries. Furthermore, with regard to the mortality rate, it was found that more people who did not receive the benefit died from AIDS-related causes than those who did. The proportion was around 10 deaths per 100,000 people among non-beneficiaries, compared to around nine deaths per 100,000 people among beneficiaries. Analyzing 22,212 screened cases with HIV/AIDS syndrome, it was observed that lethality among these people was higher among non-beneficiaries, with approximately nine deaths per 100 people. Among beneficiaries, lethality was lower, with around seven deaths per 100 people.

Based on the data collected, when assessing the effects of Bolsa Família, the study identified reduced incidence, mortality and lethality rates among program beneficiaries compared to non-beneficiaries. "This means that a person participating in the program is 41% less likely to develop AIDS than someone with similar characteristics who is not in the program. On the other hand, the likelihood of a person receiving Bolsa Família dying from AIDS is 39% lower compared to those who do not receive the benefit. Finally, case-fatality rates, which represent the proportion of fatal cases among diagnosed AIDS cases, also fell by 25% among participants of the program. In other words, the chance of a person dying after being diagnosed with AIDS is 25% lower for those who are part of the program," Andréa explained.

Moreover, the study provides evidence that the effects were more significant among people with extremely low income when they were beneficiaries of the PBF, as opposed to those in the same economic situation who were not receiving the benefit. "There was a 55% reduction in the incidence of AIDS among these participants, a 54% drop in AIDS-related mortality and a 37% decrease in lethality rates." For people in higher income brackets, the effects gradually diminished. "This detailed analysis of the different socio-economic strata provides valuable insights into the effectiveness of the program in different economic contexts," Andréa added.

In the study, it is important to note that the effects of the PBF are more pronounced among women and adolescent beneficiaries. Women who are beneficiaries have a 40% reduction in the chances of developing the syndrome compared to non-beneficiaries, and a 42% reduction in the mortality rate. In the case of adolescents, the reduction is even more significant: 52% in the chances of incidence of the syndrome and 54% in the mortality rate.

These results may be related to the program's conditionalities, such as in health and education, like child immunization and pre-natal monitoring, which may encourage families to seek out health services and receive guidance on prevention and treatment against the HIV virus and AIDS syndrome. "This suggests that the program can have a particularly positive impact on the health of these demographic groups, highlighting its importance in reducing gender and age inequalities in health," explained the researcher associated with ISC/UFBA and Cidacs/Fiocruz Bahia. The positive effects of the program have also been seen in the notification of HIV cases, pointing to a reduction in the spread of the disease.

Shaping public policy

Brazil is an international reference in the treatment of HIV/AIDS, providing antiretroviral therapy (ART), used both for people who have already developed AIDS and for those who are infected with HIV, even before they show symptoms of the disease. Additionally, Post-Exposure Prophylaxis (PEP) and Pre-Exposure Prophylaxis (PrEP), preventive treatments for the HIV virus, are also available. However, it should be noted that people and groups in different situations of vulnerability can be affected by not having full access to prevention and treatment resources, which affects the mitigation of HIV infection and the complications associated with AIDS.

Therefore, the evidence from this research supports the orientation of public policies towards tackling HIV/AIDS and reducing social and health inequalities. "They are crucial for supporting evidence-based public policies, providing government authorities with reliable information for decision-making and targeting resources more effectively," Andréa said.

Furthermore, understanding the limitations of the Bolsa Família program, Andréa pointed out that these evidences can "inspire the development of complementary programs aimed at specifically addressing the health needs of vulnerable populations. For example, initiatives can be created to increase access to sexual and reproductive health services, promote adherence to antiretroviral therapy and educate and raise awareness on HIV/AIDS prevention."

These findings also suggest the usefulness of this intervention in helping to achieve the AIDS-related sustainable development goals of the UN 2030 Agenda. Additionally, it can provide useful evidence for the federal government, within the framework of the Interministerial Committee for the Elimination of Tuberculosis and Other Socially Determined Diseases (CIEDDS), established in April 2023, whose goal is reducing the incidence of diseases that affect populations in situations of greater social vulnerability, including AIDS.

Neglected conditions require interventions beyond health care, a closer look at environmental, social and economic vulnerabilities, in other words, the social determinants of health. Thus, caring for people living with HIV and who may develop AIDS requires a look that sees past the pathological and the prejudices and stigmas, it being necessary to guide and develop public policies with financial investments and quality information in order to understand the complexity of this health condition that goes beyond specific communities, affecting the entire population in unequal ways.

Limitation and the database

The main limitation of this study pointed out by the research team is that the analysis only contains data from people registered in the Unified Registry for Social Programs (Cadastro Único para Programas Sociais – CadÚnico), which is the part of the population with the lowest income, thus not covering the entire population of Brazil. These are the data from more than 50% of the population included in the 100 Million Cohort, a scientific innovation for public health studies developed at Cidacs/Fiocruz Bahia.

It should be emphasized that the Cohort of 100 Million Brazilians preserves ethical issues and the anonymization of sensitive data, since the information that identifies people does not matter, only the data that enables analysis and evidence-based contributions to public health studies.