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Abstract
Living with extremely low income is a significant risk factor for HIV/AIDS, which can be mitigated by conditional cash transfers. Using a cohort of 22.7 million low-income individuals over 9 years, we evaluated the effects of the world’s largest conditional cash transfer, the Programa Bolsa Família, on HIV/AIDS-related outcomes. Exposure to Programa Bolsa Família was associated with a 41% reduction in AIDS incidence (RR:0.59; 95%CI:0.57-0.61), a 39% reduction in mortality (RR:0.61; 95%CI:0.57-0.64), and a 25% reduction in case fatality rates (RR:0.75; 95%CI:0.66-0.85). The effects were stronger among individuals with extremely low income, showing a reduction of 55% in incidence (RR:0.45, 95% CI:0.42-0.47), 54% in mortality (RR:0.46, 95% CI:0.42-0.49), and 37% in case-fatality (RR:0.63, 95% CI:0.51-0.76). Similar effects were observed on HIV notification, with stronger impacts among women and adolescents. Sensitivity and triangulation analyses demonstrated the robustness of the results. Conditional cash transfers can significantly reduce AIDS morbidity and mortality in extremely vulnerable populations and should be considered essential for achieving AIDS-related Sustainable Development Goals (SDGs) by 2030.
Introduction
Living with extremely low income is a well-recognized risk factor for various diseases, including HIV/AIDS, responsible for a pandemic causing over 34 million deaths globally. There is growing consensus that HIV/AIDS control interventions should focus on Social Determinants of Health (SDH) to reduce morbidity and mortality related to HIV/AIDS. Several studies indicate that low income contributes to new cases of HIV/AIDS, while wealth can also drive HIV transmission among certain populations. Socioeconomic vulnerabilities increase the risk of acquiring HIV and hinder access to appropriate care and treatment.
Conditional Cash Transfer (CCT) programs are effective interventions acting on SDH and have been implemented in almost all low- and middle-income countries (LMICs) to improve the well-being of families living in precarious conditions. CCT programs transfer cash to low-income households with conditions focused on health and education for their children, demonstrating positive effects on preventive services use, healthy behavior promotion, and health outcomes improvement.
Brazil’s Programa Bolsa Família (PBF), one of the world’s largest CCTs, aimed to alleviate poverty by providing cash transfers along with educational and health-related conditions. Implemented in 2004, PBF achieved nationwide coverage, enrolling 14.2 million families by 2018, with significant reductions in poverty and social inequalities and improvements in several health outcomes.
The success of Brazil’s response to HIV/AIDS is recognized worldwide, especially for its universalization of antiretroviral therapy (ART) in the 1990s and current distribution of free pre-exposure prophylaxis. However, AIDS incidence remains high and unequally distributed, with a national rate of 16.5 cases per 100,000 inhabitants in 2021.
Results
The 100 Million Brazilian Cohort, Linkages, and Selection Process
The final cohort consisted of 22,788,998 individuals between 2007 and 2015, with 57.99% female and 42.01% male. The cohort was derived from the 100 Million Brazilian Cohort, created through linkage between the Federal Government Unified Registry for Social Programs (Cadastro Único) and health-related datasets from the Brazilian Ministry of Health.
During follow-up, 22,212 new AIDS cases were detected: 9201 among PBF recipients and 13,011 among non-recipients. There were 7650 AIDS-related deaths: 42.2% among PBF beneficiaries and 57.8% among non-beneficiaries.
The IPTW Multivariable Regression Analyses
The adjusted Rate Ratios (RR) for associations in the total population were estimated using multivariable Poisson regressions weighted by Inverse Probability of Treatment Weight (IPTW). Receiving PBF benefits was associated with a 41% reduction in AIDS incidence rate (RR:0.59; 95%CI:0.57–0.61), a 39% reduction in AIDS mortality rate (RR:0.61; 95%CI:0.57–0.64), and a 25% reduction in case-fatality rate (RR:0.75; 95%CI:0.66–0.85).
The PBF Effect According to Wealth Levels, Sex, and Age
Stratified analyses showed stronger associations between PBF benefits receipt and all AIDS indicators among extremely low-income individuals, with reductions of 55% in AIDS incidence (RR:0.45; 95%CI:0.42-0.47), 54% in AIDS mortality (RR:0.46; 95%CI:0.42-0.49), and 37% in case-fatality rates (RR:0.63; 95%CI:0.51-0.76). The impact was also stronger among women and adolescents.
Complementary, Sensitivity, and Triangulation Analyses
Complementary analyses showed the robustness of results, including marital status as an adjusting variable with no significant differences from main models. Sensitivity analyses included different municipal-level variables, IPTW influence evaluation, endemic levels of AIDS relevance testing, different wealth proxies, model specifications variations, information quality assessment, and missing values influence evaluation.
Discussion
This study is the largest impact evaluation of a CCT program on an infectious disease, showing significant impacts on all sequential AIDS-related outcomes among low-income individuals in a LMIC. The impact was concentrated among extremely low-income individuals, demonstrating a gradient of effectiveness based on socioeconomic vulnerability levels.
CCTs aim to alleviate socioeconomic vulnerabilities promptly while ensuring long-term poverty cycle breaking through conditionalities focused on health and education for vulnerable family members.
CCTs have shown positive impacts on preventive services use, healthy behavior promotion, and various health outcomes improvement, including reductions in other infectious diseases like tuberculosis and leprosy.
The study highlights the potential of CCTs to reduce AIDS morbidity and mortality among socioeconomically vulnerable populations and their importance in achieving AIDS-related SDGs by 2030.
Methods
Study Design, Population, and Ethical Issues
This quasi-experimental cohort study design is based on longitudinal information from January 1, 2007 to December 31, 2015, involving
Analysis of the Article on Conditional Cash Transfers and HIV/AIDS Outcomes
1. Which SDGs are addressed or connected to the issues highlighted in the article?
- SDG 1: No Poverty
- SDG 3: Good Health and Well-being
- SDG 5: Gender Equality
- SDG 10: Reduced Inequalities
2. What specific targets under those SDGs can be identified based on the article’s content?
- SDG 1: No Poverty
- Target 1.2: Reduce at least by half the proportion of men, women, and children of all ages living in poverty in all its dimensions according to national definitions.
- SDG 3: Good Health and Well-being
- Target 3.3: End the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases.
- Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.
- SDG 5: Gender Equality
- Target 5.1: End all forms of discrimination against all women and girls everywhere.
- Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences.
- SDG 10: Reduced Inequalities
- Target 10.2: By 2030, empower and promote the social, economic, and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion, or economic or other status.
3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?
- SDG 1: No Poverty
- Indicator 1.2.1: Proportion of population living below the national poverty line, by sex and age.
- SDG 3: Good Health and Well-being
- Indicator 3.3.1: Number of new HIV infections per 1,000 uninfected population, by sex, age, and key populations.
- Indicator 3.8.1: Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn, and child health; infectious diseases; non-communicable diseases; and service capacity and access among the general and the most disadvantaged population).
- SDG 5: Gender Equality
- Indicator 5.1.1: Whether or not legal frameworks are in place to promote, enforce, and monitor equality and non-discrimination on the basis of sex.
- Indicator 5.6.1: Proportion of women aged 15-49 years who make their own informed decisions regarding sexual relations, contraceptive use, and reproductive health care.
- SDG 10: Reduced Inequalities
- Indicator 10.2.1: Proportion of people living below 50 percent of median income, by age, sex, and persons with disabilities.
4. Table with SDGs, Targets, and Indicators
| SDGs | Targets | Indicators |
|---|---|---|
| SDG 1: No Poverty | Target 1.2: Reduce at least by half the proportion of men, women, and children of all ages living in poverty in all its dimensions according to national definitions. | Indicator 1.2.1: Proportion of population living below the national poverty line, by sex and age. |
