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Title
The effect of primary health care on AIDS: a cohort study of 3.4 million individuals in Brazil
Presenter
Priscila Pinto
Authors
P. Pinto1,2, A. Silva1,2, I. Lua1,2, G. Jesus1,2, L. Magno3, C. Santos2, M. Ichihara2, M. Barreto2, L.E. Souza1, J. Macinko4, I. Dourado1, D. Rasella1,5
Institutions
1Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil, 2The Centre for Data and Knowledge Integration for Health (CIDACS), Salvador, Brazil, 3State University of Bahia (UNEB), Department of Life Sciences, Salvador, Brazil, 4Fielding School of Public Health of University of California (UCLA), Departments of Health Policy and Management and Community Health Sciences, Los Angeles, United States, 5ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain

BACKGROUND: Although Primary Health Care (PHC) is part of the AIDS care and prevention services, the effect of PHC on AIDS outcomes is poorly understood in low- and middle-income countries (LMICs). We evaluated the impact of one of the largest PHC programs in the world, the Brazilian Family Health Strategy (FHS), on AIDS incidence and mortality using a cohort of 3.4 million individuals over a 9-year study period in Brazil.
METHODS: We analyzed AIDS data from individuals aged 13 years or older who were members of a nationwide cohort of the poorest Brazilian people (The 100 Million Brazilians Cohort) from January 1, 2007 to December 31, 2015 and compared residents in municipalities with no FHS coverage with residents in municipalities with full FHS coverage. We used multivariable Poisson regressions, adjusted for all relevant demographic, socioeconomic, and municipal variables, and weighted with inverse probability of treatment weighting (IPTW), to estimate the effect of FHS on AIDS incidence and mortality rates. We also estimated effects by sex, age, race/ethnicity, and by AIDS municipal incidence. We conducted sensitivity and triangulation analyses.
RESULTS: FHS coverage was associated with lower AIDS incidence (rate ratio [RR] 0.76, 95%CI 0.68–0.84) and mortality (0.68, 0.56–0.82). The effect of FHS on incidence was greater among females (0.70, 0.61-0.82) and Black population (0.64, 0.45-0.92). The effect of FHS on mortality was greater among males (0.64, 0.49-0.83). For both outcomes, the effect of FHS coverage was stronger among people aged 35 years or older (0.62, 0.53-0.72 – incidence and 0.56, 0.43-0.72 - mortality), although a lower incidence was also observed among people aged 13-34 years (0.83, 0.72-0.96).
CONCLUSIONS: FHS coverage impacts AIDS morbidity and mortality among the most vulnerable populations in Brazil. Our results show the importance of expanding and strengthening PHC in LMICs to contribute to the goal of ending AIDS by 2030, including the improvement of infrastructure and human resources for the decentralization of care, treatment, and monitoring of people with HIV/AIDS.