Income determines the impact of cash transfers on HIV/AIDS: cohort study of 22.7 million Brazilians

Abstract

Living with extremely low-income is an important risk factor for HIV/AIDS and can be mitigated by conditional cash transfers. Using a cohort of 22.7 million low-income individuals during 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 reduced AIDS incidence by 41% (RR:0.59; 95%CI:0.57-0.61), mortality by 39% (RR:0.61; 95%CI:0.57-0.64), and case fatality rates by 25% (RR:0.75; 95%CI:0.66-0.85) in the cohort, and Programa Bolsa Família effects were considerably stronger among individuals of extremely low-income [reduction of 55% for incidence (RR:0.45, 95% CI:0.42-0.47), 54% mortality (RR:0.46, 95% CI:0.42-0.49), and 37% case-fatality (RR:0.63, 95% CI:0.51 -0.76)], decreasing gradually until having no effect in individuals with higher incomes. Similar effects were observed on HIV notification. Programa Bolsa Família impact was also stronger among women and adolescents. Several 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 an essential intervention to achieve AIDS-related sustainable development goals by 2030.

Fig. 1

Flowchart of the construction of the study cohort (Brazil, 2007–2015).

Fig. 2

Conceptual model of the potential pathways through which Programa Bolsa Familia (PBF) can affect AIDS incidence, mortality, and case-fatality rates.

Fig. 3. The samples size for each adjusted IPTW Poisson models.

Comparison of the average effect of the Programa Bolsa Família (PBF), obtained through adjusted IPTW Poisson models with robust standard errors, on HIV notification, AIDS incidence, AIDS mortality, and AIDS case-fatality rate, 2007–2015, in the overall study population (first four lines) and by quartiles of wealth for each outcome.