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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 worlds 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.

BACKGROUND: One of the biggest challenges of the response to the AIDS epidemic is to reach the poorest people. In 2004, Brazil implemented one of the worlds largest conditional cash transfer programmes, the Bolsa Família Programme (BFP). We aimed to evaluate the effect of BFP coverage on AIDS incidence, hospitalisations, and mortality in Brazil. METHODS: In this longitudinal ecological study, we developed a conceptual framework linking key mechanisms of BFP effects on AIDS indicators and used ecological panel data from 5507 Brazilian municipalities over the period of 2004-18. We used government sources to calculate municipal-level AIDS incidence, hospitalisation, and mortality rates, and used multivariable regressions analyses of panel data with fixed-effects negative binomial models to estimate the effect of BFP coverage, which was classified as low (0-29%), intermediate (30-69%), and high (≥70%), on AIDS indicators, while adjusting for all relevant demographic, socioeconomic, and health-care covariates at the municipal level. FINDINGS: Between 2004 and 2018, in the municipalities under study, 601 977 new cases of AIDS were notified, of which 376 772 (62·6%) were in males older than 14 years, 212 465 (35·3%) were in females older than 14 years, and 12 740 (2·1%) were in children aged 14 years or younger. 533 624 HIV/AIDS-related hospitalisations, and 176 868 AIDS-related deaths had been notified. High BFP coverage was associated with reductions in incidence rate ratios of 5·1% (95% CI 0·9-9·1) for AIDS incidence, 14·3% (7·7-20·5) for HIV/AIDS hospitalisations, and 12·0% (5·2-18·4) for AIDS mortality. The effect of the BFP on AIDS indicators was more pronounced in municipalities with higher AIDS endemicity levels, with reductions in incidence rate ratios of 12·7% (95% CI 5·4-19·4) for AIDS incidence, 21·1% (10·7-30·2) for HIV/AIDS hospitalisations, and 14·7% (3·2-24·9) for AIDS-related mortality, and reductions in AIDS incidence of 14·6% (5·9-22·5) in females older than 14 years, 9·7% (1·4-17·3) in males older than 14 years, and 24·5% (0·5-42·7) in children aged 14 years or younger. INTERPRETATION: The effect of BFP coverage on AIDS indicators in Brazil could be explained by the reduction of households poverty and by BFP health-related conditionalities. The protection of the most vulnerable populations through conditional cash transfers could contribute to the reduction of AIDS burden in low-income and middle-income countries. FUNDING: US National Institute of Allergy and Infectious Diseases, National Institutes of Health. TRANSLATION: For the Portugese translation of the abstract see Supplementary Materials section.

BackgroundDespite the great progress made over the last decades, stronger structural interventions are needed to end the HIV/AIDS pandemic in Low and Middle-Income Countries (LMIC). Brazil is one of the largest and data-richest LMIC, with rapidly changing socioeconomic characteristics and an important HIV/AIDS burden. Over the last two decades Brazil has also implemented the world's largest Conditional Cash Transfer programs, the Bolsa Familia Program (BFP), and one of the most consolidated Primary Health Care (PHC) interventions, the Family Health Strategy (FHS).ObjectiveWe will evaluate the effects of socioeconomic determinants, BFP exposure and FHS coverage on HIV/AIDS incidence, treatment adherence, hospitalizations, case fatality, and mortality using unprecedently large aggregate and individual-level longitudinal data. Moreover, we will integrate the retrospective datasets and estimated parameters with comprehensive forecasting models to project HIV/AIDS incidence, prevalence and mortality scenarios up to 2030 according to future socioeconomic conditions and alternative policy implementations.Methods and analysisWe will combine individual-level data from all national HIV/AIDS registries with large-scale databases, including the "100 Million Brazilian Cohort", over a 19-year period (2000-2018). Several approaches will be used for the retrospective quasi-experimental impact evaluations, such as Regression Discontinuity Design (RDD), Random Administrative Delays (RAD) and Propensity Score Matching (PSM), combined with multivariable Poisson regressions for cohort analyses. Moreover, we will explore in depth lagged and long-term effects of changes in living conditions and in exposures to BFP and FHS. We will also investigate the effects of the interventions in a wide range of subpopulations. Finally, we will integrate such retrospective analyses with microsimulation, compartmental and agent-based models to forecast future HIV/AIDS scenarios.ConclusionThe unprecedented datasets, analyzed through state-of-the-art quasi-experimental methods and innovative mathematical models will provide essential evidences to the understanding and control of HIV/AIDS epidemic in LMICs such as Brazil.

The aim of this study was to assess risk factors associated with low levels of HIV testing among MSM recruited through respondent driven sampling (RDS) in Brazil. Of 3,617 participants, 48.4% had never tested previously for HIV. A logistic model indicated that younger age, lower socioeconomic class, education, poor HIV/AIDS knowledge, no history of cruising, and having been tested during the study were characteristics independently associated with low levels of previous HIV testing. The HIV testing rate among MSM in Brazil is still low in spite of the availability of a large number services providing universal and free access to HIV/AIDS diagnosis and treatment. To respond to low utilization, the authors propose a higher priority for testing for key populations such as MSM, expanded education, expanding testing sites and a welcoming and nonjudgmental environment in health services.

Introduction: Discrimination related to gender identity may directly influence vulnerability to HIV through increased exposure to unprotected receptive anal intercourse (URAI). Little is known about the relationship between gender-based discrimination (GBD) and URAI with stable partners among transgender women. Methods: This mixed-methods research began with a cross-sectional survey conducted between 2014 and 2016 with transgender women in Salvador, the capital city in one of the poorest regions in Brazil. Respondent-driven sampling was used to recruit the study population. GBD was defined through Latent Class Analysis. Additionally, 19 semi-structured interviews with participants were transcribed and analyzed through thematic content analysis. Results: URAI with stable partners was commonly reported (37.3%). GDB was positively associated with URAI among stable partners (OR = 6.47; IC 95%: 1.67–25.02). The analysis of the interviews illustrated how GBD impacted transgender women in diverse ways. Experiences with GBD perpetrated by the family often initiated a trajectory of economic vulnerability that led many to engage in survival sex work. The constant experience with GBD contributed to participants feeling an immense sense of trust with their stable partners, ultimately diminished their desire to use condoms. Further, the high frequency of GBD contributed to poor mental health overall, though some participants said engagement in transgender advocacy efforts provided a vital source of resilience and support. Conclusion: Our mixed-method study capitalizes upon the strengths of diverse data sets to produce a holistic understanding of GBD and URAI with stable partners. Furthermore, by confirming the association between greater GBD and URAI, we have demonstrated how GBD can impact condom negotiation in diverse relationships. [ABSTRACT FROM AUTHOR]

Background: Salvador is the city with the highest number of HTLV-1 infected individuals in Brazil, yet the main route of HTLV-1 transmission is unknown. Objective: To investigate the association of syphilis infection as a proxy for sexual transmission of HTLV-1 infection in the general population of this city. Methods: A cross sectional population-based study was conducted with 3,451 serum samples obtained by a representative simple random sampling. Data on gender, age, income, and years of education were collected by questionnaire and the presence of HTLV, HIV and Treponema pallidum infection was determined by serology. Logistic regression analysis was used to evaluate the independent effect of the potential explanatory variables to HTLV-1 infection and Odds Ratios (OR) and 95% CI were calculated. Results: The majority of studied individuals were female (56.4%), had less than 7 years of education (55.3%) and earned two or less minimum wages (52.0%). The overall prevalence of HTLV-1 was 1.48% (51/3,451; 95% CI: 1.10%– 1.94%), which increased with age. Only three persons younger than 17 (3/958; 0.31%; CI 95% 0.06–0.91) years were infected by HTLV-1. Among the 45 syphilis positives, 12 (26.7%) were HTLV positive, while among 21 HIV positives, only one (4.8%) was HTLV positive. HTLV-1 infection was found to be associated with syphilis infection (ORADJUSTED 36.77; 95% CI 14.96–90.41). Conclusion: The data presented herein indicate that horizontal transmission between adults is the main route of HTLV-1 infection in the general population of Salvador and that this is likely to occur through sexual contact. [ABSTRACT FROM AUTHOR]

Background: A usual source of care (USC) has been conceptualized as having a health provider or place available for patients to consult when sick or in need of medical care. Having a USC is a means to achieve longitudinality of care with Primary Health Care (PHC) providers. Brazil has made enormous progress in PHC and thus provides an important opportunity to investigate USC in a middle-income country context. Methods: This study uses data from a nationally representative household survey, the 2013 National Health Survey ( = 62,986), to describe the prevalence of having a USC in Brazil and to investigate to what extent the Family n Health Strategy (FHS) has contributed to USC prevalence. Analyses include descriptive, bivariate and multivariable Poisson regression. Results: Show very high rates of people reporting any type of USC (74.4 %) and more than one third reporting PHC as their USC. Household enrolment in the FHS was positively associated with having any USC (PR:1.09; 95 % CI: 1.07-1.12) and a stronger association with having PHC as the regular source of care (PR:1.63;95 % CI:1.54-1.73). FHS enrolment was negatively associated with reporting emergency/urgent care facilities as one's USC (PR: 0.67; 95 % CI: 0.59-0.76). The association between the more consolidated FHS with having a USC was strongest in the poorest regions of the country (North, Northeast and Central-West). Having PHC as one's USC showed a positive dose- response relationship with the FHS in all regions, especially in the Central-West. Conclusions: Our results have important implications for the health care model in Brazil and in other countries, especially those seeking to base their national health systems more strongly on primary health care. The study suggests expanding primary health care can increase the establishment of a USC which can help assure better monitoring of chronic conditions and attention to patient needs. [ABSTRACT FROM AUTHOR]

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Background: Brazil has many people living with HIV (PLWH) who are unaware of their serostatus. The public health system has recently added HIV self-testing (HIVST) for key populations such as men who have sex with men (MSM). This study estimates HIVST acceptability among Brazilian MSM and explores factors associated with acceptability among MSM who have never tested for HIV or who had a previous negative result.Methods: Respondent-driven sampling (RDS) was used to recruit 4176 MSM in 12 Brazilian cities in 2016 to this biological and behavioral surveillance study. We excluded from this analysis all MSM who were aware of their positive HIV serostatus. Descriptive, bivariate and multivariate analyses were conducted. Overall proportions were weighted with Gile's estimator in RDS Analyst software and 95% confidence intervals were calculated. The analyses of HIVST acceptability were stratified by prior HIV testing (never or one or more times).Results: For this analysis, 3605 MSM were included. The acceptability of HIVST was 49.1%, lower among those who had never tested for HIV (42.7%) compared to those who had a previous HIV negative test (50.1%). In the subgroup of MSM who had never tested for HIV, those who reported discrimination or who had a medical appointment in the last 12 months reported higher HIVST acceptability. Among MSM who had a previous negative HIV test, only those reporting condomless receptive anal sex reported higher HIVST acceptability. In addition, we observed that high levels of knowledge of HIV/AIDS, taking part in lesbian, gay, bisexual, and transgender nongovernmental organizations (LGBT-NGO), or complete secondary or incomplete higher undergraduate education reported higher acceptability.Conclusions: The acceptability of HIVST was low among MSM, especially among those who never tested for HIV. Given access to HIVST in Brazil, we point to the need for programs that enhance promotion of testing addressed to MSM. [ABSTRACT FROM AUTHOR]

HIV prevalence is 15 times higher among female sex workers (FSWs) than in the overall Brazilian female population. In this article, we investigated factors associated to HIV infection among FSW, recruited by Respondent-driven sampling (RDS), in 10 Brazilian cities in 2008-2009.The total sampling was 2523 FSWs. The variables considered in the study included sociodemographic characteristics and those related to profession, knowledge, and source of information on sexually transmitted infection/AIDS, access to condoms, sexual behavior, health care and sexually transmitted infection signs, discrimination and violence, and the use of alcohol and drugs. Sampling weights were proportional to the inverse of network size and for the generation of global results for the 10 cities, data were calibrated by the population size. Multivariate logistic regression models were used, taking into account the dependency structure of observations.The longest period of prostitution (odds ratio [OR], 1.040; 95% confidence interval [CI], 1.013-1.067), the lowest price charged for sex (OR, 0.713; 95% CI, 0.522-0.970), the association with other sexually transmitted infections such as syphilis (OR, 2.186; 95% CI, 1.064-4.488), and the fact of would waive the use of condom on client's request (OR, 3.735; 95% CI, 1.449-9.661) were the most important associated risk factors to HIV infection among FSWs. Purchase of condoms (OR, 0.503; 95% CI, 0.304-0.833) was a relevant preventive factor.The use of RDS proved to be appropriate for the recruitment of FSWs as long as the statistical analysis takes into account the dependency structure of observations. The HIV infection predictors here depicted can support public health policies focused on this population group in Brazil. [ABSTRACT FROM AUTHOR]