The effect of primary health care on AIDS incidence and mortality: a cohort study of 3.4 million Brazilians

BACKGROUND. Primary Health Care (PHC) is essential for the health and wellbeing of people living with HIV/AIDS. This study evaluated the effects of one of the largest community-based PHC programs in the world, the Brazilian Family Health Strategy (FHS), on AIDS incidence and mortality. METHODS. A retrospective cohort study carried out in Brazil, from January 1 2007 to December 31 2015. We conducted a quasi-experimental effect evaluation using a cohort of 3,435,068 ≥13 years low-income individuals who were members of the 100 Million Brazilians Cohort, linked to AIDS diagnoses and deaths registries. We evaluated the effect of FHS on AIDS incidence and mortality and comparing outcomes between residents of municipalities with no FHS coverage with those in municipalities with full FHS coverage. We used multivariable Poisson regressions adjusted for all relevant municipal and individual-level demographic, socioeconomic, and contextual variables, and weighted with inverse probability of treatment weighting (IPTW). We also estimated FHS effect by sex and age, and performed a wide range of sensitivity and triangulation analyses. FINDINGS. FHS coverage was associated with lower AIDS incidence (rate ratio [RR]:0.76, 95%CI:0.68–0.84) and mortality (RR:0.68,95%CI:0.56–0.82). FHS effect was similar between men and women, but was larger in people aged ≥35 years old both for incidence (RR 0.62, 95%CI:0.53–0.72) and mortality (RR 0.56, 95%CI:0.43–0.72). CONCLUSIONS. AIDS should be an avoidable outcome for most people living with HIV today, and our study shows that FHS coverage could significantly reduce AIDS incidence and mortality among low-income populations in Brazil. Universal access to comprehensive healthcare through community-based PHC programs should be promoted to achieve the Sustainable Development Goals of ending AIDS by 2030.