Abstract

This investigation analyzed the trend of HIV/AIDS mortality by sociodemographic characteristics in the Brazilian states from 2000 to 2018. This is an ecological study of time-series of standardized rates of mortality from AIDS overall, by gender, age group, marital status, and ethnicity/skin color, employing the Prais-Winsten generalized linear model. The results showed that the states with the highest rates were Rio Grande do Sul, Rio de Janeiro, São Paulo, and Santa Catarina. The trend was increasing in the North and Northeast. Men had higher rates than women and the general population. The most advanced age groups showed a growing trend. The analysis by marital status showed higher and growing rates among the unmarried. Blacks had higher rates, except for Paraná, with a mainly increasing trend. Mortality due to HIV/AIDS had different trends by sociodemographic characteristics, with a need for preventive and care actions for men, adults, older adults, unmarried, and black people due to the change in the mortality profile.

Key words:
Mortality; HIV; Acquired Immunodeficiency Syndrome; Time-series studies

Introduction

Some 690,000 deaths from HIV/AIDS were recorded in the world in 2019, with a 39% drop in global deaths from 2010 to 2019¹1 UNAIDS. 2020 Global AIDS Update - Seizing the moment - Tackling entrenched inequalities to end epidemics. Geneva: UNAIDS; 2020.. Brazil recorded 349,784 deaths from HIV/AIDS from the early 1980s until December 2019, with a drop in the country’s mortality rate from 2009 to 2019. This pattern was not found in the states of Acre, Pará, Amapá, Maranhão, Rio Grande do Norte, and Paraíba, which showed a resurgence of this disease²2 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Boletim Epidemiológico de HIV/Aids. Brasília: MS; 2020.. Also, HIV infections affect mostly males, young people aged 20-34 years, and blacks²2 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Boletim Epidemiológico de HIV/Aids. Brasília: MS; 2020..

This epidemic seems to be concentrated in specific places. However, it is heterogeneous when observing the increase in part of the states and municipalities³3 Teixeira TR A, Gracie R, Malta MS, Bastos FI. Social geography of AIDS in Brazil: identifying patterns of regional inequalities. Cad Saude Publica 2014; 30(2):259-271.. The concentrated hike in mortality from HIV/AIDS in some places can be explained by the sociodemographic features of the population⁴4 Pereira BS, Costa MCO, Amaral MTR, Costa HS, Silva CAL, Sampaio VS. Fatores associados à infecção pelo HIV/AIDS entre adolescentes e adultos jovens matriculados em Centro de Testagem e Aconselhamento no Estado da Bahia, Brasil. Cien Saude Colet 2014; 19(3):747-758.^,55 Pinto VM, Basso CR, Barros CRS, Gutierrez EB. Fatores associados às infecções sexualmente transmissíveis: inquérito populacional no município de São Paulo, Brasil. Cien Saude Colet 2018; 23(7):2423-2432., such as gender, age group, marital status, and ethnicity/skin color.

One study comparing the registration of mortality from HIV/AIDS in Brazil in the Mortality Information System (SIM) and the global burden of the disease showed that mortality from HIV/AIDS needs attention and, regardless of the methods applied in the studies, mortality from the disease shows significant rates and are a matter of concern⁶6 Guimarães MDC, Carneiro M, Abreu DMX, França EB. Mortalidade por HIV/Aids no Brasil, 2000-2015: motivos para preocupação? Rev Bras Epidemiol 2017; 20(Supl. 1):182-190..

The temporal analysis of HIV/AIDS mortality in Brazilian states based on gender, age group, marital status, and ethnicity/skin color is essential as it cements knowledge about the profile of death from HIV/AIDS and directs actions to control the advance of the disease.

Updated studies that encompass these variables together, especially concerning the marital status and ethnicity/skin color, are not observed in the literature since existing investigations focus on mortality from the disease based on overall mortality coefficients and do not consider other characteristics that could increase knowledge of the profile of the disease’s occurrence from a sociodemographic perspective.

In light of the above, this study aims to analyze the trend of mortality from HIV/AIDS in Brazil and Federative Units by sociodemographic characteristics from 2000 to 2018.

Methods

This is an ecological time-series study on HIV/AIDS mortality rates, with data from the Mortality Information System (SIM). All deaths from HIV/AIDS in Brazil from 2000 to 2018 were included in the study.

Deaths related to HIV/AIDS whose International Disease Code (ICD) refers to the range B20-B24 were considered to calculate mortality rates per 100,000 inhabitants. The standardized overall mortality rates by gender, ethnicity/skin color, and marital status were calculated using the direct method, and the 2010 Brazilian population was established as the standard. Mortality rates for HIV/AIDS by age group were also presented.

The information on the resident population used to calculate the HIV/AIDS mortality rates overall, by gender, and age group from 2000 to 2018 corresponds to the population estimates available on the DATASUS website in demographic and socioeconomic information.

Populations by ethnicity/skin color and marital status were extracted from the Brazilian Institute of Geography and Statistics (IBGE) through the IBGE Automatic Recovery System (SIDRA) by searching the API on this site and the SidraR package contained in the RStudio statistical program. These populations are only available for 2000 and 2010. Therefore, it was necessary to estimate them from the calculation of the population growth rate to identify the populations from 2001 to 2009 and from 2011 to 2018. The black and brown categories were merged in the black group, while the indigenous and yellow categories were excluded from the analysis due to their negligible number.

The trend analysis was performed using the Prais-Winsten⁷7 Antunes JLF, Cardoso MRA. Uso da análise de séries temporais em estudos epidemiológicos. Epidemiol Serv Saude 2015; 24(3):565-576. generalized linear analysis model, where the independent variables (X) were the years of deaths and the dependent variables (Y) were the mortality rates. The value of b0 refers to the intersection between the line and the vertical axis, while the value of b1 represents the line’s slope. This value allowed us to estimate the Annual Percentage Change (APC). It is necessary to apply the logarithmic transformation of the Y values (mortality rates) to measure this rate.

The application of the logarithmic transformation allows reducing the heterogeneity of variance of the regression analysis residuals. When the APC is positive, the time-series is classified as increasing, while it is decreasing when negative. The time-series will be stationary when there is no significant difference between its value and zero⁷7 Antunes JLF, Cardoso MRA. Uso da análise de séries temporais em estudos epidemiológicos. Epidemiol Serv Saude 2015; 24(3):565-576.. Data organization, rate calculation, trend analysis, maps, and charts were performed using the RStudio version 4.0.2 program, and the level of significance of 5% was considered for trend analysis.

This study used freely available secondary data and did not directly involve human beings, thus not requiring submission to the Research Ethics Committee (CEP).

Results

Brazil recorded 222,205 deaths from AIDS from 2000 to 2018. Among these deaths, 580 (0.3%) had no information on the age group, 40 (0.02%) did not show gender-related data, 13,709 (6.2%) had no registered ethnicity/skin color data, and 19,065 (8.6%) had no record of marital status. Data that did not have records were excluded from the analysis.

Brazil had higher standardized mortality rates for males. Overall and female mortality rates had similar values. Rates varied in the states, with the highest values observed in Rio Grande do Sul, Rio de Janeiro, São Paulo, and Santa Catarina. Most states had higher rates among males; only Acre and Tocantins showed higher rates among females in some points of the series (Figure 1).

Mato Grosso had similar rates until 2015, with a wide discrepancy in subsequent years. Amapá showed similar rates throughout the period, while São Paulo and Rio Grande do Sul had more accentuated rate falls. On the other hand, Amazonas, Pará, and Maranhão had increased rates over the period (Figure 1).

Trends were decreasing in Brazil for overall mortality and male/female. Most states in the North and Northeast had an increasing trend towards different stratifications. The South, Southeast, and Midwest states showed steady and decreasing trends in the period for the general population and both genders (Figure 1).

In Brazil, the most significant rates were found in the 30-59 years age group, with a resurgence among those aged 60 and over. However, trends decreased in the 0-14 years, 15-29 years, and 30-59 years age groups and increased in the 60 years or more age group.

In the federative units, rates by age were also more significant in the 15-29 years, 30-59 years, and 60 years or more age groups. However, those aged 30-59 years were more prominent, with an increase in Amazonas, Amapá, Paraíba, Pernambuco, and the Federal District, with a decline in Rio de Janeiro and Paraná. Also, increased rates were observed in the states among those over 60 years of age, with important variations in Roraima and Amapá.

Trends were mainly decreasing and stationary in most states, with an increasing trend only observed in Rondônia. In the 15-29 years age group, the North and Northeast showed increasing trends, and stationary trends were only observed in Acre, Roraima, Tocantins, Paraíba, Pernambuco, and Bahia. In those aged between 30-59 years, trends were increasing or stationary in the North and Northeast, except for Acre. Only Minas Gerais had an increasing trend in the Southeast region, while the other states in this region had stationary or decreasing trends. The age group of 60 years or more showed a growing trend in most Brazilian states, except for Acre, Amapá, and the Federal District (Figure 2).

In Brazil, standardized mortality rates by marital status were higher among the unmarried, but trends were declining in both categories (Figure 3). Mortality rates by marital status were higher among the unmarried in the states of the federation. Amazonas, Pará, Maranhão, Pernambuco, and Bahia had growing rates over the years. On the other hand, despite the higher rates, Minas Gerais, Rio de Janeiro, São Paulo, and Santa Catarina decreased over the years. Trends among the unmarried were increasing in most states in the North and Northeast. The trend was declining or stationary in the other states of the country. Trends were increasing in only two states among married couples: Rondônia and Tocantins. Trends were stationary or decreasing in other states (Figure 3).

Mortality rates standardized by ethnicity/skin color in Brazil were more significant among whites from 2000 to 2005, with a subtle rate overlapping for blacks. Trends in the period were decreasing among whites and stationary among blacks (Figure 4).

Mortality rates by ethnicity/skin color showed different patterns when the states were verified. Paraná was the only one with higher mortality rates among whites. Mortality rates between blacks and whites showed similar rates in São Paulo, Santa Catarina, Mato Grosso do Sul, Goiás, and the Federal District. It is noteworthy that Pará and Pernambuco had higher rates from 2000 to 2018. Rio Grande do Sul and Rio de Janeiro showed higher rates among blacks (Figure 4).

Blacks had a more significant number of states with an increasing trend than whites. It is noteworthy that the mortality trend was growing in blacks in all states in the North and Midwest, except for Acre. The trend was also increasing in some states among whites, with a concentration in the North and Northeast (Figure 4).

Figure 5 represents the annual percentage changes (APC) and confidence intervals, showing that the South, Southeast, and Midwest states showed variations that point to a fall or stationarity. The states of the North and Northeast showed mainly growing variations.

Discussion

The study on the Brazilian trend of mortality from HIV/AIDS found that the rate was increasing only among those over 60 years of age and stationary among blacks and decreasing in the other categories of analysis. The pattern of falling mortality from the disease in Brazil was also observed in other studies²2 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Boletim Epidemiológico de HIV/Aids. Brasília: MS; 2020.^,88 GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2015: the Global Burden of Disease Study 2015. Lancet HIV 2016; 3(8):e361-87..

The results of this study point to differences in mortality trends in the states of the North and Northeast, with increasing trends concentrated in these locations. The literature points out that greater attention is required in the North and Northeast as there is an upsurge in mortality, incidence, and prevalence³3 Teixeira TR A, Gracie R, Malta MS, Bastos FI. Social geography of AIDS in Brazil: identifying patterns of regional inequalities. Cad Saude Publica 2014; 30(2):259-271.^,66 Guimarães MDC, Carneiro M, Abreu DMX, França EB. Mortalidade por HIV/Aids no Brasil, 2000-2015: motivos para preocupação? Rev Bras Epidemiol 2017; 20(Supl. 1):182-190.^,99 Damacena GN, Szwarcwald CL, Motta LRD, Kato SK, Adami AG, Paganella MP, Pereira GFM, Sperhacke RD. A portrait of risk behavior towards HIV infection among Brazilian Army conscripts by geographic regions, 2016. Rev Bras Epidemiol 2019; 22(Supl. 1):e190009.^,1010 Mangal TD, Meireles MV, Pascom ARP, Coelho RA, Benzaken AS, Hallett TB. Determinants of survival of people living with HIV/AIDS on antiretroviral therapy in Brazil 2006-2015. BMC Infect Dis 2019; 19(1):206., also noting that the shortage of specialized services and late access to treatment leads to a higher probability of low adherence to the treatment of People Living with HIV/AIDS (PLWHA), which aggravates the disease setting in these places¹⁰10 Mangal TD, Meireles MV, Pascom ARP, Coelho RA, Benzaken AS, Hallett TB. Determinants of survival of people living with HIV/AIDS on antiretroviral therapy in Brazil 2006-2015. BMC Infect Dis 2019; 19(1):206.

11 Grangeiro A, Escuder MML, Castilho EA. A epidemia de AIDS no Brasil e as desigualdades regionais e de oferta de serviço. Cad Saude Publica 2010; 26(12):2355-2367.^-1212 Veras MASM, Ribeiro MCA, Jamal LF, McFarland W, Bastos FI, Ribeiro KB, Barata RB, Moraes JC, Reingold AL. The "AMA-Brazil" cooperative project: a nation-wide assessment of the clinical and epidemiological profile of AIDS-related deaths in Brazil in the antiretroviral treatment era. Cad Saude Publica 2011; 27(Suppl. 1):s104-113..

The high mortality rate in males is also observed in national and international studies, which show that men are more affected by HIV/AIDS¹³13 Druyts E, Dybul M, Kanters S, Nachega J, Birungi J, Ford N, Thorlund K, Negin J, Lester R, Yaya S, Mills EJ. Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: a systematic review and meta-analysis. AIDS 2013; 27(3):417-425.

14 Abioye AI, Soipe AI, Salako AA, Odesanya MO, Okuneye TA, Abioye AI, Ismail KA, Omotayo MO. Are there differences in disease progression and mortality among male and female HIV patients on antiretroviral therapy? A meta-analysis of observational cohorts. AIDS Care 2015; 27(12):1468-1486.

15 Oliveira RSM, Benzaken AS, Saraceni V, Sabidó M. HIV/AIDS epidemic in the State of Amazonas: characteristics and trends from 2001 to 2012. Rev Soc Bras Med Trop 2015; 48(Supl. 1):70-78.

16 Zayeri F, Talebi Ghane E, Borumandnia N. Assessing the trend of HIV/AIDS mortality rate in Asia and North Africa: an application of latent growth models. Epidemiol Infect 2016; 144(3):548-555.

17 Gao D, Zou Z, Dong B, Zhang W, Chen T, Cui W, Ma Y. Secular trends in HIV/AIDS mortality in China from 1990 to 2016: gender disparities. PLoS One 2019; 14(7):e0219689.^-1818 Weber A, Tombini LHT, Silva DTR, Pitilin ÉDB, Rosa GFD, Souza TD. Análise da tendência temporal da infecção pelo HIV/AIDS na região oeste catarinense: estudo retrospectivo 1984-2015. Rev Epidemiologia e Controle de Infecção 2020; 10(1) [periódico na Internet]. 2020 maio [acessado 2020 out 25]; 10(1): [cerca de 6 p.]. Disponível em: https://doi.org/10.17058/jeic.v1i1.13089
https://doi.org/10.17058/jeic.v1i1.13089... . Men are at greater risk of reaching an advanced stage of the disease and also starting treatment later than women¹⁹19 Jiang H, Yin J, Fan Y, Liu J, Zhang Z, Liu L, Nie S. Gender difference in advanced HIV disease and late presentation according to European consensus definitions. Sci Rep 2015; 5:14543.^,2020 Abgrall S, del Amo J. Effect of sociodemographic factors on survival of people living with HIV. Curr Opin HIV AIDS 2016; 11(5):501-506..

The analysis according to females indicates that the North and Northeast regions have an increasing trend among women, although the rates among women are not as expressive as males. Some factors that can justify this situation are the unequal conditions that women are exposed to daily and also make them vulnerable to HIV/AIDS, such as an environment permeated by submissive practices that influence their choices regarding sexual practice, abusive relationships characterized by violent situations, difficulties in accessing diagnostic services, and poverty²¹21 Hernández-Ávila JE, Palacio-Mejía LS, Hernández-Romieu A, Bautista-Arredondo S, Amor JS, Hernández-Ávila M. Effect of Universal Access to Antiretroviral Therapy on HIV/AIDS Mortality in Mexico 1990-2011. J Acquir Immune De?c Syndr 2015; 69(3): e100-e108.

22 Villela WV, Barbosa RM. Trajetórias de mulheres vivendo com HIV/aids no Brasil. Avanços e permanências da resposta à epidemia. Cien Saude Colet 2017; 22(1):87-96.

23 Sousa RMRB, Frota MMA, Castro C, Sousa FB, Kendall BC, Kerr LRFS. Prostituição, HIV/Aids e vulnerabilidades: a "cama da casa" e a "cama da rua". Cad Saude Colet 2017; 25(4):423-428.

24 Anderson S. Legal Origins and Female HIV. Am Econ Rev 2018; 108(6):1407-1439.

25 Braksmajer A, Leblanc NM, El-Bassel N, Urban MA, McMahon JM. Feasibility and acceptability of pre-exposure prophylaxis use among women in violent relationships. AIDS Care 2019; 31(4):475-480.

26 Hale F, Bell E, Banda A, Kwagala B, van der Merwe LL, Petretti S, Yuvaraj A. Keeping our core values ALIV[H]E. Holistic, community-led, participatory and rights-based approaches to addressing the links between violence against women and girls, and HIV. J Virus Erad 2018; 4(3):189-192.^-2727 Willie TC, Stockman JK, Perler R, Kershaw TS. Associations between intimate partner violence, violence-related policies, and HIV diagnosis rate among women in the United States. Ann Epidemiol 2018; 28(12):881-885..

Mortality from HIV/AIDS by age group showed a decreasing trend among children and adolescents, which was also observed in a study that assessed mortality in this population from 1990 to 2016²⁸28 Masquelier B, Hug L, Sharrow D, You D, Hogan D, Hill K, Liu J, Pedersen J, Alkema L; United Nations Inter-agency Group for Child Mortality Estimation. Global, regional, and national mortality trends in older children and young adolescents (5-14 years) from 1990 to 2016: an analysis of empirical data. Lancet Glob Health 2018; 6(10):e1087-99.. On the other hand, this trend has progressed accordingly with the aging of PLWHA, which can be seen with the higher number of states with an increasing trend with age, a pattern that was also identified in surveys carried out in Brazil and Iran¹⁵15 Oliveira RSM, Benzaken AS, Saraceni V, Sabidó M. HIV/AIDS epidemic in the State of Amazonas: characteristics and trends from 2001 to 2012. Rev Soc Bras Med Trop 2015; 48(Supl. 1):70-78.^,2929 Oliveira MLC, Paz LC, Melo GF. Dez anos de epidemia do HIVAIDS em maiores de 60 anos no Distrito Federal - Brasil. Rev Bras Epidemiol 2013;16(1):30-39.

30 Lima MS, Firmo AAM, Martins-Melo FR. Trends in AIDS-related mortality among people aged 60 years and older in Brazil: a nationwide population-based study. AIDS Care 2016; 28(12):1533-1540.^-3131 Hamidi O, Poorolajal J, Tapak L. Identifying predictors of progression to AIDS and mortality post-HIV infection using parametric multistate model. Epidemiol Biostat Public 2017; 4:1-9.. Other factors may contribute to higher rates at older ages, such as Antiretroviral Therapy (ART), which increased life expectancy of PLWHA and advanced HIV diagnosis in the older population³²32 Cardoso SW, Torres TS, Santini-Oliveira M, Marins LMS, Veloso VG, Grinsztejn B. Aging with HIV: a practical review. Braz J Infect Dis 2013; 17(4):464-479.

33 O'Keefe KJ, Scheer S, Chen M-J, Hughes AJ, Pipkin S. People fifty years or older now account for the majority of AIDS cases in San Francisco, California, 2010. AIDS Care 2013; 25(9):1145-1148.

34 Piggott DA, Muzaale AD, Mehta SH, Brown TT, Patel KV, Leng SX, Kirk GD. Frailty, HIV Infection, and Mortality in an Aging Cohort of Injection Drug Users. PLoS One 2013; 8(1):e54910.^-3535 Chambers LA, Wilson MG, Rueda S, Gogolishvili D, Shi MQ, Rourke SB; Positive Aging Review Team. Evidence informing the intersection of HIV, aging and health: a scoping review. AIDS Behav 2014; 18(4):661-675..

Mortality rates by marital status are more significant among unmarried people, as found in other studies³⁶36 Reis AC, Santos EM, Cruz MM. A mortalidade por aids no Brasil: um estudo exploratório de sua evolução temporal. Epidemiol Serv Saude 2007; 16(3)16(3):195-205.

37 Kposowa AJ. Marital status and HIV/AIDS mortality: evidence from the US National Longitudinal Mortality Study. Int J Infect Dis 2013; 17(10):e868-74.^-3838 Waine I, Rantetampang AL, Msen Y, Mallongi A. Factors related to HIV/AIDS transmission by people with HIV/AIDS in Dogiyai District Papua Province. International Journal of Science and Healthcare Research 2018; 3(4).. It was found that people in stable relationships have less vulnerability to HIV/AIDS and greater adherence to treatment³⁹39 Shisana O, Risher K, Celentano DD, Zungu N, Rehle T, Ngcaweni B, Evans MG. Does marital status matter in an HIV hyperendemic country? Findings from the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey. AIDS Care 2016; 28(2):234-241.^,4040 Tran BX, Fleming M, Do HP, Nguyen LH, Latkin CA. Quality of life improvement, social stigma and antiretroviral treatment adherence: implications for long-term HIV/AIDS care. AIDS Care 2018; 30(12):1524-1531.. Also, being married and having a high educational level can contribute to fighting the infection, reducing the vulnerability of these people to HIV/AIDS, and helping to avoid the symptomatic form of the disease⁴¹41 Akpabio II, Uyanah DA, Osuchukwu NC, Samson-Akpan PE. Influence of marital and educational status on clients' psychosocial adjustment to HIV/AIDS in Calabar, Nigeria: psychological adjustment to HIV/AIDS. Nurs Health Sci 2010; 12(2):155-161..

Concerning the analysis by ethnicity/skin color, blacks had similar rates but higher than whites, noting that blacks show increasing trends in many states. The findings of this study corroborate those of other studies⁴²42 Guibu IA, Barros MB A, Donalísio MR, Tayra A, Alves MCGP. Survival of AIDS patients in the Southeast and South of Brazil: analysis of the 1998-1999 cohort. Cad Saude Publica 2011; 27(Supl. 1):s79-92.

43 Murphy K, Hoover DR, Shi Q, Cohen M, Gandhi M, Golub ET, Gustafson DR, Pearce CL, Young M, Anastos K. Association of self-reported race with AIDS death in continuous HAART users in a cohort of HIV-infected women in the United States. AIDS 2013; 27(15):2413-2423.^-4444 Cunha AP, Cruz MM, Torres RMC, Cunha AP, Cruz MM, Torres RMC. Tendência da mortalidade por aids segundo características sociodemográficas no Rio Grande do Sul e em Porto Alegre: 2000-2011. Epidemiol Serv Saude 2016; 25(3):477-486.. The high rate among blacks may be related to a set of factors that place the black population in a situation of greater vulnerability to mortality from HIV/AIDS, as it is inserted in unfavorable living conditions and exposed to greater social vulnerability and access to services due to the prevailing structural racism⁴⁵45 Barata RB. Como e por que as desigualdades sociais fazem mal à saúde. Rio de Janeiro: Fiocruz; 2009. (Coleção Temas em saúde).

46 Dillon PJ, Basu A. HIV/AIDS and minority men who have sex with men: a meta-ethnographic synthesis of qualitative research. Health Commun 2014; 29(2):182-192.

47 Cockerham WC. Social causes of health and disease. Cambridge; Malden: Polity Press; 2013.^-4848 Brasil. Ministério da Saúde (MS). Secretaria de Gestão Estratégica e Participativa. Política Nacional de Saúde Integral da População Negra: uma política do SUS. Brasília: MS; 2010..

This study has potential and advantages for using secondary data and providing relevant information to guide public policies but has limitations related to the incompleteness and inconsistency of the accessed data. The SIM data showed improvements due to the reduced registration of deaths from ill-defined causes, which causes an increase in specific mortality rates in those regions with significant registration of deaths from ill-defined causes, which is the case of the North and Northeast. From this scenario, it is essential to point out a possible underestimation of the rates at the onset of this study’s period.

Another limitation of this study is the impossibility of analyzing the sexual orientation of people who died from the disease, as no such recording field is available in the SIM. This information would contribute to a better understanding of the epidemic’s dynamics among populations vulnerable to the disease.

Mortality from HIV/AIDS is characterized as a complex event permeated by social issues that must be incorporated into HIV/AIDS response policies and programs in light of the change in this setting. Despite this need, there is still a significant focus on the biomedical model to face this epidemic, which contributes to the reinforcing inequalities in death from this disease because when there is no attention to issues that also contribute to vulnerabilities and the problem is not being addressed at its core, giving preference to strategies focused on the pathogen rather than the subject and their relationships.

Although it was not the object of this study, it would be essential to carry out studies that included living conditions to explain mortality from HIV/AIDS, which may be a way to visualize how inequalities are expressed socially, as epidemiological and social aspects of the places where one circulates can affect the health of individuals. It is also necessary to pay attention to differences in the characteristics of populations that can contribute to inequalities, and it is crucial to select relevant variables for the analysis of inequalities.

Finally, these findings can contribute to the planning and managing prevention and care actions in PLWHA care within the SUS. However, they point to the need to deepen knowledge of the factors that influence mortality from HIV/AIDS, such as access to services and the inclusion of living conditions to understand this dynamic at different scales.

References

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