Reduction trends in AIDS indicators (incidence, hospitalization and mortality rates) associated with conditional cash transfer measures in Brazil: an ecological study

BACKGROUND: Brazil has long been recognized for its strong response to the HIV/AIDS epidemic. Although the epidemic is classified as stable at the national level, AIDS incidence, hospitalizations and mortality rates vary geographically. Brazil is also one of the most unequal countries in the world, and it has implemented in the last two decades one of the largest Conditional Cash Transfer (CCT) programs, the Bolsa Familia Programme (BFP). BFP's target populations are poor households earning between US$35'70 per person per month. It is important to note that the BFP has two conditionalities: the beneficiary families are obliged to keep the children in school and to be accompanied in health units. We aimed to evaluate the impact of BFP coverage on trends in the rates of AIDS incidence, hospitalizations and mortality in Brazil.
METHODS: An ecologic panel data study, with all 5,507 Brazilian municipalities over the 2004-2012 period, was performed. We employed a fixed-effects multivariate negative binomial model to estimate the association between BFP coverage - of the eligible poor population -, classified as low (0% to 29%); intermediate (30% to 69%); and high ('¥ 70%), and AIDS indicators, adjusting for all relevant covariates.
RESULTS: At the national level, a BFP coverage of 70% or more of the poorest population, in municipalities with the highest AIDS incidence, was associated with a 10.3% (95%CI:3.7-16.5) reduction in the incidence, with an even stronger effect among women (15%; 95%CI:6.6-22.6) and children under 14 years old (38.7%; 95%CI:20.9-52.5). Higher BFP coverage was also associated with a decline in AIDS-related hospitalizations (26.4%; 95%CI:18.0-34.0) and AIDS mortality rates (9.7%; 95%CI:1.8-17.0).
CONCLUSIONS: This is the first study to evaluate the association between BFP coverage and trends in AIDS indicators in all Brazilian municipalities over a long period. BFP contributed to reduce the incidence, hospitalizations and mortality by AIDS in Brazil, which could be explained by both its money allowances and conditionalities. These results have important implications for countries with social protection measures such as conditional cash transfers. They are evidence of the impact of a policy that can be adapted to other low- and middle-income countries with high socioeconomic inequalities.