Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil.
The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil.
PLoS Med. 2024 Jul 11;21(7):e1004302. doi: 10.1371/journal.pmed.1004302. eCollection 2024 Jul.
BACKGROUND: Primary Health Care (PHC) is essential for effective, efficient, and more equitable health systems for all people, including those living with HIV/AIDS. This study evaluated the impact of the exposure to one of the largest community-based PHC programs in the world, the Brazilian Family Health Strategy (FHS), on AIDS incidence and mortality. METHODS AND FINDINGS: A retrospective cohort study carried out in Brazil from January 1, 2007 to December 31, 2015. We conducted an impact 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 impact of FHS on AIDS incidence and mortality and compared outcomes between residents of municipalities with low or no FHS coverage (unexposed) with those in municipalities with 100% FHS coverage (exposed). 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 the FHS impact by sex and age and performed a wide range of sensitivity and triangulation analyses; 100% FHS coverage was associated with lower AIDS incidence (rate ratio [RR]: 0.76, 95% CI: 0.68 to 0.84) and mortality (RR: 0.68, 95%CI: 0.56 to 0.82). FHS impact 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 to 0.72) and mortality (RR: 0.56, 95% CI: 0.43 to 0.72). The absence of important confounding variables (e.g., sexual behavior) is a key limitation of this study. 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.
背景：初级卫生保健（PHC）对于建立有效的、高效的、更加公平的全民卫生体系至关重要，包括艾滋病毒/艾滋病感染者。本研究评估了暴露于世界上最大的社区为基础的初级卫生保健方案之一，即巴西家庭卫生战略（FHS），对艾滋病发病率和死亡率的影响。
方法和发现：这是在巴西进行的一项回顾性队列研究，时间范围为 2007 年 1 月 1 日至 2015 年 12 月 31 日。我们使用来自 1 亿巴西人队列的≥13 岁低收入人群的队列进行了一项影响评估，该队列与艾滋病诊断和死亡登记相关联。我们评估了 FHS 对艾滋病发病率和死亡率的影响，并比较了低或无 FHS 覆盖率的城市（未暴露）和 100% FHS 覆盖率的城市（暴露）的结果。我们使用多变量泊松回归模型调整了所有相关的市和个人层面的人口统计学、社会经济和背景变量，并进行了反概率治疗加权（IPTW）。我们还按性别和年龄估计了 FHS 的影响，并进行了广泛的敏感性和三角分析；100%的 FHS 覆盖率与较低的艾滋病发病率（发病率比 [RR]：0.76，95%置信区间：0.68 至 0.84）和死亡率（RR：0.68，95%置信区间：0.56 至 0.82）相关。FHS 的影响在男女之间相似，但在≥35 岁的人群中，发病率（RR：0.62，95%置信区间：0.53 至 0.72）和死亡率（RR：0.56，95%置信区间：0.43 至 0.72）的影响更大。本研究的一个关键局限性是不存在重要的混杂变量（例如性行为）。
结论：艾滋病应该是当今大多数艾滋病毒感染者可以避免的结果，我们的研究表明，FHS 的覆盖范围可以显著降低巴西低收入人群的艾滋病发病率和死亡率。应该通过以社区为基础的初级卫生保健方案普及全面的医疗保健，以实现到 2030 年终止艾滋病的可持续发展目标。
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