Abstract
Despite progress in addressing HIV/AIDS, the burden remains uneven, especially in low- and middle-income countries (LMICs). Social determinants of health (SDH) significantly influence HIV/AIDS. We studied the impact of SDH inequalities on AIDS incidence in Brazil, a large and diverse LMIC. We used an agent-based model (ABM) to introduce the SDH inequalities of income, education, sex and race in an HIV/AIDS model of 1 172 721 residents in 10 Brazilian state capitals. We simulated the poorest half of the population using the Cadastro Único database and calibrated our baseline models for each city with AIDS incidence from 2012 to 2019. We compared them with an alternative scenario where the effect of inequalities in SDH was removed. The difference between scenarios and subpopulations was measured in terms of cumulative rate ratios (RR) and avoidable cases over the study period. If there were no inequality in income, education, sex and race, there would be 38.8% lower AIDS incidence (95% CI 33% to 44.4%) compared with the baseline scenario. Furthermore, AIDS incidence was lower among individuals with low income (44.9%, 95% CI 34.7% to 61%), lower education (39.8%, 95% CI 34.6% to 46.5%) and people of Brown or Black race (39.3%, 95% CI 33.5% to 47.3%), in the alternative scenario compared with the baseline scenario. Furthermore, addressing inequality in the selected SDH had a positive spillover effect in reducing AIDS incidence in high income (31%, 95% CI 23.3% to 48.8%), highly educated (13.7%, 95% CI 8.4% to 27.8%) and white or Asian (35.4%, 95% CI 27.5% to 46.6%) populations, indicating a strong benefit to the whole of society. Our results suggest that addressing social inequalities in key SDH could reduce the number of AIDS cases among Brazil's poorest population by at least a third from 2012 to 2019. This effect is particularly significant in subpopulations with higher vulnerabilities. Implementing social protection policies to tackle these inequalities has the potential to help control the HIV/AIDS epidemic and advance the AIDS-related Social Development Goals.