Social Determinants of In-Hospital AIDS-Related Mortality: A Cohort Study of 13,266 Low-Income Patients in Brazil

BackgroundSocial determinants of health (SDOH)--including socioeconomic, demographic, and geographic factors--are closely linked to HIV/AIDS outcomes. This study assessed the association between SDOH and in-hospital AIDS-related mortality among low-income individuals in Brazil. MethodsWe conducted a cohort study using data from the 100 Million Brazilian Cohort, which includes individuals who applied for government social programs (2008-2018), linked to national HIV/AIDS hospitalization and mortality records. Multivariable Poisson regression with a hierarchical framework was used to evaluate associations between individual and household-level SDOH and in-hospital AIDS mortality. FindingsAmong 13,266 individuals hospitalized for AIDS, 2,108 (15.8%) died during hospitalization, yielding a case-fatality rate of 6.7% (95% CI: 6.4-7.0%). Higher mortality was independently associated with older age (adjusted Rate Ratio [aRR]: 2.3; 95% CI: 1.8-3.0), residence in the North region (aRR: 1.4; CI: 1.1-1.7)--a structurally disadvantaged area with poor health indicators--male sex (aRR: 1.3; CI: 1.2-1.4), lower household wealth (aRR: 1.3; CI: 1.1-1.6), Black (aRR: 1.2; CI: 1.0-1.4) and Pardo (Brown) (aRR: 1.2; CI: 1.0-1.3) race/ethnicity, and low schooling - illiterate people or people who have never attended school - (aRR: 1.2; CI: 1.0-1.5). ConclusionsIn-hospital AIDS mortality disproportionately affects individuals facing social vulnerabilities, including poverty, racial inequities, and geographic isolation. These findings highlight the enduring impact of structural inequities and reinforce the need for targeted social policies--such as cash transfer programs and expanded healthcare access--to reduce AIDS-related mortality in low- and middle-income countries. FundingThis study was funded by the National Institute of Allergy and Infectious Diseases--NAIDS/NIH, Grant Number: 1R01AI152938.