Evaluating the intersectionality of social determinants of health on AIDS using a cohort of 28.3 million Brazilians
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Institute of Collective Health at the Federal University of Bahia (ISC/UFBA); Center for Integration of Data and Knowledge for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Brazil
ISGlobal, Hospital Clinic - Universitat de Barcelona, Barcel, Spain
Department of Life Sciences, Bahia State University (DCV/UNEB), Brazil
Department of Health Policy and Management, University of California, Los Angeles, USA
Department of Chronic Conditions Diseases and Sexually Transmitted Infections, Ministry of Health, Brazil
Institute of Collective Health at the Federal University of Bahia (ISC/UFBA)., Brazil
Publication date: 2023-04-26
Popul. Med. 2023;5(Supplement):A790
Background and Objective:
Societies that live with socio-structural inequalities and health inequities need to better understand these processes . In that regard intersectionality theory becomes fundamental to public health. The scientific literature on HIV/AIDS presents associations and isolated effects of some social determinants of health (SDH), but the intersection between them is still poorly addressed. Thus, our objective was to evaluate the intersectional effects of SDH on AIDS outcomes: incidence, mortality, and case-fatality rates.

A retrospective cohort of 28.3 million individuals was evaluated over a 9-year period (2007-2015). The multivariable Poisson regression were estimated using robust standard errors clustered on the municipality of residence, for each outcome. The intersections and combined effects were evaluate from the dummy variables of interaction of the highest exposure categories of the variables race/skin color, education, and wealth. Interactions additive was estimated from the index of synergy (S).

The risk of getting sick and dying from AIDS was higher in the intersection groups of the 3 highest exposure categories: black people, lower wealth, and lower education, had the highest AIDS incidence (34.33/100,000py; RRa:3.07, 95%CI:2.68-3.52) mortality (14.10/100,000py; RRa:5.01, 95%CI:4.04-6.22) and case-fatality rates (7.53/100py; RRa: 1.62; 95%CI:1.18-2.21). This intersection represents a positive additive interaction for the risk of getting sick (S:1.60) and dying (S:2.40) from AIDS. Among people living with AIDS the synergistic effect for case-fatality was even greater (S:2.95).

The intersections of identities that mark socio-structural inequalities, amplify the risks of getting sick and dying from AIDS, exceeding the sum of the risks of each exposure separately. The skin color stands out, since the (sub)groups with the combination of black color were those with the worst outcomes. Since this is an unchangeable characteristic, it highlights the need for social policies to expand education and income for these groups.

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