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ANÁLISE DAS TENDÊNCIAS DAS COMORBIDADES ASSOCIADAS À MORTALIDADE POR HIV NO BRASIL, 2000 A 2022: ESTUDO ECOLÓGICO
TRENDS IN COMORBIDITIES ASSOCIATED WITH HIV MORTALITY IN BRAZIL, 2000 TO 2022: AN ECOLOGICAL STUDY
Ana Paula da Cunha – Escola Nacional de Saúde Pública Sergio Arouca; cunhaenf2010@gmail.com, https://orcid.org/0000-0002-1400-1472
Marly Marques da Cruz - Escola Nacional de Saúde Pública Sergio Arouca; marlycruz12@gmail.com, https://orcid.org/0000-0002-4061-474X

Resumo: O objetivo foi analisar as tendências das comorbidades associadas à mortalidade por HIV no Brasil de 2000 a 2022. Estudo ecológico de séries temporais que utilizou dados do Sistema de Informações sobre Mortalidade, incluindo todos os óbitos registrados com os códigos B20 a B24 da CID-10. As comorbidades foram classificadas de acordo com os capítulos da CID-10. Foram calculadas taxas de mortalidade padronizadas pelo método direto. As tendências foram analisadas pela regressão de Prais-Winsten. A taxa média de mortalidade foi 6,40 óbitos por 100.000 habitantes, a de condições definidoras foi 5,71 óbitos por 100.000 habitantes e a de condições não definidoras foi 0,65 óbitos por 100.000 habitantes. Observou-se tendência decrescente apenas para as doenças infecciosas no Brasil (APC = -2,94; p valor < 0,001), padrão este que não foi verificado em alguns estados das regiões Norte e Nordeste que tiveram tendência crescente. Observou-se tendência crescente para as neoplasias (APC = 4,69; p = 0,002) e para as doenças circulatórias (APC = 6,97; p = 0,002) no Brasil. Apesar da tendência decrescente da mortalidade por condições definidoras no Brasil, ainda se observam elevadas taxas de mortalidade por essas causas e tendência crescente em alguns estados.
Palavras-chave: Mortalidade; HIV; Síndrome de Imunodeficiência Adquirida; Estudos de séries temporais; Comorbidades.

Abstract: This study aimed to analyze trends in comorbidities associated with HIV-related mortality in Brazil from 2000 to 2022. This ecological time-series study used Mortality Information System data, including all deaths recorded under ICD-10 codes B20 to B24. Comorbidities were classified under ICD-10 chapters. Age-standardized mortality rates were calculated using the direct method. Trends were analyzed using Prais-Winsten regression. The mean mortality rate was 6.40 deaths per 100,000 inhabitants; for AIDS-defining conditions, the rate was 5.71 deaths per 100,000 inhabitants; and for non-AIDS-defining conditions, 0.65 deaths per 100,000 inhabitants. A decreasing trend was observed only for infectious diseases in Brazil (APC = -2.94; p-value < 0.001), a pattern not observed in some Northern and Northeastern states, where increasing trends were identified. Neoplasms showed a growing trend (APC = 4.69; p-value = 0.002), as did circulatory diseases (APC = 6.97; p-value = 0.002) in Brazil. High mortality rates for AIDS-defining conditions persist despite their overall declining trend, with increasing trends in some states.
Keywords: Mortality; HIV; Acquired Immunodeficiency Syndrome; Time-series studies; Comorbidities.

INTRODUCTION
In 2023, an estimated 630,000 people died from HIV-related conditions worldwide, representing a significant reduction of 68.5% from the peak in 2004, when 2 million deaths were attributed to the disease1. Despite this global decline, mortality rates remain high in low- and middle-income countries, such as those in sub-Saharan Africa, Eastern Europe, Central Asia, Latin America, the Middle East, and North Africa2. In these regions, inequalities in access to effective interventions and healthcare, compounded by structural challenges and insufficient financing, continue to hinder a more significant downfall in HIV-related deaths3,4.
In Brazil, 382,521 deaths from HIV-related causes were recorded from 1980 to 20225. HIV mortality rates declined from 2012 to 2022. In 2012, the mortality rate was approximately 5.6 deaths per 100,000 inhabitants, while this rate fell to approximately 4.1 deaths per 100,000 inhabitants in 2022, a reduction of approximately 26.8%5. The Southeast accounted for most of these deaths, representing 37.7% of the total, followed by the Northeast with 23.7% and the South with 19.4%. The North and Midwest accounted for 12.1% and 7.1% of deaths, respectively5.
Mortality among people living with HIV is often associated with comorbidities6, which can be classified as AIDS-defining (such as tuberculosis and opportunistic infections) or non-defining (such as neoplasms and cardiovascular diseases)7. Notably, while defining comorbidities are associated with HIV progression to the most advanced stage (AIDS), non-defining comorbidities reflect the impact of aging and chronic conditions in people living with HIV, even in the era of ART8-10.
In Brazil, the availability of antiretroviral therapy (ART) as of 1996, universally and free of charge, has reduced the incidence of opportunistic diseases and the need for hospitalizations among people living with HIV11,12. However, unequal access to these treatments and health services across different regions of the country contributes to variations in the clinical outcomes of people living with HIV. Structural factors, such as poverty and regional inequalities, widen gaps in the organization of health services, hindering prevention and management of these conditions and contributing to persistent mortality from AIDS-defining conditions13-15.
Given the mentioned above, understanding the trends in comorbidities associated with HIV mortality in Brazil is essential to reveal patterns that reflect regional inequalities and gaps in access to healthcare. These comorbidities complicate the clinical course of people living with HIV and are primarily influenced by structural factors.
By investigating these trends, this study seeks to highlight how HIV-associated conditions affect mortality over time and in different regional contexts, allowing us to assess the effects of public policies, such as the universalization of antiretroviral therapy (ART). This study’s results may support interventions aimed at reducing mortality rates, focusing on health equity, and improving the quality of life of people living with HIV.
This study aimed to analyze the trends in comorbidities associated with HIV mortality in Brazil from 2000 to 2022.
METHODS
Study type
Ecological time series study of standardized HIV mortality rates per the chapters of the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). The units of analysis of this study were the Federative Units (UF) and the country.
Population
All HIV deaths recorded from 2000 to 2022 in the Mortality Information System (SIM), containing ICD-10 codes B20 to B24 as the underlying or associated cause, were included.
Inclusion criteria
The inclusion criteria adopted in this study were death records with ICD-10 codes B20 to B24 in lines A, B, C, D, and part II of the death certificate (DC); deaths occurring from 2000 to 2022 in all Brazilian Federation Units; and complete records with sociodemographic and clinical variables relevant to the study.
Study variables
The population analyzed in the period was characterized by the proportions by sex (female and male), age group (0-19 years, 20-59 years, and 60 years and over), marital status (married and unmarried), and ethnicity/skin color (Black and non-Black). As for the variables that referred to comorbidities, the following chapters of ICD-10 were used to represent them: infectious, circulatory, digestive, endocrine, neoplasms, genitourinary, respiratory diseases, and other diseases.
Database collection and data processing
Mortality Information System (SIM) microdata were used. They were retrieved from the “Services” section of the website of the Information Technology Department of the Unified Health System (DATASUS). In this section, we accessed the “File Transfer/Download” option, where the files corresponding to the SIM were located and downloaded in August 2024. Two experienced researchers trained in the analysis of secondary databases and the use of DATASUS systems conducted this process.
In the data processing stage, we considered deaths with records of ICD codes B20 to B24, which refer to the group “Disease caused by the human immunodeficiency virus”, in at least one of the following fields: underlying cause, lines A, B, C, D and part II. Then, considering that the DC may have more than one ICD registered, codes B20 to B24 in at least one of the mentioned fields were tracked. In this way, deaths related to this group were identified, regardless of the underlying or associated cause.
After this stage, we grouped the other ICDs in the death records from B20 to B24 per the ICD-10 chapters, considering those with the highest proportions, namely, infectious, circulatory, digestive, endocrine, neoplasms, genitourinary, respiratory diseases, and other diseases. This last category covered all the remaining ICDs due to the low proportion identified under their respective ICD-10 chapters.
Infectious diseases included the defining conditions of AIDS, while non-defining diseases included others, namely circulatory, digestive, endocrine, neoplasms, genitourinary, respiratory diseases, and other diseases.
In the case of neoplasms, a distinction was adopted in the classification, with AIDS-defining neoplasms being considered those recognized as the syndrome’s markers, such as non-Hodgkin’s lymphoma (C83-C85), Kaposi’s sarcoma (C46), and invasive cervical cancer (C53), which were included in the group of AIDS-defining diseases. The other neoplasms (such as lung, liver, and stomach cancer) were classified as non-defining conditions, making up the group of causes associated with HIV, but which do not characterize the AIDS stage.
Standardized mortality rates were calculated per the chapters mentioned above. We adopted the direct method to standardize the rates, considering the Brazilian population as the standard16. The standardized rates aimed to adjust the effect of age on the mortality rate, using a population with a known age distribution, to which the weights recognized by the proportion of people in each age group in the standard population were applied. Under the selected ICD-10 chapters, the population data for calculating mortality rates were the estimates made available by DATASUS based on data from the Brazilian Institute of Geography and Statistics (IBGE) in August 2024.
Two researchers with previous experience in ecological studies performed search, extraction, and analyses based on secondary data from national health information systems, such as SIM. Both actively participated in the study design, definition of variables, standardization of search filters, and validation of the extracted data.
The activities were conducted independently in pairs, with subsequent conferences to resolve any disagreements by consensus. The researchers also received prior training related to using SIM databases, categorizing the causes of death per the ICD-10, and conducting ecological studies to ensure standardized procedures and the analyzed data’s reliability.
Statistical analysis
From the organized and standardized data, statistical analysis was applied to investigate trends in HIV mortality over the study period. The Prais-Winsten generalized linear regression model17 was applied to analyze trends. The independent variables (X) correspond to the years in which the deaths occurred, and the dependent variables (Y) refer to the standardized mortality rates.
This model was applied to correct the serial autocorrelation of the time series. The first step in operationalizing this model was to apply the Durbin-Watson test, where the test value is evaluated on a scale ranging from 0 to 4, with values close to 4 indicating negative serial autocorrelation, while values close to 2 indicate the lack of serial autocorrelation.
Subsequently, the logarithmic transformation of the rates was applied to reduce the heterogeneity of the variance of the model residuals. After the adjustment, the Prais-Winsten autoregressive model was applied to estimate the b1 values of the standardized mortality rates, which refer to the line’s slope. For the b1 values, the formula for calculating the Annual Percentage Change (APC) was applied:
APC: [-1+ eb1]*100%
The APC measured the rate of change and thus verified the trends. In this model, a positive APC corresponds to an increasing trend, while a negative APC indicates a decreasing trend. Finally, the time series was classified as stationary when no significant difference was identified between its value and zero17. The 95% confidence intervals (95% CI) of the measurements were also calculated by applying the formula below:
CI95% = [-1+10bminimum] *100%; [-1+10bmaximum] *100%
The minimum and maximum values of b were extracted from the CI95% parameters generated by the statistical analysis program and applied to the formula.
The Rstudio program version 4.0.2 was employed in the stages of data organization, rate calculation, trend analysis, and graphs to obtain the results and construct the analysis. A significance level of 5% was considered for the Prais-Winsten model for trend analysis in this investigation.
Ethical aspects
This study used publicly accessible and anonymized secondary data, ensuring compliance with the ethical guidelines of Resolution N° 466/2012 of the National Health Council. Even so, the Research Ethics Committee (CEP) of the Sergio Arouca National School of Public Health of the Oswaldo Cruz Foundation (CEP/ENSP/Fiocruz) approved the study under Opinion N° 16/2020.
RESULTS
From 2000 to 2022, 288,080 deaths from HIV were recorded in at least one of the fields of the death certificate that contains the ICD code (underlying cause, lines A, B, C, D, and part II). The results indicate that most deaths from HIV occurred among male individuals in the country, with 66.65% (n=192,053).
Regarding age distribution, the highest proportion of deaths was recorded among those aged 60 and over, with 56.79% (n=163,565), followed by those aged 20-59, with 42.70% (n=122,979), while only 0.51% (n=1,536) of deaths occurred among individuals aged 0-19.
Regarding marital status, 75.03% (n=216,122) of deaths occurred among unmarried individuals. As for the ethnicity/skin color variable, 49.20% (n=141,747) of deaths were among Black subjects (45.44%, n=130,926), while the remainder occurred among non-Black individuals or were classified as unknown (Figure 1).
FIGURE 1
AIDS-defining conditions accounted for an average of 89.34% of deaths related to the infection in the period analyzed, while non-defining conditions accounted for 10.66%. The mean mortality rate from HIV was 6.40 deaths per 100,000 inhabitants; 5.71 deaths per 100,000 inhabitants were attributed to defining conditions, and 0.65 deaths per 100,000 inhabitants to non-defining conditions (Figure 2).
The highest rates were observed among infectious diseases. The states with the highest mean rates were Amazonas (8.68 deaths per 100,000 inhabitants), Roraima (9.27 deaths per 100,000 inhabitants), Pará (7.80 deaths per 100,000 inhabitants), and Maranhão (5.39 deaths per 100,000 inhabitants).
From 2000 to 2022, Brazil showed a significant reduction in mortality rates from infectious diseases associated with HIV (APC = -2.94; 95% CI: -3.71; -2.10, p-value < 0.001) (Figure 2). Among the states, the most significant reductions were observed in Minas Gerais (APC = -4.12; 95% CI: -4.81; -3.41, p-value < 0.001), Rio de Janeiro (APC = -3.43; 95% CI: -4.27; -2.59, p-value < 0.001), and São Paulo (APC = -6.73; 95% CI: -7.16; -6.30, p-value < 0.001). Santa Catarina (APC = -4.01; 95% CI: -5.42; -2.58, p-value < 0.001), Rio Grande do Sul (APC = -2.70; 95%CI: -4.25; -1.12, p-value = 0.003), and the Federal District (APC = -4.95; 95%CI: -5.62; -4.29, p-value < 0.001) also recorded significant drops (Figure 2).
On the other hand, we observed an increasing trend in mortality rates from infectious diseases in the Northern and Northeastern states, highlighting regional inequalities throughout the period analyzed (Figure 2).
Circulatory diseases, in turn, showed a slight increase in Brazil (APC=6.98; 95% CI: 3.04; 11.1; p-value=0.002). Despite this, some more significant drops were observed in Roraima (APC=-5.39; 95% CI: -9.35; -1.25; p-value=0.019), Amapá (APC=-6.4; 95% CI: -8.8; -3.88; p-value < 0.001), and Tocantins (APC=-8.30; 95% CI: -13.5; -2.77; p-value=0.009). Sergipe was the only state with a significant decreasing trend in the period analyzed (APC=-7.74; 95% CI: -14.16; -0.84; p-value=0.040) (Figure 2).
FIGURE 2
Mortality rates from HIV-associated digestive and endocrine diseases remained below 1.5 deaths per 100,000 inhabitants throughout Brazil from 2000 to 2022. Roraima had the highest rates in these groups in some years of the series, with 0.13 deaths per 100,000 inhabitants for digestive diseases and 0.10 deaths per 100,000 inhabitants for endocrine diseases, compared to the other states (Figure 3).
For digestive diseases, some states showed a significant decline, such as Paraíba (APC=-14.99; 95% CI: -18.32; -11.53; p-value < 0.001), the Federal District (APC=-12.45; 95% CI: -17.18; -7.44; p-value < 0.001), and Piauí (APC=-15.46; 95% CI: -21.59; -8.85; p-value < 0.001) (Figure 3).
Endocrine diseases significantly fell in Ceará (APC=-18.7; 95% CI: -26.78; -9.71; p-value < 0.001). On the other hand, Pernambuco (APC=6.13; 95% CI: 2.37; 10.02; p-value=0.004) and Santa Catarina (APC=3.71; 95% CI: 1.39; 6.09; p-value=0.005) showed increasing trends, indicating relevant regional variations (Figure 3).
FIGURE 3
Neoplasms had HIV-associated mortality rates below 0.8/100,000 deaths per 100,000 population (Figure 4). An increasing trend was observed in Brazil (APC=4.70, 95% CI: 2.00;7.46, p-value=0.002), Pernambuco (APC=11.20, 95% CI: 7.82; 14.69, p-value <0.001), Paraná (APC=8.12, 95% CI: 6.10; 10.17, p-value <0.001), and Rio Grande do Sul (APC=5.64, 95% CI: 3.05; 8.29, p-value <0.001) (Figure 4).
In HIV-associated genitourinary diseases, mortality rates decreased significantly in Maranhão (APC=-15.79; 95% CI: -21.51; -9.64; p-value < 0.001), Rio Grande do Norte (APC=-13.61; 95% CI: -21.85; -4.50; p-value = 0.009), and Bahia (APC=-12.78; 95% CI: -21.26; -3.38; p-value = 0.016). On the other hand, Pernambuco rates showed an increasing trend (APC= 8.97; 95% CI: 2.76; 15.56; p-value = 0.009) (Figure 4).
FIGURE 4
Deaths from respiratory diseases were more significant in Rondônia (0.06 deaths per 100,000 inhabitants), Acre (0.04 deaths per 100,000 inhabitants), Roraima (0.03 deaths per 100,000 inhabitants), Pará (0.06 deaths per 100,000 inhabitants), Amapá (0.03 deaths per 100,000 inhabitants) and Mato Grosso (0.15 deaths per 100,000 inhabitants). Regarding deaths from other diseases, the states with the highest rates were Rondônia (0.07 deaths per 100,000 inhabitants), Roraima (0.02 deaths per 100,000 inhabitants), and Amapá (0.07 deaths per 100,000 inhabitants) (Figure 5).
Rondônia (APC=-9.22, 95% CI: -13.4;-4.75, p-value <0.001), Mato Grosso (APC =-12.19, 95% CI: -15.91;-8.32, p-value <0.001), Pará (APC=-7.69, 95% CI: -12.94.-2.12, p-value=0.014), and Tocantins (APC=-7.31, 95% CI: -13.45, 0.73, p-value = 0.042) showed decreasing rates throughout the period (Figure 5).
As for other conditions associated with HIV, Brazil showed an growing trend in mortality rates (APC=4.70; 95% CI: 2.00; 7.46; p-value = 0.002). Pernambuco (APC=11.20; 95% CI: 7.82; 14.69), Paraná (APC=8.12; 95% CI: 6.10; 10.17), and Goiás (APC=7.99; 95% CI: 5.66; 10.36) stood out with significant elevations. In contrast, Paraíba (APC=-13.74; 95% CI: -18.96; -8.18), Amazonas (APC=-10.60; 95% CI: -16.52; -4.26), and Piauí (APC=-10.95; 95%CI: -17.59; -3.77) showed significant drops in mortality rates (Figure 5).
FIGURE 5
DISCUSSION
The results of this study highlighted regional disparities and changes in the Brazilian HIV mortality profile from 2000 to 2022. Despite the national reduction in mortality rates due to AIDS-defining conditions, the increase observed in Northern and Northeastern states highlights structural inequalities in access to and effectiveness of health interventions. These findings reinforce patterns identified in other national and international studies that associate regional inequalities with unequal access to antiretroviral therapy (ART) and the fragmentation of health services14,18.
This study showed that defining conditions continue to be the leading cause of death among people living with HIV, even with the advancement of ART. These findings align with a study that analyzed the temporal trend of mortality due to AIDS-defining and non-defining conditions in Brazil from 2000 to 2018. The research revealed that, although defining conditions showed the highest rates, there was a decreasing trend in mortality associated with these conditions. In contrast, non-defining conditions showed an increasing trend, indicating a transition in the mortality profile over time7.
A similar pattern was identified in a study in Rio de Janeiro from 1999 to 2015, which identified AIDS-defining conditions as one of the leading causes of death among people living with HIV, highlighting its persistence over time as a significant factor in the mortality of this population19.
In the international backdrop, a cohort study conducted in North America, Europe, and Asia from 2000 to 2022 followed 189,301 people living with HIV. It showed a decline in mortality rates due to AIDS-defining conditions among those on ART. However, disparities persisted between different population groups, with 32% of deaths still attributed to AIDS-defining conditions, highlighting the need to expand access to treatment to curb these deaths14 further. Similarly, a study conducted in Thailand from 2014 to 2019 indicated the persistence of these diseases as causes of mortality, mainly associated with the lack of adequate access to treatment13.
In addition to the disparities observed for defining conditions, the results of this study highlighted the importance of also analyzing non-HIV-defining conditions, such as circulatory diseases, which emerge as a significant cause of mortality in people living with HIV in Brazil. The increasing trend observed in mortality rates for these conditions in this study points to a transition in the mortality profile.
Mortality rates from circulatory diseases have grown in Brazil and most states. The upward trend observed in mortality rates from these conditions in this study indicates a transition in the mortality profile, where chronic complications, such as cardiovascular diseases, play an increasing role. This finding aligns with an investigation conducted in South Carolina, United States, from 2006 to 2019, which followed 9,082 adults diagnosed with HIV. This study showed that, despite the lower risk of cardiovascular diseases associated with preserved high levels of CD4 cells and effective viral suppression, circulatory diseases continue to represent a challenge for the health management of people living with HIV, contributing significantly to mortality in this population20.
Another study conducted in the United States showed that people living with HIV have a higher risk of heart failure, stroke, and hospitalization for cardiovascular diseases than the general population, highlighting this population’s vulnerability21. Similarly, a comparative analysis between sub-Saharan Africa and high-income countries revealed that, although mortality rates are lower in higher-income countries, disparities continue to impact low disproportionately- and middle-income countries22.
This study revealed that mortality rates from HIV-associated digestive diseases were consistently low throughout the period analyzed. However, regional inequalities persisted, with an increasing trend observed in the Northern states. This finding corroborates a European study that evaluated the mortality trend among people living with HIV from 2001 to 2020 and identified a declining mortality related to digestive diseases, specifically liver diseases, attributed to improved treatment and management of these conditions23.
Similarly, analysis of temporal trends in causes of death in the Swiss HIV Cohort revealed a marked reduction in liver-related deaths from 2005 to 2022. During this period, 166 deaths (10.2%) were attributed to liver conditions, most of which were associated with hepatitis C virus co-infection, reinforcing the importance of integrated treatment and management of co-infections24. However, a study conducted in Uganda showed different results from those identified in Europe and Switzerland, indicating that liver diseases are determining factors in HIV mortality, with increased odds of up to 77%25.
Mortality rates from endocrine diseases were higher in Northeastern and Southern states but were stationary for Brazil. These findings align with studies conducted in different global contexts, such as in Iran, Nigeria, Tanzania, and China, which highlighted the prevalence of metabolic and endocrine conditions in people living with HIV. These conditions remain ongoing threats, suggesting the need for integrated approaches to HIV treatment26-29.
The results of this study indicated an increasing trend in mortality rates from HIV-associated neoplasms in Brazil from 2000 to 2022, especially in Southeastern and Southern states. Non-defining neoplasms, such as lung and liver cancer, gained relevance, standing out as significant causes of death. These findings align with studies conducted in Spain and China, which showed a transition in the mortality profile among people living with HIV, with a higher proportion of deaths attributed to non-defining neoplasms29,30. Reinforcing the findings of this article, a French multicenter study from 2020 to 2021 identified that non-HIV-defining neoplasms emerged as the leading cause of death, representing a significant portion of deaths among people living with HIV9.
This study revealed a stationary trend for mortality rates from HIV-associated genitourinary diseases in Brazil from 2000 to 2022. However, regional disparities were identified, with higher rates in the North and Northeast, which may reflect inequalities in access to and quality of health care. Despite being a topic poorly explored in the scientific literature, a Chinese study with more than 4,000 people living with HIV over 13 showed that advanced age, low educational level, and low CD4 cell count were strongly associated with a higher risk of death from genitourinary diseases31.
In addition, research conducted in Uganda highlighted that kidney disease was one of the main comorbidities associated with hospital mortality in people living with HIV, especially in those with CD4 cell counts below 200 cells/µL32.
Mortality from respiratory diseases showed a steady trend in the present investigation, evidencing these conditions’ persistence as significant causes of death among people living with HIV. A French study from 1997 to 2020 highlighted that respiratory diseases continue to play a relevant role in the mortality of this population33 despite advances in ART.
The incidence of bacterial pneumonia, for example, remains high, with a tenfold increased risk among people living with HIV against the general population. Factors such as smoking, intravenous drug use, advanced age, and low CD4 cell count further aggravate this risk. Although the introduction of ART has reduced the incidence of bacterial pneumonia, especially in individuals with higher CD4 counts, pneumonia is still among the leading causes of hospitalization and death32. Furthermore, in critical conditions, particularly in intensive care units, acute respiratory distress syndrome and pneumonia are frequent causes of hospitalization and have high mortality rates33.
In summary, concerning mortality due to non-HIV-defining conditions, characterized in this study by the diseases contained in the following chapters of the ICD: circulatory, digestive, endocrine, neoplasms, genitourinary and respiratory, their occurrence may be associated with the vulnerability of people living with HIV to these conditions, often exacerbated by co-infections, low CD4 cell count, and unequal access to HIV treatment34,35. Urgent interventions focusing on the prevention and management of these comorbidities are needed, emphasizing lifestyle changes, continuous monitoring, and integration of care for these conditions into HIV treatment36.
Recent studies highlight that poor immunological and virological status, often associated with interruption of antiretroviral therapy, is among the main risk factors for mortality in people living with HIV. This relationship reinforces the need for strategies that prioritize early diagnosis, regular monitoring of parameters such as CD4 and viral load, and continued adherence to treatment. Furthermore, conditions such as active tuberculosis continue to negatively impact survival, highlighting the importance of an integrated and equitable approach to the care of these populations, as observed in international studies32.
Notably, although this article highlights the advantages of using secondary data and presents relevant information for the study of HIV comorbidities and for public policies, it also has limitations regarding the incomplete and inconsistent data accessed. The SIM data improved after qualifying the records, which reduced the registration of deaths due to ill-defined causes. However, it also increased specific mortality rates in certain regions that previously had high records of deaths from ill-defined causes, such as the North and Northeast. Given this, these data may have been underestimated at the beginning of the period of this investigation.
Another point to be considered is that part of the data used in this study corresponds to the COVID-19 pandemic years, which may have influenced the results and the interpretation of the observed mortality trends. Data from the HIV and AIDS Epidemiological Bulletin5 reveal that the COVID-19 pandemic significantly affected HIV mortality data in Brazil, mainly reflected in a possible underreporting of cases and lower HIV testing levels during the period.
The overload of health services during the pandemic led to a decrease in AIDS notifications, resulting in a sharp 20.2% drop in case records from 2019 to 2020. This reduction in detection and notification may have compromised the accurate assessment of the evolution of the HIV epidemic in the country, highlighting the need to consider these factors when interpreting HIV-related mortality and morbidity data during and after the pandemic1.
A study by Luna et al. (2024)18 also highlighted declining mortality rates in the Midwest, Southeast, and South until 2020. However, an increase in deaths was observed from 2020 onwards, especially in the North and Northeast, which may be an impact of the COVID-19 pandemic that exacerbated these inequalities by compromising treatment continuity and early diagnosis. The study reinforces the need for public policies aimed at regional equity, especially in areas of greater socioeconomic vulnerability.
We conclude that although the mortality rate from infectious diseases associated with HIV shows a decreasing trend in Brazil, these rates remain considerably higher than those from non-HIV-defining conditions. In addition, the increasing trend of mortality from HIV-defining conditions and the decline from non-HIV-defining conditions in the Northern and Northeastern states is noteworthy, reflecting profound regional disparities.
These patterns can be attributed to factors such as late diagnosis, interruption or abandonment of antiretroviral treatment, and adverse socioeconomic conditions that impact care continuity. Finally, despite advances in reducing mortality, new challenges emerge, highlighting the need for an integrated and comprehensive public health approach that addresses the diverse health demands of people living with HIV, focusing on equitable and sustainable interventions.

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