Artigos

Introduction
The human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome
(AIDS) have represented one of the most challenging global public health problems since the
1980s, with profound impacts on the lives of millions of people, regardless of demographic
group or level of national development.¹ However, the dynamics of the HIV/AIDS epidemic

have changed over the decades, both in terms of the epidemiological profile and with respect
to strategies for prevention, diagnosis, and treatment 2,3 .
Global data highlights the persistence and magnitude of the HIV/AIDS epidemic. In
2023, the number of people living with HIV reached 39.9 million worldwide, with
approximately 630,000 deaths from AIDS-related illnesses???. The distribution of the
disease burden, however, is marked by profound geographic and socioeconomic disparities,
with a higher concentration of new cases and deaths in countries of the Global South,
particularly in Sub-Saharan Africa?. In Brazil, the response to HIV/AIDS has been
characterized by significant advances, especially following the introduction of antiretroviral
therapy (ART) by the Unified Health System (SUS) in 1996?. This public policy contributed
to a major shift in the disease scenario, increasing the survival of people living with
HIV/AIDS (PLWHA) and substantially reducing associated mortality rates. Nevertheless, the
country continues to face important challenges, such as late diagnosis, irregular adherence to
treatment, social stigma, and regional inequalities in access to health services?. Although
Brazil has experienced a reduction in HIV/AIDS mortality rates over the past two decades,
this decline has not occurred uniformly across the country. Studies have documented
important inter- and intraregional disparities in mortality trends¹? , ¹¹. An analysis conducted in
2022 showed that, between 2000 and 2018, the states of Rio Grande do Sul, Rio de Janeiro,
São Paulo, and Santa Catarina maintained the highest mortality rates, whereas increasing
trends were observed in the North and Northeast regions, highlighting persistent
socioeconomic and structural inequalities in the national response to HIV/AIDS 11 .
Despite advances in recent decades in addressing the HIV/AIDS epidemic, the virus
still represents a significant global public health threat. International initiatives such as the
Millennium Development Goals (MDGs) and the Sustainable Development Goals (SDGs)
established ambitious targets to curb the spread of HIV, expand access to treatment, and, more
recently, eliminate AIDS as a public health threat by 2030. Although MDG 6, which aimed to
halt and reverse the spread of HIV by 2015, was not fully achieved, substantial reductions in
incidence and mortality rates have been observed over the past 20 years.
The study period encompasses distinct phases of Brazil’s HIV/AIDS policy response,
including the consolidation of access to treatment, the introduction of new diagnostic
technologies, and periods of political and economic instability that may have affected public
health management. The analysis of HIV/AIDS mortality is crucial not only for understanding
the evolution of the epidemic but also for guiding strategies aimed at equity in care,
overcoming barriers to treatment access, and continuously improving public health policies.

Considering this context, the objective of this study is to analyze the trends in HIV/AIDS
mortality rates in Brazil between 2000 and 2022, with emphasis on identifying temporal
patterns and potential regional inequalities.
Method
Design
This is an ecological time-series study that analyzed the trend of HIV/AIDS mortality
rates disaggregated by sex, age group, federative unit (FU), and major regions of Brazil.
Context
The study was based on data on deaths from HIV/AIDS in Brazil, recorded from
January 1, 2000, to December 31, 2022. According to IBGE (2020), the Brazilian population
was 213,317,639 people, covering a territorial area of 8,510,345.538 km², with an average
population density of 22.43 inhabitants per km². Education in Brazil has been a priority, with
99.7% of the population between 6 and 14 years old enrolled in school, although the illiteracy
rate among those over 15 years old is 6.6%.
The country is divided into five major geographic regions North, Northeast, Center-
West, South, and Southeast comprising 26 states and the Federal District. In the North region,
which comprises 45% of the national territory, there are about 18.6 million inhabitants. In the
Northeast region, the population reaches approximately 57 million inhabitants. The Center-
West has a population of 16,085,855 inhabitants. In the Southeast region, around 87,711,946
inhabitants reside. Finally, the South, which accounts for 7% of the territory, is home to about
29,975,984 inhabitants. Data from the Brazilian Institute of Geography and Statistics (IBGE)
refer to the year 2019.
Population
The study population consisted of all deaths from HIV/AIDS recorded during the
study period, regardless of age group and sex. Deaths were included when the underlying
cause, according to the 10th Revision of the International Classification of Diseases (ICD-10),
was coded as B20-B24 (B20: HIV disease resulting in infectious and parasitic diseases; B21:
HIV disease resulting in malignant neoplasms; B22: HIV disease resulting in other specified
diseases; B23: HIV disease resulting in other conditions; and B24: HIV disease,
unspecified) 12 .
Data Source

Data on the number of deaths from HIV/AIDS by age group, sex, federative unit,
region, and year were obtained from the Mortality Information System (Sistema de
Informação sobre Mortalidade). The Mortality Information System is a system developed by
the Brazilian Ministry of Health to collect, process, and analyze mortality data nationwide. It
was created in 1975, with the main objective of providing accurate and up-to-date information
on deaths, enabling a comprehensive Health Situation Analysis, including trend analyses, and
supporting public policies aimed at reducing mortality 13.14 .
The Mortality Information System uses the Death Certificate (Declaração de Óbito) as
its primary data source, which is completed by physicians to record the cause of death. The
Death Certificate contains detailed information on the underlying cause of death,
demographic characteristics, and other relevant variables. Based on this information, it is
possible to extract the underlying cause of death 14 . In the present study, deaths coded as B24
according to ICD-10 were extracted.
Population data were obtained from intercensal projections and the 2010 demographic
census conducted by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro
de Geografia e Estatística, IBGE). These data were accessed through the TABNET platform
of the Department of Informatics of the Brazilian Unified Health System (DATASUS).
Analyzed Indicator
The indicator analyzed was the HIV/AIDS mortality rate, calculated using the
following formula:
Number of deaths from HIV/AIDS

_______________________________??100.000

Population
This indicator was calculated disaggregated by sex, age group, federative units, and
major regions.
Statistical Analysis and Modeling
Data were analyzed using STATA software, version 17.0. The units of analysis were
the years of the time series (2000-2022) for each federative unit, region, Brazil, sex stratum,
and age group. To assess trends, a Prais-Winsten linear regression model with robust variance
was applied 15 . The dependent variable (Y) was the HIV/AIDS mortality rate, and the
independent variable (X) was the year of the time series. Prior to inclusion in the regression

models, the mortality rates were log-transformed to base 10 to reduce heterogeneity in the
variance of residuals and to improve the accuracy of temporal trend analysis 15 .
The regression equation is defined as Log (Yt) = ?0 + ?1t + et, where Log (Yt)
represents the HIV/AIDS mortality rates after logarithmic transformation, ?0 is the intercept
or regression constant, ?1 is the slope of the line, and et is the random error. The subscript “t”
represents the time points in the dataset {t1, …, t21}, in this case t1 = 2005 and t21 = 2020. In
addition, the annual percent change (APC) and the corresponding 95% confidence intervals
(95% CI) were calculated from the values of the linear regression coefficients (?1) and the
robust standard errors (SE). The APC was calculated using the following formula:

APC = (1 + 10) ?? 1 × 10

where ?1 is the slope of the line obtained in the regression equation. The 95% CI of the APC
was calculated using the following formula:

95% CI = (1 + 10 (?? 1±??×SE)) × 100

where ?1 is the slope of the regression line, t is the value from Student’s t-distribution with 18
degrees of freedom at a two-tailed 95% CI, and SE is the standard error. The t statistics were
used to determine statistical significance. Values of p < 0.05 were considered statistically
significant. Trends were classified as increasing (positive APC and significant p-value),
decreasing (negative APC and significant p-value), or stationary (positive or negative APC
and non-significant p-value), based on the APC and p-values obtained from the regression.
Results
Between 2000 and 2022, a total of 244,120 deaths from HIV/AIDS were recorded in
Brazil. The highest proportions of cases were observed among men (66.9%), individuals aged
30–39 years (30.6%), and residents of the Southeast region (47%). The age-standardized
mortality rate (ASMR) for the period was 5.88 deaths per 100,000 inhabitants. Men had
higher rates compared with women (7.91 deaths per 100,000 men versus 3.87 deaths per
100,000 women). Across age groups, HIV/AIDS mortality rates were highest among
individuals aged 30-39 years (11.43 deaths per 100,000) and 40-49 years (13.23 deaths per
100,000). The geographic regions with the highest HIV/AIDS mortality rates were the South
(8.02 deaths per 100,000) and the Southeast (6.19 deaths per 100,000) (Table 1).

Tab.1

The states with the highest HIV/AIDS mortality burden during the period were
Rio Grande do Sul (11.31 deaths per 100,000 inhabitants) and Rio de Janeiro (9.72
deaths per 100,000 inhabitants) (Figure 1).

Fig.1

Figure 1. HIV/AIDS mortality rate by federative unit, Brazil, 2000-2022
A decreasing trend in HIV/AIDS mortality rates was observed among men (APC:
–1.7; 95% CI: –2.1, –1.3) and women (APC: –1.5; 95% CI: –2.5, –0.6). Regarding age
groups, a decreasing trend was found among individuals aged 0-9 years (APC: –8.9; 95% CI:
–9.7, –8.2), 10-19 years (APC: –2.4; 95% CI: –4.6, –0.3), 20–29 years (APC: –2.3; 95% CI:
–3.0, –1.6), 30-39 years (APC: –3.9; 95% CI: –4.3, –3.5), and 40-49 years (APC: –1.6; 95%
CI: –2.7, –0.4). Conversely, an increasing trend was observed among those aged 50-59 years
(APC: 1.2; 95% CI: 0.3, 2.1) and 60 years or older (APC: 3.9; 95% CI: 3.4, 4.4). Among the
five geographic regions, three showed a decreasing trend in HIV/AIDS mortality rates:
Central-West (APC: –0.8; 95% CI: –1.4, –0.2), Southeast (APC: –3.6; 95% CI: –4.1, –3.6),
and South (APC: –1.9; 95% CI: –2.7, –1.1). The Northeast (APC: 2.0; 95% CI: 1.0, 3.1) and
North (APC: 3.8; 95% CI: 2.7, 5.0) regions presented increasing trends. For Brazil overall, the
trend was decreasing (APC: –1.6; 95% CI: –2.2, –1.1) (Table 2).

Tab.2

Discussion
This study identified 244,120 HIV/AIDS-related deaths recorded in Brazil between
2000 and 2022, revealing significant epidemiological patterns that reflect persistent
sociodemographic and regional inequalities. The descriptive analysis of HIV/AIDS mortality
rates during the study period underscores the persistence of HIV/AIDS mortality as a public
health problem in the country. The disparity between sexes in the adjusted mortality rate
reinforces the need for specific prevention and treatment strategies targeted at men. The
South, Southeast, and North regions showed the highest mortality rates.
Higher HIV/AIDS mortality rates were observed among men. This finding is
consistent with previous studies conducted in Brazil, which have documented a
disproportionate burden of HIV/AIDS mortality among men 11,17 .Several factors may explain
this pattern. Men tend to seek healthcare services less frequently than women, often delaying
HIV testing and initiating treatment at more advanced stages of infection 9,11 . In addition, lower
adherence to antiretroviral therapy and poorer retention in care have been reported among
men, increasing the likelihood of disease progression and HIV-related complications 9
.Sociocultural norms related to masculinity may further discourage preventive healthcare-
seeking behaviors and contribute to delayed diagnosis and treatment 10 . Women, in contrast,
generally have more opportunities for contact with healthcare services, particularly through
reproductive and maternal health programs, facilitating earlier diagnosis and linkage to care.
Although declining mortality trends were observed among both sexes in the present study, the
persistence of mortality rates among men highlights the need to strengthen strategies aimed at
expanding HIV testing, improving retention in care, and reducing barriers to healthcare access
among this population 11,17 .
Regarding age group, the highest mortality rates occurred among individuals aged 30-
49 years, highlighting the need to intensify prevention and early diagnosis efforts among
adolescents and young adults. Late detection of HIV is a critical factor that undermines the
effectiveness of treatment and increases the risk of death?. A decreasing trend in mortality
was noted, particularly among children aged 0-9 years, reflecting the success of policies
aimed at preventing vertical transmission of HIV in Brazil 17 . The reduction in mortality rates
among adolescents (10-19 years) and young adults (20-29 years) may be attributed to
prevention campaigns and greater access to early diagnosis²³. However, an increasing trend
was observed in the 50-59 and ?60 age groups, indicating the aging of the population living
with HIV due to the widespread use of cART, but also linked to sexual activity and a low
perception of the risk of acquiring the infection 17,19,20 . Consistent with these findings, a study

conducted in China using Global Burden of Disease data on mortality among older adults
aged 50–79 years demonstrated upward trends in mortality rates in this age group for both
sexes, particularly among men aged 75-79 years. Among women, the peak was observed in
those aged 65–69 years 21 .
Important regional disparities were also identified. Mortality rates (per 100,000
inhabitants) in the South, Southeast, and North regions exceeded the national mortality rate,
with additional intraregional variations observed. Rio Grande do Sul has stood out for having
the highest HIV/AIDS mortality rates in the country, which may be attributed to factors such
as high infection prevalence, socioeconomic inequalities, and challenges in the
implementation of effective public policies 17 .
Despite this, our findings indicated a decreasing trend in HIV/AIDS mortality rates.
This reduction may be attributed to the expansion of access to antiretroviral therapy and
prevention strategies implemented by the Brazilian Unified Health System (SUS). However,
an inflection in the curve was observed in 2020, reflecting the disruption of public health
services during the COVID-19 pandemic 18,19 , which compromised the accuracy of this and
other social and health indicators during that period. With the control of the pandemic,
mortality rates returned to their previous or near-previous levels. Nevertheless, the persistence
of higher rates among men underscores the need to intensify targeted actions for this group,
considering factors such as lower health service utilization and delayed diagnosis²².
The Southeast, South, and Central-West regions showed a decreasing trend in
HIV/AIDS mortality, likely due to better health infrastructure and broader coverage of
prevention and treatment services 17,22 . In contrast, the North and Northeast regions presented
increasing trends, reflecting regional inequalities in access to health services, diagnosis, and
treatment 17,22 . These regional disparities highlight the need for public policies that consider
local sociodemographic and cultural characteristics, ensuring that control and prevention
strategies are more effective and promote equity in addressing the epidemic 23 .
Analysis at the federative unit level further demonstrated the heterogeneous nature of
the HIV/AIDS epidemic in Brazil. Federative units with decreasing trends included states
such as São Paulo, Rio de Janeiro, and Rio Grande do Sul, which recorded the highest
HIV/AIDS mortality rates during the study period. This reduction may be attributed to the
effective implementation of public health policies, such as universal access to antiretroviral
therapy (ART) and programs for prevention and early diagnosis 24,25 . Conversely, states in the
North and Northeast, such as Acre, Pará, Amapá, Maranhão, Rio Grande do Norte, and
Paraíba, exhibited increasing mortality trends, suggesting challenges in accessing health

services and implementing prevention and treatment policies. The stationary trend observed in
two federative units underscores the need to evaluate and strengthen epidemic response
strategies in these locations.
This study has some limitations. First, it is an ecological analysis based on secondary
data from SIM, which may be subject to underreporting, delays in updates, and errors in
cause-of-death classification. The use of aggregated data by sex, age group, region, and
federative unit precludes analysis of individual factors associated with HIV/AIDS mortality,
such as education, socioeconomic status, time between diagnosis and treatment initiation,
adherence to ART, and presence of comorbidities. Consequently, the findings are subject to
ecological fallacy, preventing inferences from the population level to the individual level. In
addition, it was not possible to stratify data by key populations (e.g., men who have sex with
men, transgender people, people who use drugs, and sex workers), which limits the
understanding of structural inequalities in the epidemic. Finally, the impacts of the COVID-19
pandemic, particularly between 2020 and 2021, may have disrupted the consistency of records
and access to health services, affecting the accuracy of the most recent estimates.
Despite these limitations, this study contributes to the understanding of the HIV/AIDS
epidemic in Brazil by using an extensive historical series and nationally representative data,
allowing the identification of temporal trends and regional patterns of HIV/AIDS mortality.
Such information is essential to support public policies, guide prevention strategies, and
expand access to diagnosis and treatment, thereby contributing to the reduction of regional
inequalities and strengthening the national response to the epidemic.

Conclusion
The analysis of HIV/AIDS mortality trends in Brazil between 2000 and 2022
highlights important progress, such as the progressive reduction in rates across several regions
of the country, attributed to the expansion of universal access to antiretroviral therapy,
prevention strategies, and early diagnosis. However, some challenges persist, including
regional inequalities, especially in the North and Northeast regions higher mortality among
men, and the impact of late diagnosis, which still compromises the effectiveness of treatment.
In this context, it is essential to strengthen public policies that promote equity in access,
expand testing, encourage treatment adherence, and address social stigma, while ensuring the
continuity of SUS as a public, free, and universal health system. Studies such as this are
fundamental to informing evidence-based policies and supporting Brazil in achieving the goal

of eliminating AIDS as a public health problem by 2030, in line with international
commitments made with the UN and WHO.
Authors’ contributions
SC Charles drafted and edited the manuscript. RA Guimarães conceived the study, curated the
data, performed the formal analysis, supervised and validated the results, and contributed to
editing and visualization. LS Magalhães drafted and edited the manuscript. KAA Caetano
drafted and edited the manuscript. SA Teles conceived the study, conducted the formal
analysis, managed the project, supervised and validated the results, and contributed to drafting
and editing the manuscript.
Funding
No funding
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