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Intersectional impact of cash transfers on AIDS among 12.3 million Brazilian women

Nature Human Behaviour (2025)Cite this article

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Abstract

Multiple socioeconomic vulnerabilities are associated with an increased burden of human immunodeficiency virus and its progression to acquired immunodeficiency syndrome (AIDS). Here, using a quasi-experimental impact evaluation design and a cohort of 12.3 million low-income Brazilian women (daughters and mothers) from 2007 to 2015, we evaluated the impact and intersectional effectiveness of the world’s largest conditional cash transfer, the Programa Bolsa Família (PBF) on AIDS incidence and AIDS-related mortality. Among daughters, PBF was associated with reductions in AIDS incidence (rate ratio (RR) 0.53, 95% confidence interval (CI) 0.42–0.66) and AIDS-related mortality (RR 0.45, 95% CI 0.27–0.74). Among mothers, PBF was associated with reductions in AIDS incidence (RR 0.58, 95% CI 0.55–0.61) and AIDS-related mortality (RR 0.57, 95% CI 0.53–0.63). The effects of PBF were stronger among mothers with 1 vulnerability, and even higher with 2 intersecting vulnerabilities, specifically for AIDS incidence among brown/Black and extremely low income (RR 0.47, 95% CI 0.44–0.49). The greatest effect was observed in extremely low-income, brown/Black mothers with higher education (RR 0.44, 95% CI 0.38–0.53). Conditional cash transfer could substantially contribute towards reducing AIDS-related inequalities and achieving the AIDS-related Sustainable Development Goal.

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Fig. 1: Study cohort flowchart (2007–2015).

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Data availability

The protocol for the creation of the 100 Million Brazilian Cohort and the cohort profile of the 100 Million Brazilian Cohort is available in the publications referenced in the article, and further material is available at https://cidacs.bahia.fiocruz.br/en/platform/cohort-of-100-millionbrazilians. The linkage protocols are explained in the referenced publications, and the codes are available on GitHub at https://gitHub.com/gcgbarbosa/cidacs-rl. However, the datasets generated and analysed during the current study are not publicly available due to confidentiality and ethical issues. To request access, contact us at https://cidacs.bahia.fiocruz.br/contato/fale-conosco/. The results supporting the findings of this study are available within the main paper and its supplementary materials. Additional supporting information can be found in the Online Appendix.

Code availability

The code is available upon request due to confidentiality and ethical considerations. To request access, contact us at https://cidacs.bahia.fiocruz.br/contato/fale-conosco/.

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Acknowledgements

This study was supported by the US National Institute of Allergy and Infectious Diseases, National Institutes of Health (grant number 1R01AI152938). We thank the data production team and all Center for Data Integration and Knowledge in Health—FIOCRUZ collaborators for their work on building the 100 Million Brazilian Cohort. We thank our colleagues from the Collective Health Institute (Federal University of Bahia, Salvador, Brazil) for their valuable contributions during the development of the study. We acknowledge the foundational contribution of Silva, A. F. et al. (Nature Communications, 2024) in the development of the data structure and methodological framework that supported this study. D.M.C. and D.R. acknowledge funding from the Medical Research Council (MR/Y004884/1). D.R. acknowledges support from grant CEX2023-0001290-S funded by MCIN/AEI/10.13039/501100011033 and support from Generalitat de Catalunya through the CERCA Program.

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Authors and Affiliations

  1. Institute of Collective Health, Federal University of Bahia, Salvador, Brazil

    Andréa F. Silva, Priscila F. P. S. Gestal, Daniella M. Cavalcanti, Mauricio L. Barreto, Laio Magno, Luis E. Souza, Inês Dourado & Davide Rasella

  2. Center for Data and Knowledge Integration for Health, Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Brazil

    Andréa F. Silva, Gabriela S. Jesus, Priscila F. P. S. Gestal, Carlos A. S. T. Santos, Maria Y. Ichihara, Mauricio L. Barreto & Davide Rasella

  3. Department of Health, State University of Feira de Santana, Feira de Santana, Brazil

    Iracema Lua

  4. Faculty of Medicine, Federal University of Bahia, Salvador, Brazil

    Gabriela S. Jesus

  5. Department of Life Sciences, State University of Bahia, Salvador, Brazil

    Laio Magno

  6. Department of Health Policy and Management, Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, CA, USA

    James Macinko

  7. ISGlobal, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain

    Davide Rasella

  8. ICREA, Barcelona, Spain

    Davide Rasella

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  1. Andréa F. Silva
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Contributions

D.R. and A.F.S. developed the study concept. M.Y.I., M.L.B. and A.F.S. collected the data. D.R., A.F.S., I.L., G.S.J., P.F.P.S.G. and D.M.C. designed the study and investigation. A.F.S., D.R. and P.F.P.S.G. did the data analysis and wrote the first draft of the paper. C.A.S.T.S., L.M., L.E.S. and D.M.C. have contributed to the first draft of the paper. All authors contributed to data interpretation and reviewed and edited the paper. D.R., I.D. and J.M. supervised the study process.

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Correspondence to Andréa F. Silva.

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Supplementary discussion, Figs. 1 and 2, and Tables 1–18.

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Silva, A.F., Lua, I., Jesus, G.S. et al. Intersectional impact of cash transfers on AIDS among 12.3 million Brazilian women. Nat Hum Behav (2025). https://doi.org/10.1038/s41562-025-02278-3

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