Is it possible to reduce AIDS deaths without reinforcing socioeconomic inequalities in health?

BACKGROUND The wide use of highly active antiretroviral therapy has led to an impressive improvement in AIDS survival after the mid-1990s in cities and countries with a high access to these medications. Notwithstanding its beneficial overall effect, antiretroviral therapy was also reported as a factor for the increase in socioeconomic inequalities in health, because AIDS patients have unequal access and adherence to these medications. METHODS We assessed trends AIDS mortality in districts of Sao Paulo, Brazil, from 1995 to 2002, in order to test their association with area-level socioeconomic indices in a city with a large-scale and cost-free distribution of highly active antiretroviral therapy. We gathered information on yearly death rates due to AIDS, adjusted for gender, age group, income, instruction, living standards, and the human development index. Trend estimation used the autoregression procedure of exact maximum-likelihood estimation for time-series analysis. Regression analysis was used to study the association between the annual percentage decrease in AIDS deaths and socioeconomic indices. RESULTS AIDS mortality decreased in Sao Paulo from 32.1 deaths (per 100 000 inhabitants) in 1995 to 11.2 deaths (per 100 000 inhabitants) in 2002. District-level figures of social development did not show an association with the annual percentage decrease in AIDS mortality, with all correlation coefficients corresponding to P-values >0.27. CONCLUSIONS This observation indicates that the perspective of public policies addressed to the entire population contribute to reducing inequalities in health, while attaining an overall reduction in AIDS deaths, may have been feasible in the Brazilian context.