Where inequalities are concentrated: retention, treatment and viral suppression among Indigenous people living with HIV in Brazil, 2018–2021

Abstract

Brazil's HIV response has advanced toward the 95-95-95 targets, but gains remain unevenly distributed across population groups. This study examined the stages of the HIV continuum of care at which inequalities between Indigenous peoples and other race/colour groups were concentrated in Brazil from 2018 to 2021. We conducted an ecological time-series study using secondary aggregated data, complemented by an interpretive documentary analysis of public policies and selected literature. Indicators were extracted from the Brazilian Ministry of Health Clinical Monitoring Reports on HIV and refer exclusively to people living with HIV (PLHIV) already linked to health services. Between 2018 and 2021, the gap between Indigenous and white/yellow populations remained 6 percentage points for retention in care and increased from 1 to 7 percentage points for antiretroviral therapy coverage. For viral suppression, the gaps were 5 percentage points in 2018 and 14 in 2021; these values used different viral-load thresholds and do not constitute a direct longitudinal comparison. In 2021, late presentation, defined as a first CD4 count below 200 cells/mm³, was 18% among Indigenous people, 26% among white/yellow people and 28% among Black people, while the median time from the first recorded CD4 test to treatment initiation was similar across groups. However, 61% of Indigenous people initiated antiretroviral therapy within one month, compared with 72% and 69% in the other groups, and 14% initiated after six months or had no recorded initiation. Among PLHIV already linked to services, available indicators did not suggest an Indigenous disadvantage in late presentation or median time to therapy, whereas the largest inequalities were concentrated in timely treatment initiation and, particularly, viral suppression. These findings identify continuity of care as a programmatic priority but do not support conclusions about people who remain undiagnosed or have not yet been linked to services.