HIV/AIDS Mortality Trends in Peru: A Natural Experiment of COVID-19's Disruption and Health Disparities (2017-2024)

Peru's already concentrated HIV epidemic confronted an unprecedented shock with the arrival of SARS-CoV-2. With a natural experiment design, leveraging 96 months (2017-2024) of aggregate national death-certificate data (n = 9,917), we applied join-point regression, attributable-fraction calculations of deaths excess, and Newey-West-corrected interrupted time series models to disentangle indirect service disruptions from direct viral coinfection on HIV/AIDS mortality. Using population-level data, we estimated both relative and absolute measures of disparity, providing novel insights into population-level differences. A sharp inflection occurred in March 2020, producing an immediate monthly surge of 56.3 additional HIV/AIDS deaths (95% CI 42.81-69.93). Across the pandemic biennium 2020-2021, deaths rose from 2,258 to 3,357-an excess of 48.7% versus the 2018-2019 baseline. Co-occurring HIV/COVID-19 accounted for 38% of the excess, while HIV/AIDS-only deaths evidenced the heavier burden, underscoring collateral damage from disrupted testing, ART refills, and inpatient capacity. Analysis of population subgroups revealed substantial disparities: relative rate ratios peaked at 80.5 for adults ≥ 50 years, 4.7 for secondary-versus-university education, and 141 for users of the public Seguro Integral de Salud compared with private insurance. Although mortality declined after mass vaccination and service adaptations, 2024 levels remained above pre-pandemic trajectories. Findings reveal a dual pathway-biological vulnerability plus health-system failure-that nearly erased a decade of progress, disproportionately harming socially marginalized Peruvians. Safeguarding HIV programs within pandemic preparedness plans and targeting equity gaps are therefore urgent to avert similar reversals in future crises.