(March 2005) It was early February of this year, and Brazil had practically closed down once again for the annual carnival festivities. Amidst the four-day revelry, volunteers from more than 1,800 nongovernmental organizations (NGOs) handed out more than 11 million condoms paid for by Brazil’s Ministry of Health, on top of the 20 million normally distributed each month.

The condom-distribution effort is one of two trademarks of Brazil’s bold anti-AIDS policies that, by most accounts, are among the most effective in the world. The second trademark is the country’s assertion that, regardless of economic means, Brazilians affected by the pandemic have a constitutional right to the antiretroviral drugs used to treat HIV/AIDS.

“The Brazilian AIDS program has conclusively shown that it is possible to curb the epidemic in developing countries by tightly linking prevention and treatment,” says Dr. Mauro Schechter, professor of infectious diseases and head of the AIDS Research Laboratory at the Rio de Janeiro Federal University.

While the number of Brazilians with HIV is still growing, some measure of Brazil’s success can be determined by how much worse the situation could be. First identified in Brazil in 1983, AIDS had the potential to be as devastating in Latin America’s biggest country as it has been in Africa.

In the early 1990s, the World Bank estimated that 1.2 million Brazilians would have HIV by the year 2000. However, UNAIDS estimated that, at the end of 2001, some 630,000 adults and children in Brazil were living with HIV/AIDS. At the end of 2003, the number had grown by less than 1 percent, to 660,000.1

Brazil’s adult HIV prevalence is 0.7 percent. While this proportion is small compared with countries such as those in southern Africa (for example, South Africa has a prevalence rate of more than 20 percent), the sheer size of Brazil’s population means that the epidemic could potentially affect large numbers of people.2 A country of 179 million people, Brazil accounts for roughly 1 in 4 of those living with HIV in Latin America, according to UNAIDS.

Prevention and Treatment a Key Connection

It’s been 20 years since Brazil instituted its national AIDS program, one that has evolved into today’s two-pronged strategy for treatment and prevention.

On the prevention side, Brazil actively and openly promotes safe sex among high-risk and vulnerable groups, including prostitutes and adolescents. According to Ministry of Health figures, 96 percent of Brazilians know that condoms prevent the spread of sexually transmitted infections, 25 percent of Brazilians use condoms in all sexual relations, and 67 percent do so during sex with a casual partner.3 Brazil has also instituted “harm-reduction” programs for drug users, including free needle exchanges to halt HIV transmission.

On the treatment side, the Brazilian government provides free antiretroviral drugs (ARVs) to Brazilians who need them. The government began providing this treatment in 1996; today, about 150,000 Brazilians receive ARVs through the public health system. The government estimates that prevention and early treatment have saved Brazil more than $2.2 billion in direct hospital costs since the inception of the crisis.4

According to Schechter, Brazil’s AIDS policies evolved as a result of several societal pressures, and their development was independent of any government or political party.

“In the early 80s, AIDS in Brazil was a middle-class problem, affecting mostly white, urban residents who could not get the drugs they needed for treatment from their private health plans, so they were forced to use the public health system,” Schechter said. “In the process, they also transformed the system.”

Government and NGOs Cooperate

Today, AIDS in Brazil is a model of cooperation between the government and the civil sector.

The World Bank notes that NGOs working on AIDS issues have proliferated in Brazil, growing from 120 registered groups in 1992 to more than 500 six years later. Brazilian NGOs have focused on fighting social exclusion and pressing for government responsiveness to the unfolding crisis, and the bank suggests that some prevention initiatives could not have succeeded without their participation. In addition, NGOs were key to the creation of legislation to mandate nationwide HIV testing of blood donations, and they also created home-care programs, HIV support groups, and preventive and educational efforts.

Brazil’s health ministry and the World Bank have welcomed the government-NGO collaboration on HIV/AIDS issues. For example, NGOs serve on the National AIDS Council, which monitors the country’s AIDS policies. NGO researchers have also been hired to provide technical assistance to grant recipients for HIV/AIDS work and to design, monitor, and evaluate activities for new AIDS-related projects.5

New AIDS Cases Continue to Rise

While progress has been made in prevention and treatment efforts, the situation is far from ideal in Brazil. In 2003, more than 32,000 new AIDS cases were registered by the network of registration systems coordinated by the health ministry. The number compares with some 18,000 new cases 10 years earlier. The ministry also acknowledges that underreporting of cases is an issue.6

In the health ministry’s latest Epidemiological Bulletin of AIDS and STDs, Dr. Pedro Chequer, director of Brazil’s National AIDS and STD program, highlights some of the trends in the Brazilian epidemic:7

  • HIV prevalence rates among men fell from roughly 26 cases per 100,000 population in 1998 to close to 23 cases per 100,000 in 2003. Among women, prevalence rates increased from some 13 cases per 100,000 in 1998 to 14 cases per 100,000 five years later.
  • HIV transmission through injecting drug use among men appears to be falling, while new cases attributed to men who have sex with men appear to have stabilized at 26 percent. New cases attributed to heterosexual contact are still rising, however.
  • Between 2001 and 2004, more than 60 percent of new male HIV cases occurred among whites. Among women, new cases have decreased among whites but increased among blacks. Overall, whites, who make up 54 percent of the population, represent some 51 percent of Brazil’s AIDS cases. Blacks and people of mixed races account for 33 percent, while Indians, Asians, and others account for the remaining cases.
  • Incidence is rising in all of Brazil’s geographic areas except the Southeast—the country’s most economically advanced region, which includes Sao Paulo, Rio de Janeiro, Minas Gerais, and Espirito Santo. This finding confirms another trend: Higher incidence occurs among the least educated groups in Brazil. Roughly one-half of new cases registered are among populations with little or no education, compared with 30 percent among people with a high school education or higher.
  • Finally, the number of registered AIDS deaths increased in 2003, after having fallen for several years. More than 11,000 AIDS-related deaths were registered in 2003, representing a 2 percent rise over 2002.

“The virus will keep growing,” says Schechter. “And these people will eventually need treatment, which will raise costs for the government both in terms of medication and in terms of the necessary infrastructure to deliver the medication and treat full-blown AIDS cases.”

Another problem on the horizon is Brazil’s tenuous relationship with the research-based pharmaceutical industry. Before Brazil approved intellectual protection laws in the late 1990s, Brazilian scientists at the Oswaldo Cruz Foundation began copying seven ARVs. Today, Brazil makes eight of the 15 drugs in the anti-AIDS cocktail.8

While Brazil has not yet broken any patents, the future of the program is becoming more complicated as the country struggles with intellectual property laws demanded by its modernizing economy and as newer drugs come onto the market, many of them patented. Claiming that AIDS represents a national health emergency, Brazil argues that it can invoke special provisions to issue compulsory licenses and produce the drugs at government labs.

To avoid that scenario, drug companies have agreed to sell Brazil large quantities of ARVs at prices discounted from 45 percent to 70 percent. Treatment costs per patient have decreased from $3,810 in 1996 to $1,591 in 2003.9

The announcement in December 2004 by Chequer of Brazil’s plans to copy five new drugs in 2005 has heralded a new round of negotiations with the pharmaceutical industry. But the policy has increased risks over time—in this case, in terms of declining drug innovation. According to one study published in 2003 by the London-based Pharmaprojects, the number of drug companies engaged in HIV/AIDS research has fallen 25 percent since 1997. The number of new ARV drugs in development also has decreased by 33 percent.

Brazil Promotes Cooperation Among HIV-Affected Countries

According to the health ministry, more than 30 countries have adopted some part of Brazil’s AIDS program. Brazil receives frequent requests for consultation from countries affected by the pandemic; it also promotes greater cooperation among these countries.

In January, Brazil hosted a meeting of the International Network of Technological Cooperation in HIV/AIDS in Rio de Janeiro. Representatives from China, Cuba, India, Nigeria, Thailand, and the Ukraine—which together with Brazil have almost 5 million people with HIV10—discussed strategy, epidemiology, and intellectual property laws and their potential for ARV production.

Brazil hopes the network will grow and increase its bargaining power as more countries join. Membership requirements include a political commitment to control the epidemic, the will to have a flexible attitude toward intellectual property, and the technical capacity to produce and develop raw materials and medicines.

“Brazil has a lot to gain internationally if it maintains its current relationship with the research-based drug industry,” said Schechter. “In my personal opinion, going forward without an agreement and breaking patents to maintain today’s model would be a general defeat, with no winners. In the medium- and long-term, everyone involved in this crisis—the patients, countries, and the pharmaceutical industry—lose if there is no collaboration between all the parties that must act together to combat this disease.”


Flavia Sekles is a Brazilian journalist and director of the nonprofit Brazil Information Center in the United States.


References

  1. Joint United Nations Programme on HIV/AIDS (UNAIDS), 2004 Report on the Global AIDS Epidemic (Geneva: UNAIDS, 2004).
  2. UNAIDS, 2004 Report on the Global AIDS Epidemic.
  3. Brazilian Ministry of Health, National Program on STD and AIDS, Boletim Epidemiologico: AIDS e DST, Ano I, no. 1, 2004.
  4. Brazilian Ministry of Health, National Program on STD and AIDS, Press Office (based on statements by Dr. Roberto Teixeira).
  5. Barbara L. Boyd and John Garrison, “NGO Participation in HIV/AIDS Control Project in Brazil Achieves Results,” World Bank Social Development Note No. 47 (May 1999), accessed online at http://lnweb18.worldbank.org, on Feb. 14, 2005.
  6. Brazilian Ministry of Health, National Program on STD and AIDS, Boletim Epidemiologico: AIDS e DST.
  7. Brazilian Ministry of Health, National Program on STD and AIDS, Boletim Epidemiologico: AIDS e DST.
  8. Brazilian Ministry of Health, National Program on STD and AIDS, Press Office, accessed online at www.aids.gov.br/imprensa, on Feb. 14, 2005.
  9. Brazilian Ministry of Health, National Program on STD and AIDS, Press Office.
  10. Brazilian Ministry of Health, National Program on STD and AIDS, Press Office.