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HIV/AIDS: The Problem
Brazil: The Success Story1
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Marie Charles, MD, MIA; Columbia University, NY, NY, USA
Brazil is the one country in the world that has
successfully managed to cut its nationwide HIV-prevalence
rate in half AND mitigate the impact of the epidemic
on society at the same time. What is Brazil’s
secret?
Brazil’s program has been extraordinarily
successful not only in decreasing deaths due to
AIDS, but also in reducing the HIV prevalence rate
and in producing financial benefits for the country.
This program did not happen overnight, but was part
of a systemic, multi-sectoral, decentralized approach
at a time when the HIV epidemic was still very small.
Brazil’s actions set a great example for other
countries attempting to curb the epidemic.
From its inception, the program in Brazil has been
based upon the philosophy that access to healthcare
is considered a constitutional right; hence HIV
care and treatment are provided for free in balance
with prevention activities. However, this combination
of care and prevention is not sufficient to explain
the success of the program. Much of the success
has been achieved because the government chose to
act very early in the epidemic, when the HIV prevalence
was a relatively small 1.2%.
The systemic, multi-sectoral and decentralized
approach contained five essential components:
- The Brazilian government showed strong political
leadership and mobilized the civil society by forming
partnerships with grassroots and non-governmental
organizations at all levels to ensure that the HIV/AIDS
education and awareness messages would reach traditionally
hard-to-reach high risk groups.
- Action was taken early on in the epidemic.
- Brazil implemented effective HIV/AIDS prevention
strategies. Effective HIV/AIDS prevention is combination
prevention which means that all groups at risk for
HIV/AIDS are targeted, not just selected groups.
Very concretely it means that: condoms are available
to all even while delayed sexual activity is advocated
and clean needles are handed out to injection drug
users and transmission from the mother to the baby
is being prevented and blood transfusions are done
in a safe manner, etc.
- Universal access to free ARV therapy in Brazil
was made possible through a combination of locally
manufactured drug supplies and lower negotiated
prices for those ARVs still under patent protection.
Notably, even though Brazil threatened to offer
compulsory licensing, it has yet to break any patent
laws. Instead, Brazil has managed to successfully
negotiate affordable prices with the pharmaceutical
industry for those drugs still under patent protection.9
- However, as experience shows, the availability
of free drug supplies is not a guarantee for an
increased number of HIV-infected patients on treatment
if the healthcare infrastructure is not equipped
to deal with the patient load. In 1997, Brazil’s
public health system was vastly underpowered. Part
of the program in Brazil, therefore, included healthcare
capacity building programs conducted at various
levels. Eventually, this led to a national network
of 900 alternative care clinics, 208 voluntary testing
and counseling centers, 424 AIDS Drug Dispensing
Units, and a network of 158 labs created to monitor
the patients on treatment. Computer systems that
link the drug distribution with laboratory tests
also help the Brazilian government monitor whether
patients are receiving ARV therapy within the scope
of the national treatment guidelines and ensures
drug supply and stock management. In addition to
building the physical infrastructure and systems
required for treatment of HIV/AIDS, Brazil trained
its healthcare workers to diagnose and treat HIV/AIDS
and related opportunistic infections.
As a result of this comprehensive program, the
HIV prevalence rate in Brazil has been cut in half,
from 1.2% in 1997 to 0.6% in 2001, AIDS death rates
have dropped 60 – 80%, mitigating the impact
of the epidemic on society, opportunistic infections
have dropped significantly, decreasing healthcare
expenditures, the incidence of TB has been reduced
by 80%, and there has been a seven-fold reduction
in hospital admissions. In addition to the value
of these health benefits on individuals and on the
Brazilian society, the Brazilian government estimates
that their comprehensive HIV/AIDS program has produced
actual financial savings of more than 2.2 billion
USD over 5 years in reduced hospital and ambulatory
care costs. While the epidemic has not been halted
yet in Brazil, data suggest that it may be manageable
now. Brazil’s success can be an example to
other countries that are working to stop the expansion
of HIV/AIDS.
- Teixeira P. et al. “The Brazilian experience in providing universal
access to antiretroviral therapy” Economics of AIDS and Access to
HIV/AIDS care in developing countries. Issues and Challenges. ANRS. Pg 69-86
- Telles Dias P.R. et al. “Factors associated with declining HIV
infection rates among IDUs in Rio de Janeiro in Brazil.” Abstract MoPeC3399.
IAC Barcelona, July 7-12, 2002.
- Bermudez J. et al. “Essential Medicines and AIDS care in Brazil: recent
lessons learnt.” UNAIDS 2002. www.unaids.org
- Reardon C., “How Brazil turned the tide” Ford Foundation report.
Summer 2002. www.fordfound.org/publications/
- Charles, M; “Access-to-care in developing countries”: highlights
from IAC 2002, Barcelona. www.hivandhepatitis.com
- Attawell K. et al., “Provision of antiretroviral therapy in resource-limited
settings: a review of experience up to August 2003.” WHO and the UK’s
Department for International Development. November 2003
www.healthsystemsrc.org
- Creese A, et al., “Cost-effectiveness of HIV/AIDS interventions in Africa:
a systematic review of the evidence.” Lancet, Volume 359, number 9318, May 11, 2002.
www.lancet.com
- Blower S., Farmer P., “Predicting the public health impact of antiretrovirals:
preventing HIV in developing countries”. AIDScience Vol. 3, No. 11, 2003
- Galvao J. “Access to antiretroviral drugs in Brazil” Lancet, Volume 360,
Number 9348, December 7, 2002.
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