HIV/AIDS: The Problem
Brazil: The Success Story1 2 3 4 5 6 7 8
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.