Roll out and deliver

Ten years after Brazil decided to roll out antiretrovirals, experts wonder whether much has been achieved, explains Klaus Morales

In 1996, Brazil decided to offer access to antiretroviral drugs to all its citizens with HIV or AIDS who needed them. More than 4000 delegates throughout Brazil met at a conference this November to celebrate the country's decision and to discuss future challenges.

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"Public policies must combine prevention and treatment simultaneously. They're not competitors, and there is no legitimacy in having prevention programmes if solid treatment strategies do not also exist," Mariângela Simão, the head of Brazil's sexually transmitted disease and AIDS programme, told the studentBMJ.

A report issued by Brazil's health ministry and distributed at the conference said that about 600 000 Brazilians are HIV positive or have AIDS. An article published in the New England Journal of Medicine this year said that the World Bank had predicted in the early 1990s that 1.2 million people in Brazil would be infected with HIV by 2000 (2006;354: 1977-81). This was proved wrong by surveillance data in the report. This can be partly attributed to successful prevention programmes, for example, in prisons, and also intensive media alert campaigns, especially during the carnivals.

Reasons for optimism

The situation in Brazil is described as a "concentrated" epidemic: the prevalence in subgroups of the population prone to risk exceeds 5% but is less than 1% in pregnant women. The prevalence in Brazil in people aged 15-49 years is 0.6%. About a third of the sexually active population has been tested for HIV. The rate of testing is higher in women because the government gives incentives to pregnant women to get tested.

After universal access to antiretrovirals was introduced there was much reason for celebration. The number of deaths from AIDS related illnesses fell and, from 2000, stabilised at about 6.3 deaths per 100 000 population. Until 1995 the prevalence had been about 9.7.

"Brazil, undoubtedly, is the strongest country in Latin America regarding prevention of HIV and AIDS, and the continent can be considered one of the regions where demands are being met efficiently," Mrs Simão added.

Latin America has better treatment coverage (62%) of people needing antiretrovirals than sub-Saharan Africa and eastern Europe, where treatment coverage is 11% and 13%, respectively. About 175000 Brazilians are being treated under the universal access policy.

"The budget for the Brazilian AIDS programme was doubled in the last presidential mandate. We're very optimistic after the recent re-election of the president and the government's position on fighting AIDS," Mrs Simão said.

The HIV and AIDS budget is about 3% of the total healthcare budget, and the country's response to the epidemic has been strengthened by help from various organisations, such as Unicef, the World Bank, and the Global Fund to fight AIDS, Tuberculosis, and Malaria.

Marie Pierre-Poirier, representing Unicef, said, "Brazil is not only a reference point in the battle against HIV and AIDS but also an inspiration for other countries in Latin America, Africa, and the rest of the world."

Another hot topic in the conference was the worldwide increasing incidence of the co-infection between HIV/AIDS, hepatitis, and tuberculosis. This is mainly because of the possibility of long term survival of patients who are taking antiretroviral drugs. About 10 million people are living with HIV and hepatitis C infection, and 3.2 million people have HIV and hepatitis B infection worldwide. Tuberculosis is still a prevalent disease in poorer countries, with an incidence of 110 000 new cases a year in Brazil.

High hopes, greater challenges

Much needs to be achieved, though. The main challenges for the government in sexual health are improving the quality of services for people with AIDS; the battle against homophobia; clarifying the responsibilities of different levels of government; and dealing with the growing number of women with AIDS. Delegates also wanted universal access to antiretrovirals to continue.

Last year Brazil took a step towards allowing exemption from patents for antiretrovirals but then dropped the idea; it continues to negotiate directly with drug companies for better prices. Brazil manufactures eight of these drugs, but the government and Brazilians remain dissatisfied with the current management of patents and intellectual property.

Some Brazilians are also angry about a decision by the country's National Agency for Sanitary Vigilance to ban blood donation by men who have had sex with other men in the past year as well as by their male or female sexual partners. Gay rights activists protested during the conference's opening ceremony against prejudice and urged the government to rethink the decision.

See www.aids.gov.br for more ­information.