Portal de Periódicos da CAPES

Viewpoint: The Brazilian HIV/AIDS ‘success story’– can others do it?

2004; Wiley; Volume: 9; Issue: 2 Linguagem: Inglês

10.1046/j.1365-3156.2003.01188.x

1365-3156

V. Oliveira‐Cruz, Jeanne Kowalski, Barbara McPake,

HIV/AIDS Impact and Responses

Discussions on the use of anti-retroviral drugs (ARVs) in developing countries have in the past focused on the limitations caused by the high cost of the drugs and by the lack of health system capacity to adequately deliver and make use of them (Colebunders et al. 2000; The New York Times 2001). An additional concern has been the risk of increasing resistance to ARVs if there were widespread inappropriate administration and lack of monitoring (Harries et al. 2001). Lately, however, including at the 2002 International AIDS Conference in Barcelona, there have been stronger calls for scaling up access to ARVs with less attention paid to these concerns and limitations, as expressed by Lange (2002): 'If we can get cold Coca-Cola and beer to every remote corner of Africa, it should not be impossible to do the same with drugs'. The experience of Brazil has often been mentioned in this context. One prominent feature of Brazil's HIV/acquired immunodeficiency syndrome (AIDS) programme – universal access to ARVs – plus epidemiological data indicating that the spread of the disease has been brought under control, have resulted in the programme often being hailed as a 'success story'. Numerous comments have been made to the effects that if Brazil, a developing country, can do it, so can other developing countries (Bastos et al. 2001; Rosenberg 2001; The Economist 2002; Szwarcwald 2002). At the beginning of 2003 the official statistics showed that there were approximately 125 000 people in Brazil benefiting from a policy that ensures AIDS patients receive the full range of ARV treatments, completely cost-free, in the national public health system (Brazilian Ministry of Health 2003a). The programme offers 15 anti-retrovirals, eight of which are produced nationally (Brazilian National STD/AIDS Programme 2003). The number of patients on ARV treatment corresponds to essentially 100% of the total number of registered AIDS cases1 (Brazilian Ministry of Health 2003a); and 20% of the total estimated number of HIV-infected individuals.2 This paper intends to shed light on the current debate by elucidating possible factors contributing to Brazil's encouraging results and considering the presence or absence of those factors in other countries which might be looking to emulate the Brazilian success. As mentioned earlier, Brazil's national AIDS programme is often considered to be a success precisely because it has been able to provide universal access to ARVs. More important, however, is the fact that the country has been able to control the spread of the HIV epidemic, as evidenced by the trends in the number of infections. In 1992, the World Bank predicted that Brazil would reach a figure of 1200 000 HIV infections by the year 2000, yet the most recent figure estimated by the Brazilian Ministry of Health is 600 000, only half of the predicted number (Brazilian Ministry of Health 2003a). Moreover, after a period of stabilization of the epidemic in the late 1990s there has been a trend towards a decline in the incidence rate,3 from 14.0 to 11.2 per 100 000 inhabitants over the period of 1999–2000 (Brazilian Ministry of Health 2001). Two recent publications (Galvão 2002a; Levi & Vitoria 2002) have provided detailed presentations and discussions of the Brazilian HIV/AIDS policy, in particular the ARVs programme. Levi and Vitoria (2002) provide an overview of Brazilian policies and experiences in this area, including the crucial involvement of civil society, the importance of the prevention strategies, the impact of universal access to ARVs and the role of the national laboratory network. They argue that while some elements of the Brazilian experience may be useful as examples to other countries, this might be restricted to countries with similar social dynamics and levels of economic development, such as other Latin American ones. Galvão's (2002a) paper, which focuses specifically on the ARVs policy, analyses the history of the policy and its political, financial and logistical challenges. She also suggests that while individual lessons from the Brazilian experience might be of use for other developing countries, local conditions could make it difficult to apply as a model. Even for Brazil itself, she points out, high drug prices could still represent a threat to the sustainability of universal ARV access. Our objective is to evaluate the feasibility of replicating in other developing countries those elements of Brazil's programme that have been judged critical to its success. We review these critical elements and consider their feasibility in a range of developing countries, especially taking into account the relative importance of the ARV strategy. Universal access to ARVs has been a major gain for AIDS patients in Brazil, and a showcase element of the Brazilian programme. However, ARV provision is but one part of the Brazilian effort to deal with the epidemic, and the achievements need to be understood in the broader context of the economic, political, social and epidemiological characteristics of the epidemic and the varied responses to it. The epidemic started in the cities of São Paulo and Rio de Janeiro (Teixeira et al. 2001), with the first AIDS case registered in 1982 (Amato Neto et al. 1983). The initial failure of government authorities to respond to the epidemic was confronted by strong social mobilization, particularly of gay groups who were among the first to organize into non-governmental organizations (NGOs) (Levi & Vitoria 2002). By 1983 an advocacy group had already started activities in São Paulo and the government of that state responded by establishing a centre for HIV/AIDS prevention activities in 1985, while the federal government responded with the creation of a National AIDS Programme in the same year (Brazilian Ministry of Health 1997). In Rio de Janeiro an association of activists and professionals was created in 1986 (Brazilian Ministry of Health 1997). Such an early and rapid response has not been seen in South Africa, for example, where government authorities have only belatedly begun to emerge from a de facto state of denial regarding the scale and implications of this massive public health problem (Schneider & Fassin 2002). The response was concerted, through partnerships involving the public, non-governmental and private sectors. The sectors combined and complemented each other's expertise and resources, and thus were able to expand the range and coverage of HIV/AIDS activities. Strong leadership in government and civil society played an important part in consolidating the response. Uganda reacted in a similarly concerted way (Parkhurst 2002); but in Russia the political response to the epidemic has been feeble (O'Grady 2000). The government has failed to establish a prevention programme and instead has concentrated on testing (without pre- and post-test counselling) individuals deemed to be at high risk, such as drug users and prisoners. For instance, O'Grady (2000) estimated that approximately 150–200 million mandatory HIV tests were run in the late 80s through the district 'AIDS centres' across the country. In terms of governance, Brazil has had a democratic government as the end of military rule in 1984, with political stability and participatory democratic structures that have been gaining strength over time. There exist firmly rooted structures for public accountability, channels for public opinion, and a vigorous free press. Politicians have embraced the cause, and civil servants have exercised commitment and vision. These factors have been crucial to the implementation of effective HIV/AIDS programmes. The role played by civil society, in the institutional form of the NGO, has also been a key dimension of the Brazilian programme (Brazilian Ministry of Health 1997; Galvão 2002b). Civil society participates actively in policy formulation and evaluation, through presence on steering committees of the national HIV/AIDS programme and in other government forums. NGOs also collaborate in programme delivery,4 particularly to high-risk groups. Lastly, civil society also forms pressure groups outside of formal structures when crucial opportunities and decisions arise. In September 1999, for example, when financial constraints threatened the international purchase of ARVs, NGOs organized street demonstrations and efforts to send messages to government authorities (Galvão 2002b). Treatment, including ARVs, is just one part of a balanced programme which has also placed strong emphasis on prevention and human rights protection. The government has established a set of comprehensive prevention activities, such as media campaigns and distribution systems for preventive commodities, aimed at both the general public and specific high-risk population groups. Empirical evidence of the impact of prevention programmes is scarce, but existing data show positive results. For example, the use of condoms in first sexual intercourse in Brazil increased from 4% in 1986 to 55% in 20035 (Brazilian Ministry of Health 2003b). In addition, there has been a reduction in the national HIV prevalence rate among injecting drug users (IDUs) from 52% in 19996 to 41.5% in 20017 (Brazilian Ministry of Health 2002a). Human rights protection, secured by a series of legislated measures outlawing discrimination against people living with HIV/AIDS (Brazilian Ministry of Health 2003a), has been crucial in encouraging individuals and communities to deal openly with the disease and to seek diagnosis and treatment. In contrast to Brazil, the move towards anti-discriminatory safeguards has been weak in Bangladesh (Saleem 2000) and Russia (Flanagan 2001). The Russian Federation appears not to have experienced the degree of community and political response, which has underpinned the prioritization of the problem in Brazil. The prevalence rate, presently at 0.9% (UNAIDS 2002), has continued to increase rapidly. It is worth noting that the nature of the epidemic in the Russian Federation is quite distinct from the one in Brazil, thus posing different challenges. The Russian epidemic is driven by injecting drug use with approximately 50% of AIDS cases reported under this category (Rhodes et al. 1999) in comparison with 11.4% in Brazil (Brazilian Ministry of Health 2003a). IDUs are a stigmatized group and drug use is illegal. These factors hamper the widespread implementation of interventions targeted at this population such as needle exchange programmes (NEPs) and drug substitution therapies (such as methadone for heroin8 users). In contrast, NEPs in Brazil have been scaled up since 1992 under the official endorsement and financial support of the federal government and international agencies (Bastos & Strathdee 2000). A focus on the functioning of the health system immediately suggests analysis of health infrastructure and human resources. In relation to infrastructure, the Brazilian AIDS programme has established a specific network of units (not necessarily by creating new physical units, but often by strengthening existing ones with additional resources) for the provision of care that includes: 375 conventional hospitals and 79 day-hospitals accredited for HIV/AIDS care (Brazilian Ministry of Health 2002a); 53 home care therapeutic services (Brazilian Ministry of Health 2002a); 381 specialized outpatient care units (Brazilian Ministry of Health 2002a); 73 laboratories for TCD4+ count (Brazilian Ministry of Health 2002a); 65 laboratories for viral load count (Brazilian Ministry of Health 2002a); 12 laboratories for ARV resistance genotyping (Brazilian Ministry of Health 2002a); 1126 health units providing sexually transmitted infection (STI) care on the basis of syndromic management (Brazilian Ministry of Health 2002a); 220 voluntary counselling and testing (VCT) centres (Brazilian Ministry of Health 2002b). As shown in Table 1, Brazil has a better functioning health system in terms of human resources (apart from the number of nurses) and hospital beds than other countries of similar and lower income levels but also with higher and lower prevalence rates – the main exception being the Russian Federation. Brazil's 0.7% AIDS prevalence among the adult population (15–49 years) is low compared with, for example, 38.8% in Botswana, 20.1% in South Africa or 5.0% in Uganda (UNAIDS 2002). Hence the stresses put on the health system and public spending in combating the disease, including the provision of universal ARVs, have been correspondingly smaller and more manageable than if the number of infected were as high as in many other countries. Universal access to ARVs relies not only on patented drugs but also on generic ones produced in country by publicly owned laboratories. While domestic production takes place in India as well (Keatinge 2002), it is not the case in most other developing countries such as Uganda or even South Africa. According to estimates by Szwarcwald (2002) the cost of providing ARVs in Brazil would increase by 32% if all the drugs were patented imports. The Brazilian government has been steadfastly negotiating with drug companies, and with national governments defending corporate interests, to lower the price of patented ARVs for Brazil, by contemplating use of the 'national emergency' clause of the trade-related aspects of intellectual property rights (TRIPS) agreements regarding compulsory local licensing, and by investigating possible parallel importing from other cheaper non-patent-holder sources. With respect to its economic basis, Brazil's per capita gross domestic product (GDP)9 of US$6625 (World Bank 2000) places the country in the upper middle income ranking10. The resulting sizable fiscal resources available to the different levels of government in Brazil have been crucial in enabling the development and continuation of an effective national AIDS programme. The average annual cost in Brazil, in 1998, of ARV therapy per patient was US$445911 and the total annual spending on ARVs was US$242 million (Szwarcwald 2002). In the same year, total annual spending on AIDS activities amounted to US$634 million (Brazilian National STD/AIDS Programme 2002b). Considering Brazil's level of national income and fiscal capacity, these expenditures represent a tolerable strain on overall finances. The annual expenditure on HIV/AIDS in 1998 amounted to only 0.07% of Brazil's GDP, which represents an average of US$4 per person (Brazilian National STD/AIDS Programme 2002b). Brazil's per capita expenditure on health, of US$308 (Brazilian National STD/AIDS Programme 2002b), is above the average of those countries normally classed as 'developing' and even of South Africa (average health expenditure of US$230 (UNDP 2002)12 a comparably 'middle income' country. The epidemic is still largely centred in the urban southeast and south. This region of Brazil is significantly wealthier than the national average and thus has had even greater financial, technical and health system resources available locally to combat the epidemic than the national averages indicate. Certainly universal access to ARVs in Brazil has brought tremendous gains for people living with HIV/AIDS in the country, as evidenced by, for example, a 50% drop in the AIDS-related mortality rate since 1995 (Brazilian Ministry of Health 2003a). However, such successes are linked to much more than just the single factor of ARV provision. Brazil developed a timely response that was comprehensive in terms of the participating actors and coordinated in terms of its activities, and it is precisely this combination that needs to be highlighted rather than any single component of the strategy. Brazil's approach to theHIV/AIDS epidemic has been characterized by an early public sector response, strong civil society participation, multisectoral mobilization of efforts and resources, a balanced and comprehensive approach to prevention and treatment and the inclusion of a human rights perspective in all strategies (Levi & Vitoria 2002). Brazil has been able to implement a successful national HIV/AIDS programme, balancing several elements of prevention and treatment, which has brought the epidemic under control in the country. The lessons to be learned depend on the interaction between pre-existing characteristics and possible interventions. While capacity elements and enabling factors that appear to have been important in Brazil are not unique, they are also not universal. Other countries need to evaluate to what degree they might have sufficient conditions for implementing a programme of the type and in a manner such as Brazil. Where important pre-intervention factors differ, the most effective HIV programme may need to be different as well. Priority interventions may need to take place parallel to the HIV sector, for example in health systems strengthening. Questions regarding cost estimates and financial resources, whether domestic or donor based, must be faced candidly and early in the policy process. We do not argue that low income countries should not strive for access to anti-retrovirals or for other effective elements of an HIV/AIDS programme. However, we do believe that an appreciation is needed of the multiple capacities, players and activities that seem to form the necessary parts of effective AIDS strategies, and that proper attention must be paid to local potentialities and constraints. Valeria Oliveira-Cruz was involved in the implementation of the 'AIDS I and AIDS II' projects of the Brazilian Ministry of Health in the period of 1994 to 1999. While this experience has offered her invaluable insights into the Brazilian AIDS Programme, this has not influenced the content of this paper. This paper draws on the following work: 'Capacity issues in the Brazilian health system in providing HIV/AIDS prevention and care' which received the Young Investigator Award from the International AIDS Society during the XIV AIDS Conference. Authors are members of the Health Systems Development Programme, which is supported by programme funds from the UK Department for International Development. We are very grateful to three anonymous referees and Christoph Kurowski for valuable comments that assisted us in revising the original manuscript. We thank Denise Doneda and Rosemeire Munhoz for suggestions and guidance with documents from the National STD/AIDS Programme. We also thank Isabel Sinha for helpful assistance.