HIV/AIDS in Brazil

The first AIDS case identified in Brazil was in 1982. Infection rates climbed exponentially throughout the 1980s, and in 1990 the World Bank famously predicted 1,200,000 cases by 2000, approximately double the actual number that was later reported by the Brazilian Ministry of Health and most international organizations. South and Southeast have 75% or more of this infection (Rio Grande do Sul, São Paulo and Rio de Janeiro). The Northeast has 33% of the population but only 10% of AIDS. The first AIDS case identified in Brazil was in 1982. Infection rates climbed exponentially throughout the 1980s, and in 1990 the World Bank famously predicted 1,200,000 cases by 2000, approximately double the actual number that was later reported by the Brazilian Ministry of Health and most international organizations. South and Southeast have 75% or more of this infection (Rio Grande do Sul, São Paulo and Rio de Janeiro). The Northeast has 33% of the population but only 10% of AIDS. The Brazilian experience is frequently cited as a model for other developing countries facing the AIDS epidemic, including the internationally controversial policies of the Brazilian government such as the universal provision of antiretroviral drugs (ARVs), progressive social policies toward risk groups, and collaboration with non-governmental organizations. Brazil's first AIDS case was reported in 1982. Brazil’s AIDS response was crafted in 1985, just after the country had returned from military rule to democracy, at a time when only four AIDS cases had been reported. The Brazilian Ministry of Health laid the groundwork for a National AIDS Control Program (NACP) which was established in 1986, and placed under the aegis of the National AIDS Control Committee, a group composed of scientists and members of civil society organizations, in 1987. The program was reorganized again in 1992 with more emphasis on linkages between government and NGOs. AIDS Project I garnered $90 million in domestic funds and a $160 million loan from the World Bank between 1992 and 1998. AIDS Project II also composed of both domestic funds and a World Bank loan totaled $370 million between 1998 and 2002. In 1990—a year when more than 10,000 new cases were reported—the World Bank estimated that Brazil would have 1,200,000 in infections by 2000. However, by 2002, there were fewer than 600,000 estimated infections, less than half the prediction. The single most controversial element of the Brazilian HIV/AIDS response remains the free, universal provision of anti-retroviral drugs (ARVs), including protease inhibitors, starting in December 1996 with Law No. 9313/1996. The guidelines for antiretroviral therapy (ART) are formulated annually by a Support Committee which determines the diagnostic guidelines and the contents of the ARV cocktail. In 2003, 125,000 Brazilians received free ART treatment, accounting for 100% of the total registered AIDS cases but only 20% of the estimated AIDS cases. ART was traditionally considered too expensive in resource-poor settings in developing countries, which are believed to have a poor capacity for adherence to complicated treatments. However, a 2004 study of 322 outpatient services in Brazil—comprising 87,000 patients—found the rate of adherence to be 75%. Some authors also argue that if the decline in hospital admissions and ambulatory care are taken into account, the policy of universal provision of ART has accumulated a net savings of approximately $200 million. In the context of Brazil, some have challenged the degree to which improvements in public health can be attributed to ART as opposed to other factors. For example, a 2002 World Bank Policy Research Working Paper, states: A 2003 study, using data from diagnoses occurring in Brazil in 1995 and 1996, found that antiretroviral treatment was the single greatest predictor of survival. The authors demonstrate that variables like year of diagnosis, higher education, sexual exposure category, gender, the presence of specific pathogens all appeared to predict survival in a univariate analysis; however, in a multivariate analysis only antiretroviral treatment, diagnostic criteria, and transmission category remained significant. The authors conclude that no factor other than ART 'could reasonably explain the very large increase in survival observed' between the 1980s and 1996. Brazil's response has been characterized by reaching out to groups which account for a high percentage of AIDS transmission, including relationships with non-governmental organizations. For example, in contrast to many parts of the world, condoms were prioritized early and aggressively. Condom use in first sexual intercourse increased from 4% in 1986 to 48% in 1999 and to 55% in 2003, spurred by government programs to increase awareness, decrease the price, and increase the availability of condoms. Prostitute groups were involved in the distribution of information materials and condoms. Similarly, needle exchange programs were implemented. The prevalence of HIV among injecting drug users (IDUs) fell from 52% in 1999 to 41.5% in 2001. 12 needle exchange programs were implemented between 1994 and 1998; 40 had been implemented by 2000, distributing 1,500,000 syringes in just a year. HIV prevalence among IDU decreased even more dramatically in some cities. In 1988 comprehensive screening tests were implemented nationwide in blood banks, following a similar program in São Paulo in 1986; however, the results of these programs were not realized fully until 2000 as a result of the incubation period of the virus, but new cases from blood transfusion became virtually non-existent at that time and new and more effective nucleic acid testing is being considered. Mother-to-child transmission was similarly practically eradicated, falling to a transmission rate of 3%, a level comparable to most developed countries, with the implementation of zidovudine treatment regimes to mother and child and recommendations against breastfeeding.