Scaling up antiretroviral therapy: lessons from Brazil

Julian Meldrum, Julian Meldrum
Published: 12 July 2002

At the International Conference on AIDS in Barcelona, governments north and south were challenged to address the needs of their people as the Brazilians reiterated their commitment to support other developing countries in responding to those needs.

Dr Paulo Roberto Teixeira spoke in Thursday morning’s plenary session as the head of the Brazilian Federal Government’s STD/AIDS programme.

Brazil has recorded more than 220,000 AIDS cases with 105,000 deaths. 0.6% of the adult population is living with HIV+ in Brazil, which while low compared to some is still “a tragedy that cannot be tolerated”. 600,000 people in Brazil are currently living with HIV, which is around half the number predicted in 1992 for the year 2000. There have been successes in reducing transmission among men who have sex with men and injecting drug use, and in promoting use of condoms by young people at the time of their first sexual relationships (which he said is now comparable to the rates seen in the UK).

Both the number of deaths from AIDS and new AIDS cases have fallen. In Brazil the median survival time before ART was six months; it is now closer to five years. Most patients go on working and have had a far higher quality of life than before treatment was introduced.

Overall life expectancy in Brazil has been maintained, in contrast to what has happened in South Africa, yet ten years ago, South Africa and Brazil had the same HIV infection rates.

Dr Teixeira didn’t want to imply they had no problems. They were still not giving same standards of prevention and care to prison inmates in Brazil as to the rest of the community.

Brazil could not have achieved what has been done without participation from the community of people living with and affected by HIV and AIDS. There had been action in support of men who have sex with men, injecting drug users and sex workers, including measures to ensure the availability of condoms and syringes.

The provision of treatment is an essential part of ensuring the kind of positive relationship between governments and peoples that is needed

In Brazil, the cost of treatment with triple drug combinations has halved in a few years as local production began. In total, 16 drugs are currently used, 8 of which are produced locally. In addition to the cost reduction achieved through this local production, the companies Abbott, Merck and Roche have each agreed 50% reductions in the cost of their treatments in Brazil.

Beyond Brazil, Dr Teixeira said that there must be governmental accountability for responding to AIDS. Minority groups are still excluded from and discriminated against in many national responses, although tackling that is inexpensive.

There must not be ambiguous prevention messages. Programmes must continue to emphasise condom provision and not allow religious groups to substitute messages about delaying sex because that was more convenient for their own religious agendas.

Dr Teixeira observed that a number of governments didn’t include ART provision in their bids to the Global Fund. Nonetheless, the lack of funds is outrageous, especially taking account of the millions who have died. There should be a new Marshall Plan – the USA, Japan and Western Europe need to take responsibility for changing this situation. Need for international agencies such as WHO to scale up their efforts to provide technical assistance.

Brazil is sharing its experiences with other developing countries – more than 30 projects have been initiated in the last three years. It is willing to transfer to other countries the technology to manufacture drugs and renewed that commitment today.

Although a current World Bank loan agreement covers only 10% of Brazil’s HIV/AIDS funding and has not funded treatment, it has provided significant support to Brazil’s efforts on HIV prevention and care. A new loan agreement is now being negotiated which will include support for developing new drugs and vaccines. He called for better terms for middle income countries on such loans from the World Bank

In the longer run we need a preventive vaccine and global efforts in that area are still insufficient. Brazil has therefore pledged US$6 million in the next five years to developing trial infrastructure for vaccines development, and the previous day had signed a protocol of cooperation with the International AIDS Vaccine Initiative (IAVI).

In the last few months, Brazil had received many requests from other countries, including from Latin America, to export locally produced generic drugs to other countries. He said he was saddened and felt the same indignation about the situation as the people who have written to him. However, it is the responsibility of each and every government to address the needs of its people. It would not be appropriate for the Brazilian public health service to take on international needs at the expense of addressing the needs of the Brazilian people.

Despite this, in May 2002 Brazil decided to establish an international assistance programme which will supply assistance in kind, including provision of drugs to other countries. US$1 million dollars would be committed annually in 10 pilot projects; Brazil will work with NGOs and other institutions as well as with other governments to demonstrate what can be done.

Through the rest of the conference there were a considerable number of presentations relating to Brazil’s experience. Two of particular interest were a presentation by Dr Cledy Eliana Santos on the development of services in Brazil, and by an economist, Célia Landman Szwarcwald, on the savings Brazil had made by local production of drugs.

Dr Santos reported on a programme than now has 1,000 healthcare facilities with trained HIV multidisciplinary teams, throughout Brazil. These included 375 accredited hospitals, 79 day hospitals, 54 home care teams, 381 specialised ambulatory (outpatient) care units, and 424 maternity services providing mother-to-child prevention services for women diagnosed with HIV. All are linked to primary healthcare system with 11,000 facilities, from which people are referred for specialist care. Training had begun in 1994 but the main underpinning of what is now provided is the November 1996 Act of Congress which gave a right to treatment, including antiretrovirals, to people with HIV.

Dr Szwarcwald showed that there had been a 43% reduction in the cost of triple drug combinations (including a PI or NNRTI) from 1997 to 2000, and a 34% reduction of quadruple drug combinations (using ritonavir-boosted PIs. The number of patients on treatment in Brazil has been increasing linearly by 1400 per month; the average individual cost is currently 13.3 US dollars per day.

Total costs for ART provision in Brazil:

y1997 174 million US$

y1998 241 million US$

y1999 281 million US$

y2000 258 million US$

If average 1997 cost had been maintained, 220 million more would have been spent in the period 1998-2000. In the year 2000 alone, they saved 82 million US dollars by use of locally produced drugs. The average cost per patient 3063 per year vs 10,293.

At the maximum price, other health expenditure would have been cut by 5% if overall health budget had stayed the same.

Condom use among army conscripts increased from 38% to 50% from 1997 to 2000 – so prevention has not been neglected.

Universal access to ARV medicines is an achievable goal; strategies for negotiation with pharmaceutical companies should be based on equity prices.

The main challenge now is to improve the early detection of HIV so that access to treatment can be provided on a more equal basis to all sections of society.


Santos CE et al. Building up an AIDS care services network in Brazil. Fourteenth International AIDS Conference, Barcelona, 7-12 July, abstract ThOrF1514, 2002.

Swarcwald CL. The impact of national production of ARV drugs on the cost of the ARV therapy in Brazil, 1997-2000. Fourteenth International AIDS Conference, Barcelona, 7-12 July, abstract ThOrE1424, 2002.

Teixeira PR. Program implementation and scaling up: barriers and successes. Fourteenth International AIDS Conference, Barcelona, 7-12 July, abstract ThOr241, 2002.

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