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The National Response to HIV/AIDS in Brazil

Brazilian STD/AIDS ProgramMinistry of Health

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• Population (2005) – 185 mln

• Federative Republic with 27 States

• Municipalities - 5,561

• Territory: 8,5 mln sq km

• GNP (2004) US$ 750 bi

• Per capita GNP (2004) - US$ 4,041

• HDI Rank (2005) - 63th (0.792)

Country Profile

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• Accumulated AIDS cases (06/2005): 371,827

• AIDS incidence rate (2004): 17,2/100,000 inhabitants

• Estimated n. of PLWHA (2004): around 600,000

• Prevalence: (15 to 49 years of age)

•2000: 0.61%

•2004: 0.61%

• Aids deaths (1980-2004): 171,923

• Mortality rate: 6,1/100,000 (2004) inhabitants

Epidemiological Profile

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Current epidemiological trends

Relative stabilization,

-decreasing: southeast, MSM, IDU

-Stabilized: big cities

Increasingly affecting:

- Heterosexuals

- Women

- Low-income groups

- Smaller cities

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Total investment in STD/AIDS control program by the Federal Government. Brazil, 1997-2005

Total investment in STD/AIDS control program by the Federal Government. Brazil, 1997-2005

Source: PN STD-AIDS//MOH

11%

89%

National budget

World Bank Loan

Average investment per year:

US$ 400 MILLION

1997 to date: US$ 3.5 billion (HIV response)US$ 2 billion for ART

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Major features of theBrazilian ResponseMajor features of theBrazilian Response

Country-driven approach: Social Control: robust participation by civil society

in decision making and implementation

Balanced prevention and treatment approach

Comprehensive ethical and rights-based approach

Early response by government (since 1983)

Multi-sectoral mobilization

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The 1988 Brazilian Constitution: access to

health is a basic right Main precepts:

- comprehensive approach

- universal access and equity

- civil society participation

Key feature: decentralization Virtuous circle (AIDS Programmes Public Health

System)

The “backbone” of the BrazilianResponse: the Public Health SystemThe “backbone” of the BrazilianResponse: the Public Health System

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• Expand access to prevention commodities (male/female condoms, lubricating gel, harm reduction supplies)

• Extend joint activities with CSO’s, CBO’s, uniformed services, social movements and other government programs

• Implement education programs throughout the public school system at all levels

• Increase coverage in poorest areas, emphasizing counselling and testing through the primary health system

Prevention FrameworkPrevention Framework

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Regular condom use (last 12 mo.)among those aged 16-65 (2005)Regular condom use (last 12 mo.)among those aged 16-65 (2005)

35,4%

23,9%

0%

5%

10%

15%

20%

25%

30%

35%

40%

1998 2005Fonte: Pesquisa CEBRAP, 2005.

10

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

jan

/97

abr/

97

jul/9

7

ou

t/97

jan

/98

abr/

98

jul/9

8

ou

t/98

jan

/99

abr/

99

jul/9

9

ou

t/99

jan

/00

abr/

00

jul/0

0

ou

t/00

jan

/01

abr/

01

jul/0

1

ou

t/01

jan

/02

abr/

02

jul/0

2

ou

t/02

jan

/03

abr/

03

jul/0

3

ou

t/03

jan

/04

abr/

04

jul/0

4

ou

t/04

jan

/05

abr/

05

jul/0

5

ou

t/05

170.000

* Dados preliminares

Projected

Number of patients receiving ARV therapy (1997 – 2005)

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Average cost of ARV therapy per patient/year (US$). Brazil, 2005

Average cost of ARV therapy per patient/year (US$). Brazil, 2005

6240

5486

4603

3464

2210

1500 1359 1336

2500

0

1000

2000

3000

4000

5000

6000

7000

1997 1998 1999 2000 2001 2002 2003 2004 2005*

Year

Th

ou

san

ds

(US

$)

Introduction of expensive new ARVs• Substantial falls in prices of

second-line patented drugs have ceased

•Number of people using them has increased dramatically

12*Brazilian local production

RITONAVIR (1996)* SAQUINAVIR (1996)* INDINAVIR (1997)* NELFINAVIR (1998) AMPRENAVIR (2001) LOPINAVIR/r (2002) ATAZANAVIR (2004)

ZIDOVUDINE (1993)* ESTAVUDINE (1997)* DIDANOSINE (1998)* LAMIVUDINE (1999)* ABACAVIR (2001)

DIDANOSINE EC (2005)

TENOFOVIR (2003)

NEVIRAPINE (2001)* EFAVIRENZ (1999)

ITRN and ITRNt

ENFUVIRTIDE (2005)

IP

FUSION INHIBITORITRNN

Antiretroviral drugs distributed through the Brazilian public health system (and year of introduction)

Antiretroviral drugs distributed through the Brazilian public health system (and year of introduction)

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Aids Incidence and mortality rates (by 100,000 inhabitants) Brazil, 1986-2004.

* SINAN and SISCEL AIDS cases reported through june 2005.Source: Aids: MS/SVS/PN-DST/AIDS Mortality: MS/SVS/SIM.

86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04

ano

0

5

10

15

20rates

Mortality Aids

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Total number and estimated value of hospitalizations averted (non-cumulative figures)

Total number and estimated value of hospitalizations averted (non-cumulative figures)

Estimated value of hospitalizations avoided Estimated number of hospitalizations avoided

$0.00

$100,000,000.00

$200,000,000.00

$300,000,000.00

$400,000,000.00

$500,000,000.00

$600,000,000.00

1997 1998 1999 2000 2001 2002 2003 2004

Exp

end

itu

res

(in

US

$)

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

Nu

mb

er o

f h

osp

ital

izat

ion

s

Total:

Hospitalizations avoided: 791,069

Total savings: US$ $2,289,654,584

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South-South Cooperation: Network for Technological Cooperation in HIV/AIDS

South-South Cooperation: Network for Technological Cooperation in HIV/AIDS

Launched in 2004, involving Argentina, Brazil, China, Cuba, Nigeria, Russia, Thailand and Ukraine

Key support provided by the Ford Foundation: US$ 1 million

Objectives: technology transfer, R&D and production:- antiretrovirals - vaccines and microbycides- condoms- laboratory supplies

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The GCTH – Group for Horizontal

Technical Cooperation.

Launched in 1995 to establish direct cooperation between the Latin American and Caribbean State Governments on HIV and AIDS control and prevention.

Objectives:

- Reference for building up regional statements for International Events.

- Courses , Conferences and Forums. - Development of the Price Bank. - Development of web-page and improvement of electronic

communication.

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Other South-South Cooperation InitiativesOther South-South Cooperation Initiatives

Technical Areas:

Institutional development, management and capacity building

Care and support

Clinical management

Antiretroviral logistics and management

Epidemiological surveillance

Promotion of safer sexual practices

Promotion of human rights

Advocacy and Civil Society participation

Care and support for HIV+ pregnant women and children exposed to HIV

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International Cooperation with Developed CountriesInternational Cooperation with Developed Countries

Institutions involved:

ANRS (France), CDC, USAID, Ford, GTZ, DFID

United Nations :UNAIDS, UNFPA, UNICEF, UNODC, UNESCO, ILO,

Thematic areas:

Monitoring and Evaluation;Promotion of safer sexual practicesPromotion of human rightsAdvocacy and Civil Society participationScientific and technological development

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International Center for Technical Cooperation: a Joint Brazil/UNAIDS Initiative

International Center for Technical Cooperation: a Joint Brazil/UNAIDS Initiative

Created in 2005, the ICTC aims to create and strengthen national technical capabilities for implementing comprehensive AIDS responses through horizontal technical cooperation;

Example of activities undertaken: Coordination of technical missions in Honduras, Nicaragua, Peru,

Ecuador and Bolivia Identification of technical assistance needs of Latin American

countries receiving financial support from the Global Fund

Total investments: Brazilian Government (US$ 500,000), UNAIDS (US$ 500,000),

DFID (£ 250,000 - under negotiation), GTZ (€ 250,000 – under negotiation)

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Challenges: to develop new technologies and systems to halt spread

of the HIV/AIDS epidemic

Challenges: to develop new technologies and systems to halt spread

of the HIV/AIDS epidemic Technologies: Prevention (e.g., microbycides, etc)Treatment and care (e.g., new FDCs)Vaccine

Systems:Monitoring and Evaluation and Operational ResearchPersonnel (health and management)Management

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Brazil’s Recommendations to the 2006 UNGASS

• Universal Access to Prevention, Treatment, Care and Support: “We recognize the importance of intellectual property rights. But no right of a commercial nature can be upheld to the detriment of the right to life and health.” Ambassador Celso Amorim, UNGASS 2006.

• Prevention: “Individual moral values, respectable as they are, cannot be the basis of public health policies. Prevention must reach vulnerable groups – homosexuals, drug users and sex workers(…)” C.A. 2006

• Finance: “Donors must increase the amount of resources available so that health systems can be strengthened (…) Africa is the region that has been most affected. It should continue to deserve priority attention.” C.A. 2006