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 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.

In 2019, Brazil had 920,000 people living with HIV/AIDS. In 2019, 0.60% of the population had HIV/AIDS. The Brazilian Ministry of Health laid the groundwork for a National AIDS Control Program (NACP) in 1986. In 1987, it was placed under the aegis of the National AIDS Control Committee, a group composed of scientists and members of civil society organizations. The program was reorganized again in 1992 with more emphasis on linkages between government and NGOs.

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. 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:
The impact caused by the introduction of therapeutic measures, like the antiretrovirals in their different compositions and associations and/or health promotion and protection measured, though evident, has not been completely explored yet. 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. 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.

The average annual cost of ART per patient in 1997 was $4,469—compared to over $10,000 in most of the developed world—totaling only $242 million per annum. However, in 2001, Brazil manufactured locally 8 of the 12 drugs in the national ARV cocktail; in 2003 and 2005, 8 of the 15. If all of the drugs were patented imports, the cost of these ARV programs would increase by 32%. Article 71 of the 1997 Brazilian patent law requires that foreign products be manufactured in Brazil within three years of receiving a patent. If a foreign company does not comply, Brazil may authorize a local company to produce the drug without the consent of the patent holder, a tactic known as "compulsory licensing" or the "bargaining chip and as a last resort." In addition, Article 68 authorizes "parallel importing" from the lowest international generic bidder, effectively destroying the patent holder's monopoly as well. Prodded by domestic pharmaceutical lobbies, the U. S. challenged Article 68 within the framework of the World Trade Organization's Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPs) regime for allegedly discriminating against imported products; Article 71—to the chagrin of many companies—was not included in the complaint. In addition, the U. S. placed Brazil on the "Special 301" watch list, opening the possibility for "unilateral sanctions," and companies individually threatened to pull out of the Brazilian market altogether. Brazil argued that the law only applied to cases where the patent holder abuses their economic power, a loophole specifically allowed by the TRIPS agreement. If this trend proceeds, it will be a global pandemic of AIDS that will grow uncontrollable because the Brazilian move will destroy the whole legal order that is the basis for developing new drugs and continuing research. The pharmaceutical companies were not just afraid of the immediate loss of the Brazilian market, but with the larger implications of other developing countries following Brazil's example. Large developing countries, like India, with large industrial capacities and evolving intellectual property regimes are the true elephant in the room. Brazil invoked the Article 71 for the first time on August 22, 2001, when José Serra, Brazil's Minister of Health, authorized Far Manguinhos—a Brazilian pharmaceutical company—to produce Nelfinavir, a drug patented by Pfizer but licensed to Roche in the Brazilian market. This unilateral action prompted a flurry of negotiations where Roche and Merck agreed to reduce the prices of five drugs by 40 65%. An advertisement distributed by the Brazilian government proclaimed: "Local manufacturing of many of the drugs used in the anti AIDS cocktail is not a declaration of war against the drugs industry. It is simply a fight for life." Brazil carried out such a compulsory licensing threat for the first time in May 2007, on efavirenz, produced by Merck. The agreements signed on November 14, 2001, at the WTO conference in Qatar reaffirmed that TRIPs "does not and should not prevent Members from taking measures to protect public health" including "medicines for all." In 2005, Brazil wrote to the United States Agency for International Development (USAID) declining to condemn prostitution, effectively rejecting the remainder of a grant for $48 million between 2003 and 2006. Brazil considered its partnerships with prostitutes—in distributing contraceptives, educating the public about the disease, and voluntary testing—critical to its overall AIDS prevention strategy. One Ministry of Health pamphlet depicts a character, "Maria Sem Vergonha" (Portuguese for "Maria that knows No Shame", but also a pun on the Brazilian name of the flowering genera "Impatiens spp. ", maria sem vergonha), a scantily clad sex worker who encourages prostitutes to take pride in their work and use condoms. Despite the fact that Brazil has the largest population of Roman Catholics in the world, the Brazilian Roman Catholic Church has not demanded the abstinence only prevention strategies, voicing only intermittent "mild complaints" about government programs which refuse to acknowledge moral or religious issues. Some scholars, such as Levi and Vitória, argue that the Brazilian model can only be applied to other countries with similar level of economic development and civil society sectors. Galvão argues that the unique local conditions in Brazil complicate the application of the Brazilian experience to other regions with their own local problems and structures. A Washington Post article stated that the Brazilian anti AIDS program is considered by the United Nations to be the most successful in the developing world, and The Economist echoed this position: "no developing country has had more success in tackling AIDS than Brazil.