The Age of Aids [home page]

Brazil: A Remarkable Commitment

Living with HIV (2005)*: 620,000 (0.5% pop.)
Receiving Drugs (2005): 165,000-183,000 (83% of those who need them)
Est. AIDS Deaths (2005): 14,000

HIV took root in Brazil's poor neighborhoods
azt in hand

Part Two: Chapter Three The Struggle to Get the Drugs

chinese condom distribution

Part Two: Chapter Six New Challenges

doctor with patient

Part Two: Chapter Seven 40M Infections Today -- And 40M to Come


No one can argue that Brazil's way of combating the spread of HIV/AIDS hasn't worked. Back in 1991, Brazil and South Africa both had HIV prevalence rates of just over 1 percent of the population. A decade later, South Africa's rate had skyrocketed to 25 percent. Brazil's rate remained at 1 percent.

By the mid-1990s, Brazil had half a million people who were HIV positive, most of them living in Brazil's huge cities where stigma and desperation flourished. The government had built AIDS clinics in poor neighborhoods but said it couldn't afford to give patients the triple cocktail drug therapy for HIV.

But then, schoolteacher Nair Brito, who'd been infected with HIV by a boyfriend, sued the government for access to the drugs -- and won. As she lay near death in her hospital bed, a judge ruled she was entitled to the drugs immediately. Soon after, Brazil passed a law guaranteeing access to HIV drugs for all its citizens who needed them.

The government introduced a national health care service, the Sistema Unico de Saude (SUS), which began procuring drugs for HIV/AIDS, while local authorities and states administered treatment for opportunistic infections and sexually transmitted diseases. A multi-layered program of care, prevention, counseling and treatment was developed through collaboration with civil society groups and religious organizations, and aided by major loans from the World Bank.

But Brazil's treasury was being heavily taxed. Despite having promised universal access to antiretrovirals, there was no way the country could afford to continue to pay the high prices for brand-name pharmaceuticals. So Brazilian labs started manufacturing generic AIDS drugs. And with this leverage, Brazil negotiated lower prices from the global pharmaceutical industry, which held the patents for the triple cocktail.

While many thought a developing country like Brazil couldn't afford to sustain a program of free universal treatment, the government argued it was actually cost effective. Despite spending millions of dollars on antiretroviral drugs, the government estimates that early access to treatment has saved Brazil more than $2 billion in health care costs since the beginning of the epidemic.

The drug treatment was an important prevention tool, because it keeps the levels of the virus in the body low, thereby making it harder to spread. But the Brazilians also realized a vigorous educational campaign was needed to halt new infections by changing behaviors that help spread HIV. So, playing off its cultural openness about sexuality, Brazil launched a national advertising campaign in the 1990s with an upbeat message -- Sex can still be fun, you don't have to worry about dying, just use condoms!

Of course, in a country where over 70 percent of the population is Roman Catholic, there's been some debate about condom use within the Catholic Church. One "rebel" priest in the district of Sao Paolo was threatened with excommunication when he produced a video urging people to use condoms. But Father Paitoni says, "Given the reality of today's world, given the type of society in which we live, if we want to keep our feet firmly on the ground, we cannot think we can use evangelical values to oppose a pandemic of scale such as HIV/AIDS. So, if you cannot fully live the evangelical values, at least listen to what science tells you and use a condom."

The morality debate surrounding AIDS prevention in Brazil stretched beyond the country's borders. In 2005, the U.S. government insisted that groups receiving U.S. funding for AIDS sign a statement condemning prostitution. Prostitution is legal in Brazil, and the government views sex workers as partners in helping to educate their clients. In defiance, Brazil turned down $40 million in U.S. assistance.

Brazil has also continued pushing back with the global pharmaceutical companies. Since 2000, battles over pricing have flared up again and Brazil has threatened to break patents. On Dec. 1, 2004, in the face of rising treatment costs, officials announced Brazil would break patents in 2005 in order to contain costs. On March 14, 2005, Brazil asked three research-based companies -- Merck, Abbott Laboratories, and Gilead -- to grant it voluntary licenses for specified drugs produced by these companies. The Brazilian Ministry of Health gave these U.S.-based companies only until April 4, 2005, to agree to transfer technology to Brazilian drug producers so that they could start production.

After a long struggle, in October 2005, Brazilian Minister of Health Jose Saraiva Felipe announced that an agreement had been reached with Abbott, and on Nov. 30 the CEO of Abbott confirmed an agreement in Financial Times but stressed that continued attacks on patents would weaken future research and development.

In an interview with FRONTLINE, former President Bill Clinton summed up Brazil's story this way: "All of us in the rich countries have to understand that our impact is going to be very limited unless the countries in questions are really committed.... If you look at the marvelous job done by Brazil where you had commitment from government, civil society, the church, the grassroots level, to turn this around, and they did. That's what we have to have everywhere."

But recent problems with access to drugs have threatened Brazil's progress. In April 2005, Brazil suffered a minor crisis when the government ran out of supplies of tenofovir, a member of a class of drugs known as Nucleoside Reverse Transcriptase Inhibitors (NRTIs). Some Brazilians blamed it on poor planning; others on high prices, and an inability to manufacture a generic form of tenofovir.

Whatever the reason, the implications are staggering, and the effects are potentially devastating. The crisis last spring was averted, when the government bought supplies from neighboring Argentina. In May 2006, Brazil Gilead reached a deal to slash the price of tenofovir, which the ministry says will save the government $15.2 million annually. But the worries for patients around the country who were temporarily without treatment are just beginning. Many fear that they will become drug resistant, or that the medications will run out again.

The rest of the world is now facing the same potential problems. Many experts fear that when the Global Fund and President Bush's Emergency Plan for AIDS Relief (PEPFAR) run out of money in 2008, patients will have to be taken off their medications. Scientists and activists around the world are warning governments to take action now. Perhaps the world should watch to see how Brazil handles the situation. Because when it comes to tackling AIDS, Brazil has followed its own path, with remarkable success.

* Note: Figures reflect most recent statistics from UNAIDS and the World Health Organization.

  • Related Links
  • Living with HIV: Maria Lucia and Laerte
    Maria Lucia da Silva ("Lucia") and Laerte Vicente, a middle-aged couple in Brazil, did not know each other when they were diagnosed, but have since formed a life together. Here they describe how nothing about living with HIV is easy -- they still fight against stigma every day -- but one particular challenge is negotiating their different feelings about sex after HIV.
  • UNAIDS Country Report: Brazil
    This page has UNAIDS statistics on HIV/AIDS in Brazil, an epidemiological fact sheet and analysis of the problem. It notes, "Brazil's response to HIV has benefited from consistently strong political support from the highest levels of government."
  • Brazil's AIDS Drugs Policy
    This Web site outlines the AIDS drugs policy of Brazil's Ministry of Health.
  • Brazil Announces Decision to Break Drug Patents
    In this BBC News article, Dr. Pedro Chequer is interviewed about Brazil's decision to confront the pharmaceutical companies and break drug patents.
  • Lessons Learned From Brazil
    This article in The New England Journal of Medicine describes the lessons learned from Brazil's fight against AIDS and poses the potential problems of the future.
  • Ban on Condom Use Divides Catholic Church
    This article describes Father Valeriano Paitoni's efforts to combat HIV/AIDS and the conflict with the Catholic Church.

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posted may 30, 2006; updated june 19, 2006

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