Experts fear for the future of Brazil’s successful approach to fighting HIV
RIO DE JANEIRO – In the 10 years that Dr. Anna Cabral has been treating AIDS patients, she said she has seen a change in the people who would come to her clinic in a large public hospital.
Where once a diagnosis would instill them with “terror,” she said, today they have hope.
“They had the ‘eyes of snakes,’ ” she said. “It is not so anymore.”
Cabral, a teaching doctor at the Pedro Ernesto University Hospital in Rio de Janeiro, said the outlook is "very different from the old days,” when an AIDS diagnosis was basically a death sentence, as the variety and quality of treatments available to patients to continues to improve.
Much of the improvement is attributed to the success of Brazil’s HIV/AIDS treatment and prevention program, which calls for the near-universal distribution of medication to patients across the country.
The program has not been without controversy. The Brazilian government broke international patent laws to mass produce the medications at a lower cost, and further invited controversy when health authorities recruited sex workers as “partners” in promoting disease prevention and distributing condoms.
But experts have doubts about how much longer the program can survive.
"We have progressed in constructing a public health system oriented in these principles [social justice and universality], but at this moment, there is a crisis," said Veriano Terto, a psychologist specializing in public health and a member of the coordination staff for the Brazilian Interdisciplinary AIDS Association (ABIA).
ABIA, one of a number of AIDS-related non-government organizations in Brazil, is putting much of its resources toward finding a way to sustain the access to AIDS treatments.
"There is a weakening,” Terto said. “we're trying to survive." He said that the AIDS movement in Brazil has a reached a “very complicated moment.”
AIDS activists fear a lack of funding and the fact that Brazil’s AIDS polices may not be sustainable indefinitely, he said. He likened the problem to “trying to fix a wheel on a car that is already moving.”
Richard Parker, an American medical anthropologist and president of ABIA, echoed the sentiment, saying there is less support from the government under Dilma Rousseff than there was under Luiz Inacio Lula da Silva, better known as Lula. The result, he said, is a “potential crisis.”
“There is now destructuring of what was a great program,” he said.
According to country reports from both the United States Agency for International Development and the Joint United Nations Programme on HIV/AIDS, both written in 2010, the Brazilian HIV/AIDS program faces funding problems in part because those receiving treatment are often living longer than they would have in the past.
The United States report says “new strategies are required” to address this issue, because as patients live longer but still require treatment, the cost to the Brazilian government increases.
For the Brazilian activists, the concerns also lie in the fact that Brazil has become what they consider an international leader in HIV/AIDS programs.
“The issue is that Brazil had, clearly, what was a model for the response to AIDS in the developing world,” Parker said. “That model program is now in jeopardy.”
Pamela Bermudez, adviser on HIV at the Pan American Health Organization’s Brazil office, wrote in an email that Brazil’s ability to hold a prominent position on AIDS policies is part of what makes the program important to maintain.
“It has always been said that the Brazilian model has inspired different countries to fight for universal access and to gain political space regarding the participation of civil society and human rights perspective in health,” she wrote.
The first case of acquired immunodeficiency syndrome (AIDS) in Brazil was recorded in 1982, and since then, the country has established a number of policies in both AIDS treatment and prevention. In 1992, the World Bank predicted that 1.2 million Brazilians would be infected with AIDS by the year 2002. In 2007, the Joint United Nations Programme on HIV/AIDS estimated the number to be 620,000 – half of the original prediction.
Much like in the United States and United Kingdom, it took the death of a popular rock star to bring the issue of the growing AIDS epidemic to the forefront, Cabral said.
The Rio-based singer Agenor Miranda Araújo Neto, known by the stage name "Cazuza", publically admitted his condition in 1989. When he died from the illness in 1990, his mother to set up the Viva Cazuza Society, a charity involved in sponsoring AIDS prevention and providing homes for children with HIV.
Cabral said she, like many others, decided to get involved in the fight against AIDS after the singer's death at 32.
The Brazilian government, however, was a step ahead. In 1991, Brazilian health officials began to distribute free azidothymidine (AZT) treatments to AIDS patients.
Terto said he sees the AIDS movement as a parallel to Brazil’s journey out of a dictatorship.
“We were also in symphony with the process of constructing democracy in Brazil, especially in the 1980s and 90s,” he said.
By the mid-1990s, the older treatments were replaced with more effective and powerful antiretroviral therapies, and in 1996 Brazil declared that it would offer free antiretroviral treatment to all citizens with AIDS.
Parker said getting the law passed was the major victory of that generation of the AIDS movement.
“It took a number of years and pressure for the law to take effect,” he said. “That was probably the big success of 1990s.”
In 2007, in a move that would anger some of Brazil’s allies, Lula announced that the country would begin to import a lower-cost version of one of the antiretroviral drugs. He signed a compulsory license for the antiretroviral drug efavirenz, medication originally developed and patented by US drug company Merck, and the drug began to be produced in Brazil for a lower cost.
A similar move for the same drug had been made by the government of Thailand shortly before.
Bermudez said the decision to produce AIDS medications internally is one of the key steps taken toward making the Brazilian model an effective one, even though it brought Brazil into conflict with the United States after the patents were broken.
"We had to deal with intellectual property rights, and breaking patent rights on drugs," he said. "But we just continued to push for the public health emergency that AIDS is."
Mark Grayson, a spokesman for the Pharmaceutical Research and Manufacturers of America (PhRMA), acknowledged Brazil’s strides in AIDS treatments but was quick to denounce the use of compulsory licenses. PhRMA is a trade group that represents drug companies in the United States, and one of the group’s focuses is intellectual property rights.
“It’s generally better off for patients and the government to work with the industry,” Grayson said. “They certainly want newer medicines, and if they want newer medications to help patients they need to play a part in helping to research the medicine.”
Former PhRMA president and CEO Billy Tauzin released a statement in 2007 in response to the actions of Brazil and Thailand, condemning international use of compulsory license for American-created medications and calling the trend “dangerous.”
“If the result of these costly and lengthy innovative processes is the theft of the patented intellectual property, then companies will have less incentive to develop new life-saving treatment options,” Tauzin said in the statement.
Tauzin also said using compulsory licenses has a “misguided focus,” and what seems like a short-term budget fix will also have long-term consequences.
Parker pointed out that the initial round of broken patents occurred in 2001, and the United States defied its own stance shortly thereafter once the anthrax scare forced the nation to mass produce drugs to treat anthrax.
“They’re not afraid to break rules when they’re in the interest of US companies,” he said.
Brazil has also been home to new and innovative ways to spread awareness of sexual health issues and to promote safe sex practices, Parker said, something that has helped the country curb the spread of AIDS as well.
He said the Brazilian Interdisciplinary AIDS Association adopted approach that put little emphasis on symptoms or risks associated with AIDS itself, instead focusing on empowering people and mobilizing them to safe sex practices. He cited an example of a pamphlet they found particularly effective, which contained a series of three erotic stories that put a positive light on condom use.
The pamphlets did not mention any facts about AIDS or HIV.
Parker said ABIA faced conflicts with US-backed aid groups about the strategies for AIDS prevention and sexual health, so ABIA was careful to monitor the use of that funding.
“[Our approach is] more shocking than anything produced in the US,” he said.
Bermudez said the Brazilians’ openness to sexual education programs and the public availability of condoms and other preventative items is part of what makes the Brazilian model a strong one internationally.
Controversy has also sprung up with the Brazil’s willingness to partner with sex workers to promote safe sex practices to the public and also to better protect people in the sex industry from AIDS and HIV.
In 2002, Ministry of Health of Brazil referred to sex workers as “partners” in the fight for safe sex and HIV and AIDS prevention.
A series of posters, leaflets and stickers depicted cartoon character “Maria Without Shame,” a female sex worker who promoted a positive view of women in the sex industry. The advertisements proclaimed, “You need have no shame, girl. You have a profession.”
According to the Joint United Nations Programme on HIV/AIDS 2010 Country Progress Report for Brazil, 47 percent of women sex workers received some sort of assistance from an AIDS prevention program in 2009.
Despite the near-universal access to medication and aggressive approaches to prevention, the fears of Terto, Parker and others have not abated.
“We have a kind of silence with what is happening with health in Brazil,” Terto said. “We don’t like to admit our mistakes.”
Bermudez said the Pan American Health Organization sees no reason why the program would no longer be effective internally – as the level of social participation is sustainable – but she could not comment on the effect of outside funding.
Cabral said, despite these fears, she has not seen any negative impacts on AIDS treatments in Pedro Ernesto University Hospital, and that the drop in support is something that happens with other diseases as well.
“Like with other contagious diseases, there are some diseases that lack in that for a period,” she said, adding that she sees that the necessities are generally taken care of.
From her perspective, the focus should shift from concerns about the treatments to lessening the stigma associated with having AIDS.
She said people were becoming more humane toward the disease, but there is a lot of progress left to be made in that area.
“It is essential that there is progress against prejudice,” Cabral said. “I think it will continue to get better.”