HIV & AIDS in Brazil

The first case of AIDS was recorded in Brazil in 1982, and whilst many countries have struggled to curb the spread of HIV and to care for those with AIDS, Brazil’s response has been seen as a success story. Working alongside civil society groups, the Brazilian government has made aggressive efforts to minimise the impact of the AIDS epidemic. By the end of 2007, 730,000 Brazilians were living with HIV¹ – just over half the number that estimates in the previous decade had predicted.² The AIDS mortality rate has fallen and the number of people who avoided hospital due to to effective treatment saved over US$2 billion in medical costs between 1996 and 2004.³
To understand Brazil’s achievements, the historical context in which they took place must first be acknowledged.

The history of AIDS in Brazil

Although it was first declared a republic in 1889, Brazil spent most of the following century under a series of military dictatorships. It was under the last of these dictatorships, at a time when citizen groups and non-governmental organisations (NGOs) were expanding and becoming more outspoken in their calls for change, that the country’s first AIDS case was recorded in 1982. ⁴ Although relatively few cases of HIV were recorded over the next few years, these civil society groups made sure that the government was quick to act and did not ignore the problem. As the country moved closer to democracy, they encouraged a climate of social solidarity, allowing open and frank debate about HIV and AIDS.

Brazil's AIDS epidemic was initially concentrated in large cities such as Sao Paulo.

“We were living under the dictatorship, so little groups formed but not just political ones. They were responding to larger, deeper issues of repression, with worldwide implications. We were trapped in a symbolic prison; homosexuals had to hide, to live in very closed circles. The right to the body was bound up with the issue of democracy.” Wildenay Contrera, AIDS Prevention and Support Group⁵

In 1985, the same year that democracy was restored to Brazil, the government set up the National AIDS Program (NAP) in partnership with civil society groups. This program initially focused on distributing information about HIV and AIDS, especially to high-risk groups such as men who have sex with men (MSM), who accounted for many of the country’s first HIV infections. ⁶ In the same year, the AIDS Prevention and Support Group (known as GAPA in Brazil) was set up as the first Brazilian HIV and AIDS NGO. By this time, the rate of new HIV infections was rapidly increasing.
Several similar groups were set up in the following years, including Grupo Pela Vidda (‘Group for Life’), the country’s first self-identified group for people living with HIV. Groups such as this put pressure on politicians to improve treatment and care for people living with HIV.

“The important thing was solidarity, full participation by everyone based on respect for differences, fighting for full citizenship, not just for HIV-positive people, but for everyone facing a situation of vulnerability.” Veriano Terto, Brazilian Interdisciplinary AIDS Association (ABIA)⁷

In 1988, a new Constitution of Brazil was established, with a heavy focus on human rights. The Constitution was very significant to people living with HIV, since it included articles that gave them legal protection against discrimination and defended their right to free healthcare. Legal guidelines on how these articles could be applied to people living with HIV were subsequently established, including Legal Opinion CFM No.14/88, which set out ethical guidelines for the management of HIV/AIDS in relation to professionals such as doctors, physicians and researchers. ⁸
Despite such advances, not everyone was happy with the way that the government was handling the epidemic. In a book published in 1993, Herbert Daniel, an HIV positive activist, wrote:

Dinner at centre for People Living with HIV and AIDS.

“To this day the government has taken no significant action in response to the epidemic, continuing the five-year record of inaction and indifference of the previous administration. There is today no adequate national programme for controlling the epidemic.”⁹

By the second half of the 1990s, though, the Brazlilian government was being widely commended for its HIV/AIDS policies, largely due to its treatment programme. An important element of the 1988 Constitution had been the declaration that healthcare was “a right of all and a duty of the state".¹⁰ When trials in 1996 showed that HAART - a form of treatment involving combinations of antiretroviral drugs (ARVs) - had significant benefits to the health of people living with HIV, activist groups in Brazil put pressure on the government to act upon this pledge. In July 1996, the Brazilian Minister of Health announced that ARVs would be provided for free to all people living with HIV that required them. ¹¹
Campaigns to prevent new people becoming infected with HIV were also expanded throughout the 1990s. In the early 1990s, the World Bank had predicted that 1.2 million people in Brazil would be living with HIV by the year 2000. Due to the effectiveness of prevention campaigns, though, the actual figure was around 600,000. ¹²
While the government’s reaction to AIDS has been impressive, the involvement of civil society groups and people living with HIV has been the most outstanding feature of Brazil’s response. These groups have ensured that stigma and discrimination have been reduced; human rights have been taken into account; moral and religious views have not impeded prevention campaigns; and the government has acted swiftly.

Trends in Brazil's AIDS epidemic

At the beginning of the Brazilian AIDS epidemic, most of the people becoming infected with HIV were men who have sex with men. The majority lived in Brazil’s biggest cities, Rio de Janeiro and São Paulo. However, the epidemic soon affected more than just MSM, and by 1993 more cases of AIDS were attributed to heterosexual transmission than homosexual transmission.^{13 14} Among adult males (13 years and over), 17% of AIDS cases were due to heterosexual sex from 1980 to 1995, compared to 35% in 2000 and over 46% in 2007. (The exposure category among 15-20% of male AIDS cases each year is unknown.) Similarly, among adult women, heterosexual sex accounted for nearly 95% of all AIDS cases in 2007 compared with 75% before 1995.¹⁵
From before 1995 until 2007, the share of injecting drug use as the exposure category in new AIDS cases declined from 27.5% to around 10% among adult males, and 21.9% to just over 4% among adult females.¹⁶
At the start of the epidemic, HIV transmission through blood transfusion and blood products was also common. In 1986 HIV blood-screening tests were made compulsory at blood banks in São Paulo, and by 1988 this policy was implemented nationwide, signalling the start of a decline in HIV-transmissions occurring through these routes. ¹⁷
Between 1996 and the turn of the century, the introduction of antiretroviral therapy led to a significant drop in the level of AIDS-related mortality.¹⁸ The number of cases where HIV was transmitted from pregnant mothers to their children also declined in this period, due to the availability of ARVs, which significantly reduce the chances of transmission occurring through this route. ¹⁹
Since 2000, the number of Brazilians living with HIV has stabilised around 600,000. However, the overall AIDS incidence rate has increased, possibly due to the delayed effect of HIV infections in previous years. The rise in AIDS incidence has not led to an increase in the AIDS mortality rate, which significantly declined since the introduction of treatment in 1996 from 9.6 annual deaths per 100,000 people, to 5.1 in 2006.²⁰ It should be noted, however, that the North and North-East regions of Brazil have seen increases in AIDS mortality over the course of the decade.²¹
Although men still account for the majority of infections, women represent an increasing share of the epidemic with the ratio of male-to-female AIDS cases shrinking from 15-to-1 in 1986 to 1.4 in 2006.²² It has become increasingly clear that young people are bearing the brunt of the epidemic, and that poor people and those with a low level of education are at a higher risk of becoming infected. ²³ HIV transmission resulting from contaminated blood products and blood transfusions is now thought to be practically non-existent, ²⁴ and studies in major cities have pointed to a decline in HIV prevalence among IDUs. ^{25 26}

HIV testing in Brazil

TA social worker counsels an HIV-positive woman.

Encouraging people to access testing is an important part of worldwide HIV prevention, as HIV-positive people who are aware of their status are less likely to pass infection on to other people. People who test positive can also be directed towards support and treatment, and be given advice for the future. HIV testing in Brazil either takes place through public health facilities such as hospitals or through centres that provide voluntary counselling and testing (VCT, a process that combines HIV testing with counselling, advice and support). Since the mid-1990s, the availability of ARVs has given people more incentive to get tested and has led to testing becoming more popular and more widely available. Between 1997 and 2002, both the number of VCT centres and the number of HIV tests carried out through the public sector doubled.²⁷
The Brazilian government has used media campaigns to promote universal HIV testing. The central message of these campaigns is that everyone in the country should know their status. One major initiative, known by its slogan ‘Fique Sabendo’ (‘Be in the Know’), enlisted the help of models and other celebrities to promote testing. Before this campaign was unveiled through TV and newspaper adverts in 2003, it was promoted at one of the country’s biggest fashion shows in São Paulo. Models wore t-shirts decorated with the campaign’s logo – a smiling face with ‘plus’ and ‘minus’ signs for its eyes, representing the two possible results of a HIV test. ²⁸ In many countries, such an event would be unimaginable given the stigma and taboo surrounding HIV.
Despite the success of such initiatives, there is still a need for many more people to access testing facilities. It is estimated that only one third of HIV-positive Brazilians are aware of their status, and that just 20% of Brazil’s sexually active population has been tested for HIV.²⁹

AIDS treatment in Brazil

When AZT (one of the first antiretroviral drugs available to treat HIV) was first developed in the late 1980s, small quantities were made available for free in São Paulo state. In 1991 the government announced that it would make the drug available for free to all Brazilians that required it. ³⁰ Although there were a number of problems with AZT, the government’s decision to distribute it universally set the precedent that people living with HIV had a right to receive treatment.
In 1996 HAART was developed, revolutionising HIV treatment. Once again, the drugs were made available for free throughout the public sector. In following years the national AIDS mortality rate began to decline due to the effectiveness of the treatment.³¹ By 2002 the Ministry of Health estimated that the availability of ARVs had prevented around 358,000 HIV-related hospitalisations, resulting in a saving of more than US$1.1 billion. ³²
By the end of 2007, it was estimated that 181,000 people living with HIV in Brazil were receiving ARVs – 80% of those requiring the drugs. ³³ This level of treatment coverage is more typical of a developed nation than a middle-income country such as Brazil.
A major factor in Brazil’s success has been its ability to produce several AIDS drugs locally. Brazil has a large pharmaceutical industry and around 40% of ARVs currently purchased by the government are manufactured domestically.³⁴ Since 1996 Brazil has complied with the international Agreement on Trade Related Aspects of Intellectual Property (TRIPS), which was established to protect the patent rights of pharmaceutical companies. This agreement limits the production of generic drugs that have already been patented in another country. Several ARVs that are produced generically in Brazil were patented before the TRIPS agreement, which means that they can legally be copied. ³⁵

Transport union members educate a truck driver about HIV and AIDS, Sao Paulo, Brazil

However, some of the ARVs required for the Brazilian treatment program have to be obtained internationally. To ensure that these drugs are not too expensive, the government has continually put pressure on international pharmaceutical companies to lower their prices. A major tool in these negotiations has been a clause in the TRIPS agreement that allows developing countries to issue 'compulsory licenses' for drugs. Compulsory licenses allow countries to override patent laws and produce their own generic (copied) versions of company-owned drugs, and can be issued when the government of a developing country deems it to be a public health emergency. Many developing countries are hesitant to actually issue compulsory licenses, because of fears about damaging trade relations with drug companies and governments such as the U.S. who are keen to protect pharmaceutical patents. For years the Brazilian government frequently threatened to invoke compulsory licenses for AIDS drugs, without actually going ahead, and this led to significant price reductions.³⁶

“Brazil’s unprecedented accomplishments in AIDS treatment have profoundly influenced global AIDS and health policy.”

In May 2007 however, the Brazilian President Luiz Inacio Lula da Silva announced that Brazil would be issuing a compulsory license to import a lower cost version of the ARV efavirenz, patented by the company Merck. This followed Thailand's decision five months earlier to break patent for the same drug, along with others. The Brazilian government had previously been in talks with Merck on lowering the price of efavirenz, and although the company had offered to sell the drug at a lowered price, the government argued that these reductions did not go far enough. The Brazilian government estimated that their decision would save them $240 million by 2012, when Merck's patent on the drug expires, and would help them to improve the provision of ARVS.³⁷
As expected, the government's decision to break the patent on efavirenz received a mixed reaction. AIDS activists and many officials involved in the global fight against AIDS applauded the move. Michael Weinstein, president of AIDS Healthcare Foundation, which operates clinics in Latin America, called it:

“A victory for Aids activists and patients everywhere, and proof that drug companies will go down in defeat every time they place themselves in the way of justice for Aids patients.”³⁸

On the other hand, Merck, along with other pharmaceutical companies and business experts, argued that the government's decision was unfair on the patent holder and was likely to discourage investment in AIDS drug research and production. The U.S.-Brazil Business Council called the move:

“A major step backward for the country's development. Brazil is working to attract investment in innovative industries that rely on intellectual property, and this move will likely cause investments to go elsewhere.”³⁹

Brazil has now also begun producing a generic version of efavirenz, and is expected to import a generic version of tenofovir following the 2008 rejection of its patent.⁴⁰
While some criticise the tactics that the Brazilian government has used to get cheaper AIDS drugs, their strategy seems to have worked well so far, and has undoubtedly saved many lives.

"Local manufacturing of many of the drugs used in the anti-AIDS cocktail permits Brazil to continue to control the spread of AIDS. The drugs industry sees this as an act of war. We see it as an act of life." Publicity poster released by the Ministry of Health and civil society groups⁴¹

It has also been suggested that Brazil's strong stance against pharmaceutical companies in its bid to promote access to HIV treatment has greatly influenced treatment provision globally. Thanks to Brazil's public debate about the cost of AIDS treatment, transparency about drug prices has been promoted in other developing countries. The economies of scale that Brazil offered to the generic ARV market encouraged more firms to enter it, thereby increasing competition and driving costs down.⁴² One paper concluded that Brazil's achievements have "profoundly inf luenced global AIDS and health policy".⁴³

Tensions between Brazil and the United States

Among those who criticised Brazil’s treatment campaign for the pressure it put on pharmaceutical companies was the United States government. In February 2001 the U.S. issued a complaint to the World Trade Organisation, claiming that Brazil’s threats to manufacture generic ARVs undermined the intellectual property rights of drug companies. By forcing companies to lower their prices, the U.S. argued, Brazil was discouraging the drug industry from researching and producing new ARVs. In response, the Brazilian government argued that western drug firms could easily afford to reduce their prices. They also pointed out that the vast profits such companies make in richer countries (where patenting laws are more restrictive) provide enough incentive for them to continue ARV production regardless of what happens in poorer countries. The U.S. eventually dropped their complaint, perhaps due to pressure from the United Nations.^{44 45}
Brazil’s HIV prevention policies, such as its focus on condom promotion, have also been a point of dispute. When working with developing countries, the U.S. government generally encourages them to adopt an ‘ABC’ approach to HIV prevention, which promotes abstinence and being faithful to one partner as well as condom use. Although Brazil does incorporate these other messages into its prevention schemes, it has placed a heavy emphasis on condom use and refused to stick to an ABC approach. This has been a source of conflict with U.S. officials. ⁴⁶
On top of this, the Brazilian government's focus on preventing HIV amongst sex workers has clashed with the U.S. policy of refusing aid to any HIV and AIDS prevention schemes that do not explicitly oppose the sex trade. In 2005, the Brazilian government refused the US government’s offer of $40 million funding for HIV and AIDS programs, as it would have required them to state that they are against the practice of commercial sex work.⁴⁷ As Katia Guimaraes from the National AIDS program stated, this was not viable in Brazil:

“Prostitutes are very major partners in this program. They work along with us. We could never say that we are against prostitution, because it is not illegal in Brazil. It’s a tolerated, regulated profession.”⁴⁸

HIV prevention in Brazil

Sexuality and sexual expression are integral to Brazilian culture and are discussed openly. While some cultures associate sex with shame and corruption, many Brazilians see it as something that should be celebrated, and this social climate has made it much easier to carry out HIV prevention work.

“Brazil’s sexual culture is very different from the puritanical tradition in [countries such as] the United States. Our AIDS programs have also been radically different. The denial and the stigma that you find attached to sexual health issues in so many places isn’t found in Brazil” Sonia Correa, Brazilian AIDS activist⁴⁹

Condom use

In 1986 it was estimated that only 4% of the Brazilian population used condoms during their first sexual encounter. By 1999, the level had increased to 48%.⁵⁰ Both female and male condoms have been widely distributed and promoted by the government, and there has been a dramatic increase in condom sales. In 2005, a study of Brazilian adults revealed that 35% used a condom during the previous year, compared with 24% in 1998. ⁵¹ The increase in condom use has not only occurred among the general population, but also among HIV-positive people.⁵²

Condom distribution at the Carnaval de Olinda, Brazil.

The Brazilian government has vigorously promoted the use of condoms through media campaigns, adverts and other prevention initiatives. Around 45 million are handed out a month with more handed out at big events such as carnivals, which are linked with increased sexual activity. During the 2009 carnival season, for example, a further 20 million condoms were distributed.⁵³ Condom use has also been promoted by NGOs working in the favelas (shanty towns), where young people have been educated about AIDS and encouraged to act as ‘information spreaders’, passing information on to their peers. ⁵⁴
Brazil’s aggressive efforts to promote condom use, as part of its fight against AIDS make it the world’s largest importer buying 1.2 billion in 2009.⁵⁵ Furthermore, a state-run factory began producing 100 million condoms a year from Amazon rainforest rubber in 2008. The move was designed to reduce the reliance on foreign imports and to preserve a large area of tropical rainforest.⁵⁶

Media campaigns

HIV prevention messages have been promoted through a variety of media, including television, newspapers and public spaces such as billboards and bus shelters. The messages conveyed by these campaigns are among the most explicit that any government has put forward, causing controversy among some groups. They address issues such as homosexuality, the rights of HIV-positive people, the stigma surrounding HIV and AIDS, and condom promotion. A number of Brazilian celebrities have helped to get these messages across, such as athletes, entertainers and models. For example, in one media campaign, the famous pop-singer Kelly Key tells her teenage audience “Show how you’ve grown up. This carnival, use condoms.” ⁵⁷
Telenovelas (television soap operas) are very popular in Brazil, and have also been used to educate people about HIV/AIDS. The program ‘Malhaçã’, for instance, has featured characters living with HIV and has demonstrated how ARVs should be taken. ⁵⁸

Preventing mother-to-child transmission (PMTCT)

The first recorded case of HIV being transmitted from a pregnant mother to her child in Brazil occurred in 1987. Since then a number of measures have been taken to reduce the rate of mother-to-child transmission (MTCT).

An AIDS reception center for patients.

These include the routine recommendation that HIV-positive mothers do not breastfeed (which can result in HIV being transmitted), the provision of infant formula (a replacement for breast milk) to all children with HIV-positive mothers, the introduction of rapid HIV tests in maternity units, and the routine recommendation to all pregnant women that they should be tested.⁵⁹
The introduction of ARVs in 1996 had a significant impact on the situation, as women who take ARVs during pregnancy are much less likely to pass HIV on to their baby. At the end of 2005, more than half of HIV-positive pregnant women in Brazil were receiving ARVs.⁶⁰ While this means that large numbers of pregnant women are still not accessing treatment, particularly in poorer areas, the availability of ARVs has made a big impact. In São Paulo state, the area of Brazil hit hardest by AIDS, the rate of MTCT fell from 16% in 1995 to 2.4% in 2002.⁶¹ The national rate fell from 8.6% in 2000 to 6.8% in 2004 - a 20% decline - and in 2007 the Operational Plan to Reduce Mother-to-Child Transmission of HIV and Syphilis was launched aiming to reduce the rate even further by 2011 through coordination between the different levels of government.⁶²
For more information on this issue, visit our page on preventing mother-to-child transmission.

HIV prevention with high-risk groups in Brazil

The idea that HIV and AIDS are confined only to certain risk groups - sometimes referred to as the ‘someone else’s problem’ attitude - is misguided and can make people less likely to take precautions against HIV, increasing the risk of infection. In Brazil, as elsewhere, the epidemic affects people from all parts of society. Nonetheless, there are certain groups that run a greater risk of becoming infected than others. HIV prevention campaigns in Brazil have attempted to target these specific groups with information, advice and support.

Men who have sex with men

Civil society groups representing gay men played an important role in Brazil’s initial response to AIDS, and have continued to do so as the epidemic has progressed. Although there is still a lot of stigma surrounding homosexuality, the openness of Brazilian culture has led to a greater tolerance of gay people than is seen in many other countries. The government has supported this tolerance, and has worked to reduce discrimination by carrying out media campaigns and working with NGOs. An example of this is SOMOS, an HIV prevention and care project run jointly by the government and the Brazilian Gay, Lesbian and Transgender Association. SOMOS promotes gay rights and HIV prevention messages. It also provides support to gay men living with HIV. ⁶³
Although the majority of HIV-positive Brazilians become infected through heterosexual sex, men who have sex with men (MSM) still face a proportionately higher risk. The government has estimated that MSM are around 11 times more likely to become infected with HIV than heterosexual people. ⁶⁴

Sex workers

Sex work is not illegal in Brazil and the government has taken an unprejudiced approach to preventing HIV infection among this group. A number of schemes have been carried out, including a high profile campaign based around a cartoon character called ‘Maria without Shame’. Advertised on posters, leaflets and stickers placed in women’s toilets, this character was shown with the message “You need have no shame, girl. You have a profession”. A radio advert featuring a famous Brazilian singer was also broadcast. The aim of this campaign was to improve the self-esteem of sex workers and to encourage them to take care of their health, with an emphasis on using condoms.⁶⁵
Sex workers in Brazil still face many barriers to condom use though, such as fear of violence, increased payment for unprotected sex and competition for clients.⁶⁶

Injecting drug users

Injecting drug users (IDUs) accounted for a large proportion of HIV cases in the early stages of Brazil’s epidemic. This problem escalated during the early 1990s, leading the government to implement widespread harm reduction strategies including needle exchange programmes. Needle exchanges reduce the risk that HIV will be spread through needle sharing by providing IDUs with clean needles. They also offer counselling and information, which can encourage people to stop taking drugs. Such schemes have proved effective around the world and Brazil has been no exception, with studies in major cities indicating a significant decline in HIV prevalence among IDUs since needle exchanges were implemented. For example, the city of Santos saw a 20% decline in HIV prevalence among IDUs between 1998 and 2000. The total number of needle exchanges in Brazil increased from 12 in 1998 to 40 by the end of 2000, with around 150,000 syringes exchanged between 1999 and 2000.⁶⁷ The number of AIDS cases attributable to IDUs dropped dramatically between 1996 (4,814 cases) and 2006 (1,319 cases).⁶⁸
Brazil has also led the way in providing IDUs with access to treatment. Of the 34,000 former and current injecting drug users on antiretroviral therapy in 2004 in 50 developing and transitional countries, 30,000 were in Brazil.⁶⁹

Combating stigma and discrimination

Globally, stigma has widely been recognised as a contributing factor to the spread of HIV. Fear of discrimination stops people going for HIV tests, causes denial in communities (which can lead to prevention messages being ignored) and can prevent HIV-positive people from admitting their status or from accessing medication. The prejudice that people living with HIV face also adds to the emotional strain and suffering that they must deal with.
Brazil is a rare example of a country that has managed to minimise this problem. The human rights movement that emerged in Brazil during the 1980s was active in fighting AIDS-related discrimination, and encouraged the government to protect the rights of people living with HIV. The government has since shown commitment to protecting the rights of marginalised groups who may be affected by HIV and AIDS, such as sex workers, gay men and drug users. It has also been generous with funding to groups of people living with HIV and AIDS, as well as events such as gay pride marches, which encourage people to respect sexual diversity. The fight against stigma has been understood as a central part of responding to the epidemic.⁷⁰
To learn more about the stigma surrounding HIV globally, visit our stigma and discrimination page.

What can other countries learn from Brazil's response to AIDS?

No developing country has had more success in tackling AIDS than Brazil.⁷¹

- The Economist

Brazil has faced (and continues to face) a significant number of social, economic and political problems. Its population is divided by vast inequalities, and in many areas people live in great poverty. In the struggle to overcome HIV and AIDS, though, Brazil has made impressive progress. Close ties between civil society groups and the government, which largely resulted from the struggle for democracy in the 1980s, have ensured that fast, effective action has been taken to stem the spread of HIV. Efforts to treat and care for people living with HIV have also been extensive, and the level of stigma and discrimination facing such people has been minimised. Brazil’s ARV program is comparable to those of more wealthy, developed countries.
It has often been said that Brazil’s mobilisation against AIDS should act as a model for other developing countries to follow. A number of countries have already attempted to follow its example; by 2003 Brazil’s guidelines for treatment and prevention had been adopted by 31 developing countries. ⁷² In the same year, the late Lee Jong-Wook (then head of the World Health Organization) asked the chief of Brazil’s National AIDS Program to visit Geneva to help formulate new policies for fighting AIDS around the world. ⁷³
While Brazil’s response to AIDS must be understood within the context of the social and political changes that have occurred within the country, there are many elements of its success that other countries – both developing and developed – can learn from.
Some major elements of Brazil’s success that could possibly be encouraged in other countries are:

• A strong relationship between the government, civil society groups and NGOs.
• Strong political leadership and will to fight the epidemic.
• A tolerant, non-judgemental approach to HIV prevention.
• A strong focus on condom promotion.
• The provision of free treatment to all, and aggressive efforts to minimise the cost of ARVs.
• A commitment to fighting stigma and discrimination, and encouraging a culture where people living with HIV are not looked down upon, but are actively involved in helping the government respond to the epidemic.

The future of Brazil’s AIDS epidemic

The pattern of Brazil’s AIDS epidemic has changed in recent years. The epidemic is evolving more slowly among men who have sex with men and injecting drug users than before, but its impact on the heterosexual population has increased dramatically. This increase has brought with it an alarming rise in the percentage of women affected by HIV. There is evidence that women are less likely to use condoms when having sex with casual partners than men, adding to concerns that many women do not see themselves as being at risk of becoming infected with HIV. ⁷⁴ Men and women are still divided by gender inequalities in many parts of Brazil, and the subordinate social position of women may be fuelling the large numbers of heterosexually acquired infections that are being seen, by giving women less control over their sexual relationships and allowing men to have multiple partners. The epidemic has also had an increasing effect on poorer members of Brazilian society, and those with lower levels of education. ⁷⁵
Prevention campaigns that target these risk groups need to be maintained and strengthened. It is also important that prevention campaigns continue to target the general population, as the optimism surrounding Brazil’s successes in regards to HIV and AIDS may lead to an increase in unsafe sexual practices in coming years. ⁷⁶
Though Brazil has been very successful in providing HIV treatment to those who need it, particularly through its promotion of cheaper imported and locally-produced generic ARVs, it is facing some challenges in this area. Providing a high level of access to treatment means the overall cost of treatment is rising. In this way, Brazil could be said to be a victim of its own success: more and more people are receiving treatment and living longer thanks to ARVs, and more drugs are being added to its treatment guidelines.⁷⁷ Brazil relies more on locally-produced generic drugs than do other developing countries, when imported drugs are often cheaper, and the cost of manufacturing drugs locally rose in the late 2000s.⁷⁸ However, the challenges faced by Brazil's approach to treatment approach are likely far outweighed by its positive results.
Brazil should take pride in its success, but it is important that complacency does not take hold and that both prevention and treatment programs are sustained and improved.

Sources:

•  UNAIDS 2008 Report on the global AIDS epidemic
• Berkman A. et al. (July 2005), 'A critical analysis of the Brazilian response to HIV/AIDS: Lessons learned for controlling and mitigating the epidemic in developing countries', American Journal of Public Health, Volume 95, No. 7
• Okie S. (May 2006), 'Fighting HIV - lessons from Brazil', The New England Journal of Medicine 354;19

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