Fighting against AIDS

Introduction Brazil was among the countries to be the earliest and the most intensely affected by the AIDS epidemic. After the first AIDS case was reported in 1982 1 new cases sky-rocketed to more than 10 000 in the beginning of 1990 2. In that year, the World Bank estimated that Brazil would experience 1 200 000 HIV infections by the year 2000, explicitly expressing the fear that the epidemic would then be totally out of control. However, a recent estimate by the Brazilian Ministry of Health (MoH) has reduced that number to under 600 000, and all AIDS-related figures are much more encouraging than anticipated a decade ago. The objective of this article is to review the actions taken that have prevented the above expectations. General aspects Table 1 summarizes the Brazilian response to the AIDS epidemic. The fight against the disease set the stage for a new kind of interaction between state and society. Whether addressing the rights of those living with HIV/AIDS, or fighting against prejudice, discrimination and social isolation (often rooted in personal views towards sexual behaviour) social movements and organizations drastically changed the relationship between the public and private sectors to make them both more collaborative and more participative. Importantly, the Brazilian experience with HIV/AIDS has contributed substantially to stronger democratic institutions, to a greater recognition of all Brazilians as citizens, and to an open debate on the ethics of national healthcare. In this regard, Brazil was one of the first countries in the world to establish in 1988 ethical guidelines for the management of HIV/AIDS, and these guidelines were the standard for all physicians in the nation 3. Table 1: Characteristics of the Brazilian response to the AIDS epidemic. At the onset of the epidemic, however, most government agencies were both in denial of the severity of the problem and reluctant to respond to the needs of the new epidemic. Civil pressure and the growing number of cases ultimately mandated more effective federal intervention. In May 1985, the MoH established the guidelines for the creation of the National AIDS Control Program (NACP) of Brazil. At that time, governmental activities focused on epidemiological surveillance, medical assistance, and the release of non-discriminating and prevention messages to patients and the general public. Funding was scarce, though. As of 1986, the NACP was consolidated with the inclusion of sexually transmitted infections as the centre of action. The AIDS/sexually transmitted diseases (STD) approach grew increasingly more pragmatic and technical, and counted on increasing international cooperation. In 1987, the National AIDS Control Committee of Brazil, made up of scientific community representatives as well as organized civil society members, was created to act as the focus for a social and political approach towards the epidemic, with the intent of involving Brazilian society as a whole, and to somehow get Brazil ‘up to speed’ after the period of denial of AIDS treatment in the early 1980s. After some delays in the early 1990s, the NACP was reorganized in 1992: links with civil society and with other areas in government were formed, and key agreements were established with other countries and international institutions for technical cooperation with Brazil. Fig. 1 shows the organization of the National AIDS Program in the MoH, its location in the Secretariat of Health Policies, and its structure as of July 2002. Fig. 1.: Position of the National AIDS Program in the Ministry of Health of Brazil and its structure, July 2002. MSM, Men who have sex with men; NGO, non-governmental organizations; STD, sexually transmitted diseases. In 1992, a loan agreement with the World Bank was signed to support prevention and control activities. The agreement, called AIDS Project I, was effective between 1992 and 1998, with funding reaching US250 million, of which US160 million comprised the loan and US90 million was derived from domestic contributions. AIDS Project II followed, effective from 1998 to 2002, with funds reaching US300 million. As of 1992, after a specific and financially more attractive payment system was implemented for the hospitalization of AIDS patients, the MoH established procedures for the accreditation of public hospitals, and expanded the hospital network for the care of HIV-infected patients. With the creation of the Alternative Assistance Program, professionals were trained in HIV care and funds were transferred to state and municipal governments to assist patient care at different need levels. As a result, outpatient assistance services, day-hospital services, and home care services were established. Multidisciplinary teams that served the needs of both patients and their families typically provided these services. It should be pointed out that the expansion of outpatient units and day-hospital services proved cost-effective when compared with pre-existing inpatient services for individuals with HIV/AIDS. With time, this framework expanded and improved. By March 2002, the NACP already comprised 375 accredited hospitals, 79 hospitals with day clinics, 53 home care service agencies and 381 specialized outpatient services, covering practically the whole of Brazil 4. Prevention Key targets were identified for the prevention of infection: the promotion of HIV testing; promotion and education on condom use; the provision of disposable syringes; increasing the availability and provision of incentives for pre-natal testing, and the prevention of other STD. Priority messages were: `Consistent condom use is the safest way to prevent HIV/AIDS and other sexually transmitted diseases'. `Syringes and needles must not be shared'. `Every pregnant woman must be informed that she must be tested for HIV. If HIV-positive she is entitled to treatment as recommended to prevent HIV transmission to the baby before, during, and after delivery'. `Every citizen must be entitled to free access to antiretroviral therapy (ART). Effective compliance with treatment is key for prevention and control, with direct, positive impact on the life of HIV/AIDS patients'. These messages were spread through a number of informational/educational campaigns. During the ‘Carnaval’ periods between 1994 and early 2000, 35 campaigns were broadcast on radio stations, at movie theatres, on TV, on billboards, and through magazine print-ads. Many addressed the entire population; some focused on specific targets: injection drug users, people already infected, truck drivers, women of childbearing age. Carnaval and World AIDS Prevention Day were targeted for focused preventative campaigns. In 2002, the first campaign was launched focusing on homosexual men, because cases reported in that population, especially among young homosexual men, are now increasing after a long period of decreasing incidence. The campaign will focus not only on the use of condoms for sexual intercourse, but will also aim at making health and education professionals more open and more aware, so that they can play key roles both in the prevention of STD and AIDS and in the fight against prejudice based upon sexual orientation. Condom use A 1986 study showed that only 4% of the Brazilian population used condoms during their first sexual encounter. In 1999, that rate had increased to 48% 5. This increase was caused both by greater population awareness, and also by the more affordable price of condoms, and greater availability of free condoms. Fig. 2 shows the increase in men's condom sales in parallel with the approximately 50% decrease in the cost per condom between 1996 and 2000 6, 7. In addition, the MoH increased its acquisition of condoms fourfold between 1999 and 2000, reaching 200 million units acquired in the year of 2000 8. Fig. 2.: Cost of condoms and total sales in Brazil, 1996–2000. ░ Condom sales; –♦– average price. Needle exchange Another important intervention was the implementation of syringe and needle exchange. Between 1994 and 1998 only 12 projects were implemented; this number increased to 40 by the end of 2000, with a total exchange of 1 500 000 syringes in the period 1999–2000. The initial results, analysed in two major cities covered by the programme, were encouraging, with a reduction in the incidence of HIV prevalence in intravenous drug users from 63 to 42% in one city in 7 years, and from 50 to 7% in 4 years in the other. These findings stimulated the MoH to increase the number of cities with this type of intervention in the future. Blood testing In the early days of the epidemic, HIV infection through blood and blood products was common in Brazil 9, 10 (Fig. 3). In 1986, São Paulo, the state most affected by the epidemic, made HIV screening tests compulsory at all blood banks. By 1988, screening tests were compulsory nationwide. Initially, first generation enzyme-linked immunosorbent assay tests were used. Currently, two third-generation enzyme-linked immunosorbent assay tests are used, and blood components with a single positive test are discarded. Confirmation for the purpose of donor notification and counselling is provided by Western blot. Fig. 3.: AIDS cases reported in the haemophilic/transfusion subcategory. These policies had a demonstrable impact on HIV transmission by blood and blood components. As a result of the long incubation period, the number of new AIDS cases in this subcategory remained high for a decade; by 2000, the cases acquired by transfusion were rare 9, 10 (Fig. 3), and now we believe that this form of transmission is practically non-existent. Even so, in an attempt to reduce even further the risk of possible transmission in the window period, there are plans to implement nucleic acid testing at blood banks in the near future. Heterosexual transmission: HIV-infected women In Brazil, as in other parts of the world, the steady increase in HIV/AIDS incidence through heterosexual exposure has had an enormous impact on women: the male: female ratio, which in 1985 was 28: 1 reached 4: 1 in 1992, and in the most recent 5 years has been 2: 1. Among individuals aged 15–19 years the male: female ratio is now 1: 1 11. Because of both biological and cultural vulnerability, women, who originally accounted for fewer than 5% of all AIDS cases reported in Brazil, now account for 30% of current cases, with more than 90% of all women's cases diagnosed in the past 10 years 12. During this time, the incidence among women, which in 1992 was 0. 03 cases per 100 000, now stands at 5. 41 cases per 100 000, reflecting an annual rate increase of 0. 53 cases per 100 000 women a year 13. Mother-to-child transmission Among over 40 000 women with AIDS, 80% are of childbearing age, most are concentrated in the 25–39 year age group 14. As nearly all paediatric cases reported in the past 10 years result from mother-to-child transmission, AIDS reports for children have been increasing, paralleling women's cases until 1997. In the year 2000, it was estimated that the number of individuals in the 0–14 year range living with HIV/AIDS was approximately 13 000 15. By 1997, with the implementation of zidovudine-based prophylaxis to prevent perinatal HIV transmission, as per AIDS Clinical Trials Group Protocol 076 findings, perinatal HIV transmission rates in Brazil have diminished. Mother-to-child transmission case incidence, which in 1997 reached 3. 6% of cases for all categories, shows the same trend (Fig. 4) 10, even if data from 2000 have not been closed yet, and the final numbers may still increase and indicate a less marked reduction. Fig. 4.: AIDS cases reported in the perinatal category after 1997. This decrease has been observed even with zidovudine monotherapy, despite the poor provision of proper prenatal care: between 1995–1998 an estimated 17% of pregnant women received appropriate treatment as recommended by the NACP. In recent years, however, there has been some improvement: in the first half of 2000 there was a 78% increase in the number of pregnant women who received intravenous zidovudine during delivery 16, although percentages for the country as a whole are still low. Pregnant women The prevalence of HIV infection in pregnancy is estimated to be between 0. 4 and 0. 6% 15, 17. The MoH promotes counselling and volunteer testing for all pregnant women, and ensures that treatment will be provided for those found to be HIV positive. A remaining obstacle is that approximately 40% of HIV-infected women reach delivery without having had proper prenatal assistance. In an attempt to remedy this situation, the MoH has recently acquired 300 000 rapid HIV test kits that will permit the detection of the virus and treatment of the mother with zidovudine immediately upon presentation during delivery and of the newborn after delivery. Early detection of perinatal infection has also substantially changed the natural history of paediatric AIDS, resulting in both decreased mortality and also an improvement in the quality of life for the children's families. The survival of parents has saved thousands of children and teenagers from being orphans; this alone represents social gains that by far outweigh the cost of the programme. The strategy used by the government has curbed medication costs. Expenses for the three phases of the AIDS Clinical Trials Group Protocol 076 regimen (zidovudine to the mother, orally during pregnancy from the 14th week on and intravenously during labour, and to the newborn orally for 6 weeks), for example, has fallen to US208 in 2000, from US662 in 1996, a decrease of 69% 16 This saving permits the allocation of funding to replace breastfeeding, as well as other activities that are crucial to reach the successful results planned. These activities include: educational programmes for pregnant women and the public, through courses, print-ads, videos, radio and and technical for health prenatal care and care for or In a recent of these is recommended for pregnant women, based on and With the current against breastfeeding, as well as for mother-to-child transmission rates are to as has been the case in It is to out an of the impact of of these actions on the epidemic in Brazil, because other as access to antiretroviral therapy have also had a impact on the epidemic. However, data indicate that the in the epidemic was reduced by these (Fig. of new cases and prevalence of AIDS in Brazil, per year, society organization of the to the successful Brazilian response to AIDS was social individuals were the first to non-governmental organizations to fight the epidemic. HIV-positive individuals and individuals with AIDS prejudice at the to all of and for their on the in the and at public health assistance civil group and community and in these and by the year 2000, the number of in the fight against AIDS in Brazil was nearly These organizations as for HIV-positive and individuals by educational programmes and support for patients who have been from society. care to children who are AIDS orphans; assistance. focus on the of and civil these have been as of their is not they are and and was recently when Brazil to make HIV more The of Brazilian was of the of the in to between them and the Brazilian In recent years, those were and consolidated when the NACP established in specific population as their The were then to with institutions and served as effective between them and the As a result of these in the period between and 1997, approximately million was to community projects out by NGO, the of infection prevention and public assistance the At the with the MoH number In the past years, projects have from their support Table The focus now is on the of the with that of state and municipal of organizations in Brazil by the Ministry of Health in the period therapy the the approach towards HIV/AIDS patients was to the treatment of By 1988, the MoH had in a to public health network with some of the used for that By was also made However, in the period when only or treatment with was patients in Brazil were over 000 patients were being as of the end of In that year, with the of more effective for patients but more for physicians to It was at that that two crucial in 1996, federal mandated the free provision of through the public health and the Committee was This group of was to a year, to and guidelines and on and them as At the time, guidelines that should be to with AIDS-related or a of 200 or is also when the is between 200 and if the patient is to treatment and it It is important to that the Committee with total from the MoH, and its guidelines are by scientific and In years, all in Brazil increasingly At the different and different A regimen is three but those already therapy with a response are to to their current As of 2000, 78% of patients were were and were antiretroviral (Fig. different antiretroviral therapy in between 1997 and antiretroviral two one two one two therapy in Brazil by the Ministry of Health in the number of public health system patients being increased to 000 in This represents approximately of patients under treatment in Brazil. and free access to treatment to increased for the NACP. high for a single disease million in have not nearly the of the programme, but to government intervention to reduce the of medication and the of medication as a of the total cost of AIDS patient the in medication were under control by MoH in Brazilian which 50% of all used in the Fig. shows the impact of that In addition, the government successful price with of of for example, for and of domestic on the cost of antiretroviral therapy in Brazil, cost of antiretroviral therapy treatment per –♦– cost per result was a 48% annual cost reduction per patient from in 1997 to in As in Fig. the cost per from in 1997 to in for these price would have reached levels. If in Brazil had remained at or as of the year 2000, the total would have been million or million, of million. in to of the high allocation of AIDS as a of total government total in were of the MoH total less than of domestic the proper of the of it is important to that control of HIV infection results in in other AIDS as outpatient and day-hospital assistance, for and other more to as from for patients and and for public assistance to children who would have been not the mortality rate reduction has been Fig. shows the mortality rate in Brazil with a reduction after 1996, when With to hospitalization the MoH that in the period between 1996 and the average per patient per year from to with 000 having been and resulting in of more than were also on treatment for Fig. shows the number of annual cases in São Paulo, of the most infection in Brazil In the period between 1996 and a reduction was reported for new patients. The most reduction of in with the first availability of AIDS in Brazil, cases of in HIV-positive in the of São Paulo, after availability of antiretroviral cases of disease and in HIV-positive individuals at the of after availability of antiretroviral with of the of other infections was Fig. shows the number of new cases at the of Day in São that the HIV/AIDS assistance in the of and for the period the reduction in new cases is data for the country that as early as a reduction in for infection was and for the was Another of cost reduction by is in the use of at the of In 1996, were used, and in this number to even more patients were being at that at the personal Even the to care for individuals with HIV/AIDS, from a of the of and free has been by the in AIDS care costs. network the government to to all citizens, it was to a network of to and At the time, public were of was not to the anticipated The MoH implemented an to have for the tests the A network for and for were with for and the provision of immediately as which and to with between and the with which a network had to be established. are units and most with in Brazil. quality control was also both as a and also as a result of international cooperation. the first have been taken towards a network for are already and three are being As only tests have been the is to patients their first as an of the greater than 0. 5 from or between two This is also by the that screening and can only be by professionals who are accredited by the national for and results results are provided to with for based on the With to HIV the MoH now is that rates are still to the high that would be for an study recently individuals a of transmitted drug in the that may are that the of experience will to other in their fight against AIDS, and may to reduce the marked in the AIDS-related mortality rate between Brazil and other countries with that are affected by the epidemic (Fig. experience is most to be in cultural and to Brazil to However, we to make it that we not a country must its response in of its and social and cultural This is a in which are AIDS estimated in ░ Brazil. The Brazilian experience however, that if there is political involving and civil society even in countries by AIDS can be and its expansion there is A way is up as The are to and for their and for their with the for the for in the of the for and general and for in the of this