The first

AIDS The HIV, human immunodeficiency virus (HIV) is a retrovirus that attacks the immune system. Without treatment, it can lead to a spectrum of conditions including acquired immunodeficiency syndrome (AIDS). It is a Preventive healthcare, pr ...

case identified in

Brazil Brazil, officially the Federative Republic of Brazil, is the largest country in South America. It is the world's List of countries and dependencies by area, fifth-largest country by area and the List of countries and dependencies by population ...

was in 1982. Infection rates climbed exponentially throughout the 1980s, and in 1990 the

World Bank The World Bank is an international financial institution that provides loans and Grant (money), grants to the governments of Least developed countries, low- and Developing country, middle-income countries for the purposes of economic development ...

famously predicted 1,200,000 cases by 2000, approximately double the actual number that was later reported by the

Brazilian Ministry of Health This is a list of the federal institutions of Brazil: Legislative branch *National Congress, ''Congresso Nacional'' :*Chamber of Deputies, ''Câmara dos Deputados'' :*Senate of Brazil, ''Senado Federal'' * Court of Audit of the Union, ''Tribu ...

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 The global pandemic of HIV/AIDS (human immunodeficiency virus infection and acquired immunodeficiency syndrome) began in 1981, and is an ongoing worldwide public health issue. According to the World Health Organization (WHO), by 2023, HIV/AIDS ...

, including the internationally controversial policies of the Brazilian government such as the universal provision of

antiretroviral drug The management of HIV/AIDS normally includes the use of multiple Antiviral drug, antiretroviral drugs as a strategy to control HIV/AIDS, HIV infection. There are several classes of antiretroviral agents that act on different stages of the HIV li ...

s (ARVs), progressive social policies toward risk groups, and collaboration with

non-governmental organizations A non-governmental organization (NGO) is an independent, typically nonprofit organization that operates outside government control, though it may get a significant percentage of its funding from government or corporate sources. NGOs often focus ...

Prevalence

In 2019, Brazil had 920,000 people living with HIV/AIDS. In 2019, 0.60% of the population had HIV/AIDS. In 2019, there were 14,000 deaths from HIV/AIDS.

History

Brazil's first AIDS case was reported in 1982. Brazil's AIDS response was crafted in 1985, just after Brazil had returned from military rule to democracy, at a time when only four AIDS cases had been reported.Teixeira et al., 2004, S6. 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.Levi and Vitória, 2002, p. 2373Levi and Vitória, 2002, p. 2374. The program was reorganized again in 1992 with more emphasis on linkages between government and NGOs. AIDS Project I garnered $90 million in domestic funds and a $160 million loan from the

between 1992 and 1998. AIDS Project II was funded by of both domestic funds and a World Bank loan totalling $370 million between 1998 and 2002. In 1990—a year when more than 10,000 new cases were reported—the World Bank estimated that Brazil would have 1,200,000 in infections by 2000. However, by 2002, there were fewer than 600,000 estimated infections, less than half the prediction.Ministry of Health of Brazil, 2003.

Government policies

Universal ARV provision

The single most controversial element of the Brazilian HIV/AIDS response remains the free, universal provision of anti-retroviral drugs (ARVs), including

protease inhibitors Protease inhibitors (PIs) are medications that act by interfering with protease, enzymes that cleave proteins. Some of the most well known are antiviral drugs widely used to treat HIV/AIDS, hepatitis C and COVID-19. These protease inhibitors pre ...

, 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.Levi and Vitória, 2002, p. 2378. 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. ART was traditionally considered too expensive in resource-poor settings in

developing countries A developing country is a sovereign state with a less-developed Secondary sector of the economy, industrial base and a lower Human Development Index (HDI) relative to developed countries. However, this definition is not universally agreed upon. ...

, which are believed to have a poor capacity for adherence to complicated treatments. 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.Teixeira et al., 2004, S7. 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.Marins et al., 2003, p. 1675. 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.Marins et al., 2003, p. 1678-1680. The authors conclude that no factor other than ART "could reasonably explain the very large increase in survival observed" between the 1980s and 1996.Marins et al., 2000, p. 1681.

Social policies

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 organization A non-governmental organization (NGO) is an independent, typically nonprofit organization that operates outside government control, though it may get a significant percentage of its funding from government or corporate sources. NGOs often focus ...

s. For example, in contrast to many parts of the world,

condoms A condom is a sheath-shaped barrier device used during sexual intercourse to reduce the probability of pregnancy or a sexually transmitted infection (STI). There are both external condoms, also called male condoms, and internal (female) ...

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.Levi and Vitória, 2002, p. 2375.

Prostitute Prostitution is a type of sex work that involves engaging in sexual activity in exchange for payment. The definition of "sexual activity" varies, and is often defined as an activity requiring physical contact (e.g., sexual intercourse, non-pe ...

groups were involved in the distribution of information materials and condoms.Where Prostitutes Also Fight AIDS
''

Washington Post ''The Washington Post'', locally known as ''The'' ''Post'' and, informally, ''WaPo'' or ''WP'', is an American daily newspaper published in Washington, D.C., the national capital. It is the most widely circulated newspaper in the Washington m ...

'', 2 March 2006 Similarly,

needle exchange programs A needle and syringe programme (NSP), also known as needle exchange program (NEP), is a social service that allows injection drug users (IDUs) to obtain clean and unused hypodermic needles and associated paraphernalia at little or no cost. It i ...

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. HIV prevalence among IDU decreased even more dramatically in some cities. In 1988 comprehensive screening tests were implemented nationwide in

blood bank A blood bank is a center where blood gathered as a result of blood donation is stored and preserved for later use in blood transfusion. The term "blood bank" typically refers to a department of a hospital usually within a clinical pathology labora ...

s, following a similar program in

São Paulo São Paulo (; ; Portuguese for 'Paul the Apostle, Saint Paul') is the capital of the São Paulo (state), state of São Paulo, as well as the List of cities in Brazil by population, most populous city in Brazil, the List of largest cities in the ...

in 1986. The results of these programs were not realized fully until 2000 as a result of the

incubation period Incubation period (also known as the latent period or latency period) is the time elapsed between exposure to a pathogenic organism, a chemical, or ionizing radiation, radiation, and when symptoms and signs are first apparent. In a typical infect ...

of the virus, but new cases from blood transfusion became virtually non-existent at that time and new and more effective

nucleic acid Nucleic acids are large biomolecules that are crucial in all cells and viruses. They are composed of nucleotides, which are the monomer components: a pentose, 5-carbon sugar, a phosphate group and a nitrogenous base. The two main classes of nuclei ...

testing is being considered.Levi and Vitória, 2002, p. 2376. 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 Zidovudine (ZDV), also known as azidothymidine (AZT), was the first antiretroviral medication used to prevent and treat HIV/AIDS. It is generally recommended for use in combination with other antiretrovirals. It may be used to prevent mothe ...

treatment regimes to mother and child and recommendations against

breastfeeding Breastfeeding, also known as nursing, is the process where breast milk is fed to a child. Infants may suck the milk directly from the breast, or milk may be extracted with a Breast pump, pump and then fed to the infant. The World Health Orga ...

.Levi and Vitória, 2002, p. 2377.

International conflict

Drug patents

The average annual cost of ART per patient in 1997 was $4,469—compared to over $10,000 in most of the

developed world A developed country, or advanced country, is a sovereign state that has a high quality of life, developed economy, and advanced technological infrastructure relative to other less industrialized nations. Most commonly, the criteria for eval ...

—totaling only $242 million per annum.Szwarcwald, 2002. However, in 2001, Brazil manufactured locally 8 of the 12 drugs in the national ARV cocktail; in 2003 and 2005, 8 of the 15.Gilman, 2001; Brazilian National STD/AIDS Programme, 2003 If all of the drugs were patented imports, the cost of these ARV programs would increase by 32%. Between 1996 and 2000, Brazil reduced treatment costs by 72.5% through import substitution. By contrast, the price of imports dropped by only 9.6%. Brazil has saved over US$1.1 billion in the cost of providing universal access to ART by producing anti-retroviral medications generically. Article 71 of the 1997 Brazilian patent law requires that foreign products be manufactured in Brazil within three years of receiving a

patent A patent is a type of intellectual property that gives its owner the legal right to exclude others from making, using, or selling an invention for a limited period of time in exchange for publishing an sufficiency of disclosure, enabling discl ...

. 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 A compulsory license provides that the owner of a patent or copyright licenses the use of their rights against payment either set by law or determined through some form of adjudication or arbitration. In essence, under a compulsory license, an i ...

" 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 A monopoly (from Greek language, Greek and ) is a market in which one person or company is the only supplier of a particular good or service. A monopoly is characterized by a lack of economic Competition (economics), competition to produce ...

as well. Prodded by domestic pharmaceutical lobbies, the U.S. challenged Article 68 within the framework of the

World Trade Organization The World Trade Organization (WTO) is an intergovernmental organization headquartered in Geneva, Switzerland that regulates and facilitates international trade. Governments use the organization to establish, revise, and enforce the rules that g ...

Agreement on Trade-Related Aspects of Intellectual Property Rights The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) is an international agreement, international legal agreement between all the member nations of the World Trade Organization (WTO). It establishes minimum standards f ...

(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. Advocates of

intellectual property rights Intellectual property (IP) is a category of property that includes intangible creations of the human intellect. There are many types of intellectual property, and some countries recognize more than others. The best-known types are patents, co ...

(IPR) worldwide condemned the actions of the Brazilian government. For example, Slavi Pachovski, a member of the Institute for Trade, Standards and Sustainable Development, argues: :''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 India, officially the Republic of India, is a country in South Asia. It is the List of countries and dependencies by area, seventh-largest country by area; the List of countries by population (United Nations), most populous country since ...

, with large industrial capacities and evolving intellectual property regimes are the true

elephant in the room The expression "the elephant in the room" (or "the elephant in the living room") is a metaphorical idiom in English for an important or enormous topic, question, or controversial issue that is obvious or that everyone knows about but no one ment ...

. Brazil invoked the Article 71 for the first time on August 22, 2001, when

José Serra José Serra Chirico (; born 19 March 1942) is a Brazilian politician who has served as a Congressman, Senator, Minister of Planning, Minister of Health, Mayor of São Paulo, Governor of São Paulo state, and Ministry of Foreign Affairs (Brazil) ...

, Brazil's Minister of Health, authorized Far Manguinhos—a Brazilian pharmaceutical company—to produce

Nelfinavir Nelfinavir, sold under the brand name Viracept, is an antiretroviral medication used in the treatment of HIV/AIDS. Nelfinavir belongs to the class of drugs known as protease inhibitor (pharmacology), protease inhibitors (PIs) and like other PIs ...

, a drug patented by

Pfizer Pfizer Inc. ( ) is an American Multinational corporation, multinational Pharmaceutical industry, pharmaceutical and biotechnology corporation headquartered at The Spiral (New York City), The Spiral in Manhattan, New York City. Founded in 184 ...

but licensed to

Roche F. Hoffmann-La Roche AG, commonly known as Roche (), is a Switzerland, Swiss multinational corporation, multinational holding healthcare company that operates worldwide under two divisions: Pharmaceuticals and Diagnostics. Its holding company, ...

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 Efavirenz (EFV), sold under the brand names Sustiva among others, is an antiretroviral medication used to treat and prevent HIV/AIDS. It is generally recommended for use with other antiretrovirals. It may be used for prevention after a needlesti ...

, produced by Merck.''

The Economist ''The Economist'' is a British newspaper published weekly in printed magazine format and daily on Electronic publishing, digital platforms. It publishes stories on topics that include economics, business, geopolitics, technology and culture. M ...

''. May 12, 2007. "Brazil's AIDS programme: A conflict of goals." p. 42. The agreements signed on November 14, 2001, at the WTO conference in

Qatar Qatar, officially the State of Qatar, is a country in West Asia. It occupies the Geography of Qatar, Qatar Peninsula on the northeastern coast of the Arabian Peninsula in the Middle East; it shares Qatar–Saudi Arabia border, its sole land b ...

reaffirmed that TRIPs "does not and should not prevent Members from taking measures to protect public health" including "medicines for all." That same year, the

United Nations Commission on Human Rights The United Nations Commission on Human Rights (UNCHR) was a functional commission within the United Nations System, overall framework of the United Nations from 1946 until it was replaced by the United Nations Human Rights Council in 2006. It was a ...

affirmed access to AIDS drugs as a

human right Human rights are universally recognized moral principles or norms that establish standards of human behavior and are often protected by both national and international laws. These rights are considered inherent and inalienable, meaning t ...

unanimously, with the exception of the

abstention Abstention is a term in election procedure for when a participant in a Voting, vote either does not go to vote (on election day) or, in parliamentary procedure, is present during the vote but does not cast a ballot. Abstention must be contrast ...

of the

United States The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic of 50 U.S. state, states and a federal capital district, Washington, D.C. The 48 ...

Prostitution

Two 2003

laws—one related to AIDS, the other to

sex trafficking Sex trafficking is human trafficking for the purpose of sexual exploitation. Perpetrators of the crime are called sex traffickers or pimps—people who manipulate victims to engage in various forms of commercial sex with paying customers. Se ...

—required all recipients of U.S. assistance to sign a pledge denouncing prostitution, even if U.S. funds are not used for projects directly related to prostitution.Phillips and Moffett, 2005. In 2005, Brazil wrote to the

United States Agency for International Development The United States Agency for International Development (USAID) is an agency of the United States government that has been responsible for administering civilian foreign aid and development assistance. Established in 1961 and reorganized in 1998 ...

(USAID) declining to condemn prostitution, effectively rejecting the remainder of a grant for $48 million between 2003 and 2006. In 2006, USAID officially declared Brazil ineligible to renew the AIDS prevention grant because Brazil would not condemn prostitution as "dehumanizing and degrading."Reel, 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 ''Impatiens'' is a genus of more than 1,000 species of flowering plants, widely distributed throughout the Northern Hemisphere and the tropics. Together with the genus ''Hydrocera'' (one species), ''Impatiens'' make up the family (biology), f ...

spp.''", ''maria-sem-vergonha''), a scantily-clad sex worker who encourages prostitutes to take pride in their work and use condoms. Pedro Chequer, director of Brazil's National AIDS Control Programme, was quoted as saying "we can’t control he diseasewith principles that are

Manichaean Manichaeism (; in ; ) is an endangered former major world religion currently only practiced in China around Cao'an,R. van den Broek, Wouter J. Hanegraaff ''Gnosis and Hermeticism from Antiquity to Modern Times''. SUNY Press, 1998 p. 37 found ...

theological Theology is the study of religious belief from a religious perspective, with a focus on the nature of divinity. It is taught as an academic discipline, typically in universities and seminaries. It occupies itself with the unique content of an ...

fundamentalist Fundamentalism is a tendency among certain groups and individuals that are characterized by the application of a strict literal interpretation to scriptures, dogmas, or ideologies, along with a strong belief in the importance of distinguishin ...

and

Shiite Shia Islam is the second-largest branch of Islam. It holds that Muhammad designated Ali ibn Abi Talib () as both his political successor (caliph) and as the spiritual leader of the Muslim community (imam). However, his right is understood ...

" and "sex workers are part of implementing our AIDS policy and deciding how to promote it. They are our partners. How could we ask prostitutes to take a position against themselves?"Just Say Não
, ''

The Nation ''The Nation'' is a progressive American monthly magazine that covers political and cultural news, opinion, and analysis. It was founded on July 6, 1865, as a successor to William Lloyd Garrison's '' The Liberator'', an abolitionist newspaper ...

'', 12 May 2005 Despite the fact that Brazil has the largest population of Roman Catholics in the world, the Brazilian

Roman Catholic Church The Catholic Church (), also known as the Roman Catholic Church, is the List of Christian denominations by number of members, largest Christian church, with 1.27 to 1.41 billion baptized Catholics Catholic Church by country, worldwid ...

has not demanded the

abstinence Abstinence is the practice of self-enforced restraint from indulging in bodily activities that are widely experienced as giving pleasure. Most frequently, the term refers to sexual abstinence, but it can also mean abstinence from alcohol (drug), ...

-only prevention strategies, voicing only intermittent "mild complaints" about government programs which refuse to acknowledge moral or religious issues.

A "Brazilian model"

Brazil's Health Minister,

, said in 2001, "Our example could serve as a model for other countries in Latin America, the Caribbean, even Africa. Everyone in the world has the right to access these therapies." 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.Galvão, 2002 A ''

'' article stated that the Brazilian anti-AIDS program is considered by the United Nations to be the most successful in the developing world, and ''

'' echoed this position: "no developing country has had more success in tackling AIDS than Brazil.

References

* Abadía-Barrero, César Ernesto. (2003). "The Cultural Politics of the Brazilian AIDS Social Movement: A Local and Global Revolution." Latin American Studies Association. * * Brazilian National STD/AIDS Programme. (2003). AIDS Treatment. * * Gentile, Carmen. (2005, June 3).
Brazil Says it will Break AIDS Drug Patents
" VOA News. * Gilman, Susan. (2001).

" TED Case Studies, No. 649, January. * Lawson, Mary. (2004, February). "Brazil — And the Burden of AIDS." ''The Worldly''. * * * Ministry of Health of Brazil. (2001, June). National AIDS Drugs Policy. Brazil: Ministry of Health of Brazil. * Ministry of Health of Brazil. (2002). Brazilian HIV/AIDS Vaccine Plan. Brazil: Ministry of Health of Brazil. * Ministry of Health of Brazil. (2003). Brazilian STD/AIDS Policy. Brazil: National STD/AIDS Programme. * Ministry of Health of Brazil. (2006, March 15). Declaration by the Brazilian Government on harm reduction as a public health strategy, presented at the United Nations Economic and Social Council 49th session of the Commission on Narcotic Drugs. Brazil: Ministry of Health of Brazil. * * Novaes, Hillegonda Maria Dutilh, Luna, Expedito J. A., Goldbaum, Moisés, Kilsztajn, Samuel, Rossbach, Anaclaudia, Carvalheiro, José de la Rocha. (2002).
The Potential Demand for an HIV/AIDS Vaccine in Brazil
" World Bank Policy Research Working Paper 2940. * * Oxfam GB. (2001, May).

" * Pachovski, Slavi. (2005, June 16). Remarks at the National Press Club.
The Future of U.S.-Brazil Trade Relations I the Shadow of Brazil’s Piracy of American Intellectual Property
" * ''Pan American Journal of Public Health''. (2001). "Brazil fights for affordable drugs against HIV/AIDS." 9 (5): 331–337. * Phillips, Michael M., and Moffett, Matt. (2005, May 2). "Brazil refuses U.S. AIDS funds, rejects conditions." ''Wall Street Journal''. * Reel, Monte. (2006, March 2). "Where Prostitutes Also Fight AIDS." ''Washington Post''. p. A14. * Szwarcwald, CL. (2002). "The impact of national production of ARV drugs on the cost of ARV therapy in Brazil, 1997-2000." Presented at the XIV International AIDS Conference. * Schwartz, Karyn. (2001).
Brazil: A Model Response to AIDS?
" ''NewsHour''. * Teixeira, Paulo R. Vitória, Marco Antônio, and Barcarlo, Jhoney. (2004). "Antiretroviral treatment in resource-poor settings: the Brazilian experience." ''AIDS'' 18 (suppl 3): S5-S7. * Wadia, Roy. (2001, August 16).
Brazil’s AIDS policy earns global lauds
." CNN.

Notes

External links

AIDSPortal Brazil page
{{DEFAULTSORT:HIV AIDS in Brazil