Battling AIDS in Brazil: A message of hope

An upbeat conference on AIDS?

Hard to imagine, unless you’d attended “The Brazilian Response to AIDS” on March 22, sponsored by the David Rockefeller Center for Latin American Studies.

True, Brazil has had its share of AIDS deaths, but they are far less than expected in the early days of the epidemic. In the early 1990s, the World Bank predicted that by the year 2000, there would be 1.2 million people in Brazil infected with HIV. But by 2005, there were only 600,000 infected, and the death rate from AIDS has been stabilized at 6.3 per 1,000. Moreover, people living with AIDS receive far more effective, compassionate, and consistent care in Brazil than in almost any other country in the developing world.

At the daylong conference, a group of scholars, students, and health workers presented their views on why Brazil has been so successful in dealing with this devastating disease.

One reason for the country’s success is its frank and open attitude toward sexuality, a cultural feature to which several presenters alluded.

John David, a professor emeritus at the Harvard School of Public Health (HSPH), described his efforts to distribute condoms in Salvador, the capital of the Brazilian state of Bahia. Starting in 1996, he worked with a nongovernmental organization (NGO) to give away free condoms during Carnaval. The project enjoyed a high degree of acceptance.

“That first year, we were mobbed. It was as if we were handing out ten-dollar bills,” he said.

With help from the Brazilian government, the program eventually raised its distribution total to a million condoms annually. Groups such as the musical and cultural organization Olodum helped to publicize the program, while the need for safe sex was reinforced by a series of explicit and imaginative posters.

“Attitudes toward sex are very different there,” David said. “Where else do you see huge posters telling people to wear condoms?”

He added that not even the Catholic Church had anything negative to say about the program.

“Yes, we are culturally more open to discussing sex. This is real,” said Paulo Teixeira, former director of the STD/AIDS Program in the Brazilian Ministry of Health. “The Church in Brazil has been very important in the fight against AIDS, including the distribution of condoms.”

Sofia Gruskin, an associate professor at HSPH and director of the Program on International Health and Human Rights, said that Brazil’s success in fighting AIDS is due in large part to the excellent working relationships that have evolved among activists, researchers, and the government.

“Brazil has a strong research community with strong connections to the government, as compared with the United States, where we have a strong research community and a strong government, but the ties between them are not strong.”

This collaborative atmosphere has allowed Gruskin’s work in Brazil to flourish and to positively impact public policy.

While Brazil’s public health response to AIDS was earlier than that of most societies, it appeared that women were being underserved. Gruskin and her colleagues conducted a survey to try to get to the bottom of this problem. One of their key findings was that services for women and children were not in the same location.

Faced with limited time and transportation, many women were choosing to bring their children for treatment while ignoring their own needs. Based on recommendations by Gruskin and her colleagues, public health authorities have begun bringing the two services together, with positive results.

Gruskin’s research has also led to better services for adolescents and for children orphaned by AIDS.

Bringing down the cost of expensive AIDS drugs is another key factor in Brazil’s struggle against the disease. Amy Nunn, a recent HSPH graduate, now manager of corporate relations at the Global Business Coalition on AIDS, Tuberculosis and Malaria, spoke about Brazil’s use of compulsory licensing as a tool in negotiating lower prices on AIDS drugs.

Under compulsory licensing, the government invokes a state of emergency as a pretext to permit local companies to produce generic versions of a patented drug. By wielding this threat, Brazil has not only negotiated lower prices for itself, but has also “had a tremendous impact on global drug costs,” Nunn said.

These negotiations have allowed Brazil to save about $1 billion on AIDS drugs and has enabled the country to make good on its 1996 resolution to make medical treatment for AIDS free and accessible to all citizens.

David Martin ’07, who did his senior honors thesis on Brazil’s response to AIDS, spoke about the role of civil society in the country’s efforts to come to grips with the disease. He credited the many NGOs working against AIDS in Brazil with helping to bring treatment to marginalized groups and people living in remote areas.

Martin described an interview with a woman living with AIDS who had lost her job and been abandoned by her family and as a result became severely depressed. Her life began to take a turn for the better, however, after she became associated with a group called Gestos.

“The medicines saved my body,” she told Martin, “but Gestos saved my life.”

Varun Gauri of the Developmental Research Group of the World Bank considered various explanations for Brazil’s response to AIDS, which was quicker, more effective, and more generous in its investment of resources than that of almost any other country.

He compared Brazil’s experience with that of South Africa, both of which managed to throw off oppressive regimes around the beginning of the AIDS epidemic (Brazil ended its military dictatorship in 1985 and South Africa began dismantling its apartheid policies in the early 1990s). South Africa, however, has faced great difficulties in dealing with its AIDS epidemic.

The difference, Gauri suggested, is that South Africa is still affected by the strict racial policies that characterized its society for so many years, while in Brazil racial boundaries are far more porous.

“If you think there’s a strong ethnic boundary and the groups don’t mix, you’ll be more likely to think it’s the other group’s problem, not yours.”

Surveys have shown that people in South Africa are twice as likely to object to having a neighbor with AIDS as are people in Brazil, Gauri said.

Teixeira delivered the keynote address, providing a synopsis of Brazil’s struggle against AIDS. The basis for Brazil’s public health record, he said, stems from article 196 of the country’s 1988 constitution, which states that health is the right of all. The attitude underlying this law was what allowed Brazil to attack the problem early.

“The numbers were low in the beginning, but the population saw it as a tragedy that could not be tolerated,” he said.

As a result, the number of those dead from AIDS has been less than 50 percent of what was predicted, while early intervention and treatment policies have saved an estimated $2 billion in hospitalizations. Prevention programs have increased condom use by about 80 percent, and about 70 percent of Brazilian schools now provide AIDS education and free condom distribution.

On the other hand, the price of AIDS drugs, held at affordable levels for many years, has begun to rise, which Teixeira sees as a cause for concern.

“These statistics show we’re on the right path, but our response to the disease still needs improvement,” he said.