HIV/AIDS in Brazil: Lessons for Policy

AIDS was first detected in Brazil in 1982 in Sao Paulo (Costa-Marques, 2002). Since then, the Brazilian government has become the largest governmental purchaser and distributor of condoms, “importing about a billion of them each year” (Brown University, 2012). Brazil is considered to have one of the most successful policy approaches for HIV/AIDS prevention and treatment, and their progress in addressing the AIDS epidemic is even more remarkable given their status as a middle-income country with a diverse population. Part of their renown is in having defied their odds, as the World Bank predicted in the early 1990s that there would be more than a million people living with HIV/AIDS in Brazil by 2000, but the United Nations AIDS organization estimates that as of 2017 only 860,000 adults and children were living with HIV in Brazil (Greco & Simão, 2007; UNAIDS, 2019). Approximately how many lives have been saved by prevention and treatment efforts is impossible to know. However, it is still certain that Brazil’s investment in their HIV/AIDS response has been instrumental in providing hope and a better future for all.

There are several historical and contextual factors that contributed to Brazil’s remarkable progression in addressing the AIDS epidemic, but policy and programming could not have been implemented without a strong sense of social solidarity. This social solidarity was the result of a civil society mobilization that united many diverse social movements and groups in Brazil (Berkman et al, 2005). The National Program for STDs and AIDS (Programa Nacional de DSTs e AIDS) was established in 1985 in the context of a unified push of “labor unions, universities, women’s rights activists, antiracist activists and NGOs” to create a greater democratic state (Caldwell, 2017, p.147). Largely because of the civil society movement for democracy, the Brazilian government recognizes health care as a “fundamental right of all citizens and a fundamental responsibility of the government,” (Berkman et al., 2005, p. 1167). Recognition of healthcare as a human right was paramount to the formation of HIV/AIDS policy and initiatives that focused on prevention and universal access to treatment. Brazil was ahead of the rest of the world for being the first “developing country to pledge free and universal access” to antiretroviral therapy to HIV-positive individuals, making strides in promoting equity and human rights (Caldwell, 2017, p.146).

Because Brazil’s public health policy approach has been focused on universal access, HIV/AIDS initiatives included methods of prevention and treatment for all Brazilians regardless of class, gender, race, age, or sexuality. Part of what makes Brazil’s HIV/AIDS response unique is their prioritization of prevention, which includes community education, destigmatization of HIV/AIDS in order to encourage people to seek treatment, and an emphasis on condom usage, despite opposition from the Catholic church on condom usage (Murary et al., 2011). Brazil’s human rights perspective is clear in this approach, as it not only reaches the general population but makes prevention and treatment more accessible to those with marginalized identities including women, LGBTQ individuals, and sex workers, all of whom are commonly at higher risk for exposure to HIV/AIDS. Brazil’s innovation and dedication to universal access to anti-retroviral therapies (ARTs) is represented in their successful reduction of treatment costs “by reverse engineering antiretroviral drugs and promoting the production of generics in both public and private sector laboratories” (Biehl, 2007, p.1087). Universal access to ARTs is indispensable not only because it slows the progression of HIV as a form of treatment, but also because it can be used as a prevention method for those at higher risk of exposure to HIV/AIDS (HIV.gov, 2019).

Brazil’s HIV/AIDS infrastructure is organized to incorporate prevention and treatment into accessible resources for everyone. As of 2007, their facilities include “397 accredited hospitals, 79 day-care hospitals, 58 home-care centers and 422 outpatient facilities, 82 lymphocyte phenotyping, 71 viral load laboratories, and 18 genotyping centres” (Greco & Simão, 2007, p. 39). It is by their integrated and innovative approach that Brazil demonstrated to the rest of the world that “a universal and comprehensive prevention and treatment approach is the only adequate strategy to face the epidemic in humanitarian and economic terms” (Abadía-Berreo & Castro, 2006).

Brazil has a long problematic history of inequality, racism, and “oppressive gender relationships,” which cannot be ignored in the discussion of Brazilian HIV/AIDS policy (Berkman et al., 2005, p. 1165). On one hand, this history culminated in citizens coming together in the AIDS crisis to fight for democracy and the formation of the National AIDS Program. On the other hand, while their efforts are worth applauding, it must be acknowledged that social stratification persists in Brazil as a whole and that there are flaws in the system of public health and HIV/AIDS infrastructure. According to Berkman et al.’s critical analysis of Brazil’s response to HIV/AIDS, “the prevention program has not succeeded in stopping increasing rates of HIV infection among the poorest strata of society, particularly poor women” (2005, p. 1170). Additionally, while Brazil did initiate a rather rapid response (relative to national government's typically slow reaction times to impending epidemics), construction of both policy and infrastructure for HIV/AIDS experienced setbacks and has weaknesses that persist to the present. Notably, Brazilian public health officials and policy makers must recognize the need to pursue decentralization from solely state actors and organizations to include civil society participation in policy formation (Costa-Marques, 2002). Leadership should also be wary of the increasing trend towards neoliberal governmentality, which threatens the integration of prevention and treatment access; as policy shifts towards treatment and “biologically-based rights”, social welfare interventions that would also be beneficial to HIV/AIDS prevention should not be left behind (Biehl, 2007, p. 1096). The rest of the world can learn from Brazil’s exemplary response to HIV/AIDS. Brazil shows that both prevention programming and universal access to anti-retroviral therapies are essential to see a reduction in the incidence of HIV/AIDS. Additionally, other governments can learn from Brazil’s innovation in using local manufactures to produce more affordable ARTs, their capacity to use complex therapies, and strategy in creating international alliances (Berkman et al., 2005). It can also be inferred from the Brazilian case that democracy and a focus on human rights is essential to a successful approach to reducing HIV incidence and treating people living with AIDS.

HIV/AIDS posters in Brazil

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References

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