Pragmatism Helps Slow AIDS

Brazil 2001

By Trudy Rubin

June 09, 2009

Instead of debating for three days in New York over what to do with the money in an international AIDS fund, this week's special United Nations assembly on AIDS should have met in Brazil.

Brazil is the only developing nation that has found a successful formula to combat the AIDS menace. In 1994, the World Bank projected that Brazil would have 1.2 million HIV-positive cases by 2000, but the rate seems to have stabilized at about half that number. Unless the Brazilian strategy is broadly adopted, neither cheaper drugs nor higher contributions to the newer U.N. AIDS fund will check this plague.

So what have the Brazilians learned?

Talks with Brazilian Health Minister Jose Serra, officials of the national AIDS program, and doctors at an AIDS clinic in Brazil's largest city, Sao Paulo, quickly focus on three key principles.

Principle one is committed political leadership from the top down, starting with President Fernando Henrique Cardoso. "It was very important that we had the support of the politicians," explains Rosemaire Mumhoz, an expert on AIDS prevention who advises the Ministry of Health in the capital, Brasilia. Compare this to South Africa, where President Thabo Mbeki still doubts HIV causes AIDS and prevention lags because of his lukewarm commitment. Or Kenya, where President Daniel arap Moi blocks AIDS prevention. Africa's most successful AIDS-prevention program is in Uganda, where President Yoweri Museveni has personally led the campaign.

Principle two is the heavy involvement of civic and community organizations, which are essential for reaching the poor and helping them take the complicated regimen of drugs. "Our cooperation with NGOs [nongovernmental organizations] is really extraordinary," Serra says.

At the spanking-clean Center for Reference and Training, an AIDS testing and treatment clinic in crowded Sao Paulo, the director, Dr. Artur Kalichman, talked about how NGOs help in reaching high-risk groups. "We work with NGOs which are accustomed to working with the homeless and know how to get them to take their medicines. We work with NGOs linked with the gay movement."

Such civic groups, he says, are more willing than conventional health workers to distribute "Kama Sutra cards" with images of safe sex to saunas frequented by gays, or materials with pictures rather than words to poor illiterates in the slums.

A special Brazilian quality that helps make HIV-AIDS treatment easier is an openness to talking about sex. This contrasts with many African countries, where admitting to having HIV-AIDS is still taboo, and sex education in the schools is forbidden. Education on sex and AIDS in Brazilian schools starts at 12. Packs of condoms appear in Rio hotels alongside the peanuts.

"We deal with sex, drugs, and rock and roll [at the clinic] all the time," says Kalichman wryly. "If we couldn't deal with differences it would be tragic." A transsexual named Greta, with long hennaed hair, who works as an on-stage impersonator of Ann-Margret, pops up from a line of waiting patients to talk about how free AIDS drugs for the last two years have given her back her life.

Which leads to Brazilian principle number three: cheap medicine to treat AIDS patients. Brazil has distributed the AIDS cocktail free to any needy person since 1997. This is possible because Brazil produces cheap, generic versions of several antiretroviral drugs - and because Brazil is a rich poor country. But even if global drug prices drop, Brazil could not deliver the drugs if it didn't already have a good public-health network.

"If a country has a public health system . . . it can copy Brazil," says Dr. Mylva Rossi of the Sao Paulo clinic, who just returned from Botswana to consult on the Brazilian model. "African countries don't have such a public health system, so their challenge is bigger than ours."

So here's the catch. In poorest Africa, where the number of HIV-AIDS cases is hugely higher than in Brazil, the health system is sketchy and the Brazilian model may be out of reach. But it could work in Latin America, in India, in urban South Africa. And Brazilian specialists are ready to consult with poorer African nations on how to distribute cheaper AIDS drugs in a more limited way.

In the meantime, hard-hit African nations can adopt Brazil's first two principles of top-down, bottom-up leadership to push prevention and develop a health network. Without such leadership, no amount of cheap drugs will do any good.