In some circles, Brazil is most commonly associated with its colorful and raucous Carnaval celebration, but among those concerned about HIV/AIDS, Brazil is best known for its pioneering antiretroviral treatment program that began in 1996 and now provides treatment to 170,000 Brazilians. Brazil, ranked as a middle income country, is realizing the long-time agenda of AIDS treatment advocates: universal access to life saving medications, free of charge. A new report in the New England Journal of Medicine shows how this famed program is only one part of the Brazilian success story in addressing HIV/AIDS. Government backed, comprehensive HIV-prevention efforts have curtailed the spread of the virus and contained the epidemic, making the treatment program feasible and reducing the impact of AIDS on the country overall.
Brazil 's success with prevention and treatment are inextricably linked. In the context of readily available antiretroviral medications (ARVs), people are less afraid to be tested, those living with HIV/AIDS are less stigmatized, and AIDS is generally more openly discussed. On the other hand, a universal access treatment program would be financially and logistically unfeasible if the numbers of those needing ARVs mushroomed. “What [ Brazil ] did in the early 90s was to really head this epidemic off at the pass. By the time treatment became available, Brazil had already had remarkable success, had controlled epidemic spread, and had a relatively low and stable prevalence,” said Chris Beyrer, an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health, who recently helped to assess Brazil's National STD and AIDS Programme.1
Disseminating accurate information is the starting point for prevention in Brazil. The government and non-governmental organizations (NGOs) have created campaigns and programs to reach every person potentially at risk of HIV infection. These efforts meet people where they are: at the post office, in bars, at home, in brothels, on the bus, in prisons, and at the famed Carnaval. In these venues, mass media campaigns and outreach and education programs raise awareness about HIV/AIDS, promote testing, advertise treatment, and normalize condom use for sexually active people.
The condom use campaigns, in particular, have been criticized by the most conservative elements of Brazilian society. The Brazilian government, however, has been steadfast in putting forth correct information about condoms to dispel the ignorance and myths that hinder correct and consistent condom use. For example, when Catholic leaders made public statements questioning the efficacy of condoms, the Ministry of Health sponsored a poster campaign featuring a goldfish swimming in a water-filled condom. The message: “Nothing Passes through a Condom. Use It and Trust It.” In Brazil, the priority is to craft a message that is effective in convincing a target audience to change its behavior. Explains Emivaldo Sousa, an advertising adviser to the National STD and HIV/AIDS Programme (NAP), “when we put out a mass campaign to talk very explicitly about homosexual relations, we had a huge negative response from the general public but high praise from homosexuals.”2
Not surprisingly, campaigns designed to speak to young people, draw the most ire from social and religious conservatives, including many parents. Although this has had little impact on the ability of the government to run ad campaigns, conservative attitudes held by parents about teenagers and sexuality makes bringing complimentary education into the schools difficult. Only about 45 percent of schools in Brazil currently have sexuality education programs, and only about 17 percent of high schools make condoms available. “It is something that is changing,” said Francois Figueiroa, coordinator of STD and AIDS prevention for the state of Pernambuco. Parents “know that if they don't talk to their kids, they are going to…get sick.” Expanding in-school sexuality education is a priority for NAP.3
This on-going expansion and elaboration of prevention efforts has had a tremendous impact and offers a model for other countries. In the early 1990s, the World Bank predicted that by 2000, 1.2 million of Brazil 's 186 million people would be infected with HIV, yet sentinel surveillance data suggests that only about 600,000 Brazilians are currently infected. The prevalence of HIV infection among Brazilians ages 15–49 years has been stable at .6 percent since 2000, and there have been approximately 25,000 new AIDS cases annually since then as well. Advocates in other middle and low-income countries with similar epidemics are eager to adopt the Brazilian approach. For example, in Viet Nam, AIDS advocates are widely discussing the New England Journal of Medicine article as proof that their country can likewise provide ARVs and adopt a comprehensive approach to prevention.
Brazil offers an example not only of logistics, financing, programming, and messages but also of commitment to policies that support comprehensive prevention based on human rights and public health standards. Most notably, Brazil rejected U.S. assistance in 2005 because officials felt that the U.S. required an approach to prevention “that harms the Brazilian policy regarding diversity, ethical principles and human rights.”4 The criticism stemmed primarily from the focus on abstinence to the exclusion of all other prevention messages, especially for young people, and the requirement that organizations receiving U.S. funds adopt a pledge opposing prostitution—a loyalty oath that undermines the ability to work cooperatively with sex workers to empower that community and reduce risk of infection. In an interview with The Guardian, Sonia Correa, a Brazilian AIDS activist, explained, “the U.S. is doing the same in other countries—bullying, pushing and forcing. But not every country has the chance to say no.”5
- Susan Okie, “Fighting HIV — Lessons from Brazil,” New England Journal of Medicine, 354.19 (11 May 2006): 1977–1981, accessed 6 June 2006, <http://content.nejm.org/cgi/content/full/354/19/1977>.
- “Brazil Refuses $40M in U.S. AIDS Grants To Protest Policy Requiring Groups To Condemn Commercial Sex Work,” Kaiser Daily HIV/AIDS Report, 2 May 2005, accessed 6 June 2005.
- Sarah Boseley and Suzanne Goldenberg, “ Brazil spurns US provisos for AIDS relief,” The Guardian, 5 May 2005, accessed 6 June 2005.