Ministry of Health

Health Surveillance Secretariat

NATIONAL STD/AIDS PROGRAMME

National Response to HIV and AIDS in Brazil

• Population - 169.799.170 (2000)• GNP per capita: US$ 2569 (2002)

• ACCUMULATED AIDS CASES (2003): 310,310

• AIDS INCIDENCE RATE (2002): 12.8/100,000

• ESTIMATED N. OF PEOPLE LIVING WITH HIV (2003): 600,000

• PREVALENCE: 0.65% (15 to 49 years of age)

• AIDS DEATHS (1980-2002): 149,559

• MORTALITY RATE: 6.3/100,000 (2002)

BRAZIL

11146,000 (on ARV)

146,000 (on ARV)

89,000 (without ARV)

89,000 (without ARV)

365,000(majority don’t know they are HIV+)

235,000 (being monitored)

Brazil600,000 PLHA

BRAZILTrends of the epidemic

• Stabilization

• Heterosexualisation

• Feminisation

• Pauperisation

• Interiorisation

InteriorisationMunicipalities with at least one AIDS case Brazil, 1980 - 2004.

1980-1987

1988-1994

1995-2004

Fonte: PN DST e AIDS – SVS - MS.

Pauperisation% Aids cases over age 19 X schoolingBrazil, 1985 - 2002.

85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 020%

20%

40%

60%

80%

100%

3º Grau 2º Grau 1º Grau Analfabeto

Annual mortality rate by sex. Brazil, 1984 – 2002.

Source: Brazilian STD/AIDS Program

0

2

4

6

8

10

12

14

16

84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02

year of death

per

10

0,0

00 i

nh

ab

.

men women Brazil

Characteristics of the Brazilian Response• Early government response - since 1983

• Strong participation of civil society in all decision levels

• Multi-sectoral mobilization

• Specificity of Brazilian culture

• Balanced approach between prevention and treatment

Human rights perspective in all the strategies and actions

Source: IPEA/2001

295,0

394,8

595,5

445,9359,9

243,2

44,6

41,0

44,2

57,2

41,4

30,7

1997 1998 1999 2000 2001 2002

Year

0

100

200

300

400

500

600

700

(US$) Million

Federal

WB

Distribution of Public Resources in external

source WB* and Government source.

Health Promotion and Prevention

• Promotion of human rights

• Implementation of major national media campaigns

• Prevention actions for general population and specific groups

Early diagnosis of HIV infection

• STD diagnosis and treatment

Health Promotionand Prevention

Access to condoms 700 million / year

1317

2013

3839

80126

148

260 Progressive increase of Public Distribution (20x)

Steady growth of Market sales (3x)

152186

227267

325373

430497

548

700Growth trend of condom use (4.6 x)

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

139 169 207 254 287 334 350 371 400 440

Condom use (in millions of units)

Sources: DKT and PN-DST/AIDSMarketed Public Distribution

Adoption of Safer Sex practices (1998 - 2003)

Source: (1) CEBRAP/MS/PN-DST-AIDS/SVS

(2) MS - IBOPE

Use of condom in last sexual intercourse

With occasional partners (%) With regular partners (%)

64

79,5

1998

2003

0 20 40 60 80 100

21

20,2

1998

2003

0 20 40 60 80 100

(1) (1)

(2)(2)

69% of the population is sexually active

70

150

130

120

50

Number of Institutions which distribute Female Condoms, per Macro-Region2000-2003

Distribution of 4 million condoms / year

Priority Population:

Seropositive women

Sex workers

IDUs and their partners

Women victims of domestic sexual violence

5241,5

1999 2001

21,4

11,4

reduction of needle sharing

HIV BEHAVIOR

6046,2

1999 2001

HCV

HARM REDUCTION

Support to 125 projects with 65,000 ID users - estimated 20% coverage

Today 1.8 million people are tested per year

30% of the sexually active population have

taken the test.

300 and 400 thousand HIV+ are not aware of

their status.

Diagnosis is made 4/5 years after infection.

Access to HIV diagnosisGoal is to test 4.5 million a year

Impact of prevention interventions – vulnerable populations

Drop in HIV infection rates

• Sex workers – From 17% in 1992 to 6.1% in

2000

• MSM - from 10.8% in 1999 to 4.7% in 2001

• IDU - from 21% of AIDS cases 1994 to 11.4%

in 2000

Mother to Child Transmission, Brazil, 1997 to 2003

3.420

2.512

1.364

5.149

5.969 5.983

6.661

0

1.000

2.000

3.000

4.000

5.000

6.000

7.000

1997 1998 1999 2000 2001 2002 2003* Ano

N. of pregnant women

* Preliminary data

Estimated 17thousand pregnant women infected per year

Rate of Mother to Child Transmission (%) per year of birth - Brazil, 1997-2002

Tess, 1998; Succi, 2003 (preliminary data)

16

9.7

7.8

3.7

0

2

4

6

8

10

12

14

16

1998 2000 2001 2002

Health Care

HIV/AIDS services

Accredited hospitals: 375

Day hospitals: 79

Home care: 54

Outpatient services: 381

Source: UDAT/PN-DST-AIDS. March/2002

2

11

1122

1

1

2

21

531

1

11

5 31 1

4 32

1

2 1193 1 4

11

221

3111

1113

2 1 1 1

4 4

633 133210 5

5015186158174924

11 1 7 114 410

321 9 9

1

6 1 8

Access to Treatment 889 services for PLHA

Laboratories: Viral Load, CD4+ count and Genotyping

PLHA on ARV useBrasil, 1997 a Jun/2004

0

20000

40000

60000

80000

100000

120000

140000

160000

jan/

97

abr/

97

jul/9

7

out/9

7

jan/

98

abr/

98

jul/9

8

out/9

8

jan/

99

abr/

99

jul/9

9

out/9

9

jan/

00

abr/

00

jul/0

0

out/0

0

jan/

01

abr/

01

jul/0

1

out/0

1

jan/

02

abr/

02

jul/0

2

out/0

2

jan/

03

abr/

03

jul/0

3

out/0

3

jan/

04

abr/

04

146.000

Dados preliminares

ZIDOVUDINE (ZDV)* DIDANOSINE (ddI)* LAMIVUDINE (3TC)* STAVUDINE (d4T)* ABACAVIR INDINAVIR* TENOFOVIR

16 ARVs distributed

RITONAVIR* SAQUINAVIR NELFINAVIR AMPRENAVIR NEVIRAPINE* EFAVIRENZ LOPINAVIR / r ATAZANAVIR

(*) Brazilian state production available

•Universal and free of charge access to ARV - federal law Nov.1996

MEDIAN SURVIVAL AFTER AIDS

DIAGNOSIS IN BRAZIL

MEDIAN SURVIVAL AFTER AIDS

DIAGNOSIS IN BRAZIL

Source: Chequer et al, 1992; Marins et al. 2002

58

18

50

10

20

30

40

50

60

70

1989 1995 1996

Mo

nth

s o

f su

rviv

al

Introduction of Potent ARV Therapy in Brazil

LPV.r NFV EFZ 12 other ARVs

Exp

end

itu

res

(in

mill

ion

s o

f R

$)

121

131

106

215

2003

21%

23%

19%

573

37%

Access to treatment3 imported drugs take up 63% of the budget - 2003

LPV.r+ EFZ+ NFV

63%

12 other ARVs

37%

ARV drug expenditures avoided trough negotiation (In millions of US$), for 2004 - Brazil (Jan/2004)

9,4560483,7440258

7,539552

12,32544

63,65448

3

Efavirenz Nelfinavir Lopinavir/ritonavirTenofovir Atazanavir Outras negociações

Total US$ 99,7

Fonte: PN-DST/AIDS

Expenditures (In millions of US$) with ARV Drugs and Average Number of Patients under treatment - Brazil (1997-2004*)

*Data subject to alterations

224

305

336

303

232

179 181169

35,9

55,673

87,5104

119,3132,9

148,512

0

50

100

150

200

250

300

350

400

1997 1998 1999 2000 2001 2002 2003 2004*Ano

Gastos (Em milhões de US$) Média de pacientes/1000

527

SE

M R

ED

UÇ

ÃO

SOURCE: PN-DST/AIDS

** Average dollar of the year used for conversion to R$

MoH / 2003

3810

48604540

4240

3320

2223 2035

1996 1997 1998 1999 2000 2001 2002

Average cost (US$) of ARV per Patient/year -1996 - 2003*

1630

2003

* Preliminares datas

Impact of the Brazilian ARV Policy (1996-2002)

reduction of mortality 40%

90,000 deaths prevented

reduction of morbidity 70%

reduction of hospitalizations 80%

358,000 hospitalizations prevented - average of

hospitalizations / patient per year reduced from

1,65 in 1996 to 0,28 in 2003.

Impact of ARV Therapy Policy (1996-2002)

Cost Savings - US$ 2.2 billion

US$ 1.23 billion in hospitals and treatment opportunistic infections

US$ 960 million reduction in drug prices

“Life sleeps in the crude earth,

dreams beauty in the flowers,

wakes with power in the animals

and in man has consciousness

of infinite possibilities”

Yogananda