TCS Daily

On AIDS, Brazil's New Way Forward

By Richard Tren - February 11, 2004 12:00 AM

São Paulo, Brazil -- One is struck by Dr. Artur Kalichman's energy and enthusiasm as soon as one meets him. When Kalichman was showing a U.S. delegation around São Paulo's Centro de Referência e Treinamento (Reference and Treatment Center) for AIDS patients, which he directs, another quality became evident -- his pride. It's well earned.

Kalichman and the Brazilian Ministry of Health have put in place one of the most outstanding and admired AIDS treatment and prevention programs in the world.

But a big question is: Will Kalichman's vibrant program be sustainable? How it deals with the drugs industry in the future may determine its fate.

Taking It Seriously

From the earliest days of the AIDS epidemic, the Brazilian government took the disease seriously. The first AIDS programme in São Paulo was developed as early as 1983, and, by 1985, the government had instituted a national programme based on prevention, treatment and the respect of the basic rights of people living with HIV/AIDS.

As anti-retroviral drugs (ARVs) were developed, Brazil's government took the bold step of providing free ARVs to all who needed them and started building the infrastructure and the logistical systems to deliver the drugs. The first ARVs were offered free in 1996; today, around 130 000 people receive therapy. As a result, unlike much of Africa, China and India, HIV infection as well as AIDS morbidity and mortality have been falling in Brazil for some years. The number of AIDS deaths peaked at 8,000 in 1996 and by 2002 was down to 4,000, despite an increase in the total number of people living with HIV/AIDS.

The Brazilian AIDS program has not only improved lives of thousands of people immeasurably but it has saved a lot of money as well. The Ministry of Health estimates that by treating people early and preventing new infections, it has saved the country US$2.2 billion in direct hospital costs. If one considers the indirect benefits of improved productivity, the figure would surely be far higher.

Concern for the Future

Yet, there are some concerns about Brazil's poor relationship with the research-based drugs industry and the implications of this for future AIDS patients.

A key feature of Brazil's programme is that the state drug maker, FarManguinos manufactures some of the ARVs locally. Some key ARVs were developed before Brazil introduced intellectual property laws; so the government isn't breaking any drug patents by producing generic versions of drugs that are patented elsewhere. The Brazilian government claims that the local manufacturing capacity has been a key tool in ensuring cut-price access to patented drugs. The government says that its threat to issue compulsory licences (whereby patents would be set aside and licences to produce local generic versions issued) has successfully managed to get the research-based drugs industry to cut its prices.

It is a strategy that seems to have worked -- in the short term. According to Kalichman, the treatment cost per patient per year has come down from US$ 3,810 in 1996 to US$ 1,591 in 2003.

Decline in AIDS Research

But threatening the drug developers with compulsory licences risks long-term harm, as it undermines the drug industry's profit potential and thereby does little to encourage ongoing drug development. In addition, continual demonization of the drugs industry by some activists makes drug making a political nightmare.

These factors helped account for a dramatic decline in the number of drug companies engaged in HIV/AIDS research. According to consultancy firm, Pharmaprojects, since 1997, that number is down by 25%, with the number of ARV drugs in development off by 33% over the same period.

This fall-off in research has serious implications for future AIDS sufferers in Brazil and elsewhere. Although the incidence of drug resistance in Brazil is reportedly not very high now, given the nature of the disease it is likely to grow. And when the current generation of ARVs become ineffective, new drugs will be needed. Unless the private sector has incentives to make new drugs, those drugs may not exist.

As Abner Mason, executive director of the AIDS Responsibility Project puts it, "We ignore the needs of future AIDS patients at our peril."


A panel discussion organised by the AIDS Responsibility Project in São Paulo, in which Kalichman and other senior government officials participated, may have started a reconciliation process between the drug companies and the government. The discussion was notable for its reasonable and conciliatory tone and, perhaps thanks to the fact that some of the more radical activists were not present, will do more for AIDS patients around the world than any of the hysterical antics favoured by those groups.

Brazil truly is a world leader when it comes to HIV/AIDS treatment and prevention. If it can find a way of working with the drugs industry better and can tone down its aggression towards the people from whom investment is required to develop the drugs Brazil needs, Kalichman's and Brazil's AIDS program may remain strong and become a true model for other countries to follow.

Richard Tren is a director of the South Africa based health advocacy group Africa Fighting Malaria and accompanied the AIDS Responsibility Project on its tour to Brazil.


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