1. 1 The National Response to HIV/AIDS in Brazil Brazilian STD/AIDS Program Ministry of Health

2. 2 Population (2005) – 185 mln Federative Republic with 27 States Municipalities - 5,561 Territory: 8,5 mln sq km GNP (2004) US$ 750 bi Per capita GNP (2004) - US$ 4,041 HDI Rank (2005) - 63 th (0.792) Country Profile

3. 3 Accumulated AIDS cases (06/2005): 371,827 AIDS incidence rate (2004): 17,2/100,000 inhabitants Estimated n. of PLWHA (2004): around 600,000 Prevalence: (15 to 49 years of age) 2000: 0.61% 2004: 0.61% Aids deaths (1980-2004): 171,923 Mortality rate: 6,1/100,000 (2004) inhabitants Epidemiological Profile

4. 4 Current epidemiological trends Relative stabilization, -decreasing: southeast, MSM, IDU -Stabilized: big cities Increasingly affecting: - Heterosexuals - Women - Low-income groups - Smaller cities

5. 5 Total investment in STD/AIDS control program by the Federal Government. Brazil, 1997-2005 Source: PN STD-AIDS//MOH 11% 89% National budget World Bank Loan Average investment per year: US$ 400 MILLION 1997 to date: US$ 3.5 billion (HIV response) US$ 2 billion for ART

6. 6 The 1988 Brazilian Constitution: access to health is a basic right  Main precepts: - comprehensive approach - universal access and equity - civil society participation  Key feature: decentralization  Virtuous circle (AIDS Programmes  Public Health System) The “backbone” of the Brazilian Response: the Public Health System The “backbone” of the Brazilian Response: the Public Health System

7. 7 History of Health Policy Actions on health promotion and disease prevention were a responsibility of the Social Security Institute 1988 – Federal Constitution – Health as Right of all and a duty of the State. 1990 - Law 8.080 – Creation of the Unified Health System.

8. 8 History of Health Policy Regulations of the Unified Health System: –93  fund to fund transfer of Health financial resources. –96  increase of funds transfers. Assistance regulations: – organization of the System through regional assistance policies. – introduction of criteria for the inclusion of states and municipalities into the System and strengthening of decentralization.

9. 9 1982-1985 Notification of the first AIDS cases; creation of the State of São Paulo Aids Program; establishment of the first NGOs; negligence of governmental authorities; panic and prejudice 1986-1990 Creation of a response at national level; pragmatic approach about the epidemic; spread of NGOs all over the country; mobilization de People Living with HIV/Aids 1990-1992 Interruption of some of the key elements of the National Program; opposition between the NAP and the organized civil society; Deterioration on international relations *(Parker, 1997) Political Response to the epidemic*

10. 10 1992-1997Return to the dialog with NGOs ; First Agreement with the World Bank (AIDS I); Adoption of a policy of universal access to ARV drugs 1998-2006 Decentralization/Disconcentration; Empowerment of the social movement; Consolidation of public policies; Enlargement of partnerships; Human Rights as a transversal issue; AIDS II and AIDS III; Horizontal TechnicalCooperation; Consolidation of the process of cooperation with international agencies; Visibility and recognition at international level

11. 11 Priorities for 2006-2007 Universal access to Prevention, Care and Treatment Strengthen, implementation and extend of the prevention, promotion and care policies related to HIV and Aids on the scope of the Health system network (SUS), with a comprehensive approach and according to the SUS principles. Promote the defense of human rights and reduce stigma and discrimination of people living with HIV and aids and of the most vulnerable population.

12. 12 Major features of the Brazilian Response Country-driven approach:  Social Control: robust participation by civil society in decision making and implementation  Balanced prevention and treatment approach  Comprehensive ethical and rights-based approach  Early response by government (since 1983)  Multi-sectoral mobilization Human Rights perspective in all the strategies and actions

13. 13 National Health System (SUS) Ministry Of Heath State Health Secretaries National Health Council Municipal Health Secretaries State Health Councils Municipal Health Councils Unified Decentralized Participation of civil society in decision making Principles

14. 14 Ministry Of Heath UNAIDS Thematic Group National HIV/AIDS Commitee AIDS Business Council Aids National Management Health Surveillance Secretariat Health Surveillance Secretariat National STD/AIDS Program 3 Ones in practice

15. 15 STRUCTURE OF THE NAP MINISTRY OF HEALTH SECRETARIAT FOR HEALTH SURVEILLANCE UNAIDS THEMATIC GROUP COM. FOR INTERACTION WITH CIVIL SOCIETY MOVEMENTS NATIONAL STD AIDS PROGRAM ADVISORY COMMITTEES* INTERNATIONAL COOPERATION ADVISORY PLANNING ADVISORY INFORMATION SYSTEMS’ ADVISORY COMMUNICATION ADVISORY Civil Soc. And H. R. ADMINISTRATIONS’ COMMITTEE NATIONAL AIDS COMMISSION PRIVATE SECTOR’S NATIONAL COUNCIL FOR HIV / AIDS * Advisory Committees International Center for Technical Cooperation - ICTC GTZ CDC Assist. and treat. Lab. STD Surv. M&A Hum Res. Tech Dev. Adm. Prevention

16. 16 Expand access to prevention commodities (male/female condoms, lubricating gel, harm reduction supplies) Extend joint activities with CSO’s, CBO’s, uniformed services, social movements and other government programs Increase coverage in poorest areas, emphasizing counselling and testing through the primary health system Implement education programs throughout the public school system at all levels - Prevention Program in Public Schools in Brazil-2005 Prevention Framework

17. 17 Prevention Program in Public Schools in Brazil-2005 Number of questionnaires analyzed: 161.679 % of brazilian schools = 78% # of schools with STI/Aids as part of school program = 97.600 % of schools with STI/Aids as part of school program = 60,4% # of schools distributing condoms = 9.200 % of schools distributing condoms = 9,1% (17% in high school) % of schools work with topic: sexual and reproductive health as part of the school program = 45,3% % of schools work with topic: adolescent pregnancy as part of the school program = 51,8% % of schools work with topic: drugs as part of the school program = 71%

18. 18 VISTA-SE

19. 19

20. 20 Condom supply by the NAP-Brazil, 1997-2006 Millions

21. 21

22. 22

23. 23 Regular condom use (last 12 mo.) among those aged 16-65 (2005) Regular condom use (last 12 mo.) among those aged 16-65 (2005) 35,4% 23,9% 0% 5% 10% 15% 20% 25% 30% 35% 40% 19982005 Fonte: Pesquisa CEBRAP, 2005.

24. 24 Percentage change in condom use among young people in first sexual intercourse Percentage change in condom use among young people in first sexual intercourse Sources: (1) BEMFAM (2) CEBRAP/MH/PN-STD/AIDS/SVS (3) MH/PN-STD/AIDS/SVS – (PCAP_BR_2003,IBOPE) 1986 1998 2003 010203040506070 (1) (2) (3)

25. 25 CONDOM USE IN THE FIRST SEXUAL INTERCOURSE BY BIRTH COHORT - BRAZIL, 2004

26. 26 Percentage of condom use among sexually-active population according to age group - Brazil, 2004 Percentage of condom use among sexually-active population according to age group - Brazil, 2004 24.9 51.5 16.2 41.5 21.9 48.7 38.8 58.4 Fixed partner Casual partner 25.316.122.039.0 Regular use (any partners) 67.051.266.574.1 Last sexual intercourse with casual partner 38.422.336.657.3Last sexual intercourse 40-5425-3915-24TotalCondom use Source: Survey on behavior, attitudes and practices related to STD/AIDS, 2004, PN-STD-AIDS/SVS/MH

27. 27 Harm Reduction: a basic prevention strategy  Estimated number of IDUs in Brazil: 193,000 (Source: PCAP, 2004)  Percentage of IDUs who reported no syringe/needle sharing: 76% (Source: PCAP - 2004)  AIDS cases among IDUs:  1993 = 4926 cases (28.0% of total reported cases)  2003 = 1871 cases (10.2% of total reported cases)

28. 28 Treatment, Care and Support 1980’s: Treatment and care centered around OI treatment –Capacity and institution building, training –1988: AZT is introduced in the Brazilian market 1991: distribution of AZT through the public health system is initiated 1996: “Sarney” Law 9313 (Universal access to HAART) 1997-1998: establishment of monitoring and logistic systems

29. 29 People living with AIDS under ARV treatment. BRASIL, 1997 A 2006 Fonte: PN DST/Aids, MS

30. 30 Average cost of ARV therapy per patient/year (US$). Brazil, 2005 6240 5486 4603 3464 2210 1500 13591336 2500 0 1000 2000 3000 4000 5000 6000 7000 199719981999200020012002200320042005* Year Thousands (US$) Introduction of expensive new ARVs Substantial falls in prices of second-line patented drugs have ceased Number of people using them has increased dramatically

31. 31 * Brazilian local production  RITONAVIR (1996)*  SAQUINAVIR (1996)*  INDINAVIR (1997)*  NELFINAVIR (1998)  AMPRENAVIR (2001)  LOPINAVIR/r (2002)  ATAZANAVIR (2004)  ZIDOVUDINE (1993)*  ESTAVUDINE (1997)*  DIDANOSINE (1998)*  LAMIVUDINE (1999)*  ABACAVIR (2001) DIDANOSINE EC (2005) TENOFOVIR (2003)  NEVIRAPINE (2001)*  EFAVIRENZ (1999) ITRN and ITRNt  ENFUVIRTIDE (2005) IP FUSION INHIBITORITRNN Antiretroviral drugs distributed through the Brazilian public health system (and year of introduction) Antiretroviral drugs distributed through the Brazilian public health system (and year of introduction)

32. 32

33. 33 Average number of AIDS-related hospitalizations per patient / year Average number of AIDS-related hospitalizations per patient / year 0.81 0.56 0.43 0.38 0.26 0.28 0.26 0.24 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 19971998199920002001200220032004 Average of AIDS related hospitalizations per patient / year

34. 34 Difference between the number of AIDS-related hospitalizations effectively registered and its potential* Difference between the number of AIDS-related hospitalizations effectively registered and its potential*

35. 35 Total number and estimated value of hospitalizations averted (non-cumulative figures) Total number and estimated value of hospitalizations averted (non-cumulative figures) Estimated value of hospitalizations avoidedEstimated number of hospitalizations avoided $0.00 $100,000,000.00 $200,000,000.00 $300,000,000.00 $400,000,000.00 $500,000,000.00 $600,000,000.00 19971998199920002001200220032004 Expenditures (in US$) 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 180,000 Number of hospitalizations Total: Hospitalizations avoided: 791,069 Total savings: US$ $2,289,654,584

36. 36 2003-2005: design of an updated, integrated and comprehensive national M&E plan Current phase: –implementation of the national M&E plan and its real- time informational system (www.aids.gov.br/monitoraids); –Capacity Building in M&E (health professionals, public health managers, universities, NGOs etc) –Implementation of five sites of excellence in M&E Monitoring and Evaluation Framework

37. 37 South-South Cooperation: Network for Technological Cooperation in HIV/AIDS South-South Cooperation: Network for Technological Cooperation in HIV/AIDS Launched in 2004, involving Argentina, Brazil, China, Cuba, Nigeria, Russia, Thailand and Ukraine Key support provided by the Ford Foundation: US$ 1 million Objectives: technology transfer, R&D and production: - antiretrovirals - vaccines and microbycides - condoms - laboratory supplies

38. 38 The GCTH – Group for Horizontal Technical Cooperation. Launched in 1995 to establish direct cooperation between the Latin American and Caribbean State Governments onHIV and AIDS control and prevention. Objectives: - Reference for building up regional statements for International Events. - Courses, Conferences and Forums. - Development of the Price Bank. - Development of web-page and improvement of electronic communication.

39. 39 Other South-South Cooperation Initiatives Technical Areas: Institutional development, management and capacity building Care and support Clinical management Antiretroviral logistics and management Epidemiological surveillance Promotion of safer sexual practices Promotion of human rights Advocacy and Civil Society participation Care and support for HIV+ pregnant women and children exposed to HIV

40. 40 International Cooperation with Developed Countries International Cooperation with Developed Countries Institutions involved: ANRS (France), CDC, USAID, Ford, GTZ, DFID United Nations :UNAIDS, UNFPA, UNICEF, UNODC, UNESCO, ILO, Thematic areas: Monitoring and Evaluation; Promotion of safer sexual practices Promotion of human rights Advocacy and Civil Society participation Scientific and technological development

41. 41 sharing experiences - not “vertical” building partnerships commitment to attend to specific needs of each country – “tailored” approach donor X recipient?? role of multilateral partners? Based on “ Horizontal” Technical Cooperation

42. 42 Laços Sul Sul – Lazos Sur- Sur 8 countries - Brazil, Cabo Verde, Guine- Bissau, São Tome e Principe, Bolivia, Nicaragua e Paraguai, Timor Leste based initially on bilateral projects with Brazil – technical cooperation and provision of ARV partnership with Unicef(and Unaids) – since 2004

43. 43 La ç os Sul Sul - main aspects so far a truly horizontal type of cooperation – every country has some experience to share based entirely on the 3 Ones Principles countries ownership – part of the national plans some concrete results – increased access to prevention and treatment services for women and children Unicef acts as a “focal point” in-country – within UN HIV/AIDS Team Groups

44. 44 Main challenges each country at its own pace – partnership may help “speed up” some national responses to AIDS fragile health systems / governance – LSS Initiative may help countries with difficulties to scale up access to prevention and health services provision

45. 45 International Center for Technical Cooperation: a Joint Brazil/UNAIDS Initiative International Center for Technical Cooperation: a Joint Brazil/UNAIDS Initiative Created in 2005, the ICTC aims to create and strengthen national technical capabilities for implementing comprehensive AIDS responses through horizontal technical cooperation; Example of activities undertaken:  Coordination of technical missions in Honduras, Nicaragua, Peru, Ecuador and Bolivia  Identification of technical assistance needs of Latin American countries receiving financial support from the Global Fund Total investments:  Brazilian Government (US$ 500,000), UNAIDS (US$ 500,000), DFID (£ 250,000 - under negotiation), GTZ (€ 250,000 – under negotiation)