1. MONITORING SYSTEM FOR THE ANTIRETROVIRAL THERAPY IN BRAZIL: LESSONS LEARNED AND FUTURE DIRECTIONS Marco Vitória, MD Brazilian STD/AIDS Programme - MOH July 2003

2. Source: Ministry of Health PATIENTS ON ARV THERAPY IN THE PUBLIC HEALTH SYSTEM - BRAZIL, 1997 - 2002* * December 2002, estimated data 0 20000 40000 60000 80000 100000 120000 140000 jan/97mai/97set/97jan/98mai/98set/98jan/99mai/99set/99jan/00mai/00set/00jan/01mai/01set/01jan/02mai/02 set/02 125,000

3.  CUMULATIVE AIDS CASES (Dec/2002): 257,780  CUMULATIVE AIDS DEATHS (Dec/2002): 113,840  ESTIMATED NUMBER OF HIV+ INDIVIDUALS (2000): 597,000  INCIDENCE RATE OF AIDS (2000): 12,4 / 100.000  PREVALENCE RATE OF HIV (2000): 0,65%  CUMULATIVE AIDS CASES (Dec/2002): 257,780  CUMULATIVE AIDS DEATHS (Dec/2002): 113,840  ESTIMATED NUMBER OF HIV+ INDIVIDUALS (2000): 597,000  INCIDENCE RATE OF AIDS (2000): 12,4 / 100.000  PREVALENCE RATE OF HIV (2000): 0,65% BRAZIL: EPIDEMIC PROFILE

4. The Brazilian Public Health System (SUS)  Organized by the Brazilian Constitution of 1988 Main principles: - integrality - universality - equity - social control  Strong catalytic element  Virtuous circle (AIDS  Public Health System)  Organized by the Brazilian Constitution of 1988 Main principles: - integrality - universality - equity - social control  Strong catalytic element  Virtuous circle (AIDS  Public Health System)

5. MAJOR ASPECTS IN BRAZILIAN RESPONSE TO HIV/AIDS  EARLY GOVERNMENTAL RESPONSE  STRONG CIVIL SOCIETY PARTICIPATION IN ALL DECISION LEVELS  MULTISECTORIAL MOBILIZATION  BALANCED PREVENTION & TREATMENT APPROACH  HUMAN RIGHTS PERSPECTIVE IN ALL STRATEGIES AND ACTIONS  EARLY GOVERNMENTAL RESPONSE  STRONG CIVIL SOCIETY PARTICIPATION IN ALL DECISION LEVELS  MULTISECTORIAL MOBILIZATION  BALANCED PREVENTION & TREATMENT APPROACH  HUMAN RIGHTS PERSPECTIVE IN ALL STRATEGIES AND ACTIONS

6. BRAZILIAN ARV ACCESS PROGRAM: MAJOR ASPECTS  NATIONAL NETWORK OF PUBLIC ALTERNATIVE CARE SERVICES: ~ 900 SERVICES  NATIONAL NETWORK OF VCT FOR HIV: 208 SERVICES  NATIONAL NETWORKS OF LABORATORY SUPPORT  HIV VIRAL LOAD: 78 LABORATORIES  T-CD4+ CELL COUNT: 66 LABORATORIES  HIV RESISTANCE TESTING: 14 LABORATORIES  NATIONAL ARV LOGISTIC CONTROL SYSTEM: 480 DISPENSARY UNITS  NATIONAL NETWORK OF PUBLIC ALTERNATIVE CARE SERVICES: ~ 900 SERVICES  NATIONAL NETWORK OF VCT FOR HIV: 208 SERVICES  NATIONAL NETWORKS OF LABORATORY SUPPORT  HIV VIRAL LOAD: 78 LABORATORIES  T-CD4+ CELL COUNT: 66 LABORATORIES  HIV RESISTANCE TESTING: 14 LABORATORIES  NATIONAL ARV LOGISTIC CONTROL SYSTEM: 480 DISPENSARY UNITS

8. IMPACT OF UNIVERSAL ACCESS TO HAART ON AVERAGE SURVIVAL AFTER AIDS DIAGNOSIS IN BRAZIL Chequer et al, 1992; Marins et al. 2002 58 16 6 6 0 0 10 20 30 40 50 60 70 1982-1989 1995 1996 Months of Survival Introduction of universal access to HAART in Brazil

9. Source: V.E.CRT-DST/Aids (datauntil31/12/02) Tuberculosis in HIV + Patients CRT – DST/AIDS, São Paulo, Brazil (1994 – 2002) 1997/96: - 53,3% 2001/96: - 65,3% 2002/96: - 71,8% Introduction of HAART in Brazil

10. IMPACT OF MOH ARV DRUG POLICY (1996 - 2002)   Mortality reduction  40 - 70%  Morbidity reduction  60 - 80%  Occurrence of new AIDS cases  58,000 avoided cases  Occurrence of AIDS related deaths  90,000 avoided deaths  Reduction in Hospitalization needs  Seven fold reduction  358.000 avoided admissions (1997- 2001)   Mortality reduction  40 - 70%  Morbidity reduction  60 - 80%  Occurrence of new AIDS cases  58,000 avoided cases  Occurrence of AIDS related deaths  90,000 avoided deaths  Reduction in Hospitalization needs  Seven fold reduction  358.000 avoided admissions (1997- 2001) Estimated Savings  U$ 2.2 billions (Hospital and Ambulatory Care)

11.  ZIDOVUDINE (ZDV)*  DIDANOSINE (ddI) *  LAMIVUDINE (3TC) *  STAVUDINE (d4T) *  ZDV + 3TC *  ABACAVIR  INDINAVIR *  RITONAVIR*  ZIDOVUDINE (ZDV)*  DIDANOSINE (ddI) *  LAMIVUDINE (3TC) *  STAVUDINE (d4T) *  ZDV + 3TC *  ABACAVIR  INDINAVIR *  RITONAVIR* ARV Drugs Distributed by Ministry of Health - Brazil (2003)  SAQUINAVIR  NELFINAVIR  AMPRENAVIR  NEVIRAPINE *  EFAVIRENZ  LOPINAVIR / r  SAQUINAVIR  NELFINAVIR  AMPRENAVIR  NEVIRAPINE *  EFAVIRENZ  LOPINAVIR / r (*) generic version available

12. HIVBResNet Study - Genotypic distribution of HIV primary mutations in ARV naive treated patients (Brazil,2001)

13. ** = Crude rate (CI not available) N = 1972 patients (from 60 health services) Nemes et al, 2003 (in press) Adherence to Antiretroviral Therapy in Brazil Preliminary Results* - 2002

14. PARTNERSHIPS WITH CIVIL SOCIETY  Participation and social control;  Guaranteeing human rights for people living with HIV and AIDS;  Support for community projects.  Adherence Groups  Support Houses

15. THE BRAZILIAN EXPERIENCE: LESSONS LEARNED AND FUTURE DIRECTIONS  Adherence strategies to optimize ARV therapy and reduce viral resistance must be always used.  Universal access to ARV therapy and generic drug policy  Quality with Price Reduction  Fixed-Dose Combinations.  Diagnostic and treatment monitoring approach using simple clinical and laboratorial tools are needed.  Adherence strategies to optimize ARV therapy and reduce viral resistance must be always used.  Universal access to ARV therapy and generic drug policy  Quality with Price Reduction  Fixed-Dose Combinations.  Diagnostic and treatment monitoring approach using simple clinical and laboratorial tools are needed.