1. Rodrigo Zilli Haanwinckel Ministry of Health of Brazil Health Surveillance Secretariat Department of STD, AIDS and Hepatitis Prevention of vertical transmission of HIV in Brazil

2. 3 Population – 190 million 27 States Municipalities - 5,561 Area: 8,5 million sq km Brazil

3. SUS - National Health System Federal law # 8080 (1988) - National Health System (SUS) established – “health as a citizen’s right and the government’s duty” - free and universal access to health care 100% of Brazilian people have the right to access the National Health System, including the prisoners.

4. Prevalence : 0.61% (pop. 15 to 49 years old) fem: 0.42% male: 0.80% HIV: General Data. Brazil, Estimate nr of PLHA 620,000

5. Detection of Pregnant Women with HIV/aids (cases and incidence rate/100,000 live births), by year. Brazil, 2005-2009 (1) FONTE: MS/ SVS/ Departamento de DST, Aids e Hepatites Virais NOTA: (1) Casos notificados no Sinan até 30/06/2010 (2) Utilizados nascidos vivos no ano de 2008 Dados preliminares para os últimos 5 anos 20052006200720082009 nratenratenratenratenrate 60912,061002,165322,359032,061042,1

6. Reported Cases of MCT of HIV in children less than five years-old. YearCases 2004678 2005683 2006564 2007483 2008 2009 533 468

7. Incidence rate of AIDS (by 100,000 inhabitants) in children less than 5 years- old by Brazilian region and year of diagnosis. Brazil, 1997 to 2009. FONTE: MS/SVS/Departamento de DST Aids e Hepatites Virais. POPULA Ç ÃO: MS/SE/DATASUS em no menu informa ç ões em sa ú de > Demogr á fica e socioeconômicas, acessado em 20/10/2009. NOTA: (1) Casos notificados no SINAN e registrados no SISCEL/SICLOM at é 30/06/2009 e SIM de 2000 a 2008. Dados preliminares para os ú ltimos cinco anos. 0,0 2,0 4,0 6,0 8,0 10,0 12,0 14,0 1997199819992000200120022003200420052006200720082009 Year of diagnosis Incidence rate BrazilNorthNortheastSoutheastSouthMidwest

8. *Brazilian local production (10 out of 21) Year of introduction in parenthesis  RITONAVIR (1996)*  SAQUINAVIR (1996)*  INDINAVIR (1997)*  NELFINAVIR (1998)  AMPRENAVIR (2001)  LOPINAVIR/r (2002)  ATAZANAVIR (2004)  DARUNAVIR (2008)  TIPRANAVIR (2010)  ZIDOVUDINE (1993)*  ESTAVUDINE (1997)*  DIDANOSINE (1998)*  LAMIVUDINE (1999)*  ABACAVIR (2001)  DIDANOSINE EC (2005)  TENOFOVIR (2003)-2011*  NEVIRAPINE (2001)*  EFAVIRENZ (1999)-2007*  ETRAVIRINE (2011) NTRI  ENFUVIRTIDE (2005) PI FUSION INHIBITOR NNTRI  RALTEGRAVIR (2009) INTEGRASE INHIBITOR Antiretroviral drugs universally available in Brazil

9. Brazilian Penitentiary System Scenario (Dec/2011):  Incarcerated population: 471,254  441,907 (94%) – Men  29,347 (6%) – Women 1,779 penal facilities – 4 federal prisons 1,779 penal facilities – 4 federal prisons

11. HIV, HPV and Syphilis prevalence in São Paulo’s feminine prison – 1997/1998 – Public Health Review - 2001 F. Lopes; M. Latorre; A. Pignarati; C. Buchalla Population: female prisoners; City: São Paulo, SP Samples: 262 HIV: 14,5%; HPV: 16,3%; Syphilis: 5,7% Behaviour associated to HIV and HCV infection in female prisoners in a penitentiary of São Paulo, Brazil – Public Health Review - 2007 L. Strazza; E. Massad; R.Azevedo; H.Carvalho; Population: female prisoners City: São Paulo, SP Samples: 290 (299) HIV: 13,9%; HCV: 16,2% Prevalence of HIV/AIDS in female in prision Prevalence of HIV/AIDS in female in prision :

12. Increasing vulnerability context  Confining Conditions OvercrowdingOvercrowding Inadequate facilitiesInadequate facilities Difficulties in accessing prevention and hygiene materials (condoms, lubricants, toothbrushes, shavers)Difficulties in accessing prevention and hygiene materials (condoms, lubricants, toothbrushes, shavers) ViolenceViolence Poor health carePoor health care Limited access to informationLimited access to information  Practices that increase vulnerability Drug UseDrug Use Unprotected sexUnprotected sex Sharing of tattoo and piercing equipmentSharing of tattoo and piercing equipment

13. The Brazilian Response to HIV & AIDS  Is focused on principles of protection and human rights;  Universal access;  Is structured by the Policy of Attention to Incarcerated Individuals;  Is based on integral attention and access to prevention materials (condoms, ART and testing);  Multisectoral actions.

14. HIV & AIDS in the Penitentiary System National Actions National Plan for Health in the Penitentiary System, 2003 National Plan for Health in the Penitentiary System, 2003 Regional Consultation for Latin America and the Caribbean on HIV & AIDS in Prison Settings, 2008 Regional Consultation for Latin America and the Caribbean on HIV & AIDS in Prison Settings, 2008 National Consultation on HIV & AIDS in Prison Settings, 2009 National Consultation on HIV & AIDS in Prison Settings, 2009 Technical Cooperation Project – Ministry of Health, Penitentiary System Authority and UNODC: HIV & AIDS prevention and assistance - Strengthening health care in the penitentiary system. Technical Cooperation Project – Ministry of Health, Penitentiary System Authority and UNODC: HIV & AIDS prevention and assistance - Strengthening health care in the penitentiary system. National Plan for Health in the Penitentiary System - Revision National Plan for Health in the Penitentiary System - Revision

15. National Plan for Health in the Penitentiary System Purpose: Organize the access of inmates to public health services Targeted population: 100% of Brazilian inmates 18 Brazilian states qualified and developing

16. Health Network  Prevention: Prevention commodities (condoms and harm reduction kits) Prevention commodities (condoms and harm reduction kits) Breast milk substitute for exposed children Breast milk substitute for exposed children Medication to inhibit breast milk production Medication to inhibit breast milk production Hepatitis B vaccination Hepatitis B vaccination  Diagnosis: Testing (HIV, STD, TB, hepatitis B and C) Testing (HIV, STD, TB, hepatitis B and C) Follow-up procedures: viral load, CD4, genotype Follow-up procedures: viral load, CD4, genotype  Treatment: ART ART Treatment for opportunistic infections; Treatment for opportunistic infections; STD treatment STD treatment

17. Operational Plan for The Reduction of MCT of HIV and Syphilis Goals: Reducing HIV MCT rate to less than 1% Eradicating congenital syphilis (<1 case/1,000) nationwide. Main achievement: From 1997 to 2009: 49% reduction in the incidence rate of AIDS cases in children under 5 years old.

18. Challenges   Organization of the health care network   Access to prevention materials   Access to diagnosis and specialized care to women in prision   Monitoring of the PMCT in this population   Human rights as a key issue to reduce vulnerabilities

19. THANK YOU! rodrigo.zilli@aids.gov.br FAÇA O TESTE DE AIDS, SÍFILIS E HEPATITE