1. The UNAIDS Investment Framework: Setting priorities for HIV prevention in today’s global economic climate Resource allocation decisions for HIV prevention Brazilian experience Considerations on combined approaches for the control of the AIDS epidemic XIX International AIDS Conference Washington DC USA 22-27 July 2012 Department of STD, AIDS and Viral Hepatitis Health Surveillance Secretariat Ministry of Health Brazil

2. 3  Population – 190 million  GNI/capita:$10,260 (PPP)  Federative Republic, independent 7 Sept 1822  27 States  Municipalities - 5,561  Area: 8,5 million sq km Brazil

3. AIDS Epidemic in Brazil HIV epidemic is concentrated in urban centres and in more vulnerable segments –Gays and other MSM: 10.5% –Drug users: 5.9% –Sexual workers: 5% –General population: 0.6% Increasing survival and quality of life

4. AIDS Epidemic in Brazil In 2012, 217,000 people on HAART, with access to 20 drugs, 10 of them locally produced Approximately 5,000 on third-line regimens ARV – app. US$ 450 million in 2011 Each year over 25,000 PLHA initiate ARVs

5. AIDS incidence rate spatial distribution (15-24 years) * Used as a proxy of HIV incidence. 1982-19852000-2006

6. 217,000 2 On ART and follow up in the public health system 94,000 3 Follow up in the public health system without ART 59,000 4 On ART without follow up in the public health system 265,000 5 Do not know their serological status 630,000 1 PLWHA Concentrated epidemic - HIV prevalence (2009) General population 0.6% Gays and other MSM: 10.5% Drug users: 5.9% Sexual workers: 5% The AIDS Epidemic in Brazil

7. How to prevent new infections? Traditional approaches Combined approaches Traditional approaches Traditional approaches Traditional approaches

8. Condom distribution in numbers

9. Condom use among sexually active individuals – 15-64 y, per gender (%) Condom useMenWomenTotal First sexual relation (15-24 y)63.857.660.9 In all sexual relations with casual partners in the last 12 mo. 51,034.645.7 Fonte: Pesquisa de Conhecimentos, Atitudes e Práticas da População Brasileira de 15 a 64 anos de idade, 2008.

10. At the State of Acre’s Chico Mendes Extractive Reserve, Amazon Region Condom Plant Production (2011): 100 million units

11. Testing almost doubled in the last decade The percentage of sexually active women who have tested increased almost threefold (from 18% to 50%) Among men the percentage remained constant (30.1% in 1998 and 30.4% in 2008) HIV Test Coverage Sex199820042008 Men30.121.428.2 Women18.035.049.0 Total23.928.138.6 Percentage of sexually active individuals aged 15 to 54 who have tested for HIV at some time in their lives. Brazil, 1998, 2004 and 2008. Sources: Berquó, 1998; PCAP, 2004; PCAP, 2008.

12. Plans and Initiatives

13. Prevention at the Work Place Businessmen and workers sharing responsibilities in the fight against HIV/AIDS Companies encouraging prevention at the work place

14. Mobilization Strategies HIV Rapid Test

15. Prevention: Condom distribution Carnival campaign, 2004 – The largest communication action of the year: “Nothing passes through a condom. Use and trust it” Relesead after the Catholic Church questioned the efficacy of condoms.

16. Campaigns targeted at specific populations

17. PMTCT Between 1998 and 2010 there was a 40.7% reduction in AIDS incidence in children under 5 years of age All prevention inputs for the prevention of vertical transmission of HIV and syphilis are financed by the Federal Government, including formula feeding and lactation inhibitors Rede Cegonha (Stork Network): implementation of rapid tests for HIV and syphilis during prenatal care in all basic healthcare providers, as part of a comprehensive program for women and children Rapid Tests coverage for pregnant women in Primary Care : 2012 – 50% 2013 – 75% 2014 – 90% 2015 – 100% (around 3 million/year)

18. Universal Access Timeline 1980’s: –Treatment and care centered around OI treatment –Capacity and institution building 1988: Brazilian Federal Constitution The Brazilian health system (SUS) is implemented in three management levels (central, regional and local) - “Health is a right of all people and a duty of the State” 1996: a federal law was approved guaranteeing free of charge access to antiretroviral therapy to all PLWA 2007 – Compulsory license issued for efavirenz 2011: the Government Budget for ARV Purchases reached U$ 450 million

19. Number of patients on ARV Brazil, 1999 – 2011

20.  RITONAVIR (1996)  SAQUINAVIR (1996)*  INDINAVIR (1997)*  AMPRENAVIR (2001)  LOPINAVIR/r -cap (2002)  LOPINAVIR/r-tablet (2006)  ATAZANAVIR (2004)  FOSAMPRENAVIR (2005)  DARUNAVIR (2007)  ZIDOVUDINE (1993)*  STAVUDINE (1997)*  DIDANOSINE (1998)*  LAMIVUDINE (1999)*  ABACAVIR (2001)  DIDANOSINE EC (2005)  TENOFOVIR (2003)-2011*  NEVIRAPINE (2001)*  EFAVIRENZ (1999)-2007*  ETRAVIRINE (2010) RTNI and RTNt  ENFUVIRTIDE (2005) PI FUSION INHIBITOR NNRTI INTEGRASE INHIBITOR  RALTEGRAVIR (2009) *Local production Year of introduction in parenthesis Universal Access

21. Breakdown of expenditure* on ARV procurement (2011), by source – Brazil, 2011 *US$ million for 214,000 patients

22. Last viral load of patients on HAART Period: Sept 2010 to Sept 2011 Viral loadFrequencyProportion < 50 copies109,35667% 50 – 1,000 copies17,87711% 1,001 to 10,00013,8188.4% 10,001 to 50,00011,9227.3% > 50,00011,1106.8% Total164,083100 Last viral load of patients on HAART

23. YearCD4 < 200CD4 200-349CD4 350-499CD4 > 500 200332.122.51926.4 200429.922.319.428.4 200530.621.119.428.8 200632.52017.929.6 20073119.518.830.6 200832.218.117.432.3 200931.117.717.833.4 201031.717.717.932.6 Naive Patients: first CD4 count

24. Impact of ART Policy in Brazil Mortality reduction 40-70% Morbidity reduction 60-80% Hospitalization 85% reduction (360,000 avoided) New AIDS Cases: 58,000 avoided cases Improved survival after AIDS diagnosis Estimated Savings  US$ 2 billion (1996- 2003) (Hospital, drug costs and outpatient care) Diagnosis period1981 – 19891995-1996 1998-1999 Last year of follow-up198920002007 Mean survival time5.1 months*58 months**> 108 months***

25. Testing and Counseling Key populations (Sex Work, MSM, IDU Programmes) PMTCT Condom promotion and distribution Social and Behaviour change communication Treatment care and support to PLWHA Blood Safety BASIC PROGRAMME ACTIVITIES Reduce risk Reduce the likelihood of transmission Testing, Prevention and Treatment Strategies Combined Approaches

26. CRITICAL ENABLERS Investment Framework – Brazil Objectives SOCIAL ENABLERS PROGRAMME ENABLERS Reduce risk Reduce likelihood of transmissio n Testing and Counselling Key populations (Sex Work, MSM, IDU Programmes) PMTCT Condom promotion and distribution Social and Behaviour change communication BASIC PROGRAMME ACTIVITIES Treatment care and support to PLWH Reduce mortality & morbidity Social protection, Education, Legal reform, Gender equality, Poverty reduction, Health systems (incl. STI treatment, Blood safety), Community systems, Employer practices SYNERGIES WITH DEVELOPMENT SECTORS Blood Safety 90.5% 9.5%

27. Proposals 1.AIDS policy integrated to primary health care – focus on early diagnosis of HIV, syphilis, hepatitis 2.Involvement of other ministries: e.g., education, human rights, justice, women, external affairs, defense, tourism 3.Ensure availability of sufficient local funds 4.Access to treatment and prevention/laboratory tools: Intellectual property issues utilizing TRIPS flexibility for licensing, local production of generic and other tools 5.Horizontal (South-South) cooperation- including but not limited to exchange of experience, pricing of drugs/prevention&Lab tools, generic production and socializing products amongst countries 6.Decisions based on locally relevant scientific evidence 7.Truly incorporating the notions emanated from UNAIDS 3-ones

28. In conclusion Key strategies in Brazilian response consider that the main prevention initiatives are aimed at safe sexual practices, with: Human rights promotion Targeted approaches to vulnerability reduction Respect for autonomy and informed decision making Increasing access to early diagnosis of HIV infection to lower mortality and morbidity and also to prevent new infections Attention to short and long term impact of more individuals on treatment: logistics, health professionals need, cost of drugs, use of DOHA flexibilities Finally, the Brazilian Ministry of Health, with treasury only funds, develops strategies with strict respect to human rights: with transparency, clear information, access to needed medication, services and tools facilitating an autonomous decision for all.

29. FAÇA O TESTE DE AIDS, SÍFILIS E HEPATITE Muito obrigado, thank you! Brasil Ministério da Saúde Secretaria de Vigilância em Saúde Departamento de DST, Aids e Hepatites Virais Dirceu.greco@aids.gov.br www.aids.gov.br