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 Like the United States and the world's richer nations
Brazil—with much cunning, lots of daring, plenty of work
and little money—has transformed AIDS from a lethal scourge
into something much more manageable and pronounceable:
a chronic disease. The whole world, mainly
the developing countries want to learn how can
they do the same for their own AIDS victims.
By Francesco Neves
As has often been the case, not until renowned French daily Le Monde and Yankee
publications like The Washington Post, The Wall Street Journal, Time magazine
and The New York Times had talked about the subject, did the main Brazilian press
open space to report that Brazil has become a model and an inspiration for nations around
the world on how to fight and win the war against AIDS. Not a small feat for a country
that often appears very low on international lists of health care providers and high on
rosters of violent and corrupt nations.
Brazilians felt good that for once it could make news as example for other countries to
follow. Thanks to a free government program of AIDS medicine distribution the nation won
some headlines on the positive column although multinational laboratories and the US tried
to paint the country as an outlaw infringing on patent and stealing intellectual property.
International organizations like the United Nations and Nobel Prize Winner France-based
Médecins Sans Frontières (Doctors Without Frontiers), however, had only words of praise
for the pioneer work of Brazil. The Médecins group praised "the political commitment
of the Brazilian government, which cut in half the number of deaths caused by AIDS from
1996 to 1999."
While rich countries have been able to keep AIDS victims alive and leading a productive
life, the same didn't happen to the rest of the world that cannot afford the expensive
antiretroviral treatment, which can cost as much as $15,000 a year in the United States.
That's why the disease is ravaging Africa, India and has become a serious health problem
for Eastern Europe. Brazil should also be in very bad shape according to estimates from
the early '90s.
In 1994 the World Bank predicted that Brazil would have 1.2 million AIDS victims by the
end of the year 2000. And they seemed right. During the '80s, the number of new cases of
AIDS was growing by 35 percent a year in the country. Brazil, however, surprised the World
Bank and itself. The country today has 530,000 cases of the disease—less than half of
what the Bank predicted—and the epidemic has stabilized with 20,000 new cases a year
for the last three years. It's believed that four-fifths of those infected with the
disease in Brazil don't even know they have AIDS. Many of the 95,000 people infected with
AIDS and receiving treatment are being seen as outpatients and are living an almost normal
life. The program should be extended to 110,000 patients by year's end.
Now, while 20 percent of adults in South Africa and many African nations are infected
with HIV, the rate of Brazilians with AIDS is 0.6 percent. Throughout the country, special
places created to attend to HIV-positive people, like Casa da AIDS (AIDS Home), in Santos,
São Paulo, use beds reserved for AIDS victims to care for other diseases, since those
with AIDS come only once in a while to pick up their medicine and take it home. Brazil's
public health policy has lowered the AIDS infection rate among adults to 0.6 percent.
Compare this to Botswana where this rate—the world's highest—is 35.8 percent.
Since 1997, virtually every Brazilian who needs the saving cocktail, the same drug
mixture that keeps AIDS victims alive and productive in the US and Europe, can get it for
free from a government administered clinic. Even in the US, AIDS victims from some states
who cannot afford the expensive antiretroviral medication might die without having access
to it.
In the last four years, the number of deaths caused by AIDS has dropped 50 percent at
the same time that the number of people being admitted to the hospital due to
complications of AIDS fell 80 percent. As Paulo Teixeira, the Health Ministry's
coordinator for the AIDS fighting program recently told Brazilian reporters: "The
disease's expansion has been contained."
For Luiz Loures, UNAIDS' s chief for Latin America and the Caribbean, Brazil's
pioneering has been a worldwide inspiration: "The Brazilian response is kind of a
flagship not only in Latin America and the Caribbean but also at the global level,"
he said, adding, "The Brazilian response is transferable. While Brazil is wealthier
than some other developing nations, political will and community support have made the
difference in a variety of countries. We are also looking at other countries, such as
Senegal and Uganda, that have taken the lead in Africa or other regions to provide symbols
in this fight."
The harder battle, the one that demanded the most effort—a discipline other
countries didn't believe Brazil would be able to demonstrate—was that from patient to
patient. The effort from an Army of officials, doctors, helpers and
volunteers—approximately 600 NGOs (Non-Governmental Organizations) have joined
forces—that united in a common work to distribute the saving medicine and guarantee
it is taken correctly, at the right times, some with food, some without.
Daily O Estado de S. Paulo reported on a telling story that illustrates how AIDS
was cornered and controlled in the country. In 1991, when doctor Robinson Fernandes de
Camargo started to treat HIV positive people in Sapopemba, in the east side of São Paulo,
people in the average were surviving two years, and his main effort was to guarantee that
the infected person had a dignified death since there was no prospect of prolonging his or
her life. Ten years later, at the Centro de Referência Herbert de Souza
"Betinho" AIDS continues to kill—there were six AIDS related deaths in
2000—but the situation would be much worse without some dramatic changes that
occurred since 1996 when patients started to be given the so-called anti-AIDS cocktail. In
comparison, in 1993 there were 78 deaths with 50 of these people having died within a year
of finding out about their disease. No patient survived past 14 months.
Survival of the Species
Data from the consortium UNAIDS, which is a joint effort between several UN agencies
and the World Bank, last December there were 36,1 million people contaminated with the HIV
virus in the world. 25,3 million of them were living in sub-Saharan Africa. While 95
percent of AIDS victims live in poor countries, more than 90 percent of those who get
adequate treatment for the disease live in rich nations.
The AIDS epidemic has already killed 21.8 million Africans. In the year 2000 alone more
than 3 million Africans died from AIDS while 5.3 million others were infected by the
disease. Thanks in great part to AIDS, life expectation in Africa has fallen to around 40
to 45 years. While Africa carries a disproportionate burden with 70 percent of the cases
(having 10 percent of the world population) and 17 million AIDS caused deaths, Brazil
would be in a much worse shape than it is today if it weren't for some courageous measures
taken by President Fernando Henrique Cardoso, often criticized for his neglect of social
problems. Against the reasoning of aides and political allies who advised him to cut the
budget of AIDS programs when the Brazilian economy was showing signs of imminent crisis at
the beginning of 1999, Cardoso chose to continue funding it.
Former President José Sarney—a conservative, he was the first civilian president
after the military dictatorship that lasted from 1964 to 1985— in 1996, became an
unlikely ally. As a senator for the state of Amapá he sponsored in congress a law that
guarantees every AIDS patient in Brazil, regardless of his or her financial capability,
the best treatment available. In an interview with The New York Times, Sarney
talked about being made aware of the triple therapy that could reduce the presence of HIV
to undetectable levels and that was announced during a Vancouver, Canada, AIDS conference:
"A doctor friend informed me about what was going on in Vancouver. I saw that most of
the medicine in the cocktail would not be available to the poor, and I felt that we were
talking about the survival of the species."
The same World Bank that in the '80s and '90s together with the IMF (International
Monetary Fund) advocated a "structural adjustment" that decimated health budgets
all across the developing world estimates that the cost preventing AIDS in Africa is over
$2 billion, while there is no more than $160 million available for this fight. Today
African countries are looking towards Brazil as an inspiration to fight and threaten
multinational laboratories that charge prices extremely high for their AIDS medication.
Seven countries alone—US, Canada, Japan, Germany, France, England and
Italy—bring to the pharmaceutical laboratories 80 percent of their revenues and an
even bigger share of their profits. Deriving a ridiculous 1 percent of its sales from
Africa, the big labs could afford to be humane and do humankind a favor by giving their
anti-viral drugs away for free. But for years they haven't lowered a cent in their
extortive prices, more interested in answering to corporate interests than save lives.
They wouldn't consider offering a discount to poor countries lest their clients in the US
and Europe would find they were being gouged and demand equal treatment.
According to Jean-Hervé Bradol from Médecins Sans Frontières AIDS is the locomotive
for remedies in general. In the wake of AIDS the question of access to drugs is very
important for diseases such as tuberculosis and paludism. Some of these remedies are not
manufactured anymore—like the ones that fight the sleeping sickness. And for 20 years
there haven't been investments in the research of tropical medicine."
Pirate Brazil
The Brazilian story is still being written and it's not without controversy, foes and
defamers. In order to make the AIDS treatment affordable, Brazil decided to copy patented
drugs and to replicate them in its laboratories. The country is now producing 8 of the 12
drugs commonly used in the AIDS cocktail. Since 1998 when it started making copies of
brand-name medications to treat the disease, the country was able to reduce by 80 percent
the cost of such drugs. The same triple drug cocktail treatment that costs around $10,000
a year in the US and Europe can be offered for $2,000 in Brazil and this price tends to go
down to $700 or even less as the nation improves its technique and convinces international
labs to lower their prices.
Unabashedly the country made drug piracy an official undertaking. Brazil has been a
paradise for pirates of all kinds of products: from Rolex watches to Levi's jeans, from
French perfumes to American computer software. But now, invoking humanitarian reasons
contemplated in international agreements, the poor Brazilian government started to copy
patented formulas from rich and stingy laboratories to save lives that otherwise would be
lost. The program of free distribution of antiretroviral drugs started in 1996.
To produce the medicines Brazil had to find the raw material in countries like China
and India, which disregard the international law of patents. But the nation continued to
buy from foreign labs two essential products in the fight against AIDS: Efavirenz produced
by Merck Sharp & Dohme and Nelfinavir manufactured by Roche. In a package of 12 drugs,
these two alone consumed 36 percent of the $306 million spent by the Health Ministry in
the purchase of AIDS drugs. Tough-talking José Serra, the Health Minister, let it be
known that the country would end up manufacturing all AIDS drugs unless the laboratories
would substantially cut their prices.
Not that the Brazilian government does not believe in intellectual property and in the
importance of drug patents for medical research and the development of new medications
that otherwise would never be produced. Six years ago, Brazil was one of the first nations
to adopt legislation based on the criteria established by the World Trade Organization.
According to Brazilian law, drugs produced before 1997 can be replicated in the country,
but not those that were released since that year.
It is estimated that a laboratory spends between $400 million and $1 billion to develop
a new AIDS drug. Merck, Sharp, & Dohme said that it spent six years of research and
half a million dollars to develop Efavirenz, one of the drugs Brazil threatened to pirate.
The equipment Brazil purchased to replicate the medicine cost much less: $250,000. It was
acquired by Far-Manguinhos, a public laboratory associated with publicly-owned Fundação
Oswaldo Cruz. And the laboratory believes that it will be able to copy the Merck drug by
September.
Wrote The New York Times Magazine on a superb cover story by Tina Rosenberg on
the status of AIDS in the world and the Brazilian contribution to solve the worldwide AIDS
crisis: "Brazil is showing that no one who dies of AIDS dies of natural causes. Those
who die have been failed—by feckless leaders who see weapons as more alluring
purchases than medicines, by wealthy countries (notably the United States) that have
threatened the livelihood of poor nations who seek to manufacture cheap medicine and by
the multinational drug companies who have kept the price of antiretroviral drugs
needlessly out of reach of the vast majority of the world's population."
And the article continues: "At first glance, it would seem that Brazil has
advantages that are hard to duplicate. It has a well-organized network of civic groups,
which were essential to building support for the program, designing it and making it work.
It is a big country, with a large market of drugs. It has a health care system, however
patchy. And while it is a poor country, it is a rich poor country. Some countries will be
unable to follow—they are too corrupt or war-torn or venally governed or not governed
at all."
Brazil is already starting to export its technology for the manufacturing of AIDS drugs
as well as control of quality techniques and ways of administering the medicine, much of
this for free. A delegation from Burkina Faso, Africa, has visited the country recently to
learn how Brazilians are managing their AIDS predicament. The government has also signed
cooperation pacts with Angola, Guinea-Bissau, Mozambique and São Tomé and Príncipe.
International aid group Oxfam has joined the increasingly loud chorus of those
defending the idea that Third World countries should be allowed to copy drugs and to
manufacture them at much cheaper prices not only to treat AIDS but also to deal with
respiratory tract infections and childhood diarrhea. Oxfam has also appealed to Washington
and major pharmaceutical labs to drop their suits against countries that are copying
patented AIDS drugs. In a statement released recently Oxfam explained its position:
"This industry campaign has been led by the Pharmaceutical Research and Manufacturers
of America (PhRMA), one of the worlds most politically influential and well-financed
industrial lobbies. The primary source of PhRMA's power is its influence over the office
of the US Trade Representative, which has repeatedly backed its claims with the threat of
trade sanctions."
Mark Grayson, spokesman for PhRMA, responded that his organization has the same
concerns as anybody regarding access to affordable drugs in developing nation and blamed
the poor countries for not having an infrastructure good enough to take advantage of a
possible deal with labs. He also accused some governments of having little interest in
health matters. As for Brazil, Grayson, as expected, doesn't like the government's
approach: "We believe Brazilian officials have had some good efforts putting
resources toward this major problem, but they are still part of the world order and need
to work things out with our companies." In an interview with weekly newsmagazine Veja
he was even more incisive: "I'm sure Brazil is already paying prices well below
those charged other developing countries. What else does the Brazilian government want?
The same treatment as Botswana?"
The Goliaths Brazil decided to face and who have a powerful godfather mostly in the
government of the United States have names like Boehringer Inelheim, Bristol Myers Squibb,
Glaxo Wellcome, F. Hoffmann Laroche and Merck and Co. Only in May, 2000, these five
pharmaceutical giants agreed on giving discounts for their AIDS drugs to poor nations.
Senegal, Uganda and Rwanda were able to sign secret agreements with the labs with the
price charged not being publicly revealed. The government of Ivory Coast also disclosed
that the laboratories Glaxo SmithKline, Bristol Myers Squibb and Merck decided to sell
them antiretroviral drugs discounted up to 90 percent. That would allow the country to
spend as little as 1,200 in AIDS drugs to treat a patient for a year.
Only in recent weeks, after much posturing and threats of suits, however, the giant
laboratories started to be more flexible in their discussions with Brazil. It helped a lot
that the country has shown determination, starting to produce its own generic drugs and
seriously contemplating the patent breakage of some intransigent companies. This didn't go
well in Washington though, and the democratic administration of Bill Clinton has taken
Brazil to the World Trade Organization's Dispute Settlement Body. The country is being
challenged in its program of distributing free drugs to AIDS patients.
No wonder there were no takers, last year, when the Clinton administration made
available $1 billion through the Eximbank to fight AIDS. It happens that the money was a
loan charging regular commercial interest rates. Besides, the borrowers were supposed to
buy drugs from American laboratories for the full price they are sold in the US. It was
inevitable that such arrangement would generate the universal chorus of "thanks, but
no thanks" that it did.
Doubts, doubts
Even among AIDS researchers the Brazilian effort was questioned early on. Some doubted
that Brazil would have the technology to produce proper generic equivalents. Others feared
that a mismanaged program with people taking the drugs irregularly would create more
resistant strands of the HIV virus. "I was against the Brazilian program at
first," said Brazilian Mauro Schechter, one of the world's most respected AIDS
researchers who is head of Universidade Federal do Rio de Janeiro's AIDS Research
Laboratory. "I thought it would be very expensive and difficult to establish the
necessary lab infrastructure. But the program has been very effective." He admits,
however, that some of Brazil's generic drugs may not have the same quality of the top name
brands.
Why did Brazil lead the way in this worldwide war? Brazil was the only nation smart and
brave enough to take advantage of a "loophole" in the Agreement on Trade Related
Aspects of Intellectual Property Rights (TRIPS), a pact practically imposed by the
international lobby of several multinational groups on the World Trade Organization (WTO).
The treaty that gives pharmaceutical companies the right to hold to their patents and
charge as much as they wish for a drug for the period of 20 years, also, recognizes the
right of a nation to break a patent in case of national emergency.
Before the Brazilian chutzpah act, however, this clause had no teeth. Countries that
tried to invoke the emergency clause were massacred by the threatened laboratories and by
Washington. When South Africa and Thailand, for example, tried to manufacture their own
AIDS drugs, the American government sided with the pharmaceutical industries and
threatened with trade sanctions. They seem intent also now in dissuading Brazil from
selling the generic AIDS drugs it produces to third countries. They would also like to
forbid these countries from obtaining the Brazilian medicine.
For UN secretary general Kofi Annan, part of the success of the Brazilian experience
should be attributed to the government's decision to manufacture its own AIDS drugs even
without the permission of the laboratories that developed the medicine. Persistence was
the other factor of this equation. Despite all the cost involved and the pressure from the
Catholic Church and other conservative forces against the ample distribution of condoms
and educational campaigns about AIDS and how to prevent it the Health ministry went ahead
and was able to control the disease.
While other countries with similar AIDS epidemics have adopted programs similar to
those implanted in Brazil only rich countries like the US were able to give continuity to
them in a so large a scale. The Brazilian open attitude about sex and the mobilization of
the gay community were fundamental since the beginning of the fight against the AIDS
epidemic. Brazilian campaigns on AIDS awareness were taken not only to the airwaves and
the pages of the press but also to churches' and nightclub's doors, to prostitution areas
and gay clubs. The Brazilian youngster has become the best informed in the world about the
AIDS virus, according to a UNAIDS study. Tens of millions of condoms have been distributed
for free and annual consumption of the product has reached 320 million units. Drug addicts
can also easily get disposable syringes.
Being a pioneer in the treatment of AIDS victims has taught Brazilian health officials
some precious lessons that are helping patients themselves and the national AIDS treatment
program. Artur Kalichman, coordinator of the São Paulo Program of AIDS Combat, has found
out, for example, that stronger drugs shouldn't be used before the patient shows symptoms
of the disease. "We soon noticed," he told weekly Veja magazine,
"that it is more convenient to wait for the first symptoms of immunological weakening
instead of attacking the HIV as soon as it is found in the organism." This procedure
not only frees patients from side effects from drugs they don't need now since the disease
can sometimes take years to manifest itself, but also allows more people to enjoy the
benefit of these expensive and helpful drugs.
A Breakthrough
In March, after lengthy negotiations with the Brazilian Health Ministry, New
Jersey-based Merck announced that it was cutting the price on Efavirenz and Indinavir, two
of its AIDS drugs. It was a significant drop. The Efavirenz capsule had its price reduced
from $2.32 to 84 cents (64 percent) and the Indinavir was reduced from $1.62 to 47 cents
(71 percent). According to the Health Ministry, Brazil will save $38 million a year with
the discounted price. "This is a big victory that was possible only because Brazil
has been fighting for this here and overseas," said outspoken Health minister José
Serra. "The price offered is lower than what we would get by breaking the patent and
producing the drug in the country."
On March 30, one day after announcing the price-cuts by Merck, the Health Ministry
revealed that it would once again appeal to Swiss drug maker Roche Holding AG to also cut
the price of its AIDS drug, Nelfinavir. Together with the appeal there was again a threat
that the country could break the patent of the medicine and start to produce the drug as a
generic as soon as June.
The ministry said also that the state-owned Far-Manguinhos laboratory will keep
studying the composition of the Nelfinavir in order to replicate it, since the 13 percent
cut announced by Roche a few weeks ago was not good enough. "If an agreement isn't
reached, the Health Ministry will ask for compulsory licensing for national laboratories
to produce Nelfinavir," said the ministry spokesperson.
Reacting to the Merck's announcement, Paulo Teixeira, coordinator of the AIDS National
Program, said that "for the first time in the history of the market economies, a
multinational was guided by UN's HDI (Human Development Index). "We have here,"
Teixeira said, " a differentiated price charged according to the paying ability of
each country." While the tablet of Efavirenz is being sold for 84 cents in Brazil,
they are paying 45 cents for it in Africa and $4.32 in the US.
This drug is being taken by 15 percent of the 95 patients being treated for AIDS in
Brazil and represented 11 percent of the cocktail's whole price. Roche's Nelfinavir is
used by 23 percent of the patients and is consuming now 23 percent of the money spent in
AIDS remedies.
High Times
The explosive arrival of AIDS in Brazil, in 1985, coincided with the end of a
repressive and moralistic military dictatorship that had lasted 21 years. There was a new
generation ready to experience life, sex, and drugs to the fullest, ready to use the pill
but unwilling to wear condoms, following the letter of Milton Nascimento's lyrics:
"any kind of love is worth loving." An explosive combination guaranteed to
easily spread a disease that's mostly transmitted through sex and contaminated syringes.
It's not by coincidence that 66 percent of the AIDS victims in São Paulo were born
between 1955 and 1971. They were between 14 and 30 years of age when the disease started
to spread in the country.
"It was the generation that didn't trust anyone over 30 and lived the time of the
so-called free love, with heterosexual practices and growing homosexual
permissiveness," according to São Paulo economist and PUC's (Pontifícia
Universidade Católica—Pontifical Catholic University) professor Samuel Kilsztajn,
49. He is the co-author of the study Notified Cases of AIDS in the State of São Paulo
_ The Vulnerable Generation.
Among the celebrities who were taken by the disease were Cazuza, singer-composer who
was born in 1958 and died in 1991; rock composer Renato Russo who died in 1996 at age 36;
soap-opera leading man Lauro Corona who was a TV sensation when he died in 1989 (he was
born in '57) and Cláudia Magno, another TV actress who died at age 34, in 1994.
With the worse behind, Brazil now is afraid that people will forget the times of fear.
Half of those being infected by AIDS today are young people who didn't experience first
hand the full blow of the epidemic Recent research shows that the AIDS explosion of cases
in 1985 didn't translate immediately in a great number of deaths due to the nature of the
disease that takes an average of eight years to reveal its symptoms. It took ten years for
the 1985 explosion to show in the death statistics. In 20 years of epidemic the worst year
was 1995.
While homosexuals were the first to be infected, there was a second outbreak that
affected mainly those using intravenous drugs. Most recently heterosexuals have been the
main victims of AIDS due to the initial misconception that this was a gay disease. Much
has been said and written about the feminization of the disease in Brazil. Most of the
women are married living in a monogamous relationship and are being infected by their
husbands. For Health Minister Serra this development was anticipated by health experts.
"There was no surprise there because the Ministry was following this growth. Now we
have to improve our prevention work among women, and they need to adopt a more assertive
posture in order to avoid the contamination."
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