Access to Antiretroviral Drugs in Brazil

Since 1996, the Brazilian Ministry of Health has offered free, universal access to antiretroviral treatment for people living with HIV/AIDS. This well-known aspect of the Brazilian National AIDS Program has had political, financial and logistical challenges. The current study examines the history and context of Brazil's antiretroviral policy, the logistics of the drugs' distribution and the government's strategies for acquiring the drugs.

In 1988, the Brazilian public health system began to distribute drugs to treat opportunistic infections; in 1991, it started to offer zidovudine. In November 1996, Brazilian president Fernando Henrique Cardoso signed a law establishing free distribution of antiretrovirals to HIV/AIDS patients. Since the coordinated distribution began, the number of people receiving treatment has steadily increased.

Brazil's government continues the distribution program despite escalating drug costs for two reasons: the reduction of deaths and the reduction in hospital admissions and associated treatment costs from opportunistic infections. Other benefits of the program are a reduction in under-reporting of cases, enhanced quality of life for HIV/AIDS patients, increased numbers of people getting tested, and the social recognition patients gained when the government affirmed their value to society by upholding their right to treatment.

Logistically, the country was challenged to devise a strategy to distribute and monitor antiretrovirals through the public health system. Currently, Brazil has 424 sites where patients can receive antiretrovirals, called AIDS Drugs Dispensing Units, and located in public hospitals or health centers. The National AIDS Program implemented a system in 1998 to keep computerized records of drug distribution and to track prescriptions. Another database tracks test results and generates graphs of changes in CD4 and viral load for clinicians' use. To ensure confidentiality, access to both databases is limited, and patients' names are not divulged.

The high cost of antiretrovirals is one hazard to Brazil's continuation of free and widespread access to the drugs. To assuage that difficulty, Brazil has steadily increased its domestic share of drug production, until by the end of 2001, the country was producing seven of the 13 antiretrovirals used to treat its citizens. On the international market, Brazil has sought to negotiate the best possible price for pharmaceuticals, sometimes threatening to break patents if pharmaceutical companies do not reduce their prices. Called compulsory licensing, the practice is permissible under certain circumstances according to Brazilian patent law. Although it has not invoked compulsory licensing, Brazil has used the threat to pressure manufacturers into lowering prices on drugs such as nelfinavir and efavirenz. In November 2001, the World Trade Organization released a declaration allowing the use of compulsory licensing in cases of national public health emergencies, a development that strengthened Brazil's position and possibly paved the way for other developing nations to acquire HIV/AIDS drugs at lower costs.

"In conclusion," the author wrote, "the Brazilian response to the HIV/AIDS epidemic merits being seen as an example of one developing nation's determination to meet the treatment needs of people living with HIV/AIDS. Although local realities could make it difficult to apply the Brazilian model to other countries, much can be learned from Brazil's experience. At the same time, the country's commitment to free and widespread access to antiretroviral treatment warrants further study with respect to its effectiveness, dynamics, and sustainability."

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