Civil society had to fight for universal access to AIDS drugs in Brazil
Graham McKerrow, HIV i-Base
Different social movements in Brazil united to press the authorities to provide universal access to treatments before the government would take action that has resulted in the country being held up as a model for others to follow, reported a speaker from the Brazilian Interdisciplinary AIDS Association.
Another speaker told a separate session that the production of generic versions of antiretroviral (ARV) drugs allowed universal access to the drugs and had resulted in an 80% reduction in the number of hospitalisations, cut the death rate and saved Brazil $222 million between 1997 and 2000.
Carlos André Passarelli, and colleagues from Rio de Janeiro, carried out a study of how Brazil achieved its much-admired treatment policies. 
They conclude that “the universal access guarantee is a continuous process of follow-up and improvement, which depends on the civil society’s involvement to uphold the social control” of Brazilian public health policy.
Passarelli said Brazilian laboratories started producing AZT in 1993 and two years later the ministry of health said the distribution of antiretrovirals (ARVs) was a state responsibility. The following year the 11th International AIDS Conference reported on the efficacy of drug combinations.
In 1999 Brazilian NGOs held demonstrations to demand state funding of ARVs. In 2001 the USA sued Brazil over their patent law and 39 pharmaceuticals filed suit to protect their licences in South Africa. The same year the World Trade Organisation (WTO) ministerial conference agreed that the TRIPS (the WTO’s Agreement on Trade-Related Aspects of Intellectual Property Rights) agreements would not override health requirements.
The researchers reported that Brazil’s history of activism, the characteristics of the Brazilian public health system and the local manufacture of AIDS drugs, all played their parts in achieving universal access to treatments. Also key factors in the success were “the use and application of legal and constitutional mechanisms and the Brazilian government’s commitment to acquire and produce AIDS drugs”.
Passarelli said the social gains of the Brazilian ARV policy included a better quality of life for PLWHA and the commitment of PLWHA on prevention issues.
Celia Szwarcwald, professor of biostatistics at the Brazilian National School of Public Health, said Brazil was a low-income country with a GDP per capita of only $4,500 and a huge wealth gap. It is the unique low-income country to provide universal access to ARV therapy, a policy that has resulted in an 80% reduction in hospitalisations, she said, and has cut the number of deaths while the number of new cases continued to grow.
However, the cost of the drugs was a challenge to the Brazilian programme so, following the publication of evidence about the efficacy of combination therapy, the country stepped up production of generics.
Szwarcwald and colleagues conducted a mathematical analysis of the annual total cost of ARV therapy in the period 1997 to 2000. 
They found a reduction of 72% in the average individual cost of dual therapy, and a reduction of 64% in the individual cost of triple therapy over the period.
They also found that despite the increasing number of patients, the total annual therapy costs decreased 8% from 1999 to 2000, and did not exceed the budget limit of £300 million.
Szwarcwald said the average cost of triple therapy was $17 a day in 1998 but that was reduced by 40% by 2000. The total ARV therapy bill for Brazil fell from $281 million in 1999 to $258 million the following year. The researchers calculated that generic production saved the country $222 million between 1997 and 2000.
She added: “The national production of ARV drugs has provided the basis of negotiations with drug companies.”
The researchers concluded: “As a result of the national production of generics, the cost of ARV treatment has not escalated in recent years, making [it] possible to maintain universal access to ARV therapy. The Brazilian model offers important lessons to developing countries, as it shows that universal anti-AIDS therapy is an achievable goal, even in a low-income country context.”
Another presentation showed that median survival of people with AIDS diagnoses was five months for patients diagnosed before 1989, 16 months in 1995, and 58 months in 1996. 
The researchers concluded: “Survival time has increased by over ten fold for adult Brazilian AIDS patients with the greatest improvement in recent years, coincident with universal HAART treatment.”
- V Terto Jr., C A Passarelli, R Parker et al. Civil society fight to get universal access to AIDS drugs: the Brazilian case. XIV International AIDS Conference, Barcelona, 7-12 July, Abstract MoOrG1082.
- C L Szwarcwald. The impact of national production of ARV drugs on the cost of the ARV therapy in Brazil, 1997-2000. XIV International AIDS Conference, Barcelona, 7-12 July, Abstract ThOrE1424.
- JRP Marins, MB Barros, LF Jamal et al. Dramatic improvement in survival time of adult Brazilian AIDS patients. XIV International AIDS Conference, Barcelona, 7-12 July, Abstract WePeC6055