The HIV and AIDS epidemic in Brazil is classified as stable at the national level, with a prevalence rate in the general population of 0.4%. However, HIV prevalence varies geographically, with higher levels noted in the South and Southeast of the country.1
In 2013, it is estimated that 734,000 people were living with HIV in Brazil, yet only 589,000 of these people knew their status.2 As a result of not accessing antiretroviral treatment, 16,000 people died of HIV-related illnesses during 2013.3
Key affected populations in Brazil
Data reveals that the HIV epidemic is concentrated among key populations in Brazil. Additionally, the last 10 years has also revealed changes in the age profile of reported HIV and AIDS incidence. Most notable has been a shift to younger individuals, among both men and women. While the highest rates of infection are reported among people aged 30–49, there is an increasing trend in detection rates among young people aged 15–24 years and adults aged over 50 years.3
People who inject drugs in Brazil
The government of Brazil implements a harm reduction strategy to address the needs of people who inject drugs (PWID). In the 1990s, HIV and AIDS cases linked to PWID reached 25% in Brazil. However, the implementation of an expanded programme has shown a dramatic reduction of up to 72% between 1996 and 2006.4
HIV prevalence among PWID in Brazil has remained relatively unchanged, ranging between 5% and 5.9% during the period 2008 through 2013. The Brazilian government, as part of its harm reduction strategy for PWID, continues to provide supplies including free needle exchanges as a key component to achieve a reduction in the transmission of HIV and other blood-borne infections. More recently, trends are showing increasing dependence on non-injecting drug use to consume crack and other stimulants.4 Varied strategies and diversified approaches are required to address these practices.
Prisoners in Brazil
HIV prevalence among people who inject drugs who are also part of the prison population in Brazil, continues to be higher than that of the general population. The incidence of HIV is accelerated by issues of overcrowding and violence, and is exacerbated by other social and welfare vulnerabilities, and legal and policy constraints.4
In January 2014, the Ministry of Health launched the National Policy on Comprehensive Health Care for Prison Populations, which aims to ensure access to the Unified Health System for this population.1 The package of interventions to address HIV in prisons settings will include: access to HTC, HIV treatment and care, information, education and communication, prevention, diagnosis and treatment of tuberculosis, availability of condom and needle and syringe programmes.
Sex workers in Brazil
Current prevalence of HIV among female sex workers in Brazil is 4.9%.1 3 Sex work is legal in Brazil, and the government has implemented HIV prevention interventions through the Ministry of Health which involve a rights based approach. These include campaigns that promote the self-esteem and rights of sex workers, and emphasise consistent condom use. Of note however, owning a brothel or engaging in any business associated with sex work is criminalised (but individual sex work is not).5
Additionally, as a result of lobbying by sex worker organisations, sex work has been included as a profession in Brazil, thereby entitling sex workers to social security and other work benefits.5
Knowledge of HIV prevention methods and condom use with clients is reported as high among female sex workers – 90% used a condom with their most recent client.1 6 However, only 17.5% of sex workers in Brazil were tested for HIV in the last 12 months.1
Community empowerment has been identified as a key success factor in promoting and sustaining change, to address health and human rights among sex workers.6 However, sex workers in Brazil still face structural factors and exposure to HIV as a result of fear of violence, and socio-economic constraints, which increase high risk practices among the population.
However, in the past 5 years, HIV prevention and sex-worker rights interventions have become more restricted in scope as a result of declining national and international political and financial support. At the national level, the Brazilian Minister of Health vetoed, and replaced a rights-based anti-stigma HIV prevention campaign created in partnership between sex workers and the STD/AIDS department of the Ministry of Health. The restructured campaign focused exclusively on condom use without any reference to human rights or citizenship, which is indicative of the ongoing challenges for the Brazilian sex worker community.6
Men who have sex with men in Brazil
HIV transmission among men who have sex with men (MSM) in Brazil remains predominant, with 10.5% of this group living with HIV.1 In the last decade, there has also been an increase of AIDS cases among this population. In a recent study, HIV prevalence among MSM ranged from 9.1% to 16%.7
HIV prevalence varies significantly on the basis of geography and other factors such as age and socio-economic realities. For example, in the age group of 18–24, the national prevalence is 4%, while for São Paulo, the prevalence rate in this group reached 15% in 2012.1 Additionally, there has been an increase of AIDS cases among MSM aged 15 – 24.
Despite the gains of the last 20 years, the proportion of men reporting unsafe sex in high-risk settings has dramatically increased.8 There is need to address the structural barriers affecting uptake of services, but also to implement a comprehensive approach towards prevention and treatment of HIV among MSM. It must take into account the community and social norms that contribute to individual risks.
HIV testing and counselling in Brazil
The Brazilian Department of STD/AIDS and Viral Hepatitis (DDAHV) over the last three years has been decentralising its HIV testing services including increasing the use of rapid tests (finger-prick) in primary care services throughout the country. By 2013, uptake of testing among the adult sexually active population had increased to 37%, where at least one HIV test was reported.1
However, testing coverage drops to 13% (9.7% among men and 15.4% among women) among individuals 15 – 49 years old who have had at least one HIV test in the past 12 months and know the result. Awareness of testing services varies, with 51% of individuals aged 15 – 64 being able to identify locations where HIV testing is available free of charge. A similar proportion was found among gay men and other MSM (50%), while among female sex workers the observed proportion was 57%.1
Strategies have been implemented in partnership with nongovernmental organisations (NGOs) to scale up testing among key populations. As recently as November 2013, representatives of 40 NGOs were trained in rapid testing for HIV with a focus on people at most risk of HIV, including people who inject drugs, men who have sex with men, sex workers and transgender people. The deployment of this new strategy facilitates HIV testing to be conducted beyond health centres, expanding access to the key populations at various times or in diverse locations such as social events or on the street.9
Mobile HIV testing
The Department of STD/AIDS and Viral Hepatitis has partnered with the NGO EPAH, to implement the project “Quero Fazer” (I want to be tested). It targets men who have sex with men and transgender people with the use of a mobile unit. This strategy has been successfully expanded to other cities including Recife, Rio de Janeiro, Brasília, and São Paulo. These units reach populations in community settings with high HIV prevalence, and who also face great challenges for early diagnosis, mainly due to stigma and discrimination that are still prevalent in some traditional healthcare facilities.1
HIV prevention in Brazil
The national HIV and AIDS Response for Brazil is situated within the Ministry of Health and is integrated into the Health Strategic Plan. One of the objectives is ‘reducing HIV transmission’.10 The multipronged approach involves promoting and improving access to HIV testing, and adoption of treatment as prevention combined with the provision of pre- and post-exposure prophylaxis.
Brazil’s Ministry of Health figures state 96% of Brazilians identify condoms as a barrier that can prevent the spread of sexually transmitted infections (STIs) and HIV. The knowledge of where to get tested for HIV and access free condoms, is considered by the Brazilian Ministry of Health as an indicator of access to prevention programs.1
Condom use, however, varies widely with only 25% of the population reporting condom use in all sexual relations, and 63% during sex with a casual partner. Reported condom use in key populations is higher than that observed in the general population – with 60% of MSM reporting having used a condom during their last sexual intercourse in the last 12 months. Among PWID, reported condom use was approximately 41%; while among female sex workers, condom use at last sexual encounter with a client was more than 90%.1
Free condoms and lubricant are widely available, with at least one third of the general population accessing commodities at public health services, NGOs or other institutions. Among key populations, access is significantly higher – 70% among gay men and other MSM and 77% among female sex workers.1
Antiretroviral treatment (ART) in Brazil
Antiretroviral treatment coverage (among adults 15 years and older) for Brazil was an estimated 41% in 2013.3 Among those diagnosed (734,000), around 404,000 people have started antiretroviral treatment. Among people on ART, 338,000 have an undetectable viral load, meaning they are adhering to treatment well.10
Free ARVs are available to all Brazilians living with HIV. Brazil began manufacture of generic ARVs in the 1990s and now produces 11 of the 20 ARV used for HIV and AIDS treatment.11
HIV treatment and care in Brazil is coordinated by a decentralised network of specialists, tasked to provide quality care and services to people living with HIV. Known as the Specialised Care Services (SAE), there are more than 700 of these teams located across all Brazilian states. Although quality and consistent care and follow-up is provided, challenges as a result of the demand from new and existing patients has overburdened services.1
Additionally, various measures and actions have been implemented with a focus on HIV prevention and treatment for children and adolescents:
- in 2012, Brazil adopted the recommended Option B+, in which pregnant women should start treatment regardless of CD4 count, and should not discontinue treatment after childbirth
- in 2013, an updated version of the Guidelines of Comprehensive Care to Adolescents and Young People Living with HIV and AIDS was published.1
Treatment as Prevention (TasP)
Brazil has implemented TasP since December 2013, which allows for treatment to be initiated immediately after confirmation of an HIV diagnosis, regardless the CD4 count. The implementation of this new approach is intended to improve the quality of life of people living with HIV, and reduce the likelihood of transmission as a result of viral suppression.3
Barriers to HIV prevention in Brazil
One major platform of the Brazilian HIV response has been its inclusion of a human rights perspective, which focused on promoting the visibility of health as a right, and addressing stigma and discrimination. Despite this, issues of violence and stigma and discrimination, particularly against key populations, remains a challenge for the national response.
On-going collaboration between various governmental departments and civil society is in support of the implementation of several legal and sociocultural initiatives to promote and protect the rights of all citizens, and also fight homophobia, violence against women and lack of respect for the other.11
The future of HIV and AIDS in Brazil
The Brazilian HIV and AIDS response has received international acclaim for a comprehensive public health approach, which has yielded dramatic results in its more than 25 years of implementation.12 However, HIV and AIDS remains a significant challenge for the country. This is evident particularly in the number of new infections and the scale of the epidemic among key affected populations.
Within the last four years, there has been a resurgence of the Brazilian national HIV response. It has demonstrated the efficacy of implementing a combination approach to HIV, which has improved early diagnosis and linkages to treatment and care.
Access to antiretroviral treatment has been expanded, with 49,000 persons added in 2013, bringing the total number of persons to 404,000. The government of Brazil continues to be a leader in the manufacture of generic ARVs, which has been a key factor in the cost effectiveness and efficiency of its drug provision.1
- 1. a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. r. Brazilian Ministry of Health (2014) ‘Global AIDS Response Progress Reporting Narrative Report – Brazil’
- 2. Brazilian Department of STD, AIDS and Viral Hepatitis (2015) ‘Brazil progresses towards the achievement of the 90-90-90 target'
- 3. a. b. c. d. e. f. g. h. UNAIDS (2014) 'The Gap Report'
- 4. a. b. c. UNODC, Liaison and Partnership Office (LPO) in Brazil (accessed May 2015) ‘HIV and AIDS Actions’
- 5. a. b. Kerrigan, D., et al (2013) ‘The Global HIV Epidemics among Sex Workers’, The World Bank
- 6. a. b. c. Kerrigan, D., et al (2014) ‘A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up.’ The Lancet, Vol. 385, No. 9963, p172–185
- 7. Kerr LR., et al (2013) ‘HIV among MSM in a large middle-income country’, AIDS Journal, Vol 27:427-435
- 8. Braga Cunha, C., et al (2014) ‘Unprotected sex among men who have sex with men living with HIV in Brazil: a cross-sectional study in Rio de Janeiro’, BMC Public Health, Vol 14: 379
- 9. UNODC (2013) ‘Brazil expands HIV testing with the help of NGOs’
- 10. a. b. Brazilian Department of STD, AIDS and Viral Hepatitis (2015) ‘Brazil progresses towards the achievement of the 90-90-90 target
- 11. a. b. Brazil Department of STD, AIDS and Viral Hepatitis (2012) ‘AIDS in Brazil – Brazilian Policy Focus’
- 12. Gómez, EJ., (2010) ‘What the United States can learn from Brazil in response to HIV/AIDS: international reputation and strategic centralization in a context of health policy devolution Health Policy Plan’, Vol 25 (6): 529-54