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Brazil's AIDS policy earns global plaudits

Dr. Kalichman at Sao Paulo's main AIDS/HIV research center
Dr. Kalichman at Sao Paulo's main AIDS/HIV research center  

By Roy Wadia

CNN's Roy Wadia was one of 12 U.S.-based journalists who traveled recently to Brazil as part of the Pew Gatekeeper Fellowship program. The fact-finding trip was sponsored by the Pew International Journalism Program at International Studies of the Johns Hopkins University.

BRASILIA, Brazil (CNN) -- The journalists visiting from the United States didn't know it that afternoon of June 21, 2001, and perhaps neither did their host, Brazil's Health Minister Jose Serra -- but Brasilia was on the verge of a major policy victory in the global arena.

At dispute: Brazil's decision to manufacture generic AIDS drugs for its own use. Serra's ministry saw this policy as the best way to provide the AIDS cocktail free under the public health system to those who needed it the most.

Several U.S. pharmaceutical giants, backed by Washington, decried a key provision in Brazil's patent law, saying it could be used to force foreign companies to manufacture their inventions in Brazil if the South American country declared HIV/AIDS a "medical state of emergency."

The United States wanted to haul the case before the World Trade Organization, accusing Brazil of violating WTO law.

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Serra mounted a multipronged defense. He dispatched Brazil's AIDS policy chief, Paulo Teixeira, to Geneva, Switzerland, to testify before a WTO panel; in Washington, Brazilian diplomats, backed by sympathetic U.S. organizations, lobbied the Bush administration to reconsider, and Brazil launched a media campaign extolling its policy in prominent publications such as The New York Times and The Wall Street Journal.

Depicting a mother holding a frightened daughter, the ad pleaded, "Local manufacturing of many of the drugs used in the anti-AIDS cocktail is not a declaration of war against the drugs industry. It is simply a fight for life."

Faced with mounting international pressure and a potential public relations disaster, Washington gave in. It agreed not to blow up the issue before the WTO.

In a statement, the U.S. Embassy in Brazil said: "This dispute was not about health or access to drugs. The United States never sought or intended to undermine Brazil's successful anti-AIDS effort. Let there be no mistake; we applaud this effort."

Privately, a senior official at the U.S. Embassy admitted, "Brazil handled this really well. They had world opinion on their side and played their cards beautifully."

The victory was all the sweeter because it coincided with the United Nations' Special Session on HIV/AIDS, where Brazil -- represented by Serra -- was singled out for praise for its programs, including the manufacture and distribution of generic drugs.

As the world marked the 20th anniversary of the diagnosis of HIV, Brazil emerged as the only developing nation to have carved out a promising strategy to help combat the pandemic.

Sex not taboo in this Catholic country

Barely a week before Serra's triumph, the minister and his aides were quizzed about the generic drugs debate by a group of journalists visiting from the United States.

Ads such as this were part of Brazil's media campaign to gain awareness for its policies
Ads such as this were part of Brazil's media campaign to gain awareness for its AIDS policies  

"Frankly, I'm surprised there is an international dispute at all, and we're surprised at the United States taking up the issue," Serra said.

Warming to his theme, Serra added, "The trouble is, the patent for AIDS drugs represents a pure monopoly condition in what's become a global epidemic.

"The drugs' prices are about 10 times their cost. Is this necessary to finance investment and research as their manufacturers claim? I don't think so."

There's no denying that the government's gamble on generic drugs, universal free access of such drugs since 1997 as well as high-profile AIDS awareness programs has paid visible dividends.

The World Bank had estimated that Brazil would have some 1.2 million HIV/AIDS cases by 2000. Based on government statistics and projections, however, the number was about half that amount.

The reasons, health officials said, include a groundswell of support from politicians, society leaders and citizens across all walks of life.

"Our politicians have taken a lead in the anti-AIDS campaign for many years now," said Rosemeire Munhoz, a top adviser on AIDS issues to the health ministry. "As important, the private sector is involved -- we have a business council of 22 top companies who work together on AIDS awareness programs. And, thankfully, many religious leaders and NGOs (nongovernmental organizations) are very interested in working with the government."

The fact is that in much of largely Roman Catholic Brazil, sex is not a taboo subject. Sex education starts at an early age in schools. Hotel rooms in Rio de Janeiro and other popular tourist destinations stock condoms in the minibar. Even the church assists in the effort, at least on occasion.

"The church is divided, but there are some sectors that cooperate with the government," Munhoz said. "We know of priests and nuns who advise people to use condoms. And there's a church in Fortaleza where they've distributed condoms in the church itself."

Many gay men remain in the closet

There are lingering societal hurdles, of course. One concerns attitudes toward gay sex.

In a largely macho culture, where open homosexuality is often frowned upon, many gay men remain in the closet, said Dr. Artur Olhovetchi Kalichman at the main HIV/AIDS treatment and research center in Sao Paulo.

"So you do find that men who have sex with other men hide behind marriages to women," Kalichman said. "Many of these men don't take precautions -- they get infected; they infect their wives."

Greta Sequeira, a transsexual who impersonates Hollywood actresses in Sao Paulo's entertainment scene, expands on that scenario.

"Many gay men just don't think they're gay if they take the man's role," she said. "They have this mental block, and it ends up killing them."

Sequeira speaks from experience. She's been infected for years and almost developed full-blown AIDS two years ago. "I nearly died," she said, "but thank God, I started taking the drugs. They're free, and they saved my life."

Like hundreds of patients, Sequeira comes to Kalichman's clinic for her medication and checkups. How is she faring these days? "I'm absolutely fine!" she exclaimed, tossing her red Ann-Margret hair, "and I'm going to stay that way."

A model for other countries?

Far from the crowded megalopolis of Sao Paulo, in the government enclave of Brasilia, Serra reflects on the health ministry's accomplishments.

"Our example," he said, "could serve as a model for other countries in Latin America, the Caribbean, even Africa. Everyone in the world has the right to access these therapies."

But what about countries such as South Africa, whose president openly doubts whether HIV leads to AIDS? And what of nations closer to Brazil, where cultural taboos forbid an open discussion of the issue?

"You have to accept the reality of AIDS," Serra insisted. "At first, it's not easy. But Brazil did it. Of course, we already had a good public health network in place.

"It's a whole response -- awareness, then prevention and then treatment. Prevention is important, yes, but treatment completes the circle."

Will Brazil keep up with the latest advances in AIDS therapies and roll out generic versions of new drugs as they appear?

"Well, negotiations are under way with Merck and other companies to work more closely together hopefully," Munhoz said. "We've already achieved significant price reductions for two of the recent therapies. But in the future, we frankly want more flexibility when it comes to licenses and other legal issues. Are we going to talk about this in terms of breaking a patent or saving lives?"

As Brazil and its health ministry cautiously savor their AIDS policy success, the health minister himself is being cited as a possible candidate in the 2002 presidential election.

For the government of President Fernando Henrique Cardoso, who cannot by law run for a third term, Serra's triumphs are one bright spot in a political season marred by an energy crisis, a moribund economy and corruption scandals.

For now, though, Serra is refusing to entertain speculation. "AIDS policy has nothing to do with a presidential run," he snapped at a journalist who raised the question.

In the next breath, however, he said, "When it comes to health policies, especially at this time in our fight against AIDS, you need continuity. If you look at our ministry, we've kept to our targets in our public health campaigns -- and the world recognizes us as a success. I think we should keep that going in the years ahead."

A proud health minister -- as well as a presidential candidate in the wings? Political observers here say the government's AIDS policy may be one of the best bets in attracting voters during next year's campaign season.

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