Hugo Hagstron cuts a distinguished figure in a brightly coloured waistcoat and black beret as he leans on his walking stick in the foyer of the Sao Paulo Training and Referral Centre ‘€“ a compact hospital on Rua Santa Cruz in downtown Sao Paulo. He was infected with HIV in 1985 and has been registered at the centre since 1988.

Hagstron is 42 years old and a veteran of the struggle for access to drugs and the needs of people living with AIDS in the cityof 15 million. Although the disease is now spreading to more rural and remote parts of the country, Sao Paulo accounts for half of all AIDS cases in Brazil.

Hagstron was healthy until the early 1990s when he began to develop opportunistic infections and suffered his first bout of pneumonia. In 1991, five years before the breakthrough in treatment heralded by Highly Active Antiretroviral Therapy (HAART) he received monotherapy with one of the first available antiretroviral drugs, AZT, which the Brazilian government distributed free of charge.

The provision of free treatment, so central to the Brazilian response to HIV/AIDS, has its roots in the profound socio-political changes that were taking place in the early 1980s when the disease was first identified and Brazil was emerging from two decades of military rule.

During the military dictatorship of the 1960s and 70s a reform movement led by public health activists laid a foundation for a new health policy based on dialogue between communities, civil society and health officials.

The notion that ‘€œhealth is a duty of the state and a right of the citizen’€ was a principle that grew out of this movement and became a cornerstone of the Brazilian constitution passed in 1988 to mark the end of military rule and the re-introduction of democracy.

‘€œIt was a movement of inclusion of racial minorities and sexual minorities,’€ says Christine Pimenta who was among those who campaigned for change. Pimenta typifies the warmth and charm of many Brazilians working in the public health sector. She’€™s justifiably proud of what her country has achieved in its response to HIV/AIDS but is also realistic about how much work remains and the challenges that still lie ahead despite two decades of struggle.

Pimenta works with the Brazilian Interdisciplinary AIDS Association (ABIA) in Rio de Janeiro, the largest AIDS NGO and one of the oldest established in 1986. She says the redemocratisation movement of the 1980s responded specifically to the poor and marginalised ‘€“ an important antidote to the stigma and discrimination often associated with HIV/AIDS.

‘€œPeople who do not have access to health services do not have access to information or to condoms. The social movements worked together with the government to build a national response that would atttend to the needs of the population, especially the most needy,’€ she explains.

However, Pimenta says it has taken a 15-year battle to ensure that a constitutional commitment to health for the poor and people living with AIDS has translated into practice.

‘€œThere is a broad commitment between the federal government and social movements. We have monitored social policy and tried to feed government with information on the needs of the population especially the target groups to ensure that public policy addresses those needs.’€

Hugo Hagstron is one of the many beneficiaries of the decision by the Brazilian government to extend HAART to all its citizens free of charge in November 1996. But he emphasises it was the determination of civilian activists that ensured that government delivered on its mandate of free healthcare for all.

 ‘€œIt’€™s important to say that access to free medicines was something that was achieved by citizens ‘€“ homosexuals and people who were HIV positive. There’€™s a general impression that the government was good enough to offer free drugs, but this was not the case. We had to fight for it and we won,’€ he explains.

He acknowledges that the partnership between government and civil society is efficient and effective, but stresses that it took time to build this relationship.

 ‘€œIn the beginning it was a fight,’€ he says.

To provide free medication, Brazil had to take a firm position against multinational drug companies in negotiating for lower prices. Their key bargaining chip is the domestic capacity to produce generic copies of the drugs in the Far-Manguinhos federal laboratory in Rio de Janeiro (and six other state-owned facilities) if prices aren’€™t affordable.

In 1997 it cost $4 860 (approximately R34 000) per patient per year on ARVs. By 2002 this amount had dropped to $2 035 (R14 245). By 2002 some 125 000 Brazilians were under treatment, 95% of whom were adults, the rest children.

Dr Humberta Costa, the health minister in the socialist government of President Luiz Inacio Lula da Silva, commonly known as ‘€œLula’€, says Brazil is not so much a poor country as an unequal one.

‘€œBrazil has many inequalities but it is a good market for drug companies so pharmaceutical companies from the US, Switzerland and the UK do not want to get into a fight,’€ says Costa. ‘€œIt is in our mutual interest to negotiate.’€

He said the fact that drug companies could reduce a price by 85% when threatened with the issuing of a compulsory licence to allow for generic production showed the extent of the profits attached to these medicines.

Costa says the accusation from the international pharmaceutical companies that Brazil wants to break patents in order to access products like Viagra is totally false.

‘€œWe want to respect patents and intellectual property rights, but international pharmaceutical companies must respect the public health needs of the people. Our focus is on essential drugs for public health. We want to negotiate, we don’€™t want to fight,’€ he added.

Brazil’€™s commitment to medicines for those who most need it is a key reason it has decided not to apply for money from the Global Fund for AIDS, TB and malaria. Leaving more resources for countries that need them most.

To date Brazil has not broken any patents ‘€“ negotiations to secure reduced prices having been successful. Of the 14 antiretroviral drugs distributed by the Brazilian health ministry during 2002, eight were locally produced generics.

Dr Paulo Teixeira is the former head of the Brazilian national STD and AIDS programme. He served under the governments of both President Fernando Cardoso and President Lula and recently was appointed to the World Health Organisation as director of HIV/AIDS. In a presentation to the World Bank in Washington in June he said that the average cost per patient treated with antiretroviral therapy has decreased by 60% in recent years in spite of an increasing number of patients needing more complex and expensive treatments.

‘€œDomestic production capacity is a crucial element that strengthens the bargaining power of government agencies,’€ Teixeira told World Bank officials in explaining the Brazilian strategy of threatening to use the internationally acceptable mechanism of issuing a compulsory licence to produce generic versions of drugs it cannot afford.

The effectiveness of the Brazilian approach is born out clearly by the numbers. Since the first case was identified in Sao Paulo in 1983, a comprehensive response between government and civil society has helped keep the HIV prevalence rate down to 0,65% in a country of more than 175 million.

In 1990 the World Bank predicted that within ten years there would be 1,2 million HIV infections in Brazil. Thirteen years later, this scenario has yet to materialise. The latest estimates are that half that number ‘€“ some 600 000 Brazilians are HIV positive while 257 771 have AIDS.

This September, Brazil commemorated 20 years of its campaign against HVI/AIDS. Health interventions include huge condom distribution campaigns (condom use for a first sexual encounter has risen from 4% in 1986 to 55% in 2003), widespread social marketing through television soap dramas and during the Rio carnival, and of course Brazil’€™s much vaunted free access to antiretroviral therapy for all citizens.

All this has been underpinned by a strong political commitment at all levels of government and a non-judgemental attitude towards those who contract HIV/AIDS.

‘€œThe sexual culture in Brazil is more tolerant than in other countries,’€ says Teixeira. ‘€œIn fact, in general Brazilian behaviour is more tolerant. Over the past five years we’€™ve had some opposition but in general the critical voices are very isolated.’€

Despite the strength of the Catholic church in Brazilian society, Teixeira says there has been been relatively little criticism of the country’€™s aggressive promotion of condoms and safer sex messages in the media.

‘€œPeople are suffering and dying, the church must respond, we’€™ve had no problems with the church trying to prevent open, frank programmes from being implemented. It’€™s agreed, condoms are vital.’€

Health minister Umberto Costa is even more blunt. ‘€œWe are not interested in discussing philosophical or religious problems, we are interested in the health of the people,’€ he asserts.

Dr Arthur Kalichman is the co-ordinator of the STD/AIDS programme in the state of Sao Paulo and director of the Training and Referral Centre in the state’€™s capital city. He began working in AIDS in 1988 and says the present capacity to offer antiretroviral therapy is because of foresight and a ‘€œstep by step’€ process to incorporate treatment into existing programmes as it became available.

‘€œIf Brazil hadn’€™t begun to do something some time ago, we wouldn’€™t be in the position to offer what we can now,’€ he says.

But, he adds, treatment is the easy part of combating HIV/AIDS. Addressing issues of poverty and how to give poor and marginalised communities a sense that they can access their right to health as citizens, are far more complex.

Kalichman is encouraged by data that shows that it is the quality of the health service that defines the chances of successful treatment rather than the socio-economic status of the patient.

‘€œThis is very nice because to solve the income gap in Brazil and to solve the poverty problem will take a long time and is outside our control as health workers. But once we saw that the quality of the health service is more important for compliance we can work to improve the quality of the health services, to realise the policies of inclusion and to promote citizenship and promote access to treatment.’€

The value of antiretroviral therapy in preventing TB ‘€“ a disease widely associated with poverty ‘€“ is significant in an analysis of the number of TB cases in Sao Paulo.

‘€œFor people who are co-infected with HIV and TB we’€™ve seen a drop of 75% in the number of new TB cases among people who are HIV positive. At the end of the day, ARVs lessen the problem of TB, at least among the HIV positive population,’€ says Kalichman.

Where AIDS used to be the main cause of death in the city and state of Sao Paulo, violence is the key cause of death for both young men and women.

‘€œThis violence among young people is related to poverty,’€ says Kalichman. ‘€œIf we can increase the citizenship rights and quality of life of poor people I believe this pattern will also change,’€ he says.

Any concerns that resources channelled into antiretroviral therapy might detract from other services have, according to officials, proved groundless.

On the contrary, ABIA researcher and activist, Christine Pimenta says the provision of ARVs has had useful spin-offs for the wider health service.

‘€œIt’€™s not that you are taking from other health services to give to AIDS, you’€™re bringing up the level of treatment and diagnosis and infrastructure for the country as a whole,’€ she says.

The partnership between civil society and government is a critical element of Brazil’€™s success. Between 1995 and 1998 $10 million was spent on 559 projects. In the past four years this amount has increased three fold to $30 million and 1 944 projects dedicated to HIV/AIDS prevention and treatment are rooted in civil society.

‘€œThe combination of responses from the government and civil society as well as business is very important because they are complimentary. Even if government puts resources into actions they often concentrate on infrastructure, in training health professionals, but you also need NGOs to work with specific segments of the population, so it’€™s a combination,’€ says Pimenta.

‘€œAIDS is not just a health problem, it’€™s a political problem and an economic problem, you need to involve all sectors.’€

Despite the widespead successes, social advocate and AIDS specialist Christine Pimenta is cautious about holding up Brazil as a ‘€œmodel’€. She says the country’€™s response to HIV/AIDS has been effective, but it is particular to Brazil.

‘€œYou can learn from it, you can adapt it, you can look at political processes and social context, but you have to work with your population. You have to involve both government and the target populations as well as segments of the population who are affected and design your own response.’€

E-mail Sue Valentine