Health care systems in transition: Brazil Part II: The current status of AIDS in Brazil

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1 Journl of Public Helth Medicine Vol. 8, No. 3, pp Printed in Gret Britin Helth cre systems in trnsition: Brzil Prt II: The current sttus of AIDS in Brzil Breno Riegel Sntos nd Nemor Tregngo Brcellos Keywords: Brzil, helth systems trnsition, AIDS Introduction Aprt from its delyed industriliztion, Brzil hs suffered prolonged periods of politicl instbility nd continues to fce deep economic problems. Development mong its 7 sttes is extremely vrible, mking the Northern nd North-Estern regions the poorest compred with the reltively rich South-Estern nd Southern regions. Such discrepncies, long with different culturl chrcteristics, prllel the epidemiologicl differences in the AIDS epidemic mong the vrious sttes nd, consequently, in the resources vilble to them to combt the epidemic. HIV nd STD control policies re co-ordinted t centrl level by the Ministry of Helth through the Ntionl Control Progrmme of STDs nd AIDS (PNC DST-AIDS). At stte level, such policies re controlled by the stte helth secretrit through the STD-AIDS Control Progrmme. At locl level, disese notifictions re monitored (notifiction is required for AIDS cses), medictions re provided to individuls nd public hospitls, nd bulletins re regulrly published with sttistics which describe the progress of the epidemic. Epidemiology At the end of December 994, Brzil rnked second in the world with 894 reported AIDS cses. By September 99, the totl number of AIDS cses reported to PNC DST-AIDS hd incresed to 7? The mjority (87 per cent) of cses were from the South-Estern nd Southern regions (Tble ), nd per cent of ll cses cme from S3o Pulo, the most populous stte in Brzil. Of the 7 reported AIDS cses, 8 per cent were men nd 8 per cent women. Of the 8 7 men reported with AIDS, risk fctors were known for 4789 (8 per cent). Of these, per cent were men who hd hd sex with other men, per cent were injecting drug users (IDUs), per cent were heterosexul men, nd per cent were trnsfusion recipients. Of the 44 femle AIDS cses reported by September 99, risk fctors were known for 948 (7 per cent). Of these, 0 per cent were heterosexul women, 30 per cent IDUs nd per cent were trnsfusion recipients. The mjority of heterosexul women to dte hve been infected by bisexul or IDU sexul prtners. 3 " Some uthorities refer to this trend s n 'Africniztion' of the epidemic in Brzil. 3 Given the reltively low incidence of HIV infection in non- IDU heterosexuls, this nlogy seems inpproprite t lest t present. Certinly, since the beginning of the epidemic in Brzil the mle:femle rtio hs come down from 43: in 98, to : in 99. In one So Pulo HIV clinic, the mle:femle rtio hs come down to : 3 (Figs nd ). Owing to the ever-incresing number of infected femles, the number of infected children hs incresed, 4 nd they now mke up 3- per cent of ll AIDS cses. Importntly, the number of cses of HIV infection which occurred through trnsfusions with infected blood nd blood products hs been decresing, minly owing to more effective testing for HIV in blood bnks, which hs been enforced by federl lw since 987. To monitor the geogrphic, temporl nd demogrphic dissemintion of HIV- infection mong the popultion, seroprevlence studies re being conducted in sentinel clinics. Such seroprevlence studies re nonlinked nd nonymous, nd hve been used to study 'high-risk' popultions, such s STD clinic users, nd 'low-risk' popultions, such s pregnnt women. Seroprevlence mong STD clinic ttenders vries Infectious Diseses Service, Hospitl Senhor d Conceico, Ru Frncisco Trein 9, Porto Alegre-RS, Brzil. BRENO RIEGEL SANTOS, Chief STD-AIDS Control Progrm, Stte Secretrit of Helth, Av. Joo Pesso 37, Porto Alegre-RS, Brzil. NEMORA TREGNANO BARCELLOS, Co-ordintor Address correspondence to Dr B. R. Sntos. Oxford University Press 99 Downloded from by guest on August 9, 0

2 TABLE AIDS cse distribution by geogrphicl regions (with percentges given in prentheses) nd incidence per popultion, Brzil, " Region North Northest Centre-west Southest South Totl Number 93 (-3) 89(7-3) 99 (4-) 448 (7-) 799 (0-7) 7 (00) *As of September. Reference, dpted. BRAZIL'S HEALTH CARE SYSTEM 97 Incidence from per cent in So Pulo to per cent in Arcju (Tble ). Similrly, seroprevlence mong pregnnt women ttending ntentl clinics rnge from 0 per cent in Belem to 0- per cent in So Pulo (Tble ). 0) «CD U CO Q E o CD 3 3 Public cmpigns Public cmpigns nd helth promotion progrmmes re imed t two mjor groups: first, the generl popultion through rdio nd television brodcsts, nd primry nd secondry school children through specil eductionl clsses; second, specific subpopultions considered to be t incresed risk: miners, lorry drivers, trnsvestites, IDUs, commercil sex workers nd homosexul men. A number of cmpigns orgnized by non-governmentl orgniztions (NGOs), some of which re funded by the PNC DST-AIDS, re thought to hve been more effective in reching certin trget popultions thn government ctivities. Although there re no direct mesures of the effectiveness of government or non-governmentl eductionl cmpigns lunched so fr, t lest two studies showed tht two prticulr Downloded from by guest on August 9, Yer of reporting unknown Verticl trnsmission E Trnsfusion IV Drug user Heterosexul Homosexul/Bisexul Vlues re numbers FIGURE Annul mle Brzilin AIDS cses reported till December 99 by risk fctors for HIV infection.

3 m JOURNAL OF PUBLIC HEALTH MEDICINE » w o Q < 9 O Yer of reporting unknown Verticl trnsmission 0 Trnsfusion Vlues re numbers IV Drug user Heterosexul FIGURE Annul femle Brzilin AIDS cses reported till December 99 by risk fctors for HIV infection. groups, commercil sex workers nd mle smb drummers in So Pulo, hd good fctul knowledge bout HIV nd AIDS. 78 The helth system response Few centres, even in the mjor cities where cse-lods re high, re ble to concentrte exclusively on HIVrelted cre or reserch nd provide the ltest knowledge to users of the service. PNC DST-AIDS provides some medicines free of chrge on regulr bsis to tret HrV infection nd complictions, including nti-retrovirl drugs such s zidovudine nd didnosine, or compounds such s gnciclovir nd pentmidine. Becuse of bureucrtic problems, the supply of some of these drugs is intermittent. At recent government-orgnized meeting in Brsili on combintion nti-retrovirl therpy, it ws decided tht the dditionlfinncilburden incurred by treting HIV-infected ptients with combintion ntiretrovirl therpy will be evluted. Bsed on this evlution it will be decided whether combintion ntiretrovirl therpy will be ble to be provided free of chrge. However, s fr s the uthors re wre, currently there is very little informtion on the cost of cring for HIV-infected ptients in Brzil, including those with AIDS. To cope with the ever-incresing numbers of people infected with HIV nd suffering from AIDS, within the recently lunched Ntionl Unified Helth System (SUS) pproches re being developed s lterntives to trditionl hospitl-bsed services. These include: centres for nonymous mbultory serologicl testing Downloded from by guest on August 9, 0

4 TABLE Percentge of HIV-infected individuls (with 90 per cent confidence intervls given in prentheses) ttending STD clinics, nte-ntl clinics nd mternity wrds bsed on sentinel studies in selected Brzilin stte cpitls, Ante-ntl nd City STD clinics mternity wrds Arcju, SE Belem, PA Belo Horizonte, MG Brsili, DF Cmpo Grnde, MS Itji, SC Recife, PE Rio de Jneiro, RJ Slvdor, BA SSo Pulo, SP Porto Alegre, RS Source: Reference. -3(00-4 0) - (--9-) -3(--3-) -9 (---0) -4 (-0--0) 9-4 (--8 ) -3 (0--9-9) 4- (-9--3) BRAZIL'S HEALTH CARE SYSTEM (0-0- 0) 0- (0-8-3-) 0 (0-0-0 ) 0- (0-0--0) 0- (0-0--0) (COAS); specilized ssistnce service, which is ble to provide bsic clinicl trining to smll centres, thereby decentrlizing medicl cre (SAE); therpeutic domiciliry ssistnce, which consists of mobile units ble to deliver medicl nd nursing ssistnce to the ptient's home(adt); dy wrds in which hospitl fcilities, including blood tests nd other bsic investigtions, blood trnsfusions nd the dministrtion of medicines, re mde vilble to mbultory ptients (HD). These ventures re prtilly supported by PNC STD-AIDS using World Bnk funds mtched by Brzilin Government funding through the SUS. To quntify the number of existing medicl fcilities ble to provide cre to HIV-infected persons, PNC DST-AIDS nd individul co-ordintors of stte control progrmmes were contcted by us nd surveyed bout the tretment fcilities, in existence or plnned, in the 3 of the 7 Brzilin sttes which hve stte AIDS control progrmme. Ten of the co-ordintors (44 per cent) nswered the questionnire on vilble tretment fcilities (Tble 3). They reported tht most of the tretment fcilities re locted in the lrge cities or metropolitn res, which so fr mirrors the distribution of the cse-lod. For those living in smller cities, the cre provided cn be precrious; ptients need to be trnsferred to mjor centres, jeoprdizing the lredy overcrowded csulty deprtments. Aprt from the lrge public hospitls funded by the public helth system (SUS), officil out-ptient clinics which re run nd owned by the stte, municiplity or unions (Snitry Units), privte hospitls nd physicins form the bsic network of medicl cre for HIV-infected persons. Some chritble homes, funded by religious institutions, NGOs or individul inititive, hve ppered nd proved to be of gret vlue in the cre of the poor nd orphns. The extent of the involvement of primry cre physicins in HIV-relted cre is currently unknown. It is of interest tht yers fter the first utochthonous Brzilin AIDS cse ws reported, 9 the curricul of medicl schools hve still not dpted to the requirements nd chllenge of the epidemic in terms of trining undergrdutes in the mngement of individuls seeking HIV testing, newly HIV-infected persons or ptients with HIV disese. TABLE 3 The vrious tretment fcilities for AIDS ptients in plce or plnned in Brzilin Sttes in December 99 Stte Centre for Serologicl Testing nd Orienttion In plce Plnned Specilized ssistnce services In plce Plnned Therpeutic domiciliry ssistnce In plce Plnned Dy wrds In plce Plnned Trditionl fcilities In plce Plnned Downloded from by guest on August 9, 0 Bhi S8o Pulo Piui Snt Ctrin Mto Grosso du Sl Espirito Sntos Prib Mins Geris Rio Grnde do Sul Sergipe Totl NS' " NS: not stted.

5 300 JOURNAL OF PUBLIC HEALTH MEDICINE Conclusions Brzil hs fced more thn century during which there hve been successive periods of profound politicl nd economic crisis. Like other developing countries in the 980s, Brzil hd to turn to the World Bnk nd the Interntionl Monetry Fund for so-clled structurl djustment progrmmes (SAP). 0 The SAP re progrmmes imposed on developing countries s condition of lons from these gencies or privte bnks. They include number of components imed t stimulting privte mrkets nd export businesses so s to mke the economy more competitive interntionlly. The desired result is to enhnce the security of lon pyments. SAP progrmmes include - long with other mesures - cuts in public funding or welfre progrmmes. One of the net results in Brzil - long with other not yet mesured socil ctstrophes - hs been n incresed number of street children 0 nd extreme difficulties fcing public hospitls in coping with the ever-incresing number of sick people. The AIDS epidemic hs cught the country midst profound crisis in its public helth system. The disese hs dded new problems to other s yet unresolved problems. The response of society nd government hs been frgile owing to politicl nd religious pressures. Nevertheless, despite this ominous bckground, Brzil is fcing the AIDS epidemic reltively positively. Public cmpigns hve been fr reching, owing to welldeveloped communiction infrstructure, nd hve been effective, for instnce, in terms of condom distribution. 8 Twelve yers fter the dignosis of the first Brzilin AIDS cse, the epidemic is fr from reching plteu nd chnges in ptterns of trnsmission re being seen, with heterosexul trnsmission incresing in importnce." The foreseeble future, lredy ttined in plces such s So Pulo, 3 points to n incresing number of HIV-infected men nd women nd consequently incresing numbers of HIV-infected children. Recent economic nd politicl stbility hs llowed new pproches to be developed in terms of public cmpigns, lthough funds for reserch nd tretment remin scrce. Novel pproches re lso being sought to del with the incresing number of individuls suffering from HIV disese, for instnce through the introduction of domiciliry tretment nd dy wrds. References ' Anonymous.World Helth Orgniztion globl sttistics. AIDS 99; 9: Progrm Ntionl de Doencs Sexulmente Trnsmissiveis/AIDS do Ministerio d Sude do Brsil. AIDS - Boletin Epidemiol 99; Ano VIII: No Bincrelli A. Mulher igul homem em cso de AIDS. Folh de So Pulo 99(9 October); Cderno Cotidino:. 4 Quinn TC, Zcris FRK, St John RK. AIDS in the Americs - n emerging public helth crisis. N Engl J Med 989; 30: Sntos BR, Beck EJ, Peixoto MF, Kitchen V, Weber J. Chnging ptterns of HIV- trnsmission in Southern Brzil Int J STD AIDS 994; : 0-0. Progrm Ntionl de Doencs Sexulmente Trnsissiveis/ AIDS do Ministerio d Sude do Brsil. AIDS - Boletin Epidemiol 994; Ano VII, No Lurie P, Ferndes MEL, Hughes V, et l. Socioeconomic sttus nd risk of HIV-, syphilis nd heptitis B infection mong sex workers in So Pulo Stte, Brzil. AIDS 99; 9<Suppl. ): S3-S37. 8 Hughes V, Stll RK, Klouri C, et l. AIDS risk-tking behviour during Crnivl in So Pulo, Brzil. AIDS 99:9(Suppl. ): S39-S44. 9 Amto Neto V, Uip DE, Boulos M, et l. Sindrome d imunodeficienci dquirid (AIDS): descrico do primerio cso utoctone do Brsil e estudo imunologico. Rev Pul Med 983; 0: Lurie P, Hitzen P, Lowe RA. Socioeconomic obstcles to HIV prevention nd tretment in developing countries: the roles of the Interntionl Monetry Fund nd the World Bnk. AIDS 99; 9: " Sto PA, Chin J, Mnn JM. Review of AIDS nd HIV infection: globl epidemiology nd sttistics. AIDS 989; 3<Suppl. ): S3O-S3O7. Accepted on April 99 Downloded from by guest on August 9, 0