Brazil: A Model Response to AIDS

Brazil was the first developing country to offer free treatment for AIDS to all its citizens. Paulo Teixeira, the then director of the National STD/AIDS Programme in the health ministry, played a key role in making this happen. Teixeira, who now works for the HIV programme of Sao Paulo state, following stints at the World Bank and UNAIDS, spoke to Rema Nagarajan for The Times of India.

Free treatment for all AIDS patients is said to be impractical in a developing country. What has been the Brazilian experience?

It is expensive and difficult but not impossible as Brazil has proved. We give 100 percent free drugs for HIV/AIDS and the programme covers 100 percent of AIDS patients. If we did not treat the patients there would have been an even higher cost to be paid in hospitalisation and medical care later, and also high mortality. In 2000, it cost $500 million to treat 80,000 patients. In 2011, we have 20,000 patients who we treat up to the fourth level of the AIDS treatment regime (even beyond in some special cases) and we spend just about $600 million.

How was treatment extended to more than double the patients without any huge escalation in cost?

In the early '90s we saw HIV patients dying before our eyes. Some HIV patients sued the government demanding treatment becaue health is a fundamental right in Brazil. Treatment was very expensive in those days but we had to find a way to treat these patients despite the cost. We adopted a three pronged strategy - production, compulsory licensing and negotiation. For effective treatment, we always included the most recent drugs that came into the market. This was expensive. So, we started domestic production of generic versions of most HIV drugs. Now, more than 85 percent of the HIV drugs are being manufactured in the government sector. The second strategy was to issue a compulsory license for one of the HIV drugs, Tenofovir. The third was to negotiate with companies for much lower prices for the other drugs.

How important was the compulsory licence (CL) that allows generic manufacture of a drug when the patent-holding company refuses to cut prices?

The movement against patents, identified as the reason for high cost, resulted in a CL as the company, Merck, refused to bring down the price. They never thought we would actually issue a CL. The main reason to adopt CL was because it helps you negotiate better and strongly with private companies. We managed to negotiate cheaper prices with companies and in some cases succeeded in getting 60 percent reduction in prices. Now, we pay a high price only for certain new drugs.

What about the threat that companies will not bring the latest drug or invest in your country if you use CL?

You need to use the odds to your advantage. We are one of the biggest public markets. Government is the biggest client buying 98 percent of the drugs in the country and so there is no competition between government and the private sector. So, negotiations are very different. Moreover, we have our own research institutions, which tell us how much it costs to actually produce the drugs - a key piece of information when you sit down to negotiate. You can use several options to neutralise threats from companies. They will always argue that they cannot spend on research if they don't charge a high price. We need to have the right arguments to counter these claims. Anyway, even when we issue a CL it does not mean we get anything free. We transfer a certain amount as royalty for the intellectual property to the company that holds the patent, an amount that is agreed to be fair by international standards.

How did Brazil deal with threats from companies?

We forged international partnerships that could be leveraged to fight back, such as importing generics from India. And we used all political opportunities, raising the issue of access to drugs at WHO, UNAIDS, WTO and in the international media emphasising that we would not allow such violence by the companies. The main goal was universal access to drugs at a good price which we have more or less achieved.

Will the government produce all AIDS medicine in the public sector to keep prices low?

Public sector cannot be the sole producer. About 8 to 10 of the anti-retroviral drugs are produced by national laboratories. There are some domestic private companies, too. However, the latest drugs are imported. And we try our best to be a strong client and negotiate for the best price. Transparency and a very strong civil society movement in HIV/AIDS sector keep a check on the working of the system.

If all these expensive drugs are being distributed free-of-cost, what stops people from procuring the drugs and selling them in the open market?

There is no private or open market for something that is available for free to every citizen. Plus, prescriptions are closely monitored. There were some instances of the drugs being smuggled across the border to neighbouring countries where the drugs were not available. We made it permissible along the border to use the Brazilian HIV treatment centers. We then enquired how many patients there were in Bolivia, Paraguay, Uruguay etc. The numbers were not that big and so we provided the drugs for the patients in those countries. This was not just from a humanitarian perspective, but also a strategic approach. It would be much more expensive to enforce a border control mechanism.