The Prevention and Care of HIV-Infected Drug Users in Contemporary Brazil

Brazil has a unique situation in the field of HIV/AIDS prevention and care, worldwide. The first developing country to fully implement universal access to anti-retroviral therapy (ART), its National Program has been considered a model to be followed by other developing countries. However, attempts to emulate the so-called “Brazilian model” are much probably doomed to failure if other countries do not pay attention on some special conditions observed in Brazil.

The Brazilian AIDS epidemic is basically urban, and although some spread has been described from metropolitan areas toward middle-sized and small cities, the extent the epidemic has been affected the countryside is negligible (Petersen et al., 2006).

In some transitional countries, such as Russia and former Soviet/newly independent republics from Eastern Europe, the epidemic dynamic is basically linked to the spread of HIV/AIDS (and other sexually and blood-borne infections) among a large population of injection drug users (IDUs). In Brazil, a relatively modest population of IDUs was deeply affected by the epidemic in the early 1990s, but have been spared in recent years, with the sole exception of the southern coastal area, where the epidemic among this specific population has been growing unabated (Hacker et al., 2006). A pronounced decline of HIV and HCV infection rates among IDUs has been observed in major metropolitan areas of southeastern, industrialized, Brazil, much probably due to a combination of saturation of a relatively small population, spontaneous behavior chance and the positive effects of different preventive strategies (Bastos et al., 2005).

So, Brazil has all preconditions to move one step further, averting new infections and many other drug-related harms, with the implementation of comprehensive programs, targeting not only the very exchange of needle and syringes, but also renewed strategies such as agile referral to services dealing with both psychosocial support and case-management of drug abuse and clinical treatment of a variety of conditions, including abscesses, viral hepatitis and HIV/AIDS, and vaccination against hepatitis B, Doing so, Brazil's health professionals will profit from a window of opportunity that can be closed very fast, if complacency and neglect resurface in a context of naïve optimism. Brazilian health professionals and policy makers must understand that the current honeymoon could be short-lived: ART is becoming more and more complex and expensive (with the progressive accumulation of viral resistance and serious adverse effects); the monitoring of a growing number of people living with HIV/AIDS, hepatitis B and C (many times co-infected by these pathogens) presents a formidable and permanent challenge; and, last but not least, the current support provided by the Brazilian Ministry of Health and the World Bank could not be counted as eternal, since it depends on fragile international agreements and domestic politics.

The present comment is a call for a renewed effort, with no room for lenience. Brazil must better integrate health and other public policies, minimizing the deep-entrenched stigma against drug users, that force them to hide and to create and use private caches of paraphernalia used in the preparation and injection of illicit drugs (as discussed in the current issue—Bastos et al., 2006).

We must highlight two other key challenges to be faced by Brazilians in the near future: first of all, to move beyond the focal attempts to integrate this or that marginalized populations toward an actual reversal of our current social, economic and ethnic divide. The expression “Brazilian citizen” must mean something beyond the mere rhetoric.

Secondly, Brazilians must move beyond their rich oral (and musical) tradition and learn that public money must be always spent with caution and thorough monitoring, something unfortunately far from our current habits and practices, as shown by a recent paper addressing the monitoring and evaluation of Brazilian NEPs (Massard et al., 2006). The findings of such small survey point to deficiencies in terms of the accountability of programs than were born as “underground” initiatives but that, like Peter Pan, refuse to grow and mature under favorable conditions. That's time to action! Any strategy but sustained and concerted effort could jeopardize the undeniable achievements Brazil has made so far.