New Internationalist

Cocktails and carnival

Issue 346

Thousands of people across the South can’t afford to buy AIDS drugs. But not in Brazil. Matthew Flynn describes how one country fought back.

Make AIDS drugs available to all

Antiretroviral drugs have cut the AIDS death rate in the North by 70 per cent. But across the South they are available only to the wealthy or to a lucky few. Compulsory licensing and opening Southern markets to generic drugs could dramatically increase their availability.

The first thing people usually associate with Brazil is carnival — the world’s biggest, loudest and most infamous party. For one week, normal life stops and parades, floats and dancing take over. Behind the scenes, however, carnival has a serious side: it is also the time when Brazil’s Health Ministry redoubles its efforts to educate party-goers about the risk of AIDS. Billboards, T-shirts and television commercials encourage young and old alike to have safe sex and use condoms — ‘the party gowns of life’. The message could not come at a better time. In a culture famous for its libidinous ways, carnival is the wildest time of all. Nearly a decade ago, the World Bank warned that Brazil would have over a million AIDS cases by the turn of the century if action were not taken. Today, while the country has lost 100,000 people to the deadly virus, infection rates remain a low 0.6 per cent and the predicted epidemic has been avoided.

Prevention is one of the pillars of Brazil’s successful AIDS programme. But treatment and human rights are also key.

Brazil began investing in drug therapies in the early 1990s, even though aid agencies argued that drug therapy was not ‘cost effective’ and that scarce resources should be concentrated on prevention.

But, says Paulo Teixeira, head of the government AIDS programme, the Brazilian thinking was different: ‘It is impossible to mobilize a society, to mobilize people — infected or not — for a national effort if you do not provide what they are expecting to receive: support and clinical treatment.’

Brazil’s commitment to providing affordable drug therapy is abundantly clear. Last year, the Health Ministry distributed antiretroviral (ARV) drugs to 110,000 registered HIV patients — free of charge.

‘Access to free medication encourages more people to test themselves and helps curb the spread of the disease,’ explains Veriano Terto, general co-ordinator of the Associação Brasileira Interdisciplinar de AIDS. ABIA is a non-profit organization which conducts research and provides counselling to HIV-positive people.

Terto, who learned that he was HIV positive in 1996 and began treatment the following year, says that in a developing nation like Brazil drug therapy needs to be available and affordable.

‘Like most other Brazilians I would not be able to afford the high price of the medication.’ Since learning of his illness Terto has been able to continue working normally and was able to finish a doctorate in public health.

Like other cash-strapped developing countries, Brazil was faced with the problem of providing a growing number of AIDS patients with expensive treatments sold only by large, international drug companies.

Brazil’s answer: manufacture the drugs locally.

‘We started producing those drugs before the country signed the WTO Trade Related Intellectual Property agreement (TRIPs) in 1996,’ recalls Teixeira. ‘The first consequence was that the price dropped tremendously — some 80 per cent.’ While treatment in the US costs $12,000, in Brazil it is $2,500 and falling. With most ARVs already on the market before the country adjusted its patent laws to WTO requirements, Brazil could sidestep steep royalties to the companies when making generic copies.

Government labs currently produce 8 of the 14 ingredients that make up the so-called AIDS cocktail. The government saves $250 million a year by not paying for the high-priced, patent-protected imported drugs, and it avoids the additional expenses of hospital care for untreated patients.

‘The reduction in the incidence of AIDS-related diseases has saved us $670 million over three years,’ reports Dr Marco Antônio Victória, chief medical advisor to Brazil’s AIDS programme.

Government participation in Brazil’s $6.5 billion domestic drug market was not cheered by everyone. The giant multinational companies, collectively known as Big Pharma, were angered by the cheaper, generic drugs. More recently, their ire has focused on government research into newer ARV treatments. Unlike generics, Efavirenz (sold by Merck) and Nelfinavir (made by Hoffmann-La Roche) are protected by Brazilian patent legislation.

The US, pressured by Big Pharma, threatened a WTO investigation of Brazil’s breach of the TRIPs accord. But unlike smaller nations that often back down in the face of pressure, Brazil rallied international support for its case. Both the UN Commission of Human Rights (UNCHR) and the World Health Organization (WHO) approved Brazilian-sponsored motions supporting access to life-saving drugs as a basic human right. The country then scored another small victory at the WTO’s annual meeting in Doha, Qatar last November where the US — partially owing to the Anthrax scare — offered lukewarm support to a similar measure.

Meanwhile, the government lab FarManguinhos was diligently working to crack the secret of Efavirenz and Nelfinavir.

After learning how the drugs were manufactured, Brazil would be in a position to threaten to break their patents and produce them locally — or negotiate better prices with suppliers Merck and Hoffmann-La Roche.

Eloan Pinheiro, director of the state-owned FarManguinhos lab, adds that after discovering the make-up of a drug it is possible to compare the cost of production to the retail price. ‘It was easy to calculate the profit margin. It was enormous and continuous to be exorbitant,’ she says.

With the drug companies stripped of their clothes, the Health Ministry negotiated price reductions of 58 per cent for Nelfinavir (from $1.53 a capsule to $0.65) and 64 per cent for Efavirenz (from $2.32 a capsule to $0.84).

Brazil’s commitment to providing affordable drug therapy is abundantly clear

Despite the success of Brazil’s generic programme, it is far from perfect. The country has 110,000 HIV-positive patients who receive the drugs, but another half-million people are estimated to be infected who don’t benefit from government programmes. ‘We still have AIDS being contracted by socially excluded, more marginalized people,’ says Veriano Terto of the ABIA. ‘And while the conditions of poverty, unemployment and violence that create such marginalization are not combated, it will be difficult to control the spread of AIDS in these populations.’

Brazil remains a highly stratified society and its public-health system continues to be underfunded. But whatever its shortcomings, the country has made significant progress despite limited resources.

In fact, one of Brazil’s newest exports is its expertise in dealing with HIV/AIDS. Médecins Sans Frontières (MSF) recently signed an agreement with FarManguinhos to use their generic antiretrovirals in MSF projects. In return, MSF helps fund FarManguinhos’ efforts to find new cures for diseases ignored by Big Pharma.

Brazil has also signed technical co-operation agreements with four African countries — Angola, Mozambique, Guinea Bissau and São Tomé. And several others, including Namibia, Zimbabwe, South Africa, Kenya, Nigeria and Botswana are said to be interested in the country’s AIDS drugs.

Matthew Flynn is a freelance journalist based in Brazil. He is researching Brazilian industrial policy at the Universidade de São Paulo and can be reached at matthew.flynn@journalist.com

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