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MONITORING SYSTEM FOR THE ANTIRETROVIRAL THERAPY IN BRAZIL: LESSONS LEARNED AND FUTURE DIRECTIONS Marco Vitria, MD Brazilian STD/AIDS Programme - MOH July 2003

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Source: Ministry of Health PATIENTS ON ARV THERAPY IN THE PUBLIC HEALTH SYSTEM - BRAZIL, 1997 - 2002* * December 2002, estimated data 0 20000 40000 60000 80000 100000 120000 140000 jan/97mai/97set/97jan/98mai/98set/98jan/99mai/99set/99jan/00mai/00set/00jan/01mai/01set/01jan/02mai/02 set/02 125,000

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CUMULATIVE AIDS CASES (Dec/2002): 257,780 CUMULATIVE AIDS DEATHS (Dec/2002): 113,840 ESTIMATED NUMBER OF HIV+ INDIVIDUALS (2000): 597,000 INCIDENCE RATE OF AIDS (2000): 12,4 / 100.000 PREVALENCE RATE OF HIV (2000): 0,65% CUMULATIVE AIDS CASES (Dec/2002): 257,780 CUMULATIVE AIDS DEATHS (Dec/2002): 113,840 ESTIMATED NUMBER OF HIV+ INDIVIDUALS (2000): 597,000 INCIDENCE RATE OF AIDS (2000): 12,4 / 100.000 PREVALENCE RATE OF HIV (2000): 0,65% BRAZIL: EPIDEMIC PROFILE

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The Brazilian Public Health System (SUS) Organized by the Brazilian Constitution of 1988 Main principles: - integrality - universality - equity - social control Strong catalytic element Virtuous circle (AIDS Public Health System) Organized by the Brazilian Constitution of 1988 Main principles: - integrality - universality - equity - social control Strong catalytic element Virtuous circle (AIDS Public Health System)

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MAJOR ASPECTS IN BRAZILIAN RESPONSE TO HIV/AIDS EARLY GOVERNMENTAL RESPONSE STRONG CIVIL SOCIETY PARTICIPATION IN ALL DECISION LEVELS MULTISECTORIAL MOBILIZATION BALANCED PREVENTION & TREATMENT APPROACH HUMAN RIGHTS PERSPECTIVE IN ALL STRATEGIES AND ACTIONS EARLY GOVERNMENTAL RESPONSE STRONG CIVIL SOCIETY PARTICIPATION IN ALL DECISION LEVELS MULTISECTORIAL MOBILIZATION BALANCED PREVENTION & TREATMENT APPROACH HUMAN RIGHTS PERSPECTIVE IN ALL STRATEGIES AND ACTIONS

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BRAZILIAN ARV ACCESS PROGRAM: MAJOR ASPECTS NATIONAL NETWORK OF PUBLIC ALTERNATIVE CARE SERVICES: ~ 900 SERVICES NATIONAL NETWORK OF VCT FOR HIV: 208 SERVICES NATIONAL NETWORKS OF LABORATORY SUPPORT HIV VIRAL LOAD: 78 LABORATORIES T-CD4+ CELL COUNT: 66 LABORATORIES HIV RESISTANCE TESTING: 14 LABORATORIES NATIONAL ARV LOGISTIC CONTROL SYSTEM: 480 DISPENSARY UNITS NATIONAL NETWORK OF PUBLIC ALTERNATIVE CARE SERVICES: ~ 900 SERVICES NATIONAL NETWORK OF VCT FOR HIV: 208 SERVICES NATIONAL NETWORKS OF LABORATORY SUPPORT HIV VIRAL LOAD: 78 LABORATORIES T-CD4+ CELL COUNT: 66 LABORATORIES HIV RESISTANCE TESTING: 14 LABORATORIES NATIONAL ARV LOGISTIC CONTROL SYSTEM: 480 DISPENSARY UNITS

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IMPACT OF UNIVERSAL ACCESS TO HAART ON AVERAGE SURVIVAL AFTER AIDS DIAGNOSIS IN BRAZIL Chequer et al, 1992; Marins et al. 2002 58 16 6 6 0 0 10 20 30 40 50 60 70 1982-1989 1995 1996 Months of Survival Introduction of universal access to HAART in Brazil

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Source: V.E.CRT-DST/Aids (datauntil31/12/02) Tuberculosis in HIV + Patients CRT DST/AIDS, So Paulo, Brazil (1994 2002) 1997/96: - 53,3% 2001/96: - 65,3% 2002/96: - 71,8% Introduction of HAART in Brazil

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IMPACT OF MOH ARV DRUG POLICY (1996 - 2002) Mortality reduction 40 - 70% Morbidity reduction 60 - 80% Occurrence of new AIDS cases 58,000 avoided cases Occurrence of AIDS related deaths 90,000 avoided deaths Reduction in Hospitalization needs Seven fold reduction 358.000 avoided admissions (1997- 2001) Mortality reduction 40 - 70% Morbidity reduction 60 - 80% Occurrence of new AIDS cases 58,000 avoided cases Occurrence of AIDS related deaths 90,000 avoided deaths Reduction in Hospitalization needs Seven fold reduction 358.000 avoided admissions (1997- 2001) Estimated Savings U$ 2.2 billions (Hospital and Ambulatory Care)

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ZIDOVUDINE (ZDV)* DIDANOSINE (ddI) * LAMIVUDINE (3TC) * STAVUDINE (d4T) * ZDV + 3TC * ABACAVIR INDINAVIR * RITONAVIR* ZIDOVUDINE (ZDV)* DIDANOSINE (ddI) * LAMIVUDINE (3TC) * STAVUDINE (d4T) * ZDV + 3TC * ABACAVIR INDINAVIR * RITONAVIR* ARV Drugs Distributed by Ministry of Health - Brazil (2003) SAQUINAVIR NELFINAVIR AMPRENAVIR NEVIRAPINE * EFAVIRENZ LOPINAVIR / r SAQUINAVIR NELFINAVIR AMPRENAVIR NEVIRAPINE * EFAVIRENZ LOPINAVIR / r (*) generic version available

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HIVBResNet Study - Genotypic distribution of HIV primary mutations in ARV naive treated patients (Brazil,2001)

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** = Crude rate (CI not available) N = 1972 patients (from 60 health services) Nemes et al, 2003 (in press) Adherence to Antiretroviral Therapy in Brazil Preliminary Results* - 2002

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PARTNERSHIPS WITH CIVIL SOCIETY Participation and social control; Guaranteeing human rights for people living with HIV and AIDS; Support for community projects. Adherence Groups Support Houses

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THE BRAZILIAN EXPERIENCE: LESSONS LEARNED AND FUTURE DIRECTIONS Adherence strategies to optimize ARV therapy and reduce viral resistance must be always used. Universal access to ARV therapy and generic drug policy Quality with Price Reduction Fixed-Dose Combinations. Diagnostic and treatment monitoring approach using simple clinical and laboratorial tools are needed. Adherence strategies to optimize ARV therapy and reduce viral resistance must be always used. Universal access to ARV therapy and generic drug policy Quality with Price Reduction Fixed-Dose Combinations. Diagnostic and treatment monitoring approach using simple clinical and laboratorial tools are needed.