The current study critically analyzes the development of the Brazilian National AIDS Program (NAP), widely recognized as the leading example of an integrated HIV/AIDS prevention, care, and treatment program in a middle-income country with significant levels of social inequality. UN indices of human development have consistently placed Brazil around 70th place, yet the impact of the nation's response to HIV/AIDS has been impressive, the researchers noted. Incidence rates of HIV are much lower in Brazil than had been projected a decade ago; mortality rates have fallen by 50 percent; and inpatient hospitalization days have decreased by 70-80 percent over the past 7 years.

Brazil's HIV/AIDS epidemic is characterized by three major interrelated epidemiological trends: heterosexualization, feminization and pauperization. Male-to-female ratio of HIV/AIDS cases has shifted from 23.5:1 in 1985 to 1.7:1 in 2002. An increasing proportion of cases among people with lower education levels points to the pauperization of the epidemic.

The authors contend that the concepts of citizenship and solidarity underlie the social mobilization for democracy; these culminated in the new constitution of 1988 and proved to be central to the nation's response to HIV/AIDS. The sanitary reform movement, a key element in Brazil's push for democracy, was a loose affiliation of health care workers, health academics, and other segments of society who defended the right to health as a fundamental one to be guaranteed by the constitution. The movement was strong in São Paulo, where the São Paulo State Health Department led the response to the first reported AIDS cases in 1983, and it later became the model for the National Unitary Health System.

Despite great disparities of wealth, a history of social discrimination based on skin color and oppressive gender relationships, "social solidarity built up out of common suffering and struggle for democracy became a countervailing force to the stigma surrounding the emergence of HIV," the study said.

Early activism by gay men and human rights advocates helped defuse the worst aspects of stigma surrounding HIV and homosexuality, and many nongovernmental AIDS service organizations were formed in the 1980s and 1990s. Working with progressive state and municipal health departments, these groups pressured the federal government to create a national AIDS program.

The authors contend that Brazil's open approach to sex and sexuality has helped prevention by promoting condom use and creating public information campaigns to combat discrimination. Brazil has been proactive in responding to HIV and injection drug use, authorizing needle-exchange programs at the state and national levels. In 2003, the percentage of AIDS cases linked to injection use had fallen to 11 percent, down from nearly 30 percent in the mid-1990s.

"The Brazilian program of free, universal access to antiretroviral treatment has had a dramatic impact on morbidity and mortality from AIDS in Brazil and has gained considerable international recognition for its efforts," the study said. The authors noted that other countries might learn from Brazil's policies integrating treatment and prevention, universal access, local manufacture of AIDS drugs, the use of complex therapies and the creation of international alliances.

The researchers stated that a final lesson from Brazil is that NAP has become a source of national pride for Brazilians. "Solidarity and pride, it seems, may be the most effective counter to stigma. To control HIV, we must first admit that the problem belongs to all of us," the authors concluded.

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