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Access to Treatment and Prevention: Brazil and Beyond

Access to Treatment and Prevention: Brazil and Beyond. Pedro Chequer, MD, MPH Director, Brazilian National STD/AIDS Program Ministry of Health pchequer@aids.gov.br. ARV availability in low and middle income countries, according to geographical region. June, 2005*. Region. Number of.

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Access to Treatment and Prevention: Brazil and Beyond

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  1. Access to Treatment and Prevention: Brazil and Beyond Pedro Chequer, MD, MPH Director, Brazilian National STD/AIDS Program Ministry of Health pchequer@aids.gov.br

  2. ARV availability in low and middle income countries, according to geographical region. June, 2005* Region Number of Estimated Coverage people receiving ARVs need Sub-Saharan Africa 500,000 4,700,000 11% East, South and South-East Asia 155,000 1,100,000 14% North Africa and Middle East 4,000 75,000 5% Eastern Europe and Central Asia 20,000 160,000 13% Central Latin America and the Caribbean 290,000 465,000 62% Total 970,000 6,500,000 15% (Average) *Adults only, average figures Source: “Progress on Global Access to HIV Antiretroviral Therapy, June 2005 update, World Health Organization

  3. The “backbone” of the response to the AIDS epidemic: the Brazilian Public Health System • An outcome of the Brazilian Constitution of 1988 • Main precepts : - comprehensive approach - universal access and equity - civil society participation • Key feature: decentralization • Strong catalytic element • Virtuous circle (AIDS  Public Health System)

  4. Early response by government (since 1983) Robust participation by civil society in all decisions Multisectoral mobilization Balanced prevention and treatment approach, with human rights taken into account in all strategies and actions Major features of Brazil´s response to HIV/AIDS epidemic

  5. Percentage change in condom use among young people at first sexual intercourse. Brazil, 1986, 1998 and 2003 (1) 1986 (2) 1998 (3) 2003 0 10 20 30 40 50 60 70 Sources: (1) BEMFAM (2) CEBRAP/MH/PN-STD/AIDS/SVS (3) MH/PN-STD/AIDS/SVS – (PCAP_BR_2003,IBOPE)

  6. Percentage of condom use among sexually-active population according to age group. Brazil, 2004 Condom use 15-24 25-39 40-54 Total Last sexual intercourse 57.3 36.6 22.3 38.4 Last sexual intercourse with casual partner 74.1 66.5 51.2 67.0 39.0 22.0 16.1 25.3 Regular use (any partners) Fixed partner Casual partner 38.8 58.4 21.9 48.7 16.2 41.5 24.9 51.5 Source: Survey on behavior, attitudes and practices related to STD/AIDS, 2004, PN-STD-AIDS/SVS/MH

  7. Harm Reduction: a basic prevention strategy • Estimated number of IDUs in Brazil: 193,000 (Source: PCAP, 2004) • Percentage of IDUs who reported no syringe/needle sharing: 76% (Source: PCAP - 2004) • AIDS cases among IDUs: • 1993 = 4926 cases (28.0% of total reported cases) • 2003* = 1871 cases (10.2% of total reported cases) • Number of IDU specific projects supported from 1999 to 2004: • 391, representing US$ 7.5 million total investment * Not corrected due to reporting delay

  8. PREGNANT WOMEN (DURING DELIVERY) SEX WORKERS 63 (1992) n= 220 0.08 (1998) n= 29,0000 0.08 (2002) n= 30,000 CONSCRIPTS 0.4 (2004) n= 20,000 0.4 (2000) n= 20,000 6.1 (2000) n= 2,712 37 (2002) n= 287 INJECTING DRUG USERS Estimated percentage of HIV infection in selected population. Brazil, 1992, 1998, 2000, 2002, 2004 No comparable studies available Source: Brazilian MOH, 2005

  9. AIDS incidence and mortality rates (by 100,000 inhabitants) Brazil, 1985-2003 25 20 15 10 5 0 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 Incidence Mortality Sources: Incidence - PN STD-AIDS/SVS/MH. Mortality – SIM/DASIS/SVS/MH

  10. Number of patients receiving ARV therapy. Brazil, 1997 – 2005 Projected 180000 160000 140000 120000 100000 80000 60000 170.000 40000 20000 0 jul/97 jul/98 jul/99 jul/00 jul/01 jul/02 jul/03 jul/04 jul/05 jan/97 jan/98 jan/99 jan/00 jan/01 jan/02 jan/03 jan/04 jan/05 out/97 out/98 out/99 out/00 out/01 abr/97 abr/98 abr/99 abr/00 abr/01 out/02 out/03 out/04 out/05 abr/02 abr/03 abr/04 abr/05 * Dados preliminares

  11. Antiretroviral drugs distributed through Brazilian public health system, according to therapeutic category. Brazil, 2005 ITRN and ITRNt IP • ZIDOVUDINE (1993)* • ESTAVUDINE (1997)* • DIDANOSINE (1998)* • LAMIVUDINE (1999)* • ABACAVIR (2001) DIDANOSINE EC (2005) TENOFOVIR (2003) • RITONAVIR (1996)* • SAQUINAVIR (1996)* • INDINAVIR (1997)* • NELFINAVIR (1998) • AMPRENAVIR (2001) • LOPINAVIR/r (2002) • ATAZANAVIR (2004) ITRNN FUSION INHIBITOR • ENFUVIRTIDE (2005) • NEVIRAPINE (2001)* • EFAVIRENZ (1999) *Brazilian local production

  12. Average cost of ARV therapy per patient/year (US$). Brazil, 2005 7000 6240 6000 5486 Introduction of expensive new ARVs 5000 4603 4000 • Substantial falls in prices of second-line patented drugs have ceased • Number of people using them has increased dramatically 3464 3000 Thousands (US$) 2500 2210 2000 1500 1359 1336 1000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005* Year

  13. Total expenditure (in US$ million) on ARVs and average number of patients on ARV therapy. Brazil, 1997 – 2005* 450 200 395 180 400 336 160 350 305 303 140 300 120 232 250 224 Expenditure (US$ million) 203 Number of patients (thousands) 100 181 179 200 80 150 60 100 40 50 20 0 0 1997 1998 1999 2000 2001 2002 2003 2004 2005* Total expenditure (US$million) Average no. of patients (thousands) Source: PN STD-AIDS/SVS/MH * Data subject to revision and modification

  14. Breakdown of expenditure* on ARV procurement (2005), by source of drug. Brazil, 2005 106.88 309.59 Lopinavir/r 34.5% Imported from multinational 31.60 Tenofovir 12.2% manufacturers: National production 78,6% 84.07 Efavirenz 17.8% 55.09 21,4% Other ARV imported drugs: 37.5% 116.02 *US$ million for 180,000 patients

  15. Price and use patterns – the case of Lopinavir/r. Brazil, 2002 - 2005 25,000 1.8 1.6 20,000 1.4 Price: 25% 1.2 decrease 15,000 1 price per capsule (US$) number of patients 0.8 10,000 0.6 Patients: 0.4 5,000 800% increase 0.2 0 0 2002 2003 2004 2005 number of patients price per capsule (US$)

  16. Price and use patterns – the case of Lopinavir/r • Fresh negotiations launched in early 2005 • Offer submitted by drug company committed the Ministry of Health to buying around US$ 70-million worth of LPV/r per year from 2006-2010, regardless of actual demand • By significantly over-estimating future demand it over-estimated potential savings • Current price (2005): US$ 1.20/capsule Estimated price if manufactured locally: US$ 0.40/capsule • High-quality, low-cost local manufacturing is possible

  17. EFV, LPV/r and TDF – Estimated savings if manufactured locally (Far-Manguinhos) Source of data: PN-STD/AIDS and Far-Manguinhos; includes a yearly depreciation rate of 10% for EFV and LPV/r in 2006-2009 and 5% in 2010 300.00 Total potential savings (2006-2010): US$ 645,560,000 242.40 250.00 222.39 Saving: US$ 167,54 198.89 200.00 Saving: US$ 152,38 172.48 Saving: US$ 131,17 Expenditures (In US$ million) 147.47 150.00 Saving: US$ 107,79 100.00 Saving: US$ 86,69 74.86 70.01 67.72 64.69 60.78 50.00 0.00 2006 2007 2008 2009 2010 FONTE: MS/SVS/PN-DST/AIDS Expenditure estimated as result of local production (Far-Manguinhos) Expenditure estimated using 2005 prices paid by MOH for branded products

  18. Prospects for the future provision of antiretroviral treatment • Apparent affordability of antiretrovirals: • Countries will increasingly switch to 2nd line drugs • Current 2nd line drugs may become 1st line regimes • Prices of “3rd-line” drugs may skyrocket (e.g. T-20) • Current monopolies/oligopolies configuration of the market of active principle ingredients (API’s) may reduce number of potential suppliers and hinder ARV availability and price reductions • Lack of publicly-available, internationally-validated monographs and accredited laboratories for quality control

  19. Civil society participation Human rights advocacy for people living with HIV and AIDS Strengthening community-based projects and interventions Building partnerships with Civil Society

  20. International Cooperation and the Brazilian AIDS Program Two main areas: Technical cooperation in program management, development and monitoring/evaluation on the basis of technology transfer There is growing interest in financing South-South cooperation (UNAIDS, GTZ, DFID, Ford Foundation)

  21. South-South Cooperation: The Program of International Cooperation with Developing Countries Second Phase Aim on Care area: To provide free access to first line Brazilian- produced antiretroviral drugs to 100% of patients in need Countries covered: Cape Verde, Sao Tome and Principe, Guinea-Bissau, East Timor, Bolivia and Paraguay

  22. South-South Cooperation: Network for Technological Cooperation in HIV/AIDS Launched in 2004, involving Argentina, Brazil, China, Cuba, Nigeria, Russia, Thailand and Ukraine Key support provided by the Ford Foundation: US$ 1 million Objectives: technology transfer, R&D and production: - antiretrovirals - vaccines and microbycides - condoms - laboratory supplies

  23. International Center for Technical Cooperation: a Joint Brazil/UNAIDS Initiative • Created in 2005, the ICTC aims to create and strengthen national technical capabilities forimplementing comprehensive AIDS responses through horizontal technical cooperation; • Example of activities undertaken: • Coordination of technical missions in Honduras, Nicaragua, Peru, Ecuador and Bolivia • Identification of technical assistance needs of Latin American countries receiving financial support from the Global Fund • Total investments: • Brazilian Government (US$ 500,000), UNAIDS (US$ 500,000), DFID (£ 250,000 - under negotiation), GTZ (€ 250,000 – under negotiation)

  24. Challenges: to develop new technologies and systems to halt spread of the HIV/AIDS epidemic Technologies: Prevention (e.g., microbicides, etc) Treatment and care (e.g., new FDCs) Vaccine Systems: Monitoring and Evaluation and Operational Research Personnel (health and management) Management

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