A Comparison of HIV/AIDS Management in the US and Brazil: Historical Context and Lessons Learned




Zou, Michael

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BACKGROUND: Since its initial appearance in the early 1980s, the HIV pandemic has presented a worldwide challenge not just in biomedical innovation but in social and political mobilization as well. The groundbreaking innovation of HAART (highly active antiretroviral therapy) in 1996 was buttressed by an era of public health mobilization to limit the scale of the epidemic prior to 1996 and an era to ensure access to this treatment. The actions taken in these two eras have shaped the current character of the epidemic in all countries; the US and Brazil are no different. On the one hand, the US lags behind its countries in metrics such as the UN AIDS 90-90-90 initiative. In contrast, Brazil has emerged as the leader in Latin America in the 90-90-90 metric, achieving marks that are comparable to the US despite differing levels of development. OBJECTIVE: Brazil implemented bold public health policies that led to it becoming one of the leaders in Latin America in HIV management. This thesis will explore the historical context and implementation of these policies with an eye towards possible application in the US. METHODS: Historical analysis was performed on the public health policies of Brazil and the US regarding HIV/AIDS management. Sources include but are not limited to contemporaneous newspapers, presidential recordings and speeches, congressional legislation and briefings, documentaries, epidemiologic figures, interviews, government and activist images and posters, mathematical models of the HIV epidemic, and other studies comparing the two countries. RESULTS: To a much greater extent in the United States, there was alignment in values and action between federal and local governments, civil society, the Constitution, and international donors. This led to the historic and controversial decree in 1996, proclaiming universal and free HAART for all Brazilians. Since then, Brazil has maintained a successful and solvent HIV program through partnerships with community leaders to increase outreach, aggressive negotiation for medication pricing internationally, and sophisticated centralized databases permitting cutting-edge patient care and research. In contrast, the early HIV movement in the United States was characterized by conflict between the federal government and activists who fought for recognition and treatment for people living with HIV (PLWHIV). Other branches of the federal government in addition to local governments provided some leadership, but the lack of a unified response led to an increase in the scope of the epidemic, ultimately making it more difficult to manage. Both countries find their HIV programs at a crossroads. In Brazil, an increasingly conservative government and a defunding of the public health system (SUS) has led to a disturbing increase in incidence, especially among the youth of Brazil. In contrast, the United States has reinvigorated its domestic response to AIDS with the 'National HIV/AIDS Strategy' of President Obama and the 'Ending the Epidemic' initiative of President Trump. However, ultimate success in the HIV epidemic in the US may require a more fundamental rethinking of the healthcare system. CONCLUSION: Prior work comparing the the the Brazilian and American response to the HIV epidemic have centered on the roles of activism, executive leadership, and international factors that have shaped policies, in particular the policy of universal and free HAART in Brazil. This thesis builds on this work by examining interventions that Brazil has implemented in the last decade with an examination of recent policies enacted by the Obama, Trump, and Bolsonaro administrations. Such a comparative approach may prove useful to policymakers interested in using the experiences of other nations to devise innovative approaches to the HIV epidemic.

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