Book Review

Sex, Drugs, and HIV/AIDS in Brazil

N Engl J Med 2001; 344:1257-1258April 19, 2001

Article

Sex, Drugs, and HIV/AIDS in Brazil
By James A. Inciardi, Hilary L. Surratt, and Paulo R. Telles. 185 pp. Boulder, Colo., Westview Press, 2000. $30. ISBN: 0-8133-3424-1

There has been considerable scientific, social, and economic interest in the study of the AIDS epidemic in Brazil, a developing country that ranks second only to the United States in the number of reported cases of AIDS (196,000 by September 2000). Since 1996, there has been a stable yearly incidence of 14 per 100,000 population. Sex, Drugs, and HIV/AIDS in Brazil describes some of the components of the epidemic in Brazil, in particular the transmission of HIV among drug users, women, transvestites (from the results of research projects conducted in the city of Rio de Janeiro), and children living on the streets (the data on children are from the available literature).

This endeavor is a formidable task. Brazil is an enormous country with great economic, social, cultural, and behavioral diversity. It is frequently said by Brazilians that there are several different Brazils. The country includes small villages in some northeastern states that have no access to electricity, telephones, or tap water and cosmopolitan cities in the southeast. This diversity is reflected in the prevalence of human immunodeficiency virus (HIV) infection and cases of AIDS: 69.5 percent of reported cases are from the southeastern region of Brazil; among these, 71.0 percent are from the state of São Paulo and 21.7 percent are from the state of Rio de Janeiro. The picture is quite different, however, for the cumulative incidence rates of HIV infection from 1991 to 1999: the four cities with the highest rates are from the southern part of the country, and Rio de Janeiro and São Paulo rank 30th and 31st, respectively. It is worth emphasizing that more than 20 percent of reported subtypes of HIV in the southern region of the country belong to clade C, whereas in the rest of the country, as in the United States, B is the dominant subtype. This probably reflects the recent introduction into Brazil of HIV subtypes different from those in the initial cases, which were traced to sexual contact with infected persons in the United States.

In Brazil, there are about 100,000 people with HIV infection or AIDS who receive antiretroviral drugs free of charge. This policy is made possible by the production of such drugs in Brazil; today, the country produces 8 of the 12 antiretroviral drugs that are currently being used. Production of these drugs has reduced the annual cost of treatment for a patient with AIDS by 47 percent (from $7,858 U.S. dollars in 1997 to $4,137 at present); by contrast, the price of imported drugs has dropped by only 9.6 percent, and Brazil spends about $170 million annually on four imported drugs. Among these are two patent-protected antiretroviral drugs, which account for 36 percent of the total amount spent on AIDS treatment. With the appearance of new patent-protected drugs that are more effective but are also more expensive, the Brazilian Ministry of Health predicts that the national treatment program could be compromised. In the opinion of the ministry, the best solution would be for the pharmaceutical industry to negotiate the sale of antiretroviral drugs, taking into account the market purchasing power. It is worth noting that the Brazilian industrial-property law includes a provision for compulsory licensing of a patent if the patent holder exercises the rights or uses the economic power granted by the patent in an abusive manner.

Despite the lack of external validity of the data for the country as whole, this book is an important contribution to the understanding of the AIDS epidemic in urban areas of southeastern Brazil. Its eight chapters and two appendixes cover the historical aspects of the epidemic worldwide and in Brazil; the difficulties in establishing intervention programs in developing countries; the results of intervention programs for drug users; the use of female condoms; drug use and sexual behavior in transvestites; drug use in homeless children; and harm-reduction initiatives, which are discussed in an epilogue. Appendix A describes the National Institute on Drug Abuse Standard HIV/AIDS Intervention Program implemented in Rio de Janeiro, and Appendix B presents a discussion of racial identity in Brazil.

The first two chapters, although somewhat outdated, are informative and will be helpful for those not familiar with the epidemic worldwide and particularly in Brazil. Besides the historical perspective, official data from the United Nations AIDS Program and the Brazilian Ministry of Health are presented. Sexuality in Brazil is discussed in terms of social factors; the roles of religion and carnival in shaping the Brazilian sexual ideology are appraised. Statistics about drug use in Brazil are also presented.

The discussion in chapter 3 of how to establish and implement an intervention program in a developing country is excellent. Problems in designing the protocol and selecting the research sites, most of them due to inaccurate base-line data, are discussed. The authors also discuss how different perceptions of the objectives of an investigation, which are most often due to cultural and language differences, affect the implementation of the protocol. Difficulties in budget administration and the relationships between investigators and staff members are emphasized. Anyone who has been involved in multinational research projects knows the difficulties of overcoming these problems.

The results obtained by the HIV/AIDS Prevention–Intervention Program among drug users in Rio de Janeiro are presented in chapter 4, and their limitations and applicability are discussed. A similar approach is used in discussions of investigations into the female condom and transvestism in chapters 5 and 6. The information on homeless children and the connection between drugs and AIDS in chapter 7 is based on published results, mainly from investigations conducted in Brazil.

The epilogue covers the concept of harm reduction, focusing on AIDS-related interventions, especially those linked to injection-drug use such as needle- and syringe-exchange programs. The authors refute the criticism of the Brazilian arm of the project for its exclusion of a needle- and syringe-exchange component, arguing that 90 percent of the drug users in the investigation were noninjectors and that only 9 percent of them tested HIV-positive and noting the legal difficulties of implementing such activity under the Brazilian law. At the end of the epilogue, Brazilian initiatives in AIDS prevention are listed.

Those wanting to understand the spread of the AIDS epidemic in a developing country — specifically, in an urban setting in southeastern Brazil — will find the material presented in this book new and interesting.

Carlos M.F. Antunes, Sc.D.
Universidade Federal de Minas Gerais, 31340-510 Belo Horizonte, MG, Brazil