Published by the New York Times December 12, 2017
By Shasta Darlington
SÃO PAULO, Brazil — Seeking to stem a sharp rise in H.I.V. cases among young people, Brazil began offering a drug this month that can prevent infection to those deemed at high risk.
Brazil is the first country in Latin America, and among the first in the developing world, to adopt the pill Truvada, under a program known as PrEP, short for pre-exposure prophylaxis, as an integral part of its preventive health care policy.
The blue pill — which drastically reduces the risk of contracting the virus when taken daily — will be made available at no cost to eligible Brazilians at 35 public health clinics in 22 cities during an inaugural phase of the program.
The Brazilian Health Ministry is paying Gilead Sciences, the American manufacturer of the drug, about 75 cents a dose, a fraction of the price users pay in the United States, where the pill sells for upward of $1,600 for a month’s supply.
The drug is being rolled out at a crucial time in Brazil, with the country’s health officials particularly alarmed by the rise of the virus among young men and other groups considered at higher risk.
Between 2006 and 2015, the number of AIDS cases in men aged 15-19 almost tripled, to 6.9 cases per 100,000 people. Among men 20-24, the rate almost doubled to 33.1 cases per 100,000, according to U.N.AIDS, a United Nations agency that coordinates H.I.V. prevention policy around the world.
Approximately 48,000 new cases of H.I.V. were reported in Brazil in 2016 and about 14,000 deaths related to AIDS, the agency said.
While the transmission of the virus from mother to child has been significantly reduced, about one in 10 men who have sex with men in Brazil have H.I.V., the agency said.
“Our hope is that with PrEP and other measures we can reduce the rate of new infections,” said Adele Benzaken, the director of the AIDS department at Brazil’s Health Ministry. “But it’s a big challenge.”
PrEP is being made available to prostitutes, transgender people, men who have sex with men, some drug users and people in relationships with partners who have H.I.V.
Brazil has long been recognized for its strong response to the H.I.V. epidemic. It challenged pharmaceutical companies in the 1990s by producing generic versions of costly antiretroviral drugs, which lowered prices globally. Brazil’s government buys and distributes more condoms than any other country, and in 2013 it started providing antiretroviral therapy free to all H.I.V.-positive adults seeking care.
Proponents of PrEP say Brazil’s experience will show the economic benefits of investing in prevention.
“With the addition of PrEP, Brazil is using all of the strategies that we recommend,” said Georgiana Braga-Orillard, the director of U.N.AIDS Brazil. “This is a large-scale operation, and Brazil could become an example to all of Latin America that we need to see an integrated approach.”
Since the United States Federal Drug Administration approved Truvada as a prevention drug for H.I.V. in 2012, several countries have sought to make it available and affordable to people at risk of contracting H.I.V.
For the first year of Brazil’s program, the Health Ministry spent $2.7 million for 3.6 million pills. Screening and additional care will be provided at no cost at public clinics.
Ms. Benzaken, the ministry official, said Brazil expected to spend less on this preventive care next year as generic versions of the drug arrive in the market.
“It was a good deal,” she said. “But we need to bring the price down even more.”
She said two pharmaceutical companies, including Mylan, had applied to Brazil’s health regulatory agency, Anvisa, for approval of generic versions of Truvada.
People have grown less concerned about H.I.V., leading to a decline in the use of condoms, said Jose Valdez Madruga of the São Paulo Health Secretariat, who was one of the coordinators of a PrEP trial in Brazil carried out ahead of its implementation. The drug provides an additional safeguard.
“With PrEP, it puts the decision in the hands of one person, said Mr. Madruga, the head of the secretariat’s AIDS and sexually transmitted disease center. “You don’t need the agreement of the other partner, as with condoms.”
According to a survey in Brazil by the gay-dating app Hornet and U.N.AIDS, 36 percent of respondents said they would probably use PrEP if it were available.
Critics of PrEP have said it incentivizes condomless sex, leading to the spread of other sexually transmitted diseases.
Marcio Pierezan, 29, a patient who participated in the trial, said those fears were overblown. He started taking the pill two years ago.
“It was at a time when four close friends had tested positive for H.I.V., and I was in an open relationship with someone who had tested positive,” he said. “I was in constant fear that I would be next, even though I used condoms.”
Mr. Pierezan says that the pill is as an added protection, but that he never stopped using condoms. “It became part of my routine,” he said. “I take it with coffee in the morning, and it’s been a huge relief for me, my friends, my mother!”
Piero Mori, 34, a systems analyst who is gay, says he never liked using condoms, which meant new sexual encounters often brought weeks of anxiety as he tested yet again for H.I.V.
“Condoms will always be the most complete protection,” he said. “But for those who just can’t or won’t use them, PrEP is a salvation. It protects you against the most serious disease.”
The new tool in Brazil’s effort to contain the spread of H.I.V. is being deployed as budget shortfalls in some states have led to personnel and medicine shortages that have crippled several hospitals. Additionally, public schools that provide comprehensive sex education have come under attack from conservative politicians.
Still, health officials have high hopes for the impact PrEP can have on keeping people healthy. In order to promote it, they are considering partnering with popular YouTube personalities and advertising on online dating apps.
“We don’t have all the answers yet,” Ms. Benzaken said. “But we are using all the tools at our disposal.”
Correction: December 12, 2017
An earlier version of this article misidentified the H.I.V. prevention pill to be given away in Brazil. The drug is Truvada, not PrEP, which describes the overall treatment strategy, pre-exposure prophylaxis.