Half a million Brazilians are infected with the virus that causes acquired immunodeficiency syndrome (AIDS), and millions more are at high risk of contracting the incurable ailment, a federal study reported. The Health Ministry study is Brazil’s first official attempt to seek an estimate of the number of residents infected with human immunodeficiency virus (HIV). Many had doubted the government’s prior number of 94,997. The report by the National Program for Transmissible Diseases/AIDS said 27 million Brazilians are at high risk to contract AIDS, and another 36 million are considered to be at a medium risk. It said Brazil could have 7.5 million AIDS victims in the next decade.
“If we are going to combat this epidemic, we have to do it now,” said Pedro Chequer, a Health Ministry official. Chequer said the Health Ministry would spend $300 million next year, distributing medicine and 250 million condoms and bringing AIDS awareness campaigns to the urban slums, where the disease is most rampant. Last month, Brazil became one of the few countries to offer a promising AIDS drug free to those who need it. The drug can cost as much as $12,000 a year per patient.
AIDS cases in Brazil have risen so dramatically for married women that the state of São Paulo decided that it must attack a basic cultural practice in Latin America: Their husbands don’t practice safe sex. Last month, the government of Brazil’s megalopolis started promoting the newly released female condom. Many of the new AIDS cases in Brazil are married women who
have children, according to a report released last month at the PanAmerican Conference on AIDS in Lima, Peru. Worldwide, women constitute the fastest-growing group of those diagnosed with HIV. And of the 30.6 million people who are diagnosed with HIV, 90 percent live in poor countries.
One Brazilian mother, Rosana Dolores, knows well why women cannot count on male partners to use condoms. She and her late husband never thought of protecting their future children against AIDS. “We were married. We wanted to have kids,” says Dolores, both of whose children were born HIV positive. “These days, I would advise young people to always use condoms. But married couples . . . who is going to?”
Brazil, with its 187 million people and the largest population in South America, has the second-highest number of reported HIV infections in the Americas, after the United States, according to a report released by the United Nations agency UNAIDS.
Public health officials say one reason why AIDS prevention efforts have failed is that many Brazilians just don’t like condoms. Although use in Brazil has quadrupled in the past six years, it is still the least popular method of birth control— a touchy issue in the predominantly Roman Catholic country. Another reason is that condoms cost about 75 cents each, making them more expensive here than anywhere else in the world, health officials say.
Plus, Latin-style machismo leaves women with little bargaining power. Only 14 percent of Brazilian heterosexual men used condoms last year, according to AIDSCAP, an AIDS prevention program funded by the U.S. Agency for International Development. In other studies, many women said they would not ask their partner to use a condom, even if they knew he was sleeping with others. “Women are afraid of asking their men to have safe sex, afraid of getting beaten, afraid of losing their economic support,” says Guido Carlos Levi, a director at the health department at Emilio Ribas Hospital. “This is not Mexico, but we’re quite a machoistic society here.”
The frequency with which Latin men stray from monogamous relationships has compounded the problem. In studies conducted in Cuba by the Pan American Health Organization, 49 percent of men and 14 percent of women in stable relationships admitted they had had an affair in the past year.
In light of statistics showing AIDS as the number one killer of women of childbearing age in São Paulo state, public health officials launched a campaign promoting the female condom. The hope is that it will help women—especially poor women—protect themselves and their children. But the female condom seemed unlikely to spark a latex revolution when it hit city stores. The price is $2.50 apiece—more than three times the price of most male condoms.
The Family Health Association is asking the government to help subsidize the product and to cut the taxes on condoms that make them out of reach for many poor Brazilians. “We’re looking for a pragmatic solution to prevent the transmission of HIVAIDS,” group President Maria Eugenia Lemos Fernandes said. “Studies show there is a high acceptance of this method because it’s a product under the control of women.”
While 75 percent of the women and 63 percent of the men in a pilot study on the female condom said they approved of the device, many women with AIDS say they would have been no more likely to have used a female condom than a conventional one.
Part of the problem is perception: 80 percent of women and 85 percent of men in Brazil believe they are not at risk of contracting HIV, according to a study conducted by the Civil Society for the Well-Being of the Brazilian Family. Also at risk are married women, 40 percent of whom undergo sterilization as an affordable way of getting around the Catholic church’s condemnation of birth control, health officials noted. “It’s mostly married women who are the victims. You just never think it could be you,” says a former hospital administrator who was diagnosed with the virus after her husband had several extramarital affairs. He died two years ago. “I knew everything there was to know about AIDS—I worked in a hospital—but I never suspected he was going out like that. He always denied it,” she says.
While HIV is making inroads in rural areas and among teenagers in Brazil, Fernandes says it doesn’t have to reach epidemic proportions as in Uganda or Tanzania. “There is a very big window of opportunity here.”
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Cases 4 Developing Global Marketing Strategies
Brazil’s Health Ministry has added a new ingredient to the heady mix that makes up the country’s annual Carnival—condoms. The ministry will distribute 10 million condoms next month, along with free advice on how to prevent the spread of AIDS, at places like Rio de Janeiro’s sambadrome, where bare-breasted dancing girls attract millions of spectators every year.
“It’s considered as a period of increased sexual activity,” a spokeswoman at the ministry’s AIDS coordination department said on Monday. “The euphoria provoked by Carnival and the excessive consumption of alcohol make it a moment when people are more likely to forget about prevention,” she explained.
It is no coincidence that Rio de Janeiro was chosen to host a Conference on HIV Pathogenesis and Treatment. Brazil’s handling of the epidemic is widely regarded as exemplary. In the early 1990s, the World Bank predicted that by 2000, HIV would have infected 1.2 million Brazilians. Five years after that deadline, the total was just half the prediction, at about 600,000. So how did Brazil do it, and can other poor countries learn from what was done?
Perhaps the first lesson is don’t be squeamish. Brazil, a predominantly Catholic country, hands out free condoms in abundance. Some 20 million are given away every month—a figure boosted by 50 percent in February to accommodate for the exuberance of the country’s famous carnivals. Drug users, too, are treated sensibly. Those who inject are offered regular supplies of clean needles and, as a result, three-fourths of them claim never to share needles with others. Nor are prostitutes neglected. Both ladies and gentlemen of the night are the targets of campaigns intended to promote condom use.
The second lesson is to treat freely. Brazilian law gives all residents the right to the best available drug treatment at no cost. This is important, because having to pay discourages people from complying with the full treatment and thus encourages the emergence of drug-resistant viruses. Providing free treatment is, of course, expensive. This year, the government will spend $395 million on anti-HIV drugs, almost two-thirds of it on three expensive patented drugs. This has brought it into conflict with foreign drug companies.
Although it has never actually broken a drug-company patent, the government has exploited every available loophole to evade patents and buy or manufacture generic versions of drugs. For those patents that cannot legally be evaded, the government has played chicken with the patent owners over prices, knowing that manufacturers are desperate to avoid a patent-breaking precedent that others might follow. So far, it has been the companies that have blinked, though the latest sparring match, with Abbott Laboratories, an American firm, over a drug combination called Kaletra, has yet to be resolved.
The third lesson is to encourage voluntary action. In 1992, Brazil had 120 charities and voluntary groups devoted to AIDS. By the turn of the century, that had risen to 500. The virtues of voluntarism were recently confirmed when the Global Fund (the main multilateral distributor of anti-AIDS money to poor countries) audited the success of its donations. It found that spending by voluntary groups usually produced the best value for the money.
The fourth lesson is to do the sums. One of the arguments that has sustained Brazil’s anti-AIDS program is “if you think action is expensive, try inaction.” The government spent $1.8 billion on antiretroviral drugs between 1996 and 2002 but estimates that early treatment saved it more than $2.2 billion in hospital costs over the same period. Add that to the GDP loss that Brazil would have suffered if the World Bank had been right, and an aggressive program of prevention and treatment does not seem so costly after all.
S. Mani’s small barbershop in a southern Indian city looks like any other the world over. It’s equipped with all the tools of the trade: scissors, combs, razors—and condoms, too. A blue box full of free prophylactics stands in plain view of his customers as Mani trims hair and dispenses advice on safe sex, a new dimension to his 20-year career. “I start by talking about the family and children,” Mani explains, snipping a client’s moustache. “Slowly, I get to women, AIDS, and condoms.” Many Indian men are too embarrassed to buy condoms at a drugstore or to talk freely about sex with health counselors and family members. There’s one place where they let down their hair: the barbershop. So, the state of Tamil Nadu is training barbers to be frontline soldiers in the fight against AIDS.
Programs like the barber scheme are what make Tamil Nadu, a relatively poor Indian state that’s home to 60 million people, a possible model for innovative and cost-effective methods to contain AIDS in the developing world. Six years after it was first detected in India, the AIDS virus is quickly spreading in the world’s second most populous nation. Already, up to 2.4 million of India’s 1 billion people are infected with HIV—more than in any other country, according to UNAIDS, the United Nations’ AIDS agency.
But faced with more immediate and widespread health woes, such as tuberculosis and malaria, officials in many Indian states are reluctant to make AIDS prevention a priority. And in some states, the acquired immunodeficiency syndrome is regarded as a Western disease of decadence; officials deny that prostitution and drug use even exist in their midst. “Some Indian states are still in total denial or ignorance about the AIDS problem,” says Salim Habayeb, a World Bank physician who oversees an $84 million loan to India for AIDS prevention activities.
Tamil Nadu, the state with the third-highest incidence of HIV infection, has been open about its problem. Before turning to barbers for help, Tamil Nadu was the first state to introduce AIDS education in high school and the first to set up a statewide information hotline. Its comprehensive AIDS education program targets the overall population, rather than only high-risk groups.
In the past two years, awareness of AIDS in Tamil Nadu has jumped to 95 percent of those polled, from 64 percent, according to Operations Research Group, an independent survey group. “Just two years ago, it was very difficult to talk about AIDS and the condom,” says P. R. Bindhu Madhavan, director of the Tamil Nadu State AIDS Control Society, the autonomous state agency managing the prevention effort. The AIDS fighters take maximum advantage of the local culture to get the message across. Tamils are among the most ardent moviegoers in this film-crazed country. In the city of Madras, people line up for morning screenings even during weekdays. Half of the state’s 630 theaters are paid to screen an AIDS-awareness short before the main feature. The spots are usually melodramatic musicals laced with warnings.
In the countryside, where cinemas are scarce, a movie mobile does the job. The concept mimics that used by multinationals, such as Colgate-Palmolive, for rural advertising. Bright red-and-blue trucks ply the back roads, blaring music from well-known movie soundtracks whose lyrics have been rewritten to address AIDS issues. In villages, hundreds gather for the show, on a screen that pops out of the rear of the truck.
In one six-minute musical, a young husband’s infidelity leads to his death from AIDS, the financial ruin of his family, and then the death of his wife, also infected. The couple’s toddler is left alone in the world. The heart-rending tale is followed by a brief lecture by an AIDS educator—and the offer of a free pack of condoms and an AIDS brochure. Tamil Nadu’s innovations have met with obstacles. It took several months for state officials to persuade Indian government television, Doordarshan, to broadcast an AIDS commercial featuring the Hindu gods of chastity and death. Even then, Madhavan says, Doordarshan “wouldn’t do it as a social ad, so we have to pay a commercial rate.”
Later, the network refused to air a three-minute spot in which a woman urges her husband, a truck driver, to use a condom when he’s on the road. Safe infidelity was deemed “inappropriate for Indian living rooms,” says Madhavan. A number of commercial satellite channels have been willing to run the ad.
Tamil Nadu has met little resistance recruiting prostitutes for the cause. For almost a year, 37-year-old prostitute Vasanthi has been distributing condoms to colleagues. With state funding, a nongovernmental agency has trained her to spread the word about AIDS and other sexually transmitted diseases. As an incentive, the state pays participants like Vasanthi, a mother of three, the equivalent of $14 a month, about what she earns from entertaining a client.
Before Vasanthi joined the plan, she didn’t know that the condom could help prevent HIV infection. These days, if any client refuses to wear a condom, “I kick him out, even if it takes using my shoes,” she says. “I’m not flexible about this.” More men are also carrying their own condoms, she says.
Thank barbers such as Mani for that. Especially in blue-collar areas of Madras, men “trim their hair and beard before frequenting a commercial sex worker,” says Madhavan. They can pick up their condom on the way out.
Tamil Nadu launched the barber program in Madras last March. So far, it has enlisted 5,000 barbers, who receive AIDS education at meetings each Tuesday—the barbers’ day off. The barbers aren’t paid to be AIDS counselors, but they appear to take pride in their new responsibility.
Over the generations, India’s barbers have been respected as traditional healers and trusted advisers. “If you want to get to the king’s ears, you tell his barber,” says Madhavan, the state AIDS director. Reinforcing the image of barbers as healers, the local trade group is called the Tamil Nadu Medical Barber Association. “I first talked about AIDS with my barber,” says Thiyagrajan, an electrician in his 40s. “I don’t have multiple partners, so I don’t need a condom, but I take them for my friends.”
One recent night, a man in his 30s walked into Aruna Hair Arts, greeted Swami, then headed out the door with a fistful of condoms scooped from the plastic dispenser. “That’s OK,” Swami says approvingly. “He’s a regular customer.” A local nongovernmental organization helps barbers replenish condom stocks by providing each shop with self-addressed order forms. But the central government hasn’t always been able to meet supply, for reasons ranging from bureaucracy to price disputes with manufacturers.
Tamil Nadu has started sourcing condoms from elsewhere. But they’re too expensive to give away. So the next stage of the barber scheme, just under way, is to charge two rupees (six cents) for a two-condom “pleasure pack.” The barbers will get a 25 percent commission. Thus far, the only perk of participating has been a free wall calendar listing AIDS prevention tips.
Roughly 30 percent of barbers approached by Tamil Nadu have refused to participate in the AIDS program, fearing that they would alienate customers. But those who take part insist that carrying the AIDS message hasn’t hurt business. “We give the message about AIDS, but we still gossip about women,” says barber N. V. Durairaj at Rolex Salon.
Multinational soft drink giants Coke and Pepsi may soon become part of the Indian government’s efforts to reach out to people in far-flung areas to spread awareness about HIV/AIDS and promote the use of condoms. Where social marketing efforts have failed in reaching supplies of condoms, the idea is to reach out through the soft drink firms that have managed to set up a marketing network estimated at more than 1 million outlets across the country. “Realizing their reach, we have appealed to the cola companies PepsiCo and Coca-Cola to allow us to piggyback on
their advertisement, including possible slogans on their soft drinks bottles,” a senior health ministry official said. “We have also asked them to help us with the distribution of condoms through their outlets in remote areas.”
The requests have elicited encouraging response from both the multinationals. “We are planning to talk to them and hope that they will soon be on board with our awareness campaign and promotion of condom use,” the official said.
What led to the National AIDS Control Organisation (NACO) looking to Coke and Pepsi for support was the encouraging response they received for advertisements featuring cricket stars advising on the need for preparedness. Some campaigns even had them carrying condoms along with the cricket gear.
Backed by 10 countries, including India, the International Cricket Council (ICC) has been actively supporting efforts to promote awareness about HIV/AIDS through campaigns on safe sex. “So whether it is cricket stumps bearing condoms or cricketers themselves urging the need for preparedness, we are finding good response among the public.” NACO also wants to take the campaign forward with celebrity endorsement at a time when sensitive films about HIV/ AIDS like Phir Milenge (“We’ll Meet Again”) and My Brother Nikhil have struck a responsive chord among viewers.
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