Brazil Could Teach the US about HIV/AIDS

Those of us who seek societal change have to think about how we can create impact. As an educator, I have the opportunity to share my ideas with students, who can think about them, modify them to suit their needs, and apply them to problems they are attacking. That source of impact is my privilege.

Erica Anzalone-Newman was student in a course I teach on "Solving 
Society's Problems through Innovation and Enterprise." In the essay 
that follows, she beautifully illustrates key themes from the my book, Design Your Life, Change the World: Your Path as a Social Entrepreneur. These themes are:

  • Big Picture Design. First, design everything:make sure that you consider everything in your design thinking, not just the central product or service you're providing. Among other features, these would likely include how you distribute your product, gain acceptance for it, and make it affordable. And second, steal shamelessly: attempt to identify ideas with proven merit and use them for the problem you're addressing.
  • Make It Appropriate. Ensure that your product or service not only is relevant -- but is also perceived as being relevant -- to the context in which you are working.

  • Make It Stick. Make sure that you have the means to successfully introduce a product or service to a new region and that you can "embed" it so that it gains long-term acceptance.
  • Make It Bigger. Find ways to spread you product or service to other regions so that it benefits more people. Also, you can increase awareness of your ideas or recruit others to join you so that your idea is taken up and spread.

Learning from Brazil's Assault on HIV/AIDS: Applications in US Urban Communities

by Erica Anzalone-Newman

Examples of transplanting modified, developed-world innovations to the developing world are rampant. Yet there is much to be gained by organizations serving US populations adopting and adapting business and service delivery models developed in developing countries. More specifically, Brazilian groups have developed and executed one of the most successful responses to HIV and AIDS in the developing world, if not the world at large. The Brazilian response to HIV/AIDS is based on component elements that might be modified for implementation in US urban centers, including Newark, NJ.

Before I explain how that can occur, I present a brief history of the spread of HIV/AIDS in both 
locales. HIV/AIDS in Newark, NJ: History and Context Newark has a long history of a high incidence of HIV/AIDS cases, wrought by the virus essentially since its first detection in 1981. The context for Newark's AIDS crisis began with the infamous race riots of 1967, after which the population declined significantly and many businesses left the city. Employment rates plunged, and the poverty rate soared. By the late 1980s, one-third of the residents lived below the poverty line, and homelessness was three times that in New York City [1].

As the city lost the vast majority of its middle-class, an "underground" economy began to thrive [2], and Newark became plagued by political corruption, insidious crime and, importantly, pervasive drug use. According to a New York Times article written at the height of the AIDS epidemic, "[New Jersey] stands apart as the first state in which intravenous drug abusers, rather than homosexuals, make up the largest group of victims." [3]

This was especially true in Newark, New Jersey's largest city. Indirect effects of intravenous drug use were that women, with virtually no job prospects, turned to prostitution to support addictions, increasing exposure to and the spread of HIV [4]. Drug-addicted men, as well as those engaging in sex with prostitutes, were similarly exposed; in turn, they began to infect non-drug using wives and other sexual partners, who were often unaware that they were infected until their newborns were found to be HIV-positive at birth. According to one Coordinator from the U.S. Centers for Disease Control, "'In cities like Newark, AIDS [had quickly] become a disease of the family" [5]. By early 1989, there were nearly 1,200 cases of AIDS in Newark, of which more than half resulted in death [6]. Clinical research was fairly prominent in Newark; however, community-based efforts, such as outreach, prevention, treatment and care were minimal [7]. 

HIV/AIDS in Brazil: History and Context The first case of AIDS in Brazil was recorded in 1982 [8]. In the early years of the epidemic, the majority of HIV carriers and AIDS victims were men who have sex with men in large urban centers. Other populations initially affected in disproportionate numbers included intravenous drug users and individuals requiring blood transfusions [9]. However, since 1993, heterosexual transmission has been most prominent [10]. During the early- to mid-1980s, as Brazil was realizing true democracy for the first time, NGOs were instrumental change agents within Brazilian society. These groups were vocal proponents of government intervention on a variety of fronts, including HIV/AIDS prevention and treatment. They were also instrumental in encouraging "a climate of social solidarity, allowing open and frank debate about HIV and AIDS." [11]. The responsiveness of the government, inspired by the pressure imposed and partnerships formed by NGOs, has been central in stemming the spread of HIV/AIDS in Brazil. 

A Critical Look at the Brazilian Approach to Combating HIV/AIDS

  • Big Picture Design and Making It Bigger

Based on the spread of HIV in Brazil through the early 1990s, World Bank estimates indicated that 1.2 million Brazilians would carry HIV by 2000; instead, the true figure was only six hundred thousand, and HIV growth since 2000 has been slower than in many other nations, as well [12]. 

It seems that adherence to the tenets of Big Picture Design and emphasis on growing efforts to scale have been central to this relative success story. Certainly there were numerous elements of the Brazilian approach that were grassroots in nature (i.e. not developed as part of a master "Big Picture Design" plan); still, the approach is impressively comprehensive in terms of the demographic and geographic segments it covers; the attentiveness to all aspects of product and information dissemination - including the underlying tone or message accompanying each individual initiative; the combination of top-down and bottom-up 
initiatives; and the efforts aimed at both prevention and treatment. 

NGOs started the conversation about HIV in Brazil, but quickly sought government involvement to set the tone for addressing the virus nationwide. The government first undertook distribution of information, to raise awareness and educate on prevention, with a focus on the highest-risk groups within the population [13].

In 1988, the country's new constitution included legal protection against discrimination for people living with HIV, as well as free access to healthcare for all Brazilians. Healthcare for all included the provision of free antiretroviral drugs (ARVs) to people living with HIV; by 2007, 80% of those requiring ARVs were receiving them [14]. Availability of ARVs drastically improved AIDS-related mortality rates and also reduced the number of mother-to-child transmissions.

The government has also promoted growth within the Brazilian pharmaceutical industry, which is now equipped to produce 40% of AIDS drugs domestically; this increases the long-term viability of free distribution to citizens, as it enables the government to purchase ARVs at lower prices those drugs that must be produced internationally, the government has put significant pressure on foreign pharmaceutical firms, threatening the issuance of "compulsory licenses" to elicit lower prices. "Compulsory licenses allow countries to override patent laws and produce their own generic (copied) versions of company-owned drugs, and can be issued when the government of a developing country deems it to be a public health emergency." [17]

In 2007, the Brazilian government actually issued a compulsory license for an AIDS drug produced by Merck. This action has had an impact beyond lower ARV prices; it demonstrates the government's willingness to provide bold support for HIV/AIDS initiatives even in the face of harsh criticism. 

These are just a few examples that illustrate the collaborative "passing of the baton" back and forth, between the Brazilian government (top-down) and NGOs (bottom-up), which has contributed to Big Picture Design in that the Brazilian approach has the necessary scope and scale to be effective.

These examples also illustrate the notion of "designing everything." For instance, it is not enough to make HIV testing available; you must also provide resources, so that people are not deterred by their inabilities to respond to the test results, financially or otherwise. Finally, these examples speak to the complementarity between prevention and treatment efforts, which could only be discovered through careful analysis of the "Big Picture": the virus's entire life cycle.

  • Making It Appropriate

The Brazilian approach involves a supreme focus on being relevant and perceived as relevant. For example, media campaigns for testing have featured celebrity advocates, who tend to be especially influential among youth, and prevention campaigns use all types of media, including TV, newspapers, billboards, bus shelters, and others [18]. Much HIV-prevention work is based on condom distribution, with particular emphasis on settings and geographies in which condoms are most absent. For example, during the 2009 carnival season, 65 million condoms were distributed - an increase of 45% over the usual number distributed in an average month - because carnival season tends to be correlated with increased sexual activity in Brazil [19]. Condom distribution and other forms of grassroots education and support have also been especially prominent for sex workers, as prostitution is legal in Brazil, and sex workers are at high risk for both contracting and transmitting HIV [20]. 

There are other examples of "making it appropriate," too. There is an emphasis on preventing HIV-positive mothers from breastfeeding, by providing both education and breast milk alternatives. Additionally, rapid HIV tests are widely available in maternity wards. Needle exchange programs for intravenous drug users are widespread, as is counseling and access to treatment targeted at this group. In "shanty towns," NGOs have fostered peer-to-peer education networks by training youth representatives [21].

The Brazilian approach involves being present at absolutely every touch point in an individual's life when HIV could potentially be transmitted, and providing information and products through channels that are familiar and disarming.

  • Making It Stick

The paramount explanation for why the fight against HIV/AIDS is so embedded in communities within Brazil is the work that has been done to de-stigmatize and de-politicize the virus. From the outset, NGOs pushed the government to approach the need for HIV/AIDS prevention and treatment as a human rights issue, not a moral or religious issue, or one that impacts only certain minority groups withinthe country [22]. "The Brazilian response has... pushed for everyone - from the President to prostitutes - to practice safe sex. Public health experts say Brazil's approach works because it doesn't discriminate" - just like the virus [23]. Brazil's fight against stigma, as well as its "tolerant, non-judgmental approach to HIV prevention," are considered unique differentiators in the fight against AIDS [24].

Potential Applications in Newark, NJ

It is reasonable and realistic to acknowledge that certain Brazilian programs, particularly some of the governmental programs, are not precisely replicable in the US due to fairly different social mores; some Americans may raise moral objections to some of the Brazilian methodologies. Ultimately, however, Brazil's success vis-à-vis the de-politicization of responding to HIV/AIDS, is too great to ignore. (Recall: Big Picture Design advocates "stealing shamelessly.") Perhaps the only way to respond to HIV/AIDS so comprehensively within the US is to shift the majority of the load to private organizations, rather than relying on government intervention to the degree that Brazilians did. (Making ItAppropriate means seeking relevance through flexibility, not rigidly applying an approach that will be unwelcome and rejected.)

One opportunity area involves modifying the Brazilian model for partnering with sex workers, to partner with intravenous drug users in Newark instead. These two populations are approximately the same in their respective locales in terms of bearing disproportionate risk of carrying and transmitting HIV. There have been some recent needle exchange efforts in Newark, but there is also a long history of NJ state government opposition to such programs. Needle exchanges have consistently correlated with reduced spread of HIV in pilot areas, and given the direct and indirect contact that drug users have with other segments of the Newark community, this would seem to be a worthwhile early investment.

Perhaps a new enterprise is needed for this to be feasible: a syringe manufacturer that sells syringes to local doctors' offices, hospitals, and clinics in order to subsidize the costs associated with needle exchange programs. This enterprise could even arise as a subsidiary of one of NJ's many pharmaceutical and medical supply producers. To be most relevant, needle exchanges would need to be most prominent around the first of each month, when welfare checks are distributed and spending on drugs is highest in Newark.

Another opportunity area involves replicating Brazil's myriad campaigns to reduce the stigma associated with HIV/AIDS,as this has historically been a severe problem within the predominantlyblack and Latino communities in Newark. The subject matter of the campaigns could run the gamut from human rights-themed messages, to celebrity (local or national) endorsements of HIV testing, to educational public health messages that inform/remind people about how HIV is transmitted.

While there are surely a number of other specific applications of the Brazilian strategy for Newark, generally speaking, Newark should focus on a few thematic lessons from the Brazilian case: First, Newark organizations should learn from the Brazilian concentration on being relevant and relentless at every touch point in individuals' lives at which they might be exposed to HIV; action at manyof the aforementioned touch points in the Brazilian context would be directly transferrable to the Newark context. Second, Newark organizations should recognize the importance of making AIDS a sustained, public conversation about a public health issue - whether that is done with or without the government's assistance. Finally, Newark health organizations (e.g. hospitals and clinics) and/or the local government should focus on identifying incentives for private sector producers of products that are needed for prevention and treatment efforts, in order to procure these products at manageable prices. 

[1] Williams, L. (1989, February 2). Inner city under siege: fighting AIDS in Newark. The New York Times. Retrieved 13 Nov, 2010, from

[2] Tierney, J. (1990, December 16). Urban Epidemic: addicts and AIDS - A Special Report: in Newark, a spiral of drugs and AIDS. The New York Times. Retrieved 13 Nov, 2010, from 

[3] Narvaez, A. A. (1987, July 21). Newark hospitals seek unit for AIDS treatment. The New York Times. Retrieved 13 Nov, 2010, from

[4] Tierney, J.

[5] Williams, L. 

[6] House of Representatives Committee on Governmental Operations. (1990). "The AIDS Epidemic in Newark and Detroit." Washington, DC: U. S. 

Government Printing Office. Page 50.

[7] Ibid, page 35.

[8] Accessed 14 Nov. 2010.

[9] Ibid.

[10] Bacon, Pecoraro, et al. "HIV/AIDS in Brazil." UCSF Country AIDS Policy Analysis Project. San Francisco (2004): 9.

[11] Accessed 14 Nov. 2010.

[12] The Economist. (10 May 2007). "Brazil's AIDS Programme: A Conflict of Goals." Sao Paolo. Retrieved 13 Nov, 2010, from

[13] Accessed 14 Nov. 2010.
14 Ibid.

[15] Public Radio International. (11 Jan 2010). "Brazil's Effective HIV Prev

ention Strategies." Accessed 13 Nov, 2010, from

[16] Accessed 14 Nov. 2010.

[17] Ibid.

[18] Ibid.

[19] Ibid.
 20 Ibid.

[21] Ibid.

[22] Ibid.

[23] Public Radio International. (11 Jan 2010). "Brazil's Effective HIV Prevention Strategies." Accessed 13 Nov, 2010, from

[24] Accessed 14 Nov. 2010

About this Entry

This page contains a single entry by Michael Gordon published on June 8, 2011 2:57 PM.

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