In 1996, Brazil shook the treatment globewhen it began offering free antiretroviral medicines to every HIV positive citizen who needed it. The government first bought generic drugs from Asia, then broke patents and produced generic meds itself, sparking opposition from the U.S. pharmaceutical industry. Brazil has saved the equivalent of $1.7 billion in AIDS-related hospitalizations, and its HIV prevalence rate, which was once on course to rival South Africa’s (where the average rate is now 20 percent), is 0.06 percent.

But over time, tens of thousands of Brazilians have become resistant to the generics. Patients now need newer (read: brand-name, high-priced) drugs, such as Gilead’s Viread (tenofovir) and Merck’s Stocrin (efavirenz), both imported from the U.S. and Europe. Indeed, 80 percent of all medications purchased by Brazil’s Ministry of Health are now expensive imports. The country’s annual price per patient had dropped from $6,240 to $1,336 from 1997 to 2004; brand names bumped it back up to $2,500 in 2005.

The government is at a crossroads: It can keep paying for brand-name drugs and risk bankrupting the treasury, or break new patents. The global Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement allows generic manufacturing, despite active patents on name brands, in a natural disaster or public-health crisis. But experts say that the Brazilian government might think twice before producing new generics. “They are afraid [potential] retaliations on trade agreements from the U.S. and Europe would affect agriculture and other services,” says Veriano Terto Jr., executive director of Rio’s Brazilian Interdisciplinary AIDS Association. But Terto also stresses that the stakes are too high for the 180,000 Brazilians on antiretrovirals: “Public health is more important than trade.”


Several nations have followed Brazil’s lead, offering free HIV treatment, regardless of income. A sampler:


Population: 1.6 million
HIV prevalence: 24%
This ravaged Southern African country began providing universal free ARV treatment in 2002; in recent years, AIDS deaths there have dropped by 25%.


Population: 64 million
HIV prevalence: 1.4%
Making its own generics, Thailand has covered ARVs through its health system since 2005; AIDS deaths dropped from over 5,000 in 2004 to 1,640 in 2005.


Population: 12 million
HIV prevalence: 0.9%
Senegal, in West Africa, began offering free antiretrovirals in 2003 after a study showed that even the lowest user fee kept patients from treatment.