They make several furtive passes of the front door of Pela Vidda before they duck inside and mumble a request at the front desk. They are whisked upstairs, where a calm counsellor speaks to them for a few minutes, then swabs the inside of their mouths and whips out a little plastic tray. A few more minutes and they get the news. Sometimes it's good, but remarkably often the test says HIV-positive.
The scene plays out every day in the gleaming offices of this AIDS organization. Anxious walk-ins, most of them gay or transgender youth, tug their hoodies over their heads and come seeking a rapid HIV test on a residential street. And with every cheek swabbed, this country takes another small step toward achieving a very big goal.
Brazil has a long history of innovation on HIV and is held up as the great developing country success story in fighting AIDS.
It had national free public AIDS treatment before anywhere else, and it had huge success enlisting gay men, sex workers and drug users in the fight to stop the virus. But with a new plan launched late last year, Brazil is poised to go one step further. It wants to stop the spread of HIV by putting every single person who has the virus on treatment, whether they are sick or not.
The concept – known as "treatment as prevention" – has Canadian roots. It was pioneered by, among others, Julio Montaner, a leading AIDS physician in British Columbia and former president of the International AIDS Society who credits it with the fact that Vancouver closed its AIDS ward earlier this year. It's policy now in B.C. – and while Canada as a whole hasn't adopted it, China, Australia, France and the U.S. all want to use the model.
But Brazil has gone furthest, and with 720,000 people living with HIV, this country has taken the concept to a whole new scale, once again blazing an ambitious path in the response to AIDS.
Thirty years ago, Brazil's dedicated push on HIV helped rein in the epidemic, cutting new infections sharply. But those numbers started to creep up again because Brazil got complacent, its own officials agree, and for two other key reasons. First, the virus has spread into every nook and cranny of the country, including the vast swaths of the Amazon forest where the health system struggles to provide even basic care. And second, in Brazil like everywhere else, there is a generation of young people who don't recall the decimation AIDS wrought in the 1980s, who think of it as a treatable illness, and for whom safer-sex messages fall on deaf ears.
"Our strategies have been failing, and it's clear we need a new one," said Inacio Queiroz, president of the chapter of Pela Vidda (For Life) in this city across the bay from Rio de Janeiro.
That's where the new plan comes in. Putting people on anti-retroviral therapy (ARVs) stops the spread of HIV because people on treatment have so little presence of the virus in their bodily fluids that it's called "undetectable"; they are 90 per cent less likely to infect partners with whom they have unprotected sex or share needles. (The virus is still present in genomic material in their cells and eventually starts to circulate again, when it grows resistant to the medication.)
Under the leadership of Fabio Mesquita, a hard-charging public health expert who took over the national AIDS program in mid-2013, Brazil resolved to get all 720,000 people with HIV on to treatment within a few years, including the 150,000 people who don't yet know they have the virus. And while it is hard enough to do in the heart of a major city like Sao Paulo, it's wildly difficult in the Amazon.
Brazil has posted remarkable results: In a normal year, the country was putting 34,000 new people on ARV treatment; by the end of this year, it will have started 85,000.
Key to the swift expansion is offering more tests – especially to the young gay men, crack addicts, sex workers, people with TB, the homeless and others considered vulnerable. Testing has been taken out of clinics and is now offered at community organizations such as Pela Vidda. Its staffers go into the streets on raucous Friday nights to encourage people to drop in for the rapid mouth swab.
Until recently, Brazil followed the global guideline, starting patients on ARVs when their CD4 count – a crucial measure of the immune system that is eroded by HIV – hit 500 or below. But Dr. Montaner said a surprise finding from Vancouver was that people tolerate the drugs better, stay healthier longer and have an overall drop in mortality if they start treatment while they are still showing no signs of ill health.
But not everyone is convinced the new plan is a good one. "We support the universality of treatment, of course, but treatment is more than drugs and there isn't consensus universally that this is the best policy," said Ana Lucia Amarante, a researcher and psychologist who works with Pela Vidda.
She ticked off concerns: Offering testing is fine, but what if it becomes pressure or forcing people? Can Brazil's health system hold up to monitoring all these people? How would patients be supported to stay on their medication, which must be taken daily without interruption? What if they started to get slack about safer sex, when their viral load might be creeping up? And there isn't yet sufficient research on the health impact of taking the drugs long-term, she said, or how it might create new avenues for the spread of resistant strains of HIV.
Dr. Montaner noted that activists had identical concerns in Canada at the outset, but soon saw benefits and became supporters of the program.
"It's not really 'test and treat,'" said Sergio Aquino, who heads the AIDS program for the city of Rio de Janeiro, citing the slogan from the big United Nations push. "For us, it's 'test and talk.' Some people don't want to start right away, and they have that right … some don't want to think of themselves as people with an illness.
"People say we're putting the national interest above the individual patient, but we're not really – the only form of prevention we have is condoms," Dr. Aquino added. "Collective prevention is all that we have left – that's true globally, not just for Brazil."
Simultaneously, Brazil is implementing a large-scale "pre-exposure prophylaxis" plan, in which people who are HIV-negative but believed to be at highest risk are offered ARVs to keep them from getting infected should they be exposed. It's by far the largest such initiative in the world.
"There's no precedent for doing this in an epidemic like ours," said Dr. Mesquita, the national AIDS program chief. "But we think we can do it."
HIV in Brazil
• The two hotspots in Brazil's HIV epidemic are at opposite ends of the country. In the Amazon rainforest, it's a heterosexual epidemic driven by limited access to health care: people don't get tested, and they don't hear a lot of prevention messages. Way in the south, in Rio Grande de Sul, it's an epidemic concentrated among drug users and men who have sex with men (but may not identify as "gay" in a heavily macho cultural, and so aren't catching prevention messages).
• A few years ago, injection drug use in Brazil began to be supplanted by crack, of which this country is now the largest consumer. That might have had a grim silver lining – fewer shared syringes – except that any gain was cancelled out by the swift and brutal toll crack takes on the lives of its users. Many are soon homeless, occasionally relying on casual sex work for cash, and as much or more at risk of HIV exposure than they were from dirty needles. Five per cent of crack users in Brazil today have HIV-AIDS, a rate 12 times higher than in the general population.
• HIV education in Brazil is limited by the power of the Catholic Church and by the large and growing influence of evangelical Christians, who have successfully campaigned to scupper a number of education campaigns targeting sex workers, gay men and condom use. HIV education is not included in the curriculum of Brazilian schools.
• Yet the fight against AIDS in Brazil continues to have a strong grounding in human rights: Last year it became the first country in the world to pass a law criminalizing discrimination based on HIV status.