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THE CONTEMPORARY RESPONSE
OF THE BRAZILIAN GOVERNMENT,
THE CIVIL SOCIETY AND UNESCO
TO THE
HIV/AIDS EPIDEMIC
CCO Meeting, New York, October 2003
BR/2004/PI/H/1
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"Brazil has handled HIV/AIDS problems with much innovation and
effectiveness, thereby creating good practices that other countries can learn from.
As a universal organization, with a mandate encompassing the whole world,
UNESCO must seek solutions wherever it can. Today, preventive education to
fight HIV/AIDS is at the top of its agenda. Hence we must draw lessons
from Brazil's experience so that your example can save lives and help
development elsewhere: in Latin America, in Asia, in Africa, in Europe. We
must learn from Brazil. We must learn fast. And we must apply what we learn
quickly and effectively".
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CCO MEETING, NEW YORK
OCTOBER 2003
THE CONTEMPORARY RESPONSE OF THE BRAZILIAN GOVERNMENT,
THE CIVIL SOCIETY AND UNESCO TO THE HIV/AIDS EPIDEMIC
I - An overview of the "Brazilian model" and the current scenario of the epidemic
The Brazilian response to the HIV/AIDS epidemic has effectively started in the early 80s with the
creation of the
Sao Paulo State Program and later on with the creation of the National STD/AIDS Program
at the Ministry of Health. Since then the organizations of the civil society, mainly those organizations
of people dealing with HIV/AIDS, have been key partners
of the Brazilian Government in order to contribute to the
accomplishment of policies of assistance, prevention and
human rights. The principles of the program are equity,
integrality of the actions taken, the universal access to health
goods and services, social control, as well as
decentralization towards States and Municipalities.
The participation of the civil society, as one of
the guidelines of the Brazilian Program of AIDS, has been
expanded under the perspective of the construction of social
responses to the epidemic, such as the formulation of strategies
and actions that are aimed to the promotion of public health
policies. The incentive to the participation of representatives
from the civil society in several instances of the government - in the federal, state and municipal levels - so as
the collaboration of nongovernmental organizations that develop projects with special communities, are
mechanisms which have been magnified by the participation of civil society organizations across the country. These
instruments are done through an intense work of advocacy and sophisticated networking in councils and fora
which have been present in the formulation, follow-up and implementation of policies for HIV/AIDS.
Box I - Brazil: Epidemic Profile
- Estimated number of HIV+ individuals (2000): 597,000
- Cumulative AIDS cases (December/2002): 257,780
- Cumulative AIDS deaths (December/2002): 110,710
- IV prevalence rate (2000): 0,65%
- IV incidence rate (2001): 12,3 / 100.000
Source: National Coordination of HIV/AIDS
Brazil has also been internationally praised not only for the actions related to the fight against the
epidemic, but also to the model of partnerships established between the civil society and the government. In
addition to that, we should also stress the role played by the international cooperation - including the role of
UNESCO as one of the key actors in the response to the epidemic, an institution which has been extremely
collaborative in meeting the "Declaration of Commitment on HIV/AIDS", established at UNGASS in 2001,
which involves international cooperation and transfer of technology to other countries as key components
of its strategy.
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CCO MEETING, NEW YORK
OCTOBER 2003
II - UNESCO and the Brazilian AIDS Programme
Brazil's experience in the struggle against Sexually Transmitted Diseases (STDs) and AIDS has been
praised as a success story in many international fora. Over the past 20 years, the Brazilian national response to
HIV has brought together a highly diverse group of national and international bodies in a joint effort to
contain and reverse the spread of the epidemic. It is generally agreed that the Brazilian strategy relies on
three key principles: political leadership from the top starting with the President; heavy involvement of civic and
community organizations which are essential for reaching the poor and helping them take the complicated
regimen of drugs; cheap medicine to treat the patients as a result of national production and effective
negotiation with international drug companies.
The involvement of UNESCO in the Brazilian AIDS Program follows from a strong emphasis on
health education. UNESCO is seen as well placed to offer appropriate technical assistance in relation to training
and education, public awareness raising and research, as well as a more general understanding of the technical
and human rights implications of this kind of program. Three specific and relevant contributions by
UNESCO in this co-operation should be outlined:
I. Partnerships with the civil-society: policymakers, experts and scholars have pointed out that a major
contribution offered by UNESCO was the networking it created with NGOs, which are of outmost
importance for the success of the Program. The civil society is usually resistant to engaging in direct
partnerships with governmental agencies. After UNESCO started to co-operate with the Brazilian Program,
1,000 NGOs started to take part in the initiative, acting as direct implementing agencies of many of
the actions developed, financed by the Government itself.
2. Horizontal co-operation: one of the major elements within the strategy of the Brazilian
Government was helping in the framing of the international policy of the AIDS Program in the
building of partnerships with developing countries. In this regard, a number of actions have been
taken to increase co-operation with Portuguese-speaking countries in Africa. UNESCO and USAID are
jointly implementing a project in Mozambique to strengthen networks involving NGOs that work
directly with youngsters, trying to replicate the model of a successful case that took place in Brazil.
3. Shifting the view of preventive education: perhaps one of the most important contributions of
UNESCO to the AIDS Program in this country was to extend the scope of the Program itself.
Fighting AIDS was initially conceived mainly as a public health issue - it is not coincidental that the
Brazilian AIDS Unit works within the Ministry of Health. The partnership with UNESCO all wed
the introduction of strong actions for preventive education, which have already
been evaluated and
demonstrated their relevant success. Currently, AIDS is seen as a multifaceted and cross-cutting issue -
the Brazilian response now involves a number of different activities targeting various groups with special
focus on the school, youngsters and women. A very relevant indicator of the continuous extension of
AIDS policies in Brazil is the ongoing creation of a Division for AIDS-related matters within the
Ministry of Education.
III - UNESCO's particular input to governmental and civil society responses
As far as AIDS is concerned, UNESCO has been a partner of the Brazilian government since 1998,
after the execution of the second loan agreement of the World Bank (Project AIDS II). Since that date
UNESCO has been contributing to the strengthening of management, so as helping in the implementation
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CCO MEETING, NEW YORK
OCTOBER 2003
of strategies in response to the epidemic. In that sense, strengthening the population in order to cope with
the HIV/AIDS challenge means that UNESCO should place its added value in order to promote actions
that could: a) alleviate the discrimination and stigma in regard to people HIV positive; b) stimulate a change in
behavior; c) promote a preventive message among key opinion-formers; d) build networks for the exchange of
expertise among countries so the Brazilian experience could be adapted to different realities; and e) take advantage of the
potentiality of education and the school as a privileged locus for change.
The actions of combat to the epidemic in Brazil are built according to the individual and collective
characteristics of the population. The Unified Health System (Sistema Único de Saúde - SUS) ensures a policy
of access to preventive material and wide health assistance. Brazil has built over the years a wide network for diagnosis,
counseling and laboratory monitoring. The free distribution of medicine and anti-retroviral drugs done through
the Unified Health System (SUS) since 1992 has brought a considerable decrease of 50% in mortality and has
reduced in over 80% the need of hospital admissions. More than 358 thousand hospital admissions were saved
in the last 5 years, what has resulted into a saving of US$ 2.2 billion (plus US$ 1.23 billion in hospitals and treatment
of opportunistic infections). One way to ensure sustainability was the local production of drugs and the direct
negotiation of prices with the laboratories. However, the main challenge of Brazil is still to ensure an integral assistance -
and of quality - to HIV patients. The alternatives implemented since 1993 have demonstrated considerable social and
economic benefits and the Brazilian government has been expanding the number of patients assisted by the
Unified Health System (SUS).
The Brazilian government, based on the data that demonstrates the efficiency of condom use in the
prevention of STDs and AIDS, not to mention the belief that the State should not intervene in the
structure of the sexual behavior of the population, has been one of the protagonists of the use of this
instrument of prevention. The consumption of condoms has been one of the main evaluation indicators of
the National Brazilian Program. The last survey conducted in 2003 has demonstrated that 64.4% of the
population under 20 years old uses the condom in their first sexual relation. The great challenge is now to
maintain that behavior, mainly among the youth segment, which usually tend to discard condom use after
establishing a relationship with his/her partner. Aiming to promote a change of behavior and foster the
practice of safe sex, the Ministries of Education and Health have launched in August 2003 - in partnership
with UNESCO - a project to make available male preservatives in public schools for youngsters ranging from
15-19 years old. Such project has as its main target, until July 2004, 105 thousand students of the public
network of schools and, until the end of 2006, 2,5 million students. Until 2006 there will be distributed
over 235 million units of preservatives/year.
Moreover, UNESCO has an important role in that action as it will evaluate the results and strategies
implemented in the schools of five Brazilian municipalities so, by the end of 2006, every municipality in the
Country will have adhered to the proposal of making available preservatives, being this proposal linked to a
program of sexual education.
Box 2 – Major aspects in the Brazilian
response to HIV/AIDS
- Balanced prevention & treatment approach with a
human rights perspective in all strategies and action
- Early governmental response;
- Strong civil society participation in all decision leve
- Multisectorial mobilization.
Among the successful strategies of the
UNESCO Brasilia Office (UBO) in accomplishing the
mandate of our organization we highlight its action with
organizations of the civil society, main partners of the
Ministry of Health, both as final beneficiaries of
funding for preventive contents and direct assistance and
also support of technical-institutional nature.
The funding to NGOs, through the National
STD/AIDS Program, from the Ministry of Health, by
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the means of two loans of the World Bank (Projects AIDS I and II), have favored the development of
communitarian actions of NGOs in the last years. We have observed - in the 90s - the need of establishing
local partnerships to maintain community actions, since the number of NGOs in Brazil has considerably
increased.
The loans of the World Bank, whereas they have made viable the development of actions of national
scope, either by the Government or NGOs (fostering ties between the two levels), on the other hand have
indirectly contributed from an international perspective that there are available funds in Brazil, what makes
unnecessary additional influx of capital to fight the epidemic. In that sense, UNESCO has been actively
contributing towards demonstrating to the international community that these experiences have an important role
in the Brazilian scenario and they need support to be successfully adapted to other international contexts.
Through the cooperation with the National STDs and HIV/AIDS Program of the Ministry of Health,
UNESCO has been developing a study of national scope to evaluate the responses of the civil society to the
challenge that HIV/AIDS entails. Although the study is expected to be finished by April 2004, we highlight
some of the data collected until the moment. These are analysis of the action of the civil society in regard to
HIV/AIDS, especially those supported by UNESCO.
The study comes to reinforce the understanding that social control has an impressive influence in the
construction of public policies for HIV/AIDS in Brazil. This means that the civil society has helped the
government to ensure to citizens living with HIV the necessary means for prevention, treatment and assistance,
the latter being done through the free distribution of drugs, but also better living conditions - socially, physically
and mentally.
UNESCO has been also stimulating NGOs which are eligible to its support to participate in the overall
strategy of social control. Therefore, those which are politically and technically sustainable are able to get
inserted into national, state and municipal representations with the aim to follow-up, discuss and propose
alternatives to health public issues.
Among the actions supported by UNESCO in partnership with the Brazilian government we highlight:
actions of capacity-building/training of professionals (health and education, social development, public
safety and volunteers (social educators); projects of treatment for HIV positives; programs to promote social
inclusion of HIV positives in poverty living conditions; juridical support to improve human rights and the
citizenship of people with HIV/AIDS; visits to HIV households who need special care; and support homes
for the HIV population in poverty conditions.
The work of the civil society in the field of HIV/AIDS is widespreading to other related issues. There
are now NGOs that deal with the issue from a transversal manner, understanding that HIV/AIDS is a problem that
needs to be faced through several political fronts, what entails that a healthy social life has implications in sexual
rights and, moreover, on reproductive rights.
IV - Concrete results of UNESCO's partnership with civil society
Recognizing the need to provide continued assistance to youth through AIDS education, UNESCO has
also been supporting civil society's activities to prevent the spread of HIV among Brazilian youth. A
successful experience implemented by UNESCO Brazil is the creation of the UNAIDS Youth Working Group
in close collaboration with the National STD/AIDS Program of the Ministry of Health. In 2000, as the UNAIDS
Chair Agency in Brazil, UNESCO encouraged and supported
CCO MEETING, NEW YORK. OCTOSER 2001
youth representation in the AIDS Thematic Group, aimed at strengthening local youth networks and including
issues that relate to the life style and the dynamics that rule relationships among youth in programs
implemented by the government, civil society and international organizations.
Box 3 -The Bagunçaço Cultural Group:
This initiative gathered seven young people (three boys and four girls from different parts of the country
with experience in "peer education". During several meetings the Group discussed about AIDS related themes
such as gender, behavior changing, media, aids at workplace, preventive education at schools and young
people living with AIDS among others.
UNESCO consolidated the youngsters' thoughts
into a publication that brings recommendations in
the field of AIDS for public policies and
preventive education through their perspective.
Bearing in mind that preventive education
and cultural sensitive communication through peer
education on HIV/AIDS brings about a significant
potential for positive behavior change, such
initiative can be replicated to other countries.
HIV/AIDS preventive education requires more
horizontally oriented communication (between
peers instead of the more traditional way of
vertical communication.
Therefore, the UNESCO Brasilia Office in
partnership with the UNESCO Maputo Office is
also implementing a strategic project funded by
UNFIP aiming to provide capacity-building for civil
society organizations that work with young people
addressing reproductive health and
STD/HIV/AIDS preventive education through
youth leadership, taking advantage of the
Brazilian experience with these themes. The adaptation of successful Brazilian experiences with civil society
organizations is one of the cores of this project. UNESCO's interest in replicating Brazilian experiences in
Mozambique and strengthening youth networks in that country coincided with advanced negotiations with
USAID/Brazil in order to promote an exchange between Brazilian youth from Salvador (capital city of Bahia
State and Mozambican youth around art education and aids prevention issues.
Box 2 – The Bagunçaço Cultural Group
Bagunçaço is an organization serving youth and led by these
same youth in the neighborhood of Alagados, the poorest area
of Salvador Its strength is based in empowering children and
adolescents to build the necessary abilities to fight the causes
and effects of social exclusion. Using music, dance, and African-
Brazilian values, this institution works towards promoting the
social reinsertion of children and youth, promoting changes in
the community's views and attitudes towards its own children.
Based on a holistic view of assistance to children and
adolescents, Bagunçaço's methodology and activities include
providing information on AIDS prevention; building democratic
values and environmental education; promoting social and
community reinsertion; and encouraging youth pro-activeness.
Bagunçaço's adolescents will work with Mozambican youth in
the manufacture and use of percussion instruments, using waste
recycling techniques. These workshops will allow Brazilian and
Mozambican youth to exchange inform and values relating
to AIDS prevention and health-related risk behavior
Bagunçaço's experience in creating and maintaining
community-based safety networks will be of key importance to
this process.
It is important to highlight that Brazil and Mozambique share a number of similarities and cultural
identification factors: Portuguese is the common language to both countries, which are former Portuguese
colonies; aspects of the African culture are deeply rooted in Brazilian regions that concentrate large populations of
African-descendants; in these two countries the largest portion of the population is composed by children,
adolescents and young adults; and even though AIDS prevention and treatment activities have advanced faster in
Brazil, the AIDS epidemic has taken a considerable toll in both countries.
During fifteen days last February, twelve Brazilian youths from three Salvador/Bahia NGOs (Axé Project,
the Bagunçaço Cultural Group, and CRIA - Integrated Reference Center for Adolescents) and three
Brazilian educators involved with AIDS prevention and
network-building activities, visited Maputo and shared
methodological society organizations and projects. This
first "Exchange Between Brazilian and Mozambican
Youth for Peer Education On HIV/AIDS Prevention
through Art-Education" (funded by USAID and
UNESCO) represented a challenge and a unique
opportunity for peer educators in different continents to
interact and learn from each others efforts to break down
old paradigms by employing a great deal of creativity. The
approach of the workshops was focused on youth
proactivity-based methodologies developed to appeal to
young people. The Brazilian youth conducted the
activities with a strong contribution from the
Mozambicans. The topics discussed were basically related
to youth networking, legislation and advocacy, art-education and HIV/AIDS issues. Through dance, theatre and
music, the participants exchanged views and experiences by using these artistic languages as tools to facilitate youth
in the development of strategies which make possible the raising of awareness about HIV/AIDS, sexuality and
other cultural aspects that influence preventive education in that country. Such approach and its
methodologies, transferred to Mozambican institutions information about the framework that, in Brazil, leads to
successful prevention programs focused on youth.
The second part of this exchange will take part on early November. Seventeen youth from five
different provinces from Mozambique will be together in Salvador to share their experiences in promoting
the art education methodology in preventing HIV/AIDS. By involving and empowering youth and their
associations, this project will achieve sustainable results that will have a lasting impact beyond the project
implementation period.
Box 4 - CRIA (Integrated Reference Center for
Adolescents):
Box 4 – CRIA (Integrated Reference Center for
Adolescents)
CRIA leads the 300 NGOs and GOs from the youth
network that implements the HIV/AIDS program in
Salvador Through this network, CRIA has been able to
disseminate AIDS prevention information to over 500
public schools in Salvador Using theater as its core
methodology, CRIA encourages youth to develop theater
plays, poetry sessions, publications, internet sites and other
instruments to disseminate information to the largest
possible number of youth in other NGOs and government
programs. Besides working with Mozambican youth, CRIA will
work with the National and Provincial Youth Councils on
networking methodologies
Box 5 - Project Axé:
This project was created in 1990 to address the increasingly
difficult conditions faced by street boys and girls in Salvador.
Today, Axé assists 1,500 children and youth ages 5-18, mostly
of African-descendants, who carry the burden of centuries of
racial discrimination, poverty, and physical, psychological, and
social violence. Through art, education and the use of African-
Brazilian values, Axé has managed to reintegrate children into
their families, provide all 1,500 children and youth with
access to formal education, build their self-esteem and
develop a pedagogical approach which is counted among the
most successful in the world to deal with high-risk
populations. Axé's health unit has developed, tested and
validated innovative methodologies to disseminate contents
related to AIDS prevention among high-risk youth.
V - Conclusions
One of the main successes of the National IDS
Program of the Brazilian government is its articulation
with the civil society for several tasks. The universal
distribution of anti-retroviral drugs, the implementation
of laws that guarantee rights to the HIV positives and
the consolidated structure of specialized support are
successful practices that relate directly to the role of
civil society in fostering social control. The robustness
of civil society in the field of HIV/AIDS goes
beyond the action of NGOs, including networks, fora
and scientific meetings. The exchange of expertise,
strongly stimulated and promoted by UNESCO, has put
together different ways to deal with the epidemic in
Brazil, what brings considerable knowledge that, applied
to a vast country such as Brazil, has contributed to the fact that information will become an asset to public wellbeing
and the construction of alternatives to face the challenges imposed by the epidemic.
The collective work between government and civil society in Brazil, without a doubt, deserves special attention
in what is related to the shape that this partnership was established. Whereas in a majority of the countries civil
society organizations are considered a threat to governments as they unveil the fragility of governmental programs, this
partnership between historically non-collaborative sectors, counting on the support of an organization such as
UNESCO, has proven that the collaboration between these institutional set-ups - as long as their independence is
maintained - will ensure the capillarity of actions and will offer concrete results such as efficiency in the approach to
particularly vulnerable groups, agility in the execution of projects, methodological creativity, reduced operational costs,
and efficiency in multiplying the experience to other countries.
Koichiro Matsuura, Director-General of UNESCO
"At a relatively early stage, UNESCO recognized that the weapons with
the biggest potential to respond to the threat of HIV/Aids were NGOs.
NGOs are not only ideally situated, but also well equipped to disseminate the
message of preventive education to the population. It is in this context that
UNESCO displayed its immense value and contribution in HIV/Aids
prevention: the creation of partnerships with more than 1,000 Brazilian
AIDS-NGOs, the promotion of NGO activity development in the field of
preventive education and the exchange of their subsequent experiences in the
struggle against HIV/Aids. Together with the Brazilian National Aids Program,
UNESCO has developed a formidable Aids-NGO network to counter the
threat posed by the HIV/AIDS epidemic, thus contributing to the big success
of the Brazilian response to STD/AIDS".
UNESCO/Brazil
SAS - Quadra 5 - Bloco H - Lote 6
Ed. CNPq/IBICT/UNESCO - 9°andar
70070-914 - Brasília - DF - Brasil
Phone: 55 (61) 2106-3500
• Fax: 55 (61) 322-4261
E-mail: [email protected]