AIDScience Vol. 1, No. 15, November 27, 2001 Treatment for HIV/ AIDS in Brazil: strengths, challenges, and opportunities for operations research Francisco Inácio Bastos 1 , Deanna Kerrigan 2 , Monica Malta 1 , Claudia Carneiro-da-Cunha 1 , and Steffanie A. Strathdee 2 1 Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil. 2 Johns Hopkins School of Public Health , Baltimore, Maryland, United States. Abstract razil is the only middle-income country to provide free, universal access to antiretroviral (ARV) therapy for the treatment of HIV/AIDS. Currently, the Brazilian National STD/AIDS Program provides ARV therapy to over 95,000 people living with HIV/AIDS (PLWHA). But a successful HIV/AIDS treatment program must provide more than drugs. It must offer a comprehensive set of services along the continuum of care and support, including promoting early entrance into care, facilitating adherence to ARV therapy especially among vulnerable populations, integrating psychosocial support services into care, ensuring that access to ARV therapy does not lead to unintended behaviors, and providing ongoing training to medical personnel and psychosocial support staff. Additionally, the ARV therapy and related support services must be affordable. Brazil has been engaged in a permanent effort to foster national production of ARV and to negotiate substantial discounts with international drug companies. This paper outlines Brazil's significant achievements in creating and sustaining access to ARVs and other anti-AIDS drugs as well as developing innovative care and support services with which to respond to the multifaceted needs of PLWHA in Brazil. The paper also reviews the improvements in AIDS-related mortality and morbidity and subsequent cost savings attributed to the provision of universal access to ARV therapy in Brazil. Introduction Increasing the availability of antiretroviral (ARV) therapy for the treatment of HIV/AIDS is urgently needed to achieve significant reductions in HIV/AIDS-related morbidity and mortality globally. Brazil is currently the only middle or low-income country to provide free, universal access to ARV therapy for the treatment of HIV/AIDS. Universal access to ARV therapy was established by Brazilian Federal Law No. 9.313 on 13 November 1996. This law states: "HIV-infected people and/or people living with AIDS are entitled to receive, at no cost, all medicines necessary for their treatment, from the National Health System" ( 1 ). At present, more than 95,000 persons receive ARV therapy in Brazil. There are an estimated 622,973 people living with HIV/AIDS (PLWHA) currently in Brazil ( 2 ). This proportion of approximately 15% of PLWHA under ARV treatment corresponds to the number of persons who have been identified as needing such treatment by the Brazilian National Health System. The Brazilian criteria for free ARV, which is currently under revision, covers any HIV-positive person who is clinically ill or who has less than 500 CD4+ cells/mm3 and a viral load greater than 30,000 copies. The full criteria and guidelines are available on the Internet ( 3 ). A successful HIV/AIDS treatment program must provide more than access to ARV and other HIV-related drugs. It must offer a comprehensive set of services along the continuum of care and support, including the promotion of early entrance into care; facilitating adherence to ARV therapy especially among vulnerable populations; integrating psychosocial support services into care; ensuring that access to ARV therapy does not lead to unintended behaviors; and the provision of on-going training to medical personnel and psychosocial support staff. Additionally,