BRAZIL

Monitoting and Evaluation of HIV/AIDS programs

Pedro Chequer, Cristina Pimenta, Julio Barrios, Ivo Brito

Background

Brazil is the largest country in South America and has a population of 163 million. The AIDS epidemic was first identified in 1982 among men who had sex with men (MSM). During the next year AIDS cases were identified among intravenous drug users (IDU). Shortly thereafter, HIV moved into the heterosexual population. The South and Southeast regions have the most severe epidemic. In 1996, between 338,000 and 484,000 individuals 15-49 years were estimated to be HIV infected. Brazil has a generalized epi demic with HIV prevalence ranging from 0.3-3.1% among antenatal women (1995).

National response

An early AIDS control programme was established in 1985 with guidelines from the Ministry of Health; government actions focused on epidemiological surveillance, medical care and dissemination of health messages through mass media. In 1987 the National Commission for AIDS was created and included representatives from the scientific community and the organized civil society. With the inclusion of STDs under the programme umbrella, the National STD/AIDS Programme was created in 1988 as part of the Secreta riat for Health Policy in the Ministry of Health. In addition to programmatic activities, the National STD/AIDS Programme is responsible for monitoring and evaluating results of programme activities. Programme activities are carried out in collaboration with the 27 states and federal district, the municipalities and the more than 300 NGOs in Brazil. Decentralization of STD/HIV programmes is a key structural feature in Brazil. The main intervention strategy is to promote safe practices related to sexual, parenteral and vertical forms of transmission, ensuring the access to and quality of diagnosis and treatment services for STD and HIV/AIDS prevention and treatment.

In the early 1990s prevention activities moved from targeting high-risk groups to focusing on the general population. Mass media was harnessed for broad dissemination of information. Condom promotion and free distribution directed to lower income segm ents of the population, adolescents and high-risk groups are part of the national programme. The programme has been well financed through a World Bank loan agreement of US $250 million for the period 1994-98. The Brazilian government aims to provide free access to anti-retroviral drugs, including protease inhibitors, to all HIV infected persons. There is also a network of 125 free and voluntary HIV counseling and testing centers. There is a long distance public television training programme for teachers of primary and secondary school children, which has the potential to reach 30 million public school children. The UNAIDS theme group was formed in September 1997.

Monitoring and evaluation

The Brazil National STD/AIDS Control Programme has a number of committees including a research steering committee and a committee for the evaluation and selection of NGO projects. The use of epidemiology to define programme priorities is an important s trategy of the national programme. M&E has always been an essential management tool for making informed decisions during the process of planning and programme implementation. One aim is to implement sentinel surveillance for HIV, AIDS, STD and tubercu losis throughout the country.

The national health information system in Brazil is not considered adequate to meet the needs of the AIDS programme. The national AIDS information system is composed of notification of AIDS and syphilis cases, mortality information system, hospitalizat ion and ambulatory information systems, and public health and medical research. All are integrated in a unified public health system data service.

There is a large volume of local, regional and sometimes national studies to document knowledge, attitude and sexual practices among the general population, adolescents, IDUs, MSMs, and other target populations. A substantial number of these studies ar e intervention studies. In 1996 a national DHS also included sexual behaviour questions. To a limited extent use has been made of the WHO/GPA prevention indicators, although a range of other indicators have also been used.

A computerized system is in place to manage and monitor the distribution and logistic control of anti-retroviral drugs through the 101 distribution points in the country. A system of control of laboratory exams is also in place.

Input, output and context

Condom sales are monitored by the national programme; over 200 million condoms were purchased in 1998. The private sector sales are monitored as well, showing an increase in sales from 100 million in 1994 to 260 million in 1997. The school programme inputs and outputs are monitored and show the numbers of schools that have been reached (52,000), the numbers of programmem developed (67) and the numbers of teachers reached by the programme (144,000). A wide range of surveys has provided information on the knowledge and attitude of various populations. Some, such as national surveys of army conscripts in 1996 and again in 1997 have national coverage.

Also telephone surveys have been carried out. Blood screening is applied but is not universal, although surveys indicate that blood transfusion associated transmission is a minor factor in the spread of HIV. The VCT centers are regularly monitored and data for 1988-1997 from 90 centers indicate that 286,000 HIV tests have been registered (6.6% were positive).

Proximate determinants

Multiple local studies on sexual behaviour, including condom use, have been conducted in various parts of Brazil and suggest that multiple partnerships are less common than in the past and condom use has increased considerably. Also evaluation studies among intravenous drug users and men who have sex with men show favorable behaviour changes, which is attributed to interventions.

HIV and STD

From 1992 sentinel surveillance was used to monitor the trend of HIV infection, but in a rather decentralized manner. Skewed distribution of sites and lack of continuity led to a reformulation of the strategy in 1996. A national sentinel network was es tablished including antenatal clinics, medical emergency services and STD patients. By 1998, 220 STD clinic sites were involved in sentinel surveillance. HIV prevalence data are also available from blood donor records and VCT centers. Reporting rate in 1 998 was 75%. HIV prevalence ranges from 0.3-3.1% among antenatal women (1995), 3.4-5.3% among trauma patients (1997) and 0.3-13.3% among STD patients (1995) and 1.9%-2.6% among blood donors (1996). An enhanced surveillance project of STDs is currently b eing implemented.

AIDS impact mitigation

AIDS cases are notifiable and some background characteristics are available, such as education level. In 1995, 15,000 adult deaths were attributed to AIDS. Data from Sao Paulo and Rio de Janeiro show a marked decrease in mortality during 1995-98. AI DS care and support are now focused on anti-retroviral drug treatment and monitoring of the health of AIDS patients receiving such treatment at one of the 101 centers in the country.

Conclusion

Monitoring and evaluation has been an integral component of the Brazil national AIDS programme. Evaluation is not perceived as a set of methods and techniques to collect information, but considered as an integral part of policy making and planning. The re is a strong and extensive system of data collection and analysis, from basic programme input data to detailed research data that are integrated at the national level. At present, efforts are made to improve the surveillance system, which has not functi oned optimally, and generate better data to evaluate interventions in greater detail.