Free Drugs ≠ Quality Care

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Science  28 Jul 2006:
Vol. 313, Issue 5786, pp. 486
DOI: 10.1126/science.313.5786.486

RIO DE JANEIRO, BRAZIL—Thanks to the persistence of a niece, Luis Silva, 50, made his way to the highly regarded AIDS clinic at the Evandro Chagas Clinical Research Institute one morning in June. After suffering persistent fevers and night sweats, Silva in August 2005 had sought medical care at a clinic near the poor neighborhood where he lives. An HIV test indicated that he had been infected, but Brazilian regulations require a second, confirmatory test before doctors order expensive immune tests, which in turn are needed before they can prescribe antiretroviral drugs. The doctors treated what they thought was a pulmonary infection, and for a time Silva's condition improved, so he skipped the second test. But then the slightly built man lost 20 kilos and developed a hacking cough, which led him to several other doctors, who offered little help. Finally, his niece, who is a nurse, brought him here.

A chest x-ray taken that day showed strong evidence of tuberculosis, and Silva's doctor said she was all but certain that he has AIDS. Still, even she had to wait 10 days for the lab to determine his HIV status, as only pregnant women have access to the rapid test that can give results in a few hours. The clinic's director, Valdiléa Veloso, notes that many other facilities in Brazil routinely run out of HIV test kits. “It's crazy,” says Veloso. “It would have been much better for the government to have made the decision about rapid tests years ago.”

Delayed reactions.

Luis Silva (left) had to jump through many hoops to see whether he was HIV infected and eligible for treatment.

As progressive a stance as Brazil has taken on HIV/AIDS prevention and care, it remains a middle-income country offering uneven health care services. “In Rio, it's not uncommon to receive in the emergency room HIV-infected people who were not treated,” says Pedro Chequer, who twice headed the country's national AIDS program and now works for the Joint United Nations Programme on HIV/AIDS. “The health care system here is collapsing.”

Activist Ezio Tavora dos Santos Filho recently completed a report of the tuberculosis care offered in Brazil, which he notes is in the “shameful position” of being 15th on the World Health Organization's list of 22 countries that have a high TB burden. “It's indefensible,” says Tavora. According to his report, federal, state, and city TB programs are only now beginning to work together, as officials recognize that 12% of HIV-infected people are coinfected with TB.

Solange Cesar Cavalcante, who heads the TB program for Rio, notes that unlike HIV/AIDS, TB is not a “sexy” topic and so far has not mobilized affected communities. Says Cavalcante, “Tuberculosis is trying to learn from the AIDS program.”

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