According to the Brazilian Ministry of Health, more than 600,000 people in Brazil were living with HIV in 2002. HIV/AIDS prevention is thus a top priority. Brazil is well known internationally for providing free anti-retroviral drugs, which has reduced mortality from AIDS by 50 percent and cut hospital admissions by 80 percent.

Brazil has the highest number of tuberculosis cases in the Americas. The nation ranks 14th in the list of 22 countries identified by the World Health Organization as most burdened by TB infections. Brazil's TB detection and cure rates have plunged in the past twelve years, a trend that health authorities are hoping to reverse by expanding TB treatment through the country's family health care system. In 2002, Brazil announced its commitment to expand TB treatment via DOTS (directly-observed-therapy) to 80 percent of the country by 2005.

Studies from the 1990s have shown that the two infections are linked. Approximately 20 percent of patients with AIDS also have TB and it is estimated that 50 percent of those infected with HIV will develop TB during their lifetimes.

M&L's technical assistance has been concentrated in the areas of HIV/AIDS and TB. We worked (through November 2003) with the Ministry of Health, the National STD/AIDS Coordinating Unit & National Lung Health Unit; Ceará State Secretariat of Health; Rio de Janeiro State Secretariat of Health; and a number of community non-governmental organizations (NGOs) that specialize in HIV/AIDS.

M&L worked in partnership with Brazil's national AIDS coordinating unit and the local USAID mission to prevent HIV/AIDS transmission in four states: Rio de Janeiro, São Paulo, Bahia, and Ceará. Our work with public sector HIV/AIDS programs focused on implementing voluntary counseling and testing (VCT). We also provided management assistance to NGOs involved in HIV/AIDS prevention, primarily in the north (Amazon) region.

MSH collaborated with USAID to support the national TB program and the state TB program in Rio de Janeiro state. This work included mobilizing political and administrative support for TB control, organizing TB conferences and workshops, establishing DOTS programs in municipalities, and improving health management skills to improve data-based decision-making.

HIV/AIDS
Expansion of voluntary counseling and testing services is a top public health priority in Brazil. M&L's work in Ceará demonstrates that access to quality VCT services can be increased by successfully decentralizing services to municipal health facilities. M&L designed a project that mobilized support from NGOs, federal, state, and municipal resources to establish local VCT capabilities. The project involved remodeling municipal health centers, establishing quality testing and monitoring procedures, and training staff in counseling and testing services.

One of the successful strategies of the Brazilian response to the AIDS epidemic has been the engagement of NGOs to provide HIV/AIDS prevention services. To strengthen NGOs that work in this area, M&L compiled a database of HIV/AIDS NGOs and drafted a booklet in the form of Frequently Asked Questions (FAQ) addressing NGO legal concerns. We also worked intensively with four HIV/AIDS NGOs to strengthen management systems. The organizations applied a MSH-developed tool - APROGE, the Portugese language version of MSH's MOST (Management for Organizational Sustainability Tool) process to develop action plans that improved human resource management, financial management, and fundraising.

TB
M&L has provided the tools, procedures, and training to scale up implementation of DOTS to 22 municipalities in Rio de Janeiro state. We started by implementing a no-frills DOTS program in just three months in Duque de Caxias, a poor municipality in a community of 775,000 people. This program, in a state which accounts for 20 percent of Brazil's notified TB cases, will serve as a model for expanding DOTS in a cost-effective manner to other municipalities.

Focusing on DOTS in the context of primary care delivered by family health teams, the setting in which most Brazilians receive their health care, will make DOTS the foundation for the country's TB control.