摘要：Objectives. We investigated involvement and cooperation patterns of local Brazilian AIDS program actors and the consequences of these patterns for program implementation and sustainability. Methods. We performed a public policy analysis (documentary analysis, direct observation, semistructured interviews of health service and nongovernmental organization [NGO] actors) in 5 towns in 2 states, São Paulo and Pará. Results. Patterns suggested 3 models. In model 1, local government, NGOs, and primary health care services were involved in AIDS programs with satisfactory response to new epidemiological trends but a risk that HIV/AIDS would become low priority. In model 2, mainly because of NGO activism, HIV/AIDS remained an exceptional issue, with limited responses to new epidemiological trends and program sustainability undermined by political instability. In model 3, involvement of public agencies and NGOs was limited, with inadequate response to epidemiological trends and poor mobilization threatening program sustainability. Conclusions. Within a common national AIDS policy framework, the degree of involvement and cooperation between public and NGO actors deeply impacts population coverage and program sustainability. Specific processes are required to maintain actor mobilization without isolating AIDS programs. In low- and middle-income countries, the HIV/AIDS epidemic continues to spread among the most vulnerable groups, 1 notably the poor and women (with vulnerability defined as “the extent to which individuals are capable of making and effecting free and informed decisions about their life” 2 (p441)). 3 , 4 The global cumulative prevalence of HIV-infected people is 33.2 million persons. Countries of sub-Saharan Africa are particularly affected, with an HIV seroprevalence of 18% among young adults in some countries. 1 Where there are weak health care systems, control of the epidemic remains an unsolved issue. 5 In Brazil, the HIV seroprevalence among young adults is estimated at 0.65%, and AIDS mortality has decreased significantly since 1997, when highly active antiretroviral therapy became available for free. 6 The Brazilian federal and local (state and municipal) AIDS programs are considered to be a model for low- and middle-income countries because they have developed a close cooperation between government, health services, and nongovernmental organization (NGO) actors (persons or groups involved in the formulation and implementation of policies and programs). The Ministry of Health defined ambitious prevention policies and provided free access to antiretroviral treatment. 7 – 13 Implemented at 3 levels—federal, state, and municipal—the AIDS programs have been developed within the Brazilian universal health system (Systema Unico de Saude), impelled by the sanitarist movement. 14 – 16 This movement involved physicians, public health workers, and politicians who in the 1980s advocated and then implemented this new health system, which is based on prevention and free access to care. Programs have been established in 27 states and more than 400 municipalities. In these states and municipalities, several HIV/AIDS facilities have been implemented, including voluntary counseling and testing centers, specialized assistance services for ambulatory care, and hospital services. 17 Many NGOs, whether AIDS-specific (AIDS NGOs) or generalist, are involved in service provision and policy-making. 18 During the past decade, the Brazilian epidemic has changed. 13 Initially, the epidemic affected mainly urban men of middle and upper classes in the southeastern part of the country. Thereafter, it affected more and more the poor 19 – 21 and women 22 , 23 and diffused throughout the country. The national AIDS program has also been confronted with the rising cost of antiretroviral drugs, making the sustainability of the existing programs questionable. 24 , 25 These changes require strategic evolution of the current AIDS policies. To address these new trends, Brazil has, among recent initiatives, decentralized the handling of AIDS policies through incentivos (incentives), financial incentives allocated to states and municipalities that develop AIDS programs appropriate for the local epidemiological situation and integrated into the local health system. Within the incentives policy framework, states and municipalities define their action plan yearly. Such plans are adopted by state or municipal health councils, composed equally of health care professionals, end-users, and local government representatives. After approval by the national program, the states and municipalities receive federal resources earmarked for AIDS programs. The responses to these new trends in the HIV/AIDS epidemic have been studied by focusing on national AIDS policies, ignoring what happens at subnational levels. 7 – 13 Moreover, very few published articles have adopted a political science stance and public policy analysis to identify what happens at the front line, to assess how different actors cooperate, and to assess what consequences their cooperation induces for prevention of HIV infection, care of the patient, and sustainability of AIDS programs. We studied how decentralized approaches to the HIV/AIDS epidemic in Brazil addressed the new trends of the epidemic, highlighting positive effects and difficulties, and make recommendations for Brazilian policymakers and to other low- and middle-income countries.
