HIV/AIDS in the state of Amazonas, Brazilian Amazon: decentralization, third-party support and community action

Amazonas is Brazil's largest state and a paradigmatic tropical medicine setting: vast territories connected mainly by rivers, high cultural and linguistic diversity, and multiple co-endemic infections. The state comprises 62 municipalities and roughly 4.3 million inhabitants, with approximately half of its inhabitants residing in Manaus, the capital, where specialized human immunodeficiency virus (HIV ) services have historically been concentrated. However, the HIV/ acquired immunodeficiency syndrome (AIDS) epidemic has shown sustained interiorization beyond the capital and a high AIDS mortality coefficient, reflecting late diagnosis and gaps in retention in care. Over the last decade, expanded testing, rapid initiation of antiretroviral therapy (ART), the introduction of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), HIV self-testing, and decentralized municipal services in partnership with third parties, such as the AIDS Healthcare Foundation (AHF), have coincided with declining AIDS mortality, yet heterogeneity across municipalities remains pronounced, including in predominantly Indigenous areas and border regions. This review synthesizes key programmatic inflection points and highlights the complementary roles of the public sector, third-party organizations, and civil society in implementing combination prevention, improving linkage to care and monitoring loss to follow-up. In this narrative review, we argue that HIV in the Brazilian Amazon should be understood through a syndemic lens encompassing tuberculosis co-infection, mobility and geographic dispersion, and that progress toward 95-95-95-aligned targets will require differentiated service delivery, integrated tuberculosis (TB)/HIV strategies, and supply-chain and workforce resilience tailored to riverine, rural and Indigenous contexts.