Study analyzes the causes of the setback of the national AIDS policy, considered a model in the history of global health
Imagine an unknown disease that spreads worldwide, causing perplexity, suffering and death; that isolates sufferers as soon as the first symptoms appear and makes others fear them; an incurable infection caused by a virus named using a combination of letters. What can be done? In Brazil, the Ministry of Health established programs with state and municipal governments, implemented campaigns to raise awareness of forms of prevention, established partnerships with social organizations and acted to guarantee universal, free access to drugs.
For healthcare activists, AIDS was exceptional because it legitimized sexual identities and helped combat social stigmas, denounce drug prices and mitigate global power asymmetriese
The epidemic in question — easy to identify — is not Covid-19, although it has also spurred worldwide fear. Caused by the HIV virus, the acquired immunodeficiency syndrome (AIDS) has hit Brazil in the 1980s. Over the next few decades, the South American country became a world reference in the control of the disease, recognized by the United Nations (UN). "One of the most striking aspects of the history of the fight against HIV/AIDS is its relationship with human rights, and the mobilization of civil society together with governments and multilateral agencies to formulate prevention and treatment policies," notes historian Marcos Cueto, a researcher at the Casa de Oswaldo Cruz, one of Fiocruz’s institutes in Rio de Janeiro.
In an article published in the journal Global Public Health, Cueto and Gabriel Lopes, a postdoctoral researcher at the Casa de Oswaldo Cruz, highlight the factors that made Brazil a model in the global history of fighting the disease, which is still incurable and without a vaccine, and analyze the causes behind the setback in terms of AIDS policies in Brazil — the Latin American country most affected by the epidemic. The authors argue that the regression was the result of interactions between global and domestic factors.
“Brazil was recognized for its pioneering work in the fight against HIV/AIDS because, in addition to providing antiretroviral therapy through the Unified Health System [SUS, Brazil’s publicly funded healthcare system], there was favorable alignment between NGOs, patients and civil society so that there was not only treatment of the disease, but also a campaign to prevent stigma against those with the disease and a focus on information and prevention, with free distribution of condoms, syringes and disposable needles. In the article, we determined that the period during which Brazil was a reference ranged from approximately the mid-1990s to the end of the first decade of the twenty-first century,” adds Cueto, scientific editor of the HCS-Manguinhos journal, published by the Casa de Oswaldo Cruz.
Brazil’s AIDS policy: one of the greatest achievements of its health system
The coordination mentioned by Cueto was motivated principally by the idea of healthcare as a right, adds Lopes. In the decade in which AIDS emerged, Brazil was experiencing redemocratization, a process that included several achievements, such as the creation of the SUS and the definition of healthcare as a universal right and an obligation of the State, pursuant to the 1988 Constitution. The policy to combat the disease, according to the authors, was one of the greatest achievements of the public health system.
Brazil managed to significantly reduce AIDS mortality and the number of children born with HIV. It adopted innovative and inclusive measures: it was the first country to guarantee access to antiretrovirals (medicines that inhibit the multiplication of the virus in the body, preventing damage to the immune system and increasing the life expectancy of HIV-positive people) to all citizens, and one of the first to implement needle exchange programs.
Globally, the regression of responses to the epidemic marked the end of its status as exceptional, from which it had benefitted since the late 1980s. This prominence justified the allocation of funds and services specifically to fight AIDS. Depending on the audience, the term took on a broader dimension. “For healthcare activists, AIDS was exceptional because it legitimized sexual identities and helped combat social stigmas, denounce drug prices and mitigate global power asymmetries,” write the researchers, who investigated the end of this exceptionalism in Brazil, analyzing the decline of the National STI/AIDS Program.
Exceptionalism becomes "sustainability"
In discourse on AIDS, here and worldwide, the term exceptional has been replaced by “sustainable.” “We analyzed in more detail the lack of coordination between institutions — both multilateral agencies such as UNAIDS and the Brazilian government — in relation to the demands of NGOs and patients, especially in relation to information and prevention policies. Another factor was the economic crisis that began in 2008, the underfunding of important institutions, and biomedicalization focused on a strict vision of "sustainability," which tends to favor high-income countries as it neglects the dimensions of prevention, combating stigma and emphasizing human rights,” says Cueto.
The decline of policies to fight the virus "was encouraged by conservatives, who insisted on the moralization of HIV/AIDS rather than the understanding of this pandemic as a public health problem, in which the fight against stigma and homophobia are fundamental elements of a successful program,” adds Lopes.
According to the researchers, during the governments of Fernando Henrique Cardoso and Luiz Inácio Lula da Silva, from 1995 to 2011, the AIDS program had “continuity and integrity.” Under both presidents, the Ministry of Health negotiated with pharmaceutical companies to reduce the price of antiretroviral drugs and thus guarantee universal access to treatment. To this end, it promoted domestic production of generic drugs and, in 2007, required mandatory licensing of antiretroviral drugs.
However, during President Dilma Rousseff's two terms (2011-2016), despite certain advances, there was a weakening of social control in relation to government actions and a "timid position in relation to patented drugs, despite abusive prices," they write in the article.
With the next president, new problems arose. During Michel Temer's term (2016-2019), public funding for the SUS was frozen for 20 years, negatively affecting the fight against AIDS. The current government, led by Jair Bolsonaro, who took office in January 2019, went even further, add Cueto and Lopes. It dismissed important AIDS program employees, suspended contracts with public laboratories that produce generics, extinguished entities responsible for the National Policy for Social Participation, such as the National Council for Combating Discrimination and Promoting the Rights of LGBTs, and canceled the HIV Harm Reduction Policy, which provided free needle exchanges for users of injectable drugs, one of the ways through which HIV is transmitted..
Authoritarianism and conservatism
“The regression of AIDS policies in Brazil resulted from national and global political developments and represents the end of the exceptionalism attributed to the disease,” conclude the authors of Backlash in global health and the end of AIDS' exceptionalism in Brazil, in 2007-2009. At the domestic level, they mention, in addition to the fragmentation of the left; “the erosion of the alliance between government officials, public health workers, diplomats and healthcare activists who supported progressive anti-AIDS policies; the rise of authoritarian and neoliberal governments; and the prominence achieved by conservative evangelicals and Catholics.”
Judging by the epidemiological data, we are far from the "end of AIDS," the motto of the international campaign that estimates that there will be zero cases globally by 2030. According to the Joint United Nations Program on HIV/AIDS (UNAIDS), there were 37.6 million people living with HIV in the world in 2020, and 690,000 AIDS-related deaths were reported that year. From the beginning of the epidemic until the end of 2020, 77.5 million people have been infected with the virus and 34.7 million have died.
After four decades, universal access to antiretroviral therapy remains unattainable for millions of people, as it affects 73% of HIV-positive people. Mortality and total new infections have dropped significantly, but every week about 5,000 women aged 15 to 24 are infected with HIV. In 2019, 10,565 deaths were recorded in Brazil, a number that surges to 349,784 if we look at the total since the discovery of the disease.
Translated by Naomi Sutcliffe de Moraes