In June, infectious disease specialist Felipe Pires was at a loss. He didn’t know how much medication to give his HIV-positive patients in Porto Alegre, a coastal city in southern Brazil with the highest rate of AIDS in Brazil — more than twice that of other major cities. His supply of viral load tests, which measure the amount of HIV genetic material in the blood, was being rationed by federal health officials. “Miscalculating [the dosage] could make my patients irreversibly sicker faster, he told OZY.
Rationing of vital medical supplies has sounded the alarm in Brazil about how much the public health system stands to lose from federal austerity measures that began in 2015 under former president Dilma Rousseff and, after her impeachment, deepened dramatically under center-right interim president Michel Temer. Temer’s latest belt-tightening, which included a pledge to cap growth in government spending for the next two decades at the rate of inflation (currently 2.46 percent), is intended to bounce Brazil out of its worst economic slump in decades.
Particularly striking have been the effects of slashed health budgets on Brazilians at risk for HIV and those already HIV-positive, like Pires’ patients. Experts tell OZY that cutbacks in the number of specialized doctors, outreach and safe-sex programs, and citizen policy oversight committees have all contributed to Brazil moving against the global trend of decline in new HIV infections. While worldwide the yearly total of new HIV cases dropped 16 percent between 2010 and 2016, in Brazil it rose 2 percent, with 48,000 new cases in 2016, according to UNAids.
Prior to the austerity era, Brazil’s AIDS response was hailed as a Global South success story — one that was developed by hard-charging activists in the late ’80s. In 1996, Brazil became one the first countries to offer free universal AIDS treatment through a public health system. Two years later, the federal public school curriculum began to include sex education. By 2005, a school census showed that 60 percent of schools had STD/AIDS prevention programs. And Brazil shocked the world in 2007 when it began to break drug patents to offer affordable generic antiretroviral drugs to people with HIV. “First came the political will” to fight AIDS, says Columbia University public health professor Richard Parker, who has researched AIDS in Brazil for 30 years. “Then, once laws passed, [came] the technical conditions,” such as prevention programs and national drug distribution, “to make them possible.”
These days the political will to deal with the epidemic is meeting tough opposition in the form of a socially conservative evangelical movement. In 2014, evangelical voters sent 74 representatives to the 513-seat lower house of Congress — double the number in 2006 — and today evangelical representatives are a third of that body. They form a disciplined coalition that’s been effective in blocking progressive agendas, including legislation aimed at penalizing anti-gay discrimination and hate crimes. Marco Feliciano, a member of the evangelical congressional bloc, famously described AIDS as “a gay cancer.” (Feliciano did not reply to a request for comment.)
This new conservative political muscle has rolled back some of Brazil’s advances in confronting AIDS. Prevention campaigns that featured sex workers — a key HIV-affected population — were canceled, as was the public school program that taught openly about safe sex. Government research now shows condom use is decreasing among young Brazilians, which has consequences beyond HIV: Health ministry reports of syphilis rose from 1,249 cases in 2010 to 65,878 new cases in 2015.
Meanwhile, what Parker calls Brazil’s “triumphalist narrative” led international foundations to begin defunding prevention programs on the assumption that the health crisis was under control. The budget of Parker’s own watchdog NGO, the Brazilian Interdisciplinary Aids Association (ABIA), has been roughly halved since 2007. University of São Paulo medical school professor Mario Scheffer sums up Brazil’s retreat on AIDS response as “a deadly warning sign against declaring early victory.”
Brazil’s internationally praised ability to deliver medicine to clinics in remote parts of the country is still robust, and it is currently rolling out universal access to the new HIV-treatment drug Dolutegravir. This makes the current trend a paradox, says Scheffer, because “crucial non-pharmaceutical interventions like preventative education are withering.” So, too, is follow-up on patient care: 14,000 Brazilians die of AIDS-related illnesses each year, a number that has not dropped since 2005 and that Scheffer says is high for a country with universal treatment.
Ministry of Health AIDS official Adele Benzaken tells OZY that the health funding cap will not hurt the response to HIV “under any hypothesis.” To address the rising infection rate in young men ages 15 to 29, she points to a government peer-testing program and partnerships with YouTube stars and the hookup app Hornet that promote condom use. Benzaken says Porto Alegre’s shortage of viral tests was due to “pharmaceutical companies’ failure to bid on government drug contracts at a reasonable price.” In an email, a spokesperson for the state health department tells OZY that “we have a depletion of specialized services for treatment retention,” and that state officials are teaming up with federal health HIV/AIDS providers “to help the cities most affected by the epidemic.”
The viral tests were restocked in July. Still, ABIA vice president Veriano Terto says the drug shortages in Porto Alegre — treatment drugs for pregnant women and newborns were rationed in July — “is proof that civil society should be able to monitor government drug auctions, something we’ve long demanded and been denied.”
When the state government closed the Porto Alegre headquarters of an NGO called Group of Aids Prevention Help (GAPA), it ignited two months of protests and public hearings, which led the city to provide a new shared space for the organization. According to GAPA director Carla Almeida, “We need to return to being bold in the way we talk and act about AIDS.”