Brazil: A Model Response to AIDS

AIDS is the first epidemic of the age of corporate globalization, and responding to the AIDS crisis is a challenge for all societies. In Latin America, Brazil is both a model and an inspiration. How has it done it? What factors have created such an effective social cocktail?

Pascual Ortells

Since 1849, when a cholera epidemic decimated London’s population and Dr. John Snow discovered that most victims had drunk water from a source on Broad Street, recommended that it be closed and thus resolved the public health crisis, the study of epidemics has earned its place among the medical sciences. From time to time, it even makes headlines.

In 1981, a team from the US Center for Disease Control published the first report on five rare cases of pneumonia in young men caused by Pneumocistis carinii. The following year, US health authorities used the acronym AIDS—Acquired Immune Deficiency Syndrome—to cover the growing number of cases of immune defense breakdowns in hemophiliacs, injected drug users and homosexual men. A year later, the first two cases of women with AIDS appeared.

In 1983, the French researcher Luc Montagnier and his team at the Pasteur Institute in Paris discovered the cause of AIDS, which was by then rapidly spreading all over the world. The cause was a kind of retrovirus, which they named the Human Immunodeficiency Virus, or HIV. In 1984, Robert Gallo at the National Cancer Institute in Bethesda, Maryland, in the United States, announced that his institute had also isolated the agent that causes AIDS. Three years later, the United States and France reached an agreement to share the discovery.

While the cure remains distant,
effective therapy is now available

Research, finances, politics and social and international mobilizations have characterized the history of AIDS, the first epidemic in the age of corporate globalization. Unlike previous epidemics—the plague, cholera, malaria—it is not located in a single country or group of countries, but rather affects all continents, with infection rates that have continually risen over the 20 years of its known history.

The International AIDS Conference held in Barcelona in July 2002 confirmed two ideas about this global epidemic or pandemic. First, the cure for the AIDS infection remains in the distant future. Second, it has been effectively demonstrated that Highly Active Antiretroviral Therapy (HAART) can halt the infection’s evolution and restore or conserve much of the body’s immune response capacity for many years.

Some 15,000 scientists, government officials, industry executives and activists from all over the world met in Barcelona for this 14th International AIDS Conference, where access to the antiretroviral treatment was the main issue. A year earlier, in its 57th session, the United Nations Commission on Human Rights issued Resolution 33/2001 declaring that access to drugs to treat AIDS is a human right. Currently, only 4% of the 36 million people living with the HIV infection around the world receive antiretroviral drugs.

Nearly half the people in poor countries who receive this therapy are Brazilian, which is the main reason, though not the only one, that Brazil has become an example of a country with efficient, compassionate public health policies in response to AIDS. Other countries of the South with exemplary policies include Thailand in Asia and Uganda in Africa. These three countries are among the few that have managed to halt and reverse the appearance of new HIV infections among their populations and have implemented treatment and care programs for people living with the infection. Brazil’s HIV infection rate during the epidemic’s early years in the 1980s was similar to that of South Africa. Currently, the rate among adults in Brazil is 0.6%, while in South Africa it has now reached 25%.

Brazil’s bold policy: A model for the South

UNAIDS has calculated that some 600,000 people, including men and women of all ages, live with HIV in Brazil. Of these, 116,000 need antiretroviral therapy and receive it free of charge through the public health system. The cost of antiretroviral therapy in Brazil is roughly US$1,000 per person per year, a tenth of the therapy’s cost in developed countries.

The Brazilian model demonstrates that universal treatment of people affected by HIV is possible. The Brazilian government produces 8 of the 15 drugs used in antiretroviral therapy in the country as generics, and buys the other 7 from outside labs at below-market prices, thanks to agreements with the manufacturers. For example, Brazil does not currently produce protease inhibitors, which are extremely important in the treatment. The state laboratory FAR-Manguinhos has produced low-cost generic drugs for many years, including those most frequently used in treating malaria, tuberculosis, leprosy, leishmaniasis or mountain leprosy, and high blood pressure. When the need arose, Brazil began to produce generic antiretroviral drugs against AIDS in the framework of this policy. This production began before 1997, when the country approved a patent protection law.

Although the government program of universal access to AIDS treatment does not cover 100% of the demand, the results of Brazil’s audacious policy are readily apparent. Since 1996, the mortality rate due to AIDS has dropped 50%, while AIDS-related hospitalizations in the public health system are down by 80%. With each passing year, the government is spending less money on AIDS-related treatments, despite the fact that 15,000 new patients are incorporated into the public health system every year. "Brazil is a great example in the fight against AIDS," Zackie Achmat said in Barcelona. Achmat is a South African activist who has refused to receive antiretroviral treatment as long as all his compatriots do not also have access to the drugs. Roberto Paulo Teixeira, coordinator of Brazil’s AIDS program, sees the Brazilian model’s importance in the fact that it symbolizes "the enactment of the universal principles of the right to health and to life." Teixeira is convinced that "the Brazilian government’s commitment is a commitment to life."

The formula: Social struggle
plus a public health tradition

Brazil has managed to maintain its public health system despite the IMF’s structural adjustment plans. The struggle to create and defend the current health system goes back to the 1980s, as Brazilian activist Veriano Terto explained to me in April 2002: "It needs to be improved, but it’s a very good system. The fact that the model existed even before our struggle began was very important in our getting access to treatment. Our health system is based on universality, equity and a holistic approach. AIDS cannot be addressed through prevention alone. You need a comprehensive approach, with prevention and treatment. And this includes the drugs."
Terto coordinates the Brazilian Interdisciplinary AIDS Association (ABIA, for its Portuguese acronym), a pioneering organization in Latin America in mobilizing people to respond to AIDS’ challenges by providing information, developing public policies and training people living with HIV on their rights. It was the first NGO with a president openly recognized as HIV-positive: Herbert de Souza or "Betinho," known all over Brazil for leading a massive grassroots Campaign Against Hunger every year. Through his writings and actions, Betinho transformed the vision of AIDS. In 1992 he wrote, "AIDS is not mortal. We are all are mortal."
Terto said that one of the factors behind the Brazilian government’s decision to produce generic anti-retroviral drugs, even knowing that doing so would put it at odds with multinational pharmaceutical companies, was the country’s solid public health history. "We already had a tradition in this area, and although our health system had deteriorated considerably because of the military government, low salaries and all that, the public health tradition is very big and very national. The organized social movements were also very important, as was the legislation, since Brazil’s Constitution establishes the right to life and health as a collective right and a state responsibility. The policy came about because of a set of factors and it should be analyzed as such: a grassroots social struggle for a single, universal, equitable and holistic health care system for everyone."

The key to success:
Partnering with social movements

The success of Brazil’s national AIDS program is largely due to its partnership with social movements. The Brazilian model would have been impossible without the government’s unconditional commitment. The government made it, however, in response to the mobilization of broad sectors of Brazilian society, which from the late 1980s through the 1990s waged a tough battle with the state, demanding that the public health system provide antiretroviral therapy just as it provided other drugs for other illnesses. For two consecutive years, organized anti-AIDS groups took to the streets demanding that the Health Ministry devote more resources to drugs and other medical supplies, and not just for AIDS. Previously, the battle had also been waged in the courts to defend the right to treatment. In most cases, the courts found in favor of people with HIV who were suing for their rights.

In 1996, in response to the pressure exerted by social movements, the Brazilian government decided to make generic versions of the anti-AIDS drugs generally available in the country. The decision vexed the United States, which denounced Brazil to the World Trade Organization (WTO) for violating TRIPS, the Trade-Related Intellectual Property Rights agreement. The pressure of international public opinion and the powerful set of Brazilian NGOs obliged the US government to drop its case.

On two occasions, Brazil’s Health Ministry warned that a budget shortfall would prevent it from providing anti-AIDS and other drugs. On both occasions, NGO pressure forced the Treasury to come up with the money. This is what the alliance between the government and civil society—the Brazilian partnership—consists of. Teixeira, the head of Brazil’s national AIDS program, described joint work between the NGOs and people living with HIV as "one of the pillars of Brazil’s policy to control the epidemic." Working in the field, the NGOs guarantee prevention and assistance to the most vulnerable social sectors.

Brazil remains unique
among countries of the South

Brazil’s civil society supports and legitimates the government’s proposals in the international arena, where according to Terto, the pharmaceutical industries, US government and European Union call the shots. "The government needs support, a relationship with civil society to have legitimacy," he explains. "There has to be support for the government’s positions, so they are seen as the country’s position. That way there’s not the government and civil society, it’s the country as a whole that’s proposing the strategy. There has to be an exchange, a relationship and dialogue so that the proposals and demands are linked and approved." As Terto also explains, "so far, Brazil remains quite unique among developing countries in its degree of success in the fight for this cause."
Naturally, neither the model nor the partnership is perfect, and the country still has a long way to go. ABIA’s coordinators lament the fact that shortages in Brazil’s public health system make it hard to provide correct follow-up to people undergoing antiretroviral treatment. Brazil does not have enough lab kits for either the HIV antibody test used to diagnose infection or the exams used to monitor it. There are problems with exams to monitor the virus level and the lymphocyte or CD4 cell count. Opportunistic infections are often not adequately treated, and there are serious obstacles to providing adequate care for other diseases and doing optimal prevention work.

A broken myth and a community proposal

Despite all these problems in the system, another positive factor is the alliance between the Brazilian government and associations of people living with HIV, which plays a part in issues like people’s adherence to treatment. Following the prescribed treatment is both vitally important and easily forgotten; think of how ready we are to stop treatment for other medical problems as soon as we see the first sign of improvement. But in the case of antiretroviral therapies, a failure to follow the regime can be fatal, causing the virus level in the blood to increase drastically. Since these therapies require people to take several pills a day for life, the need to follow the regime is clearly their Achilles’ heel.
With this in mind, it is important to note that, according to Terto, the adherence rate in Brazil is around 60-70% and over the years has been roughly equal to the rates in the United States and France. Brazil has thus broken the myth that poor countries are unable to establish much less maintain good public health policies. "We are increasingly involving HIV-positive people as part of the solution to the crisis called AIDS and what it means as a social phenomenon. This is also a way to see adherence not merely as an individual question. It is also a political question: people know that taking their medication correctly is not only going to benefit them individually, it will also benefit the whole collective of people around them. This commitment is also a political position."

Brazil has proven the validity
and effectiveness of the cocktails

Few people in Nicaragua know the first antiretroviral drug, AZT or zidovudine, which has been produced since 1985 by Wellcome under the commercial name of Retrovir. For years, it was the only drug used to contain the HIV infection and is currently administered in combination with other drugs several weeks before childbirth in women living with the infection for preventing perinatal transmission of HIV.

Six other drugs that work like AZT are on the world market today. These are known as inhibitors of reverse transcriptase, the protein that intervenes in the process of converting HIV’s genetic information into the CD4 cell’s DNA. Researchers are currently looking into three other drugs in the family of the transcriptase inhibitors. AZT and its "cousins" are only a part of a spectrum of antiretroviral drugs that are now being investigated, however, with enormous investments from the leading pharmaceutical companies: GlaxoSmithKline, Bristol-Myers Squibb, Roche Holding and Abbott Labs.

There are eight families of antiretroviral drugs altogether. Some act during the phase when the virus passes its genetic information to the human cell, which happens in the initial phase of the replication process. Others act in the phase when new viruses are formed with the material from the CD4 cells. These are protease inhibitors, and were presented by David Ho at the 1996 International AIDS Conference in Vancouver, Canada. The therapeutic action of integrase inhibitors is also currently being investigated. Integrase is the protein that intervenes in the CD4 cell’s nucleus. Other antiretroviral drugs still in the research stage include the zinc finger inhibitors that act directly on HIV.

The upshot of all this is that one drug is not enough to control the reproduction of HIV. A combination of two, three or even four antiretroviral drugs is required—the famous cocktails. In medical terms, the therapy is called HAART: highly active antiretroviral therapy. It was introduced in 1998 as the most effective way to reduce the virus’ presence to undetectable levels, thus allowing people who live with the infection to enjoy a very acceptable quality of life.

Antiretroviral therapy is the best that science has done thus far against HIV infections, but it is not a cure because the virus, even if undetected, remains in the organism. Its level in the blood increases when the therapy is interrupted or when, for little studied and less understood reasons, one of the cocktails fails, and two or three of the drugs have to be replaced by another, completely different combination.

Antiretroviral drugs are a global experiment, and little has been said about their secondary effects: the accumulation of fat in the breasts, stomach and shoulders and disappearance of fat in the gluteals and cheeks, along with other less known effects. When I mentioned the dark side of antiretroviral drugs to Terto during the meeting of the Latin American and Caribbean Secretariat of NGOs with AIDS-related services, he answered me emphatically: "The numbers show you a mortality rate that has fallen 50% and a better quality of life for people. This means that the antiretroviral drugs are effective. The fall in the mortality rate in a poor country, with such poor health care services, with inadequate basic care and so many problems in the health care system, is surprising. This means that the drugs are very effective. They are so effective that they may even outweigh the inadequate health care services, poor doctor care, problems with antibiotics and several other structural problems. In Brazil it has been proven that the antiretroviral drugs are very powerful and guarantee people’s survival."

The pillars of the system:
Universality, equity, a holistic approach

What lessons can we draw from the Brazilian experience? One of the most important is its defense of human rights as a paradigm of health. "These pillars of the health system were fundamental. And this is the Brazilian lesson: we have to develop—or defend, in the case of countries that already have it—a health system based on universality, equity and a holistic approach," maintains Terto.

Because of the principle of equity, people with HIV have the right to treatment, just like people with tuberculosis. The principle of universality means that all Brazilian citizens receive the health services for free, and this includes people infected with HIV, people who have an HIV-related opportunistic disease and people already in the AIDS stage. A holistic approach means that health care must address all aspects of the human being.

Terto says, "AIDS is the result of a crisis, an economic and social crisis, that has produced the conditions that allowed this epidemic to appear. So dealing with it also means dealing to some extent with the crisis that produced it. One of the important lessons we can draw from Brazil’s experience is that if civil society participates, we can make good progress against the epidemic. Community participation is a health policy. If we want a health policy, we have to establish it with citizen participation. This is an important lesson we have to offer."

Brazilian leadership encourages solidarity

In Latin American AIDS forums, Brazilian activists are the ones who talk the most about solidarity. In ABIA’s case, the roots of this conviction can be found in their first leaders, Betinho and Herbert Daniel. These two men did not see solidarity as some vague sentiment. "It is a political strategy, very, very political," says Terto, "that seeks concrete results." You have to find ways for this responsibility to be expressed in concrete things and must demand to see the accounts of commitments made. You have to make sure promises are kept. "Solidarity means the capacity to put yourself in the place of another person and feel in that position that the other person’s problem is also your problem and your responsibility."
"Solidarity humanizes us," said Herbert Daniel. In May 1991, Daniel closed his speech to a meeting on the human condition and rights, organized by the International Court of Justice in The Hague, with a cry of passionate love for life: "We all live with AIDS. Let’s make life on our planet an inventory of uncountable beauty. Together let’s raise a cry of exaltation and hope whose echo will be heard around the world and for all time. Long live life!"
Herbert Daniel participated in the armed resistance against the military dictatorship in Brazil from 1960-1970. His struggle led him into seven years of political exile before he was able to return to his country after the 1979 amnesty. As a writer and political activist he was tireless in his commitment to causes related to the liberation and rights of sexual minorities. He was president of the Grupo pela VIDDA (Pela Valorizaçao, Integraçao e Dignidade de Doente de AIDS)—the Group for Life, for the Appreciation, Integration and Dignity of People with AIDS—and vice-president of ABIA. He died as a result of AIDS in March 1992 at the age of 45. Betinho died in 1997, after nearly two decades of living with and fighting AIDS, with an extraordinary energy that belied his 100 pounds.

The relationship between Brazil’s Catholic Church and the government and social movements also provides an interesting lesson for the rest of Latin America. The Brazilian Bishops Conference has a national commission responsible for pastoral work in the area of AIDS and sexually transmitted diseases. It is true that the Church sees problems with prevention work—because of the promotion of condoms—and the role of the media, and equally true that many activists see the problem as the Catholic Church’s official position on homosexuality and sexual and reproductive rights. Despite these differences, there is an atmosphere of mutual respect in Brazil, as all do their work without attacking the positions of others. Many in the Brazilian Catholic Church are involved in humanitarian aid actions as well as actions to defend the right to life and prevent stigmatization and discrimination because of AIDS. The country has 40 Catholic NGOs providing various AIDS-related services. The Brazilian cardinal Paulo Evaristo Arns is an important figure in this work, not only in his country’s Catholic Church but also at a national and international level.

What can Brazil do for Latin America?

Obviously, the responsibility for providing antiretroviral treatments to all Latin Americans who need it cannot fall on the shoulders of a single country. Nor does it make sense to assume that all countries in Latin America can follow Brazil’s model of national drug production. The technical difficulties in producing this family of drugs makes national production impossible in small countries with small populations and scarce resources, like those in Central America and the Caribbean, except for Cuba. National production is too expensive to be competitive in our countries, as has already been proven in the Dominican Republic and Costa Rica.

The Brazilian government’s investment makes it possible to respond to the growing national demand, but does not yet contemplate export. It is calculated that Brazil could increase its production of antiretroviral drugs by some 50,000 additional treatments. But this production volume would not substantially address the need for these drugs in Latin America. It would only serve to continue covering the country’s own internal demand, as nearly 20,000 people begin antiretroviral treatment in Brazil each year.

One possibility is technology transfer to encourage the production of antiretroviral drugs in countries that already have sufficient technical and economic means, like Mexico, Colombia and Venezuela. Another is the sale of antiretroviral drugs to countries that cannot produce them, or until they begin their own production. These may be good solutions. Most Latin American countries have no intellectual property rights impediments related to the most commonly used antiretroviral drugs.

Patents against patients: A fight for life

In early 2001, Brazil launched a campaign in the United States to argue that "local production of many of the drugs used in the fight against AIDS does not represent a declaration of war against the pharmaceutical industry. It is simply a way to fight for life." Although the Brazilian AIDS program respects national law and international patent agreements, the global pharmaceutical industry opposes the Brazilian initiative. After several years of activism in a various international forums, however, Brazil has won victories that legitimate its production of generic antiretroviral drugs.

In an email letter sent out in May 2002, Cristina Pimenta and Veriano Terto wrote, "The excessive profits of pharmaceutical companies, the neoliberal policies that privatize public health, the unjust intellectual property laws imposed over and above public and community interests, and the failure of many of our rulers to address social inequalities mark the history of developing countries. All of these factors are killing people who live with HIV in Latin America and the world."
They propose that we ask developed countries how they have dealt with the question of intellectual property rights in crises. For example, in response to the shortage of cipro in the United States resulting from the disproportionate demand created by the anthrax letters, the US government decided to produce a generic version of the drug without paying the intellectual property patent rights. The situation was clear: without treatment, 100% of patients affected by inhalation anthrax die. With early treatment, some survive. Penicillin was not effective against the anthrax in the United States after September 11, leaving cipro as the only effective drug. Faced with this scenario, the government acted.

Pharmaceutical companies
staged a tactical retreat

We must also ask about the interests being defended when pressure was applied on the South African government to prevent it from importing or producing generic drugs for antiretroviral therapy. In the end, the transnational pharmaceutical companies dropped their suit against South Africa. Alejandro Teitelbaun, the American Association of Jurists’ permanent representative to the United Nations organizations in Geneva, described it as a "tactical retreat," since Africa represents only 1.3% of sales in the global drug market.

During the AIDS Conference in Barcelona, some pharmaceutical industry executives again accused the Brazilian government of "piracy" for its policy of producing anti-retrovirals, but they did so in private. No one dared publicly criticize the plan announced by the director of the Brazilian AIDS program, whose objective is to help developing countries create the conditions to produce generic antiretroviral drugs. According to this plan, Brazil will provide anti-retroviral drugs to ten different projects presented by poor countries at a cost of US$1 million a year. It will also provide assistance and medical training in the use of these drugs, and training and technology for their future production. The Brazilian Fund approved by the country’s Health Ministry will provide antiretroviral treatment to some 1,000 people.

Jeff Sturchio, an executive with the transnational pharmaceutical company Merck, said that "expansion of access to anti-AIDS drugs is a complex problem, and various approaches will be necessary. Generics will have to play an important role." Other pharmaceutical giants, however, do not share Merck’s flexible policy.

Brazil does very effective
lobbying on global policies

Brazil’s successful response to the AIDS crisis has given the country special clout in international forums. For example, the country played a leading role in creating the United Nations’ Global AIDS, Tuberculosis and Malaria Fund.

UNAIDS has recognized Brazil’s influence in global and regional policies, as well as its pioneering care with generic drugs, as important factors in the increased access to treatment at a global level that has taken place in recent years. The new paradigm adopted during the United Nations General Assembly’s Special Sessions on HIV/AIDS, which includes an integrated prevention and treatment focus, was based on the Brazilian experience as an open letter published several months ago by Luiz Loures, a top UNAIDS official in Geneva, Switzerland, recognized.

Brazil’s effective lobbying with the international community has played a pivotal role in the following series of declarations, all of utmost importance:
* The approval of Resolution 33/2001 by the United Nations Commission on Human Rights during its 57th session, which establishes access to AIDS drugs as a basic human right.

* The approval of Brazil’s May 2001 proposal to the World Health Organization on the need to have drugs at accessible prices available to all people living with HIV.

* The commitment signed at the UN General Assembly Special Session on HIV/AIDS in June 2001, which reiterates the need for a holistic approach including prevention, care, treatment and the protection of human rights.

* The establishment of the Global AIDS, Tuberculosis and Malaria Fund, which guarantees equal participation in resource administration to rich and poor countries and thus constitutes a unique case among international funds. Guaranteeing that the Global AIDS Fund will finance projects that include distribution of antiretroviral drugs among their activities was another important achievement.

* The declaration of the WTO’s Fourth Inter-Ministerial Conference, held in Doha, Qatar, in November 2001. This declaration, promoted by Brazil and other countries, defends the preeminence of public health above intellectual property rights.

"After the Doha declaration on patents was announced in November, several opportunities were created for developing countries to gain access to these treatments," Teixeira explained. "We’re just trying to do what’s possible to help." One of the first actions to help was the establishment of a lab in Guyana for the national production of antiretroviral drugs. Eloan Pinheiro, director of the main drug production lab in Río de Janeiro, said that many countries already have the infrastructure needed to begin production. The main problem would be quality control. Brazil is trying to address this problem through the transfer of technology aimed at ensuring bioequivalence and bioquality controls, to ensure that generic drugs possess the same properties as the original patented drugs.

The cheapest drugs:
India and Thailand

Factors that can facilitate access to treatment for the 36 million people who live with HIV around the world include a reduction in prices, local production and the mobilization of international funds to purchase drugs.

On the issue of prices, negotiations held under the auspices of UNAIDS, have led international pharmaceutical companies to offer treatments ranging in price from $1,600 to $2,000 per person per year. This is a significant reduction if compared to current prices of between $5,000 and $9,000 per person per year, depending on the particular combination used. The reduction is even more significant if we compare it to the $15,000-$20,000 per person per year that the therapies cost only six years ago. Nevertheless, these reduced prices have been offered to only a few countries in Africa, and are well above the prices offered by the private lab Cipla Ltd. of India or the government of Thailand. The latter announced at the start of 2002 that it would put the world’s most economical antiretroviral therapy on the market, offering a combination of three generic antiretroviral drugs for some $330 dollars a year, or less than a dollar a day. Currently some 2,000 people with HIV/AIDS are receiving free antiretroviral therapy in Thailand, where an estimated 695,000 are in need of the treatment.

For the first time, in an action that could help lower the price of AIDS drugs in poor countries, the World Health Organization (WHO) included generic drugs that are still under patent on its list of approved drugs for treatment of HIV/AIDS published early this year. The move has been described as a challenge to the transnational pharmaceutical companies. UNAIDS director Peter Piot said that he trusts the list will help patients gain "greater access to affordable, good quality drugs."
The list includes 11 antiretroviral formulas and 5 drugs to treat opportunistic infections, such as zoster infections, bacterial infections and Kaposi’s Sarcoma. The largest pharmaceutical companies appear on the list, along with Cipla Ltd. The Indian lab was the first generic drug producer to try to break the patent monopoly at an international level by offering antiretroviral therapy to charitable organizations and African governments in February 2001.

The foreign debt kills in
many ways, including AIDS

There are still no signs of any initiative by UNAIDS, WHO or any other agency associated with this joint United Nations program to convince the IMF to let the governments of the most impoverished, highly indebted countries increase their health budgets in response to the AIDS crisis. During a WHO meeting in October 2000, Harvard economist and professor Jeffrey Sachs argued that an annual investment of 3% of the GDP in health for many of the poorest countries comes to only US$8 per capita, while in rich countries the figure is in the $3,000-$5,000 range.

Heavily indebted poor countries, which in Latin America include Nicaragua, Honduras, Haiti, Guyana and Bolivia, must choose between paying the foreign debt or paying their social debt by investing in health, education and food security. Reducing the foreign debt depends on applying structural adjustment programs that require cutting the share of the national budget devoted to health, education and food security, but unless they do so they become ineligible for new loans. In this vicious circle, there is no question but that debt kills. During the UN Special Session on HIV/AIDS held in New York, Archbishop Lozano, the Vatican’s representative, recognized this in saying, "Too often we have failed to raise our voices to denounce the structural injustices and social sins perpetuated by the structural adjustment programs of the International Monetary Fund and the global economic system, which directly affect the poor."
Pope John Paul II’s message on that occasion denounced such scandalous inequalities and lamented that the high cost of the patented drugs required for antiretroviral therapy has made it impossible to treat HIV infections in poor countries. He recalled that there is a social debt outstanding on all private goods, and called for applying the same criteria to intellectual property rights since "the law of profits cannot be the only one applied in the struggle against hunger, disease and poverty."

Antiretroviral drugs in Central America

In Central America, only a small percentage of those who need antiretroviral treatments receive them. Access to these treatments has been the principle demand at the two Central American AIDS Conferences, the first held in San Pedro Sula, Honduras, in 1999 and the other in Guatemala City in 2001.
Costa Rica is the only Central American country where all people who need antiretroviral therapy, including foreign residents, receive it. The Costa Rican Supreme Court issued a decision in 1997 obliging the Social Security Institute to provide antiretroviral drugs based on the argument that economic interests cannot stand above the right to life and health.

In Panama, the government ostensibly offered full coverage to people who need antiretroviral therapy, but so far only those covered by social security receive the drugs, and then only as the result of an intense campaign led by Orlando Quintero, director of PROBIDSIDA, in 1999. The policy of ensuring universal access to antiretroviral drugs is making very slow progress due to the country’s bureaucracy and infrastructure problems, according to Norma García de Paredes, of the International Human Rights and Health Institute, and to Quintero himself.

Since 1999, people living with HIV/AIDS in El Salvador have demanded an AIDS law based on a bill they submitted. The Salvadoran Social Security Institute began to provide antiretroviral therapy to some people with HIV who are covered by social security in 2000. People who are not covered have repeatedly demanded that the government provide the treatments free of charge. In a major step backward, the Salvadoran Congress approved a law last year allowing employers to demand an HIV test from prospective employees.

In Guatemala, some 30,000 people infected by HIV sued the government in May 2002 demanding dignified treatment in hospitals and access to therapy, and reached an agreement with the President.

Street protests in Honduras

In Honduras last year, with support from the UNAIDS program to facilitate drug access, the government convinced several pharmaceutical companies to reduce the cost of antiretroviral therapies by as much as 85%, cutting them to $1,300 per person per year. At the same time, the Honduran congress approved $190 million in emergency spending to buy antiretroviral drugs, but bureaucratic snags stalled the purchase.

In May this year, responding to the tide of public opinion supporting the Honduran organization of people living with HIV, Honduran Health Minister Elías Lizardo announced that 260 people would be given antiretroviral therapy beginning in June and that the government had requested $27 million for AIDS alone, including $8 million to buy antiretroviral drugs. This represented two-thirds of the $41 million the Honduran government requested from the Global AIDS, Tuberculosis and Malaria Fund. Lizardo made these announcements in the city of Tela, speaking to over a hundred people living with HIV at their third national conference. The previous day, hundreds of activists and people affected by the epidemic had demonstrated in the streets of Tela to demand medical attention, non-discriminatory treatment, drugs for opportunistic infections and access to antiretroviral therapy.

Nicaragua: A law that’s just paper

Like her Central American colleagues, the Nicaraguan health minister made a commitment in June 2001 to put the agreements reached at the United Nations Special Session on HIV/AIDS into practice. Among other things, the declaration proposes to "make every effort to progressively and sustainably provide the highest attainable standard of treatment for HIV/AIDS, including prevention and treatment of opportunistic infections and effective, careful and monitored use of quality-controlled antiretroviral therapy to improve adherence and effectiveness and reduce the risk of developing resistance."
This commitment reaffirmed article 46 of the Constitution and articles 1, 3 and 19-30 of Law 238, the Law to Promote, Protect and Defend Human Rights against AIDS, which specifically establishes the right of all Nicaraguans to decent treatment and care, with no discrimination based on gender, ethnic group, social condition or HIV status. The Nicaraguan government has requested $34 million from the Global Fund for five years to meet the objectives of the National Strategic Plan to Prevent and Control STDs and HIV/AIDS.

Very few people in Nicaragua receive antiretroviral treatment, and those few thanks only to the support of their families or other people acting in solidarity. Social security does not cover treatment for HIV infections or AIDS. Even worse, some insurance companies have done HIV tests without permission and, on finding a positive result, turned people away refusing to serve them, thus violating their human rights and article 5 of Law 238.

The varying costs of treatment

Another sign of the critical situation of Nicaragua’s public health system is the lack of drugs, which tends to increase their price. For example, one tablet of fluconazole by Pffizer costs nearly $14.40, while in Guatemala, Doctors Without Borders obtain it at $0.28. This drug is not an antiretroviral but is indispensable in treating meningitis caused by criptococos, a fairly common opportunistic infection.

The price differences between generic and brand name products are considerable for all of the antiretroviral drugs. For example, Costa Rica buys generic AZT at $0.17 a tablet, while Panama buys a patented AZT for over $2 a tablet. Costa Rica buys D4T at $0.38 a tablet, while the same product sold under a brand name can run from $3-$7 a tablet in other countries.

The cost of antiretroviral treatment also varies significantly within each Central American country. The cheapest therapy in Guatemala is one using three generic anti-retroviral drugs distributed by Doctors without Borders at an annual cost of $788 per person. The Guatemalan government spends around $5,000 per person per year for a similar combination of brand-name antiretroviral drugs, benefiting only a small group of people selected by lottery. Another combination of three different brand-name antiretroviral drugs costs the Guatemalan government even more: $17,297 per person per year.

It is important to note that the kind of treatment varies according to medical criteria, since each case is different. The price of antiretroviral therapies in Costa Rica ranges from $2,469 to $6,050, according to a price chart provided by Richard Stern, who has been following access to treatment in Central America very closely over the last six years.

Human rights: The new health paradigm

The social crisis posed by AIDS clearly involves a whole set of human rights: the right to information, to respect for one’s private life, to decide, and above all, to equality without any kind of discrimination. Because of AIDS, human rights have become the new health paradigm, as is increasingly recognized by public opinion and included in the political agenda of the countries of the world. Preventing discrimination in health care is the most appropriate, viable strategy for responding to the HIV/AIDS epidemic, not only for humanitarian reasons, but also for those of efficiency and effectiveness.

This paradigm demands that we use different schemes for understanding the HIV epidemic than those used in classical epidemiology. Measures like isolation, obligatory testing, quarantine, migratory restrictions and subtle or open repression simply do not work in response to the AIDS crisis. Health must be seen from a generational, human rights, gender and sustainable development perspective.

All over the world, AIDS has also highlighted ethical dilemmas of various sorts. One of the most important is the unjust distribution of wealth. The vast majority of people with HIV live in poor countries ruined by the inequitable laws governing world trade, the current financial globalization and cookie-cutter structural adjustment plans.

Lack of political will,
commitment and solidarity

Throughout the 1990s, 95% of the $7 billion invested in AIDS prevention, education, treatment and research was invested in rich countries. In 2000, it was estimated that African countries would need some $3 billion a year to respond to AIDS, for prevention, basic care and the care of orphans. This is not an unreasonable or inaccessible amount, if compared to the $52 billion that the United States invests every year in dealing with the consequences of obesity. And it is more than reasonable if compared to that country’s enormous military spending.

The AIDS pandemic is far from reaching its peak, and future prospects are so grim that there is no room for complacency. A last fact worth emphasizing is that despite the solemn declarations, the real tragedies and the growing national and international mobilizations, there is still a lack of political will, commitment and leadership to address the global AIDS crisis. UNAIDS has only received US$2.8 billion of the $10 billion that it calculated it needed to launch the Global AIDS, Tuberculosis and Malaria Fund and that the G-8 countries promised to provide.

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