December 2015
For the past 30 years, the medical anthropologist Dr. Richard Parker has been dedicating his life to the study and fight against AIDS. He is a professor of sociomedical sciences at Columbia University and his research focuses on the construction of gender and sexuality, the social and political aspects of HIV/AIDS, and the relationship between social inequality, stigma and discrimination.
In this exclusive interview to the HCSM blog, he discusses the huge impact of health promotion policies against HIV in Brazil and in the rest of Latin America. Despite its great strides, the region also faced some setbacks in recent years, due to the growth of conservative forces and conservative political pressure, which led to increasing restrictions on prevention programs.
According to Parker, “We have advanced far more in other aspects of the fight against AIDS than we have in successfully fighting AIDS-related stigma, prejudice and discrimination.”
How have prevention policies towards HIV in Latin America been shaped since the beginning of the 80s? Which were the main changes over that time?
He is currently the Director and President of the Brazilian Interdisciplinary AIDS Association (ABIA) and the Editor-in-Chief for the journal, Global Public Health.
I think that there has been a kind of pendulum effect. Early in the epidemic, many countries in Latin America were slow to respond to HIV, and especially where the Catholic Church was most powerful, and most conservative, there was great resistance to bold prevention policies.
During the second decade of the epidemic, in the 1990s, this began to change, and increasingly direct and daring education and health promotion policies began to become more common. These policies had a huge impact in responding to the epidemic in Latin America, especially when compared to other regions of the world.
But sustaining this success over time has been difficult, and the growth of conservative forces, such as the Evangelical movement that has grown stronger in many parts of the region, and due to conservative political pressure, the pendulum seems to have swung back in the other direction, with increasing restrictions on prevention programs.
Even in Brazil, where the success of the response to the epidemic was recognized as especially great, in recent years we have seen the censorship of prevention programs for gay men and sex workers.
There is a serious risk that this will lead to a resurgence of the epidemic, especially among stigmatized and marginalized population groups. There is an urgent need to reprioritize the response to HIV and the development of frank and open prevention programs.Brazil’s lead was quickly picked up by many other Latin American countries, in spite of resistance on the part of conservative religious and political forces.
What has been the impact of Brazilian´s policy of free access to antiretrovirals and a holistic prevention program in the rest of Latin America and the world? Can you comment on the recent changes in Brazil´s program on AIDS? Especially with regards to the collaboration between AIDS activists, NGOs and the government?
After a very slow start, during the 1980s, when government officials at every level dragged their feet and found reasons not to address the emerging epidemic, as a result of significant pressure from activists, over the course of the 1990s, Brazil became a pioneering leader in the response to HIV and AIDS.
It adopted a human rights perspective that drew not only on AIDS activism, but also on the long tradition of the sanitary reform movement, and made a commitment to access to antiretroviral treatment almost immediately after effective treatments became available in the mid-1990s. This was linked to bold and daring prevention programs that dealt openly with controversial issues related to sexuality and injecting drug use.
Brazil’s lead was quickly picked up by many other Latin American countries, in spite of resistance on the part of conservative religious and political forces. And Brazil’s rapid commitment to treatment access reverberated around the world. As the New York Times put it in an influential article, “Look at Brazil”, once Brazil succeeded in implementing a policy for universal access, other countries in the global South – and donor countries from the North – could no longer argue that treatment was prohibitively expensive and therefore would not be possible.
Unfortunately, the kind of holistic or “integral” program that Brazil once pioneered has suffered important setbacks in recent years. While a commitment to access to treatment has continued to be an important policy in Brazil, the decentralization of HIV-related programs and the necessary incorporation of these programs into the unified public health system has highlighted continued problems in that system, and the quality of care has become a serious barrier in recent years – and especially in the present, as the current financial crisis in Brazil has led to serious funding cuts for health more generally.
Equally worrisome, the growth of conservative movements and their increasing political influence has had a serious negative effect. The current Brazilian government has repeatedly given in to pressure from religious conservatives in Congress, and has censored its own prevention campaigns for vulnerable populations and communities.
And massive cutbacks in funding from both government and from private donors who have withdrawn from funding HIV-related work in Brazil has seriously weakened civil society organizations. The incorrect assumption that everything is resolved and the HIV epidemic is under control in Brazil has led to major setback and an epidemic that is now growing again among key groups such as young people, and especially among young gay, and among transgender youth.
The alliance that once existed between activists, NGOs, and government has been tested and shows signs of serious weakening. While this situation is especially difficult in Brazil, it appears to be a trend in other parts of Latin America, and perhaps even a global trend.
UNAIDS and other international agencies have begun to promise the end of AIDS by 2030, but the reality on the ground, in the front lines of the response to the epidemic does not feel anything like an epidemic that is soon going to end. We have to wonder if the discourse about the end of AIDS is not just a smoke screen that covers up the reality of the epidemic and justifies redirecting scarce resources to other issues.
Attention to HIV patients in Brazil has been considered a success. Is it still a success? Does the same happen in the rest of Latin America?
I think that the answer must be a qualified “yes”. Brazil was pioneering in its policy of universal access to antiretroviral treatment beginning in 1996. It led the way, first in Latin America, where many other governments followed Brazil’s lead, and counted on Brazil’s collaboration, in implementing treatment access programs – and then in deepening access in countries around the world.
This commitment to treatment access has continued to mark both Brazil and Latin America. But we must also admit that the health systems in the region have not progressed as much as we would like, and treatment access is just one part of the integral health care that patients with HIV depend on the health care system for.
In Brazil, the challenges are currently immense. Funding cuts threaten the effectiveness of SUS, and even the commitment to the principles of SUS seem to be in doubt due to neoliberal policies, economic adjustments, and changes in direction and personnel that we have seen with the current Brazilian government – and many of these trends seem to reflect processes of change going on across the region.
Because of this, I fear that both Brazil and Latin America more generally has lost its pioneering leadership in the global response to the epidemic, and there is much to be done to revive the response to AIDS that once existed. It is imperative that we do everything we can to get AIDS back onto the policy agenda of governments in the region so that they will again give the epidemic the priority that they once did.
AIDS has always been linked to discrimination, stigma and prejudice. Has this changed?
AIDS has definitely always bee associated with discrimination, stigma and prejudice – from the very earliest history of the emerging epidemic in the early 1980s, on up to the present. Indeed, I think that it is true to say that stigma, prejudice and discrimination are perhaps the most persistent feature of the HIV epidemic.
Many people, including myself, hoped that once effective treatment became available, that would help to “normalize” AIDS, reducing the stigma associated with what had perceived to be an inevitably fatal disease. But for the most part, this has not happened.
I think that this highlights how deeply rooted AIDS-related stigma, prejudice and discrimination are with a range of other intersecting stigmas related to sexuality, gender, race and ethnicity and class. Because HIV is associated with a range of populations and communities that are already highly marginalized – that are already stigmatized and discriminated against independent of HIV, AID-related stigma tends to work in synergy with other forms of stigma, and is especially vicious because of this.
More than 25 years ago, my good friend and co-author, the Brazilian writer and AIDS activist, Herbert Daniel, said that the “ideological virus” of HIV may be even more deadly than the biological virus.
Sadly, I think that there are many ways in which this is true, and in recent years, both in Brazil and in some other parts of Latin America, we have seen the return of the ideological virus, associated especially with the growth of religious conservatism and intolerance of difference.
We have advanced far more in other aspects of the fight against AIDS than we have in successfully fighting AIDS-related stigma, prejudice and discrimination.
