Plagues in World History (35 page)

The answer seems to be found in the country that has attracted the disproportionate share of AIDS observers’ attention to the region: Brazil. As the largest and most populous country in Latin America with a reputedly liberal sexual culture (both gay and straight), wide gaps in wealth distribution, prevalent drug use and a vulnerable population of street children in the city’s
favelas
or slums, a recent history of military dictatorship, and an underfunded health system, Brazil’s prognosis for beating the AIDS epidemic was not good. Moreover, begin-AIDS y 171

ning in the second half of the 1980s, Brazil embarked on an AIDS policy that emphasized treatment in addition or even in preference to prevention, which most said was beyond the means of poor, developing countries in the third world. In 1991, the government began distributing AZT to AIDS patients, and in 1996, the year that triple combination drug therapy was announced to the world at the international AIDS conference in Vancouver, it took the remarkable and unprecedented step of offering HAART free to all who needed it, the first program of its kind in the world. Brazil also proved that developing countries could achieve high rates of compliance, and thus low rates of drug resistance, in treatment therapy programs. Much of the initiative for the Brazilian law mandat-ing ARV access came from hundreds of local AIDS NGOs, many of which had sprung up at first in the gay community whose members were relatively affluent and unstigmatized in Brazilian society. As the disease spread into more and more regions of the country and affected not only high-risk groups but also all sectors of the population, especially the poor, political pressure began building on Brazil’s politicians to take a more proactive approach to the epidemic. But even as the NGOs were organizing demonstrations and sponsoring lawsuits on behalf of its AIDS constituency, state and federal governments did prove responsive and headed off much of the confrontation through its bold ARV program. In a sense this was already predetermined by the country’s 1988 constitution, which en-shrined a universal right of access to health care for all its citizens, and AIDS

proved to be the first big test of the young democracy (established in 1985).

Despite the cost, antiretrovirals were also a good investment, as they kept patients out of hospitals (where treatment would be even more expensive), reduced viral loads and therefore the risk of new infections, and allowed patients to remain active members of society, whereas otherwise their lost productivity would be another drain on the country’s economy.73

Yet, an even bigger challenge was to come from outside Brazil. In 1994, Brazil had signed the international Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), and in 1996, the country passed its own industrial property law recognizing pharmaceutical patents. In order to be able to afford its free drug distribution program, Brazil began manufacturing generic versions of antiretrovirals in its own manufacturing facilities and administering them through a home-grown network of dispensaries, in itself no mean feat.

Brazil justified its generics program in legal terms on the grounds of an exception clause in TRIPS that allowed for violations in cases of “national emergency” and that its drugs were those manufactured prior to 1997, when its national patent law went into effect. Nonetheless, the pharmaceutical industry, with the backing of the U.S. government and the World Trade Organization (WTO), threatened a legal challenge and tariff sanctions since it perceived the Brazilian program as 172 y Chapter 6

simply the start of a domino effect whereby other third world countries would seek to mimic Brazil’s end run around the prohibitive cost of ARVs at Western prices. The end result of this standoff was that U.S. drug companies such as Bristol-Myers Squibb, Merck, Roche, and Abbott negotiated drastic price reductions (down to about $140 for a year’s worth of treatment) in exchange for a suspension and notification of compulsory licensing of patented drugs. This was a clear victory for the third world’s right to access the same “miracle” treatments for AIDS that were enjoyed by the affluent West, which in some ways could be considered a natural extension of political AIDS activism that had emerged in the early 1980s in the United States. Brazil won in part because it was able to mobilize world opinion on its side, even to the point of securing World Bank loans for its program. However, there is ongoing conflict about Brazil’s efforts to export its logistical and technical expertise to other poor nations seeking to start their own generic drug programs, particularly elsewhere in Latin America and the Caribbean and in sub-Saharan Africa.74 On one side of the debate is the argument that “Big Pharma,” by the very nature of its business of health care, has a moral and social obligation to help sick people in need, especially when its companies are some of the most profitable on earth and many of its products are developed with the aid of public money or institutions, such as the National Cancer Institute; on the other hand, it is pointed out that drug companies will have little financial incentive to develop new antiretrovirals and protease inhibitors that are much needed in the fight against AIDS unless there is a sufficient profit motive to do so, and the industry itself claims that it needs to charge high prices in order to recoup the millions of dollars that are invested in research and development of new drugs, most of which do not end up being marketable.75

Some also question whether Brazil’s success story can be imitated around the world, given its unique context. It could be said that Brazil at this point in time had a most fortuitous combination of circumstances, including democratic reform, an existing (if poorly endowed) health infrastructure, biomedical know-how, a mobilized and tolerant civil sector on behalf of AIDS victims, and the economic wherewithal, political will, and diplomatic credentials to bring its program to fruition. But Brazil, by its very example of beating great odds to show that Western-style treatments for citizens with AIDS can be done in a developing country, is a powerful counterargument to naysayers and has given hope and inspiration to other activists who have had to prod their governments into providing similar antiretroviral programs, such as we have seen in South Africa.

What is more, Brazil has adopted a leadership role in this effort to expand access to HAART around the world, and not just in terms of lending advice and support already mentioned but also in the very act of making bulk purchases of the active ingredients of drugs and negotiating price reductions from drug manufac-AIDS y 173

turers, by means of which it has made antiretrovirals that much more affordable for other countries.76

One other success story in Latin America that we should mention is Mexico, which aside from Cuba has one of the lowest HIV prevalence rates in the region, currently at 0.3 percent of the adult population (half of Brazil’s 0.6 percent).

Mexico has achieved this in part by means of a network of proactive AIDS

NGOs, free distribution of antiretrovirals, and an educational program that operates with the tacit complicity (or benign neglect) of the Catholic Church, just like in Brazil. But Mexico also has a policy of closely monitoring and regulating its (legal) prostitution population, which has reduced cofactors such as STDs, de-creased drug use, and increased availability and acceptance of condoms, placing it more in the mold of Thailand.77 As a consequence, married housewives are said to be as much as ten times more likely to get AIDS than commercial sex workers in Mexico; thus, the country still faces a threat of AIDS spreading into the wider heterosexual population and into rural areas, largely through migrant labor, hidden bisexual behaviors, and drug use, especially along the U.S. border.78

Finally, let us briefly address the Pattern III countries, where the AIDS pandemic is stil emerging and much of whose history with the disease is yet to be written. In Asia, dire predictions of a “second wave” of HIV infection, particularly in India and China, that would catapult the region ahead of sub-Saharan Africa with tens of millions of AIDS victims by 2010 have so far failed to materialize.79

As of 2008, there were 4.7 million people living with AIDS in the region, about half of whom were in India alone. This still places Asia second only to Africa in terms of numbers of people living with AIDS (which is perhaps inevitable given that the region is home to 60 percent of the world’s population), but the epidemic there does seem to be stabilizing. Overall, new HIV infections and AIDS-related deaths have so far been on the decline during the twenty-first century, with some notable exceptions such as China, Pakistan, and Bangladesh, and adult seroprevalence rates are below 1 percent everywhere except Thailand.80 Nonetheless, Thailand is widely touted as one of the greatest success stories in the region and a model that has influenced adjacent countries such as Cambodia and Laos. An epidemic that was rampaging in the 1990s, fueled by the country’s commercial sex industry intertwined with IV drug use, was contained by means of a targeted program that promoted AIDS education and universal condom use in brothels and which was led at the highest levels by government officials such as Senator Mechai Viravaidya (affectionately nicknamed “Mr. Condom”). Thailand has also benefited from hundreds of proactive AIDS NGOs which, as in Brazil, have lob-bied for increased access to antiretrovirals and manufacturing of cheap generic drugs in spite of patent protections such as TRIPS, and which have also helped administer ARV distribution through district hospitals and gain acceptance and 174 y Chapter 6

tolerance of people with AIDS in Thai society.81 Thailand’s seroprevalence rate and AIDS population has been brought down from 2 percent and nearly eight hundred thousand, respectively, during the 1990s to current levels of 1.4 percent and just over six hundred thousand, while the number of AIDS deaths has been cut in half from over sixty thousand per year between 2000 and 2003 to just thirty-one thousand today. Equally impressive are containment efforts in Japan and South Korea, where HIV prevalence rates are practical y zero—each country as of 2008 reported only several thousand cases of people living with AIDS (most of whom got the disease through homosexual and heterosexual contact) out of total populations in the tens of millions. Such results have apparently been achieved through a combination of AIDS education and awareness programs, free voluntary HIV testing and counseling, and public health support networks that provide access to antiretrovirals and other medical services.82

Prevention programs targeted at commercial sex workers have also proven effective in stabilizing the epidemic in south India, mainly by increasing condom use and reducing STDs, even though there is a history of discrimination and violence against high-risk groups for AIDS in the country. Meanwhile, another area where the epidemic has been localized for the present is northeastern India, where the disease is mainly fueled by intravenous drug use, as is likewise the case for neighboring Pakistan and Bangladesh.83 The extent of China’s AIDS epidemic is still somewhat of a mystery. As of 2008, its population of people living with AIDS

was reported to be three-quarters of a million, for a seroprevalence rate of 0.1

percent, but credible figures on annual rates of HIV infection and progression to AIDS have been released only in the last few years, and the first admission of transmission among men having sex with men was not made until 2005. Initial y, China’s epidemic was said to be almost exclusively confined to IV drug users, but lately heterosexual transmission—primarily through the country’s underground network of commercial sex workers—has overtaken drug use as the leading risk behavior for AIDS, according to the most recent UNAIDS report.84 While China has adopted some harm reduction measures such as methadone maintenance and needle exchange programs, these are undermined by oppressive actions by the Communist government, such as condemning drug users and sex workers, both officially classed as criminals, into undergoing “reeducation” or “rehabilitation” in forced labor camps. Hence, needle sharing remains high and condom use low owing to victims’ fear of prosecution and police crackdowns; criminalization and stigmatization of AIDS victims has also hampered efforts at HIV testing, as was likewise true until recently in India. China and India also share a high level of ignorance or misconceptions about AIDS (such as that healthy looking people are not infective) among the general population. Some of China’s epidemic has been self-inflicted. During the 1990s, a “bloodhead” scandal erupted in Henan prov-AIDS y 175

ince in east-central China, when whole villages and as many as fifty thousand people were infected with HIV owing to a business scheme whereby blood plasma was donated and then the remaining blood cells from different donors was mixed all together and reinjected into “blood sellers” (using reused needles) in order to allow them to keep donating on a continual basis; those who have not died are currently being treated with antiretrovirals.85

Elsewhere around the world, another region of concern is Eastern Europe and Central Asia, where the AIDS epidemic has grown rapidly in the twenty-first century, increasing by 66 percent since 2001 and currently afflicting one and a half million persons throughout the region. Ukraine, Russia, and Estonia all currently lead the region in HIV prevalence rates, which are over 1 percent of the adult population in each country.86 Intravenous drug use has to date been the main engine of the epidemic here, although heterosexual intercourse has been steadily on the rise as an associated risk behavior, especially among commercial sex workers. Facilitating transmission of the disease have been an economic and social collapse in the aftermath of the disintegration of the former Soviet Union and its satellite states, high rates of migration in search of work, rise of a criminal mafia controlling drug and sex trafficking, and a concurrent tuberculosis epidemic, including MDRTB, which is especially prevalent in Russia and its prison population. The only hope for the region seems to be an expansion of ARV treatment and harm reduction programs, access to which is currently below the global average.87